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2 Outline Definitions and prevalence Age of onset and duration of untreated psychosis Costs of psychosis Best outcomes and national policy Recovery model and planned care. Medication. How do we work together best -and what kind of service do GPs want? Psychosis in young people

3 Definitions and incidence ICD definitions F23-29 Acute; polymorphic (with prominent affective features and disturbance of thought); with symptoms of schizophrenia (and without); predominently delusional; predominently affective including Bipolar Mood Disorder; Catatonia; transient; substance related; Not Otherwise Specified. Guiding evidence based principles- Schneiderian First rank symptoms - hallucinations, delusions and formal thought disorder; incongruity of mood and negative symptoms; predominance of mood, hallucinatory or delusional features; persistence-more than a month-number of symptoms; distress and impact. Schizophrenia spectrum disorder Incidence of schizophrenia 1% lifetime incidence. Incidence of Psychosis is greater and shows more variation between ethnic groups (AESOP)

4 Issues for Early Identification Management and Referral of Adolescents Rate of hallucinations in the normal population of children 9% of 7/8 year olds have auditory hallucinations in a given year - more frequent in teenagers 1% have multiple persistent symptoms more predictive of psychotic episode Think of referring- Young people with persistent multiple symptoms, especially those more suggestive of psychosis, who are distressed. Lower threshold if there are additional risks- Risk of self harm or harm to others Family history of Psychosis; personal history of recurrent subclinical episodes or anxiety, problems of interpersonal skills and learning difficulties. Should we have Prodromal Clinics?

5 Age of Onset and duration of untreated psychosis Peak incidence for schizophrenia - 20 s and 60 s Reports of patients when presenting to services suggest symptoms frequently began 6 years before Onset of psychosis peak Significance of duration of untreated psychosis for outcome.

6 Costs of Psychosis Major cause of suicide in young people Period of increased risk Distress of symptoms and associated effects of illness Chronic and secondary mental health problems into and through adulthood. Full financial costs of chronic illness on a World Scale. Secondary destructive effects of episode of illness - Stigmatisation, impact on psychological functioning, employment and earnings, education, relationships, social inclusion. Impact of medication.

7 Best outcomes NICE Guidelines for treatment of Schizophrenia 2009; DH Policy Implementation Guidelines and best practice for Early Intervention in Psychosis Active pharmacological treatment from the earliest stage (Short DUP) with lowest effective doses of atypical antipsychotics Dedicated standalone specialist multi-disciplinary teams Interventions and relationship with patient and carers using the recovery model Includes use of CBT, family interventions, assessment and support with activities of daily living, positive approach to optimise functioning and prevent/repair social damage. Case managed approach

8 Recovery Model Vulnerability factors and trigger Prodrome-frequently changes in social interaction, mood, anxiety, hallucinations and delusions / worrying ideas-1-2 years Requires? Prodromal Clinic. Illness - 1 year Requires acute assessment, crisis plan and treatment. Remission and recovery years Requires repair of confidence, return to optimal functioning, education, family and personal adjustment to stress management, work on early warning signs and relapse prevention, resilience building. Preparation for discharge - 1 year. Requires promotion of independence; self monitoring; building resilience and support systems; aftercare; relapse prevention; easy identification of relapse and return to specialist care. National guidelines suggest 3 year intervention package.

9 Medication issues Atypical (Second Generation) Antipsychotics Risperidone, olanzapine, quetiapine, arinpiprazole and others. Baseline monitoring Physical status. BP, Ht and Wt and indicator of obesity-eg BMI Confirm absence of extrapyramidal side-effects (EPSE) ECG- if evidence of cardiac problems especially WPW in the personal or family history. (Thyroid function) Liver and renal function; haematological indices; prolactin; lipid profile, blood sugar. Ongoing monitoring (at least 6 monthly) BP; measure of obesity; EPSE; symptoms indicative of hyperprolactinaemia Lipid Profile; blood sugar; prolactin

10 Medication ctd Concordance-frank exchange! Use medication along with psychological therapies for best symptom control Dosage schedules lowest effective level in the therapeutic range taking account of side-effects 6 weeks trial period Change to next agent if effective level not obtained Consider clozapine if second trial has been ineffective Special considerations (consider depot if this better meets patients wishes and concordance is an issue) Continue for at least 1 year after episode is over

11 How do we work together best-and what kind of service do GPs want? Identification - Information in surgeries and promotions for young people to use primary care Easy access to specialist early intervention service for clinical discussion. Prompt response by flexible, positive and non-stigmatising service. Clear assessments - including areas of uncertainty Shared Care Protocols- robust medication management and communication; side-effect monitoring Clear crisis plans and relapse prevention plans Some patients prefer to be discharged back to GP at an early stage and what kind of service do GPs want?