Co-morbidity in PsychosisCo-morbidity in Psychosisdepression, substance misuse and depression, substance misuse and
neurodvelopmental disordersneurodvelopmental disorders
Alison BlairAlison Blair
Esteem GlasgowEsteem Glasgow
With thanks to Prof. Andrew GumleyWith thanks to Prof. Andrew Gumley
First person perspectiveFirst person perspective
““It is a total psychological experience. There is no It is a total psychological experience. There is no strategies you can make. You just have to sit there and strategies you can make. You just have to sit there and experience-- abuse. And, the most important thing, and I experience-- abuse. And, the most important thing, and I said this to my psychiatrist, is my illness has my entire back said this to my psychiatrist, is my illness has my entire back catalogue <laughs>. It has my entire diary, so it can pick catalogue <laughs>. It has my entire diary, so it can pick things that have happened years ago, show a symbol of it, things that have happened years ago, show a symbol of it, show a picture of it, and it’s a horrible experience because show a picture of it, and it’s a horrible experience because you begin to relive those experiences. You don’t have to you begin to relive those experiences. You don’t have to relive them because they are generally bad experiences, of relive them because they are generally bad experiences, of my schizophrenia, a lot of embarrassment, a lot of my schizophrenia, a lot of embarrassment, a lot of humiliation, and the reasons why they are so bad is that humiliation, and the reasons why they are so bad is that virtual every time I have an attack, the illness goes through virtual every time I have an attack, the illness goes through them and makes you relive them to a certain extent.”them and makes you relive them to a certain extent.”
Quality of Life and PsychosisQuality of Life and Psychosis
• Quality of life is a key dimension of outcome in complex mental Quality of life is a key dimension of outcome in complex mental health problems.health problems.
• Reflects the person’s subjective evaluation of their experience, Reflects the person’s subjective evaluation of their experience, their perceived autonomy and the wider context of their recovery. their perceived autonomy and the wider context of their recovery.
• Depression is one of the major factors contributing to poorer Depression is one of the major factors contributing to poorer quality of life amongst individuals with psychotic disorders quality of life amongst individuals with psychotic disorders generally generally Saarni et al., 2010 Saarni et al., 2010 and schizophrenia specifically. and schizophrenia specifically. Meijer et al., 2009; Meijer et al., 2009;
Narvaez et al., 2008Narvaez et al., 2008
• No association of positive, negative and disorganisation symptoms No association of positive, negative and disorganisation symptoms with quality of life.with quality of life. Meijer et al., 2009; Narvaez et al., 2008 Meijer et al., 2009; Narvaez et al., 2008
Suicide and psychosisSuicide and psychosis
• Around 6% of individuals with a diagnosis of Schizophrenia complete suicide. Around 6% of individuals with a diagnosis of Schizophrenia complete suicide. Palmer, Pankratz & Bostwick, 2005Palmer, Pankratz & Bostwick, 2005
• In first 5-years following a first episode of psychosis, 3% complete suicide. In first 5-years following a first episode of psychosis, 3% complete suicide. Bertelsen Bertelsen
et al., 2007et al., 2007
• Early phase linked to greater risk of attempted suicide and rates of 32% Early phase linked to greater risk of attempted suicide and rates of 32% attempted suicide following a first episode reported amongst adolescents.attempted suicide following a first episode reported amongst adolescents. Birchwood Birchwood
et al., 2000; Falcone et al., 2010et al., 2000; Falcone et al., 2010
• Suicide and attempted suicide linked to hallucinations, depression, social Suicide and attempted suicide linked to hallucinations, depression, social isolation, substance use, longer duration of untreated psychosis and isolation, substance use, longer duration of untreated psychosis and demoralisation. demoralisation. Pinikahana et al., 2003; Bertelsen et al., 2007; Falcone et al., 2010Pinikahana et al., 2003; Bertelsen et al., 2007; Falcone et al., 2010
