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Early intervention in first-episode psychosis: The impact of a community development campaign
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B. 13. P E T I M A G I N G O F V U L N E R A B L E COGNITIVE PROCESSES IN SCHIZOPHRENIA: CAN EARLY COMPENSATORY CHANGES BE USED AS A BIOLOGICAL MARKER FOR EARLY PSYCHOSIS? B.T. O'Sullivan L2, R. Cervantes 1, J. Young 1, B. W o o d h a m 2, N. Barrett 2, G. Smith 2, P. Michie, F. Karayanidis, Sung D u k Cho ~, B. Horwitz 3
Departments of IPsychiatry and 2physiology, Central Sydney Area Health and University of Sydney, Australia, 3National Institutes of Health, Bethesda, MA, USA Switching of attention and updating of working memory (tests of 'fluid intelligence') are especially vulnerable in people with schizophrenia 1. This study compares the dynamic correlations between prefrontal activation (ArCBF) and task performance (rection time and accuracy) in patients recently diagnosed with schizophrenia relative to normal control subjects. 150 PET was used while 10 normal subjects matched to 10 recently diagnosed and high functioning schizophrenic patients performed a battery of visual attention and working memory tasks z. Image data were analysed using SPM with MR image co-registration to identify areas of ArCBF. Correlation analyses 3 of ArCBF and psychophysical data were then performed. Both groups activated specific regions in the orbitofrontal cortex and the right dorsolateral prefrontal cortex during switching of attention and updating of working memory. In the schizophrenic group there was an unexpected finding of bilateral hyperactivation of the dorsolateral prefrontal cortex. Correlation analysis showed two quite different patterns of correlations between reaction time and prefrontal activations in the patient group compared to normals suggesting different functional brain organisation of neural networks. We believed we have identified the presence of brain compensatory mechanisms that allow patients to maintain a level of task performance equivalent to normals and propose a quantitative model using these findings as a biological marker for the early diagnosis of schizophrenia.
References 1. O'Sullivan B.T., Neuro Image, 1997: 5, 4. 2. Smith G., J Abn Psych, 1998: 107: 3. 3. Horwitz B,, J. Cogn Neuroscience, 1992: 4: 2.
B. 14. F E T Z : T H E F I R S T G E R M A N INTERVENTION CENTRE FOR SCHIZOPHRENIA
EARLY
M. Hambrecht, J. Klosterk6tter
Department of Psychiatry and Psychotherapy, University of Cologne, 50924 Cologne. Germany For decades the early stages of schizophrenia had been a major focus of German psychiatry. Meyer-Gross, Conrad,
Huber, and H~ifner published highly influential clinical descriptions, stages models, and systematic empirical and epidemiological studies on prodromes and onset of psychosis. From this more academic background, the worldwide initiatives for the implementation of early detection and early intervention of schizophrenia in psychiatric services were well received. In 1997, 'FETZ', the first German early recognition and early intervention centre, was established in Cologne with a catchment area of 1 million inhabitants. A team of psychologists and psychiatrists provides a multi-level assessment including psychopathology (particularly basic symptoms with the Bonn Scale for the Assessment of Basic Symptoms, BSABS, past history and determination of onset by the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS), family history, neurophysiology (i.e., evoked potentials), neuropsychology (e.g., attention and working memory deficits), and brain imaging. Depending on the individual risk for the transition to psychosis, psychological or pharmacological interventions are offered. Presently the centre assesses about 120 new cases per year mostly referred from consultant psychatrists in private practice, general practitioners, counseling centres, school psychologists, and family members, who become aware of the centre through a wide number of activities for the general public and for target groups. Prospective controlled studies will evaluate the predictive validity of the employed diagnostic measures and the different types of intervention.
