Prodromal psychosis talk 25-11-09
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Prodromal psychosis talk 25-11-09
- 1. Prodromal Psychosis November 2009 Jennifer Spencer, ST4, LD Psychiatry, SEPT
- 2. Classically a retrospective concept In medicine • An early symptom or set of symptoms that might indicate the start of a disease before definitive symptoms occur. • Prodromal symptoms may be non-specific or, in a rare instances, may clearly predict onset of a specific disease. In schizophrenia • The period of decreased functioning that is postulated to correlate with the onset of psychotic symptoms. • The term at risk mental state is often preferred, as prodrome can not be confirmed until the condition emerges. Prodrome
- 3. Development of psychosis over time 1. Patient first notices a change in himself 2. Family or friends first notice a change in the patient 3. Patient first notices psychotic symptoms in himself 4. Family or friends first notice psychotic symptoms in the patient 5. First psychotic intervention (estimated by McGorry in 1996 to be 1 year) (Yung et al 1996)
- 4. Historical context • Schizophrenia prodrome recognized in Kraeplin’s Classification (McGorry 1996) • Delay in treatment associated with poorer outcome (Northwick Park Study 1986) • Theory of toxic effect of psychosis (Lieberman 1990, Wyatt 1991) • Cost of treatment for patients with schizophrenia very high for National Health Services (estimated 20-25% of total cost) The prodrome as an area of potential intervention
- 5. • Potential for a reduction in biological deterioration and social disruption through early intervention • Aim to decrease morbidity and improve quality of life by • Keeping some at risk people from developing full blown schizophrenia • Minimizing the severity of symptoms in patients who did develop schizophrenia • Benefit society and Health Services • Decrease costs by making people better able to function in society (and return to work) Yung and McGorry’s Proposal (Yung et al 1995)
- 6. Worldwide programs for 5 years Cochrane Review (2006) measured 2 objectives 1. Prevention of onset of schizophrenia 2. Provision of effective treatment to reduce ultimate severity of disease (psychological &/or medical therapies) Conclusion: “Insufficient data to draw reliable conclusions” Atypical Antipsychotic Efficacy Review (Sikich 2008) • All antipsychotics evaluated were more efficacious than placebo, similar profiles to adults Conclusion: fragile evidence that atypical antipsychotics might offer possible protection, at the risk of long term medically significant side effects Is it effective?
- 7. • Funding • Identification of groups at High Risk of illness • Improved ability to predict who will “convert” (Varies according to how High Risk group is selected) • Advances in the understanding of underlying pathophysiology • Arguments put forward for improved concordance, familial acceptance and in some studies less frequent and shorter inpatient admissions (studies ongoing) Benefits
- 8. • Factorial analyses suggests there is clinical continuity between normal and at risk presentations, and between at risk presentations and full onset Schizophrenia • Schizophrenia is thought to represent the most severe form of a spectrum of normal cognitive and neuro-developmental traits (as for many other disorders in medicine and psychiatry) Hawkins et al 2004 Identification of Risk: The Schizotypal Continuum
- 9. “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group Woods et al 2009 Populations Studied
- 10. Brief intermittent Psychotic Syndrome (BIPS) Attenuated Positive Symptom Syndrome (APS) Genetic Risk and Deterioration Syndrome(GRDS) Primarily positive symptoms Primarily negative symptoms Gradation towards psychosis Presence of DSM-IV or ICD 10 Psychotic Syndrome Gradation towards psychosis Yung et al 1996 3 Proposed Prodromes
- 11. Prodrome syndromes differ from each other and from DSM- VI and ICD-10 classifications in terms of symptom • Type • Severity • Frequency • Duration Yung et al 1996 Symptom Classification
