“The way to recovery”

GAMIAN-Europe /Eastern Europe Regional Seminar

““The way to Recovery: The way to Recovery: Pharmacotherapy, Psychotherapy Pharmacotherapy, Psychotherapy and Social Rehabilitation from the and Social Rehabilitation from the

clinicians’ perspective”clinicians’ perspective”

Dr. F. Cañas de Paz

H. “Dr. R. Lafora”. Madrid. Spain

Bucarest, may 23th 2009

Positive SymptomsHallucinationsDelusionsHostilityExcitability

Negative SymptomsBlunted emotionsAnhedoniaLack of feelingLoss of motivationSocial withdrawal

CognitionVerbal Memory Executive functionAttention

Mood SymptomsDepressionManiaPoor insight

FUNCTION

Spectrum of Symptoms in Severe Mental Disorders (SMD)

CRITICAL PERIOD

Birchwood M et al. Br J Psychiatry 1998;172 (S 33):53-9.

Cronic-relapses

Age (years)

0

10

20

30

40

50

60

70

80

90

100

20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

Level of

fun

cti

on

ing

(%

)Differing courses following a first psychotic

episode

Partial response

Breier et al. Am J Psychiatry 1994;151:20–26.

Remissión-recovery

Response

Prodromal

1st episode

Relapses can have devastating consequences

Psychosocial consequences

Psychosis “toxicity”?

RECOVERYRECOVERY

1. Symptoms no longer interfere with daily life

2. Person can engage in meaninful actitivies (role fullfilment):1. Self-care2. Relationships3. Work / school

Key issue: The ability to form and sustain social relationships

Effective SMD Treatment Requires an Holistic Approach

Positive Symptoms

Negative Symptoms

Mood Disturbance

Cognitive Dysfunction

Minimising and treating side effects Encouraging

medication adherence Employment

opportunities/sources of

income

Encouraging adequate housing

Managing sleep

disturbances

Managing substance

misuse

Monitoring physical health

Integrating care teams

Involving family

Educating and informing

Why Early Identification and Treatment Matters

>70% of first-episode patients achieve full remission of

psychotic symptoms within 3–4 months1

>80% achieve stable remission at the end of 1 year1

Delayed initiation of antipsychotic medication results in

poorer outcomes:2

– More severe and persistent positive and negative symptoms

– Poorer treatment response

Recurrent episodes of psychosis associated with:3

risk of chronic residual symptoms

– Evidence of anatomical neuroprogression

1. Lieberman et al. Neuropsychopharmacol. 1996;14:13S–21S; 2. Haas et al. J Psychiatr Res. 1998;32:151–159; 3. APA Practice Guideline 2004

Overt

Covert

Non-adherence

Relapse

Partial-adherence

Relapse

Partial response

Fluctuates

IN THE FIRST YEAR OF TREATMENT: 39% non-adherent; 20% inadequately adherent Coldham EL et al. Acta Psychiatr Scand 2002;106:286-90.

POOR POOR ADHERENCEADHERENCE

ADHERENCE IN SMD

PATIENT RELATED:• insight• cognitive impairment• beliefs• doctor-patient relationship• substance abuse

MEDICATION RELATED:• cost• side effects• dosing schedule

Between 50% and 80% do not

believe that they have a disorder,

or that they require ongoing

treatment.

Dam J. Nord J Psychiatry 2006;60:114-20

Do We Really Know How Compliant Our Patients Are?

In a recent survey across Spain…

Only 43% of psychiatrists (n=844)

believed their patients were compliant

82% of relatives (n=796)

believed the patient was usually compliant

BUT

95% of patients (n=938)

said they regularly took their medication

Giner et al. Actas Esp Psiquiatr. 2006;34:386–392

Strategies for Improving Medication Adherence

Adapted from Perkins. J Clin Psychiatry 2002;63:1121–1128

Patient-related issues

Cognitive therapy

Educate about the illness and benefits of treatment

Memory aids

Involvement of patient in therapeutic alliance

Treatment-related issues

Minimise complexity of treatment regimen

Titrate to optimal dose

Minimise impact of side effects on patient’s life

Provide clear instructions on medication use

Select antipsychotic with minimal EPS, weight gain and prolactin effects

Recognising Relapse in SMD

Many patients have ‘early warning signs’ of an impending

psychotic relapse

– 2 days–4 weeks before onset of frank psychosis

Dysphoric symptoms most commonly reported

– Depressed mood, withdrawal, sleep and appetite problems

Patients’ ‘relapse signatures’ should be identified and noted

– Timely and effective intervention may arrest progression

Families play a key role in recognising early warning signs

Birchwood et al. APT 2000;6:93–101

Some Early Warning Signs of Psychotic Relapse

Birchwood et al. APT 2000;6:93–101

Thinking/perception Feelings Behaviours

Racing thoughts Helpless or useless Difficulty sleeping

Senses seem sharper Irritable Jumbled speech

Special powers Sad or low Talking to yourself

Mind being read Anxious or restless Neglecting appearance

Messages from TV/radio Religious obsessions Social withdrawal

Cannot make decisions Being watched Not eating

Hearing voices Isolated Child-like behaviour

Poor concentration Loss of trust Aggression

PREDICTORS OF TREATMENT OUTCOMEPREDICTORS OF TREATMENT OUTCOME

POORPOOR OUTCOMEOUTCOME

Poor

premorbid

adjustment

Male sex Early age

of onset

Poor

medication

adherence

Reduced brain

volumeCognitive

impairment

Inherent

refractoriness

Longer

duration of

untreated dis.

MODIFIABLE FACTORS

Robinson et al, 2004; Emsley et al, 2006

PSYCHOSOCIAL REHABILITATIONPSYCHOSOCIAL REHABILITATION

A mixture of skill (re)acquisition and support needed to maintain a person in community (A. Williams)

DYNAMIC PROCESS: SKILLS SUPPORT

Medical Education Meeting – FUM IV ‘The adherence challenge’May 12, 2009 Brussels

Medical Education Meeting – FUM IV ‘The adherence challenge’May 12, 2009 Brussels

CONCLUSIONS (1)

1. The goal in SMD treatment is recovery

2. The main poins to arrive there are:a) Early interventionb) Treatment adherencec) Relapse preventiond) Psychoeducatione) Rehabilitation and social supportf) Work / independency

CONCLUSIONS (2)

To obtain that is important:

• Reduce stigma• Engage patients (shared decission model)

and families• Organize access and countinuity of care• Mobilize social resources