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“The way to recovery” GAMIAN-Europe /Eastern Europe Regional Seminar “The way to Recovery: Pharmacotherapy, Psychotherapy and Social Rehabilitation from.

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Presentation on theme: "“The way to recovery” GAMIAN-Europe /Eastern Europe Regional Seminar “The way to Recovery: Pharmacotherapy, Psychotherapy and Social Rehabilitation from."— Presentation transcript:

1 “The way to recovery” GAMIAN-Europe /Eastern Europe Regional Seminar “The way to Recovery: Pharmacotherapy, Psychotherapy and Social Rehabilitation from the clinicians’ perspective” Dr. F. Cañas de Paz H. “Dr. R. Lafora”. Madrid. Spain Bucarest, may 23th 2009

2 Positive Symptoms Hallucinations Delusions Hostility Excitability Negative Symptoms Blunted emotions Anhedonia Lack of feeling Loss of motivation Social withdrawal Cognition Verbal Memory Executive function Attention Mood Symptoms Depression Mania Poor insight FUNCTION Spectrum of Symptoms in Severe Mental Disorders (SMD)

3 CRITICAL PERIOD Birchwood M et al. Br J Psychiatry 1998;172 (S 33):53-9. Cronic-relapses Age (years) 0 10 20 30 40 50 60 70 80 90 100 202122232425262728293031323334353637383940 Level of functioning (%) Differing courses following a first psychotic episode Partial response Breier et al. Am J Psychiatry 1994;151:20–26. Remissión-recovery Response Prodromal 1 st episode

4 Relapses can have devastating consequences Psychosocial consequencesPsychosis “toxicity”?

5 RECOVERY 1.Symptoms no longer interfere with daily life 2.Person can engage in meaninful actitivies (role fullfilment): 1.Self-care 2.Relationships 3.Work / school Key issue: The ability to form and sustain social relationships

6 Effective SMD Treatment Requires an Holistic Approach Positive Symptoms Negative Symptoms Mood Disturbanc e Cognitive Dysfunctio n Minimising and treating side effects Encouraging medication adherence Employment opportunities /sources of income Encouraging adequate housing Managing sleep disturbances Managing substance misuse Monitoring physical health Integrating care teams Involving family Educating and informing

7 Why Early Identification and Treatment Matters  >70% of first-episode patients achieve full remission of psychotic symptoms within 3–4 months 1  >80% achieve stable remission at the end of 1 year 1  Delayed initiation of antipsychotic medication results in poorer outcomes: 2 –More severe and persistent positive and negative symptoms –Poorer treatment response  Recurrent episodes of psychosis associated with: 3 –  risk of chronic residual symptoms –Evidence of anatomical neuroprogression 1. Lieberman et al. Neuropsychopharmacol. 1996;14:13S–21S; 2. Haas et al. J Psychiatr Res. 1998;32:151–159; 3. APA Practice Guideline 2004

8 Overt Covert Non-adherence Relapse Partial-adherence Relapse Partial response Fluctuates IN THE FIRST YEAR OF TREATMENT: 39% non-adherent; 20% inadequately adherent Coldham EL et al. Acta Psychiatr Scand 2002;106:286-90. POOR ADHERENCE

9 ADHERENCE IN SMD PATIENT RELATED: insight cognitive impairment beliefs doctor-patient relationship substance abuse MEDICATION RELATED: cost side effects dosing schedule Between 50% and 80% do not believe that they have a disorder, or that they require ongoing treatment. Dam J. Nord J Psychiatry 2006;60:114-20

10 Do We Really Know How Compliant Our Patients Are?  In a recent survey across Spain… Only 43% of psychiatrists (n=844) believed their patients were compliant  82% of relatives (n=796) believed the patient was usually compliant BUT 95% of patients (n=938) said they regularly took their medication Giner et al. Actas Esp Psiquiatr. 2006;34:386–392

11 Strategies for Improving Medication Adherence Adapted from Perkins. J Clin Psychiatry 2002;63:1121–1128 Patient-related issues  Cognitive therapy  Educate about the illness and benefits of treatment  Memory aids  Involvement of patient in therapeutic alliance Treatment- related issues  Minimise complexity of treatment regimen  Titrate to optimal dose  Minimise impact of side effects on patient’s life  Provide clear instructions on medication use  Select antipsychotic with minimal EPS, weight gain and prolactin effects

12 Recognising Relapse in SMD  Many patients have ‘early warning signs’ of an impending psychotic relapse –2 days–4 weeks before onset of frank psychosis  Dysphoric symptoms most commonly reported –Depressed mood, withdrawal, sleep and appetite problems  Patients’ ‘relapse signatures’ should be identified and noted –Timely and effective intervention may arrest progression  Families play a key role in recognising early warning signs Birchwood et al. APT 2000;6:93–101

13 Some Early Warning Signs of Psychotic Relapse Birchwood et al. APT 2000;6:93–101 Thinking/perceptionFeelingsBehaviours Racing thoughtsHelpless or uselessDifficulty sleeping Senses seem sharperIrritableJumbled speech Special powersSad or lowTalking to yourself Mind being readAnxious or restlessNeglecting appearance Messages from TV/radioReligious obsessionsSocial withdrawal Cannot make decisionsBeing watchedNot eating Hearing voicesIsolatedChild-like behaviour Poor concentrationLoss of trustAggression

14 PREDICTORS OF TREATMENT OUTCOME POOR OUTCOME OUTCOME Poor premorbid adjustment Male sex Early age of onset Poor medication adherence Reduced brain volume Cognitive impairment Inherent refractoriness Longer duration of untreated dis. MODIFIABLE FACTORS Robinson et al, 2004; Emsley et al, 2006



17 PSYCHOSOCIAL REHABILITATION A mixture of skill (re)acquisition and support needed to maintain a person in community (A. Williams) DYNAMIC PROCESS: SKILLS SUPPORT


19 Medical Education Meeting – FUM IV ‘The adherence challenge’ May 12, 2009 Brussels


21 CONCLUSIONS (1) 1.The goal in SMD treatment is recovery 2. The main poins to arrive there are: a) Early intervention b) Treatment adherence c) Relapse prevention d) Psychoeducation e) Rehabilitation and social support f) Work / independency

22 CONCLUSIONS (2) To obtain that is important: Reduce stigma Engage patients (shared decission model) and families Organize access and countinuity of care Mobilize social resources


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