Episode II: Understanding and preventing relapse after first episode psychosis

1. Episode II: Understanding and preventing relapse after first episode psychosis Assoc. Professor John Gleeson Department of Psychology, The University of Melbourne & Northwestern Mental Health

2. Overview • The onset phase of psychosis • Why psychological treatments in FEP? • Treatment targets in psychosis? • What are the foundations of psychological treatment in FEP? • Some outstanding clinical and research issues for EI

3. The onset phase of psychosis • The confusing, fragmenting, and traumatic nature of symptoms • Highly developmentally dynamic and sensitive period • High risk phase • Life interrupted….

4. The onset phase of psychosis First treatment First-episode acute phase Untreated psychosis Symptom severity Prodrome Early recovery Late recovery Time

5. First treatment Duration of Untreated psychosis (DUP) Response time Symptom severity Remission Time

6. Why psychological treatments? Are not biological models and treatments the critical factors?

7. Limitations of biological treatments • 10-30% fail to remit by 12 months (Emsley et al. 2007)) • Up to 40% may only partially recover • The problem of relapse • Adherence rates (Lieberman et al., 2005; Meltzer 2006) • Side-effects • Secondary morbidity and co-morbidity • Unemployment and functioning (Killackey et al.)

8. Emil Kraepelin Eugen Bleuler Kurt Schneider

9. Stress Vulnerability Model of Psychosis • Genetic & Early Risk Factors • Genetic mechanisms • Neurodevelopmental disorder • Environmental risk factors • Vulnerability • breakdown in automatic cognitive processes • anomalous experiences • related to onset of psychosis Substance Abuse Stress Life Events Psychosis

10. Integrated model of psychosis: Garety et al. 2001

11. A specific pathway from adversity to paranoia? (Bentall 2008)

12. Social anxiety as secondary morbidity (Birchwood et al., 2006) • 79 people with FEP assessed for social anxiety • 23 socially anxious (29%) and 56 non-anxious • Not predicted by psychotic symptoms, or premorbid functioning • Assessed on measures of shame/stigma of psychosis and perceived social status • controlled for depression, psychotic symptoms and general psychopathology. • Participants with social anxiety experienced greater shame with their diagnosis • Saw themselves as socially marginalized with low social status

13. Post-psychotic depressionBirchwood et al. 2000 (n = 78) • 36% developed post psychotic depression (PPD) 12 months post acute phase • 54% of patients with PPD suicidal • 18% had made suicidal plans • 4% had undertaken a suicide attempt • 36% of those with PPD had persistent sense of hopelessness • 50% of FEP developed PPD

14. From Birchwood et al., 2000 (N = 78) n = 26 n= 13

15. 35 FEP patients • 80% described being traumatized by psychosis • 38% symptomatic for PTSD • Associated with involuntary hospitalization • 31% said they had attempted suicide • May be linked with PTSD symptoms

16. Implications for psychological treatments • Developmentally sensitive phase • The role of emotion, cognitive biases and appraisal in mediating acute symptoms • The high risks of secondary psychological morbidity • The role of appraisal in mediating secondary morbidity • The risks of further setbacks or relapses • The possibilities for prevention…

17. What are the treatment targets in psychosis?

18. What are the treatment foci of CBT for psychosis • Prevention or delay of onset • Acute phase • Treatment of persistent positive symptoms • Psychological recovery • Cognitive Remediation • Adherence with medication • Cannabis and psychosis • Relapse prevention • Vocational recovery

19. The evidence for CBT for psychosis (Wykes et al., 2007) • 34 studies included • Overall beneficial effects for the target symptom (effect size = 0.400) • Including effects for: • Positive symptoms (n = 32) • Negative symptoms (n = 23) • Functioning ( n = 15) • Mood (n = 13) • Social anxiety (n = 2)

21. But a cautionary note – methodological rigour does matters! • Trials with raters aware of group allocation had an inflated effect size • Some doubt therefore about secondary benefits (Tarrier et al. 2005; Wykes et al. 2007)

22. Matching of psychological interventions to stage of psychosis Integrated therapy CBT for acute phase Relapse prevention? CBT for ultra high risk state Cannabis Family based interventions COPE for recovery Time Relapse prevention for schizophrenia and bipolar

23. The SoCRATES trial Tarrier et al., 2004

24. CBT in early psychosis • Far fewer trials • Sample sizes an issue • Effects of smaller magnitude • Difficulties showing significant treatment effects compared to control interventions • Difficulties showing sustained effects of specific interventions • Treatment as usual often of a high standard

