Emotional dysfunction in psychosis.

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1 Early intervention Service Emotional dysfunction in psychosis. 2. Depression In First Episode Psychosis (DIPS) study: The role of awareness and appraisal Max Birchwood and Rachel Upthegrove

2 Background: Kraepelin 1893, Bleuler 1911 Schneider 1959 Brockington 1979 Rates of Depression: Leff 1988: 45% Birchwood 2000: 68% Koreen 1993: 75% Depression In Acute First Episode Psychosis

3 Form and Content via Alan Bennett: Untold Stories Certainly in all her excursions to unreality Mam remained the shy, unassuming woman she had always been, none of her fantasies extravagant, her claims, however irrational they might be, modest. She might be ill, disturbed, mad even, but she knew her place.

4 Why? Suicide Relapse Recovery Transition to Psychosis

5 Models of Depression in Schizophrenia: Intrinsic Medication Negative symptoms Revealed A psychological reaction: to psychosis as a major life event Depression in Acute First Episode Psychosis

6 PSYCHOTIC SYMPTOMS AND DEPRESSION FOLLOW THE SAME COURSE PSYCHOTIC SYMPTOMS DEPRESSION Episode Time

7 Design Prospective study from acute episode Observation points at 0,3,6,9,12 months Compare :PPD vs no PPD; FEP vs multiepisode

8 Inclusion Criteria ICD - 10 Schizophrenia Current acute episode Receiving neuroleptics First data point < 7 days prior to treatment Exclusion Organic pathology as primary diagnosis Drug induced psychosis as primary diagnosis

9 The Samples First Episode Multi-episode n age episodes 1 6.8

10 30 Post-psychotic depression in schizophrenia BDI 15 No PPD PPD 0 Onset Recovery 4 months Pre PPD PPD Time Birchwood et al,2000 A cognitive approach to depression and suicidal thinking in psychosis British Journal of Psychiatry 177,516-23

11 Pathway 2: Adaptation to psychosis and emotional dysfunction Cognitive appraisals ( loss, humiliation and entrapment ) predict post-psychotic depression (Birchwood et al,2000)

12 Implications for identity and social standing Loss My illness will prevent me achieving my goals Shame/Humiliation I cannot hold my head up; I m an outsider Entrapment I cannot influence or control my illness my way forward is blocked

13 (Higher) 10 [PPD x time p<.01] 9 8 Insight (IS) 7 No PPD PPD 6 (Lower) 5 Onset Recovery Pre PPD PPD Time Birchwood et al,2000 A cognitive approach to depression and suicidal thinking in psychosis British Journal of Psychiatry 177,516-23

14 (Higher) [PPD x time p<.001] 9 8 Entrapment by 7 psychosis No PPD PPD 6 (Lower) 5 Onset Recovery Pre PPD PPD Time

15 Implications for identity and social standing Loss My illness will prevent me achieving my goals Shame/Humiliation I cannot hold my head up; I m an outsider Entrapment I cannot influence or control my illness my way forward is blocked

16 Who Develops P.P.D.? First episodes>multiple episodes Not linked to age, age at consent duration of illness number of admissions gender, marital status, ethnicity M.H.A. status depression in acute episode

17 PPD,appraisals First Episode Multi-episode PPD(%) Loss P<.05 P<.05 Shame P<.01 Entrapment P<.01

18 Depression in First Episode Psychosis Depression in Acute First Episode Psychosis

19 Aims: To explore the course of depression and suicidality in FEP To examine the role of patients appraisal of the threat posed by voices, persecutors and by the impact of the diagnosis itself in FEP.

20 Hypotheses Depression and suicidal thinking will be present in at least half of all patients with first episode psychosis. Depression will be linked to patients appraisals of the threat posed by: Voices Persecutors: and their ability to mitigate this threat Diagnosis, and its implications for approval, social role and status.

21 Methodology: Sequential Cases First Episode Psychosis Age Acute phase 6 and 12 month Follow-up Depression in Acute First Episode Psychosis

22 Measures: Baseline SCAN (WHO 1998) Present State and Prodromal Depression PANSS (Kay 1987) CDSS (Calgary Depression Scale for Schizophrenia) (Addington and Addington 1993) Depression in Acute First Episode Psychosis

23 Measures: Baseline Details of Threat Questionnaire (Freeman 2001) Personal Beliefs about Illness (PBIQ-R) (Birchwood1993) Voice Topography (Hafner 1990) Beliefs about Voices Questionnaire (BAVQ-R) (Chadwick 2000) Insight Questionnaire Suicide Attempt -Self Injury Interview (SAS-II) (Monohan 2001) Depression in Acute First Episode Psychosis

24 Measures CDSS and PANNS repeated at 6 and 12 months Thus information on Depression in 3 Phases Prodrome Acute Post Psychotic Detailed information on Appraisals in the Acute Phase

