Preventing the First Episode of Psychosis

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Preventing the First Episode of Psychosis

• William R. McFarlane, M.D., Director,
• National Program Office
• Early Detection, Intervention and Prevention of
  Psychosis Program
• Robert Wood Johnson Foundation
• Maine Medical Center Research Institute
• Portland, Maine
• Tufts University School of Medicine

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Early detection and prevention in another illness

• If you catch cancer at Stage 1 or 2, almost
  everybody lives. If you catch it at Stage 3 or
  4, almost everybody dies.
• We know from cervical cancer that by screening
  you can reduce cancer up to 70 percent.
• ---Lee Hartwell, MD
• Nobel Laureate, Medicine
• President and Director,
• Hutchinson Center
• New York Times Magazine
• December 4, 2005, p. 56

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2-3

• Proportion of youth who develop schizophrenia or
  a severe, psychotic mood disorder

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75

• Proportion of people who have one psychotic
  episode and schizophrenia and then develop
  disability

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12-15

• Proportion of people with schizophrenia or a
  psychotic mood disorder who commit suicide

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61 billion

• Annual U.S. costs for schizophrenia

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Functioning as an effect of number of psychotic
episodes
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Portland Identification and Early Referral
(PIER)
Reducing the incidence of major psychotic
disorders in a defined population, by early
detection and treatment
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Professional and public education

• Reducing stigma
• Increasing understanding of early stages of
  mental illness and prodromal symptoms
• How to get consultation, specialized assessments
  and treatment quickly

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Family practitioners
Mental health clinicians
College health services
Pediatricians
Military bases and recruiters
EDIPPP Team
School teachers, guidance counselors, nurses,
social workers
Clergy
Emergency and crisis services
Advertising
Employers
General Public
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Family-aided Assertive Community Treatment (FACT)

• In-depth assessment of symptoms of risk
• Rapid initiation of treatment
• Psychoeducational multifamily groups
• Supported employment and education
• Key intensive case management methods

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Early Detection and Intervention for the
Prevention of Psychosis (EDIPPP) A national
multisite effectiveness trial
Reducing the incidence of major psychotic
disorders in a defined population, by early
detection and treatment
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Early Detection and Intervention for the
Prevention of Psychosis

• Effectiveness Test at six sites
• Portland, Maine
• Glen Oaks and Queens, New York
• Ann Arbor, Michigan
• Salem, Oregon
• Sacramento, California
• Albuquerque, New Mexico
• Large, nationally representative sample
• PIER community outreach and identification
  systems
• Sponsored by RWJF 17 million

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Outcomes
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Early identification across cities
SITE Population Age-corrected rate, at 25/100,000 Years of community outreach
Maine 323,105 63 8
Michigan 344,791 37
Oregon 631,853 29 2.5
California 466,488 26
New York 557,725 17 1.5
New Mexico 662,564 12 1.5
Total 2,986,526 27
Rate for Nottingham, U.K., in Kirkbride, et al.,
Arch Gen Psychiatry. 200663250-258
Proportion (69.2) of ages 12-35 population
represented by ages 12-25 population
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Rates of psychosis and negative eventsOver 24
months
Low-risk High-risk
Severe Psychosis 2.3 6.3

Negative Events 22 25
Hospitalizations, incarcerations, suicide
attempts, assaults, rape
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In school or workingBaseline and 24 months
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First hospitalizations for psychosisMaine Urban
controls areas vs. Greater Portland
plt0.0001
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Savings for First Hospital Admissions for
PsychosisGreater Portland vs. Urban
Maine1999-2000 vs. 2001-2007
Difference in incidence 1999-2000 vs 2001-2007 Portland population Average 2001-2007 Cases prevented Mean LOS, days Bed Day Rate Annual savings, Greater Portland Annual per capita savings, 2001-2007
15.9 per 100,000 population 330,000 52 11 900 519,453 1.57
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Early intervention is preventionOne year rates
for conversion to psychosis
Risk reduction 66
23.0

Fusar-Poli, et al, JAMA Psychiatry, 2013
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Outcomes in First Four California PIER Programs
N 125 Baseline 12 Month
Working 15 49
In school 57 56
Onset of Psychosis 21 3
Hospitalizations 13 7
Suicide attempts 8 2
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Conclusions

• Community-wide education is feasible.
• Referral of 30 up to 60 of the at-risk
  population.
• Global outcome in FACT was better than regular
  treatment.
• The rate psychosis onset is less than 1/4 of
  expected.
• Average functioning was in the normal range by 24
  months.
• Five cities show a declining incidence.
• Programs in California are showing same results.
• ¾ were in school or working up to 10 years later.
  

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Conclusion

• As in successes for prevention in cancer and
  cardiovascular disease, early identification and
  intervention for psychosis give us enormous
  opportunities to reduce the total burden of
  disease in the United States.

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For further information
www.PIERTrainingInstitute.org PTI_at_maine.rr.com