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Introduction to At-Risk Mental States Why are we doing this work?

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Presentation on theme: "Introduction to At-Risk Mental States Why are we doing this work?"— Presentation transcript:

1 Introduction to At-Risk Mental States Why are we doing this work?

2 Introduction What is the rationale behind detecting psychosis early – is there a need? What do ‘at-risk’ clients look like Thinking about Services A very brief history…

3 Psychosis: The Early Course Adapted from Larsen et al., 2001 premorbid phasevery early symptomspsychotic symptoms The typical course of psychosis Psychosis Treatment & RecoveryRelapse?

4 Psychosis: The Early Course Adapted from Larsen et al., 2001 premorbid phasevery early symptomspsychotic symptoms The typical course of psychosis Psychosis Treatment & RecoveryRelapse? “DUP”

5 Psychosis: The Early Course Adapted from Larsen et al., 2001 premorbid phasevery early symptomspsychotic symptoms The typical course of psychosis Psychosis Treatment & RecoveryRelapse? “DUP” Early Intervention after onset of psychosis (EIS) Tertiary Prevention

6 Psychosis: The Early Course Adapted from Larsen et al., 2001 premorbid phasevery early symptomspsychotic symptoms The typical course of psychosis Psychosis Treatment & RecoveryRelapse? “DUP” Early Detection & Intervention in the at- risk phase (ED:IT) Early Intervention after onset of psychosis (EIS) Tertiary Prevention

7 Is there a need..? ‘Every year across the UK about 7,500 people will develop a first episode of psychosis, onset usually occurring in young people… …this can lead to long term problems, sometimes life long, which leave people on the margins of society, struggling to maintain relationships, or get a job, an income or a home. As many as one in ten die by suicide, often within the first five years, and their families, friends and communities often carry huge burdens of care.’ (report on early detection & intervention - Parker et al 2007)

8 Is There a Need?  Duration of Untreated Psychosis (DUP) remains approx. one year after onset of psychosis  Poorer outcome related to length of untreated psychosis (Drake et al. 2000; Yung et al. 2003)  Significant disability associated with prodrome (Yung et al., 1996)  Between 5 -15% of individuals with Schizophrenia will commit suicide – most within the first six years of psychosis (Melle et al. 2006)  Often the individual and family are in distress

9 Other Positives to earlier detection Intervening early may improve engagement with services (when insight is intact) Reduce the trauma of hospitalisation & use of M.H. act Intervening early may reduce psycho-social deterioration

10 Other Positives to earlier detection Intervening early may improve engagement with services (when insight is intact) Reduce the trauma of hospitalisation & use of M.H. act Intervening early may reduce psycho-social deterioration The possibility to PREVENT psychosis in vulnerable young people??

11 What do at-risk clients look like? What do at-risk clients look like? Employ PACE ‘at-risk’ criteria to identify:  Familial risk plus reduced level of functioning in past yr  or Attenuated psychotic symptoms  or Brief, Limited, Intermittent Psychotic Symptoms  Aged years Plus: Evidence of distress & difficulty

12 EPOS : an international prospective study of transition to psychosis in individuals at ‘ultra high risk’ European Prediction of Psychosis Study Cologne Berlin Amsterdam Turku Birmingham Manchester

13 EPOS Demographic Data 1 Sample size 246 Age (mean ± SD) 23.0 ± 5.2 Gender (m : f in %) 56.1 : 43.9 Years of schooling (incl. university) (mean ± SD) 13.5 ± 2.8 Current work situation (n [%]) Full/part time work 55 [22.3] In full time education 99 [40.2] Unemployed 36 [14.6] Unable to work (sickness/disability) 43 [17.5] Other 10 [4.0]

14 EPOS Demographic Data 2 Current Partnership Status n% Single 200[81.3] Married Cohabiting [4.1] [13.8] Separated/Divorced 2[0.4] Current Living Situation n% Lives alone 61[24.8] With another person 29[11.8] In a family 123[50.0] Flat share 30[12.2] In an institution 3[1.2]

15 EPOS Demographic Data 3 – it‘s not only about psychosis 1° relative with psychotic disorder (n[%]) 30 [12.2] 2° relative with psychotic disorder (n[%]) 17 [6.9] Schizotypal personality disorder (SIPS) (n[%]) 33 [13.4] Pre- or perinatal complications (n[%]) 39 [15.9] Any depressive disorder (n[%]) 120 [48.8] Any bipolar disorder (n[%]) 19 [7.7] Any anxiety disorder (n[%]) 118 [48.0] Any substance abuse disorder (n[%]) 100 [40.8] GAF score (mean ± SD) 51.0±11.8 BDI (depression - mean ± SD) 20.3±10.9

