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Paul French: 

Paul French Psychology Services of Salford Bolton Salford andamp; Trafford Mental Health Trust andamp; Department of Psychology Manchester University Rationale for Early Interventions in Psychosis Early Detection and Intervention Team

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Collaborators Tony Morrison Richard Bentall Shon Lewis Max Birchwood Andrew Gumley Assistants Lara Walford Aoiffe Kilcommons Joanne Green Alice Knight Marianne Kreutz Sandra Neil Uma Patel Sophie Lomax Shreeta Raja

What is Early Intervention: 

What is Early Intervention Early intervention strategies Intervening early with people who are relapsing from an established illness Intervening with people in the early stages of their illness (critical period hypothesis) including early case identification Early intervention as a preventative strategy

Why Early Intervention?: 

Why Early Intervention? Emil Kraepelin (1856-1926) Discovered schizophrenia and manic depression. Degenerative brain disorder. Current research interest

Stress vulnerability: 

Stress vulnerability Stress Vulnerability

Prognosis (roughly speaking): 

Prognosis (roughly speaking)

An early intervention serviceshould be able to: 

An early intervention service should be able to Reduce the stigma associated with psychosis and improve professional and lay awareness of the symptoms of psychosis and the need for early assessment Reduce the amount of time young people remain undiagnosed and untreated Develop meaningful engagement, provide evidence based interventions and promote recovery during the early phase of the illness

An early intervention serviceshould be able to: 

An early intervention service should be able to Increase stability in the lives of service users facilitate development and provide opportunities for personal fulfilment Provide a user centred service, seamless between 14 to 35 integrating child, adolescent and adult services and work in partnership with primary care, education, social services, youth and other services At the end of the treatment period ensure that care is transferred thoughtfully and effectively

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Duration of Untreated Psychosis DUP the amount of time from onset of symptoms of psychosis to the prescription of antipsychotic medication Duration of Untreated Illness DUI the amount of time from the recognition that things are not going well to the prescription of antipsychotic medication

Duration of Untreated Psychosis: 

Duration of Untreated Psychosis Duration of untreated Psychosis and Duration of untreated illness 0 50 100 150 200 250 300 350 400 450 500 Loebel et al 1992 Beiser et al 1993 Hafner et al 1993 McGorry et al 1996 Drake et al 2000 Studies Weeks DUP DUI

Exercise: 

Exercise If you or a member of your close family started to develop psychosis would you feel comfortable getting help? What might prevent you from getting help? What help would you want? Is this available?

Consequences of delayed treatment: 

Consequences of delayed treatment Slower and less complete recovery Poorer prognosis Increased stigma Increased risk of depression and suicide Interference with psychological and social development Strain on relationships; loss of family and social supports Disruption of parenting skills (if have children)

Consequences of delayed treatment (cont’d): 

Consequences of delayed treatment (cont’d) Disruption of study, employment and unemployment Substance abuse Violence/criminal activities Unnecessary hospitalisation Loss of self esteem and confidence Increased cost of management

Potential benefits of early intervention: 

Potential benefits of early intervention Improved recovery1,2 More rapid and complete remission2,3 Better attitudes to treatment Lower levels of expressed emotion/family burden4 Less treatment resistance 1. Birchwood and Macmillan, 1993 2. McGorry et al, 1995 3. Loebel et al, 1992 4. Stirling et al, 1991

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@ease is part of Rethink — Working together to help everyone affected by severe mental illness, including schizophrenia, to recover a better quality of life. We provide practical advice, support and information to people who have a severe mental illness, their families and friends. And we work for a better understanding, breaking down the stigma and myths about mental illness. http://www.rethink.org/at-ease/

Northwick Park StudyJohnstone et al 1986: 

Northwick Park Study Johnstone et al 1986 Study of first episode schizophrenia n=253 28% admitted within 2 months 25% admitted between 2-6 months 9% admitted 6-12 months 26% admitted after more than 1 year

Northwick Park StudyJohnstone et al 1986: 

Northwick Park Study Johnstone et al 1986 41% of patients made contact with either a hospital, a GP, private medicine faculties, social workers, religious bodies, marriage guidance, etc 13% had made more than 9 helper contacts without receiving treatment

Northwick Park StudyJohnstone et al 1986: 

Northwick Park Study Johnstone et al 1986 A subsample n=120 was included in an RCT to test antipsychotic medication against placebo. They found that DUP was a stronger predictor of relapse than antipsychotic medication.

