iepa clinical practice guidelines for arms shôn lewis university of manchester uk
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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
Distress Help seeking
Need for treatment
High risk
Isolated pic symptom
Early prodromal
ARMS (late prodromal)
1st episode psychosis
Constructs
↑ risk of psychosis
Psychotic symptom
Distress Help seeking
Need for treatment
High risk
Isolated pic symptom
Early prodromal
ARMS (late prodromal)
1st episode psychosis
Constructs
↑ risk of psychosis
Psychotic symptom
Distress Help seeking
Need for treatment
High risk
Isolated pic symptom
Early prodromal
ARMS (late prodromal)
1st episode psychosis
Constructs
↑ risk of psychosis
Psychotic symptom
Distress Help seeking
Need for treatment
High risk
Isolated pic symptom
Early prodromal
ARMS (late prodromal)
1st episode psychosis
Constructs
↑ risk of psychosis
Psychotic symptom
Distress Help seeking
Need for treatment
High risk
Isolated pic symptom
Early prodromal
ARMS (late prodromal)
1st episode psychosis
Constructs
↑ risk of psychosis
Psychotic symptom
Distress Help seeking
Need for treatment
High risk
Isolated pic 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)
Centre Transition rate
PACE 41%
PRIME 38%
TOPP 43%
EDIE 26%
PIER 23%
IEPA clinical guidelines for early psychosis
• Formulated Copenhagen 2002• 29 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 2005 187 s48 s120-124
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 2005 187 s48 s120-124
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 2005 187 s48 s120-124
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 2005 187 s48 s120-124
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 2005 187 s48 s120-124
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 2005 187 s48 s120-124
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 2005 187 s48 s120-124
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 2005 187 s48 s120-124
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: ResultsTransitions to psychosis at 12 months
0
5
10
15
20
25
30
PANSS Medication Diagnosis
control
CBT
Morrison et al, 2004