child & youth Mental Health Series First Episode Psychosis; Psychosis in Youth

Sharman Robertson BSc MD FRCPC

Date: February 25 2016 If you are connected by videoconference please mute your system and unmute to ask a question Please feel free to ask questions! By You will have had an opportunity to apply for professional credits or a certificate of attendance registering for today’s You will receive an email with a link to today’s online evaluation

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Questions? [email protected] Speaker has nothing to disclose with regard to commercial support. Declaration of conflict Speaker does not plan to discuss unlabeled/ investigational uses of commercial product. Agenda

• On Track First Episode Psychosis Program • Evolution of First Episode Psychosis Programs • Ontario Standards • Stress diathesis model • Clinical Features Psychosis in Youth • Differential Diagnosis • Treatment • Outcomes On Track

• Recovery-based • Individuals aged 16-35 with first episode of psychosis (FEP) • Champlain District 1.3 million with satellites in Hawkesbury, Cornwall and Pembroke • Case management model • Interdisciplinary team • Follow for up to 3 years • Group, individual, family work

Rationale of First Episode Programs

• Early recognition of psychosis • Shorten DUP – Improve outcomes • Symptom resolution • Return to full function – Prevent relapse – Prevent • Cognitive decline • Treatment resistant symptoms • Loss of relationships • Loss of ability to be productive • Reduction of stigma • Rehabilitative model

Long DUP

• Longer DUP

– Reduced treatment response – Poor functional outcome – Disrupted personal relationships – Increased legal involvement – Substance use – Disrupted school and work performance – Housing instability Ontario Perspective

• Yearly incidence = 12 / 100,000 • Majority between ages of 14-35 years • First 3-5 years high risk for: – Suicide (2/3 of suicides) – Relapse – Hospitalization – Loss of social supports – Disruption of work, school, housing – Substance use – Legal problems

Early Psychosis Intervention (EPI) Ontario

• 1999: Making it Happen: Implementation Plan for Mental Health Reform- psychosis requires intensive care

• 1999: Ontario Working Group for Psychosis advocated for EPI (clients, families and community mental health agencies)

• 2004: MOHLTC announced EPI program funding 30 programs

Early Intervention Ontario Network EPION

• Formerly the Ontario Working Group • Ministry funded • Volunteer • Provides www.epion.ca – Networking – Research – Knowledge sharing – Conferences – Shapes policy – FEP advocacy

Key Components

• Early identification and facilitated access • Comprehensive assessment – Up to 3 months including treatment to establish dx – May lead to enrolment if criteria met • Treatment • Psychosocial supports • Family education and support • Public education • Research On Track Eligibility and Timelines

• Age 16-35 years • < = 6 months of treatment for psychosis • Absence of severe substance use disorder, forensic history or established mood disorder • Contact client/family within 72 hours • In-person assessment within 2 weeks

• 613-737-8069

Psychosis

• Loss of touch with reality • Reduced ability to determine what is coming from within own thoughts and perceptions and what is happening in the environment • Not a diagnosis • Collection of signs and symptoms • Common end point for several mental illnesses Stress Diathesis Progression to Psychosis Neurochemistry: Dopamine

• Dopamine (DA) hypothesis:

– Too Much DA in certain brain areas • Efficacy of DA blocking medications • Psychotomimetic effect of stimulants

– DA levels actually low in prefrontal cortex

Serotonin: Modulates DA

• 5HT-2 blockade: – reduces psychotic symptoms – Reduces side-effects caused by blocking DA – • Second generation anti-psychotics (SGA’s): – 5HT-2 blockers – Risperidone, olanzapine, seroquel – Older: clozapine Cortical Glutamate Regulates DA Neurons in 2 Possible Ways

Direct action Indirect action as an as accelerator brake Cortex GLU GLU

+ +

− GABA

DA

GLU = glutamate. Adapted from Tsapakis EM, et al. Adv Psychiatr Treat. 2002;8(3):189-197. Carlsson A, et al. Br J Suppl. 1999;(37):2-6. With Psychosis NMDA Receptors are under-firing

Direct action as an accelerator

Cortex DA is too low and we see: GLU -Lack of motivation, pleasure, depressed mood -Impaired ability to concentrate, pay attention remember -Impaired ability to plan, organize, use abstract concepts +

NMDAR DA Hypofunctioning

Adapted from Tsapakis EM, et al. Adv Psychiatr Treat. 2002;8(3):189-197. Citrome L. Curr Psychiatry Suppl. 2011;10(9):S10-S14. With psychosis there is no brake for DA in the mesolimbic area

Indirect action as brake Cortex GLU

+

− GABA NMDAR Hypofunctioning DA

DA is too high in the mesolimbic area - delusions and hallucinations

Clinical Features Pre-pubertal Psychosis

• Rare, less common than autistic spectrum disorder • Abnormal development: – Soft neurological S+S – LDs – Expressive/receptive language delays – Attachment issues – Autistic features – Reduced response to treatment

Mental Status Examination

• Appearance, self-care – Dressed for weather, clean, dishevelled, mannerisms, sunglasses, make-up, unusual costumes, body odour • Behaviour – Guarding, slowing, agitation, aggression, vigilance, responding to internal stimuli, grandiosity, mannerisms • AIMs/EPS – Dyskinetic movements of mouth, lips, face – Tremor, stiffness, lack of facial expression, restlessness, robotic gate • Affect – Flat, reduced, robotic, labile, hostile, euphoric, angry, perplexed, fearful, depressed, superficial Mental Status Examination

• Mood – Numb, depressed (neuro-vegetative signs and symptoms), bored, swings, elated, irritable • Speech – Pressured, over-inclusive, prolongation of response latency, slow, muteness

Mental Status Examination

Thought form – Tangentiality: • Jumping from topic to unrelated topic – Circumstantiality: • Starting at one topic and speaking of partially related themes, over -inclusive of detail, eventually getting back to first point. – Loosening of associations: • Ideas are not related to each other and syntax of language is breaking down – Flight of ideas: • Rapid-fire thoughts that the person can not slow down – Poverty of thought: • Lack of output or devoid of content – Thought blocking – Prolongation of response latency

Thought Form Disorders in Children

Developmental stage of child is important. Normally thought form disorganized before the age of 7 years. Possible to detect thought form disorganization after this.