- 12. Positive Symptoms • Unusual thought content /Delusional ideas • Suspiciousness/Persecutory Ideas/Grandiosity • Perceptual Abnormalities/Hallucinations • Disorganized Communication Negative Symptoms • Social Anhedonia • Avolition • Expression of Emotion • Experience of Emotions and Self • Ideational Richness • Occupational Functioning Disorganization Symptoms • Odd Behaviour and Appearance • Bizarre Thinking • Trouble with Focus and Attention • Personal Hygiene General Symptoms • Sleep Disturbance • Dysphoric Mood • Motor Disturbances • Impaired Tolerance to Normal Stress Primary Risk factor: Family History of Schizotypy or Schizophrenia Types of Symptoms Miller et al 2003
- 13. Severity Prodromal States with Mainly Positive Symptoms Precursors Mild Moderate Severe Intensity of Belief Unusual thoughts (D) Considers possibility of a passing thought Believes but lacks conviction Believes, fairly convinced Abnormal perceptions (H) Odd noises Name being called Voices mumbled or far away Shadows corner of eye Disorganized speech (TD) Odd word Unusual phrase Difficulty getting point across 1 5/63 Miller et al 2003
- 14. In Previous Year Criteria BIPS • Severity of psychotic intensity (6) on one or more item • Beginning in past 3 months • Occurring at least several minutes per day at least once per month APS • Severity 3-5 on one or more item • Symptoms beginning within the past year or increasing by 1 or more point in the last year • Frequency 1/week for last month Prodromal States with Mainly Positive Symptoms Months 1 2 3 4 5 6 7 8 9 10 11 BriefintermittentPsychoticSyndrome(BIPS) BIPS + Months 1 2 3 4 5 6 7 8 9 10 11 AttenuatedPositiveSymptomSyndrome (APS) APSS+ Miller et al 2003
- 15. • First degree relative with history of any psychotic disorder OR • Patient himself has schizotypal personality disorder And • Global Assessment of Functioning ≤ 30% in last month vs 1 year ago Prodromal States with Mainly Negative Symptoms In Previous Year Criteria Months 1 2 3 4 5 6 7 8 9 10 11 GeneticRisk and Deterioration Syndrome (GRDS) GRDS - Miller et al 2003
- 16. Screening Tools North American Prodrome Longitudinal Study (NAPLS) (2003 - 2009) • Scale of Prodromal Symptoms* • Structured Interview for Prodromal Syndromes* • Global Assessment of Functioning • Criteria of Prodromal Syndromes* • Presence of Psychotic Symdrome* • DSM-IV * Based on Comprehensive Assessment for At Risk Mental State (CAARMS) (Yung 1996) Edinburgh High-Risk Study of Schizophrenia (EHRS) (1994 - 2009) • Present State Examination • Structured Inventory for Schizotypy (SIS) • Memory and Learning • Child Behaviour Checklist (CBC) • WAIS-R • Rivermead Behavioural Memory test • Minor physical abnormalities • Ocular Telorism • Dermatoglyphics • MRI scan “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group
- 17. Prediction Accuracy Edinburgh High-Risk Study of Schizophrenia (EHRS) Johnstone 2005 Single Predictor Positive pred power Negative pred power Sensitivity Specificity Rey Aud Verbal Learning Test (RAVLT) 11.8 85.1 61.1 32.8 Social withdrawal (SIS) 40 91.7 44.4 90.2 Oddness (SIS) 28.9 93.2 61.1 78 Total Score (SIS) 29.1 97.7 88.9 68.3 Rust Inventory of Schizotypal Cognitions 50 94.3 61.1 91.3 SIS - Structural Interview for Schizotypy (SIS) at baseline “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group
- 18. Prediction Accuracy North American Prodrome Longitudinal Study (NAPLS) Cannon 2008 Single Predictor Positive pred power Sensitivity Specificity Genetic risk w/ f’n’al decline 52 66 59 Unusual thought content (>3) 48 56 62 Suspicion/paranoia (>2) 43 79 37 Social Functioning (<7) 46 80 43 Any substance abuse 43 29 83 Multiple regression 1, 2, and 3 74 34 89 1, 2, and 4 81 30 90 1, 3, and 4 67 48 82 “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group
- 19. Other biological markers That might improve prediction • Oro-facial and upper limb movement abnormalities (Mittal et al) • Olfactory dysfunction (Tureisky et al 2009) • Rate (and location) of Gray Matter loss across time (Thompson et al, 2001 and 2008, Johnson et al 2009)
