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]