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David Castle- Work and Mental Illness
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Work and Mental Illness
Professor David CastleChair of Psychiatry, St. Vincent’s Hospital MelbourneDept. of Psychiatry, The University of MelbourneEmail: [email protected]
Australia “Low Prevalence” study (Jablensky et al,1997)
5.8% males, 6.1% females in full time employment
72% males, 62% females on DSP
Work exclusion in Schizophrenia
Structured daily activities
Social opportunities
Feeling socially ‘useful’
Enhanced self esteem
Regular income
(Mueser et al,1997)
Positives of work
Symptoms of mental illness
Side effects of psychiatric medications
Lack of access to vocational/educational training
Job design problems
(Human Rights and Equal Opportunities Commission,1993)
Reasons for work exclusion in schizophrenia
Support and work with other services towards “an integration of vocational and clinical services at the level of service delivery”
(Frost et al, 2002)
Optimistic symptom control and reduce side effect burden
Examples: Manage mood instability in bipolar Ameliorate effects of cognitive dysfunction in schizophrenia
“A Psychiatrist’s Perspective…”
Bipolar Affective Disorder: Psychosocial TreatmentsProfessor David CastleChair of Psychiatry, St.Vincent’s Hospital Melbourne
and the University of Melbourne
Type IBPAD
Type IIBPAD
“Cyclothymia”
Bipolar Spectrum Disorder
“Normal” Mood Varianc
e
MANICPHASE
DEPRESSED PHASE
Different Types of Bipolar Disorder Mood Profile
(Castle & Bassett, 2009)
Prodrome
Presentation with Mania
Treatment Begins
Depressed Phase Following Recovery From Mania
Prodrome
Depression
Mania Following Treatment of Depression
ELEVATED
MOOD
DEPRESSED MOOD
Longitudinal Course of Bipolar (an Example)
(Castle & Bassett, 2009)
Walking the Black Dog
The Red Dragon
Johnson and Miller, J Abnorm Psychol 1997; 106: 449-457Gitlin MJ , Hammen C Bipolar Disorder Golberg Jf, Harrow M (Eds) 1999Keck P et al 1996 Jour. Clin. Psych. 1996;57:292-97Miklowitz DJ. CNS Spectrum 1998;3:48Post et al J Clin Psych 64:6 June 2003Scott J, Br J Psychiatry 1995; 167: 581
Worse Prognosis
Bipolar Illness VariablesHigher number of episodesMore depressive episodes
Psychotic symptomsSubsyndromal symptoms
Psychosocial FactorsContribute 24-50% to outcome variables
Negative life eventsFunctional impairmentLower social support
Conflictual family relationships
Non- AdherenceRange non-adherence from 20-66%, mean 41%
Attitudes, beliefs important
Co-morbid DiagnosisSubstance abuse
Personality disorders
Prognostic Factors in Bipolar
Understanding of illness
Mood monitoring including early warning signs
Control of illness rather than illness exerting control
Symptom control
Optimal pharmacotherapy
Broader psychosocial parameters
Treatment Aims
Relapse rates high even if taking meds
Different approaches:
• Psychoeducation
• Family focused therapy (Miklowitz et al, 2000)
• CBT (Lam et al, 2003, 2005; Scott et al, 2006)
• IPSRT (Frank et al, 1999)
• Integrated models (Bauer et al, 2006; Simon et al, 2006)
• Collaborative Therapy (Berk, Berk & Castle, 2005)
- individual/group (Colom et al, 2003)
What do we know aboutPsychosocial Interventions?
(Castle et al, 2007, 2010)
Translating Effective Psychosocial Interventions
for Bipolar Disorder into Everyday Clinical Practice
Carolynne Holdsworth Cath Bunton
Frameworks for HealthSt.Vincent’s, Melbourne
(Castle et al, 2007, 2010)
Study Objectives
Primary Goals: To develop a group-based intervention and relapse
prevention package to assist consumers to manage their bipolar disorder.
