EVIDENCE AND PERSPECTIVES IN EARLY RECOGNITION AND INTERVENTION FOR PSYCHOSIS and BEYOND. Patrick McGorry

Transcription

1 EVIDENCE AND PERSPECTIVES IN EARLY RECOGNITION AND INTERVENTION FOR PSYCHOSIS and BEYOND Patrick McGorry

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4 TOTAL IEPA MEMBERS PER YEAR Members

5 T. Insel (Arch Gen Psychiatry 2009, 66: ) Currently, mental disorders are diagnosed by symptoms that emerge at a late stage, presumably years after brain systems veer from more typical development. Diagnosing schizophrenia or bipolar disorder with the emergence of psychosis may be analogous to diagnosing coronary artery disease by myocardial infarction. One of the most hopeful approaches to reducing the morbidity and mortality of serious mental illness borrows a page from the cardiology playbook. By developing biomarkers for early diagnosis, we may be able to preempt many of the most disabling aspects of our most severe mental illnesses.

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8 Progression through the prodromal period mania depression mania depression mania depression psychosis psychosis Psychosis schizophrenia Stage 1a Stage 1b Stage 2+

9 Symptom-Disability Gap in Early Psychosis Disability Symptoms Providing access during usually prolonged phase when major psychosocial disability develops (Agerbo et al 2003)

10 ATTRACTIONS and ADVANTAGES Enabling access and intervention as soon as need for care and helpseeking occur not until some arbitrary threshold reached If sustained psychosis develops DUP kept to a minimal level Engagement and trust developed before severe psychosis impairs insight Prevention of collateral damage including suicidal behaviour, substance abuse, vocational failure, social exclusion, family stress, forensic problems. Attenuation and perhaps prevention of psychosis and schizophrenia in some cases Key concept: Primary prevention of secondary disorder(s) (Kessler)

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14 Transition from UHR to frank psychosis by centre Service Total sample Psychotic PACE Melbourne (34.6%) PACE Melbourne % PRIME Yale 14 7 (50%) CARE San Diego 25 4 (16%) EDIE Manchester 23 5 (22%) PAS Newcastle, NSW 74 50% EASY Hong Kong (29%) RAP NYC 34 9 (26.5%) NAPLS US/Canada (35%)

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16 Current SCID-I Dx PACE 400 N = 354 (completers, refusers, cannot be found)

17 J Clin Psych in press (available on line 2009)

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19 Treatment Delay, DUP and TIPS: McGlashan/Johannessen/Vaglum (Larsen et al, Melle et al ) ED reduces suicidal behaviour and other collateral damage at entry but lowering threshold to care Even long DUP cases are in better shape Effects of NS persist - that is lower NS at 12, 24 months and 5 years IC and DT both needed

20 EARLY INTERVENTION: Phase- and needs-specific content: a focus for EBM in FEP Atypicals vs Typicals (Emsley et al 1999, Lieberman et al 2003, Schooler et al 2003) CATIE and CUtLASS - focused on established schizophrenia EUFEST (Kahn et al 2008) Dose-finding (Merlo et al 2002, McGorry et al 2003, Berger et al 2008) Adjunctive Therapies (EPA: Berger et al 2003, Estrogen: Kulkarni et al 2001, NAC: Berk et al 2008) Duration of initial medication (Gitlin et al 2002, Robinson et al 1999) Psychological Interventions for recovery, TR, cognitive deficits (Jackson et al 1998, 2001, 2008 Lewis et al 2002, Birchwood, Edwards etc) Guided Discontinuation/Intermittent vs Continuous therapy (Gaebel et al 2002; Wunderinck et al 2007) Vocational Recovery (Killackey et al 2008, Nuechterlein et al in press; Fowler et al 2009) Relapse Prevention (Gleeson et al 2008 Alvarez et al 2009) Suicide prevention (Power et 2003) Comorbidity esp SUD (Edwards et al 2002)

21 GAF Score LEO Trial Results Social Functioning at 18 months: GAF (N=98) (Craig, Garety et al, 2003) p<0.01

22 Means OPUS trial psychotic symptoms at one- and two-year follow-up p=.001 p=.001 p=.02 p=.02 Integrated care Standard care p=.5 p=.06 Psychotic dimension Negative dimension Disorganised dimension Psychotic dimension Negative Disorganised dimension dimension One-year follow -up Psychopathology Tw o-year follow -up

23 COMMENT No difference in 5 year as compared to 2 year clinical outcomes However still underpowered to detect moderate rather than large effects Social benefits maintained eg independent living and hospital readmission rates