25 RESULTS: Population Course of Depression through FEP Pearson Correlations with severity of Depression normal distribution Mann-Whitney-U: mean appraisal scores in depressed v/s non-depressed Linear Regression: prediction of depression

26 REFUSED NOT FEP 8 NOT ACUTE 8 NO PSYCHOSIS 92 Participants 81 Complete follow up

27 TOTAL (92) 14% (13) Affective Psychosis 86%(79) Non-affective psychosis

28 Diagnosis Schizophrenia: 58 (63%) Delusional Disorder 3 (3.3%) Acute Schizophrenia like psychotic disorder 6 (6.5%) Non- organic psychotic disorder 12 (13%) Schizoaffective disorder 2 (2.2%) Mania with psychotic symptoms 7 (7.6%) Severe Depression with Psychotic Symptoms 4 (4.3)

29 Demographics: Mean Age: 22.4 Sex : 75% male Ethnic group: 36% Black 30% Asian 34% White Depression in Acute First Episode Psychosis

30 Rates of Depression

31 During the first episode: 55% Prodromal Depression 58% Moderate/Severe Depression Acute Phase 32% Moderate/Severe Post Psychotic Depression Depression in Acute First Episode Psychosis

32 Overall The vast majority (80%) report depression in one or more phase of FEP

33 Depression in Acute Phase: Continuous: 64% De novo 36%

34 What is the course of depression through FEP?

35 Patterns emerge: Depressed throughout: 20% (18) Depressed Prodrome and Acute 18% (15) Depression in Prodrome only 13% (11) Prodrome and PPD 4% (3) No Depression throughout 18% (16) Depressed in Acute Phase only 14% (10) Acute and PPD 7% (6) PPD only: 4% (4)

36 Course of Depression 20% 15% 13% depression No depression Prodrome Acute Post-psychotic

37 Course of Depression 18% 21% 4% Depression No Depression Prodrome Acute Post-psychotic

38 Prodromal Depression predicts severity of Acute and PPD: Mean CDSS higher in those with Prodromal depression: ACUTE 9.45 (s.d.5.54) 4.98 (s.d.5.52) PPD 4.71(s.d.3.86) 2.55 (s.d.4.88) p <0.001 p=0.02 Mann-Whitney U comparison of mean CDSS scores

39 Prodromal Depression predicts more severe Acute and PPD: PRODROMAL DEPRESSION MEAN S.D. sig. 2 tailed p= 95% c.i. of difference lower upper CDSS Acute YES NO CDSS PPD YES NO

40 Suicidality: 30% report attempts at DSH at baseline Those who report DSH significantly more depressed DSH Mean CDSS= (s.d. = 5.94) No DSH Mean CDSS= 6.3 (s.d. = 5.43) p = Mann-Whitney U comparison of mean CDSS score

41 IN THE ACUTE PHASE:

42 Is depression a by-product of positive or negative symptoms?

43 Depression not linked to severity of positive or negative symptoms: 30 PANSS Pearson correlation Positive/depression Sig Negative /depression Sig CDSS

44 Role of Insight:

45 INSIGHT Insight As a symptom dimension: Total score not related to depression: Awareness of Illness significantly related: Pearsons Correlation : r = p <0.01

46 ROLE OF ILLNESS APPRAISALS:

47 Appraisal of Threat from Voices Malevolent Content p=0.002 Less benevolent Content p=0.002 Engagement p=0.01 Omnipotence n/s Resistance n/s

48 Appraisal of threat from Persecutors Imminence of Threat p=0.01 Perceived ability to cope p=0.03 Distress p=<0.001 Power of persecutors p=0.07 Strength of Belief p=0.16 Mann whitney-u comparison of means

49 The appraisal of psychosis as embodying: greater loss p=<0.001 greater shame p=<0.001 greater entrapment p=0.001 Less group fit p=<0.001 Strongly linked to depression in the acute phase Mann-Whitney-U comparison of means Depression in Acute First Episode Psychosis

50 Linear Regression Model: Total Acute Depression: Demographics Prodromal depression Appraisals

51 Linear Regression Model: MODEL R R Sq. Std. BETA VOICE MALEVOLANCE SHAME SIG 0.002

52 Conclusions:

53 In First Episode Psychosis Depression is: Common (80%) Not simply an extension of prodromal depression, or precursor of post psychotic depression Not explained by severity of psychopathology Underpinned by appraisals of voices, persecutors and implications for social roles and status Significantly linked to suicidality Depression in Acute First Episode Psychosis

54 NEXT. Informed Treatment CBT Recovery Relapse Prevention

55 Criticisms Broad diagnosis. Retrospective account of prodrome Difficulty in teasing out symptoms in acute phase Follow up: frequency and length Numbers: multiple testing Depression in Acute First Episode Psychosis

56 However: DIPS Important area of research Novel Findings Generation of further work

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