Early intervention and prevention for psychotic

disorders in Transitional Age Youth

Cameron S Carter MD

Strategies for Improving Outcome

• Understand and treat currently treatment refractory symptoms (cognitive deficits and negative symptoms)

• Earliest possible intervention

B CA

MacDonald, Carter et al 2005 American Journal of Psychiatry

Never Medicated FE Schizophrenia Patients Show Specific Deficit in Context Processing Related Prefrontal

Physiology

FE Schizophrenia Non-Schizophrenia FE Psychosis Controls

Chronic, deteriorating

Episodic, w/interepisode deficits ( common)

Episodic, w/o interepisode deficits

The course of schizophreniaThe course of schizophrenia

Broad therapeutic window forPrevention/Early intervention

Serious mental disorders in youth

• Schizophrenia, bipolar disorder and serious depressive disorders affect up to 3% of the population

• Typical onset 12-25 years (TAY)• Hospitalization, school failure,

substance abuse, disability and unemployment, criminalization and incarceration frequent complications

• We can significantly improve outcome and prevent these complications with an early intervention approach

Prevention

• Primary: Before a disease starts, prevent its onset (e.g. by immunization)

• Seconday: after a disease has started but before it has a clinical effect e.g. treating hypertension to prevent cardiovascular disease. Pap smear for cervical cancer

• Tertiary: identify and alleviate an established disease at an early stage to prevent complications, improve or maintain functional status e.g. aspirin therapy after heart attack to prevent recurrence

http://earlypsychosis.ucdavis.edu

EDAPT Clinic: Rationale

• Duration of untreated psychosis is associated with poor outcome

• Early in illness treatment response is robust

• Loss of function and treatment resistance follow repeated relapses

• Early intervention can improve functional outcome

• Tailored treatment pathways and therapies for early treatment and rehabilitation

Marshall, M. et al. Arch Gen Psychiatry 2005;62:975-983.

Summary correlations between duration of untreated psychosis (DUP) and outcomes by follow-up point

Marshall, M. et al. Arch Gen Psychiatry 2005;62:975-983.

Odds of no remission in the long vs short duration of untreated psychosis (DUP) groups

Perkins et al American J Psychiatry 2005

EDAPT Clinic: 2 “Target” Populations

• Early psychosis “first episode” patients

• Ultra high risk

First Episode Cohort

• 12-45 years of age• Onset within the previous 12

months• Goal is to engage patient (and

family/support system) in sustained treatment

• Stabilize, and support recovery of function and developmental trajectory

Clinic Description

The EDAPT Clinic provides comprehensive diagnostic and treatment services for children and young adults who have recently developed a psychotic disorder, or who are at high risk for one of these disorders.

The goals of the clinic are

1. Early Intervention2. Prevention of disease-related deficits3. Prevention of treatment-related side effects 4. Active participation in treatment 5. Progression towards personal, social, and occupational goals

Referral Sources

•Sacramento County Mental Health Treatment Center (SCMHTC)

•UC Davis Outpatient Psychiatry Clinic

•Community Psychiatric Hospitals

•NAMI

•Family Members

•School Psychologists/Nurses

•Turning Point Crisis Residential

•Sacramento County CAPPS Clinic

•UC Davis Counseling Center (CAPS)

The EDAPT Clinic

The EDAPT ClinicClinic Demographics

Screened (07/05 - 08/07) 493 Accepted into Clinic 104

Total Number Enrolled 70

First Episode Patients 49‘Ultra High Risk’ Patients 21

Age Range of Patients 11-34Average Age 19Under 18 46%

Working or in School 91%

Number hospitalized 10

Ethnic Makeup of Clinic

Caucasian 57%African American 24Latino 7Asian/Pacific Islander 9Middle Eastern 3

EDAPT Patient Ethnicity

1

2

3

4

5

Caucasian

African American

Latino

Asian/Pacific Islander

Middle Eastern

Sacramento County

Some key first episode treatment issues

• Diagnostic uncertainty, symptom based treatment, side effects

• Denial of illness, non compliance• Depression, suicidality• Family support• “re-entry”, socialization, stress,

advocacy• Individualized pathways to recovery,

value of peer groups

Key elements of treatment model

• Multidisciplinary treatment team• Rapid response, extensive medical and

psychiatric assessment• Setting, may be better outside of CMH

setting• Medication management• Individual and group therapy (psychoed,

motivational, supportive)• Advocacy (school, vocational, insurance and

disability etc)• Multifamily support group

Very Early Intervention: Ultra High Risk Cohort

• Can we delay the onset of psychosis and prevent functional decline?

