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IEPA clinical practice guidelines for ARMS Shôn Lewis University of Manchester UK

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

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IEPA clinical practice guidelines for ARMS Shôn Lewis University of Manchester UK

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  1. IEPA clinical practice guidelines for ARMSShôn LewisUniversity of Manchester UK

  2. 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

  3. 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

  4. 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

  5. Constructs

  6. Constructs

  7. Constructs

  8. Constructs

  9. Constructs

  10. Constructs

  11. 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

  12. High risk of acronyms • PACE • PRIME • EDIE • RAP • FETZ • TOPP • PIER • OASIS • EPOS • CARE • NAPLS • SPAM • Society for Prevention of Acronyms in Mental health

  13. Rates of one year transition ARMS to psychosis (adapted from Lisa Phillips et al 2005)

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. What are the outstanding issues now?

  21. 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

  22. 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

  23. 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

  24. 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

  25. Roll on the IEPA guideline update!

  26. EDIE trial: ResultsTransitions to psychosis at 12 months Morrison et al, 2004

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