Early intervention and prevention for psychotic disorders in Transitional Age Youth Cameron S Carter MD

Strategies for Improving Outcome Understand and treat currently treatment refractory symptoms (cognitive deficits and negative symptoms) Earliest possible intervention

BCA MacDonald, Carter et al 2005 American Journal of Psychiatry Never Medicated FE Schizophrenia Patients Show Specific Deficit in Context Processing Related Prefrontal Physiology FE Schizophrenia Non-Schizophrenia FE PsychosisControls

Chronic, deteriorating Episodic, w/interepisode deficits ( common) Episodic, w/o interepisode deficits The course of schizophrenia Broad therapeutic window for Prevention/Early intervention

Serious mental disorders in youth Schizophrenia, bipolar disorder and serious depressive disorders affect up to 3% of the population Typical onset years (TAY) Hospitalization, school failure, substance abuse, disability and unemployment, criminalization and incarceration frequent complications We can significantly improve outcome and prevent these complications with an early intervention approach

Prevention Primary: Before a disease starts, prevent its onset (e.g. by immunization) Seconday: after a disease has started but before it has a clinical effect e.g. treating hypertension to prevent cardiovascular disease. Pap smear for cervical cancer Tertiary: identify and alleviate an established disease at an early stage to prevent complications, improve or maintain functional status e.g. aspirin therapy after heart attack to prevent recurrence

EDAPT Clinic: Rationale Duration of untreated psychosis is associated with poor outcome Early in illness treatment response is robust Loss of function and treatment resistance follow repeated relapses Early intervention can improve functional outcome Tailored treatment pathways and therapies for early treatment and rehabilitation

Marshall, M. et al. Arch Gen Psychiatry 2005;62: Summary correlations between duration of untreated psychosis (DUP) and outcomes by follow- up point

Marshall, M. et al. Arch Gen Psychiatry 2005;62: Odds of no remission in the long vs short duration of untreated psychosis (DUP) groups

Perkins et al American J Psychiatry 2005

EDAPT Clinic: 2 “Target” Populations Early psychosis “first episode” patients Ultra high risk

First Episode Cohort years of age Onset within the previous 12 months Goal is to engage patient (and family/support system) in sustained treatment Stabilize, and support recovery of function and developmental trajectory

Clinic Description The EDAPT Clinic provides comprehensive diagnostic and treatment services for children and young adults who have recently developed a psychotic disorder, or who are at high risk for one of these disorders. The goals of the clinic are 1. Early Intervention 2. Prevention of disease-related deficits 3. Prevention of treatment-related side effects 4. Active participation in treatment 5. Progression towards personal, social, and occupational goals Referral Sources Sacramento County Mental Health Treatment Center (SCMHTC) UC Davis Outpatient Psychiatry Clinic Community Psychiatric Hospitals NAMI Family Members School Psychologists/Nurses Turning Point Crisis Residential Sacramento County CAPPS Clinic UC Davis Counseling Center (CAPS) The EDAPT Clinic

Clinic Demographics Screened (07/ /07) 493 Accepted into Clinic 104 Total Number Enrolled 70 First Episode Patients 49 ‘Ultra High Risk’ Patients 21 Age Range of Patients Average Age 19 Under 18 46% Working or in School 91% Number hospitalized 10 Ethnic Makeup of Clinic Caucasian 57% African American24 Latino7 Asian/Pacific Islander9 Middle Eastern3 Caucasian African American Latino Asian/Pacific Islander Middle Eastern Sacramento County

Some key first episode treatment issues Diagnostic uncertainty, symptom based treatment, side effects Denial of illness, non compliance Depression, suicidality Family support “re-entry”, socialization, stress, advocacy Individualized pathways to recovery, value of peer groups

Key elements of treatment model Multidisciplinary treatment team Rapid response, extensive medical and psychiatric assessment Setting, may be better outside of CMH setting Medication management Individual and group therapy (psychoed, motivational, supportive) Advocacy (school, vocational, insurance and disability etc) Multifamily support group

Very Early Intervention: Ultra High Risk Cohort Can we delay the onset of psychosis and prevent functional decline? “Ultra High Risk” strategy: subthreshold psychosis, OR genetic risk or SPD and functional decline predict 20-40% conversion rate

Three Prodromal Risk State Categories Attenuated Positive Symptom State –Onset or worsening in the past year of (a) paranoid, grandiose, or referential ideas but without full conviction, (b) perceptual disturbances but without certainty of an external source, or (c) vague, circumstantial or tangential communication that is coherent and structured under redirection Brief Intermittent Psychotic Symptom State –Onset in the last month of transient hallucinations, delusions, and/or thought disorder, lasting less than one hour per day Genetic Risk and Deterioration State –A decline of 30% or more on the GAF in the past 12 months, AND patient either (a) has a first-degree relative with schizophrenia or (b) meets criteria for schizotypal PD

PACE, PRIME, OPUS and PIER 12 month outcome

First hospitalizations for psychosis Greater Portland vs. rest of Maine

Cost savings for first admissions to a hospital for psychosis Greater Portland vs. Rest of Maine PIER begins

Improved Outcomes from Very Early Intervention Results suggestive from Australian, Danish and U.S. studies BUT Definitive results will be needed to change public policy in the U.S.