The TIPS Project: 

The TIPS Project Early detection systems for schizophrenia appear to be effective in improving help-seeking behavior, thus reducing duration of untreated psychosis (DUP), claim researchers. They stress that this could have important public health implications, particularly as a shorter DUP has been correlated with a better prognosis. The TIPS project successfully reduced DUP from 114 weeks to a mean of 26 weeks, a difference of about one and a half years.

Case Material: 

Case Material I remember when I had my first episode; I was about 21 at the time. I didn’t have a care in the world, I had my own house and a long term relationship, and things couldn’t have been more perfect. So when I found my self hiding under the quilt worried that my boyfriend was some how trying to kill me, well you can imagine, it’s a very scary thought. Who could I tell without them thinking I was mad? I was even worried about discussing it with the people close to me at the time; after all I thought my boyfriend was trying to kill me. Maybe every body else was, perhaps they were all plotting against me some how. This was just one of many irrational thoughts that came into my head and there were many more. Looking back on it now the things I thought then seem so silly now but of course they didn’t at the time.

What do people want?: 

What do people want? I just wanted answers or at least a listening ear; instead I was handed over a prescription of antidepressants and told there was basically nothing wrong with me. If there was nothing wrong with me what was the prescription for?

What Happens in the Early Stages?: 

What Happens in the Early Stages? I made further attempts to visit the surgery and by this time things had got considerably worse for me. Months had passed and I now had a new theory maybe I had a brain tumour and this was the reason why I was ill. I had swapped one fear for another, and it was only then the doctor decided to refer me to some one else. At last I thought my prayers had been answered, however, yet again it proved a very difficult road ahead.

How You Feel: 

How You Feel I was eventually referred to somebody who then referred me again to some one else and at this point I felt like the lost luggage you get at the airport, nobody knew quite what to do with me, this was quite unnerving for me.

What can we do to alter this?: 

What can we do to alter this? Work with people who are in the early stages of psychosis How early is early?

Birmingham: 

Birmingham

www.eppic.org.au/ : 

www.eppic.org.au/ Aims and Objectives: Early identification and treatment of primary symptoms of psychotic illness with correspondingly improved access and reduced delays in initial treatment. Reduction of frequency and severity of relapse and increase in time to first relapse. Reduction of burden for carers and promotion of well-being among family members. Reduction of secondary morbidity in the post psychotic phase of illness. Reduced disruption in social and vocational functioning, and in psychosocial development in the critical period of the early years following onset of illness when most disability tends to accrue.

Exercise: 

Exercise What do you think would be important factors associated with predicting someone is at risk of psychosis?

How do we predict psychosis?: 

How do we predict psychosis? Family history General population rates are 1:100 One parent with schizophrenia then 10:100 Both parents with schizophrenia then 45:100 However Only 11% of cases of schizophrenia will have a one or more parents with the same diagnosis, whilst 37% of all cases of schizophrenia will have neither a first or a second degree relative with the same diagnosis (Gottesman andamp; Erlenmeyer-Kimling 2001).

