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Early Psychosis, Recognition, and Intervention Options

Learn about the prodrome stage, challenges faced by patients and families, treatment options, and current research progress in early psychosis.

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Early Psychosis, Recognition, and Intervention Options

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  1. Early Psychosis, Recognition, and Intervention Options L. Elliot Hong, MD Professor and Director The First Episode Clinic Maryland Psychiatric Research Center Department of Psychiatry www.first episode clinic.org

  2. Learning Objective • What is prodrome vs. first episode of psychotic break? • Challenges facing patients and families experiencing the first psychosis episode • Treatment options and limitations • Update on current research progress

  3. Prodrome StageFirst Break of PsychosisEarly Stage of SchizophreniaLater Stage of Schizophrenia Disease Course of Schizophrenia Prodrome StageFirst Break of PsychosisEarly Stage of SchizophreniaLater Stage of Schizophrenia Prodrome StageFirst Break of PsychosisEarly Stage of SchizophreniaLater Stage of Schizophrenia Prodrome StageFirst Break of PsychosisEarly Stage of SchizophreniaLater Stage of Schizophrenia Prodrome StageFirst Break of PsychosisEarly Stage of SchizophreniaLater Stage of Schizophrenia Prodrome StageFirst Break of PsychosisEarly Stage of SchizophreniaLater Stage of Schizophrenia

  4. Prodrome • Prodrome phase is defined by changes in behavior and function before full episode of psychosis emerges • Typically a few months to 1-2 years before psychosis • Can be absent in some cases, or prolonged (many years)

  5. Prodrome Yung & McGorry Schizophrenia Bulletin 1996

  6. Prodrome • Two of the most common complaints: 1. Change in social interaction, social withdrawal 2. Deteriorated functions at school or work • Can be difficult to detect. • Very important to detect because emergent evidence of potential treatment options to delay or even stop psychosis onset

  7. Prodrome Other common prodrome symptoms • Attenuated positive symptoms: distorted perceptions, strange thoughts, subtle communication difficulty • Brief intermittent psychotic symptoms: subtle paranoia and hallucination, occur for a short period of times • Some subtle functional decline in school or work and odd behavior

  8. First Episode Psychosis • When it occurs, everyone knows something is wrong • Hallucinations are sensory perceptions in the absence of an external stimulus. The auditory type is common • False beliefs, seemed fixed and held tight by the individual • Disorganized thinking and behavior • Lack of motivation and interests, and isolation

  9. First Episode Psychosis • A traumatic and stressful experience to the person • Confusion, difficult to understand and manage for the family • Severe disruption of schooling and work • Disruption of social relationship, isolating patients from friends and people around him/her

  10. First principle –Reducing the duration of untreated psychosis • Meta-analysis of 43 publications on the issue * • Shorter the duration, greater the response to antipsychotic treatment • Longer the untreated psychosis, more severe in negative symptoms * Perkins et al 2005. Am J Psychiatry

  11. Second principle –Comprehensive, sustained treatment and therapy • Antipsychotic medications reduce symptoms, reduce disability associated with symptoms, and reduce chance of relapse • Comprehensive therapy and psychosocial support improve recovery, reduce disability • Many of our patients return to school and obtain full-time employment after first break of psychosis • Long term management of side effects of antipsychotic medications is required in most patients.

  12. Early Years after First Psychosis • Medication vs. no medication • Therapy vs. no therapy • Will it improve? • Will it relapse • Work and school

  13. Directions of treatment research • Clinical trials to prevent the onset of psychosis • Clinical trials to improve the outcome of first-episode psychosis

  14. Therapy to prevent conversion to psychosis - one small study, needs replication • Supportive counseling (SC) • Integrated psychological intervention (IPI): combining cognitive-behavioral therapy, group skills training, cognitive remediation and multifamily psychoeducation on prevention of psychosis Bechdolf et al 2012 Br J Psychiatry

  15. Dietary supplement for prevention of conversion to psychosis – small study, needs replication • Long chain omega-3 polyunsaturated fatty acid vs. placebo • 2 of 41 individuals (4.9%) in the treatment group and 11 of 40 (27.5%) in the placebo has a first episode Amminger et al 2010 Arch Gen Psychiatry

  16. Can drug and therapy help for preventing conversion to psychosis? • There are reports of encouraging examples of success • However, most of these reports await replication • Analysis in combination of available data, show that the evidence of success by various intervention is far from convincing (Marshall et al 2011) • Even if they will reduce conversion to psychosis, for the foreseeable future, most individuals prone to have psychosis will still develop psychosis Marshall & Rathbone 2011. Cochrane Database Syst Rev.

