Paul French

1
Paul French

• Psychology Services of Salford
• Bolton Salford Trafford Mental Health Trust
• Department of Psychology
• Manchester University
• Rationale for Early Interventions in Psychosis

Early Detection and Intervention Team
2

• 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

3
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

4
Why Early Intervention?

• Emil Kraepelin (1856-1926)Discovered
  schizophrenia and manic depression.
• Degenerative brain disorder.
• Current research interest

5
Stress vulnerability
Stress
Vulnerability
6
Prognosis (roughly speaking)
7
An early intervention serviceshould 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

8
An early intervention serviceshould 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

9

• 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

10
Duration of Untreated Psychosis
Duration of untreated Psychosis and
Duration of untreated illness
500
DUP
450
DUI
400
350
300
Weeks
250
200
150
100
50
0
Loebel et al 1992
Beiser et al 1993
Hafner et al 1993
McGorry et al 1996
Drake et al 2000
Studies
11
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?

12
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)

13
Consequences of delayed treatment (contd)

• Disruption of study, employment and unemployment
• Substance abuse
• Violence/criminal activities
• Unnecessary hospitalisation
• Loss of self esteem and confidence
• Increased cost of management

14
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
15
http//www.rethink.org/at-ease/
_at_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.
16
Northwick Park StudyJohnstone et al 1986

• Study of first episode schizophrenia
• n253
• 28 admitted within 2 months
• 25 admitted between 2-6 months
• 9 admitted 6-12 months
• 26 admitted after more than 1 year

17
Northwick Park StudyJohnstone 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

18
Northwick Park StudyJohnstone et al 1986

• A subsample n120 was included in an RCT to test
  antipsychotic medication against placebo.
• They found that DUP was a stronger predictor of
  relapse than antipsychotic medication.

19
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.

20
Case Material

• I remember when I had my first episode I was
  about 21 at the time. I didnt have a care in the
  world, I had my own house and a long term
  relationship, and things couldnt 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, its 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 didnt at
  the time.

21
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?

22
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.

23
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.

24
What can we do to alter this?

• Work with people who are in the early stages of
  psychosis
• How early is early?

25
Birmingham
26
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.

27
Exercise

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

28
How do we predict psychosis?

• Family history
• General population rates are 1100
• One parent with schizophrenia then 10100
• Both parents with schizophrenia then 45100

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 Erlenmeyer-Kimling 2001).
29
Age of onset for schizophrenia
Females
Males
35
30
25
20
Percentage
15
10
5
0
age
age
age
age
age 30
age
age
age
age 50
age
12-14
15-19
20-24
25-29
34
35-39
40-44
45-49
54
55-59
30
Assessments for Identification

• Brief Psychiatric Rating Scale (BPRS) Lukoff,
  Neuchterlein Ventura (1993)
• Positive And Negative Syndromes Scale (PANSS)
  Kay, Fiszbein 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
  Davidson
• Bonn Scale for the Assessment of Basic Symptoms
  (BSABS) Klosterkoette, Schultze-Lutter

31
Prediction of PsychosisKlosterkotter et al.Arch
Gen Psychiatry. 200158158-164

• N110
• 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

32
Prediction of psychosisYung 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

33
Prediction of PsychosisYung et al 1998 British
Journal of Psychiatry
40 made transition at six months, 50 at one
year
Number not psychotic
Months of assessment
34
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

35
Prevention of psychosisMcGorry et al 2002
Archives of General

• N58
• 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).

36
Prevention of psychosisMcGorry 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.

37
Prevention of psychosisMcGorry 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).

38
Prevention of psychosisMcGorry et al 2002
Archives of General Psychiatry
making transition to psychosis
Months
39
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. 2003617-18.
• 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.
  20036119-30.

40
Prime Study

• A double-blind comparison of olanzapine with
  placebo
• Prodromal symptoms were measured by the SOPS
• N60, 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.

41
Transition Rates
Difference is not Statistically significant
42
EDDIEA 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

43
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

44
Primary Care Guidelines for Identification of
First Episode Psychosis Adapted from Launer
MacKean (2000)
12.4.02
12.4.02
EDIT
Sub-threshold/uncertain diagnosis
IMPACT
Clearly first episode psychosis
CMHT
If immediate risk
Crisis Team
45
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

46
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

47
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.

• 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

48
Early Detection and PreventionMorrison, 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

49
A Cognitive Model of Psychotic Symptoms
50
Referrals to the team
Study Design
Not suitable
Back to referrer or other appropriate services
Client assessed by team
Suitable
Randomisation
Monitoring and Psychological Intervention 26
sessions of CBT
Monitoring 12 monthly monitoring sessions
If becomes psychotic refer as appropriate
Back to referrer
Back to referrer
If becomes psychotic refer as appropriate
51
Referred for assessment (n134)   Did not
attend (n14) Refused participation
(n14)    Assessed for eligibility
(n106)   Excluded (n46) Not meeting inclusion
criteria (n27) Refused to participate
(n3) Untreated first episode of psychosis
(n12) Receiving antipsychotic medication
(n4)   Randomised (n60) Allocated to CT
(n37) Allocated to Monitoring (n23) Received
CT (n37) Received Monitoring (n23)     Lost
to follow-up (n4) Lost to follow-up
(n4) 3 moved out of area 2 moved
out of area Dropped out of CT (n3)
Discontinued monitoring (n3) Would not engage
(n2)   Analysed (n35) Analysed
(n23) Excluded from analysis (n2) Both
reported having been psychotic at baseline
assessment
52
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
53
Suitability and transition by referral source
35
Referrals
30
Suitability
25
Transition
20
15
10
5
0
Hostel
workers
Social
Services
Youth
Services
Accident
Secondary
Emerg'y
Care
Psychology
Services
Misc/ Other
Uni/ College
Counsellors
General
Practitionerss
54
Breakdown of population
Total n 58 Female 18 (30) Male 40
(70) Attenuated 48 (80) BLIPS 6 (10) Family 6
(10)
55
EDDIE A single blind randomised controlled trial
Cognitive Therapy vs. Treatment As
Usual Preliminary Results from 12 months Follow-up
Transition rate in per group
n7
n6
n5
n2
n2
n2
Transition criteria
56
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.

57
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

58
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

59
Intervention - Process

• Develop therapeutic relationship
• Assessment
• Establish shared problem list
• Translate into smart goals
• Formulation
• Interventions derived from formulation
• Relapse prevention

60
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

61
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.

62
... 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

63
Common Themes

• loneliness
• activity scheduling
• social anxiety
• lack of confidant
• Im different
• identity
• trauma
• sealing over --gt integration for BLIPS
• stress (including work-related)
• sleep
• drugs

64
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.

65
Intervention strategies

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

66
Formulation

• The formulation using the intrusions model
  (Morrison 2001) is developed within sessions 1
  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.

67
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.

68
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.

69
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.

70
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.

71
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.

72
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.

73
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.

74
Interventions

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

75
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?

76
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

77
Early Detection and Intervention in Psychosis
Team

• Paul French
• Salford Psychology Services
• Bolton Salford Trafford Mental Health
  Partnership
• Bury New Road
• Prestwich
• M25 3BL
• Telephone [phone]
• Email pfrench_at_psychology.bstmht.nhs.uk