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Age of onset for schizophrenia 0 5 10 15 20 25 30 35 age 12-14 age 15-19 age 20-24 age 25-29 age 30 34 age 35-39 age 40-44 age 45-49 age 50 54 age 55-59 Percentage Females % Males %

Assessments for Identification: 

Assessments for Identification Brief Psychiatric Rating Scale (BPRS) Lukoff, Neuchterlein andamp; Ventura (1993) Positive And Negative Syndromes Scale (PANSS) Kay, Fiszbein andamp; Opler (1987) Comprehensive Assessment of At Risk Mental States (CAARMS) Pace clinic Yung et al 2002 Structure Interview for Prodromal Symptoms (SIPS) Scale of Prodromal Symptoms (SOPS) Prime clinic McGlashen, Miller, Woods, Rosen, Hoffman andamp; Davidson Bonn Scale for the Assessment of Basic Symptoms (BSABS) Klosterkoette, Schultze-Lutter

Prediction of PsychosisKlosterkotter et al.Arch Gen Psychiatry. 2001;58:158-164 : 

Prediction of Psychosis Klosterkotter et al.Arch Gen Psychiatry. 2001;58:158-164 N=110 Recruited from a specialist clinic Assessed using the BSABS Follow up over 9.6 years In this sample of nonpsychotic outpatients, of those who reported at least one prodromal symptom on the BSABS, 70% subsequently developed the psychosis

Prediction of psychosisYung et al. 1998: 

Prediction of psychosis Yung et al. 1998 Used the BPRS Age between 14 and 30 years AND Family history of DSM-IV psychotic disorder and reduction on GAF scale of  30, AND/OR Attenuated symptoms, occurring several times during the week for at least one week AND/OR Brief, limited or intermittent psychotic symptoms (BLIPS) for less than one week and resolving spontaneously

Prediction of PsychosisYung et al 1998 British Journal of Psychiatry: 

Prediction of Psychosis Yung et al 1998 British Journal of Psychiatry Months of assessment Number not psychotic 40% made transition at six months, 50% at one year

What prevention strategy?: 

What prevention strategy? Mrazek and Haggerty (1994) have discussed the idea of preventative interventions and identified three prevention strategies. These are: ·         Universal all of the population ·         Selective specific risk factors Indicated minimal, but detectable, signs of psychosis

Prevention of psychosisMcGorry et al 2002 Archives of General: 

Prevention of psychosis McGorry et al 2002 Archives of General N=58 Needs-based intervention. Patients assigned to this group received needs-based supportive psychotherapy primarily focusing on pertinent issues such as social relationships and vocational and family issues. Therapists also performed a case management role, providing assistance with accommodation, education or employment, and family education and support. Although patients in this group did not receive antipsychotic medication, they could receive antidepressants (sertraline hydrochloride) if moderate to severe depression was present or benzodiazepines for insomnia (usually temazepam).

Prevention of psychosisMcGorry et al 2002 Archives of General: 

Prevention of psychosis McGorry et al 2002 Archives of General Specific preventive intervention (SPI) involved all elements of NBI and 2 additional treatment components Hence, SPI, in common with NBI, aimed to treat features already manifest and, in addition, to reduce the risk of progression. The first additional component was administration of 1 to 2 mg of risperidone daily for 6 months, and the second was modified CBT. Risperidone therapy was commenced at 1 mg/d and increased to and held at 2 mg/d provided that no adverse effects were experienced. If adverse effects occurred, the dosage was reduced to 1 mg/d. Antidepressants or benzodiazepines were again used when appropriate.

Prevention of psychosisMcGorry et al 2002 Archives of General: 

Prevention of psychosis McGorry et al 2002 Archives of General Cognitive behavior therapy was conducted according to a manual developed by us. The overall aims were to develop an understanding of the symptoms experienced, to learn strategies to enhance control of these symptoms, and to reduce associated distress. These strategies were drawn from mainstream CBT for nonpsychotic disorders and, where appropriate, by adapting psychological techniques that are useful in more established psychotic disorders. The following modules were offered flexibly: Stress Management, Depression/Negative Symptoms, Positive Symptoms, and Other Comorbidity (including substance abuse, obsessive-compulsive features, and social anxiety).