Mental Status Examination

• Thought content

– Delusions Children - content involves animals, • Paranoid cartoons, super heros • Referential Adolescents - content similar to adults • Control • Religious • Pseudo-philosophical • Somatic • Grandiose • Erotomanic – Hallucinations • Auditory, visual, olfactory, senesthetic, gustatory Mental Status Examination

– Hallucinations • Auditory, visual, olfactory, tactile, gustatory

Children – Transient hallucinations possible during times of stress, loss. True hallucinations accompanied by LDs, attachment issues soft neuro S + S. Adolescents – Transient hallucinations seen with personality DO, panic attacks, trauma history. Mental Status Examination

• Attention and concentration • Ability to use abstract concepts – Similarities and proverbs • Insight and judgement – Do they think they have an illness? – How do they explain their circumstances? – Does medication help? – What are their strategies to deal with symptoms? – What is their motivation to use strategies?

Mental Status

• Suicidal thinking – Passive vs. active – Plan – Association with delusions of control or impulses – Association with command hallucinations – Degree of control a person feels they have over the thoughts/impulses – Awareness of coping strategies – Ability to use coping strategies – Alliance with their team – Hopelessness – Emotional reaction to these thoughts • Calm and resolved vs. fearful of it actually happening

Mental Status

– Homicidal thinking • Past history of violence • Medication non-adherence • Substance abuse • Delusions of persecution or control – Know the delusional system • Association with command auditory hallucinations • Insight into this as a symptom • Emotional reaction to these thoughts – Fear and shame – Aggression – Flatness

What Things Besides Schizophrenia Cause Psychosis?

• Drug or alcohol induced psychosis • General medical conditions • Mood disorders • Schizophrenia spectrum disorders

Substance and Alcohol Induced Psychosis

• Withdrawal states; • Cannabis alcohol, anxiolytics, • Prescription drugs sedatives, GHB • Stimulants; – amphetamines, cocaine • Hallucinogens; LSD,PCP, ecstasy

Can Drugs Cause Schizophrenia?

• Certain drugs can mimic psychosis when a person is high • In a drug induced- psychosis symptoms are gone within one month after stopping the drug Can Drugs Cause Schizophrenia?

• If symptoms last longer than one month something else is going on -possibly schizophrenia • If psychosis occurs with drug use that person’s nervous system is vulnerable to psychosis • Taking drugs at that point may lead to more psychosis!! General Medical Conditions

• Rarely a cause of psychosis (<10%) • Seizure disorders • Genetic conditions; – Huntington’s, Wilsons disease – Velocardiofacial syndrome • Infections; encephalitis, meningitis, HIV/AIDs • Dementia

Mood Disorders

• Major Depressive Disorder • Bipolar disorder Schizophrenia Spectrum Disorders

• Brief psychotic disorder • Schizophreniform disorder • Schizophrenia • Schizoaffective disorder • Delusional disorder Schizophrenia: Core Symptom Clusters

I. Positive symptoms II. Negative symptoms delusions affective flattening hallucinations alogia disorganized speech avolition anhedonia

Social/occupational dysfunction work interpersonal relationships self-care

III. Cognitive symptoms IV. Mood symptoms attention dysphoria memory suicidality executive functions hopelessness (e.g., abstraction) Personality Disorders

• Borderline PD • Paranoid PD • Schizotypal PD Autistic Spectrum Disorders

• It is possible to have autistic spectrum disorder and schizophrenia together • Must have prominent delusions/hallucinations and thought form disorganization Disorders and OCD

• Panic disorder • OCD Treatment

• Case management • Stage specific • Acute psychosis: – Assessment, avoid premature diagnostic closure – Patient and family psycho-education and support – Crisis management – Symptom management • Antipsychotic, antidepressant, antianxiety medication • Low dose • Metabolic management Treatment

• Stabilization: – CBT – CRT – Neuropsychological testing – Recreation therapy: • Social and exercise groups – : • Scholastic and vocational support

Treatment

• Reintegration: – Back to work and school – WRAP – FWRAP – Encourage activities outside of On Track – Relapse prevention – Attempt discontinuation of medication for some – Taper to lowest preventative dose for most

On Track Outcomes

• N= 95 • Mean age 26.4 years, 61% male

Baseline Endpoint

Admission rates 1.09 (SD = 1.11) 0.6 (SD = 0.06) ER visits 1.68 (SD = 1.41) 0.07 (SD = 0.30) Hospital days 17.86 (SD=20.95) 1.32 (SD = 8.14) PANSS total 70.67 (SD=20.95) 53.13 (SD=18.01) CGI 4.36 (SD = 1.13) 2.87 (SD = 1.14) GAF 49.20 (SD=13.57) 61.78 (SD=17.54)

School enrollment increased 45% Unemployment decreased by 33% Questions? Thank you! for participating in today’s Mental Health Series

Join us next time: TBD with Dr. Davis-Faroque – March 17, 2016 @ CHEO