Improving Outcome in Schizophrenia

8/3/2019 Improving Outcome in Schizophrenia

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Improving outcome inSchizophrenia

Cameron S. Carter MD

Department of Psychiatry

University of California at Davis

[email protected]



Chronic, deterioratin

Episodic, w/interepisod

deficits ( common)

Episodic, w/o interepisode

deficits

The course of schizophrenia

Broad therapeutic window for

Prevention/Early intervention



Strategies for Improving Outcome

in Schizophrenia and other Psychoses

Understand and treat currently treatment

refractory symptoms (cognitive deficitsand negative symptoms)

Earliest possible intervention



UCD Clinical and Research Focus

Early diagnosis, risk prediction and preventiveinterventions: clinical care and research into

early phases of psychotic disorders

Cognitive neuroscience approach tounderstanding treatment refractory aspects of the illness such as cognitive deficits: research inpeople with established schizophrenia as well astheir unaffected relatives



Department of PsychiatryClinical Programs

Center for Neuroscience

MIND Institute

Center for Mind and Brai

Imaging Research Center

Psychosis Treatment Research And Education Program



Preserving and Enhancing

Cognition in Schizophrenia Early intervention itself prevents cognitive

decline

Social Cognitive Enhancement Group

Modafanil Study

Computer Based Interventions



Prevention

Primary: Before a disease starts, prevent itsonset (e.g. by immunization)

Seconday: after a disease has started but beforeit has a clinical effect e.g. treating hypertensionto prevent cardiovascular disease. Pap smear forcervical cancer

Tertiary: identify and alleviate an established

disease at an early stage to preventcomplications, improve or maintain functionalstatus e.g. aspirin therapy after heart attack toprevent recurrence





EDAPT Clinic: 2 “Target”

Populations Early psychosis “first episode” patients

Ultra high risk





Key elements of treatment

model Multidisciplinary treatment team

Rapid response, extensive medical and psychiatricassessment

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



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, valueof peer groups



“First Episode Pathway to

Recovery”

Initial AssessmentMedical and Psychiatric

Individual and FamilyBased Treatment

Psychoeducation andSupport Group

Family Support Group

Social CognitiveEnhancement

Group

Individual Rehab andRe-entry Plan



Very Early Intervention: Ultra High

Risk Cohort Can we delay the onset of psychosis andprevent functional decline?

“Ultra High Risk” strategy: possibleprodromal states, subthreshold psychosis,functional decline predict 20-40%conversion rate

Th P d l Ri k St t



Three Prodromal Risk StateCategories

Attenuated Positive Symptom State Onset or worsening in the past year of (a) paranoid, grandiose, or

referential ideas but without full conviction, (b) perceptualdisturbances 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/orthought 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, ANDpatient either (a) has a first-degree relative with schizophrenia or (b)meets criteria for schizotypal PD



Very Early Intervention: Ultra High

Risk Cohort Ultra high risk criteria predict 20-40%

conversion to a psychotic disorder at 1-2

years Melbourne and Yale groups have shown

that low dose antipsychotic treatmentmarkedly reduces conversion but

Treat to prevent ratio is 4:1

APA treatment guidelines recommendscareful monitoring



Ultra-High Risk Treatment

Careful diagnostic assessment, SIPSinterview, plus active diagnoses and

comorbidities TARGETTED pharmacological therapies

Psycho ed, supportive therapy, family

support and therapy, testing and advocacy Research for enhanced risk prediction



Who are we caring for?

245 new referrals evaluated, 18 per month

44 currently enrolled patients

28 male, 16 female

Average age 20, range 12-33

36 with psychosis, 8 “ultra high risk”



How did they come to us?

SCMHTC

UC Davis Psychiatry

Adult Access, Child and Family Access Sacramento County Primary Care Clinic

Private Hospitals and RST’s (Heritage

Oaks,Sierra Vista, Turning Point) TAPS, UC Davis CAP

Self/web



How are they doing?

Number of hospitalizations 4

School 20

Working 10

71% are working or back in school







f b d



fMRI measures brain activity associatedwith cognition and emotion







What are Neuronal Oscillations?•Neurons can fire in a variety of frequency ranges e.g. Alpha (8-15Hz), Beta

(15-35Hz), Gamma (35-80Hz).

* Encoding and processing occurs when a population of neurons

fires at the same time AND with the same frequency.

Asynchronous firing Synchronous firing

•Sometimes populations of neurons will fire at different times from each other

(asynchronously) , and sometimes they fire together (synchronously) .



DLPFC

Controls (Red – Green)

Patients (Red – Green)

0.0 5.0

3.2

10.0

31.6

[Hz]

0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 2.2 2.4 [s]

E10

Cue Onset Probe Onset

0.0 5.0

3.2

10.0

31.6

[Hz]

0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 2.2 2.4 [s]

E10

Cue Onset Probe Onset



http://earlypsychosis.ucdavis.edu



Early Psychosis TreatmentResearch and Education

Program

Department of Psychiatry,University of California at Davis

Documents

Improving Outcome in Schizophrenia