24 Potential Impact of Early Intervention Strategies

25 EI Model and Dose Effects Fowler et al (in press) Generic CMHT 15% Full recovery at 12 months Partial EI service 24 % Full recovery at 12 months Fully Fledged EIS 52% Full Recovery at 12 months

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27 The EPPIC economic evaluation study Mihalopoulos et al 2009 Interviewed EPPIC cohort (n=51) 32 EPPIC clients Matched controls (n=51) 33 matched controls not interviewed 12 refused interview 3 lost to follow-up 4 deceased 6 refused interview 9 lost to follow-up 3 deceased T3 long-term evaluation The EPPIC long-term follow-up study (723 patients) ~1 year after initial stabilization T4 ~7.5 years

28 Long-term outcomes: psychopathology, functioning and quality of life The EPPIC group: showed a lower level of positive psychotic symptoms (p=0.007) and overall better functioning (p=0.039) showed higher levels of past and current paid employment 31.3% of the EPPIC group were currently employed, compared to 15.2% of the control group 56.3% of the EPPIC group had been employed during the last 2 years of the follow-up period, compared to 33.3% of the control group were less reliant on government support The EPPIC group received disability support for 49.5% of the previous 2 years, compared to 62.3% for the control group

29 Long term outcomes: course of illness The EPPIC group: were significantly more likely to achieve symptomatic remission on both the BPRS criteria (OR=4.5; 95% CI (1.4, 13.7)) and the BPRS-SANS criteria (OR=3.3; 95% CI (1.02, 10.3)) achieved social and vocational recovery more frequently than the control group 33.4% of the EPPIC group recovered, compared to 21.2% of the control group showed a more favourable course of illness over the last 2 years of the follow-up period ( 2 =9.0; df=2; p=0.011) 62.5% were not actively psychotic, compared to 33.3% of the control group 18.8% were continuously symptomatic compared to 54.5% of the control group

30 Overall costs The total mean health care costs (discounted) per patient for the EPPIC group were ~ $48,000 lower than those for the control group (95% bootstrap interval $18,160 - $85,591; p<0.01) The average yearly health care cost for the EPPIC group was around one third that of the control group ($1,115 versus $2,962; discounted) The control group used significantly more inpatient and outpatient services than the EPPIC group Medication costs were similar for both groups

31 Mean length of follow-up, years Mean cost per patient Mean cost per patient, per annum 95% BI (bootstrap interval) Long term cost results Control 7.25 ± 1.6 EPPIC 5.91 ± 0.7 Total costs (2000/2001 AUD) Undiscounted Total costs (2000/2001 AUD) Discounted Control $77,006 $68,863 EPPIC $22,717 $20,377 Control $10,627 $9,503 EPPIC $3,841 $3,445 Control Incremental difference (bootstrap) pre- EPPIC versus EPPIC $43,360 - $116,203 $38,782 - $104,042 EPPIC $13,843 - $33,448 $12,625 - $29,922 Mean $48,487 95% UI $18,161 - $85,592

32 Is early intervention in psychosis cost-effective? Specialized programmes delivering timely and assured care during the early illness period give better clinical and functional outcomes at a third of the cost of standard public mental health services Investment in early intervention programmes provides excellent value for money and should be considered as an additional stream of care within the specialist mental health services

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34 Early Intervention: A general principle in modern healthcare

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36 STRENGTHENING THE SYSTEM WHERE IT S WEAKEST.. Early Intervention and Developmentally Appropriate Mental Health Care for Young People Aged 12-25

37 Two Complementary Paradigms EPIDEMIOLOGICAL/ONSET OF DISORDER: EARLY INTERVENTION:POPULATION HEALTH DEVELOPMENTAL/TRANSITION: TRANSITION AGE YOUTH

38 Disease Incidence over Age

39 Prevalence and Service Use

40 Access and Engagement

41 Current health/welfare service system for young people Primary Secondary Tertiary

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43 National Health and Hospitals Reform Commission 2009

44 BECAUSE MENTAL HEALTH MATTERS 2009

45 New Structure for Expanded Child and Youth Mental Health Services for Victoria, Australia 2009

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47 Mavis Street Footscray

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50 headspace Western Melbourne

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54 SUMMARY Pattern of onset and the concentration on young people years No system of care which provides access and engagement for young people Need for EI to spread across diagnostic silos Progress in some societies but limited in many others Innovators, early adopters, early and late majority and laggards Need to learn the lessons of wider early diagnostic efforts in medicine EI has a great deal to offer psychiatry as a field Need a youth focus