16 I don't have any thoughts of killing myself I've thoughts of killing myself, but I won't carry them out I would like to kill myself I would like to kill myself if I had the chance 0.0%10.0%20.0%30.0%40.0%50.0% Percent Participants with Suicidal Ideation at Baseline (BDI) - 55% n=232

17 Cannabis use of high risk patients EPOS Study sites (n: 246) Study sites EPOSlifetimerecent-regular use > 5 times during life Last year ≥ once a month Cologne, Berlin51.6 %31.0 % Birmingham, Manchester47.2 %34.0 % Amsterdam43.2 %40.9 % Finland20.0 %9.3 % Total42.0 %28.6 %

18 Transition rate high risk patients EPOS study centres (n=246) Study sites EPOSproportion% Amsterdam 19/ % Cologne, Berlin 12/ % Birmingham, Manchester 6/ % Turku 6/ % Total43/ %

19 EPOS Transition Rates (To September 2006) Total number of transitions41 Transition rate (ref. to baseline) 12 months (n = 246)31 (12.60%) 18 months (n = 246)39 (15.04%) Transition rate (ref. to risk set) 12 months (n = 199)31 (15.57%) 18 months (n = 170)39 (22.94%)

20 Study N at baseline Observation Period (months) Transition rate EPOS Broome et al ?10.3 Mason et al >12, 26.3 ± 9.250% McGlashan et al (Plc) % Miller et al % 53.8% Morrison et al (TAU) Nordentoft et al (SD ICD-10) (ST) 12 (24) Pantelis et al % 31% Yung et al (49+55) % 34.6% Yung et al %

21 Treatment methods measured in EPOS included: - Medication (sorted by type e.g. Antipsychotic; Anxiolytic; Antidepressant.. - Psychological Therapy (sorted by type e.g. CBT; Psychotherapy.. - Monitoring (telephone / face to face etc) - Group Therapies (e.g. for Social Anxiety) - Family Interventions (e.g. Psychoeducation)

22 D Fin NL UK Mean Any psychotherapy (%) Any meds (%) Neither (%) Medication and Psychological Therapy

23 D Fin NL UK Mean Any psychotherapy (%) Any meds (%) Neither (%) SIPS Medication and Psychological Therapy

24 D Fin NL UK Mean Any psychotherapy (%) Any meds (%) Neither (%) SIPS Transition rate (%) Medication and Psychological Therapy

25 D Fin NL UK Mean Any psychotherapy (%) Any meds (%) Neither (%) SIPS Transition rate (%) Expected Transition without Intervention: 35 – 54% (SIPS/CAARMS) Medication and Psychological Therapy

26 Treating ‘at-risk’ clients Confusion as to how to treat this cohort – not ‘psychotic’ but very unwell… Little evidence as to the relative effectiveness of medication / psychological therapies / case management Guidelines for treatments for HR group developed by International Early Psychosis Association (2005) but not consistently adopted by local services Early Detection Report (Parker et al 2007) – suggested guidelines

27 Developing a Service Approach Early Detection Education, Awareness- raising, Training Accurate- assessment, Evaluation Engagement, Appropriate client/family Treatments

28 Developing a Service Approach Early Detection Education, Awareness- raising, Training

29 Stigma & the media

30 Stigma – Public Attitudes to Mental Illness 83% agreed society needs to adopt a more tolerant attitude 89% agreeing that society has a responsibility to provide people with the best possible care 74% agreed that mental illness is an illness like any other 20% said there is something about people with mental illness that makes it easy to tell them from normal people Department of Health Survey (2003) : (1897 adults, 16+)

31 Stigma – Public Attitudes to Mental Illness 2 25% agreed that people with mental illness should be excluded from public office and 16% said they should never be given any responsibility Only 21% of respondents agreed that women who were once in hospital for mental illness can be trusted as a babysitter (31% neither agree/disagree) 62% agreed that they would not want to live next door to someone who has been mentally ill 60% agreed that a woman would be foolish to marry a man who has suffered from mental illness, even if he seems fully recovered Department of Health Survey (2003) : (1897 adults, 16+)

32 Stigma & Psychosis 70% of respondents rated people with schizophrenia as dangerous to others 80% rated people with schizophrenia as unpredictable 60% rated people with schizophrenia as difficult to talk to 50% thought people with schizophrenia would never recover Crisp, A.H., et al. (2002). British Journal of Psychiatry, 177, 4-7. (1737 adults 16+)

