Psychosocial Treatment for those at Clinical High Risk of Psychosis

1. Psychosocial Treatment for those at Clinical High Risk of Psychosis Jean Addington PhD University of Calgary

2. Clinical Course of Schizophrenia Premorbid Prodromal Progressive Residual Onset of Psychosis Behavioral Functioning Psychotic Symptoms B 15 20 25 40….

3. Early Intervention Is Key Premorbid Prodromal Progressive Residual First Episode Treatment Behavioral Adaptation ?? Psychotic Symptoms B 15 20 25 40….

4. Terminology • Genetic high risk • Prodromal • Ultra high risk • Clinical high risk

5. Prodromal Syndromes • Identified by a structured interview • Structured Interview for Prodromal Syndromes (SIPS) • Syndromes • Attenuated positive symptom syndrome • Brief intermittent psychotic syndrome • Genetic risk + deterioration syndrome Miller et al., 2003; Yung et al 2005

7. Intervention Studies

8. In progress trials • FETZ program in Cologne: group & individual CBT and cognitive remediation • Bechdolf et al (in press) • PACE clinic in Melbourne: CBT vs medication • McGorry, Yung et al • ADAPT study in Toronto

9. Medication Concerns • Concerns about drug side effects particularly if subjects are false positives • Do not address potential environmental stressors • psychosocial stress • substances • Clinical high risk individuals are help seeking but only 14-16% want medication (Addington & Addington, 2005) compared to 90-95% who consent to psychological treatments

10. Why CBT? • CBT has demonstrated effectiveness for • Reduction of psychotic symptoms • Reduction of the associated distress • Non-specific emotional problems • Depression and anxiety • Metacognitions • Substance use • CBT strategies fit within a stress-vulnerability model • Teach coping strategies to protect against environmental stressors

11. CBT addresses • Normalisation • Understand anomalous experiences and perceptual abnormalities • Generating & evaluating alternative explanations • Safety behaviours • Metacognition • ‘I am different’ and other core beliefs • Social isolation French & Morrison (2004)

12. Cognitive Behavior Therapy Cognitive RemediationSubstance UseStress Management Group WorkFamily Work

13. ADAPT: Access, Detection and Psychological Treatments

14. Access, Detection & Psychological Treatments (ADAPT) • RCT to evaluate the effectiveness of CBT compared to a supportive therapy (ST) in • preventing or delaying the onset of a psychotic illness • reducing the presenting concerns (depression, anxiety, functioning etc) of the clinical high risk group

15. Assessments • Baseline • 6 months (end of treatment) • 12 months • 18 months • Symptom monitoring check • 1, 2, 3, 4, 5, 6, 9, 12, 15, 18

16. Measures • Symptoms • Prodromal Symptoms (SOPS; SPI-A) • Depression (CDSS) • Anxiety (general, social) • Metacognitions • Functioning • Premorbid functioning • Social Functioning Scale (Birchwood) • Substance Abuse (Drake et al.,) • Multnomah Community Ability Scale • Personality • Diagnostic Instrument for Personality Disorders • NEO • Therapeutic Working Alliance measures

17. Psychological Treatments • Randomly assigned to CBT or Supportive therapy • CBT • Up to 20 sessions over 6 month period • CBT focuses on • Adjustment • Presenting concerns • Attenuated psychotic symptoms • Perceptual difficulties • Depression & anxiety • Stress management • Supportive therapy focuses on support and crisis management

18. Sample • 56 consented post screening • 2 were psychotic at baseline • 3 never showed up after screening • 51 randomized • stratified by age, gender, early vs late • 24 in CBT group • 27 in supportive therapy group • Mean sessions - 12 in both groups

19. Demographics (N=51) • 36 male, 15 female • Age – 21 years (range 13- 30) • 55% white • 92% single • Education • 45% grade 12 • education on average 13 years • 47% currently working • 68% students

20. Comorbid Diagnosis • 2% no Axis 1 disorder • 55% mood disorder • 35% anxiety disorder • 10% alcohol abuse • 17% cannabis abuse • 30% Axis 2 disorder

21. Outcome at end of treatment • General Assessment of Functioning (GAF) • Groups did not differ • Both groups improved over time • Anxiety • Groups did not differ • Both groups improved over time • Negative symptoms • Groups did not differ • No improvement over time • Social functioning • Groups did not differ • No improvement over time

22. Depression • At baseline ST group more depressed • No change for CBT group • Improvement for ST group

23. Positive symptoms • At baseline and follow-up ST group had more positive symptoms • Improvement in each group

24. Conversion to psychosis • CBT group • No conversions (0%) • ST group • 3 conversions in 6 months (11%) • 3 subjects had a significant increase in positive symptoms to point of needing intensive monitoring (11%)

25. Summary • No change in negative symptoms • No change in social functioning • Improvement in anxiety, GAF, positive symptoms and depression • Conversions only in ST group

26. Comments • Possible that improvements will only be maintained by CBT group • Perhaps prodromal patients get better anyway as there is no TAU group. Not “allowed” by reviewers • Sample too small • Too small “dose” of CBT • Need to address social functioning

27. Problem focus in sessions

28. Problem focus in sessions (cont.)

29. Intervention focus in sessions

30. Intervention focus in sessions(cont)

31. Future considerations • Does the CBT group maintain improvement? • Spending a lot of time on engagement – longer therapy time or better therapists? • Is the treatment time long enough? • Can we match treatment to patients? • What do we do when patients hit the cusp of conversion?