P&B Lecture 1 PDF

Week 1 - 4th Oct Created @August 10, 2024 10:00 AM Tags Early Interventions in Psychosis & Psychosocial Interventions for Psychosis and Bipolar: Reading list: PSBS0005: Current Research in Psychosis and Bipolar | Unive...

Week 1 - 4th Oct Created @August 10, 2024 10:00 AM Tags Early Interventions in Psychosis & Psychosocial Interventions for Psychosis and Bipolar: Reading list: PSBS0005: Current Research in Psychosis and Bipolar | University College London (talis.com) Location: IOE Bedford Way (20) - 102 Drama Studio Class Prep: Additional: Read: Reducing the Duration of Untreated Psychosis (DUP) in a US Community: A Quasi-Experimental Trial Read: Preventative Interventions for Individuals at Ultra High Risk for Psychosis: An Updated and Extended Meta-Analysis Read: Comparison of Early Intervention Services vs Treatment as Usual for Early- Phase Psychosis Early Intervention in Psychosis: Concepts Evidence and Future Directions At-Risk Mental State for Psychosis: Identification and Current Treatment Approaches Read: Preventative Treatments for Psychosis: Umbrella Review (Just the Evidence) Read: Can We Reduce the Duration of Untreated Psychosis? A Systematic Review and Meta-Analysis of Controlled Interventional Studies Week 1 - 4th Oct 1  Optional - Read: Reducing the Duration of Untreated Psychosis and its Impact in the U.S.: The STEP-ED Study Optional - Cost-Effectiveness of Early Intervention in Psychosis: Systematic Review Pre: Early Detection and at Risk Mental States LO: To understand the purpose and evidence base of two out of three approaches to improving prognosis around the onset of psychosis: Early detection of psychotic symptoms – trying to shorten duration of untreated psychosis among people who already meet criteria for psychosis Interventions for ‘at risk states’/prodrome (ARMS)– trying to prevent the onset of frank psychosis in people at high risk Psychosis: The Early Course Early Detection Initiatives Early detection initiatives aim to reduce duration of untreated psychosis (DUP: typically 1-2 years without EIS) by engaging people earlier with effective treatment. Purpose: To improve prognosis, especially treatment-resistant positive symptoms, negative symptoms, social functioning, which are more frequent with high DUP To alleviate the distress of people with psychosis and those close to them To reduce the risk of adverse incidents before effective treatment Week 1 - 4th Oct 2  To reduce entry to services in crisis via coercive routes Potential Routes The TIPS Study - impact of an extensive early detection programme in Norway Melle et al. (2004) Archives of General Psychiatry 61:143-150. Extensive early detection programme in Rogaland, Norway (mixed region of towns and countryside, socially cohesive) Advertising, local radio, newspapers, cinemas, education in schools and colleges, primary care, helpline available, leaflets to homes. Comparison of areas with and without early detection (ED): Rogaland vs. two areas without ED: Median DUP: 5 weeks with ED,16 weeks without early detection (statistically significant) Symptoms at first contact: more severe without early detection Symptoms at 3 months: more severe (esp, negative, general psychopathology) without ED, less difference than at first contact. At 2 years – differences still found in negative, cognitive, depressive symptoms At 10 years – better social functioning. Week 1 - 4th Oct 3  61% hospitalised at first contact with ED, 70% without (not quite significant) Early Detection and Reducing DUP - the evidence Initiatives that did not reduce DUP Initiatives that reduced DUP ECIP (Ontario) –Community-wide TIPS (Norway) - Extensive education – DUP increased! community education LEO-CAT (London)– education EPIP (Singapore) – campaign and rapid access to EIS for GPs. targeting general public ReDIRECT (Birmingham) – Mindmap (Yale) – public education for GPs education (media, social media, OPUS case detection (Denmark) merchandise etc), engagement with – GP education, adverts in health schools, primary care. journals Camden and Islington early detection programme – community organisations, colleges universities (Lloyd-Evans et al. 2015) Overall: Evidence tipping towards extensive initiatives with public information. Often methodologically complex studies. Impediments to Early Detection Vagueness of early symptoms Seen only rarely in most settings Some of symptoms difficult to distinguish from other significant