Prevention and Recovery in Early Psychosis

Prevention and Recovery inEarly Psychosis

Name of Presenter

UCSFDate

Name of Presenter

FSADate

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

PREP Target Population

1. Recent-onset Psychosis:• Diagnosis of schizophrenia, schizophreniform or

schizoaffective disorder• Onset of full psychosis within the past 5 years

2. 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

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

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

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

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

Discover 2 by Suellen Parker

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

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

Voices by Suellen Parker

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

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

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

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

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)

Adapted from Crow et al. (1986). Brit J. Psychiatry, 148, 120-127.

Benefits of Early Intervention

• Duration of Untreated Psychosis vs. Rate of Relapse

6 12 18 240

102030405060708090

Short DUP (< 1 year) Long DUP (≥ 1 year)

# Months after treatment entry

% P

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PREP Services and Eligibility

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

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

- Outreach- Marketing- Community

Education- Stigma Reduction

PREP Collaborative

• A community partnership between:

- Training- Conducting PREP

assessments & intake

- Connecting mental health professional community to PREP services

- Program evaluation

- Connecting homeless youth to PREP services

Sojourner

- Administration of PREP program- Administration of PREP services- Training and Clinical Supervision

- Program Development

- Providing emergency care to those in need

- Connecting foster youth, at-risk families and juvenile justice system to PREP services

PREP is funded by CA Mental Health Services Act (Prop 63)

LSYSMHA-SFUCSF

FSASF

CBHS DPH

CARE Management

Algorithm-based medication management

Cognitive Behavioral Therapy (CBT)

Multi-Family Group Therapy (MFG)

Formal Diagnostic Assessment

Thorough, reliable diagnosis and comprehensive assessment of symptoms

Education/Employment Support

Substance Abuse Services

For 2 years, Care Manager addresses the broad spectrum of client and family needs

Participating families receive support from other families experiencing similar challenges

Ensures that patient choices are informed and respected and symptoms are managed at the lowest possible dose

Focuses on how a person thinks and acts. Jointly identifies problem areas in the client's life and develops specific goals to target them

Care managers work with clients to resolve issues that arise in school or on the job, and to meet their professional development goals

PREP takes an integrated approach, holding the principles of harm-reduction and meeting clients where they are

PREP Roster of Services

**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. **

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

PREP Eligibility

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

Hebrew

Assessments and Referrals

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

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 information

Step 3. Arrange appointment for PREP staff to meet client/family on unit or have them call PREP to complete phone screen.

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

The PREP Intake Process

PREP Online Screening Survey

• PQ-B (Prodromoal Questionanaire) 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

Talking About Psychosis

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

1. Hanssen, et al. (2003) Acta Psychiatr. Scand. 107 (5), 369-77.2. Armando, et al. (2010) Schizophrenia Research, 119 (1-3), 258-265.

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

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?

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

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

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!

Preliminary outcomes

Since September 2009, 69 clients have been served.

18 Ultra High Risk

20 Recent-Onset

• Only 4 developed full psychosis

• 2 hospitalized

• 26 hospitalizations prior to program entry

• 5 inpatient hospitalizations after entering program

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

PREP Referrals

Call:

(415) 476-7278

Visit:

www.prepwellness.org