Download Staying Well After Psychosis: A Cognitive Interpersonal

Co-morbidity in Psychosis
depression, substance misuse and
neurodvelopmental disorders
Alison Blair
Esteem Glasgow
With thanks to Prof. Andrew Gumley
First person perspective
“It is a total psychological experience. There is no strategies you can
make. You just have to sit there and experience-- abuse. And, the
most important thing, and I said this to my psychiatrist, is my illness
has my entire back catalogue <laughs>. It has my entire diary, so it
can pick things that have happened years ago, show a symbol of it,
show a picture of it, and it’s a horrible experience because you
begin to relive those experiences. You don’t have to relive them
because they are generally bad experiences, of my schizophrenia, a
lot of embarrassment, a lot of humiliation, and the reasons why they
are so bad is that virtual every time I have an attack, the illness
goes through them and makes you relive them to a certain extent.”
Quality of Life and Psychosis
• Quality of life is a key dimension of outcome in complex mental health
problems.
• Reflects the person’s subjective evaluation of their experience, their
perceived autonomy and the wider context of their recovery.
• Depression is one of the major factors contributing to poorer quality of life
amongst individuals with psychotic disorders generally
schizophrenia specifically. Meijer et al., 2009; Narvaez et al., 2008
Saarni et al., 2010 and
• No association of positive, negative and disorganisation symptoms with
quality of life. Meijer et al., 2009; Narvaez et al., 2008
Suicide and psychosis
•
Around 6% of individuals with a diagnosis of Schizophrenia complete suicide.
Palmer, Pankratz &
Bostwick, 2005
•
In first 5-years following a first episode of psychosis, 3% complete suicide.
•
Early phase linked to greater risk of attempted suicide and rates of 32% attempted suicide
following a first episode reported amongst adolescents. Birchwood et al., 2000; Falcone et al., 2010
•
Suicide and attempted suicide linked to hallucinations, depression, social isolation,
substance use, longer duration of untreated psychosis and demoralisation. Pinikahana et al., 2003;
Bertelsen et al., 2007
Bertelsen et al., 2007; Falcone et al., 2010
•
National Institute of Mental Health Longitudinal Study of Chronic Schizophrenia found that
over 6 years, 38% have at least one suicide attempt and 57% admitted with suicidal
ideation. Roy & Pompili, 2009
Depression and psychosis
• High risk period for development of depression is in the early years
after first episode. Birchwood et al., 2000
• Rates of depression 50% following a first episode of psychosis and
33% in established psychosis. Whitehead et al., 2002
• Post psychotic depression emerges independently of positive
symptom severity, relapse and negative symptoms.
Birchwood et al., 2000;
Iqbal et al., 2000
• Strong overlap with social anxiety in psychosis. Birchwood et al.,2006; Michail &
Birchwood, 2009
Correlates of depression in psychosis
• Depression has been found to be associated with a number of
important domains.
–
–
–
–
Less adherence to treatment. Conley, 2009
Longer duration of untreated psychosis. Drake et al., 2004
Greater problems in family relationships. Rocca et al., 2005; Mino et al., 1998
More closely associated with interpersonal adjustment than severtity of
psychiatric symptoms. Rocca et al., 2005
– Early life trauma and stressful life events. Ventura et al., 2000; Scheller-Gilkey et al.,
2002
– Greater actual experiences of stigma particularly with respect to
accessing valued social roles. Angermeyer et al., 2004
– Greater difficulties being able to identify emotional states. van der Meer et al.,
2007
Depression, hopelessness, and CBT
• A total of 15 randomised controlled trials of Cognitive Behaviour
Therapy have focused on depression as outcome and 4 trials have
focused on hopelessness. Wykes, Steel, Everitt & Tarrier, 2008
• Moderate effect size for mood = 0.36 (0.08, 0.65)
• Suggestion that CBTp may increase hopelessness = -0.19 (-0.55,
0.17) N.S.
• Significant findings for mood no longer significant when quality of
methodology is accounted for where lower quality studies (e.g. nonblinding, poor randomisation) are associated with larger treatment
effects.