Prevention of psychosisMcGorry et al 2002 Archives of General Psychiatry: 

Prevention of psychosis McGorry et al 2002 Archives of General Psychiatry Months % making transition to psychosis

PRIME Clinic: 

PRIME Clinic McGlashan TH, Miller TJ, Zipursky RB, et al. Intervention in the schizophrenic prodrome: the prevention through risk identification, management, and education initiative. Program and abstracts of the American Psychiatric Association 156th Annual Meeting; May 17-22, 2003; San Francisco, California. Abstract S39B. McGlashan TH, Zipursky RB, Perkins D, et al. The PRIME North America randomized double-blind clinical trial of olanzapine versus placebo in patients at risk of being prodromally symptomatic for psychosis. I. Study rationale and design. Schizophr Res. 2003;61:7-18. Miller TJ, Zipursky RB, Perkins D, et al. The PRIME North America randomized double-blind clinical trial of olanzapine versus placebo in patients at risk of being prodromally symptomatic for psychosis. II. Baseline characteristics of the 'prodromal' sample. Schizophr Res. 2003;61:19-30.

Prime Study: 

Prime Study A double-blind comparison of olanzapine with placebo Prodromal symptoms were measured by the SOPS N=60, and the median age was 16 years 65% males 93% of the patients had mild but definable psychotic symptoms (attenuated symptoms) The average GAF was 42. The dose of olanzapine included 5, 10, and 15 mg strengths. At 1 year, 15 of the 60 patients developed a full psychotic syndrome. Of the converters, 8 of 15 converted within the first month from baseline.

Transition Rates: 

Transition Rates Difference is not Statistically significant

EDDIEA single blind randomised controlled trial: 

EDDIE A single blind randomised controlled trial To identify indicators of risk that accurately predict transition to psychosis To examine the effectiveness of a cognitive therapy intervention in reducing the transition rate in at-risk individuals To determine the effectiveness of a monitoring intervention in reducing the duration of untreated illness and psychosis should transition occur

Eddie Entry Criteria: 

Eddie Entry Criteria Aged 16-36 Attenuated Symptoms - low-level hallucinations or unusual ideas BLIPS - ‘clinical’ psychotic experiences that resolve within a week Family history plus deterioration / caseness Schizotypal PD plus deterioration / caseness

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Primary Care Guidelines for Identification of First Episode Psychosis Adapted from Launer andamp; MacKean (2000) 12.4.02 12.4.02 EDIT IMPACT CMHT Crisis Team If immediate risk Sub-threshold/uncertain diagnosis Clearly first episode psychosis

Study Criteria: 

Study Criteria BLIPS (rating on PANSS) Those clients scoring 4+ on hallucinations 4+ on delusions 5+ on suspiciousness These symptoms should be present for less than 1 week prior to spontaneous resolution ATTENUATED SYMPTOMS (rating on PANSS) Those clients scoring 2 or 3 on hallucinations 3 on delusions 3-4 on suspiciousness 3-4 on conceptual disorganisation These symptoms should occur with a frequency of several times per week and change in mental state present for 1 week

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Early Detection: Problems Ethics of interventions in pre-psychotic phase Solution employ interventions with minimal risks / side effects employ interventions that will be useful to those who will never become psychotic informed choice

Bentall, R.P. & Morrison, A.P. (2002) More harm than good: The case against using antipsychotic drugs to prevent severe mental illness. Journal of Mental Health, 11, 351-356.: 

Bentall, R.P. andamp; Morrison, A.P. (2002) More harm than good: The case against using antipsychotic drugs to prevent severe mental illness. Journal of Mental Health, 11, 351-356. Psychosis is not necessarily dreadful Prediction not very accurate (e.g. 60% false positives) Side effects of medication (and can be fatal) atypicals commonly produce weight gain and sexual dysfunction; diabetes; cardiovascular problems Effects of medication on developing brain unknown

Early Detection and PreventionMorrison, A.P. et al. (2002) British Journal of Psychiatry, 181, supp 43, 78-84.: 

Early Detection and Prevention Morrison, A.P. et al. (2002) British Journal of Psychiatry, 181, supp 43, 78-84. Effective for psychotic symptoms (AS) Effective for relapse prevention (BLIPS) Effective for mood disorders very frequent in prodrome (Birchwood, 1996) Problem list and goals useful for other difficulties

A Cognitive Model of Psychotic Symptoms: 