- 20. “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group Teenagers in Special Schools Schizophrenia and Learning Disability
- 21. • Patients at familial risk for schizophrenia • Have consistently lower IQ prior to onset (Esp specific memory and executive function difficulties) • Schizophrenia onset is often heralded by cognitive decline • Point prevalence of of schizophrenia in mild idiopathic intellectual disability = 3% • Traits in patients with schizophrenia and mild LD are similar to those with schizophrenia alone • Structural brain changes • Positive family history • Rates of chromosomal variants and abnormalities Schizophrenia and Learning Disability “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group Teenagers in Special Schools Johnstone et al 2007
- 22. • Cognitive difficulties often precede the onset of psychotic symptoms and illness by some years • Adolescents with prodromal symptoms are therefore likely to come to their school’s attention due to intellectual disability and to enter special education • Johnstone et al (2007) carried out a longitudinal study • Focussing on adolescents in special schools • Following the design of the Edinburgh High-Risk Study of Schizophrenia “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group Teenagers in Special Schools Johnstone et al 2007 Study of Prodromal Symptoms in Teenagers with mild learning disabilities
- 23. Prodromal Screening Tools Edinburgh High-Risk Study of Schizophrenia (EHRS) • Present State Examination (PSE) • Structured Inventory for Schizotypy (SIS) • Memory and Learning • Child Behaviour Checklist (CBC) • WAIS-R • Rivermead Behavioural Memory test • Minor physical abnormalities • Ocular Telorism • Dermatoglyphics • MRI scan “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group Teenagers in Special Schools • Clinical Interview Schedule (CIS) • Structured Inventory for Schizotypy (SIS) • Memory and Learning • Child Behaviour Checklist (CBC) • WAIS-R, WISC-III • Rivermead Behavioural Memory test • Behavioural Assessment of Dysexecutive Syndrome • MRI scan Longitudinal study of Teens with borderline and mild LD Johnstone et al 2007
- 24. Results • Whole study population vs controls (all risk symptoms) • Clinical Interview Schedule (CIS) score 200% higher • Structured Inventory for Schizotypy (SIS) score 16% higher • Cut-off “high” SIS score therefore adjusted to reflect higher background level of symptomatology • Adjusted “high” SIS score present in all subjects who have since developed schizophrenia Conclusion • It will soon be possible to use simple screening tools to detect vulnerability to schizophrenia in this population Prodromal Symptoms in Teenagers with mild learning disabilities “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group Teenagers in Special Schools
- 25. • In normal teenagers, cortical gray matter increases in synaptic density above adult levels during postnatal period • Greatest synaptic volume is reached 11-16 years of age. • Age at which greatest volume is reached varies between brain regions, adult configuration not achieved until well into 3rd decade. • In normal teenagers, a synaptic pruning process occurs during adolescence and early adulthood until the number of synapses reaches adult levels • The normal pruning process is believed to occur in an extreme and exaggerated way in early onset psychosis Pathophysiology: Gray Matter Loss
- 26. Thompson P. M. et.al. PNAS 2001;98:11650-11655 ©2001 by The National Academy of Sciences Dynamic changes in male and female Teenagers with Schizophrenia
- 27. Combination studies Grey matter, Genes and Parametrics Genetically associated Grey Matter changes in the brain fMRI - NRG 1 (SNP8NRG243177) – Risk allele T/T • Decreased activation in Right medial prefrontal cortex and Right posterior temporal gyrus during sentence completion • Development of schizotypal symptoms (but not necessarily full-blown schizophrenia) sMRI and fMRI - COMT Val158Met – Risk allele Val • Reduced Grey Matter Density in anterior cingulate • Increased activation in lateral prefrontal cortex and anterior and posterior cingulate with increasing sentence difficulty on Hayling task • Increased the risk of Schizophrenia in a dose dependent manner NRG1 and COMT positive predictive power 60-70% in these populations Lawrie et al 2008
