Early treatment of psychosis

Eóin Killackey

Associate Professor

Orygen Youth Health Research Centre

DEVELOPMENT AND MENTAL ILLNESS

Youth as a distinct developmental phase

Adolescence begins earlier and finishes later than ever

Brain development dynamic from puberty until mid 20s

However the phase is culturally specific

Key developmental tasks

Transition more complex and desynchronous

Cohesive yet heterogeneous youth culture

Generational and cohort effects (Wyn)

Disease Incidence across

Lifespan

Risk factors for mental illness

HOW DOES MENTAL ILLNESS DEVELOP? – TWO POSSIBILITIES

Psychosis Risk Syndrome

Bipolar Risk Syndrome

Tenacious Depression Syndrome

THE GRAND DSM V RAILROAD

Clinical Staging

psychosis

depression mania

schizophrenia

depression mania bipolar

disorder

psychosis

STAGING MODEL AND INTERVENTION

Need for a staging model in mental illness

• Prevailing view

– Psychosis arrives due to a combination of

• Genes

• Environment

• Psychological factors

• Leads to a particular approach to treatment

• Other areas of chronic illness medicine don’t take this approach

Staging proposal

• Mental illness develops in stages

• If we can describe these stages we can potentially understand the development of illness better and treat more efficiently

• Significant disability and social exclusion could be avoided

Benefits of staging proposal

• We can start to examine the development of illness and identify earlier targets

• According to the Staging Model risks must be lower if treatment occurs earlier and treatment for ultimately more serious/exit syndrome more effective in longer term

Subthreshold and Threshold

Disorder…… Stage Definition Referral sources Potential interventions

0 Increased risk of psychotic or severe

mood symptoms but currently

asymptomatic

First-degree young relatives of

probands

Improved mental health literacy

Family and drug education

Brief cognitive skills training

1a Mild or non-specific symptoms, mild

functional change or decline

Screening of youth populations

Referral by primary care physicians

or school counsellors

Formal mental health literacy/eHealth

Problem solving and support

Family psychoeducation

Substance misuse reduction

Exercise

1b

Ultra-high risk: Moderate but

subthreshold mood/positive/negative

symptoms with moderate

neurocognitive changes and

functional decline (GAF < 70)

Referral by educational agencies,

primary care physicians, emergency

departments, welfare agencies

Formal CBT/CM

Family psychoeducation

Substance abuse reduction

Omega-3 fatty acids

Atypical antipsychotics?

Antidepressants, mood stabilizers?

2

First episode of full-threshold

disorder with moderate to severe

symptoms, neurocognitive deficits

and functional decline (GAF 30 - 50)

Referral by primary care physicians,

emergency departments, welfare

agencies, specialist care agencies,

drug and alcohol services

Formal CBT/CM

Family psychoeducation

Substance misuse reduction

Atypical antipsychotics

Antidepressants or mood stabilizers

Vocational rehabilitation

Insel, T. (2010) Nature

Only 13% of young men and 31% of young

women access the mental health care they need

access

can be

difficult

SOME COMMONSENSE REASONS FOR EARLY INTERVENTION

Symptom-Disability Gap in Early

Psychosis

Providing access during usually prolonged phase when major psychosocial disability develops (Agerbo et al 2003)

Disability

Gibb et al BJPsych 2010

“Psychiatric disorder during young adulthood was

common, with 50.1% of participants experiencing at least

one psychiatric disorder (depression, anxiety disorder or

substance dependence) between the ages of 18 and

25.”

“Many participants experienced more than one episode of

psychiatric disorder during young adulthood. Of those

who experienced any psychiatric disorder during young

adulthood, 54.5% experienced two or more episodes of

disorder.”

Potential Impact of Early Intervention Strategies

Reintegration: Work and school

• Age of onset

• Disruption of education • Only 32% with psychosis complete high school

• Maximum of 62% in other mental illnesses

• Compares to 78% for same age peers

• Poor transition to employment • 50% unemployed at outset of illness in psychosis

• Between 20% and 50% in other illnesses

• Rises quickly in psychosis to nearly 90%

• Rapid transition to benefits

• Youth Allowance, Newstart, Disability Support Pension (DSP)

Why are employment and education an issue for young people with mental illness?

Total cost of illness

Cost associated with unemployment

% of total

Australia (2001)

$1.8 billion $866 million 48%

Australia (2010)

$4.9 billion $2.17 billion 52%

USA (2004) $61 billion $32 billion 52%

Costs of people with schizophrenia not working

Employment is healthy (in general)

•The literature describes open employment as the most frequently-identified long-term goal of people with mental illness ( Rogers et al, 1991; Secker et al, 2001)

People with psychosis don’t want to work

In First Episode?

