Work and Mental Illness

Professor David CastleChair of Psychiatry, St. Vincent’s Hospital MelbourneDept. of Psychiatry, The University of MelbourneEmail: david.castle@svhm.org.au

Australia “Low Prevalence” study (Jablensky et al,1997)

5.8% males, 6.1% females in full time employment

72% males, 62% females on DSP

Work exclusion in Schizophrenia

Structured daily activities

Social opportunities

Feeling socially ‘useful’

Enhanced self esteem

Regular income

(Mueser et al,1997)

Positives of work

Symptoms of mental illness

Side effects of psychiatric medications

Lack of access to vocational/educational training

Job design problems

(Human Rights and Equal Opportunities Commission,1993)

Reasons for work exclusion in schizophrenia

Support and work with other services towards “an integration of vocational and clinical services at the level of service delivery”

(Frost et al, 2002)

Optimistic symptom control and reduce side effect burden

Examples: Manage mood instability in bipolar Ameliorate effects of cognitive dysfunction in schizophrenia

“A Psychiatrist’s Perspective…”

Bipolar Affective Disorder: Psychosocial TreatmentsProfessor David CastleChair of Psychiatry, St.Vincent’s Hospital Melbourne

and the University of Melbourne

david.castle@svhm.org.au

Type IBPAD

Type IIBPAD

“Cyclothymia”

Bipolar Spectrum Disorder

“Normal” Mood Varianc

e

MANICPHASE

DEPRESSED PHASE

Different Types of Bipolar Disorder Mood Profile

(Castle & Bassett, 2009)

Prodrome

Presentation with Mania

Treatment Begins

Depressed Phase Following Recovery From Mania

Prodrome

Depression

Mania Following Treatment of Depression

ELEVATED

MOOD

DEPRESSED MOOD

Longitudinal Course of Bipolar (an Example)

(Castle & Bassett, 2009)

Walking the Black Dog

The Red Dragon

Johnson and Miller, J Abnorm Psychol 1997; 106: 449-457Gitlin MJ , Hammen C Bipolar Disorder Golberg Jf, Harrow M (Eds) 1999Keck P et al 1996 Jour. Clin. Psych. 1996;57:292-97Miklowitz DJ. CNS Spectrum 1998;3:48Post et al J Clin Psych 64:6 June 2003Scott J, Br J Psychiatry 1995; 167: 581

Worse Prognosis

Bipolar Illness VariablesHigher number of episodesMore depressive episodes

Psychotic symptomsSubsyndromal symptoms

Psychosocial FactorsContribute 24-50% to outcome variables

Negative life eventsFunctional impairmentLower social support

Conflictual family relationships

Non- AdherenceRange non-adherence from 20-66%, mean 41%

Attitudes, beliefs important

Co-morbid DiagnosisSubstance abuse

Personality disorders

Prognostic Factors in Bipolar

Understanding of illness

Mood monitoring including early warning signs

Control of illness rather than illness exerting control

Symptom control

Optimal pharmacotherapy

Broader psychosocial parameters

Treatment Aims

Relapse rates high even if taking meds

Different approaches:

• Psychoeducation

• Family focused therapy (Miklowitz et al, 2000)

• CBT (Lam et al, 2003, 2005; Scott et al, 2006)

• IPSRT (Frank et al, 1999)

• Integrated models (Bauer et al, 2006; Simon et al, 2006)

• Collaborative Therapy (Berk, Berk & Castle, 2005)

- individual/group (Colom et al, 2003)

What do we know aboutPsychosocial Interventions?

(Castle et al, 2007, 2010)

Translating Effective Psychosocial Interventions

for Bipolar Disorder into Everyday Clinical Practice

Carolynne Holdsworth Cath Bunton

Frameworks for HealthSt.Vincent’s, Melbourne

(Castle et al, 2007, 2010)

Study Objectives

Primary Goals: To develop a group-based intervention and relapse

prevention package to assist consumers to manage their bipolar disorder.

