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Co-morbidity in Psychosis depression, substance misuse and neurodvelopmental disorders

Co-morbidity in Psychosis depression, substance misuse and neurodvelopmental disorders. Alison Blair Esteem Glasgow With thanks to Prof. Andrew Gumley. First person perspective.

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Co-morbidity in Psychosis depression, substance misuse and neurodvelopmental disorders

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  1. Co-morbidity in Psychosisdepression, substance misuse and neurodvelopmental disorders Alison Blair Esteem Glasgow With thanks to Prof. Andrew Gumley

  2. First person perspective “It is a total psychological experience. There is no strategies you can make. You just have to sit there and experience-- abuse. And, the most important thing, and I said this to my psychiatrist, is my illness has my entire back catalogue <laughs>. It has my entire diary, so it can pick things that have happened years ago, show a symbol of it, show a picture of it, and it’s a horrible experience because you begin to relive those experiences. You don’t have to relive them because they are generally bad experiences, of my schizophrenia, a lot of embarrassment, a lot of humiliation, and the reasons why they are so bad is that virtual every time I have an attack, the illness goes through them and makes you relive them to a certain extent.”

  3. Quality of Life and Psychosis Quality of life is a key dimension of outcome in complex mental health problems. Reflects the person’s subjective evaluation of their experience, their perceived autonomy and the wider context of their recovery. Depression is one of the major factors contributing to poorer quality of life amongst individuals with psychotic disorders generally Saarni et al., 2010 and schizophrenia specifically. Meijer et al., 2009; Narvaez et al., 2008 No association of positive, negative and disorganisation symptoms with quality of life. Meijer et al., 2009; Narvaez et al., 2008

  4. Suicide and psychosis Around 6% of individuals with a diagnosis of Schizophrenia complete suicide. Palmer, Pankratz & Bostwick, 2005 In first 5-years following a first episode of psychosis, 3% complete suicide. Bertelsen et al., 2007 Early phase linked to greater risk of attempted suicide and rates of 32% attempted suicide following a first episode reported amongst adolescents. Birchwood et al., 2000; Falcone et al., 2010 Suicide and attempted suicide linked to hallucinations, depression, social isolation, substance use, longer duration of untreated psychosis and demoralisation. Pinikahana et al., 2003; Bertelsen et al., 2007; Falcone et al., 2010 National Institute of Mental Health Longitudinal Study of Chronic Schizophrenia found that over 6 years, 38% have at least one suicide attempt and 57% admitted with suicidal ideation. Roy & Pompili, 2009

  5. Depression and psychosis High risk period for development of depression is in the early years after first episode. Birchwood et al., 2000 Rates of depression 50% following a first episode of psychosis and 33% in established psychosis. Whitehead et al., 2002 Post psychotic depression emerges independently of positive symptom severity, relapse and negative symptoms. Birchwood et al., 2000; Iqbal et al., 2000 Strong overlap with social anxiety in psychosis. Birchwood et al.,2006; Michail & Birchwood, 2009

  6. Correlates of depression in psychosis • Depression has been found to be associated with a number of important domains. • Less adherence to treatment. Conley, 2009 • Longer duration of untreated psychosis. Drake et al., 2004 • Greater problems in family relationships. Rocca et al., 2005; Mino et al., 1998 • More closely associated with interpersonal adjustment than severtity of psychiatric symptoms. Rocca et al., 2005 • Early life trauma and stressful life events. Ventura et al., 2000; Scheller-Gilkey et al., 2002 • Greater actual experiences of stigma particularly with respect to accessing valued social roles. Angermeyer et al., 2004 • Greater difficulties being able to identify emotional states. van der Meer et al., 2007

  7. Depression, hopelessness, and CBT A total of 15 randomised controlled trials of Cognitive Behaviour Therapy have focused on depression as outcome and 4 trials have focused on hopelessness. Wykes, Steel, Everitt & Tarrier, 2008 Moderate effect size for mood = 0.36 (0.08, 0.65) Suggestion that CBTp may increase hopelessness = -0.19 (-0.55, 0.17) N.S. Significant findings for mood no longer significant when quality of methodology is accounted for where lower quality studies (e.g. non-blinding, poor randomisation) are associated with larger treatment effects.

  8. Depression, hopelessness and medication • Survey of 37,513 psychiatrists in US found good awareness of depression however over 25% never prescribe antidepressants in this group. Siris et al., 2001 • Cochrane review of antidepressants for depression in schizophrenia included 11 studies. Whitehead et al., 2002 • “At present, there is no convincing evidence to support or refute the use of antidepressants in treating depression in people with schizophrenia.” • No difference found between typical and atypical antipsychotics in terms of depression. Mauri et al., (2008) • Small randomised controlled trial found sertraline improved depression in Schizophrenia. Mulholland et al. 2003

  9. Depression, hopelessness and service organisation Early detection aimed at reducing duration of untreated psychosis was associated with reduced depression at 2-years. Melle et al. 2008 OPUS study: a randomised controlled trial of Integrated Treatment (Assertive Outreach, antipsychotic medication, social skills training and family education) found reduced levels of hopelessness at 1-year. Nordentoft et al. 2002 Our own First Episode Psychosis service in Glasgow we see significant improvements in depression and suicidal thinking over 6-months maintained at 12-months.

