Iepa clinical practice guidelines for arms sh n lewis university of manchester uk
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IEPA clinical practice guidelines for ARMS Shôn Lewis University of Manchester UK. Early phase terminology. High risk Psychosis proneness; schizotypy Isolated psychotic symptoms Psychosis like experiences Non-clinical/subclinical psychotic symptoms Early prodromal Bonn scale

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Iepa clinical practice guidelines for arms sh n lewis university of manchester uk l.jpg

IEPA clinical practice guidelines for ARMSShôn LewisUniversity of Manchester UK


Early phase terminology l.jpg
Early phase terminology

  • High risk

    • Psychosis proneness; schizotypy

  • Isolated psychotic symptoms

    • Psychosis like experiences

    • Non-clinical/subclinical psychotic symptoms

  • Early prodromal

    • Bonn scale

  • At risk mental state

    • Late prodromal

  • First episode psychosis


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Early phase terminology

  • High risk

    • Psychosis proneness; schizotypy

  • Isolated psychotic symptoms

    • Psychosis like experiences

    • Non-clinical/subclinical psychotic symptoms

  • Early prodromal

    • Bonn scale

  • At risk mental state

    • Late prodromal

  • First episode psychosis


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Early phase terminology

  • High risk

    • OLIFE; SPQ

  • Isolated psychotic symptoms

    • LSHS

    • PDI; CAPE

  • Early prodromal: SPIA

  • At risk mental state

    • CAARMS

    • SIPS/SoPS

  • First episode psychosis

    • PANSS etc








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At risk mental state: Yung et al 1998

  • Attenuated positive symptoms

    • subthreshold for severity

  • Brief limited intermittent psychotic symptoms

    • subthreshold for duration (<1 week)

  • Schizotypal personality or first degree relative with psychosis plus recent functional deterioration

  • Seeking help


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High risk of acronyms

  • PACE

  • PRIME

  • EDIE

  • RAP

  • FETZ

  • TOPP

  • PIER

  • OASIS

  • EPOS

  • CARE

  • NAPLS

  • SPAM

    • Society for Prevention of Acronyms in Mental health


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Rates of one year transition ARMS to psychosis (adapted from Lisa Phillips et al 2005)


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IEPA clinical guidelines for early psychosis

  • Formulated Copenhagen 2002

  • 29 authors A-Y

  • Published 2005

  • To be updated 2008

  • Covered

    • ARMS

    • First episode

    • Recovery (6-18 months) and critical period phase

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124


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Prevention in early psychosis

  • Three targets for preventative interventions in early psychosis

    • Prepsychotic phase

    • Initially untreated psychosis

    • First episode

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124


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General statements

  • Early identification will reduce burden

    • May improve long term outcomes

  • Public education important

  • Careful, low dose drug treatment in first episode

  • Psychosocial treatments important in promoting recovery

  • Users and families engaged in developing better treatments

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124


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The prepsychotic period: clinical guidelines

  • At risk mental state needs to be considered in young people with deteriorating functioning or unexplained agitation

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124


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The prepsychotic period: clinical guidelines

  • Help seeking people with ARMS need to be engaged and assessed and offered

    • Regular monitoring and support

    • Specific treatment for depression or substance use

    • Psychoeducation and help to develop coping skills

    • Family education and support

    • Information about risks of psychosis

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124


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The prepsychotic period: clinical guidelines

  • Care offered in a low stigma environment

    • At home; primary care; youth-friendly office-based setting

  • Antipsychotic drugs not usually indicated

    • Exceptions might be risk of suicide or violence, or rapid deterioration

    • If used, regard as therapeutic trial for up to 6 weeks

  • If help declined, consider support from friends and family

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124



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Issues for ARMS interventions

  • Safety and acceptability

  • Efficacy and effectiveness

  • Availability and cost

  • What is the therapeutic target?

    • Prevention versus treatment

  • Ethics

    • Of treatment; Of non-treatment

  • Population impact

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124


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Issues for ARMS interventions

  • Refinement of risk estimates

  • Modifying risk and protective factors

  • Developing a clinical algorithm

    • Psychological intervention first?

    • Drug treatment second?

    • How long for?

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124


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Which psychological intervention?

  • Cognitive therapy (Morrison et al, 2006; Ruhrman et al, 2007)

  • Also? (from psychosis literature)

    • Family intervention

    • CT for relapse

    • Motivational interventions

    • Cognitive remediation


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Which drug treatments?

  • Antipsychotics?

    • Appear effective

      • RCT data with risperidone; olanzapine; amisulpride

    • BUT risks from side effects: low NNT:NNH ratio

    • Doubtful acceptability for many

  • Antidepressants?

    • Anecdotal evidence



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EDIE trial: ResultsTransitions to psychosis at 12 months

Morrison et al, 2004