- 28. Summary (of Edinburgh findings) 1. NRG1 gene = a risk factor for schizotypal traits Can lead to schizophrenia if prolonged labour or birth trauma also present 2. COMT Val allele = a risk factor for schizophrenia In future 1. Imaging indices and gene variants may be used as ‘biomarkers’ to ID those at high risk for schizophrenia 2. Very high risk people could be targeted for close monitoring and early intervention with therapies as they wished. Combination studies Grey matter, Genes and Parametrics
- 29. Haloperidol Olanzapine Effect of medical treatment on Grey Matter loss Thompson et al 2008 Time dependent trajectory of Gray Matter Loss
- 30. Rate of PANSS Score Loss Does Not Vary with Treatment Thompson et al 2008
- 31. Should Prodromal Syndromes be included in DSM-V and ICD-11? 1. Does a clinical need exist (is DSM-IV inadequate)? Yes 2. Can diagnostic reliability and validity be reproduced in clinical practice? Unknown (field trials) 3. When high-risk cases convert to DSM-IV illness • Is it predominantly psychosis? Yes • Is it specifically schizophrenia? Yes • Should the new class be placed with the group of psychoses or placed elsewhere? Psychoses 4. Do the criteria reflect behaviours that are so common that a distinction between ill and non-ill is difficult (high likelihood of false-positive)? Yes 5. Will this diagnostic category do more harm than good to the patient? Undetermined Carpenter et al 2009
- 32. • Prodromal psychoses are currently receiving a lot of attention • Predictive screening tests are becoming more and more accurate • Predictive screening tests will be appropriate for patients with borderline and mild learning disabilities • Development of effective treatments is currently advancing at a slower pace • Decision to screen patients will need to be made with great care • Population screening may not be appropriate until after effective treatments have been identified Conclusion
- 33. 統合失調症 - the integration disorder Σχίζω - “I split” ماصفال - severe madness 精神分裂症 एक प्रकार का पागलपन Шизофрения Schizofrenie Skizofreni Schizophrenia
- 34. References (1) Addington J, Cadenhead KS, Cannon TD, Cornblatt B, McGlashan TH, Perkins DO, Seidman LJ, Tsuang M, Walker EF, Woods SW, Heinssen R. North American Prodrome Longitudinal Study: a collaborative multisite approach to prodromal schizophrenia research. Schizophr Bull. 2007 May;33(3):665-72. Cannon TD, Cadenhead K, Cornblatt B, Woods SW, Addington J, Walker E, Seidman LJ, Perkins D, Tsuang M, McGlashan T, Heinssen R. Prediction of psychosis in youth at high clinical risk: a multisite longitudinal study in North America. Arch Gen Psychiatry. 2008 Jan;65(1):28-37. Carpenter WT. Anticipating DSM-V: should psychosis risk become a diagnostic class? Schizophr Bull. 2009 Sep;35(5):841- 3. Einfeld S, Tonge B, Chapman L, Mohr C, Taffe J, Horstead S. Inter-Rater Reliability of the Diagnoses of Psychosis and Depression in Individuals with Intellectual Disabilities. J Appl Res Intellect Disabil. 2007 Sep;20(5):384-390. Fletcher RJ, Havercamp SM, Ruedrich SL, Benson BA, Barnhill LJ, Cooper SA, Stavrakaki C. Clinical usefulness of the diagnostic manual-intellectual disability for mental disorders in persons with intellectual disability: results from a brief field survey. J Clin Psychiatry. 2009 Jul;70(7):967-74. Goldberg DP, Cooper B, Eastwood MR, Kedward HB, Shepherd M. A standardized psychiatric interview for use in community surveys. Br J Prev Soc Med. (1970) Hawkins KA, McGlashan TH, Quinlan D, Miller TJ, Perkins DO, Zipursky RB, Addington J, Woods SW. Factorial structure of the Scale of Prodromal Symptoms. Schizophr Res. 2004 Jun 1;68(2-3):339-47. Johnstone EC, Crow TJ, Johnson AL, MacMillan JF. The Northwick Park Study of first episodes of schizophrenia. I. Presentation of the illness and problems relating to admission. Br J Psychiatry. 1986 Feb;148:115-20.
