Psychosis PDF

7/30/2019 Psychosis PDF

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Early Psychosis: Early Detection,

Timely Management and Referral

Dr K H YeungMedical Officer, Department of Psychiatry, Kowloon Hospital

19 December 2010


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What Is Psychosis ( )? Abnormality in

Thought: delusion

Perception: hallucination

Emotion: inappropriate affect

Behaviour: disorganised


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Prevalence of Schizophrenia The lifetime risk : approximately 1% Hong Kong: about 700 cases per year Ages of onset:

Between late teens and mid 30s Men: 18 25 years Women: 25 35 years

Sex ratio:

equal

Increased prevalence in lower socioeconomic classes

Higher incidence rate for immigrants


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Aetiology of Schizophrenia Genetic Developmental factors

Complications during pregnancy and birth

Born in late winter or spring: influenza infection in 2nd trimester Brain abnormalities

Ventricular enlargement Reduced brain size

Crash Course Psychiatry 2008


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Aetiology of Schizophrenia Neurotransmitter abnormalities

Dopamine Glutamate 5 HT GABA

Life events More frequently in the month before a first psychotic disorder or

relapse

Expressed emotion Over involved, over critical, or hostile towards a schizophrenic pt More likely to relapse

Crash Course Psychiatry 3rd Edition 2008


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Lifetime Risk of Schizophrenia

Crash Course Psychiatry 3rd edition 2008


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Stahl's Essential Psychopharmacology, 3rd edition, 2008


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Stahl's Essential Psychopharmacology 3rd Edition 2008


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Mesolimbic Dopamine Hypothesis



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Glutamate & Other Symptoms



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Amygdala



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Fearful Stimuli & Schizophrenia

Stahl's Essential Psychopharmacology 2008


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Neutral Stimuli & Schizophrenia

Stahl's Essential Psychopharmacology 2008


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Negative Symptoms

in

Prodromal

Phase



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Key Negative Symptoms Identified Solely on Observation



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Key Negative Symptoms Identified with some Questioning



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Prognosis of

1

st

Episode Schizophrenia


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Stages of

Schizophrenia



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Stages of

Psychosis

8 stages 0: Increased risk, no symptoms 1a: Mild or non specific symptoms 1b: Ultra high risk: moderate but

subthreshold symptoms 2: First episode of psychotic disorder 3a: Incomplete remission from 1st episode 3b: Recurrence or relapse of psychosis 3c: Multiple relapses

4: Severe, persistent

or

unremitting

illnessModified from McGorry et al, 2006


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Ultra High

Risk

Factors

Ages: 14 to 29

At least one of the following 3 groups

Attenuated psychotic

group:

sub threshold, attenuated positive psychotic symptoms during the past year

Brief limited

intermittent

psychotic

symptoms

group:

episodes of frank psychotic symptoms for < 1 week

Alison R. Yung et al, BJPsych 2007


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Ultra High

Risk

Factors

Trait and state risk factor group:

Schizotypal personality disorder

1st degree relative with a psychotic disorder

Significant functioning decrease during the previous

year

Alison R. Yung et al, BJPsych 2007


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Different outcome

at

ages

of

onset

Pts with adolecent onset (ages 15 18)

Poorer outcome compared with young adult (ages 19 30)

Ballageer et al, J Am Acad Child Adolesc Psychiatry. 2005 Aug;44(8):782 9


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Duration of

Untreated

Psychosis

(DUP)

DUP The difference in time between the appearance of

psychotic symptoms and the first psychiatric treatment

Longer DUP

Worse clinical features Poor treatment outcome

DUP worldwide: 27 to 322 days DUP in HK:

93 days, longer DUP in male pts

JCEP Hong Kong 2010


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Duration of

Untreated

Psychosis

(DUP)

Associated with Increased duration of the acute episode (Loebel et

al, 1992; McGorry et al, 1996) Worse course and outcome (Helgason, 1990; Haas

et al, 1998) Increased risk of relapse (Crow et al, 1993) Psychosocial decline (Jones et al, 1993) Prolonged morbidity ( Wyatt et al, 1997)

Warner R, Br J Psych 2005


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DUP &

Brain

Morphology

Long DUP associated with reduced densities of

the right limbic area

The right hippocampus

Penttila M, et al Schizophr Res. 2010


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Reducing DUP

Singapore experience

Method Compare 2 groups of 1st episode psychosis before and

after Initiation of a programme of public education

Networking with

primary

health

care

providers

Results DUP reduced from a median of 12 to 4 months Increase self and family referrals Decrease police referrals

