Early detection and intervention of psychosis

Early detection and intervention of psychosis New Data Benno G. Schimmelmann University Hospital of Child and Adolescent Psychiatry Bern, Bern, Switzerland

Early detection of psychosis

Early Detection Premorbid Prodrome DUP Treatment Detect patients at risk Shorten DUP

Detect people at risk for developing psychosis Premorbid Prodrome DUP FT Detect patients at risk

At Risk Criteria UHR and Basic Symptoms UHR APS: Attenuated Psychotic Symptoms BLIPS: Brief Limited Intermittent Symptoms State/Trait Criteria: incl. family history and decline in social functioning Basic Symptom Criteria (SPI-A/SPI-CY: Schizophrenia Proneness Instrument) COGDIS: Cognitive disturbances (e.g., thought interference, disturbances of abstract thinking, receptive speech disturbances, etc.) COPER: cognitive disturbances and a few predictive perceptive disturbances

Course of «at-risk states» Help-seeking patients with at-risk states over a 3 year period: 1,2 Conversion to psychosis about 30% Persistence of at-risk symptoms about 30% Remission at-risk symptoms about 30% 1 Salokangas RKR et al. (2012) Schizophr Res 138:192-197 2 Dylan GG & Cannon TD (2011) Rev Bras Psiquitaria 33 (supp II)

EUROPEAN PSYCHIATRIC ASSOCIATION GUIDANCE ON THE EARLY DETECTION OF CLINICAL HIGH RISK STATES OF PSYCHOSES 7

UHR AS INCLUSION CRITERIA: TRANSITION RATES META-ANALYSIS FOR THE GUIDANCE PROJECT OF THE EUROPEAN PSYCHIATRIC ASSOCIATION 8

BASIC SYMPTOMS AS IC: TRANSITION RATES META-ANALYSIS FOR THE GUIDANCE PROJECT OF THE EUROPEAN PSYCHIATRIC ASSOCIATION 9

CHR: 2-YEAR TRANSITION RATES CRITERIA META-ANALYSIS FOR THE GUIDANCE PROJECT OF THE EUROPEAN PSYCHIATRIC ASSOCIATION * as examined in the respective studies 10

UHR: 2-YEAR TRANSITION RATES AGEEFFECTS META-ANALYSIS FOR THE GUIDANCE PROJECT OF THE EUROPEAN PSYCHIATRIC ASSOCIATION 11

EPA GUIDANCE ON THE EARLY DETECTION OF CLINICAL HIGH RISK STATES OF PSYCHOSES - RECOMMENDATIONS Recommendation 1 three CHR criteria should be alternatively used in the early detection of psychosis: at least any one attenuated psychotic symptom that meets the additional requirements of either SIPS or early CAARMS at least any two self-experienced and self-reported cognitive basic symptoms according to the SPI-A at least any one transient psychotic symptom that meets the additional requirements of either SIPS or early CAARMS 12

EPA GUIDANCE ON THE EARLY DETECTION OF CLINICAL HIGH RISK STATES OF PSYCHOSES - RECOMMENDATIONS Recommendation 3 a significant decline in occupational and/or social functioning (and, relatedly, in productivity) should not be an obligate requirement in the above CHR criteria Recommendation 4 CHR criteria should only be applied in persons already distressed by mental problems and seeking help for them or persons seeking clarification of their current risk for a vulnerability for psychosis, e.g., by genetic risk. Any clinical screening of other persons seems not warranted by current scientific evidence. 13

EPA GUIDANCE ON THE EARLY DETECTION OF CLINICAL HIGH RISK STATES OF PSYCHOSES - RECOMMENDATIONS Recommendation 5 CHR criteria should only be used and communicated with outmost care in children and young adolescents in whom they should nevertheless be assessed and monitored. In late adolescence, however, the CHR criteria seem to be as applicable as in adults. Recommendation 6 a trained specialist (psychiatrist, clinical psychologist or equivalent mental health professional) with sufficient experience in CHR should carry out the assessment;... Case conferences with experts in early detection of psychoses are even advised for mental health specialists. 14

EUROPEAN PSYCHIATRIC ASSOCIATION GUIDANCE ON THE EARLY INTERVENTION IN CLINICAL HIGH RISK STATES OF PSYCHOSES 15

EFFECTS OF PSYCHOLOGICAL / PHARMACOLOGICAL INTERVENTIONS ON TRANSITION RATES Follow-up period 16

ASSOCIATIONS BETWEEN AGE AND EFFECTS OF INTERVENTIONS ON TRANSITION RATES Youth: 50% minors with mean age 18 yrs and SD 18 yrs Adult: <50% minors and mean age > 18 yrs Between-sub-group effects n.s. Follow-up period 17

EPA GUIDANCE ON THE EARLY DETECTION OF CLINICAL HIGH RISK STATES OF PSYCHOSES - RECOMMENDATIONS Recommendation 1 (grade D) early intervention in patients presenting with a clinical high risk (CHR) of psychosis should not only aim to prevent the first episode of an affective or non-affective psychotic disorder but also the development of functional, i.e. social, educational or vocational deficits Recommendation 2 (grade C) psychosis-preventive intervention requires that the CHR status was assessed in full accordance with the EPA guidance on early detection of psychosis Recommendation 3 psychological, in particular CBT, as well as pharmacological interventions are able to prevent or at least postpone a first psychotic episode in adult CHR patients 18