Depression, hopelessness and
medication
•
Survey of 37,513 psychiatrists in US found good awareness of depression however
over 25% never prescribe antidepressants in this group. Siris et al., 2001
•
Cochrane review of antidepressants for depression in schizophrenia included 11
studies. Whitehead et al., 2002
– “At present, there is no convincing evidence to support or refute the use of
antidepressants in treating depression in people with schizophrenia.”
•
No difference found between typical and atypical antipsychotics in terms of
depression. Mauri et al., (2008)
•
Small randomised controlled trial found sertraline improved depression in
Schizophrenia. Mulholland et al. 2003
Depression, hopelessness and service
organisation
• Early detection aimed at reducing duration of untreated psychosis
was associated with reduced depression at 2-years. Melle et al. 2008
• OPUS study: a randomised controlled trial of Integrated Treatment
(Assertive Outreach, antipsychotic medication, social skills training
and family education) found reduced levels of hopelessness at 1year. Nordentoft et al. 2002
• Our own First Episode Psychosis service in Glasgow we see
significant improvements in depression and suicidal thinking over 6months maintained at 12-months.
Psychiatric and emotional recovery
over 12-months
40
35
30
25
Positive Symptoms
Negative Symptoms
20
General Symptoms
Beck Depression Inventory
15
10
5
0
Baseline
6-months
12-months
Changes in suicidal thinking over
12-months
35
30
25
20
Suicidal thoughts
15
10
5
0
Baseline
6-months
12-months
Possible mechanisms of depression:
the importance of shame, entrapment and loss
• There is a paradox where insight associated with positive
outcomes such as reduced psychotic symptoms but linked to
depression and suicidal thinking.
– Good insight associated with engagement, adherence and
depressed mood. Where feelings of stigma are high relationship
between depression and insight is strong. Staring et al., 2009
– Those who go on to develop post-psychotic depression experience
greater loss, humiliation and entrapment prior to emergence of
depression. Birchwood et al., 2000
– Lowered expectations for future, greater self criticism, and greater
insight precedes development of depression and suicidal thinking.
Iqbal et al., 2000
– Predictors of hopelessness were depression, severity of psychiatric
symptoms and feelings of humiliation. White, et al., 2007
– Feelings of entrapment and low self esteem predict both anxiety
and depression. Karatzias et al., 2007
Feelings of shame grounded in the
reality of personal experiences
• These feelings are associated with persisting distressing psychotic
experiences, more involuntary admissions, heightened awareness of
the negative consequences of psychosis, greater awareness of the
stigma of psychosis, being out of work, and loss of social status and
friendships. Rooke and Birchwood, 1998
• Experience of relapse linked to the evolution of feelings of
entrapment, shame and self blame over time. Gumley et al., 2006; Gumley,
2007
• Suicide and attempted suicide linked to hallucinations, social
isolation, and longer duration of untreated psychosis.
2003; Bertelsen et al., 2007; Falcone et al., 2010
Pinikahana et al.,
“Third Wave” Cognitive Behavioural
Therapies
• “Grounded in an empirical, principle-focused approach, the third wave of
behavioral and cognitive therapy is particularly sensitive to the context and
functions of psychological phenomena, not just their form, and thus tends
to emphasize contextual and experiential change strategies in addition to
more direct and didactive ones. These treatments tend to seek the
construction of broad, flexible, and effective repertoires over an eliminative
approach to narrowly defined problems…” Hayes, 2004 p 658
• Rather than altering the content or frequency of cognitions, 3rd wave
therapies seek to alter the individual’s relationship with thoughts, feelings
and sensations to promote psychological flexibility.
–
–
–
Acceptance and Commitment Therapy (ACT) focus on the person’s values and goals.
Compassion Focussed Therapy (CFT) cultivation of a compassionate soothing mentality
attuned to one’s own self critical shaming thoughts.
Mindfulness involving the cultivation of a non-judgemental awareness
Cannabis Use
• Greater severity of psychotic symptoms
• Increased risk of relapse x 4
• Strongest predictor of relapse over 12/12
period (Linzen)
L. Hides et al 2006
• No of days cannabis use most
significant predictor of time to relapse
over 6/12 period.