Conclusion Awareness campaigns targeting multiple groups with various modes of communication are effective in

influencing the DUP and patter ns of help seeking

Chong SA, et al, Soc Psychiatry Psychiatr Epidemiol 2005


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Reducing DUP

Norway experience Method:

Compare 2 groups of pts with 1st episode psychosis with (N=108) and without (n=75) information campaign

(IC) from Jan 1997 to Dec 2000 to raise awareness & recognising psychosis to public, schools and GPs Results

No IC period: DUP increased up to 15 weeks More symptoms Poorer functioning

Joa I et al, Schizophr Bull 2008


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Reducing DUP

Hong Kong Experience:

EASY Project

since

2001

DUP decreased from 513 days to 320 days (nearly 200 days)

Hospital Authority Hong Kong


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GP Training

in

1

st

Episode Psychosis

Birmingham Experience Method:

3 inner city primary care trusts in Birmingham Intervention practices addressing GP knowledge, skills

& attitudes about 1st episode psychosis

Lester H, Birchwood M, et al Br J Gen Pract 2009


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GP Training

in

1

st

Episode Psychosis

Method: Primary outcomes: Difference in the number of referrals to early

intervention services between practices Secondary outcomes: Duration of untreated psychosis (DUP) Time to recovery Use of the Mental Health Act GP consultation rate during developing illness

Lester H, Birchwood M, Br J Gen Pract 2009


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GP Training

in

1

st

Episode Psychosis

Birmingham Experience

Results 110 out of 135 eligible practices (81%) recruited

Referral of young people:

179 Intervention practices: 97 Control practices: 82

Secondary outcomes: No effect

Conclusion: GP training on 1st episode psychosis is insufficient to alter referral rates to early intervention

services or reduce the duration of untreated psychosis Training facilitates access to the new specialist team for early psychosis

Lester H, Birchwood M, Br J Gen Pract. 2009


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Treatment of

First

Episode

Psychosis

Good symptomatic response Lower dose of antipsychotics compared with

chronic schizophrenia

More susceptible

to

extrapyramidal

side

effect

Longer exposure to potential metabolic

complications of newer antipsychotics

Nicolas A et al, BJPsych 2010


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First Generation

Antipsychotics

FGAs First Episode Relapse Max

Chrorpromazine200 mg 300 mg 1000mgHaloperidol 2 mg >4 mg 30mg/dSulpiride 400 mg 800 mg 2400mgTrifluoperazine 10 mg 15 mg 30mg/d

Side effect: Parkinson like symptoms, acute dystonia, akathisia, tardive dyskinesia, neuroleptic malignant syndrome and hyperprolactinaemia

The Maudsley Prescribing Guildelines 10th Edition 2009, Crash Course 2008


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Second Generation

Antipsychotics

SGAs First Episode Relapse Max

Amisulpride 400mg 800mg 1200mg/d Risperidone 1 2mg 3 4mg 16mg/d

Olanzapine 5 mg 10 mg 20mg/dQuetiapine 150 mg 300 mg 800mg/dZiprasidone 80 mg 80 mg 160mg/d

Side Effects: metabolic syndrom, hyperprolactinaemia & agranulocytosis (Clozapine)

The Maudsley Prescribing Guidelines 10th Edition 2009


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Treatment of

1

st

Episode Psychosis

The Maudsley Prescribing Guidelines 10th Edition 2009

Agree choice of antipsychotic with pt &/or carer or, if not possible: Start SGA

Titrate to minimum effective dose

Adjust dose according to response and tolerability

Assess over 68 weeks

Continue at dose established as

effective

Change drug and follow above

process. Consider use of either a SGA or a FGA Consider depot

Clozapine

effective

Not effective

Not tolerate or poor

compliance


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Non pharmacological Treatment of

1st Episode Psychosis Family intervention

Psychotherapy:

Cognitive behavioural

therapy

Social intervention

Occupational therapy


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Factors Associated with Dangerousness

Male gender Past history of violence Active psychotic symptoms

Paranoid plus a wish to harm others Alcohol or drug abuse

Social difficulties


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Prepared by 17 y.o patient's father in 2009


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Referral

HA: EASY Clinic for ages from 15 to 25

29283283 Web site: www.ha.org.hk/easy

JECP Centres for ages from 26 to 55

Private psychiatrists

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