• National Institute of Mental Health Longitudinal Study of Chronic Schizophrenia National Institute of Mental Health Longitudinal Study of Chronic Schizophrenia found that over 6 years, 38% have at least one suicide attempt and 57% found that over 6 years, 38% have at least one suicide attempt and 57% admitted with suicidal ideation. admitted with suicidal ideation. Roy & Pompili, 2009Roy & Pompili, 2009
Depression and psychosisDepression and psychosis
• High risk period for development of depression is in the early High risk period for development of depression is in the early years after first episode. years after first episode. Birchwood et al., 2000Birchwood et al., 2000
• Rates of depression 50% following a first episode of Rates of depression 50% following a first episode of psychosis and 33% in established psychosis. psychosis and 33% in established psychosis. Whitehead et al., 2002Whitehead et al., 2002
• Post psychotic depression emerges independently of positive Post psychotic depression emerges independently of positive symptom severity, relapse and negative symptoms. symptom severity, relapse and negative symptoms. Birchwood et Birchwood et
al., 2000; Iqbal et al., 2000al., 2000; Iqbal et al., 2000
• Strong overlap with social anxiety in psychosis. Strong overlap with social anxiety in psychosis. Birchwood et al.,2006; Birchwood et al.,2006;
Michail & Birchwood, 2009 Michail & Birchwood, 2009
Correlates of depression in psychosisCorrelates of depression in psychosis
• Depression has been found to be associated with a number Depression has been found to be associated with a number of important domains.of important domains.– Less adherence to treatment. Less adherence to treatment. Conley, 2009Conley, 2009
– Longer duration of untreated psychosis. Longer duration of untreated psychosis. Drake et al., 2004Drake et al., 2004
– Greater problems in family relationships. Greater problems in family relationships. Rocca et al., 2005; Mino et al., 1998Rocca et al., 2005; Mino et al., 1998
– More closely associated with interpersonal adjustment than More closely associated with interpersonal adjustment than severtity of psychiatric symptoms. severtity of psychiatric symptoms. Rocca et al., 2005Rocca et al., 2005
– Early life trauma and stressful life events. Early life trauma and stressful life events. Ventura et al., 2000; Scheller-Gilkey Ventura et al., 2000; Scheller-Gilkey
et al., 2002et al., 2002
– Greater actual experiences of stigma particularly with respect Greater actual experiences of stigma particularly with respect to accessing valued social roles. to accessing valued social roles. Angermeyer et al., 2004Angermeyer et al., 2004
– Greater difficulties being able to identify emotional states. Greater difficulties being able to identify emotional states. van der van der Meer et al., 2007Meer et al., 2007
Depression, hopelessness, and CBTDepression, hopelessness, and CBT
• A total of 15 randomised controlled trials of Cognitive A total of 15 randomised controlled trials of Cognitive Behaviour Therapy have focused on depression as outcome Behaviour Therapy have focused on depression as outcome and 4 trials have focused on hopelessness. and 4 trials have focused on hopelessness. Wykes, Steel, Everitt & Wykes, Steel, Everitt &
Tarrier, 2008Tarrier, 2008
• Moderate effect size for mood = 0.36 (0.08, 0.65)Moderate effect size for mood = 0.36 (0.08, 0.65)
• Suggestion that CBTp may increase hopelessness = -0.19 (-Suggestion that CBTp may increase hopelessness = -0.19 (-0.55, 0.17) N.S.0.55, 0.17) N.S.
• Significant findings for mood no longer significant when Significant findings for mood no longer significant when quality of methodology is accounted for where lower quality quality of methodology is accounted for where lower quality studies (e.g. non-blinding, poor randomisation) are studies (e.g. non-blinding, poor randomisation) are associated with larger treatment effects.associated with larger treatment effects.
