EarlyPsychosis:EarlyDetection, TimelyManagementand Referral

DrKHYeung MedicalOfficer,DepartmentofPsychiatry,Kowloon Hospital 19December2010

WhatIsPsychosis()?
Abnormalityin
Thought:delusion Perception:hallucination Emotion:inappropriateaffect Behaviour:disorganised

PrevalenceofSchizophrenia
Thelifetimerisk:approximately1% HongKong:about700casesperyear Agesofonset:
Betweenlateteensandmid30s Men:1825years Women:2535years

Sexratio:equal Increasedprevalenceinlowersocioeconomic classes Higherincidencerateforimmigrants

AetiologyofSchizophrenia
Genetic Developmentalfactors
Complicationsduringpregnancyandbirth Borninlatewinterorspring:influenzainfectionin 2nd trimester

Brainabnormalities
Ventricularenlargement Reducedbrainsize
CrashCoursePsychiatry2008

AetiologyofSchizophrenia
Neurotransmitterabnormalities
Dopamine Glutamate 5HT GABA

Lifeevents
Morefrequentlyinthemonthbeforeafirstpsychoticdisorderor relapse

Expressedemotion
Overinvolved,overcritical,orhostiletowardsaschizophrenicpt Morelikelytorelapse

CrashCoursePsychiatry3rdEdition2008

LifetimeRiskofSchizophrenia

CrashCoursePsychiatry3rdedition2008

Stahl'sEssentialPsychopharmacology,3rdedition,2008

Stahl'sEssentialPsychopharmacology3rdEdition2008

MesolimbicDopamineHypothesis

Stahl'sEssentialPsychopharmacology3rdEdition2008

Stahl'sEssentialPsychopharmacology3rdEdition2008

Glutamate&OtherSymptoms

Stahl'sEssentialPsychopharmacology3rdEdition2008

Amygdala

Stahl'sEssentialPsychopharmacology3rdEdition2008

FearfulStimuli&Schizophrenia

Stahl'sEssentialPsychopharmacology2008

NeutralStimuli&Schizophrenia

Stahl'sEssentialPsychopharmacology2008

NegativeSymptomsinProdromalPhase

Stahl'sEssentialPsychopharmacology3rdEdition2008

KeyNegativeSymptomsIdentifiedSolelyonObservation

Stahl'sEssentialPsychopharmacology3rdEdition2008

KeyNegativeSymptomsIdentifiedwithsomeQuestioning

Stahl'sEssentialPsychopharmacology3rdEdition2008

Prognosisof1st EpisodeSchizophrenia

StagesofSchizophrenia

Stahl'sEssentialPsychopharmacology3rdEdition2008

StagesofPsychosis
8stages
0: 1a: 1b: 2: 3a: 3b: 3c: 4: Increasedrisk,nosymptoms Mildornonspecificsymptoms Ultrahighrisk:moderatebut subthresholdsymptoms Firstepisodeofpsychoticdisorder Incompleteremissionfrom1st episode Recurrenceorrelapseofpsychosis Multiplerelapses Severe,persistentorunremittingillness
ModifiedfromMcGorryetal,2006

UltraHighRiskFactors
Ages:
14to29

Atleastoneofthefollowing3groups
Attenuatedpsychoticgroup:
subthreshold,attenuatedpositivepsychoticsymptoms duringthepastyear

Brieflimitedintermittentpsychoticsymptoms group:
episodesoffrankpsychoticsymptomsfor<1week
AlisonR.Yungetal,BJPsych2007

UltraHighRiskFactors
Traitandstateriskfactorgroup:
Schizotypalpersonalitydisorder 1st degreerelativewithapsychoticdisorder Significantfunctioningdecreaseduringtheprevious year

AlisonR.Yungetal,BJPsych2007

Differentoutcomeatagesofonset
Ptswithadolecentonset(ages1518)
Pooreroutcomecomparedwithyoungadult(ages 1930)

Ballageeretal,JAmAcadChildAdolesc Psychiatry.2005Aug;44(8):7829

DurationofUntreatedPsychosis(DUP)
DUP
Thedifferenceintimebetweentheappearanceof psychoticsymptomsandthefirstpsychiatric treatment LongerDUP
Worseclinicalfeatures Poortreatmentoutcome

DUPworldwide:27to322days DUPinHK:
93days,longerDUPinmalepts
JCEPHongKong2010

DurationofUntreatedPsychosis(DUP)
Associatedwith
Increaseddurationoftheacuteepisode(Loebelet al,1992;McGorryetal,1996) Worsecourseandoutcome(Helgason,1990;Haas etal,1998) Increasedriskofrelapse(Crowetal,1993) Psychosocialdecline(Jonesetal,1993) Prolongedmorbidity(Wyattetal,1997)

WarnerR,BrJPsych2005

DUP&BrainMorphology
LongDUPassociatedwithreduceddensities of
therightlimbicarea Therighthippocampus