  17. Treatment to prevent relapse after first episode - what is more important • Pharmacological treatment is most important and most cost - effective to control psychosis and to prevent relapse • Meta-analysis showed that first – generation and second – generation antipsychotics are almost equally effective* • There are some modest difference in medication choices and outcomes • Drawbacks are side effects - benefit outweighs risk in most cases * Alvarez-Jimenez et al 2009 Schizophrenia Bulletin

  18. Should patients stop medication after the first episode is treated or recovered? • Maintenance treatment is more effective in preventing relapse • Deterioration (up to 57% vs 4%, P < .001) were much higher if no maintenance treatment in one year, could be worse for longer Gaebel et al 2011 J Clinical Psychiatry

  19. Should patients stop medication after the first episode is treated or recovered? • Looked at many factors, gender, age at onset, duration of untreated psychosis, clinical severity at baseline, premorbid functioning, substance use, family history of psychosis • large epidemiological sample of first-episode patients • consecutively admitted drug-naïve patients without any biases in the way patients were referred. Caseiro et all J of Psychiatric Research 2012

  20. Should patients stop medication after the first episode is treated or recovered? • In fully recovered patients, medication reduction/ discontinuation may help with functional recovery, but not symptoms • Small sample study, but encouraging LexWunderink, et al JAMA Psychiatry 2013

  21. Should patients stop medication after the first episode is treated? • No – not in principle • Do patients listen? Often not, unfortunately • An important area for clinicians managing patients who try to stop • In persistent, complete remission, reducing dose or stopping may be considered (see Wunderink et al) – but jury is out and should be very cautious Wunderink et al JAMA Psychiatry. 2013

  22. Should patients stop medication after the first episode is treated? • Patient autonomy vs. evidence-based assertive treatment recommendation • Built strong alliance with patients and family regardless patients current decision • Because most patients who decided to stop medication before full, long remission eventually may need more treatment

  23. What Matters Most in First Episode ManagementTwo basic principles most experts agree • Sooner the treatment begins after the first psychosis, shorter the duration of untreated psychosis, better the outcome • More comprehensive, higher quality pharmacology, therapy and psychosocial intervention, better the recovery

  24. Early Recognition – Best Approaches • Through primary care – a UK experience: High intensity approach using specialist mental health professional who liaised with every practice and a theory-based educational package • low-intensity: postal information for referral Perez et al Lancet Psychiatry 2015

  25. The First Episode Clinic • The first specialty care FEC in the State of Maryland • Expert clinical services for adolescents (12 & up) and young adults experiencing FEP and follow-up care • True recovery model where returning patients to employment, finishing school, is the ultimate goal • Strong emphasis in evidence based FEP care using antipsychotic treatment, family support, and therapy • Provide state-wide consultation service

  26. Therapy • Patients are generally seen once a week initially by their therapist. Additional appointments can be scheduled for family sessions and other patient needs. Regular visits are reduced as you become stable. Visits can be reduced up to every 1 to 3 months.

  27. Psychiatric Care • A psychiatrist sees patients, generally starting at one visit every one or two weeks. Visits can be reduced to every month for some patients and even longer for most patients.

  28. Group Sessions • Group therapy sessions are optional and offered to most clinic patients. • Family group therapy sessions • Employment and back-to-school assertive assistance

  29. Other Benefits • We involve families, caregivers, and/or other significant persons in the initial evaluation process to allow for the best possible results. • Employment / schooling specialist to assist return to work/school and other recovery goal. • Strong support from new Maryland Early Intervention Program (MEIP) • No insurance is OK

  30. State-Wide Consultation Service • Accept consultation requests from schools, colleges, psychiatrists, primary care and pediatric care, state institutions • Provides consultations on diagnosis, treatment recommendations, and school and family management • On-site (1 to 3 visits) and telephone consultations are welcome

  31. Research Mission • Utilizing cutting edge brain imaging, clinical trial research expertise • Identifying how stress response is associated with gender differences in age of onset and outcome in early psychosis • Longitudinal study of brain and functional response to treatment • Identify genetic and environmental stress factors contributing to first episode psychosis

  32. Conclusions • Finding better treatment for psychosis is a top priority for NIH and many research institutions • Rapid progress is making in finding the cause and treatment, but lacking new treatment. • Available drug and therapy are effective for improving symptoms and reducing disability, when appropriately managed

  33. Conclusions • Early detection and early treatment make a difference • Community awareness is key to bring a patient in for treatment and reduce duration of untreated psychosis • Drug treatment plus high quality therapies • Strong evidence-based recovery model

  34. Referral • For more information, or to schedule an intake appointment or consultation, call or email • Early Intervention Program toll free numbers: 877-277-6347. Visit us at: ww.marylandEIP.com • Beth Steger, LCSW-C 410-402-6833. bsteger@mprc.umaryland.edu www.FirstEpisodeClinic.org

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