- 35. Johnstone EC, Ebmeier KP, Miller P, Owens DG, Lawrie SM. Predicting schizophrenia: findings from the Edinburgh High-Risk Study.Br J Psychiatry. 2005 Jan;186:18-25. Johnstone EC, Owens DG, Hoare P, Gaur S, Spencer MD, Harris J, Stanfield AW, Moffat V, Brearley N, Miller P, Lawrie SM, Muir WJ. Schizotypal cognitions as a predictor of psychopathology in adolescents with mild intellectual impairment. Br J Psychiatry. 2007 Dec;191:484-92. Lawrie SM, Hall J, McIntosh AM, Cunningham-Owens DG, Johnstone EC. Neuroimaging and molecular genetics of schizophrenia: pathophysiological advances and therapeutic potential. Br J Pharmacol. 2008 Mar;153 Suppl 1:S120-4 Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004718. Review. McGorry PD, Yung AR, Bechdolf A, Amminger P. Back to the future: predicting and reshaping the course of psychotic disorder. Arch Gen Psychiatry. 2008 Jan;65(1):25-7. Miller TJ, McGlashan TH, Rosen JL, Somjee L, Markovich PJ, Stein K, Woods SW. Prospective diagnosis of the initial prodrome for schizophrenia based on the Structured Interview for Prodromal Syndromes: preliminary evidence of interrater reliability and predictive validity. Am J Psychiatry. 2002 May;159(5):863-5. Mittal VA, Neumann C, Saczawa M, Walker EF. Longitudinal progression of movement abnormalities in relation to psychotic symptoms in adolescents at high risk of schizophrenia. Arch Gen Psychiatry. 2008 Feb;65(2):165-71. Moorhead TW, Stanfield A, Spencer M, Hall J, McIntosh A, Owens DC, Lawrie S, Johnstone E. Progressive temporal lobe grey matter loss in adolescents with schizotypal traits and mild intellectual impairment. Psychiatry Res. 2009 Nov 30;174(2):105-9. References (2)
- 36. Thompson PM, Bartzokis G, Hayashi KM, Klunder AD, Lu PH, Edwards N, Hong MS, Yu M, Geaga JA, Toga AW, Charles C, Perkins DO, McEvoy J, Hamer RM, Tohen M, Tollefson GD, Lieberman JA; HGDH Study Group. Time-lapse mapping of cortical changes in schizophrenia with different treatments. Cereb Cortex. 2009 May;19(5):1107-23 Thompson PM, Vidal C, Giedd JN, Gochman P, Blumenthal J, Nicolson R, Toga AW, Rapoport JL. Mapping adolescent brain change reveals dynamic wave of accelerated gray matter loss in very early-onset schizophrenia. Proc Natl Acad Sci U S A. 2001 Sep 25;98(20):11650-5. Turetsky BI, Hahn CG, Borgmann-Winter K, Moberg PJ. Scents and nonsense: olfactory dysfunction in schizophrenia. Schizophr Bull. 2009 Nov;35(6):1117-31. Epub 2009 Sep 30. Walker EF, Cornblatt BA, Addington J, Cadenhead KS, Cannon TD, McGlashan TH, Perkins DO, Seidman LJ, Tsuang MT, Woods SW, Heinssen R.The relation of antipsychotic and antidepressant medication with baseline symptoms and symptom progression: a naturalistic study of the North American Prodrome Longitudinal Sample. Schizophr Res. 2009 Nov;115(1):50-7. Woods SW, Addington J, Cadenhead KS, Cannon TD, Cornblatt BA, Heinssen R, Perkins DO, Seidman LJ, Tsuang MT, Walker EF, McGlashan TH.Validity of the prodromal risk syndrome for first psychosis: findings from the North American Prodrome Longitudinal Study. Schizophr Bull. 2009 Sep;35(5):894-908. Yung AR, McGorry PD. The prodromal phase of first-episode psychosis: past and current conceptualizations. Schizophr Bull. 1996;22(2):353-70. Review. References (3)
- 38. “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group Teenagers in Special Schools
- 39. “Normal” Family history of psychosis Schizotypal personality Prodromal Help seeking group Teenagers in Special Schools
Hinweis der Redaktion
- Wikipaedia definitions In medicine, a prodrome is an early symptom (or set of symptoms) that might indicate the start of a disease before specific symptoms occur. Prodromes may be non-specific symptoms or, in a few instances, may clearly indicate a a particular disease, such as the prodromal migraine aura. A prodrome for schizophrenia is the period of decreased functioning that is postulated to correlate with the onset of psychotic symptoms. The concept has been reconsidered as the pathways to emerging psychosis have been investigated since the mid 1990's. [1]. The term at risk mental state is sometimes preferred, as a prodromal period can not be confirmed unless the emergence of the condition has occurred. (also see early psychosis). Early intervention in psychosis From Wikipedia, the free encyclopedia Jump to: navigation, search Early intervention in psychosis is a clinical approach to those experiencing symptoms of psychosis for the first time. It forms part of the new prevention paradigm for psychiatry[1][2] and is leading to reform of mental health services,[3] especially in the United Kingdom.[4][5] There has been considerable academic interest over the past decade.[6] This approach centers on the early detection and treatment of early symptoms of psychosis during the formative years of the psychotic condition. The first three to five years are believed to be a critical period.[7] The aim is to reduce the usual delays to treatment for those in their first episode of psychosis. The provision of optimal treatments in these early years is thought to prevent relapses and reduce the long term impact of the condition. It is considered a secondary prevention strategy. The duration of untreated psychosis (DUP) has been shown as an indicator of prognosis, with a longer DUP associated with more long term disability.