To integrate the intervention using the Collaborative Therapy Framework and implement the project in a range of service settings.

To evaluate the effectiveness of the intervention using a RCT.

Challenges:

To develop an intervention that is effective for “real-world” patients

To ensure the intervention is sustainable beyond the life of the research project.

Study Objectives

Stages of Assessment1. Baseline2. Post-Group (3 month)

3. 12 month assessment

Phase 2• Evaluate “MAPS group program” using a

randomised control trial.

Intervention (12 weeks + 3 boosters)

Phase 1• Literature review

• Focus groups to map needs• Develop treatment package &

pilot content

Phase 3• Follow-up maintenance (9 months)

1

2

3

12months

Study Design

MAPS Group Program

The group program aims to:• Provide information and develop skills to assist people to

effectively manage bipolar disorder.• Enable people with bipolar disorder to get the most out of

life despite the disorder.

12 x weekly 1 ½ hour sessions + 3 x monthly boosters.

Resources: Personal Workbook, Information Book, Collaborative Treatment Journal (CTJ)

MAPS Session OutlineSession Focus Content

1 - 2 Education Introduction bipolar disorder and triggers commonly associated with bipolar disorder

3 - 6 Core skills development

Monitoring & assessment of stress/triggersPreventing relapse using coping skills, eg problem solving, stress tolerance and SMART goal setting & medication management

7 - 9 Depression Assessing and managing early warning signs of depressionDeveloping relapse prevention plans for depression

10 - 12 Mania Assessing and managing early warning signs of maniaDeveloping relapse prevention plans for mania

Booster 1 - 3

Integrating and reinforcing skills

Consolidating skills into daily life

A Real-world Clinical Sample

Sample size: Total N= 82

(control: n=39, treatment: n=35)

Gender: Female 76%, Male

24%

Age: mean = 42, SD = 11

Employment:Part time 37%

Unemployed 32%

Full time 15%

Student 1%

A Real-world Clinical Sample Diagnosis

Bipolar 1 22% Bipolar I (with psychotic episode) 8% Bipolar II 45%

Co-morbidities Ave no per person 2.9 most common: anxiety, suicidality, alcohol & substance

use, etc

Relapse

Number of relapses post treatment:Type Treatment ControlDepression 4 14Mania 0 6Hypomania 9 6Mixed 1 1

All relapses: mean time in relapse over 9 months was 11 days for treatment and 27 days for control group, p=0.01

0.2

5.5

.75

1

0 100 200 300 0 100 200 300

Treatment ControlAny 1st relapse Any 1st relapse

Treatment Control

surv

ivor

func

tion

time (post treatment, days)

Graphs by treat

Kaplan-Meier survival estimates, by treat

Any Relapse – time to first recurrence

Depression Relapse0.

000.

250.

500.

751.

00su

rviv

or fu

nctio

n

0 100 200 300time (post treatment, days)

Treatment Control

Depression

Mania/Mixed Relapse0.

000.

250.

500.

751.

00su

rviv

or fu

nctio

n

0 100 200 300time (post treatment, days)

Treatment Control

Mania and mixed

Service UtilisationMean - Treatment Mean - Control

Item Pre post Pre Post

Admissions 1.03 0.39 0.89 0.91

Weeks 2.84 1.32 2.54 1.83CAT Crisis Visits

1.97 0.00 0.74 0.53

Getting it Out There

Acknowledgements Project Team Chief Investigators: David Castle, Monica Gilbert, Michael Berk

Isaac Schweitzer and Leon Piterman Program Developers: Lesley Berk and Sue Lauder Research Clinicians: Carolynne Holdsworth, Cath Bunton, Terence Chong

and Cathy Carman.

