Transcript Dr. William McFarlane's presentation
Preventing the First Episode of Psychosis
William R. McFarlane, M.D., Director, National Program Office Early Detection, Intervention and Prevention of Psychosis Program Robert Wood Johnson Foundation Maine Medical Center Research Institute Portland, Maine Tufts University School of Medicine
Early detection and prevention in another illness
“If you catch cancer at Stage 1 or 2, almost everybody lives. If you catch it at Stage 3 or 4, almost everybody dies. We know from cervical cancer that by screening you can reduce cancer up to 70 percent.” ---Lee Hartwell, MD Nobel Laureate, Medicine President and Director, Hutchinson Center New York Times Magazine December 4, 2005, p. 56
2-3%
Proportion of youth who develop schizophrenia or a severe, psychotic mood disorder
75%
Proportion of people who have one psychotic episode and schizophrenia and then develop disability
12-15%
Proportion of people with schizophrenia or a psychotic mood disorder who commit suicide
$61 billion
Annual U.S. costs for schizophrenia
100 90 80 70 60 50 40 30 20 10 0 0 Functioning as an effect of number of psychotic episodes 1 2 3 Number of episodes 4 5 6
Portland Identification and Early Referral (PIER)
Reducing the incidence of major psychotic disorders in a defined population, by early detection and treatment
Professional and public education
• Reducing stigma • Increasing understanding of early stages of mental illness and prodromal symptoms • How to get consultation, specialized assessments and treatment quickly
Family practitioners Pediatricians School teachers, guidance counselors, nurses, social workers Employers College health services EDIPPP Team Mental health clinicians Military bases and recruiters Clergy Advertising General Public Emergency and crisis services
Family-aided Assertive Community Treatment (FACT)
• In-depth assessment of symptoms of risk • Rapid initiation of treatment • Psychoeducational multifamily groups • Supported employment and education • Key intensive case management methods
Early Detection and Intervention for the Prevention of Psychosis (EDIPPP)
A national multisite effectiveness trial
Reducing the incidence of major psychotic disorders in a defined population, by early detection and treatment
Early Detection and Intervention for the Prevention of Psychosis
• Effectiveness Test at six sites: – Portland, Maine – Glen Oaks and Queens, New York – Ann Arbor, Michigan – Salem, Oregon – Sacramento, California – Albuquerque, New Mexico • Large, nationally representative sample • PIER community outreach and identification systems • Sponsored by RWJF: $17 million
Outcomes
Early identification across cities
SITE Population Age-corrected rate**, at 25/100,000* Years of community outreach Maine Michigan Oregon California New York New Mexico 323,105 344,791 631,853 466,488 557,725 662,564 63% 37% 29% 26% 17% 12% Total 2,986,526 27%
*Rate for Nottingham, U.K., in Kirkbride, et al., Arch Gen Psychiatry. 2006;63:250-258 ** Proportion (69.2%) of ages 12-35 population represented by ages 12-25 population
8 2.5
1.5
Rates of psychosis and negative events Over 24 months
Low-risk High-risk Severe Psychosis 2.3% 6.3% Negative Events* 22% *Hospitalizations, incarcerations, suicide attempts, assaults, rape 25%
85% 84% 83% 82% 81% 80% 79% 78% 77% 76%
In school or working:
Baseline and 24 months
84% 79% CLR In School or Working at baseline 83% 83% CHR&EFEP In School or Working at 24 months
First hospitalizations for psychosis
Maine Urban controls areas vs. Greater Portland *p<0.0001
Savings for First Hospital Admissions for Psychosis
Greater Portland vs. Urban Maine 1999-2000 vs. 2001-2007 Difference in incidence 1999-2000 vs 2001-2007 Portland population Average 2001-2007 Cases prevented Mean LOS, days Bed Day Rate Annual savings, Greater Portland
Annual per capita savings, 2001 2007
15.9 per 100,000 population 330,000 52 11 $900 $519,453
$1.57
40 30
Early intervention is prevention
One year rates for conversion to psychosis 22.9% Controls Experimental Risk reduction = 66% 23.0% % 20 10 0 PA CE PRI M E OP US PIE R ED IE O 3 PA CE II GRN EDI E II Ad din gto n ED IE III ED IP M PP ea n r ate Fusar-Poli, et al, JAMA Psychiatry, 2013 7.6%
Outcomes in First Four California PIER Programs
N = 125 Working In school Onset of Psychosis: Hospitalizations: Suicide attempts: Baseline 15% 57% 21% 13% 8% 12 Month 49% 56% 3% 7% 2%
Conclusions
• Community-wide education is feasible.
• Referral of 30% up to 60% of the at-risk population.
• Global outcome in FACT was better than regular treatment.
• The rate psychosis onset is less than 1/4 of expected.
• Average functioning was in the normal range by 24 months.
• Five cities show a declining incidence.
• Programs in California are showing same results.
• ¾ were in school or working up to 10 years later.
Conclusion
As in successes for prevention in cancer and cardiovascular disease, early identification and intervention for psychosis give us enormous opportunities to reduce the total burden of disease in the United States.
For further information:
www.PIER
Training Institute .org [email protected]