PenttilaM,etalSchizophrRes.2010

ReducingDUP
Singaporeexperience
Method
Compare2groupsof1st episodepsychosisbeforeand after
Initiationofaprogrammeofpubliceducation Networkingwithprimaryhealthcareproviders

Results
DUPreducedfromamedianof12to4months Increaseselfandfamilyreferrals Decreasepolicereferrals
Conclusion Awarenesscampaignstargetingmultiplegroupswithvariousmodes ofcommunicationareeffectivein influencingtheDUPandpatternsofhelpseeking ChongSA,etal,SocPsychiatryPsychiatrEpidemiol2005

ReducingDUP
Norwayexperience
Method:
Compare2groupsofptswith1st episodepsychosis with(N=108)andwithout(n=75)informationcampaign (IC)fromJan1997toDec2000 toraiseawareness& recognisingpsychosistopublic,schoolsandGPs

Results
NoICperiod:
DUPincreasedupto15weeks Moresymptoms Poorerfunctioning
JoaIetal,SchizophrBull2008

ReducingDUP
HongKongExperience:
EASYProjectsince2001
DUPdecreasedfrom513daysto320days(nearly200 days)

HospitalAuthorityHongKong

st GPTrainingin1

EpisodePsychosis

BirminghamExperience
Method:
3innercityprimarycaretrustsinBirmingham InterventionpracticesaddressingGPknowledge,skills &attitudesabout1st episodepsychosis

LesterH,BirchwoodM,etalBrJGenPract2009

st GPTrainingin1

EpisodePsychosis

Method: Primaryoutcomes: Differenceinthenumberofreferralstoearly interventionservicesbetweenpractices Secondaryoutcomes: Durationofuntreatedpsychosis(DUP) Timetorecovery UseoftheMentalHealthAct GPconsultationrateduringdevelopingillness

LesterH,BirchwoodM,BrJGenPract2009

st GPTrainingin1

EpisodePsychosis

BirminghamExperience
Results 110outof135eligiblepractices(81%)recruited
Referralofyoungpeople:
179 Interventionpractices:97 Controlpractices:82

Secondaryoutcomes:
Noeffect
Conclusion: GPtrainingon1st episodepsychosisisinsufficienttoalterreferralratestoearlyintervention servicesorreducethedurationofuntreatedpsychosis Trainingfacilitatesaccesstothenewspecialistteamforearly psychosis
LesterH,BirchwoodM,BrJGenPract.2009

TreatmentofFirstEpisodePsychosis
Goodsymptomaticresponse Lowerdoseofantipsychoticscomparedwith chronicschizophrenia Moresusceptibletoextrapyramidalside effect Longerexposuretopotentialmetabolic complicationsofnewerantipsychotics

NicolasAetal,BJPsych2010

FirstGenerationAntipsychotics
FGAs FirstEpisode Chrorpromazine200mg Haloperidol 2mg Sulpiride 400mg Trifluoperazine 10mg Relapse 300mg >4mg 800mg 15mg Max 1000mg 30mg/d 2400mg 30mg/d

Sideeffect:Parkinsonlikesymptoms,acutedystonia,akathisia, tardivedyskinesia,neurolepticmalignantsyndromeand hyperprolactinaemia

TheMaudsleyPrescribingGuildelines10thEdition2009,CrashCourse2008

SecondGenerationAntipsychotics
SGAs FirstEpisode Relapse Max Amisulpride 400mg 800mg1200mg/d Risperidone 12mg 34mg16mg/d Olanzapine 5mg 10mg 20mg/d Quetiapine 150mg 300mg800mg/d Ziprasidone 80mg80mg160mg/d
SideEffects:metabolicsyndrom,hyperprolactinaemia& agranulocytosis(Clozapine)
TheMaudsleyPrescribingGuidelines10thEdition2009

st Treatmentof1

EpisodePsychosis

Agreechoiceofantipsychoticwithpt&/orcareror,ifnotpossible:Start SGA Titratetominimumeffectivedose

Adjustdoseaccordingtoresponseandtolerability Assessover68weeks effective Continueatdose establishedas effective Changedrugandfollowabove process.Consideruseofeithera SGAoraFGA Not effective Clozapine
TheMaudsleyPrescribingGuidelines10thEdition2009

Nottolerate orpoor compliance Considerdepot

NonpharmacologicalTreatmentof 1st EpisodePsychosis

Familyintervention Psychotherapy:
Cognitivebehaviouraltherapy

Socialintervention Occupationaltherapy

FactorsAssociatedwithDangerousness Malegender Pasthistoryofviolence Activepsychoticsymptoms

Paranoidplusawishtoharmothers

Alcoholordrugabuse Socialdifficulties

Preparedby17y.opatient'sfatherin2009

Referral
HA:
EASYClinicforagesfrom15to25
29283283 Website:www.ha.org.hk/easy

JECPCentresforagesfrom26to55 Privatepsychiatrists