Prevention and Recovery in Early Psychosis

1. Prevention and Recovery inEarly Psychosis Name of Presenter FSA Date Name of Presenter UCSF Date

2. Purpose • The purpose of this presentation is to: • Educate those working with youth and young adults about the PREP Program and the benefits of early intervention • Encourage Clinicians to work with PREP to: • Help identify youth who may be experiencing symptoms of early psychosis • View psychosis and schizophrenia as manageable and treatable • Significantly increase PREP early intervention assessments

3. PREP Target Population • Recent-onset Psychosis: • Diagnosis of schizophrenia, schizophreniform or schizoaffective disorder • Onset of full psychosis within the past 5 years • Ultra-High-Risk/Prodromal Psychosis • Never experienced a full psychotic episode • Low-level perceptual changes or unusual thinking that predicts risk of onset of full psychosis • very brief, limited psychotic symptoms • first-degree relative with psychotic disorder and large recent drop in functioning

4. What is Psychosis? • Psychosis is a state of mental impairment marked by: • Hallucinations - disturbances of sensory perception • Delusions - false yet strongly held personal beliefs that result from an inability to separate real from unreal experiences • Psychosis is a result of continual interaction of changes in the brain with psychosocial & environmental factors • Psychosocial factors are often the nearest causes of relapse

5. Signs and Symptoms • The signs of schizophrenia are different for everyone • Symptoms may develop slowly over months or years, or may appear very abruptly • The disease may come and go in cycles of relapse and remission • If any young adult you are working with experience several of these symptoms for more than two weeks, seek help immediately

6. Common clinical symptoms • Positive Symptoms • Hallucinations, delusions, disorganized communication • Negative Symptoms • Social withdrawal, affect flattening, avolition • Cognitive Symptoms • Poor attention and concentration, memory problems, executive impairment

7. Examples of Positive Symptoms Unusual Thinking • Confusion about what is real and what is imaginary • Ideas of reference • Preoccupation with the supernatural (telepathy, ghosts, UFOs) • Other unusual thoughts: Mind tricks, somatic ideas, overvalued beliefs, delusions of control • Suspiciousness Perceptual Disturbances • Increased sensitivity to light and sound • Hearing things that other people don’t hear • Seeing things that others don’t see • Smelling, tasting, or feeling unusual sensations that other people don’t experience Voices by Suellen Parker Disorganized Communication • Difficulty getting the point across; trouble directing sentences towards a goal • Rambling, going off track during conversations • Incorrect words, irrelevant topics • Odd speech Discover 2 by Suellen Parker

8. Examples of Negative Symptoms Social Withdrawal/Avolition • Wanting to spend more time alone • Not feeling motivated to do things • Trouble understanding conversations or written materials • Difficulty identifying and expressing emotions Disorganized Symptoms • Neglect of personal hygiene • Odd appearance or behavior • Laughing at odd or inappropriate times • Trouble with attention, clear thinking, comprehension

9. Examples of Cognitive Symptoms Decline in Functioning • Memory deficits • Slowed thought process • Trouble with organizing one’s thoughts • Trouble with planning • Impulsivity • Difficulty with concentration, attention Associated Mood Symptoms • Sadness or emptiness • Loss of interest or pleasure • Physical symptoms (fatigue, weight gain/loss, aches and pains) • Disrupted sleep patterns • Thoughts of death and/or suicide • Mood lability • Distractibility, talkativeness, restlessness • Irritability or agitation

10. High Risk Syndrome • Typically occurs during adolescence or early adulthood (ages 15-25) • Average duration of 1-3 years • Likely association with brain maturation • Onset may be earlier for men than women • Approximately 35% high-risk youth develop a full psychotic disorder within 2-2.5 years1 1Source: Cannon et al., 2008; Yung et al., 2007