• “Ultra High Risk” strategy: subthreshold psychosis, OR genetic risk or SPD and functional decline predict 20-40% conversion rate

Three Prodromal Risk State Categories

• Attenuated Positive Symptom State

– Onset or worsening in the past year of (a) paranoid, grandiose, or referential ideas but without full conviction, (b) perceptual disturbances but without certainty of an external source, or (c) vague, circumstantial or tangential communication that is coherent and structured under redirection

• Brief Intermittent Psychotic Symptom State

– Onset in the last month of transient hallucinations, delusions, and/or thought disorder, lasting less than one hour per day

• Genetic Risk and Deterioration State

– A decline of 30% or more on the GAF in the past 12 months, AND patient either (a) has a first-degree relative with schizophrenia or (b) meets criteria for schizotypal PD

PACE, PRIME, OPUS and PIER12 month outcome

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First ad

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Portland

Rest of MainePIER begins

First hospitalizations for psychosis Greater Portland vs. rest of Maine

Improved Outcomes from Very Early Intervention

• Results suggestive from Australian, Danish and U.S. studies BUT

• Definitive results will be needed to change public policy in the U.S.

Early Detection and Intervention to

Prevent Psychosis (EDIPP)

Earlier Intervention: EDIPP

• Funded by a $2 million grant from the Robert Wood Johnson Foundation

• 5 sites across the nation• Sacramento City, favored due to diversity, UCDMC

favored for its strong community partnerships• Seeks to make history, change public policy• Careful diagnostic assessment, SIPS interview, plus

active diagnoses and co-morbidities• TARGETTED pharmacological therapies• PIER model multifamily Psycho education and

support groups• supportive therapy, family support and therapy,

supported education and employment and advocacy • Research for enhanced risk prediction

Community PartnershipsCommunity PartnershipsCommunity PartnershipsCommunity PartnershipsSchoolsSchoolsSacramento City Unified School DistrictSacramento City Unified School DistrictM.M.C. Mejia, PhD; Shelton YipM.M.C. Mejia, PhD; Shelton Yip**UCDavis Counseling & Psych Services UCDavis Counseling & Psych Services Diana Davis; Sandra ZehDiana Davis; Sandra Zeh**UCDavis MIND InstituteUCDavis MIND InstituteJohn BrownJohn Brown**Sacramento State Univ. CounselingSacramento State Univ. CounselingDavid CordosiDavid Cordosi

Sacramento County Mental HealthSacramento County Mental HealthDirector: Director: Ann Edwards-BuckleyAnn Edwards-Buckley**Ethnic Services &Ethnic Services & Cultural Competence Cultural Competence

Jo Ann JohnsonJo Ann Johnson**Child & Adolescent Services, PediatricsChild & Adolescent Services, PediatricsCharles MaasCharles Maas** Child & Family HealthChild & Family HealthLisa Bertaccini

*Indicates Steering Committee Member*Indicates Steering Committee Member

Mental Health AdvocacyMental Health AdvocacyNAMI SacramentoNAMI SacramentoHeidi SanbornHeidi Sanborn**Mental Health Assoc. of SacramentoMental Health Assoc. of SacramentoAndreaAndrea* * & Marilyn Hillerman& Marilyn HillermanCA Council of CMH AgenciesCA Council of CMH AgenciesRusty SelixRusty Selix**Staglin Family FoundationStaglin Family FoundationGaren & Shari StaglinGaren & Shari Staglin