Early Detection and Intervention to Prevent Psychosis (EDIPP)

Earlier Intervention: EDIPP Funded by a $2 million grant from the Robert Wood Johnson Foundation 5 sites across the nation Sacramento City, favored due to diversity, UCDMC favored for its strong community partnerships Seeks to make history, change public policy Careful diagnostic assessment, SIPS interview, plus active diagnoses and co-morbidities TARGETTED pharmacological therapies PIER model multifamily Psycho education and support groups supportive therapy, family support and therapy, supported education and employment and advocacy Research for enhanced risk prediction

Community Partnerships Schools Sacramento City Unified School District M.M.C. Mejia, PhD; Shelton Yip* UCDavis Counseling & Psych Services Diana Davis; Sandra Zeh* UCDavis MIND Institute John Brown* Sacramento State Univ. Counseling David Cordosi Sacramento County Mental Health Director: Ann Edwards-Buckley* Ethnic Services & Cultural Competence Jo Ann Johnson* Child & Adolescent Services, Pediatrics Charles Maas* Child & Family Health Sacramento County Mental Health Director: Ann Edwards-Buckley* Ethnic Services & Cultural Competence Jo Ann Johnson* Child & Adolescent Services, Pediatrics Charles Maas* Child & Family Health Lisa Bertaccini *Indicates Steering Committee Member Mental Health Advocacy NAMI Sacramento Heidi Sanborn* Mental Health Assoc. of Sacramento Andrea* & Marilyn Hillerman CA Council of CMH Agencies Rusty Selix* Staglin Family Foundation Garen & Shari Staglin Community Based Organizations Crossroads Employment Services Danny Marquez Sacramento Children’s Home Roy Alexander* African American MH Providers Dee Bridges; Maurice Dunn* El Hogar MH & Community Service Lisa Soto* La Familia Counseling Center, Inc. Anita Barnes* Southeast Asian Assistance Center Laura Leonelli* Asian Pacific Community Counseling Judy Fong Heary* Hmong Women’s Heritage Association May Ying Ly* Slavic Assistance Center Roman Romaso*

Entry Criteria Ages 12-25Ages Brief psychotic episodeBrief psychotic episode Prodromal symptoms or recent deterioration in youth with a relative with a psychotic disorder.Prodromal symptoms or recent deterioration in youth with a relative with a psychotic disorder. Within City of SacramentoWithin City of Sacramento Zip Codes: , 94211, 94229, 94230, 94232, , 94239, 94240, , , , , , 94271, 94273, 94274, , , , , , , 95857, 95860, , 95887, 95894, The EDAPT Program

What Happens following Referral? Phone Screen & Assignment or Referral Intake Clinical & Cognitive Evaluation Assignment to Case Management or Family-aided Assertive Community Treatment (FACT) The EDAPT Program

Family-aided Assertive Community Treatment (FACT): Clinical and functional intervention Rapid, crisis-oriented initiation of treatment Psychoeducational multifamily groups Case management and Medical Management using key Assertive Community Treatment methods –Integrated, multidisciplinary team; rapid response; continuous case review –Targeted pharmacological intervention as needed Supported employment and education Collaboration with schools, colleges and employers Substance abuse treatment, as indicated The EDAPT Program

Addressing diversity in EDIPP  Role of community partners in outreach, education, development of materials and MFG design  UCDMC medical interpreting services, for outreach, SIPS and individual patient evaluations and care  Development of culturally tailored MFG groups, partnering with therapists from African American, Latino and Hmong communities  Success would provide strong evidence for the value of the early intervention approach in an increasingly diverse American population

EDAPT/EDIPP Team Cameron Carter MD Robinder Bhangoo MD Jane DuBe LCSW Michael Minzenberg MD J. Daniel Ragland PhD Jong Yoon MD Marjorie Solomon PhD Kathleen Boyum PhD

Contact Information EDAPT Hours: 9:00am – 5:00pm M-F To make a referral, call: The EDAPT Program

Support NIMH Robert Wood Johnson Foundation NARSAD Dean Pomeroy and the School of Medicine Bob Hales and the Department of Psychiatry

UCD Psychosis Research Cognitive remediation for FE schizophrenia Using EEG/ERP and fMRI to enhance early diagnosis Linking PFF dysfunction to disturbances in memory, attention and language comprehension Understanding and treating negative symptoms

Key Collaborators Dan Ragland PhD Jane Dube MSW Kathleen Boyum PhD Emily Olsen Jong Yoon MD Michael Minzenberg MD Stefan Ursu Michael Buonocore MD PhD

Translational Cognitive and Affective Neuroscience Laboratory Psychotic Disorders Research Program Department of Psychiatry, University of California at Davis