Depression, hopelessness and Depression, hopelessness and medication medication
• Survey of 37,513 psychiatrists in US found good awareness of depression Survey of 37,513 psychiatrists in US found good awareness of depression however over 25% never prescribe antidepressants in this group. however over 25% never prescribe antidepressants in this group. Siris et al., 2001Siris et al., 2001
• Cochrane review of antidepressants for depression in schizophrenia Cochrane review of antidepressants for depression in schizophrenia included 11 studies. included 11 studies. Whitehead et al., 2002Whitehead et al., 2002
– ““At present, there is no convincing evidence to support or refute the At present, there is no convincing evidence to support or refute the use of antidepressants in treating depression in people with use of antidepressants in treating depression in people with schizophrenia.”schizophrenia.”
• No difference found between typical and atypical antipsychotics in terms of No difference found between typical and atypical antipsychotics in terms of depression. depression. Mauri et al., (2008)Mauri et al., (2008)
• Small randomised controlled trial found sertraline improved depression in Small randomised controlled trial found sertraline improved depression in Schizophrenia. Schizophrenia. Mulholland et al. 2003Mulholland et al. 2003
Depression, hopelessness and Depression, hopelessness and service organisation service organisation
• Early detection aimed at reducing duration of untreated Early detection aimed at reducing duration of untreated psychosis was associated with reduced depression at 2-psychosis was associated with reduced depression at 2-years. years. Melle et al. 2008Melle et al. 2008
• OPUS study: a randomised controlled trial of Integrated OPUS study: a randomised controlled trial of Integrated Treatment (Assertive Outreach, antipsychotic medication, Treatment (Assertive Outreach, antipsychotic medication, social skills training and family education) found reduced social skills training and family education) found reduced levels of hopelessness at 1-year. levels of hopelessness at 1-year. Nordentoft et al. 2002Nordentoft et al. 2002
• Our own First Episode Psychosis service in Glasgow we see Our own First Episode Psychosis service in Glasgow we see significant improvements in depression and suicidal significant improvements in depression and suicidal thinking over 6-months maintained at 12-months.thinking over 6-months maintained at 12-months.
Psychiatric and emotional Psychiatric and emotional recovery over 12-monthsrecovery over 12-months
Changes in suicidal thinking Changes in suicidal thinking over 12-monthsover 12-months
Possible mechanisms of depression:Possible mechanisms of depression:the importance of shame, entrapment and the importance of shame, entrapment and lossloss
• There is a paradox where insight associated with positive There is a paradox where insight associated with positive outcomes such as reduced psychotic symptoms but linked to outcomes such as reduced psychotic symptoms but linked to depression and suicidal thinking.depression and suicidal thinking.– Good insight associated with engagement, adherence and depressed Good insight associated with engagement, adherence and depressed
mood. Where feelings of stigma are high relationship between mood. Where feelings of stigma are high relationship between depression and insight is strong. depression and insight is strong. Staring et al., 2009Staring et al., 2009
– Those who go on to develop post-psychotic depression experience Those who go on to develop post-psychotic depression experience greater loss, humiliation and entrapment prior to emergence of greater loss, humiliation and entrapment prior to emergence of depression. depression. Birchwood et al., 2000Birchwood et al., 2000
– Lowered expectations for future, greater self criticism, and greater Lowered expectations for future, greater self criticism, and greater insight precedes development of depression and suicidal thinking. insight precedes development of depression and suicidal thinking. Iqbal Iqbal
et al., 2000et al., 2000
– Predictors of hopelessness were depression, severity of psychiatric Predictors of hopelessness were depression, severity of psychiatric symptoms and feelings of humiliation. symptoms and feelings of humiliation. White, et al., 2007White, et al., 2007
– Feelings of entrapment and low self esteem predict both anxiety and Feelings of entrapment and low self esteem predict both anxiety and depression. depression. Karatzias et al., 2007Karatzias et al., 2007
Feelings of shame grounded in the Feelings of shame grounded in the reality of personal experiencesreality of personal experiences