To integrate the intervention using the Collaborative Therapy Framework and implement the project in a range of service settings.
To evaluate the effectiveness of the intervention using a RCT.
Challenges:
To develop an intervention that is effective for “real-world” patients
To ensure the intervention is sustainable beyond the life of the research project.
Study Objectives
Stages of Assessment1. Baseline2. Post-Group (3 month)
3. 12 month assessment
Phase 2• Evaluate “MAPS group program” using a
randomised control trial.
Intervention (12 weeks + 3 boosters)
Phase 1• Literature review
• Focus groups to map needs• Develop treatment package &
pilot content
Phase 3• Follow-up maintenance (9 months)
1
2
3
12months
Study Design
MAPS Group Program
The group program aims to:• Provide information and develop skills to assist people to
effectively manage bipolar disorder.• Enable people with bipolar disorder to get the most out of
life despite the disorder.
12 x weekly 1 ½ hour sessions + 3 x monthly boosters.
Resources: Personal Workbook, Information Book, Collaborative Treatment Journal (CTJ)
MAPS Session OutlineSession Focus Content
1 - 2 Education Introduction bipolar disorder and triggers commonly associated with bipolar disorder
3 - 6 Core skills development
Monitoring & assessment of stress/triggersPreventing relapse using coping skills, eg problem solving, stress tolerance and SMART goal setting & medication management
7 - 9 Depression Assessing and managing early warning signs of depressionDeveloping relapse prevention plans for depression
10 - 12 Mania Assessing and managing early warning signs of maniaDeveloping relapse prevention plans for mania
Booster 1 - 3
Integrating and reinforcing skills
Consolidating skills into daily life
A Real-world Clinical Sample
Sample size: Total N= 82
(control: n=39, treatment: n=35)
Gender: Female 76%, Male
24%
Age: mean = 42, SD = 11
Employment:Part time 37%
Unemployed 32%
Full time 15%
Student 1%
A Real-world Clinical Sample Diagnosis
Bipolar 1 22% Bipolar I (with psychotic episode) 8% Bipolar II 45%
Co-morbidities Ave no per person 2.9 most common: anxiety, suicidality, alcohol & substance
use, etc
Relapse
Number of relapses post treatment:Type Treatment ControlDepression 4 14Mania 0 6Hypomania 9 6Mixed 1 1
All relapses: mean time in relapse over 9 months was 11 days for treatment and 27 days for control group, p=0.01
0.2
5.5
.75
1
0 100 200 300 0 100 200 300
Treatment ControlAny 1st relapse Any 1st relapse
Treatment Control
surv
ivor
func
tion
time (post treatment, days)
Graphs by treat
Kaplan-Meier survival estimates, by treat
Any Relapse – time to first recurrence
Depression Relapse0.
000.
250.
500.
751.
00su
rviv
or fu
nctio
n
0 100 200 300time (post treatment, days)
Treatment Control
Depression
Mania/Mixed Relapse0.
000.
250.
500.
751.
00su
rviv
or fu
nctio
n
0 100 200 300time (post treatment, days)
Treatment Control
Mania and mixed
Service UtilisationMean - Treatment Mean - Control
Item Pre post Pre Post
Admissions 1.03 0.39 0.89 0.91
Weeks 2.84 1.32 2.54 1.83CAT Crisis Visits
1.97 0.00 0.74 0.53
Getting it Out There
Acknowledgements Project Team Chief Investigators: David Castle, Monica Gilbert, Michael Berk
Isaac Schweitzer and Leon Piterman Program Developers: Lesley Berk and Sue Lauder Research Clinicians: Carolynne Holdsworth, Cath Bunton, Terence Chong
and Cathy Carman.