11. Attenuated Symptoms: examples • 21 year old Sarah reports seeing things out of the corner of her eye, this started about 3 months ago and happens a couple of times a week, she worries about this experience and wonders what might be happening • 14 year old Alex sits in class and wonders if the teacher can read his mind, cites examples of the teacher writing things on the board that relate to him specifically but dismisses this as a coincidence when asked further • 16 year old Milo feels like people are out to get him, reports he has the feeling that his peers are talking about him behind his back but can’t understand why they would do that since there has been no arguments or incidents with his friends, he feels uncomfortable when he is away from the home and acknowledges that this is getting in the way of going out and socializing

12. Benefits of Early Intervention • There is overwhelming evidence to suggest that intervening early has big benefits: • Caught very early, it may be possible to delay or prevent the onset of chronic and disabling psychosis • Reduces burden of psychosis to the individual and society at large (IEPA, 2005) • Leads to reduced hospitalization and increased engagement with community services (Dodgson et al, 2008)

13. Benefits of Early Intervention • Duration of Untreated Psychosis vs. Rate of Relapse Adapted from Crow et al. (1986). Brit J. Psychiatry, 148, 120-127.

14. PREP Services and Eligibility

15. PREP Overview • PREP is a breakthrough outpatient program for early psychosis and schizophrenia in San Francisco County: • Evidence-based treatment • Strength-based, harm-reduction approach • Individualized and culturally appropriate • Targeted at adolescents and transition-age youth (14-27 years old) and their families • 2-year program

16. Primary Challenges • Stigma • Schizophrenia and psychosis carry such large stigmas and discriminatory attitudes with them that those with symptoms – and their families - are extremely reluctant to disclose them and seek the help they desperately need. • PREP aims to diffuse the words schizophrenia and psychosis so they are no longer seem as scary or shameful diagnoses. • Misinformation • People are significantly misinformed about the nature of psychosis, afraid of its potentially devastating effects on a productive life trajectory and, overall, ashamed of the diagnosis. • PREP seeks to educate people about the true nature of psychosis as manageable and treatable. • Duration of Untreated Psychosis • Psychosis tends to develop slowly over years but the longer it goes untreated, the more likely it is to lead to significant disability. • PREP aims to encourage early intervention and diagnosis by providing information and tools that make it comfortable for people to come forward and seek help

17. PREP Collaborative • A community partnership between: FSASF • Administration of PREP program • Administration of PREP services • Training and Clinical Supervision • Program Development UCSF MHA-SF LSYS Sojourner CBHS DPH - Connecting homeless youth to PREP services - Connecting foster youth, at-risk families and juvenile justice system to PREP services - Providing emergency care to those in need • Training • Conducting PREP assessments & intake • Connecting mental health professional community to PREP services • Program evaluation • Outreach • Marketing • Community Education • Stigma Reduction PREP is funded by CA Mental Health Services Act (Prop 63)

18. PREP Roster of Services Formal Diagnostic Assessment Thorough, reliable diagnosis and comprehensive assessment of symptoms CARE Management For 2 years, Care Manager addresses the broad spectrum of client and family needs Multi-Family Group Therapy (MFG) Participating families receive support from other families experiencing similar challenges Algorithm-based medication management Ensures that patient choices are informed and respected and symptoms are managed at the lowest possible dose Cognitive Behavioral Therapy (CBT) Focuses on how a person thinks and acts. Jointly identifies problem areas in the client's life and develops specific goals to target them Education/Employment Support Care managers work with clients to resolve issues that arise in school or on the job, and to meet their professional development goals Substance Abuse Services PREP takes an integrated approach, holding the principles of harm-reduction and meeting clients where they are **Services will vary with each family depending on the specific needs of client and family members. Careful consideration and input from family and clients on services will be taken into account. **

19. Family Inclusion • Within PREP, family is defined as individuals who may or may not be actual relatives, but who can commit to supporting the client such as sister, brother, case manager, social worker, etc. • Family intervention: • Provides critical support, which helps decrease stress in the family environment • Reduces social and psychological stresses by buffering the effects of negative life events

20. PREP Eligibility • Youth & young adults between 12-35 years old • San Francisco County residents • Accept insured and uninsured • Language availability: Spanish, Cantonese and Hebrew

