Psychosocial Treatment for those at Clinical High Risk of Psychosis

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Psychosocial Treatment for those at Clinical High
Risk of Psychosis

• Jean Addington PhD
• University of Calgary

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Clinical Course of Schizophrenia
Premorbid
Progressive
Residual
Prodromal
Onset of Psychosis
Behavioral Functioning
Psychotic Symptoms
B 15 20
25 40.
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Early Intervention Is Key
Premorbid
Progressive
Residual
Prodromal
First Episode Treatment
Behavioral Adaptation
??
Psychotic Symptoms
B 15 20
25 40.
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Terminology

• Genetic high risk
• Prodromal
• Ultra high risk
• Clinical high risk

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Prodromal Syndromes

• Identified by a structured interview
• Structured Interview for Prodromal Syndromes
  (SIPS)
• Syndromes
• Attenuated positive symptom syndrome
• Brief intermittent psychotic syndrome
• Genetic risk deterioration syndrome
• Miller et al., 2003 Yung et al 2005

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Intervention Studies
McGorry et al., 2002, AGP Melbourne Morrison et al., 2004, BJP Manchester McGlashan et al., 2006, AJP North America
6 month FU N59 12 month FU N58 12 month FU N60
10 -Risperidone CBT 36 -needs based 9 - CBT 22-30 - monitoring 16 - olanzapine 35 - placebo
42 stopped risperidone Dropout of 13 for CBT, 14 for monitoring Dropout of 55 for olanzapine, 35 for placebo
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In progress trials

• FETZ program in Cologne group individual CBT
  and cognitive remediation
• Bechdolf et al (in press)
• PACE clinic in Melbourne CBT vs medication
• McGorry, Yung et al
• ADAPT study in Toronto

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Medication Concerns

• Concerns about drug side effects particularly if
  subjects are false positives
• Do not address potential environmental stressors
• psychosocial stress
• substances
• Clinical high risk individuals are help seeking
  but only 14-16 want medication (Addington
  Addington, 2005) compared to 90-95 who consent
  to psychological treatments

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Why CBT?

• CBT has demonstrated effectiveness for
• Reduction of psychotic symptoms
• Reduction of the associated distress
• Non-specific emotional problems
• Depression and anxiety
• Metacognitions
• Substance use
• CBT strategies fit within a stress-vulnerability
  model
• Teach coping strategies to protect against
  environmental stressors

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CBT addresses

• Normalisation
• Understand anomalous experiences and perceptual
  abnormalities
• Generating evaluating alternative explanations
• Safety behaviours
• Metacognition
• I am different and other core beliefs
• Social isolation
• French Morrison (2004)

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Cognitive Behavior Therapy Cognitive
RemediationSubstance UseStress Management
Group WorkFamily Work
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ADAPT Access, Detection and Psychological
Treatments
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Access, Detection Psychological Treatments
(ADAPT)

• RCT to evaluate the effectiveness of CBT compared
  to a supportive therapy (ST) in
• preventing or delaying the onset of a psychotic
  illness
• reducing the presenting concerns (depression,
  anxiety, functioning etc) of the clinical high
  risk group

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Assessments

• Baseline
• 6 months (end of treatment)
• 12 months
• 18 months
• Symptom monitoring check
• 1, 2, 3, 4, 5, 6, 9, 12, 15, 18

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Measures

• Symptoms
• Prodromal Symptoms (SOPS SPI-A)
• Depression (CDSS)
• Anxiety (general, social)
• Metacognitions
• Functioning
• Premorbid functioning
• Social Functioning Scale (Birchwood)
• Substance Abuse (Drake et al.,)
• Multnomah Community Ability Scale
• Personality
• Diagnostic Instrument for Personality Disorders
• NEO
• Therapeutic Working Alliance measures

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Psychological Treatments

• Randomly assigned to CBT or Supportive therapy
• CBT
• Up to 20 sessions over 6 month period
• CBT focuses on
• Adjustment
• Presenting concerns
• Attenuated psychotic symptoms
• Perceptual difficulties
• Depression anxiety
• Stress management
• Supportive therapy focuses on support and crisis
  management

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Sample

• 56 consented post screening
• 2 were psychotic at baseline
• 3 never showed up after screening
• 51 randomized
• stratified by age, gender, early vs late
• 24 in CBT group
• 27 in supportive therapy group
• Mean sessions - 12 in both groups

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Demographics (N51)

• 36 male, 15 female
• Age 21 years (range 13- 30)
• 55 white
• 92 single
• Education
• 45 grade 12
• education on average 13 years
• 47 currently working
• 68 students

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Comorbid Diagnosis

• 2 no Axis 1 disorder
• 55 mood disorder
• 35 anxiety disorder
• 10 alcohol abuse
• 17 cannabis abuse
• 30 Axis 2 disorder

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Outcome at end of treatment

• General Assessment of Functioning (GAF)
• Groups did not differ
• Both groups improved over time
• Anxiety
• Groups did not differ
• Both groups improved over time
• Negative symptoms
• Groups did not differ
• No improvement over time
• Social functioning
• Groups did not differ
• No improvement over time

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Depression

• At baseline ST group more depressed
• No change for CBT group
• Improvement for ST group

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Positive symptoms

• At baseline and follow-up ST group had more
  positive symptoms
• Improvement in each group

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Conversion to psychosis

• CBT group
• No conversions (0)
• ST group
• 3 conversions in 6 months (11)
• 3 subjects had a significant increase in positive
  symptoms to point of needing intensive monitoring
  (11)

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Summary

• No change in negative symptoms
• No change in social functioning
• Improvement in anxiety, GAF, positive symptoms
  and depression
• Conversions only in ST group

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Comments

• Possible that improvements will only be
  maintained by CBT group
• Perhaps prodromal patients get better anyway as
  there is no TAU group. Not allowed by reviewers
• Sample too small
• Too small dose of CBT
• Need to address social functioning

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Problem focus in sessions
Problem CBT group ST group
Depression 15 19
Anxiety 38 19
Positive symptoms 32 20
Relationships 32 48
Isolation 3 8
Work/school 31 36
Illness issues 4 12
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Problem focus in sessions (cont.)
Problem CBT group ST group
Loneliness 0 5
No confidante 5 0.5
Self is different 1 11
Going crazy 5 7
Accommodation 3 2
Trauma 5 2
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Intervention focus in sessions
Intervention CBT Support
Assessment 42 31
Goal setting 26 0
Engagement 47 43
Formulation 27 0
Normalization 30 0
Education 23 0
Alternative solutions 13 0
Alternative explanations 17 0
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Intervention focus in sessions (cont)
Intervention CBT Support
Safety behaviors 5 0
Metacognitive beliefs 7 0
Core beliefs 24 0
Relapse prevention 9 0
Termination 15 0
Crisis intervention 0 1
Support 0 75
Befriending 0 18
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Future considerations

• Does the CBT group maintain improvement?
• Spending a lot of time on engagement longer
  therapy time or better therapists?
• Is the treatment time long enough?
• Can we match treatment to patients?
• What do we do when patients hit the cusp of
  conversion?