mental health problems Stigma – high threshold for referral to mental health services People with psychosis withdraw and lose touch Reluctance to refer without consent Reluctance to receive referrals from families Week 1 - 4th Oct 4  Where next with Early Detection? Relatively little implementation/replication of successful approaches General public/family and friends appear most plausible target Social media and internet tested only in recent studies e.g. MindMAP Schools as a channel for early detection so far mostly untested Broader youth mental health approach may be more successful The Prodrome and ‘at risk mental states’ (ARMS) Prodrome: forerunner of illness – phase of gradual deterioration Defined as time from first change being observed to first psychotic symptom Most often used in context of schizophrenia Fuzzy definition – often very subjective and retrospective reporting Wide variety of symptoms identified early in prodromal phase, including disturbance of mood, cognition, sleep. At Risk Mental States (ARMS) Three groups: 1. Family history plus decline in functioning - First degree relative who’s had psychosis are at considerable risk 2. Sub-threshold positive symptoms: Unusual thought content, including persecutory or grandiose ideas, ideas of reference – not delusional conviction. Perceptual disturbance e.g. distortions, illusions, feeling overwhelmed by sensations, not being sure what is real and what isn’t. Disorganised speech, subjective and objective problems communicating 3. BLIPS (Brief Limited Intermittent Psychotic Symptoms)– symptoms at threshold for psychosis, remitting spontaneously after less than a week. Week 1 - 4th Oct 5  2 + 3: Seen as significant when accompanied by drop in functioning/sustained poor functioning - Yung et al. 1996 Distress and Disturbance of Functioning in the Prodrome Although frank psychotic symptoms not present, distress and impairment of functioning often already quite severe About 25% have ideas regarding harm to self or others in specialist clinic settings Some evidence that people may be aware of onset of problems at this stage, but lose this awareness as illness progresses – a reason to intervene at this stage Tools for Assessing At Risk Mental States Variety of sets of criteria CAARMS (EPPIC) Comprehensive Assessment of At Risk Mental States - most used in the UK SIPS – Structured Interview for Prodromal Syndromes & SOPS (Scale of Prodromal Symptoms) (McGlashan et al., Yale) Can the Prodrome be Accurately Identified? Systematic review of population with clinical high risk, mostly help-seekers in specialist services (Fusar-Poli 2012): 18% transition to psychosis after 6 months follow-up, 22% after 1 year, 36% after 3 years. Highest rates with stringent criteria for high risk mental state: 40%+ Promising work on potential of neuroimaging or cognitive testing, or especially on algorithms based on combination, to increase prediction of psychosis – not in clinical use yet. Pharmacological Treatment Several small trials of low dose medication, with or without non-pharmacological interventions Week 1 - 4th Oct 6  McGorry et al. (2002) PACE clinic, Melbourne: needs-based intervention with support and case management +/- 1-2mg risperidone, CBT. Sig diff at end of treatment in rates of psychosis (10/28 vs. 3/31), not at follow up. McGlashan et al. (2006), US: 31 patients receiving olanzapine vs. 29 controls. 16% of olanzapine group and 38% placebo became psychotic. Not sig, but small nos. Significant weight gain in olanzapine group. Ruhrmann et al. (2007), Germany : Needs-based intervention +/- amisulpride – greater symptom remission with amisulpride. 102 participants. Fish oils: one trial suggesting benefit, not replicated so far. Non-Pharmacological Treatment Stress-vulnerability model – psychosis may be averted by reducing stress Non-specific assessment, monitoring, support (e.g. OASIS clinic) Engagement, continuing Fusar-Poli et al. 2019: The Hype Cycle assessment, being there if full- of Preventive Treatments for Psychosis blown psychosis develops Support, reinforcement for adaptive coping behaviours Needs-led interventions for depression, anxiety, social problems Help client and family recognise and manage subthreshold symptoms Cognitive behavioural therapy for at risk states: Week 1 - 4th Oct 7  Varying results for individual trials and for systematic reviews Low rates of transition to psychosis in both treatment and control groups often a