Community Based OrganizationsCommunity Based OrganizationsCrossroads Employment ServicesCrossroads Employment ServicesDanny MarquezDanny MarquezSacramento Children’s HomeSacramento Children’s HomeRoy AlexanderRoy Alexander** African American MH ProvidersAfrican American MH ProvidersDee Bridges; Maurice DunnDee Bridges; Maurice Dunn**El Hogar MH & Community Service El Hogar MH & Community Service Lisa SotoLisa Soto**La Familia Counseling Center, Inc. La Familia Counseling Center, Inc. Anita BarnesAnita Barnes** Southeast Asian Assistance CenterSoutheast Asian Assistance CenterLaura LeonelliLaura Leonelli**Asian Pacific Community CounselingAsian Pacific Community CounselingJudy Fong HearyJudy Fong Heary**Hmong Women’s Heritage AssociationHmong Women’s Heritage AssociationMay Ying LyMay Ying Ly**Slavic Assistance CenterSlavic Assistance CenterRoman RomasoRoman Romaso**

Entry Criteria• Ages 12-25Ages 12-25

• Brief psychotic episodeBrief psychotic episode

• Prodromal symptoms Prodromal symptoms oror recent deterioration in youth recent deterioration in youth with a relative with a psychotic disorder.with a relative with a psychotic disorder.

• Within City of SacramentoWithin City of Sacramento

Zip Codes: 94203-94209, 94211, 94229, 94230, 94232, 94234-94237, 94239, 94240, 94243-94250, 94252-94254, 94256-94259, 94261-94263, 94267-94269, 94271, 94273, 94274, 94277-94280, 94282-94291, 94293-94299, 95812-95838, 95840-95843, 95851-95853, 95857, 95860, 95864-95867, 95887, 95894, 95899

The EDAPT Program

What Happens following Referral?

• Phone Screen & Assignment or Referral

• Intake Clinical & Cognitive Evaluation

• Assignment to Case Management or Family-aided Assertive Community Treatment (FACT)

The EDAPT Program

Family-aided Assertive Community Treatment (FACT):

Clinical and functional intervention

• Rapid, crisis-oriented initiation of treatment• Psychoeducational multifamily groups• Case management and Medical Management using key

Assertive Community Treatment methods– Integrated, multidisciplinary team; rapid response; continuous

case review– Targeted pharmacological intervention as needed

• Supported employment and education• Collaboration with schools, colleges and employers• Substance abuse treatment, as indicated

The EDAPT Program

Addressing diversity in EDIPP

Role of community partners in outreach, education, development of materials and MFG design

UCDMC medical interpreting services, for outreach, SIPS and individual patient evaluations and care

Development of culturally tailored MFG groups, partnering with therapists from African American, Latino and Hmong communities

Success would provide strong evidence for the value of the early intervention approach in an increasingly diverse American population

EDAPT/EDIPP TeamEDAPT/EDIPP TeamEDAPT/EDIPP TeamEDAPT/EDIPP Team

Cameron Carter MDCameron Carter MDRobinder Bhangoo MDRobinder Bhangoo MD Jane DuBe LCSWJane DuBe LCSW

Michael Minzenberg MDMichael Minzenberg MDJ. Daniel Ragland PhDJ. Daniel Ragland PhDJong Yoon MDJong Yoon MDMarjorie Solomon PhDMarjorie Solomon PhD

Kathleen Boyum PhDKathleen Boyum PhD

Contact Information

EDAPT Hours:9:00am – 5:00pm M-F

To make a referral, call:916-734-5331

http://earlypsychosis.ucdavis.edu

The EDAPT Program

Support

• NIMH• Robert Wood Johnson Foundation• NARSAD• Dean Pomeroy and the School of

Medicine• Bob Hales and the Department of

Psychiatry

UCD Psychosis Research

• Cognitive remediation for FE schizophrenia

• Using EEG/ERP and fMRI to enhance early diagnosis

• Linking PFF dysfunction to disturbances in memory, attention and language comprehension

• Understanding and treating negative symptoms

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Trial-Type

36 Controls

24 Siblings

24 Patients

Disorganization

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Key Collaborators

• Dan Ragland PhD• Jane Dube MSW• Kathleen Boyum

PhD• Emily Olsen

• Jong Yoon MD• Michael

Minzenberg MD• Stefan Ursu• Michael

Buonocore MD PhD

Translational Cognitive and Affective

Neuroscience LaboratoryPsychotic Disorders Research

ProgramDepartment of Psychiatry, University of California at

Davis