• 61% ‘relapsed’ using cannabis.
• 39% psychotic relapse
Predictors of Cannabis use
following psychosis
• Severity of psychotic symptoms.
• Baseline cannabis use.
• Medication adherence.
D. Wade et al 2006
• 103 consecutive referrals
-
53% substance misuse
42% cannabis
30%alcohol
17% other
57% poly substance use
Substance misuse
None
• Admission 45%
15%
• Remission 93%
98%
• Relapse 51%
17%
Substance Use Amongst ESTEEM
Clients: Prevalence, Forms, and
Levels of Impairment
Dr I M Kevan (Clinical Psychologist)
& Dr A Blackett (Con. Clinical Psychologist)
ESTEEM First Episode Psychosis Service
NHS Greater Glasgow & Clyde
Methodology
• Individual clinicians consulted about active
cases on the ESTEEM caseload.
• Each service-user’s current substance use
pattern was established using a clinicianrated classification system
Classification of Current* Substance
Use
–
–
–
–
–
–
(1) Non-user (abstinent)
(2) Use without impairment
(3) Use with impairment (sometimes)
(4) Use with impairment (always)
(5) Dependence
(6) Unknown Pattern
* For in-patients, current use was with reference to time in the
community before admission
Descriptive Characteristics of
Sample
• 160 current cases ESTEEM caseloads.
• Mean age: 25 years ( range 16-35).
• 112 males (70%) and 48 females (30%).
• Mean number of months on the ESTEEM
caseload was 11 ( range 1- 36 months).
Prevalence of Substance Use
 65.6 % (n = 105) service-users were current
users of substances (drugs and/or alcohol).
 34.4% (n=55) were rated as currently
abstinent.
Percentage of Active Current Substance/Alcohol
Users on ESTEEM Caseloads
90
80
82.5
73.8
70
Percentage
60
52.6
50
40
30
20
10
0
North West
North East
Team
South
Substance-Use Forms Amongst Current Users
2.9
Other
9.5
Ecstasy
12.4
Benzos
3.8
Substitute Prescribing
6.7
Opiates
9.5
Amphetamine
14.3
Cocaine/Crack
48.6
Cannabis
92.4
Alcohol
0
20
40
60
80
Percentage Using Substance
100
Clinician-Rated Impairment in
Substance Using Clients
• 33 (31.4%) of the clients currently using without
current impairment
• 33 (31.4%) were rated as ‘Use with impairment
•
•
•
(sometimes)’.
15 (14.3%) were rated as presenting with ‘Use
with impairment (always)’.
16 (15.2%) of the sample were rated as having
‘Dependence’.
8 (7.6%) clients who currently use were so
unclear that it was difficult to make a rating of the
level of impairment.
Drug-Use Associated with Highest
Impact on Functioning
more significant difficulties, [‘Use with
Impairment (always)’ or ‘Dependence’ (n
= 31)
alcohol (35.5%)
cannabis (25.8%),
and dual alcohol and cannabis misuse
(12.9%)
Interventions
• Psycho-education
• Addiction interventions within Esteem care
depending on complexity e.g. substitute
prescribing
• Motivational interviewing approach
• Individual psychology input
• Behavioural family therapy
Autism & Psychosis
• Survey of care co-ordinators in Teeside EI
service
• Comorbid autistic spectrum in 10% of
under 18 group.
• 4 – 5% in 14 – 35 year old group.
O. Stahlberg 2004
Attention deficit/hyperactivity disorder – AD/HD
Autistic Spectrum Disorder - ASD
• AD/HD patients – 30% co morbid ASD.
• ASD patients – 38%
• ASD - 7% bipolar & psychosis
- 8% schizophrenia
• AD/HD – 5% bipolar & psychosis
- 5% schizophrenic
N. Craddock, M. Owen 2010
Specific copy number variant (CNV) is
associated with schizophrenia, mental
retardation and autism.