EPA GUIDANCE ON THE EARLY INTERVENTION IN CLINICAL HIGH RISK STATES OF PSYCHOSES - RECOMMENDATIONS Recommendation 4 (grade D) in adult CHR patients a staged intervention model should be applied with the least restrictive service approach, i.e., CBT, being offered as first choice. Where psychological interventions have proved ineffective, they should be complemented by low dose second-generation antipsychotics in adult CHR patients if severe and progressive CHR symptomatology (APS with only minimal or clearly declining insight, or BLIPS in higher or increasing frequency) is present and with the primary aim to achieve a degree of symptomatic stabilization that is required for psychological interventions to be effective. Thus, any long-term antipsychotic treatment with a primarily preventive purpose is not recommended 19

EPA GUIDANCE ON THE EARLY DETECTION OF CLINICAL HIGH RISK STATES OF PSYCHOSES - RECOMMENDATIONS Recommendation 6 (grade D) the current evidence for the psychosis-predictive value of CHR criteria and for the efficacy of psychological and pharmacological interventions in children and young adolescents is not sufficient to justify primarily preventive interventions Recommendation 7 (grade A) in children and adolescents, specific psychological interventions with the aim to improve functioning should be provided as part of an overall treatment plan 20

EARLY DETECTION OF PSYCHOSIS Epidemiology of At-Risk symptoms & criteria

Bedarf für epidemiologische Daten zu Risikokriterien At-risk criteria in GPS common rare not predictive of conversion predictive of conversion clinically not significant clinically significant revise criteria! Encourage help-seeking!

Schultze-Lutter et al. Schizophrenia Bulletin 2014 Schimmelmann et al. World Psychiatry in press

background UHR Risk symptoms and criteria of psychosis only studied in helpseeking samples Moreover, no epidemiological study on age effects in prevalence and clinical significance of UHR Indications of higher prevalence of perceptive risk symptoms (attenuated or brief limited intermittent hallucinations) in children

Sample BEAR study: 1 229 interviews; participation 66% BEARS-Kid study: 119 interviews; participation 42% Exclusion: Lifetime psychosis, severe language problems 154 children/adolescents matched for gender and highest educational level of parents (8-12 yrs. (n=45), 13-15 yrs. (n=31), 16-17 yrs. (n=78)) 535 adults (18-19 yrs. (n=81), 20-24 yrs. (n=155), 25-29 yrs. (n=144), and 30-40 yrs. (n=155))

Assessments Telefone interviews: Ultra-High Risk (UHR) symptoms/critieria: with the Structured Interview of Psychosis-Risk Syndromes (SIPS) recent psychosocial functioning deficit: Social and Occupational Functioning Assessment Scale (SOFAS 70) Axis-I disorder: Mini-International Neuropsychiatric Interview, adult, und child and adolescent version (M.I.N.I. / M.I.N.I. Kid) trained and supervised psychologists excellent agreement (78% 100%) of telephone und face-to-face assessment of at-risk symptoms & criteria (Michel et al., 2014, Schizophrenia Research)

Results: prevalence at least 1 UHR symptom: 9.9% (APS, no BLIPS) at least 1 perceptive APS (P4): 4.9% at least 1 non-perceptive APS: 6.1% unusual thought content: 6.0% delusional ideas: 3.0% ideas of grandiosity: 0.3% disorganized communication: 0.7% at least 1 APS criterion: 1.3% = 13.2% in those with at least 1 UHR symptom

Results: age effects strong age effects for perceptive APS: more common in 8-15yo compared to 16-40yo no age effects for non-perceptive APS

Results: clinical significance In total sample: perceptive APS only weakly associated with functioning & axis I diagnosis Non-perceptive APS clearly associated with functioning & axis I disorder Age effects: no age effect regarding the association of APS and axis I disorder children (< 16yo) with non-perceptive APS less likely to have low functioning than adolescents and adults (Schimmelmann et al. World Psychiatry in press)

Conclusions Perceptive APS more common in children < 16yo seemingly less persistent into adulthood No age effects in prevalence of non-perceptive APS Yet, non-perceptive APS in children < 16yo less likely associated with psychosocial functioning deficit Lets see how persistent APS really are and how predictive of conversion of psychosis!

Early Detection of Psychosis Service implementation & Intervention

Implementing an ED service Service-related recommendations create a specialized service together with adult psychiatry, e.g., age-range 8-40y out of psychiatric hospital (non-stigmatizing) good service for referring professionals awareness campaigns (flyer, webpage, conferences) for professionals (pediatrics, general medicine, educational system, family councelling ) for potential clients: be carefull! (www.fetz/gef.be.ch)

Implementing an ED service Client-related recommendations diagnostic process takes 3-5 hours but is well received reflect upon what you do, if an underaged client fulfills at-risk criteria talk about the symptoms yes! talking about psychosis risk be carefull but not anxious (short term) psychotherapy and monitoring yes! psychopharmacological treatment be careful! Schimmelmann et al. Eur Child Adolesc Psychiatry 2012

Thank you for your attention!