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

2-3%

Proportion of youth who develop schizophrenia or a severe, psychotic

mood disorder

75%

Proportion of people who have one psychotic episode and schizophrenia

and then develop disability

12-15%

Proportion of people with schizophrenia or a psychotic mood

disorder who commit suicide

$61 billion

Annual U.S. costs for schizophrenia

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

Outcomes

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

First hospitalizations for psychosisMaine Urban controls areas vs. Greater Portland

*p<0.0001

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.

For further information:

www.PIERTrainingInstitute.org

PTI@maine.rr.com