IEPA clinical practice guidelines for ARMS Shôn Lewis University of Manchester UK

Early phase terminology High risk –Psychosis proneness; schizotypy Isolated psychotic symptoms –Psychosis like experiences –Non-clinical/subclinical psychotic symptoms Early prodromal –Bonn scale At risk mental state –Late prodromal First episode psychosis

Early phase terminology High risk –Psychosis proneness; schizotypy Isolated psychotic symptoms –Psychosis like experiences –Non-clinical/subclinical psychotic symptoms Early prodromal –Bonn scale At risk mental state –Late prodromal First episode psychosis

Early phase terminology High risk –OLIFE; SPQ Isolated psychotic symptoms –LSHS –PDI; CAPE Early prodromal: SPIA At risk mental state –CAARMS –SIPS/SoPS First episode psychosis –PANSS etc

Constructs ↑ risk of psychosis Psychotic symptom DistressHelp seeking Need for treatment High risk Isolated p ic symptom Early prodromal ARMS (late prodromal) 1st episode psychosis

Constructs ↑ risk of psychosis Psychotic symptom DistressHelp seeking Need for treatment High risk Isolated p ic symptom Early prodromal ARMS (late prodromal) 1st episode psychosis

Constructs ↑ risk of psychosis Psychotic symptom DistressHelp seeking Need for treatment High risk Isolated p ic symptom Early prodromal ARMS (late prodromal) 1st episode psychosis

Constructs ↑ risk of psychosis Psychotic symptom DistressHelp seeking Need for treatment High risk Isolated p ic symptom Early prodromal ARMS (late prodromal) 1st episode psychosis

Constructs ↑ risk of psychosis Psychotic symptom DistressHelp seeking Need for treatment High risk Isolated p ic symptom Early prodromal ARMS (late prodromal) 1st episode psychosis

Constructs ↑ risk of psychosis Psychotic symptom DistressHelp seeking Need for treatment High risk Isolated p ic symptom Early prodromal ARMS (late prodromal) 1st episode psychosis

At risk mental state: Yung et al 1998 Attenuated positive symptoms –subthreshold for severity Brief limited intermittent psychotic symptoms –subthreshold for duration (<1 week) Schizotypal personality or first degree relative with psychosis plus recent functional deterioration Seeking help

High risk of acronyms PACE PRIME EDIE RAP FETZ TOPP PIER OASIS EPOS CARE NAPLS SPAM –Society for Prevention of Acronyms in Mental health

Rates of one year transition ARMS to psychosis (adapted from Lisa Phillips et al 2005) CentreTransition rate PACE41% PRIME38% TOPP43% EDIE26% PIER23%

IEPA clinical guidelines for early psychosis Formulated Copenhagen authors A-Y Published 2005 To be updated 2008 Covered –ARMS –First episode –Recovery (6-18 months) and critical period phase IEPA writing group Br J Psychiatry s48 s

Prevention in early psychosis Three targets for preventative interventions in early psychosis –Prepsychotic phase –Initially untreated psychosis –First episode IEPA writing group Br J Psychiatry s48 s

General statements Early identification will reduce burden –May improve long term outcomes Public education important Careful, low dose drug treatment in first episode Psychosocial treatments important in promoting recovery Users and families engaged in developing better treatments IEPA writing group Br J Psychiatry s48 s

The prepsychotic period: clinical guidelines At risk mental state needs to be considered in young people with deteriorating functioning or unexplained agitation IEPA writing group Br J Psychiatry s48 s

The prepsychotic period: clinical guidelines Help seeking people with ARMS need to be engaged and assessed and offered –Regular monitoring and support –Specific treatment for depression or substance use –Psychoeducation and help to develop coping skills –Family education and support –Information about risks of psychosis IEPA writing group Br J Psychiatry s48 s

The prepsychotic period: clinical guidelines Care offered in a low stigma environment –At home; primary care; youth-friendly office-based setting Antipsychotic drugs not usually indicated –Exceptions might be risk of suicide or violence, or rapid deterioration –If used, regard as therapeutic trial for up to 6 weeks If help declined, consider support from friends and family IEPA writing group Br J Psychiatry s48 s

What are the outstanding issues now?

Issues for ARMS interventions Safety and acceptability Efficacy and effectiveness Availability and cost What is the therapeutic target? –Prevention versus treatment Ethics –Of treatment; Of non-treatment Population impact IEPA writing group Br J Psychiatry s48 s

Issues for ARMS interventions Refinement of risk estimates Modifying risk and protective factors Developing a clinical algorithm –Psychological intervention first? –Drug treatment second? –How long for? IEPA writing group Br J Psychiatry s48 s

Which psychological intervention? Cognitive therapy (Morrison et al, 2006; Ruhrman et al, 2007) Also? (from psychosis literature) –Family intervention –CT for relapse –Motivational interventions –Cognitive remediation

Which drug treatments? Antipsychotics? –Appear effective RCT data with risperidone; olanzapine; amisulpride –BUT risks from side effects: low NNT:NNH ratio –Doubtful acceptability for many Antidepressants? –Anecdotal evidence

Roll on the IEPA guideline update!

EDIE trial: Results Transitions to psychosis at 12 months Morrison et al, 2004