B. 15. E A R L Y I N T E R V E N T I O N IN FIRSTEPISODE PSYCHOSIS: THE IMPACT OF A COMMUNITY DEVELOPMENT CAMPAIGN H. Krstev, P.D. McGorry, S.M. Harrigan, S. Carbone
Early Psychosis Prevention and Intervention Centre, Department of Psychiatry, The University of Melbourne, Parkville, Victoria. Australia, 3052 The personal and economic costs of delaying treatment for psychotic illnesses have been well documented. Despite this, strategies attempting to reduce the duration of untreated psychosis are still in germination. This study presents the results of a small-scale community education campaign aimed at reducing the duration of untreated psychosis in a geographically defined region in the inner-western suburbs of Melbourne, Australia. The duration of untreated psychosis was then compared with a control geographical region. A mobile early detection team served both sectors. Unexpected, the overall mean duration of untreated psychosis was increased for the experimental sector. However the distribution of the duration of untreated psychosis between the two regions was markedly different, with the experimental region picking up proportionally more cases with a longer DUP. When these outliers were removed, the average DUP in the experimental region was reduced. These findings highlight the complexity of McGlashan's model for community intervention and suggest that efforts to reduce the duration of untreated psychosis have
182
two effects, not one. Firstly, that the community campaign picked up extra cases with a long DUP, presumably individuals whom otherwise may have gone undetected. Secondly, when these effects are controlled for, the average DUP for the experimental region was decreased.
B. 16. P S Y C H O S I S C O N S U L T A T I O N CONSULTATION TO GENERAL PRACTITIONERS TO FACILITATE DETECTION AND TREATMENT
TEAM: EARLY
M. Bak, S. Radstake, J. van Os
Department of Psychiatry and Neuropsvchology, Maastricht University. Correspondence. 3/L Bak MD, PMS Vijverdal, Vijverdalseweg 1, 6226 NB Maastricht, The Netherlands Background: There is interest in the early detection and treatment of (i) first-episode psychosis and of (ii) prevalent psychosis cases who remain untreated. Method: A Psychosis Consultation Team (PCT) was created to offer low-level consultation to general practitioners (GP's) in a geographically defined area of around 32,000. GP's were visited in person and offered details about the project and instructed to directly contact a member of the PCT in the case of first-episode psychosis or untreated prevalent psychosis. Sixteen GP's participated in the study for a period of ten months. Results: Over the study period, GP's referred eight cases of psychosis to the team. The majority of individuals (n = 5) were cases of first-onset psychosis, representing an incidence of 26.1 per 100,000 person-years. This incidence is higher than the registered incidence of comparable cases in the case register of the Maastricht region, suggesting that the extra service of a PCT will enhance the referral rate by GP's. Compared to firstonset cases who contacted mental health services through the regular channels, PCT cases had an 18-month reduction of the period of untreated psychosis. However, of the 5 incident cases, only 2 fully engaged with mental health services over the study period. Conclusion: A specific GP collaborative program for untreated psychosis may result in earlier detection and reduction of duration of untreated psychosis. However, it is not known if such a service is cost-effective or whether reduction of duration of untreated psychosis results in better outcome.
Reference Nazareth I., King M., See Tai S. (1996), Monitoring psychosis in the general practice: a controlled trial. British Journal of Psychiatry, 169, 475-482.
B. 17. S K I L L S I N T R E A T I N G E A R L Y PSYCHOSIS ARE EXPORTABLE H. Krstev, P.D. M c G o r r y , S. Haines, S.M. Harrigan, D. Wade, C.A. D a l t o n
Earl), Psychosis Prevention and Intervention Centre, Department of Psychiatry, The University of Melbourne, Parkville, Victoria, Australia, 3052 The Early Psychosis Prevention and Intervention Centre (EPPIC) is a comprehensive specialist service specifically aimed at young people experiencing their first episode of psychosis. The centre's primary objectives are to attempt to improve early case detection, prevent secondary morbidity and maintain psychosocial functioning in the early 'critical' period of illness. However, this model is difficult to generalise to the mental health system as a whole. We therefore developed strategies to export the knowledge and skills developed for the detection and management of early psychosis, to mental health workers throughout Victoria. This was achieved through the development of 'Early Psychosis Projects' consisting of an integrated range of activities with the aim of promoting early identification and optimal treatment during the prodromal, acute and recovery phases of psychosis in young people. To evaluate the effectiveness of the Early Psychosis projects, we compared the rates of functional recovery between a sample of patients treated at EPPIC and a similar group of first-episode patients treated by two different adult area mental health services. One service acted as an 'enhanced' adult service where an early psychosis project was implemented and the other acted as a 'standard' adult service. A comparison of rates of recovery, using the Quality of Life Scale (Heinrich and Carpenter, 1984) revealed that the EPPIC group made more rapid gains (p = 0.047). Medium to long-term functional outcomes were comparable between the EPPIC service and the enhanced adult service, and the stand-alone adult service produced comparatively worse functional outcomes. These findings generate confidence in integrating specialised early psychosis programs as well as other mental health programs into mainstream services.