• These feelings are associated with persisting distressing These feelings are associated with persisting distressing psychotic experiences, more involuntary admissions, psychotic experiences, more involuntary admissions, heightened awareness of the negative consequences of heightened awareness of the negative consequences of psychosis, greater awareness of the stigma of psychosis, psychosis, greater awareness of the stigma of psychosis, being out of work, and loss of social status and friendships. being out of work, and loss of social status and friendships. Rooke and Birchwood, 1998Rooke and Birchwood, 1998
• Experience of relapse linked to the evolution of feelings of Experience of relapse linked to the evolution of feelings of entrapment, shame and self blame over time. entrapment, shame and self blame over time. Gumley et al., 2006; Gumley et al., 2006;
Gumley, 2007Gumley, 2007
• Suicide and attempted suicide linked to hallucinations, Suicide and attempted suicide linked to hallucinations, social isolation, and longer duration of untreated psychosis. social isolation, and longer duration of untreated psychosis. Pinikahana et al., 2003; Bertelsen et al., 2007; Falcone et al., 2010Pinikahana et al., 2003; Bertelsen et al., 2007; Falcone et al., 2010
““Third Wave” Cognitive Behavioural Third Wave” Cognitive Behavioural TherapiesTherapies • ““Grounded in an empirical, principle-focused approach, the third wave Grounded in an empirical, principle-focused approach, the third wave
of behavioral and cognitive therapy is particularly sensitive to the of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactive ones. These strategies in addition to more direct and didactive ones. These treatments tend to seek the construction of broad, flexible, and treatments tend to seek the construction of broad, flexible, and effective repertoires over an eliminative approach to narrowly defined effective repertoires over an eliminative approach to narrowly defined problems…” problems…” Hayes, 2004 p 658Hayes, 2004 p 658
• Rather than altering the content or frequency of cognitions, 3Rather than altering the content or frequency of cognitions, 3rdrd wave wave therapies seek to alter the individual’s therapies seek to alter the individual’s relationship relationship with thoughts, with thoughts, feelings and sensations to promotefeelings and sensations to promote psychological flexibility.psychological flexibility.– Acceptance and Commitment Therapy (ACT) focus on the person’s values and goals.Acceptance and Commitment Therapy (ACT) focus on the person’s values and goals.– Compassion Focussed Therapy (CFT) cultivation of a compassionate soothing Compassion Focussed Therapy (CFT) cultivation of a compassionate soothing
mentality attuned to one’s own self critical shaming thoughts.mentality attuned to one’s own self critical shaming thoughts.– Mindfulness involving the cultivation of a non-judgemental awarenessMindfulness involving the cultivation of a non-judgemental awareness
CannabisCannabis UseUse
• Greater severity of psychotic Greater severity of psychotic symptomssymptoms
• Increased risk of relapse x 4Increased risk of relapse x 4
• Strongest predictor of relapse over Strongest predictor of relapse over 12/12 period (Linzen)12/12 period (Linzen)
L. Hides et al 2006L. Hides et al 2006
• No of days cannabis use most No of days cannabis use most significant predictor of time to significant predictor of time to relapse over 6/12 period.relapse over 6/12 period.
• 61% ‘relapsed’ using cannabis.61% ‘relapsed’ using cannabis.
• 39% psychotic relapse39% psychotic relapse
Predictors of Cannabis use Predictors of Cannabis use following psychosisfollowing psychosis
• Severity of psychotic symptoms.Severity of psychotic symptoms.
• Baseline cannabis use.Baseline cannabis use.
• Medication adherence.Medication adherence.
D. Wade et al 2006D. Wade et al 2006
• 103 consecutive referrals 103 consecutive referrals - 53% substance misuse53% substance misuse- 42% cannabis42% cannabis- 30%alcohol30%alcohol- 17% other17% other- 57% poly substance use57% poly substance use
Substance misuseSubstance misuse NoneNone
• Admission 45%Admission 45% 15%15%
• Remission 93%Remission 93% 98%98%
• RelapseRelapse 51%51% 17%17%
Substance Use Amongst Substance Use Amongst ESTEEM Clients: Prevalence, ESTEEM Clients: Prevalence,
Forms, and Levels of Forms, and Levels of ImpairmentImpairment
Dr I M Kevan (Clinical Psychologist) Dr I M Kevan (Clinical Psychologist) & Dr A Blackett (Con. Clinical & Dr A Blackett (Con. Clinical
Psychologist)Psychologist)ESTEEM First Episode Psychosis ServiceESTEEM First Episode Psychosis Service
NHS Greater Glasgow & ClydeNHS Greater Glasgow & Clyde
MethodologyMethodology
• Individual clinicians consulted about active cases on the ESTEEM caseload.
