Preventing Psychotic Disorders: The Role of the Family

1. Preventing Psychotic Disorders: The Role of the Family Early Detection, Intervention and Prevention of Psychosis Meriden Family Conference March 20, 2007 William R. McFarlane, M.D. Center for Psychiatric Research Maine Medical Center Portland, Maine University of Vermont

2. Early Insults Social and Environmental Triggers e.g. Disease Genes, Possibly Viral Infections, Environmental Toxins Psychosis Increasing Positive symptoms Disability Biological Vulnerability: CASIS Cognitive Deficits Affective Sx: Depression Social Isolation School Failure Brain Abnormalities Structural Biochemical Functional After Cornblatt, et al., 2005

3. * p < 0.001 **p = 0.582 G X E interaction: p=0.018 Tienari, Wynne, et al, BJM, 2004

4. Withdrawal "Oddness" Functional deterioration Social & performance deficits Social deficits Critical comments CD, EOI Anxiety Panic Misattribution High EE Psychosis Illusions Dread Insomnia Anorexia Perceptual distortions Pervasive anxiety Biosocial causal interactions in late schizophrenic prodrome Early prodrome Late prodrome Acuteonset

5. Portland Identification and Early Referral(PIER) Reducing the incidence of major psychotic disorders in a defined population, by early detection and treatment: Secondary prevention

6. Greater Portland Population ~315,000 Portland

7. Professional and Public Education • Reducing stigma • Information about modern concepts of psychotic disorders • Increasing understanding of early stages of mental illness and prodromal symptoms • How to get consultation, specialized assessments and treatment quickly • Ongoing inter-professional collaboration

9. Welcome Mental illness Getting help About PIER Resources News Contact

10. College health services Family practitioners Mental health clinicians Military bases and recruiters Pediatricians PIER Team School guidance counselors, nurses, social workers Clergy Emergency and crisis services Large employers General Public

11. Clinical Strategies

12. Signs of prodromal psychosisSchedule of Prodromal Syndrome (SOPS), McGlashan, et al A clustering of the following: 1. Changes in behavior, thoughts and emotions, with preservation of insight, such as: • Heightened perceptual sensitivity • To light, noise, touch, interpersonal distance • Magical thinking • Derealization, depersonalization, grandiose ideas, child-like logic • Unusual perceptual experiences • “Presence”, imaginary friends, fleeting apparitions, odd sounds • Unusual fears • Avoidance of bodily harm, fear of assault (cf. social phobia) • Disorganized or digressive speech • Receptive and expressive aphasia • Uncharacteristic, peculiar behavior • Satanic preoccupations, unpredictability, bizarre appearance • Reduced emotional or social responsiveness • “Depression”, alogia, anergia, mild dementia

13. Signs of prodromal psychosis • 2. A significant deterioration in functioning • Unexplained decrease in work or school performance • Decreased concentration and motivation • Decrease in personal hygiene • Decrease in the ability to cope with life events and stressors • 3. Withdrawal from family and friends • Loss of interest in friends, extracurricular sports/hobbies • Increasing sense of disconnection, alienation • Family alienation, resentment, increasing hostility, paranoia

14. Family-aided Assertive Community Treatment (FACT): Clinical and functional intervention • Rapid, crisis-oriented initiation of treatment • Psychoeducational multifamily groups • Case management using key Assertive Community Treatment methods • Integrated, multidisciplinary team; outreach PRN; rapid response; continuous case review • Supported employment and education • Collaboration with schools, colleges and employers • Cognitive assessments used in school or job • Low-dose atypical antipsychotic medication • 10-20 mg aripiprazole, 2.5-7.5 mg olanzapine, 0.25-3 mg risperidone • Mood stabilizers, as indicated by symptoms: • SSRIs, with caution, especially with aripiprazole and/or a family history of manic episodes • Mood stabilizing drugs: lamotrigine 50-150 mg, valproate, 500-1500mg, lithium at therapeutic doses by blood level 0.6-1.2

15. Key clinical strategies in family intervention specific to prodromal psychosis • Strengthening relationships and creating an optimal, protective home environment: • Reducing intensity, anxiety and over-involvement • Preventing onset of negativity and criticism • Adjusting expectations and performance demands • Minimizing internal family stressors • Marital stress • Sibling hostility • Conceptual and attributional confusion and disagreement • Buffering external stressors • Academic and employment stress • Social rejection at school or work • Cultural taboos • Entertainment stress • Romantic and sexual complications

16. PIER: Twelve month outcomes Preliminary data for SOPS-positive prodromal cases from the first 36 months of intake: n = 65 Intake: May 7, 2001- May 6, 2004 12-month outcome: May 7, 2002- May 6, 2005

17. Screening and treatment entry

18. Demographics: Referred population and SOPS+ treated sample

19. Treated cases converting to psychosisScoring 6 on SOPS, at any time, during first year of txn=55 • Cases not converted 47 85.5% • Cases converted, 1-6 days 2 3.6% • Cases converted, 7-30 days 2 3.6% • SOPS conversions* 1 1.8% • Schizophrenic disorder 3 5.5% • Intent-to-treat (n=65)** 12 18.5% *Scoring at 6 for 4 days/week for >30 days **Assuming 40% conversion of cases refusing or dropping out

20. GAF: Baseline and 12 months n=50; t=5.91; p=.001

21. Components of expressed emotion: Prodromal vs. chronic phase All differences, prodromal vs. chronic: p<0.01

22. Correlations of mothers' level of EE with duration of prodrome

23. Correlations of fathers' level of EE with duration of prodrome

24. First admissions for a psychosis: Differences in rate: Portland minus Rest of Maine PIER Starts PIER Starts

25. Differences between treated prodromal and post-psychotic states Prodromal young persons have manifested: • Maintenance of insight (prevention of loss) • Continued dysphoric/ego-dystonic response to prodromal/psychotic symptoms • High acceptance of, and adherence to, treatment • Low rates of substance abuse • More open to discontinuing heavy drug and alcohol abuse • Less resistance to family inclusion by patient • Stronger family involvement • Higher motivation to continue schooling and/or work • More trusting and grateful therapeutic relationships • Higher sensitivity to treatments • Higher likelihood of improving course of functioning

26. Conclusions • Public education is beginning to influence attitudes, knowledge and behavior. • Increasingly accurate referrals are coming from outside the mental health system. • Treatment is blocking the final common pathway to psychosis for almost every case. • Medication at low doses is adequate but appears essential for prevention of imminent, and perhaps later, psychosis. • Very low conversion rates accompany evidence-based, comprehensive treatment (~15%; ~5% for schizophrenic disorders). • A substantial proportion of the incident population can be identified and prevented from developing psychosis, in the short term.

27. PIER Sponsors PIER has been made possible with the generous support of: • Robert Wood Johnson Foundation • National Institute of Mental Health • Center for Mental Health Services (SAMHSA) • State of Maine • Maine Health Access Foundation • Bingham Fund • Betterment Fund • Brain Foundation • American Psychiatric Foundation • UnumProvident Foundation • Wrendy Haines Fund For information, go to: WWW.PREVENTMENTALILLNESS.ORG