A Cognitive Model of Psychotic Symptoms

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Client assessed by team Randomisation Monitoring and Psychological Intervention 26 sessions of CBT Monitoring 12 monthly monitoring sessions Referrals to the team If becomes psychotic refer as appropriate If becomes psychotic refer as appropriate Back to referrer Back to referrer Suitable Back to referrer or other appropriate services Not suitable Study Design

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Referred for assessment (n=134)   Did not attend (n=14) Refused participation (n=14)    Assessed for eligibility (n=106)   Excluded (n=46) Not meeting inclusion criteria (n=27) Refused to participate (n=3) Untreated first episode of psychosis (n=12) Receiving antipsychotic medication (n=4)   Randomised (n=60) Allocated to CT (n=37) Allocated to Monitoring (n=23) Received CT (n=37) Received Monitoring (n=23)     Lost to follow-up (n=4) Lost to follow-up (n=4) 3 moved out of area 2 moved out of area Dropped out of CT (n=3) Discontinued monitoring (n=3) Would not engage (n=2)   Analysed (n=35) Analysed (n=23) Excluded from analysis (n=2) Both reported having been psychotic at baseline assessment

Referral Sources / Pathways: 

Referral Sources / Pathways Secondary care services 48 Primary Care Psychological Therapy Teams 29 General Practitioners 15 University and College Counsellors 14 Accident and Emergency Departments 10 Youth Services 7 Hostels 3 Social Services 3 Others 5

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0 5 10 15 20 25 30 35 Accident andamp; Emerg'y Youth Services Secondary Care General Practitionerss Psychology Services Social Services Hostel workers Uni/ College Counsellors Misc/ Other Suitability and transition by referral source Referrals Suitability Transition

Breakdown of population: 

Breakdown of population Total n= 58 Female 18 (30%) Male 40 (70%) Attenuated 48 (80%) BLIPS 6 (10%) Family 6 (10%)

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EDDIE A single blind randomised controlled trial Cognitive Therapy vs. Treatment As Usual Preliminary Results from 12 months Follow-up n=2 n=5 n=7 n=2 Transition criteria Transition rate in % per group n=2 n=6

Predictors of transition: 

Predictors of transition PANSS-defined transition: cognitive therapy (B = -3.13; SE = 1.42; p = 0.028; Exp(B) = 0.04) baseline PANSS positive score (B = 0.41; SE = 0.20; p = 0.039; Exp(B) = 1.50) NNT to prevent PANSS-defined transition is 6.

Predictors of transition: 

Predictors of transition Prescription of antipsychotic medication CT (B = -2.86; SE = 1.17; p = 0.014; Exp(B) = 0.06) NNT for preventing prescription of antipsychotic medication is 5 DSM-IV diagnosis CT (B = -3.33; SE = 1.42; p = 0.019; Exp(B) = 0.04). NNT for preventing someone from meeting DSM-IV criteria for a psychotic disorder is 5

Our Approach: 

Our Approach To increase awareness in primary care services, secondary care services, voluntary sector, further education and the community Increase referrals through 1. Training for potential referrers 2. Rapid response 3. Flexible approach to client 4. Positive, user friendly service

Intervention - Process: 

Intervention - Process Develop therapeutic relationship Assessment Establish shared problem list Translate into ‘smart’ goals Formulation Interventions derived from formulation Relapse prevention

Engagement: 

Engagement Collaborative, shared goals, prioritised goals, SMART goals Early success Different rationales for each entry route Flexibility re: venue, time, methods Socialise with model, focus on distress Language

Problems...: 

Problems... 'I am unhappy with where I live.' 'I feel anxious when I leave the house.' 'I want to find my real mother.' 'I worry about people laughing at me when I go out.' 'I need to get a job.' 'I want more money.' 'My sister is nasty to me.' 'I want to stop it happening to me again.' 'I want to know what is wrong with me.' 'I feel depressed.' 'I feel anxious.' 'I need a girlfriend.'