•Each service-user’s current substance use pattern was established using a clinician-rated classification system
Classification of Current* Classification of Current* Substance UseSubstance Use
– (1) Non-user (abstinent)– (2) Use without impairment – (3) Use with impairment (sometimes)– (4) Use with impairment (always)– (5) Dependence– (6) Unknown Pattern
* For in-patients, current use was with reference to time in the community before admission
Descriptive Characteristics of Descriptive Characteristics of SampleSample
• 160 current cases ESTEEM caseloads.
• Mean age: 25 years ( range 16-35).
• 112 males (70%) and 48 females (30%).
• Mean number of months on the ESTEEM caseload was 11 ( range 1- 36 months).
Prevalence of Substance Use
65.6 % (n = 105) service-users were current users of substances (drugs and/or alcohol).
34.4% (n=55) were rated as currently abstinent.
Percentage of Active Current Substance/Alcohol Users on ESTEEM Caseloads
73.8
82.5
52.6
0
10
20
30
40
50
60
70
80
90
North West North East South
Team
Perc
en
tag
e
Substance-Use Forms Amongst Current Users
92.4
48.6
14.3
9.5
6.7
3.8
12.4
9.5
2.9
0 20 40 60 80 100
Alcohol
Cannabis
Cocaine/Crack
Amphetamine
Opiates
Substitute Prescribing
Benzos
Ecstasy
Other
Percentage Using Substance
Clinician-Rated Impairment in Substance Using Clients
• 33 (31.4%) of the clients currently using without current impairment
• 33 (31.4%) were rated as ‘Use with impairment (sometimes)’.
• 15 (14.3%) were rated as presenting with ‘Use with impairment (always)’.
• 16 (15.2%) of the sample were rated as having ‘Dependence’.
• 8 (7.6%) clients who currently use were so unclear that it was difficult to make a rating of the level of impairment.
Drug-Use Associated with Highest Impact on Functioning
more significant difficulties, [‘Use with Impairment (always)’ or ‘Dependence’ (n = 31)
alcohol (35.5%) cannabis (25.8%), and dual alcohol and cannabis misuse
(12.9%)
InterventionsInterventions•Psycho-education
•Addiction interventions within Esteem care depending on complexity e.g. substitute prescribing
•Motivational interviewing approach
• Individual psychology input
•Behavioural family therapy
Autism & PsychosisAutism & Psychosis
• Survey of care co-ordinators in Survey of care co-ordinators in Teeside EI serviceTeeside EI service
• Comorbid autistic spectrum in 10% of Comorbid autistic spectrum in 10% of under 18 group.under 18 group.
• 4 – 5% in 14 – 35 year old group.4 – 5% in 14 – 35 year old group.
O. Stahlberg 2004O. Stahlberg 2004
Attention deficit/hyperactivity disorder – AD/HDAttention deficit/hyperactivity disorder – AD/HDAutistic Spectrum DisorderAutistic Spectrum Disorder - ASD- ASD
• AD/HD patients – 30% co morbid ASD.AD/HD patients – 30% co morbid ASD.• ASD patients – 38%ASD patients – 38%• ASD - 7% bipolar & psychosisASD - 7% bipolar & psychosis
- 8% schizophrenia- 8% schizophrenia
• AD/HD – 5% bipolar & psychosisAD/HD – 5% bipolar & psychosis - 5% schizophrenic- 5% schizophrenic
N. Craddock, M. Owen 2010N. Craddock, M. Owen 2010
Specific copy number variant Specific copy number variant (CNV) is associated with (CNV) is associated with schizophrenia, mental schizophrenia, mental retardation and autism.retardation and autism.