Our project funding partners:
Our service partners:Pathways Support and Rehabilitation ServicesBarwon HealthHealthscope (The Melbourne & Geelong Clinics)Dr Greg Murray and Swinburne University of Technology
This project gratefully acknowledges the funding support of beyondblue the
national depression initiative
www.moodswings.net.au
Ms Sue LauderProfessor Michael BerkProfessor David Castle
Dr. Seetal DoddDr. Andrea Chester
Cognition in Schizophrenia: Can We Fix It?
Professor David CastleChair of Psychiatry, St. Vincent’s Hospital Melbourne
The University of Melbourne
What are the Cognitive Deficits in Schizophrenia?
Mild Moderate Severe
Perceptual skills Distractability Executive functioning
Delayed recognition memory
Memory and working memory
Verbal fluency
Verbal and full scale IQ Delayed recall Motor speed
(Wykes & Castle, 2003)
optimal treatment of positive symptoms important
some older (typical) antipsychotics seem to make cognition worse
benzodiazepines and anticholinergics can make cognition worse
Do Medications ImproveCognitive Impairment?
early studies suggested “yes”, but confounded by effect of halting typicals (EPSE etc.)
clozapine seems to improve attention and verbal fluency but has less effect on working memory
Do Atypical AntipsychoticsHelp Cognition?
400 patients < 5 yrs illness
Random assignment to: - Olanzapine (mean 12mg)
- Quetiapine (mean 500mg)
- Risperidone (mean 2.5mg)
400 patients started; 221 completed assessment at 12 weeks; only 81 completed neuropsychology tests at 52 weeks
(Keefe et al, 2007)
52 Week Trial of Olanzapine vs Risperidone vs Quetiapine (1)
(Keefe et al, 2007)
52 Week Trial of Olanzapine vs Risperidone vs Quetiapine (2)
areas of improvement
verbal fluency (especially Quetiapine)
letter-number sequencing
digit symbol
continuous performance task
improvements correlated modestly with vocational & social enhancement, but not significant after controlling for symptom improvement
(Keefe et al, 2007)
52 Week Trial of Olanzapine vs Risperidone vs Quetiapine (3)
Olanzapine, quetiapine, and risperidone all produced significant improvements in neurocognition in early psychosis patients. Although cognitive improvements were modest, their clinical importance was suggested by relationships with improvements in functional outcome.
BUT not corrected for multiple comparisons similar effect size seen due to practice effects alone massive subject attrition correlates with functional outcomes very modest & disappear after
controlling for symptom change
(Keefe et al, 2007)
Conclusions(Keefe et al, 2007)
“meaningful cognitive improvements will probably not come from second-generation antipsychotics”
“there was no clear procognitive effect in this study”
“the findings leave us feeling a little smarter and a lot more humble”
(Michael F Green, 2007)
Conclusions(Michael F Green, 2007)
(Michael F Green, 2007)
Conclusions(Michael F Green, 2007)
So, Green (2007) suggests:
(i) We need to look at other potential cognitive enhancing drugs; and
(ii) we need to consider “new non-pharmacological interventions that specifically target cognition”
44 people with SMI with past job failures randomised to:
supported employment alone OR supported employment plus cognitive training
Does Cognitive Remediation Enhance Work Capacity?
(McGurk et al, 2007)
Does Cognitive Remediation Enhance Work Capacity?
(McGurk et al, 2007)
cognitive assessment & job loss analysis
24 computer-based training sessions over 12wks
review and discussion of gains made and planning regarding future work
ongoing consultation with an employment specialist
Programme Components
Intervention Group(n=21)
Control Group(n=23)
No. who worked 16 (70%) 3 (14%)
Total weeks worked 27.0 5.4
Total hours worked 848.6 94.6
Total $’s earned 5320 530
Does Cognitive Remediation Enhance Work Capacity?
(McGurk et al, 2007)
Does Cognitive Remediation Enhance Work Capacity?
(McGurk et al, 2007)
Conclusions(McGurk et al, 2007)
A cognitive enhancement package can assist work capacity in SMI
Not clear what elements of the package help
Still only around 6 months work in a 3 year period
If all else fails ….