Ramsay 2011 (USA)

• Employment (53%)

• Education (38%)

• Relationships (35%)

• Housing (25%)

• Health (15%)

Iyer 2011 (India)

• Work (38.2%)

• Interpersonal (20.6%)

• School (16.2%)

• Symptom relief (10.3%)

• Living Situation (7.4%)

• The top three life domains that people with psychotic illness in Australia want to address are: • Financial matters;

• Loneliness/social isolation, and;

• Lack of employment

• Ahead of symptom management, managing physical health and the side effects of medication

SHIP study findings

Barriers

Barriers to work

18%

14%

14%

12%

12%

11%

11%

4%

2% 1% 1%

Barriers to work

Lack experience

Other

Qualifications/skills

Health/Disability

Too many applicants

Transport

Lack of desired jobs

Unsuitable hours

Discrimination

Employers think I'm too young

Language

•N=48 •7 on benefits at time of admission •30 others initiated receipt of benefits with median time 7 months from admission •Only 2 stopped receiving benefits over a 5 year follow up •At 5 years 35/48 (73% continued to receive benefits)

• Ho B-C, Andreasen N, Flaum M: Dependence on public financial support early in the course of schizophrenia. Psychiatric Services 1997; 48(7):948-950

Welfare benefits and first episode psychosis

Pensions

DSP exit points 2013

• Of people with psychiatric and psychological disabilities accessing the most intensive employment assistance only 26% achieved a placement and only 14% achieved 13 weeks of employment.

The disability employment system for people with mental illness

Stigma

The power of anticipated discrimination

Thornicroft et al., 2009 Lancet

Mismanifested care

•“we must have the opportunity to try and to fail and to try again…Professionals must embrace the concept of the dignity of risk and the right to fail if they are to be supportive of us”

•Deegan, 1996

Employment

What do we know works?

•Described by Becker & Drake (2003)

•8 core principles (updated in Swanson et al., 2011):

1. Service is open to any person with mental illness who wants to look for work

2. The IPS program is integrated with the mental health treatment team

3. Focussed on competitive employment as an outcome

4. Personalised benefits planning/counselling is provided

5. Job searching commences directly on entry into the program & is not determined by measures of work-readiness or illness variables

6. IPS worker develops relationships with employers based upon client interests

7. Potential jobs are chosen based on consumer preference

8. Support provided in the program is time-unlimited, continuing after employment is obtained, & is adapted to individual needs

Individual Placement & Support (IPS)

Competitive Employment Rates in 16 Randomized Controlled Trials of Supported Employment

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

96

NH

(IPS)

07

Aust

(IPS)

94

NY

(SE)

07

IL

(IPS)

04

CT

(IPS)

05

HK

(IPS)

06

SC

(IPS)

06

MA

(ACT)

99

DC

(IPS)

07

CA

(IPS)

95

IN

(SE)

07

EUR

(IPS)

06

QUE

(IPS)

00

NY

(SE)

97

CA

(SE)

02

MD

(IPS)

Supported Employment Control Control 2

In FEP (Killackey, Jackson & McGorry, BJP, 193, 114-120)

Recruited 41 people with first episode psychosis and randomly allocated to groups

Treatment as usual (n=21) Individual placement and support + treatment as usual (n=20)

Baseline assessment: SCID, CESD, QOL, BPRS, Job history, SANS, SOFAS

6 month assessment: SCID, CESD, QOL, BPRS, Job history, SANS, SOFAS, Indiana Job satisfaction scale, work related variables e.g. $ or hours per week etc.

IPS (n=20) TAU (n=21) Sig.

Jobs 13 2 P<0.000

Courses 4 4 ns

Weeks worked 5 0 P=0.021

Pay 2432 0 P=0.012

Benefits (change) -30% 0% P=0.025 P=0.317

Rinaldi, et al., 2010 International Review of Psychiatry

•In the IPS studies, 69% who received an intervention had a positive outcome compared with 35% in control groups

•Outcomes sustained up to 18 months in RCT and 24 months in clinical practice

Overall outcomes

Education

Employment’s foundation

People with schizophrenia % employed (n=380)

(Waghorn, 2003)

SIGNIFICANCE OF SCHOOL QUALIFICATIONS

Course of Illness <yr12 >yr12

Single episode, good recovery 16.7 66.7

Multiple episodes, good recovery 9.1 29.4

Multiple episodes, partial recovery 8.2 27.9

Chronic illness, little deterioration 14.3 12.1

Chronic illness, clear deterioration 1.5 21.7

Education intervention for people with mental illness

•19 participants 15-20 years of age

•6 month intervention

•At baseline 11 enrolled and not attending

•8 not enrolled neither “earning or learning”

•Outcome: 18 enrolled and either attending or completed

•1 neither earning or learning

Education Intervention Study

Transition: education to employment