B. 13. P E T I M A G I N G O F V U L N E R A B L E COGNITIVE PROCESSES IN SCHIZOPHRENIA: CAN EARLY COMPENSATORY CHANGES BE USED AS A BIOLOGICAL MARKER FOR EARLY PSYCHOSIS? B.T. O'Sullivan L2, R. Cervantes 1, J. Young 1, B. W o o d h a m 2, N. Barrett 2, G. Smith 2, P. Michie, F. Karayanidis, Sung D u k Cho ~, B. Horwitz 3
Departments of IPsychiatry and 2physiology, Central Sydney Area Health and University of Sydney, Australia, 3National Institutes of Health, Bethesda, MA, USA Switching of attention and updating of working memory (tests of 'fluid intelligence') are especially vulnerable in people with schizophrenia 1. This study compares the dynamic correlations between prefrontal activation (ArCBF) and task performance (rection time and accuracy) in patients recently diagnosed with schizophrenia relative to normal control subjects. 150 PET was used while 10 normal subjects matched to 10 recently diagnosed and high functioning schizophrenic patients performed a battery of visual attention and working memory tasks z. Image data were analysed using SPM with MR image co-registration to identify areas of ArCBF. Correlation analyses 3 of ArCBF and psychophysical data were then performed. Both groups activated specific regions in the orbitofrontal cortex and the right dorsolateral prefrontal cortex during switching of attention and updating of working memory. In the schizophrenic group there was an unexpected finding of bilateral hyperactivation of the dorsolateral prefrontal cortex. Correlation analysis showed two quite different patterns of correlations between reaction time and prefrontal activations in the patient group compared to normals suggesting different functional brain organisation of neural networks. We believed we have identified the presence of brain compensatory mechanisms that allow patients to maintain a level of task performance equivalent to normals and propose a quantitative model using these findings as a biological marker for the early diagnosis of schizophrenia.
References 1. O'Sullivan B.T., Neuro Image, 1997: 5, 4. 2. Smith G., J Abn Psych, 1998: 107: 3. 3. Horwitz B,, J. Cogn Neuroscience, 1992: 4: 2.
B. 14. F E T Z : T H E F I R S T G E R M A N INTERVENTION CENTRE FOR SCHIZOPHRENIA
EARLY
M. Hambrecht, J. Klosterk6tter
Department of Psychiatry and Psychotherapy, University of Cologne, 50924 Cologne. Germany For decades the early stages of schizophrenia had been a major focus of German psychiatry. Meyer-Gross, Conrad,
Huber, and H~ifner published highly influential clinical descriptions, stages models, and systematic empirical and epidemiological studies on prodromes and onset of psychosis. From this more academic background, the worldwide initiatives for the implementation of early detection and early intervention of schizophrenia in psychiatric services were well received. In 1997, 'FETZ', the first German early recognition and early intervention centre, was established in Cologne with a catchment area of 1 million inhabitants. A team of psychologists and psychiatrists provides a multi-level assessment including psychopathology (particularly basic symptoms with the Bonn Scale for the Assessment of Basic Symptoms, BSABS, past history and determination of onset by the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS), family history, neurophysiology (i.e., evoked potentials), neuropsychology (e.g., attention and working memory deficits), and brain imaging. Depending on the individual risk for the transition to psychosis, psychological or pharmacological interventions are offered. Presently the centre assesses about 120 new cases per year mostly referred from consultant psychatrists in private practice, general practitioners, counseling centres, school psychologists, and family members, who become aware of the centre through a wide number of activities for the general public and for target groups. Prospective controlled studies will evaluate the predictive validity of the employed diagnostic measures and the different types of intervention.