[8] Contents [hide] Components of the model Early psychosis treatment teams Early detection function Prodrome or "at risk mental state" clinics History Clinical outcome evidence Current literature on cost Reform of mental health services United Kingdom Australia and New Zealand Scandinavia North America Asia See also References External links [edit] Components of the model There are a number of functional components of the early psychosis model,[9][10][11] and they can be structured as different sub-teams within early psychosis services. The emerging pattern of sub-teams are currently: [edit] Early psychosis treatment teams Multiple discipline clinical teams providing an intensive case management approach for the first three to five years. The approach is similar to assertive community treatment, but with an increased focus on the engagement and treatment of this previously untreated population and the provision of evidence based, optimal interventions for clients in their first episode of psychosis. For example, the use of low-dose antipsychotic medication is promoted ("start low, go slow"), with a need for monitoring of side effects and an intensive and deliberate period of psycho-education for patients and families that are new to the mental health system. Interventions to prevent a further episodes of psychosis (a "relapse") and strategies that encourage a return to normal vocation and social activity are a priority. There is a concept of phase specific treatment for acute, early recovery and late recovery periods in the first episode of psychosis. [edit] Early detection function Interventions aimed at improving the detection and engagement of those early in the course of their psychotic conditions.[12] Key tasks include being aware of early signs of psychosis and improving pathways into treatment. Teams provide information and education to the general public and assist GPs with recognition and response to those with suspected signs, for example, EPPIC's[13] Youth Access Team (YAT)[14] (Melbourne), OPUS[15] (Denmark) TIPS,[16] (Norway), REDIRECT[17] (Birmingham), LEO CAT (London).[18] [edit] Prodrome or "at risk mental state" clinics Specialist services for those with subclinical symptoms of psychosis or other strong indicators of risk of transition to psychosis. The PACE clinic in Melbourne, Australia, is considered one of the origins of this strategy,[19] along with the Institute of Psychiatry based service OASIS in South London, [20] and Yale Medical School based clinic, PRIME. These services are able to reliably identify those at high risk of developing psychosis [21] and are beginning to publish encouraging outcomes from randomised controlled trials that reduce the chances of becoming psychotic,[22] including evidence that psychological therapy [23] and high doses of fish oil [24] have a role in the prevention of psychosis. [edit] History Early intervention in psychosis is a preventative approach for psychosis that has evolved as contemporary recovery views of psychosis and schizophrenia have gained acceptance. It subscribes to a "post Kraepelin" concept of schizophrenia, challenging the current assumptions originally promoted by Emil Kraepelin in the 19th century, that schizophrenia (or dementia praecox) was a condition with a progressing and deteriorating course. Psychosis is now formulated within a diathesis–stress model, allowing a more hopeful view of prognosis, and expects full recovery for those with early emerging psychotic symptoms. It is more aligned with psychosis as continuum (such as with the concept of schizotypy) with multiple contributing factors, rather than schizophrenia as simply a neurobiological disease. Within this changing view of psychosis and schizophrenia, the model has developed from a divergence of several different ideas, and from a number of sites beginning with the closure of psychiatric institutions signaling move toward community based care.[25] In 1986, the Northwick Park study[26] discovered an association between delays to treatment and disability, questioning the service provision for those with their first episode of schizophrenia. In the 1990s, evidence began to emerge that cognitive behavioural therapy was an effective treatment for delusions and hallucinations[27][28][29]. The next step came with the development of the EPPIC early detection service in Melbourne, Australia in 1996[13] and the prodrome clinic led by Alison Yung. This service was an inspiration to other services, such as the West Midlands IRIS group, including the consumer non-governmental organisation Rethink; the TIPS early detection randomised control trial in Norway;[16] and the Danish OPUS trial.[15] In 2001, the United Kingdom Department of Health called the development of early psychosis teams "a priority."[30] The International Early Psychosis Association, founded in 1998, issued an international consensus declaration together with the World Health Organisation in 2004.[31][32] Clinical practice guidelines have been written by consensus.