Early Intervention in Schizophrenia

Faculty Research SeriesJanuary 16, 2013

Professor Alison YungInstitute of Brain Behaviour and Mental Health

• Our land abounds in nature’s gifts• Of beauty rich and rare

Land of inventions

Early intervention in psychotic disorders such as schizophrenia

Pioneered by Pat McGorry in Melbourne

Early Intervention in Schizophrenia

• Rationale• Strategies• Challenges

EI in Schizophrenia: Rationale

• Perceptions of schizophrenia

Wikipedia - schizophrenia

• is a mental disorder characterized by a breakdown of thought processes and poor emotional responsiveness.

• Common symptoms include auditory hallucinations, paranoid or bizarre delusions or disorganised speech and thinking

• Accompanied by significant social or occupational dysfunction

Tuscon, Arizona, 2011

Clinicians’ illusion

• Health professionals do their psychiatric training in large psychiatric hospitals

• Majority of patients seen have chronic schizophrenia and/or acute exacerbations

• Impression that this is schizophrenia

But in the beginning..

Functional deterioration

• How does schizophrenia develop?• What causes deterioration?• Can deterioration be prevented?

Early intervention - rationale

The development of disability and deterioration in functioning often seen in patients with schizophrenia usually occurs early in the course of illness,

during the first few years after onset of the first psychotic episode.

functioning

age15 - 25

critical period

• “The critical period” – a target for intervention with the aim of preventing or minimising disability.

Causes of early deterioration

• Biological• Social• Psychological

Biological causes of early deterioration

• Structural and functional brain changes occurring peri-onset eg grey matter loss in frontal and temporal regions

• Some may be reversible

Other possible biological causes of deterioration

• Substance use• Side effects of medication• Disuse atrophy

Psychological causes of early deterioration

• Depression• Demoralisation• Anxiety, fear of relapse• Self-stigmatisation• Loss of identity, hopes and dreams• Post Traumatic Stress Disorder

Social causes of early deterioration

• Disruption or loss of peer and family networks

• Educational and occupational disruption• Interference with normal development• Homelessness• Stigma

Strategies

• Can early intervention prevent deterioration?

sys

time

Prodrome

First episodepsychosis

Acutetreatment

DUP

Recovery

sys

time

Prodrome

First episodepsychosis

Acutetreatment

DUP

Recovery

Focus 1: reducing the duration of untreated psychosis (DUP)

Focus 1: reducing the duration of untreated psychosis (DUP)

• DUP appears to be both a marker and independent risk factor for poor outcome

• Reviews: Marshall et al. 2005; Perkins et al. 2005

• Also confirmed in low and middle income countries (Farooq et al., 2009)

EvidenceBottlender et al 2003• Longer DUP was associated with higher

negative, positive and general symptoms and lower global functioning 15 years after the first psychiatric admission

• “Psychosis damages lives” (Lieberman and Fenton, 2000)

• There is now evidence that:• 1. It is possible to reduce DUP via a

vigorous and sustained public campaign• 2. reducing DUP improves outcome

Reducing duration of untreated psychosis

Increase recognition of psychosis and help-seeking

Making mental health services accessible

Making mental health services accessible

• Friendly to young people• Low stigma• Willing to do home assessments• Flexible eg making allowance for late

comers, after hours appointments

Reducing DUP - TIPS

• The Early Treatment and Identification of Psychosis (TIPS) study in Scandinavia - Community awareness program and early detection system.

• Targeted the general public, schools, primary care

• Accessible service• Johanessen, McGlashan, Vaglum, Larsen Melle et al

Reducing DUP improves outcome• Lower negative, depressive and

cognitive symptoms at 5 year follow-up• Reduced suicidal behaviour (Melle et al

2009)• Greater social engagement and

reduced hospitalisation (Larsen et al 2007)

Reducing DUP improves outcome – persists at 10 yr follow up

• Higher rates of remission and recovery (30.7% vs. 13.9% ( p=.01))

• More patients with full-time employment

sys

time

Prodrome

First episodepsychosis

Acutetreatment

DUP

Recovery

Non-specific sys

1 2 3 4

sys

time

Prodrome

First episodepsychosis

Acutetreatment

DUP

Recovery

Non-specific sys

1 2 3 4

Focus 2: management of first episode psychosis

Focus 1: management of first episode psychosis

• Acute phase• Recovery phase

Early intervention services

• Elements: • Focus on young people• Start low go slow antipsychotic use• Biopsychosocial approach• Family involvement• Focus on recovery

Evidence

• The first early psychosis centre, EPPIC, assessed outcomes in comparison to a historical control group. The EPPIC group had less severe psychotic symptoms, and higher levels of global functioning compared to the pre-EPPIC group.