Our project funding partners:

Our service partners:Pathways Support and Rehabilitation ServicesBarwon HealthHealthscope (The Melbourne & Geelong Clinics)Dr Greg Murray and Swinburne University of Technology

This project gratefully acknowledges the funding support of beyondblue the

national depression initiative

www.moodswings.net.au

Ms Sue LauderProfessor Michael BerkProfessor David Castle

Dr. Seetal DoddDr. Andrea Chester

Cognition in Schizophrenia: Can We Fix It?

Professor David CastleChair of Psychiatry, St. Vincent’s Hospital Melbourne

The University of Melbourne

david.castle@svhm.org.au

What are the Cognitive Deficits in Schizophrenia?

Mild Moderate Severe

Perceptual skills Distractability Executive functioning

Delayed recognition memory

Memory and working memory

Verbal fluency

Verbal and full scale IQ Delayed recall Motor speed

(Wykes & Castle, 2003)

optimal treatment of positive symptoms important

some older (typical) antipsychotics seem to make cognition worse

benzodiazepines and anticholinergics can make cognition worse

Do Medications ImproveCognitive Impairment?

early studies suggested “yes”, but confounded by effect of halting typicals (EPSE etc.)

clozapine seems to improve attention and verbal fluency but has less effect on working memory

Do Atypical AntipsychoticsHelp Cognition?

400 patients < 5 yrs illness

Random assignment to: - Olanzapine (mean 12mg)

- Quetiapine (mean 500mg)

- Risperidone (mean 2.5mg)

400 patients started; 221 completed assessment at 12 weeks; only 81 completed neuropsychology tests at 52 weeks

(Keefe et al, 2007)

52 Week Trial of Olanzapine vs Risperidone vs Quetiapine (1)

(Keefe et al, 2007)

52 Week Trial of Olanzapine vs Risperidone vs Quetiapine (2)

areas of improvement

verbal fluency (especially Quetiapine)

letter-number sequencing

digit symbol

continuous performance task

improvements correlated modestly with vocational & social enhancement, but not significant after controlling for symptom improvement

(Keefe et al, 2007)

52 Week Trial of Olanzapine vs Risperidone vs Quetiapine (3)

Olanzapine, quetiapine, and risperidone all produced significant improvements in neurocognition in early psychosis patients. Although cognitive improvements were modest, their clinical importance was suggested by relationships with improvements in functional outcome.

BUT not corrected for multiple comparisons similar effect size seen due to practice effects alone massive subject attrition correlates with functional outcomes very modest & disappear after

controlling for symptom change

(Keefe et al, 2007)

Conclusions(Keefe et al, 2007)

“meaningful cognitive improvements will probably not come from second-generation antipsychotics”

“there was no clear procognitive effect in this study”

“the findings leave us feeling a little smarter and a lot more humble”

(Michael F Green, 2007)

Conclusions(Michael F Green, 2007)

(Michael F Green, 2007)

Conclusions(Michael F Green, 2007)

So, Green (2007) suggests:

(i) We need to look at other potential cognitive enhancing drugs; and

(ii) we need to consider “new non-pharmacological interventions that specifically target cognition”

44 people with SMI with past job failures randomised to:

supported employment alone OR supported employment plus cognitive training

Does Cognitive Remediation Enhance Work Capacity?

(McGurk et al, 2007)

Does Cognitive Remediation Enhance Work Capacity?

(McGurk et al, 2007)

cognitive assessment & job loss analysis

24 computer-based training sessions over 12wks

review and discussion of gains made and planning regarding future work

ongoing consultation with an employment specialist

Programme Components

Intervention Group(n=21)

Control Group(n=23)

No. who worked 16 (70%) 3 (14%)

Total weeks worked 27.0 5.4

Total hours worked 848.6 94.6

Total $’s earned 5320 530

Does Cognitive Remediation Enhance Work Capacity?

(McGurk et al, 2007)

Does Cognitive Remediation Enhance Work Capacity?

(McGurk et al, 2007)

Conclusions(McGurk et al, 2007)

A cognitive enhancement package can assist work capacity in SMI

Not clear what elements of the package help

Still only around 6 months work in a 3 year period

If all else fails ….