problem in trial. The most recent reviews with meta-analysis tend to suggest a positive effect for CBT when trials are pooled (e.g. Mei et al. 2021). Problems with Prodromal Intervention Ethics of intervening (especially with drugs) challenging when some will not become psychotic Often hard to recruit to intervention studies Still no good way of screening for at risk states Research not substantial enough to allow clearly evidence-based practice, even though UK policy requires ARMS services in every area Long term effects of prodromal intervention entirely unclear But – very great benefits if it can be made to work A focus on a broader group of disorders might be a better basis for service planning – youth mental health service model. Neuroscience and sophisticated psychological testing may yield better ways of identifying people in the prodrome. Pre: EIS to Promote Recovery and Prevent Relapse LO: To understand the rationale and main approaches of EIS for psychosis in promoting recovery and preventing relapse after a first episode & to appreciate the strength of current evident of EIS following a first episode and the remaining gaps. Week 1 - 4th Oct 8  EIS - Critical Period Theory Evidence for the “critical period” theory (Birchwood et al. 1998) Functioning and residual symptoms tend not to change much after about 5 years Worse residual symptoms (positive & negative), slower recovery after each early relapse Approx. 2/3 suicides occur in the first 5 years The Importance of the Critical Period First few years/months after initial episode also important for: Psychological adjustment to psychosis - how it’s viewed and managed Engagement with professionals - ?if they’re seen as helpful or to be avoided Family Relationships and Involvement Maintenance of Education, Career, Social Network - Prospects are better if maintained early on Theory underpinning EIS Prognosis of psychosis could be improved through: Reduction of DUP Promotion of better social as well as clinical recovery from first episode Prevention or reduction of severity of early relapse Reduction of early co-morbidities and social damage Developing a strong therapeutic alliance with family and friends from the beginning Promoting self-management skills Making sure full set of evidence-based interventions (NICE) on offer Treatment Approaches: Acute Phase Thorough Assessment - both clinical and social Intensive, creative and flexible approach to engagement (Assertive Outreach Principles) Week 1 - 4th Oct 9  Medication - Minimum Effective Doses, ‘zero tolerance’ of side effects Adherence monitored and promoted Early use of evidence-based psychological and drug treatments for resistant psychosis Psychoeducation for clients and carers throughout illness Focus on social as well as clinical problems, especially those that are high on clients’ agenda Approaches in Recovery Continuing focus on engagement and therapeutic alliance Client’s own recovery goals and self-management skills in foreground Early return to work, education, recreational & social activities actively promoted Structured relapse prevention will all clients Early detection and active management of co-morbidities — depression, anxiety, suicidal behaviour, drug and alcohol problems Engage with client’s families, other significant social network engaged as much as possible Specific family interventions offered wherever appropriate Early reliance on welfare benefits discouraged for those making good recovery Use of ‘mainstream’ services rather than those for people with long-term SMI encouraged Contact maintained with all for 3 years to maximise opportunities for social recovery and relapse prevention - note: most likely time to relapse is the 2nd year - (may transfer to ‘distant monitoring’) Evidence for Early Intervention to Prevent Relapse and Promote Recovery Nationwide introduction in England from 2001 without much evidence But now a few key randomised control trials: Week 1 - 4th Oct 10  LEO study, London: Lambeth Early Onset Team (Craig, Garety et al.)- Assertive outreach model for people with 1st or 2nd episode psychosis Include CBT with manualised protocols, family support, vocational support Randomised: LEO vs Inpatient and CMHT as usual 30% relapse in LEO over 18 months vs 48% in CMHT Advantages for costs, negative symptoms, quality of life, adherence Positive symptoms, bed days not significantly different OPUS study, Denmark (Petersen et al. 2005) Schizophrenia spectrum,