33 TIPS – Norway DUP can be dramatically reduced through educational campaigns

34 ED:IT ED:IT Mental Health Promotion  ‘Mental health & Psychosis’ workshops for individuals working with young people (300 + attended)  ‘Lunchtime workshops’ for MH professional staff - training in ‘Early Identification’ of psychosis (200 + attended)  Educational DVD’s created by service users of the Early Intervention Services  ‘REDIRECT’ educational project for GP’s in ‘Early Signs’ of psychosis – reducing DUP

35 Developing a Service Approach Early Detection Engagement, Appropriate client/family Treatments

36 Which Therapy for at-risk clients? Evidence base for effectiveness of different treatments for HR clients remains sparse Psychological therapy suggested as more acceptable, less stigmatising to HR clients (Bentall & Morrison 2002) Possible risk of pharmacological side-effects and high non-adherence if antipsychotics used ( eg McGlashan et al. 2006) Co-morbid symptoms (anxiety/depression etc) addressed by psychological interventions

37 ED:IT Sept 2004 Interventions – Birmingham ED:IT flexible treatment options including … Intervention TypeUptake n=50 Case Management100.0% Individual CBT (Morrison & French, 2004) 86.7% Group CBT24.4% Family Support/Intervention35.5% Neuroleptic Meds (supplied by outside agency) 6.7%

38 EDIE2 (MRC funded UK Intervention Trial ) MRC funded Trial of CBT for individuals at high risk of psychosis Aim to recruit n=320 high-risk participants To reduce transition to psychosis and reduce the distress felt by help-seeking individuals Inclusion using PACE at-risk criteria

39 What sites are involved in EDIE 2? Manchester (lead site) Glasgow Birmingham/ Worcester East Anglia Cambridge Check EDIE2 website at University of Manchester

40 That’s the theory… but does it work in practice? Are we able to ‘detect’ young people in the pre-psychotic phase in the community? Do these young people actually want help from (mental health) services? Is the ‘help’ that we are offering acceptable to young people?

41 That’s the theory… but how is it working in practice? Are we able to ‘detect’ young people in the pre-psychotic phase in the community? Do these young people actually want help from (mental health) services? Is the ‘help’ that we are offering acceptable to young people? YES

42 A very Brief History of treatments for Psychosis (to remind us where we’ve been…)

43 St Mary of Bethleham hospital near London first accepts psychiatric patients (from 1776 this was also a tourist attraction) Dunking Pool

44 Head Restraint

45 Restraining Crib (single occupancy)

46 Dr Gottlieb Burkhardt attempts to alter behaviour in 6 severely agitated Swiss patients by extracting portions of their frontal lobes (2 died) Lobotomy Kit (NHS outreach model)

47 Emil Kraepelin categorises mental illnesses into those which could be cured and those which could not (e.g.dementia praecox - psychosis) Cerletti and Bini introduce electroshock convulsions Portable ECT Machine

48 Deniker Leborit & Delay discover the antipsychotic properties of chlorpromazine marking the beginning of psychopharmacology More than 55,000 men women and children in the US undergo lobotomy

49 Ian Falloon trains GP’s to identify ‘early signs’ of psychosis 1990’s - EPPIC / PACE establish Early Detection/Intervention Clinical & Research programmes in Melbourne - Early Intervention approaches introduced in UK and Internationally - TIPS Norweigian educational campaigns reduce DUP 2000’s – First Early Detection / Prevention Programmes in UK EDIE(2), ED:IT, OASIS, REDIRECT, BRITE

50 Ian Falloon trains GP’s to identify ‘early signs’ of psychosis 1990’s - EPPIC / PACE establish Early Detection/Intervention Clinical & Research programmes in Melbourne - Early Intervention approaches introduced in UK and Internationally - TIPS Norweigian educational campaigns reduce DUP 2000’s – First Early Detection / Prevention Programmes in UK EDIE(2), ED:IT, OASIS, REDIRECT, BRITE That’s a big jump in 20 years…

51 Ian Falloon trains GP’s to identify ‘early signs’ of psychosis 1990’s - EPPIC / PACE establish Early Detection/Intervention Clinical & Research programmes in Melbourne - Early Intervention approaches introduced in UK and Internationally - TIPS Norweigian educational campaigns reduce DUP 2000’s – First Early Detection / Prevention Programmes in UK EDIE(2), ED:IT, OASIS, REDIRECT, BRITE so what’s next…?

52 ED:IT Birmingham Telephone: Fax:


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