  10. Psychiatric and emotional recovery over 12-months

  11. Changes in suicidal thinking over 12-months

  12. Possible mechanisms of depression:the importance of shame, entrapment and loss • There is a paradox where insight associated with positive outcomes such as reduced psychotic symptoms but linked to depression and suicidal thinking. • Good insight associated with engagement, adherence and depressed mood. Where feelings of stigma are high relationship between depression and insight is strong. Staring et al., 2009 • Those who go on to develop post-psychotic depression experience greater loss, humiliation and entrapment prior to emergence of depression. Birchwood et al., 2000 • Lowered expectations for future, greater self criticism, and greater insight precedes development of depression and suicidal thinking. Iqbal et al., 2000 • Predictors of hopelessness were depression, severity of psychiatric symptoms and feelings of humiliation. White, et al., 2007 • Feelings of entrapment and low self esteem predict both anxiety and depression. Karatzias et al., 2007

  13. Feelings of shame grounded in the reality of personal experiences • These feelings are associated with persisting distressing psychotic experiences, more involuntary admissions, heightened awareness of the negative consequences of psychosis, greater awareness of the stigma of psychosis, being out of work, and loss of social status and friendships. Rooke and Birchwood, 1998 • Experience of relapse linked to the evolution of feelings of entrapment, shame and self blame over time. Gumley et al., 2006; Gumley, 2007 • Suicide and attempted suicide linked to hallucinations, social isolation, and longer duration of untreated psychosis. Pinikahana et al., 2003; Bertelsen et al., 2007; Falcone et al., 2010

  14. “Third Wave” Cognitive Behavioural Therapies • “Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactive ones. These treatments tend to seek the construction of broad, flexible, and effective repertoires over an eliminative approach to narrowly defined problems…” Hayes, 2004 p 658 • Rather than altering the content or frequency of cognitions, 3rd wave therapies seek to alter the individual’s relationship with thoughts, feelings and sensations to promotepsychological flexibility. • Acceptance and Commitment Therapy (ACT) focus on the person’s values and goals. • Compassion Focussed Therapy (CFT) cultivation of a compassionate soothing mentality attuned to one’s own self critical shaming thoughts. • Mindfulness involving the cultivation of a non-judgemental awareness

  15. CannabisUse • Greater severity of psychotic symptoms • Increased risk of relapse x 4 • Strongest predictor of relapse over 12/12 period (Linzen)

  16. L. Hides et al 2006 • No of days cannabis use most significant predictor of time to relapse over 6/12 period. • 61% ‘relapsed’ using cannabis. • 39% psychotic relapse

  17. Predictors of Cannabis use following psychosis • Severity of psychotic symptoms. • Baseline cannabis use. • Medication adherence.

  18. D. Wade et al 2006 • 103 consecutive referrals • 53% substance misuse • 42% cannabis • 30%alcohol • 17% other • 57% poly substance use

  19. Substance misuseNone • Admission 45% 15% • Remission 93% 98% • Relapse 51% 17%

  20. Substance Use Amongst ESTEEM Clients: Prevalence, Forms, and Levels of Impairment Dr I M Kevan (Clinical Psychologist) & Dr A Blackett (Con. Clinical Psychologist) ESTEEM First Episode Psychosis Service NHS Greater Glasgow & Clyde

  21. Methodology • Individual clinicians consulted about active cases on the ESTEEM caseload. • Each service-user’s current substance use pattern was established using a clinician-rated classification system

  22. Classification of Current* Substance Use • (1) Non-user (abstinent) • (2) Use without impairment • (3) Use with impairment (sometimes) • (4) Use with impairment (always) • (5) Dependence • (6) Unknown Pattern * For in-patients, current use was with reference to time in the community before admission

  23. Descriptive Characteristics of Sample • 160 current cases ESTEEM caseloads. • Mean age: 25 years ( range 16-35). • 112 males (70%) and 48 females (30%). • Mean number of months on the ESTEEM caseload was 11 ( range 1- 36 months).

  24. Prevalence of Substance Use • 65.6 % (n = 105) service-users were current users of substances (drugs and/or alcohol). • 34.4% (n=55) were rated as currently abstinent.

  25. Clinician-Rated Impairment in Substance Using Clients • 33 (31.4%) of the clients currently using without current impairment • 33 (31.4%) were rated as ‘Use with impairment (sometimes)’. • 15 (14.3%) were rated as presenting with ‘Use with impairment (always)’. • 16 (15.2%) of the sample were rated as having ‘Dependence’. • 8 (7.6%) clients who currently use were so unclear that it was difficult to make a rating of the level of impairment.

  26. Drug-Use Associated with Highest Impact on Functioning more significant difficulties, [‘Use with Impairment (always)’ or ‘Dependence’ (n = 31) alcohol (35.5%) cannabis (25.8%), and dual alcohol and cannabis misuse (12.9%)

  27. Interventions • Psycho-education • Addiction interventions within Esteem care depending on complexity e.g. substitute prescribing • Motivational interviewing approach • Individual psychology input • Behavioural family therapy

  28. Autism & Psychosis • Survey of care co-ordinators in Teeside EI service • Comorbid autistic spectrum in 10% of under 18 group. • 4 – 5% in 14 – 35 year old group.

  29. O. Stahlberg 2004 Attention deficit/hyperactivity disorder – AD/HD Autistic Spectrum Disorder - ASD • AD/HD patients – 30% co morbid ASD. • ASD patients – 38% • ASD - 7% bipolar & psychosis - 8% schizophrenia • AD/HD – 5% bipolar & psychosis - 5% schizophrenic

  30. N. Craddock, M. Owen 2010 Specific copy number variant (CNV) is associated with schizophrenia, mental retardation and autism.

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