• These differences were sustained even at 6 year follow up (Mihalopoulos et al 2009).

Early Intervention services

• Two service level RCTs - London and Denmark - have demonstrated advantages of early intervention

• (Craig et al., 2004, Garety et al., 2006, Petersen et al., 2005)

Early Intervention services

• Danish OPUS trial [Bertelsen et al 2008] found that those accessing EI services at 2 year follow up had:

• greater rates of independent living• reduced homelessness, • improved psychotic symptoms, • lower levels of substance abuse• better global functioning

Early Intervention services

• The LEO (Lambeth Early Onset) trial [Craig et al 2004] found that individuals treated by a specialist service had lower hospital bed use at 18 months than those receiving care as usual.

Some gains not sustained

However• Evidence that deterioration eg in

admission rates, symptoms, suicidality, occurs after withdrawal of EI service

• Although rates of independent living and days in hospital still superior at 5 yrs

• (Bertelsen et al., 2008).

• Perhaps EI service not provided for long enough

5 year EI service

• Recent study of a 5 year EI service found that symptoms and functioning continued to improve

• Norman et al 2011

Specific elements of EI services

• Psychological therapies including cognitive therapy

• Psychoeducation• Family psychoeducation and

intervention• Focus on recovery – individual and

group work eg social skills, outdoor education

• Vocational interventions

Vocational interventions

• Employment is the number one goal of first episode psychosis patients

• 49% nominated employment as a goal 33% nominated health and stability as a goal

Individual Placement Support

• Competitive employment • The IPS program is integrated with the

mental health treatment team, rather than constituting a separate vocational rehabilitation service

• 69% who received an intervention had a positive outcome compared with 35% in control groups•Outcomes sustained up to 18 months in RCT and 24 months in clinical practice

Overall outcomes – vocational intervention

•[A job] gives your day structure. You have to get up in the morning. If you’re unemployed you don’t have structure. I’d be more likely to still be getting high if I was unemployed, but I’ve stopped. Getting a job was the most important part of my recovery.

• A client in our program

A specific outcome

Unanswered questions• For how long should EI services

manage patients? eg compare 5 years with 2 years

• How can non-responders be identified early and what is the best treatment for them?

• What are the key elements in an EI service?

• Can some patients be managed without antipsychotics?

sys

time

Prodrome

First episodepsychosis

Acutetreatment

DUP

Recovery

Can we intervene even earlier?

Focus 3: the prodromal phase

• Intervention in the prodromal phase may ameliorate, delay, or even prevent onset of fully-fledged disorder.

Challenges

• Adoption of Early Intervention• Many Early Intervention services now

worldwide

Main country to adopt the Early Intervention model….

Adoption of Early Intervention• EI model endorsed in the UK (

www.nice.org.uk)• EI services rolled out across England

beginning 2002

Challenges

• Current austerity measures threatening stand alone early intervention services

Schizophrenia Commission Report November 2012

Independent commission established in November 2011 to review how outcomes in schizophrenia could be improved.Chaired by Professor Sir Robin Murray

Schizophrenia Commission Report November 2012

• “Sadly, the great innovation of the last 10 years, which everyone says works well – the early intervention in psychosis services – are currently being cut.”

Schizophrenia Commission Report recommendations included:

Challenges

• To ensure survival of EI services• Ongoing research to bridge evidence

gaps • Identify those who do not respond to

early intervention• Explore novel treatments• Ensure existing evidence based

treatments are applied

Manchester has a lot to offer

• Early psychosis a strength of the University of Manchester – linking clinical NHS services with research

• Tony Morrison, Shon Lewis, Max Marshall, Paul French, Gillian Haddock, Christine Barrowclough, Nusrat Hussein, Imran Chaudry, Sandra Bucci

The end - thanks!