21. Assessments and Referrals

22. Assessment • Diagnostic interview (SCID) takes approximately 2-3 hours • Assessment can be conducted at the PREP office, at the client’s home, in school • Wherever the client feels most comfortable • Interview includes the client and the client’s family, friends, therapist (whoever is able to provide collateral information) • Feedback scheduled with the client (and family) regardless of outcome • If eligible for PREP discussion of PREP resources and services • If not eligible for PREP discussion referrals provided to more appropriate services

23. The PREP Intake Process Step 1. Call 415-476-7278 and complete phone screen with PREP staff.Step 2. Discuss referral with client/family: - If already diagnosed, discuss treatment options. - If possible high-risk, discuss evaluation and treatment options.- Provide brochures, handouts, use screening questionnaire- Obtain consent to exchange informationStep 3. Arrange appointment for PREP staff to meet client/family on unit or have them call PREP to complete phone screen.

24. The PREP Intake Process Step 4. Client/family will complete a 2-3 hour diagnostic assessment.Step 5. PREP staff will request discharge summary or other records and contact providers for collateral. Step 6. Client/family attend feedback session with education, recommendations and referrals if not appropriate for PREP.Step 7. Plan of care developed collaboratively with client/family, may include any or all aspects of treatment at PREP, plus collaboration with other providers.Clients are eligible for PREP services for up to 2 years from entry

25. PREP Online Screening Survey • PQ-B (ProdromoalQuestionanaire) does NOT diagnose psychosis risk • Suggests whether further evaluation may be useful • Cutoff of 6 or more on Distress Score • 89% sensitivity, 68% specificity • Impairment/distress is key • Questions can be asked verbally, written or online at www.prepwellness.org • Helpful to follow up verbally on responses

26. Talking About Psychosis

27. Talking to teens and families Tip #1: Be informed • Psychotic experiences can be a part of normal development • 20% of adults in the general population report having a psychotic experience1 • Adolescents are especially prone to psychotic-like experiences - without impact on functioning2 Hanssen, et al. (2003) Acta Psychiatr. Scand. 107 (5), 369-77. Armando, et al. (2010) Schizophrenia Research, 119 (1-3), 258-265.

28. Talking to teens and families Tip #2: Treatment works • Less than 1/3 who receive treatment develop full psychosis. • People can function well with psychosis at school, work, family – disability is not always the outcome. • Violence is a MYTH

29. Talking to teens and families Tip #3: Encourage discussion • What is it like when it happens? • How often does it happen? • What do you differently because of it? • Look for avoidance or impairment in classes, with friends • When did it start? • Would you like help with it?

30. Talking to teens and families Tip #: Encourage curiosity • Visit www.prepwellness.org for: • An online version of the PQ-B Assessment Survey which will provide a recommendation about whether to call PREP • A better understanding of the true nature of psychosis and schizophrenia • Links to mental health resources around the world • Case studies and testimonials from those who have been through the PREP program • Much more information

31. Talking to teens and families Tip #4: Talk to PREP • We are a team dedicated to: • Offering all evidence-based treatments • Using recovery language • Connecting with the broader SF community

32. Talking to teens and families Tip #5: Encourage hope • PREP is committed to transforming the treatment and perception of early psychosis by intervening early with evidence-based, culturally-competent assessment and diagnosis so that most cases of psychosis are treated to remission. • Getting help early makes a big difference!

33. Preliminary outcomes Since September 2009, 69 clients have been served. 18 Ultra High Risk • Only 4 developed full psychosis • 2 hospitalized • 26 hospitalizations prior to program entry • 5 inpatient hospitalizations after entering program 20 Recent-Onset

34. Preliminary outcomes • 20 Recent-Onset clients have received medication management at PREP: 20 Recent-Onset with psychiatric care • 31 % on multiple antipsychotic medications at intake • 11% on multiple antipsychotics at one year • Average dose is 11% less than WHO defined typical dose *as defined by the World Health Organization

35. PREP Referrals Call: (415) 476-7278 Visit: www.prepwellness.org