an evidenced-/based approach to treatment- resistant schizophrenia flaum
TRANSCRIPT
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AnAn EvidenceEvidence--BasedBased Approach toApproach toTreatmentTreatment--Resistant SchizophreniaResistant Schizophrenia
Michael Flaum, MDMichael Flaum, MD
University of Iowa Carver College of MedicineUniversity of Iowa Carver College of Medicine
AACP Annual Conference, San Francisco, CAAACP Annual Conference, San Francisco, CA
March 31, 2006March 31, 2006
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Treatment Resistance in Schizophrenia:Treatment Resistance in Schizophrenia:
One Definition*One Definition*
Little or no symptomatic response toLittle or no symptomatic response tomultiple (at least two) antipsychoticmultiple (at least two) antipsychotic
trialstrials
Adequate duration (at least 6 weeks)Adequate duration (at least 6 weeks)
Adequate dose (therapeutic range)Adequate dose (therapeutic range)
*Source: APA Practice Guidelines for the*Source: APA Practice Guidelines for the
Treatment of Schizophrenia, 2Treatment of Schizophrenia, 2ndnd Edition, 2004Edition, 2004
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Terms used to describe what we areTerms used to describe what we are
talking abouttalking about
Treatment resistance / refractory /Treatment resistance / refractory /failurefailure
Non/ Incomplete/ Partial/ SuboptimalNon/ Incomplete/ Partial/ SuboptimalResponse / ResponderResponse / Responder
Incomplete RecoveryIncomplete Recovery
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Algorithms and GuidelinesAlgorithms and Guidelines
AlgorithmsAlgorithmsSpecifies sequences (stages)Specifies sequences (stages)with specific options and tactics.with specific options and tactics. StepStep--byby--stepstep
flow charts of best practices in medicationflow charts of best practices in medication
use.use. Recommends key decision pointsRecommends key decision points
GuidelinesGuidelinesOptions with levels of evidenceOptions with levels of evidence
and principles of treatment. Suggests tactics,and principles of treatment. Suggests tactics,yet user develops sequencesyet user develops sequences
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Algorithm/Guideline DevelopmentAlgorithm/Guideline Development
Sponsoring Group/ProjectSponsoring Group/Project Abv.Abv. YearYearPatient Outcome Research TeamPatient Outcome Research Team PORTPORT 94,94, 0404
TMAPTMAP
ExpertExpert
APAAPA
VAVA
CPACPACanadian Psychiatric AssociationCanadian Psychiatric Association 9898
Texas Medication AlgorithmTexas Medication Algorithm
ProjectProject96,96, 99,99, 0404
Expert Consensus Guidelines forExpert Consensus Guidelines for
the Treatment of Schizophreniathe Treatment of Schizophrenia96,96, 9999
American Psychiatric AssociationAmerican Psychiatric Association 97,97, 0404
Department of Veterans AffairsDepartment of Veterans Affairs 9797
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Timeline of FDA Approval ofTimeline of FDA Approval of
Antipsychotics in the USAntipsychotics in the US
1950 1960 1970 1980 1990 2000
Chl
orpro
mazin
e54
Clo
zapin
e9
0*
Ris
perid
one9
4
Ola
nzapin
e9
6
Que
tiapine
97
Zipr
asid
one0
1
Aripipra
zole
02
Fluphen
azin
e59
Thio
ridazi
ne5
9
Hal
operid
ol6
7
Era of First Generation APs
Man
yothe
rs56-
70
*developed in 58
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Terms used to dichotomizeTerms used to dichotomize
antipsychoticsantipsychotics
Typical vs. Atypical (T vs. A)Typical vs. Atypical (T vs. A)
Conventional vs. NovelConventional vs. Novel
Older vs. NewerOlder vs. Newer
First Generation vs. Second GenerationFirst Generation vs. Second Generation
(FGA vs. SGA)(FGA vs. SGA)
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Pharmacological Treatment AlgorithmPharmacological Treatment Algorithm
for Schizophrenia (TMAPfor Schizophrenia (TMAP 99)99)
Atypical (Risperidone, Olanzapine or Quetiapine)
4 - 8 week trial
Atypical (Risperidone, Olanzapine or Quetiapine)Atypical (Risperidone, Olanzapine or Quetiapine)
44 -- 8 week trial8 week trial
If inadequate response, switch to a different atypical
for additional 4-8 weeks
If inadequate response, switch to a different atypicalIf inadequate response, switch to a different atypical
for additional 4for additional 4--8 weeks8 weeks
If inadequate response, switch to long acting typicalagent (e.g., haloperidol decanoate) Monitor blood levelIf inadequate response, switch to long acting typicalIf inadequate response, switch to long acting typical
agent (e.g., haloperidolagent (e.g., haloperidol decanoatedecanoate)) Monitor blood levelMonitor blood level
If inadequate response, switch to ClozapineTitrate up to plasma level > 450 ng/ml as tolerated over 4 weeks
If inadequate response, switch to ClozapineIf inadequate response, switch to ClozapineTitrate up to plasma level > 450Titrate up to plasma level > 450 ngng/ml as tolerated over 4 weeks/ml as tolerated over 4 weeks
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Schizophrenia Guideline/AlgorithmSchizophrenia Guideline/Algorithm
Recommendations: 1Recommendations: 1stst
WaveWave
Expert TMAPExpert TMAP VAVA APA CPAAPA CPA
19961996
1996 19971996 1997
1997 19981997 1998
First episodeFirst episode A,TA,T A,TA,T A,TA,T A,TA,T AA
Second choiceSecond choice A,TA,T A,TA,T A,TA,T A,T,C A,TA,T,C A,T
Third choiceThird choice CC AA CC C CC C
Fourth choiceFourth choice CC
Fifth choiceFifth choice
Key: A=Atypicals T=Typicals C=Clozapine
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Consensus that clozapine remains theConsensus that clozapine remains thegold standard treatment of choice forgold standard treatment of choice for
treatment resistant Schizophreniatreatment resistant Schizophrenia
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Time frame of an adequate clozapineTime frame of an adequate clozapine
trialtrial
Carpenter vs. Meltzer debateCarpenter vs. Meltzer debate
3 months vs. one year3 months vs. one year
MeltzerMeltzer late responderslate responders furtherfurther
benefit up to 1 yearbenefit up to 1 year
In reality, what constitutes aIn reality, what constitutes areasonable trial?reasonable trial?