26. The importance of treatment context

27. Can specific psychological interventions improve upon specialist first episode care? The example of relapse…

28. Episode II: Prevention of relapse following early psychosis John Gleeson Darryl Wade Sue Cotton Mario Alvarez Donna Gee Tracey Pearce David Castle Belinda Newman Daniela Siliotacopolous Pat McGorry A Lilly Mac Initiative of the ‘Psychosocial Domain’Supported by an independent research grant from Eli Lilly

29. Rationale • Relapse is common: • 70-82% of FEP patients relapse by 5 years (Robinson et al., 2005) • Distressing for patient and family • Relapse and risk of persistent symptoms (Wiersma et al., 1998) • Treatment costs (Almond et al., 2004) • Prevention may reshape the trajectory of the illness • Comparisons with contemporary specialist FEP care needed

30. Aims • To develop and evaluate the effectiveness of a combined individual and family psychosocial treatment designed to minimize the rate of, and maximize time to, psychotic relapse (positive symptoms), following a first episode of psychosis in young people aged 15-25 years.

31. Hypothesis • Primary: • Remitted FEP patients randomized to a multi-modal targeted RPT + TAU will have: • 1) a lower rate of relapse • 2) a longer time to relapse, • compared with remitted FEP patients who randomized to TAU in a specialist FEP program at 7, 12, 18, 24 and 30 months follow-up • Secondary: • Remitted FEP patients randomized to RPT + TAU will show improved: • 1) medication adherence, psychosocial functioning, and quality of life compared to TAU group • 2) Families receiving RPT would have improved: appraisals of stressors related to caregiving; expressed emotion; and psychological morbidity

32. Design • A randomized trial, with independent rater blind to treatment condition, of a targeted, multi-modal relapse prevention treatment versus treatment as usual in a specialist first-episode service. • 30-month follow-up, post baseline

33. Recruitment and randomization • Recruitment Nov. 2003 to June 2005 • Baseline completed before randomization • RPT • Change in case-manager to research therapists • Therapy within a 7-month window • Frequency matched to standard EPPIC guidelines • Treatment as usual • Guidelines documented • Continue case-management as usual • Psychosocial interventions available

35. Individual therapy 12-13 sessions Family therapy 10-15 sessions Phase 1: Engaging the patient, assessing recovery and risk for relapse. Phase 2: Agenda setting - summarized in a letter Phase 3: Psychoeducation focused on the risk of relapse its prevention Phase 1 Engagement and assessment Phase 2 Psychoeducation regarding psychosis and relapse Early warning signs and relapse plan Phase 5: Optional modules for non-adherence, substance abuse, coping with stress, co-morbid anxiety and depression. Phase 4 Role of family in recovery Phase 5 Needs-based phase which included additional CBT interventions for specific problems Review and termination, booster sessions Structure of RPT

36. Results

40. Results: Time 2 • The relapse rate was significantly lower in the therapy condition (5.3%) compared to treatment as usual (21.8%) (p = 0.042) • Time to relapse was significantly longer for the relapse therapy condition (p = 0.03). • The number needed to treat was 6 to prevent 1 relapse over 7 months. • No differences on any secondary outcome measures Gleeson et al., 2009 Journal of Clinical Psychiatry

41. Family outcome • The RPT group demonstrated significantly greater reductions in appraisal of Negative Symptoms compared withthe TAU group (ECI) • The RPT group had significantly higher mean scores on the Positive Personal Experiences subscale and Total Positive Score compared to the TAU group (ECI) • Main effects for time on EE (FQ) • No effects for psychological morbidity (GHQ 28) Gleeson et al., in press Journal of Clinical Psychiatry

42. Foundations of CBT interventions FEP • Comprehensive psychosocial, diagnostic, and risk assessment • Collaborative, flexible engagement process • Development of individualized formulation for target problems • Sensitivity to development stage • Sensitivity to phase of disorder • Normalizing and interactive approach to psychoeducation • The responsivity principle • Flexibility with respect to involvement of family • Selective use of specific, targeted interventions • Embedded within comprehensive, team-based youth friendly service

43. Some important questions for CBT in FEP • How can we improve upon: • Relapse prevention • Substance abuse • Depression and suicide • Anxiety • Functional impairments & quality of life • Engagement over the long-term? • Outcomes for high risk sub-groups (e.g., co-morbid personality disorders)

44. Study Limitations and strenths • Limitations • Long-term follow-up data not yet analyzed • Cannot separate the contributions of individual and family components • Diagnosis breakdown • Strengths • High quality comparison • Randomization successful • Management of fidelity

45. Psychosocial treatment, antipsychotic postponement, and low does medication strategies in first-episode psychosis…Bola, Lehtinen, Culberg & Ciompi, 2009 • Soteria, USA and Switzerland • Parachute Project • Need-Adapted Treatment

46. Future Directions • When (and for whom) might psychological treatments be enough to minimize relapse? • Using interactive technology as a supplementary engagement tool.