Early Intervention in
Schizophrenia
Faculty Research Series
January 16, 2013
Professor Alison Yung
Institute 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
critical
period
15 - 25
age
• “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?
Acute
treatment
sys
Recovery
First episode
psychosis
DUP
Prodrome
time
sys
Focus 1: reducing the
duration of untreated
psychosis (DUP)
Acute
treatment
Recovery
First episode
psychosis
DUP
Prodrome
time
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)
Evidence
Bottlender 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 helpseeking
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
Acute
treatment
sys
Recovery
First episode
psychosis
Non-specific sys
1
DUP
Prodrome
2
3
4
time
Focus 2: management of first
episode psychosis
Acute
treatment
sys
Recovery
First episode
psychosis
Non-specific sys
1
DUP
Prodrome
2
3
4
time
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
Overall outcomes – vocational
intervention
• 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
A specific outcome
•[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
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?
Can we intervene even
earlier?
Acute
treatment
sys
Recovery
First episode
psychosis
DUP
Prodrome
time
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!