... and goals: 

... and goals To find out what alternative accommodation is available and send letters or contact by phone the various housing agencies in order to get on their waiting lists. When I go out, I would like to be able to distinguish with more certainty if people are laughing at me or whether I just feel this is the case (and preferably reduce distress from 60% to 30%). To begin to understand if what I am experiencing is the start of schizophrenia. If I felt less anxious I would like to be able to leave the house and go to the local shops when I felt like it (and at least three times a week). I would like to have at least two people that I can discuss my feelings with

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Common Themes loneliness activity scheduling social anxiety lack of confidant I’m different identity trauma sealing over --andgt; integration for BLIPS stress (including work-related) sleep drugs

Framework of therapy: 

Framework of therapy Cognitive therapy main intervention However it can be helpful to interweave alternative interventions Use of case management skills such as assistance with housing, bills, negotiations with college/employer/neighbours. Crisis intervention skills at times such as becoming homeless, traumatic events etc. Encourage strategies to manage these crises.

Intervention strategies: 

Intervention strategies Formulation Normalisation Working with metacognitive beliefs Generating possibilities for intrusions Safety behaviours Selective attention Activity scheduling Relapse prevention

Formulation: 

Formulation The formulation using the intrusions model (Morrison 2001) is developed within sessions 1 andamp; 2. The aim is to move from general abstract concerns the person may have to more specific ways of understanding them. One aim of this process is also to highlight occaissions when their interpretations do not lead to distress.

Normalisation: 

Normalisation This uses the existing body of work from Kingdon and Turkington (1994). Their strategy allows distress associated with symptoms to be managed by normalising the experience. In our strategy we use the same approach but more in line with the intrusions model we utilise a paper by Rachman and Silva discussing intrusive thoughts.

Working at a metacognitive level: 

Working at a metacognitive level This model of psychosis described directs treatment towards working with metacognition. Negative beliefs regarding the appraisal of the voices as being dangerous or uncontrollable may give rise to transition to psychosis.

Generating possibilities for intrusions: 

Generating possibilities for intrusions As with clients who have established psychotic symptoms generating possibilities for the psychostic experience can be extremely helpful in terms of assessment and also treatment. The development of an exhaustive list is essential,with belief ratings, and emotions generated associated with this belief. Subsequently, work through each possibility generating evidence for and against each.

Safety behaviours: 

Safety behaviours Safety behaviours in the maintainance of anxiety disorders have been extensively reviewed. The model of psychosis presented emphasises the idea of self and social knowledge. Safety behaviours perpetuate faulty self and social knowledge. A full exploration of safety behaviours should be undertaken and these should be highlighted and experiments undertaken to test their utility for the client.

Selective attention: 

Selective attention This has been strongly implicated in our experience of working with this client group. Many clients have discussed this as a means of confirming their experiences in conjunction with safety behaviours as indicating they are at risk of impending psychosis.

Activity scheduling: 

Activity scheduling Frequently people are begining to isolate themselves, reducing the frequency and duration of contacts they have with people and this leads into further preoccupation with thoughts. The use of activity scheduling can be a valuable means of monitoring and impacting upon activity levels.

Relapse prevention: 

Relapse prevention Familiar cognitive interventions developing blueprint of therapy. This should be provided in a medium which is ameanable to the person eg written or audio tape. However, one block to this is that people have been extremely reluctant to have material at home in case others come accross it.

Interventions: 

Interventions Engagement, assessment, formulation and normalising information Some people she discussed things with endorsed her ideas others did not Evaluate reasons for these experiences

Conclusions: 

Conclusions Long duration of untreated psychosis (DUP) DUP associated with poor treatment response DUP can be altered People are help seeking in the early stages What services would we want for relatives in this age group?

Conclusions: 

Conclusions CT appears to prevent progression to psychosis in people at high risk, as defined using: PANSS Prescription of medication DSM-IV Diagnoses CT reduces positive symptomatology

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Paul French Salford Psychology Services Bolton Salford andamp; Trafford Mental Health Partnership Bury New Road Prestwich M25 3BL Telephone 0161 772 3479 Email [email protected] Early Detection and Intervention in Psychosis Team