B. 15. E A R L Y I N T E R V E N T I O N IN FIRSTEPISODE PSYCHOSIS: THE IMPACT OF A COMMUNITY DEVELOPMENT CAMPAIGN H. Krstev, P.D. McGorry, S.M. Harrigan, S. Carbone
Early Psychosis Prevention and Intervention Centre, Department of Psychiatry, The University of Melbourne, Parkville, Victoria. Australia, 3052 The personal and economic costs of delaying treatment for psychotic illnesses have been well documented. Despite this, strategies attempting to reduce the duration of untreated psychosis are still in germination. This study presents the results of a small-scale community education campaign aimed at reducing the duration of untreated psychosis in a geographically defined region in the inner-western suburbs of Melbourne, Australia. The duration of untreated psychosis was then compared with a control geographical region. A mobile early detection team served both sectors. Unexpected, the overall mean duration of untreated psychosis was increased for the experimental sector. However the distribution of the duration of untreated psychosis between the two regions was markedly different, with the experimental region picking up proportionally more cases with a longer DUP. When these outliers were removed, the average DUP in the experimental region was reduced. These findings highlight the complexity of McGlashan's model for community intervention and suggest that efforts to reduce the duration of untreated psychosis have
182
two effects, not one. Firstly, that the community campaign picked up extra cases with a long DUP, presumably individuals whom otherwise may have gone undetected. Secondly, when these effects are controlled for, the average DUP for the experimental region was decreased.
B. 16. P S Y C H O S I S C O N S U L T A T I O N CONSULTATION TO GENERAL PRACTITIONERS TO FACILITATE DETECTION AND TREATMENT
TEAM: EARLY
M. Bak, S. Radstake, J. van Os
Department of Psychiatry and Neuropsvchology, Maastricht University. Correspondence. 3/L Bak MD, PMS Vijverdal, Vijverdalseweg 1, 6226 NB Maastricht, The Netherlands Background: There is interest in the early detection and treatment of (i) first-episode psychosis and of (ii) prevalent psychosis cases who remain untreated. Method: A Psychosis Consultation Team (PCT) was created to offer low-level consultation to general practitioners (GP's) in a geographically defined area of around 32,000. GP's were visited in person and offered details about the project and instructed to directly contact a member of the PCT in the case of first-episode psychosis or untreated prevalent psychosis. Sixteen GP's participated in the study for a period of ten months. Results: Over the study period, GP's referred eight cases of psychosis to the team. The majority of individuals (n = 5) were cases of first-onset psychosis, representing an incidence of 26.1 per 100,000 person-years. This incidence is higher than the registered incidence of comparable cases in the case register of the Maastricht region, suggesting that the extra service of a PCT will enhance the referral rate by GP's. Compared to firstonset cases who contacted mental health services through the regular channels, PCT cases had an 18-month reduction of the period of untreated psychosis. However, of the 5 incident cases, only 2 fully engaged with mental health services over the study period. Conclusion: A specific GP collaborative program for untreated psychosis may result in earlier detection and reduction of duration of untreated psychosis. However, it is not known if such a service is cost-effective or whether reduction of duration of untreated psychosis results in better outcome.
Reference Nazareth I., King M., See Tai S. (1996), Monitoring psychosis in the general practice: a controlled trial. British Journal of Psychiatry, 169, 475-482.
B. 17. S K I L L S I N T R E A T I N G E A R L Y PSYCHOSIS ARE EXPORTABLE H. Krstev, P.D. M c G o r r y , S. Haines, S.M. Harrigan, D. Wade, C.A. D a l t o n
Earl), Psychosis Prevention and Intervention Centre, Department of Psychiatry, The University of Melbourne, Parkville, Victoria, Australia, 3052 The Early Psychosis Prevention and Intervention Centre (EPPIC) is a comprehensive specialist service specifically aimed at young people experiencing their first episode of psychosis. The centre's primary objectives are to attempt to improve early case detection, prevent secondary morbidity and maintain psychosocial functioning in the early 'critical' period of illness. However, this model is difficult to generalise to the mental health system as a whole. We therefore developed strategies to export the knowledge and skills developed for the detection and management of early psychosis, to mental health workers throughout Victoria. This was achieved through the development of 'Early Psychosis Projects' consisting of an integrated range of activities with the aim of promoting early identification and optimal treatment during the prodromal, acute and recovery phases of psychosis in young people. To evaluate the effectiveness of the Early Psychosis projects, we compared the rates of functional recovery between a sample of patients treated at EPPIC and a similar group of first-episode patients treated by two different adult area mental health services. One service acted as an 'enhanced' adult service where an early psychosis project was implemented and the other acted as a 'standard' adult service. A comparison of rates of recovery, using the Quality of Life Scale (Heinrich and Carpenter, 1984) revealed that the EPPIC group made more rapid gains (p = 0.047). Medium to long-term functional outcomes were comparable between the EPPIC service and the enhanced adult service, and the stand-alone adult service produced comparatively worse functional outcomes. These findings generate confidence in integrating specialised early psychosis programs as well as other mental health programs into mainstream services.