[10] [edit] Clinical outcome evidence An early psychosis approach has been shown in formal studies to reduce the severity of symptoms, improve relapse rates, and decreases the use of inpatient care, in comparison to standard care, at 18 months follow up. These studies also clearly show greater levels of user satisfaction with the service.[33][34][35] Although the evidence for an ongoing positive impact has yet to be established,[36] some have noted that the underlying assumptions and lack of evidence for the current late intervention standard service approaches make the rationale early intervention "overwhelming".[37] The earlier 2006 Cochrane review continues to report a lack of strong research evidence for specific early detection and early intervention programmes, although it does acknowledge the need to intervene earlier for those with psychosis.[38] Since that time, the emerging evidence on treatment outcome for early psychosis is positive.[39] [edit] Current literature on cost Evidence from the United Kingdom suggests that the costs of an early psychosis service are considerably less compared to standard care with one year costs for early psychosis teams (£9,422) two thirds the cost of standard teams (£14,394).[40] This is maintained at Year 3 and is thought to be due to the reduced inpatient costs with the more intensive community follow up provided by early psychosis services. An Australian historical comparison of direct health costs found a clear economic advantage for an early psychosis approach compared to standard care, at 12 month follow up.[41] Another report, commissioned by Orygen Research Centre in Melbourne, concludes: :EI not only costs nearly $AUS2000 less per person annually than TAU (treatment as usual) in trial-related costs, it also saves nearly $AUS1500 in health system and other financial costs...total saving to society of nearly $AUD9000 per patient per year.[42] This does not take into account the potential benefits of EI in reducing suicides and positive impact on vocational outcomes. [edit] Reform of mental health services [edit] United Kingdom The United Kingdom has probably made the most significant service reform with their adoption of early psychosis teams, with early psychosis now considered as an integral part of comprehensive community mental health services. The Mental Health Policy Implementation Guide outlines service specifications and forms the basis of a newly developed fidelity tool.[30] [43] There is a requirement for services to reduce the duration of untreated psychosis, as this has been shown to be associated with better long term outcome. The implementation guideline recommends: 14 to 35 year age entry criteria First three years of psychotic illness Aim to reduce the duration of untreated psychosis to less than 3 months Maximum caseload ratio of 1 care coordinator to 10–15 clients For every 250,000 (depending on population characteristics), one team Total caseload 120 to 150 1.5 doctors per team Other specialist staff to provide specific evidence based interventions [edit] Australia and New Zealand Services have spread from the origin founding EPPIC initiative in Melbourne (Victoria, Australia) since the 1990s.[citation needed] New Zealand has operated significant early psychosis teams for more than ten years, following the inclusion of early psychosis in a mental health policy document in 1997.[44] There is a national early psychosis professional group, New Zealand Early Intervention in Psychosis Steering Group, organising training events and producing local resources. [edit] Scandinavia Early psychosis programmes have continued to develop from the original TIPS services in Norway[16] and the OPUS randomised trial in Denmark.[15] [edit] North America Canada has extensive coverage across most provinces, including established clinical services and comprehensive academic research in British Columbia (Vancouver), Alberta (EPT in Calgary), and Ontario (PEPP, FEPP). [edit] Asia The first meeting of the Asian Network of Early Psychosis (ANEP) was held in 2004. There are now established services in Singapore[45] and Hong Kong.[46] [edit] See also Schizophrenia Recovery model Deinstitutionalisation [edit] References ^ McGorry PD, Killackey EJ (2002). "Early intervention in psychosis: a new evidence based paradigm". Epidemiol Psichiatr Soc 11 (4): 237–47. PMID 12585014. ^ McGorry PD, Killackey E, Yung A (October 2008). "Early intervention in psychosis: concepts, evidence and future directions". World Psychiatry 7 (3): 148–56. 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- No clear corrections for multiple comparisons in EHRS
- Limitation: 27 variables tested, no apparent correction for multiple comparisons
- 240 young people between 13 and 22 years of age who were in special schools
- No clear corrections for multiple comparisons
- Dynamic changes in male and female teenagers with schizophrenia. A consistent pattern of progressive gray matter loss, in parietal, frontal, and temporal cortices, is observed in independent groups of males and female patients. A single pattern is observable in both boys and girls, supporting the anatomical specificity of the findings.