Preventing the First Episode of Psychosis
William R. McFarlane, M.D., Director,National Program Office
Early Detection, Intervention and Prevention of Psychosis ProgramRobert Wood Johnson Foundation
Maine Medical Center Research InstitutePortland, 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, MDNobel Laureate, Medicine
President and Director, Hutchinson Center
New York Times MagazineDecember 4, 2005, p. 56
75%
Proportion of people who have one psychotic episode and schizophrenia
and then develop disability
Functioning as an effect of
number of psychotic episodes
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6Number of episodes
Fu
ncti
on
ing
(G
AF
)
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
General Public
Mental health clinicians
Military bases and recruiters
Clergy
Emergency and crisis services
College health services
EDIPPP Team
Advertising
School teachers, guidance
counselors, nurses, social
workers
Employers
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
Early identification across cities
SITE PopulationAge-corrected
rate**, at 25/100,000*
Years of community
outreach
Maine 323,105 63% 8Michigan 344,791 37%Oregon 631,853 29% 2.5California 466,488 26%New York 557,725 17%
1.5New Mexico 662,564 12%Total 2,986,526 27%
** Proportion (69.2%) of ages 12-35 population represented by ages 12-25 population *Rate for Nottingham, U.K., in Kirkbride, et al., Arch Gen Psychiatry. 2006;63:250-258
Rates of psychosis and negative events
Over 24 months
Low-risk High-risk
Severe Psychosis
2.3% 6.3%
Negative Events*
22% 25%
*Hospitalizations, incarcerations, suicide attempts, assaults, rape
In school or working:Baseline and 24 months
84%83%
79%
83%
76%
77%
78%
79%
80%
81%
82%
83%
84%
85%
CLR CHR&EFEP
In School or Working at baseline In School or Working at 24 months
Savings for First Hospital Admissions for PsychosisGreater Portland vs. Urban Maine
1999-2000 vs. 2001-2007
Difference in incidence
1999-2000 vs 2001-2007
Portland populationAverage
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
population330,000 52 11 $900 $519,453 $1.57
Early intervention is preventionOne year rates for conversion to psychosis
22.9%
7.6%
0
10
20
30
40Controls Experimental
%
23.0%
Fusar-Poli, et al, JAMA Psychiatry, 2013
Risk reduction = 66%
Outcomes in First Four California PIER Programs
N = 125 Baseline 12 Month
Working 15% 49%In school 57% 56%Onset of Psychosis: 21% 3%Hospitalizations: 13% 7%Suicide attempts: 8% 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.
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