66 12 weeks at adequate doses12 weeks at adequate doses
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What is an adequate dose of clozapine?What is an adequate dose of clozapine?
Good evidence for greater efficacy ifGood evidence for greater efficacy ifClozapine blood level is > 350ng/mLClozapine blood level is > 350ng/mL
350350 420ng/mL appears optimal420ng/mL appears optimal
Dose range 175Dose range 175 825mg/day to achieve825mg/day to achieve
these levels across patientsthese levels across patients
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Schizophrenia Guideline/AlgorithmSchizophrenia Guideline/Algorithm
Recommendations: 2Recommendations: 2ndnd
WaveWave
Expert TMAP TMAP APA PORTExpert TMAP TMAP APA PORT
1999 1999 2004 2004 20041999 1999 2004 2004 2004
First episodeFirst episode AA AA A A A,TA A A,T
Second choiceSecond choice AA AA A A,T, C A,TA A,T, C A,T
Third choiceThird choice CC A C(A,T) C CA C(A,T) C C
Fourth choiceFourth choice C+ CC+ C C+C+ C+C+
Fifth choiceFifth choice C+C+ A,TA,T Sixth choiceSixth choice 2AP2AP 2AP2AP
Key: A=Atypicals T=Typicals C=ClozapineC+=Clozapine Augmentation 2AP = Combination Antipsychotics
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Antipsychotic Sequence and Stage inAntipsychotic Sequence and Stage in
Treatment Resistant SchizophreniaTreatment Resistant Schizophrenia
First episodeFirst episode
First failureFirst failure
Number of failures before clozapineNumber of failures before clozapine
Clozapine failureClozapine failure
Clozapine augmentationClozapine augmentation
Combination antipsychoticsCombination antipsychotics
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StageStageStrongStrong
EvidenceEvidenceModerateModerate
EvidenceEvidenceWeakWeak
EvidenceEvidence
First EpisodeFirst Episode Treat withTreat withantipsychoticantipsychotic
Use newerUse newer
antipsychoticantipsychotic
(SGA)(SGA)Choice of specificChoice of specific
antipsychoticantipsychotic
Failure of firstFailure of first
antipsychoticantipsychotic
Use anotherUse another
antipsychoticantipsychotic
(other than(other thanclozapine)clozapine)
Choice of specificChoice of specific
antipsychoticantipsychotic
Failure of secondFailure of second
antipsychoticantipsychoticUse clozapineUse clozapine
Use anotherUse another
antipsychoticantipsychotic
(other than(other thanclozapine)clozapine)
Failure of thirdFailure of third
antipsychoticantipsychoticUse clozapineUse clozapine
Failure of clozapineFailure of clozapineAugmentAugment
clozapineclozapine
Failure of clozapineFailure of clozapineaugmentationaugmentation
Use anotherUse another
antipsychotic orantipsychotic orcombination ofcombination of
antipsychoticsantipsychotics
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Clozapine Augmentation StrategiesClozapine Augmentation Strategies
AntidepressantsAntidepressants
Mood Stabilizers / AnticonvulsantsMood Stabilizers / Anticonvulsants
Glutamate ModulatorsGlutamate Modulators
AntipsychoticsAntipsychotics
Recently reviewed in: Remington et al,Recently reviewed in: Remington et al, CNS DrugsCNS Drugs ,,
2005; 19(10) 8432005; 19(10) 843--872872
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Augmentation of Clozapine withAugmentation of Clozapine with
AntidepressantsAntidepressants
Controlled Studies N = 2Controlled Studies N = 2
Fluoxetine; N = 33; 8 weeks; no benefitFluoxetine; N = 33; 8 weeks; no benefit
(Buchanan et al,(Buchanan et al, 96)96) MirtazapineMirtazapine; n = 24; 8 weeks; lots of; n = 24; 8 weeks; lots of
benefit (benefit (ZocaliZocali et al,et al, 04)04)
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Augmentation of Clozapine with MoodAugmentation of Clozapine with Mood
StabilizersStabilizers
Controlled Studies N = 2Controlled Studies N = 2
Lithium; N = 20; 4 weeks, crossoverLithium; N = 20; 4 weeks, crossover
design; (Small et al,design; (Small et al, 03)03)
Improvement among SA subgroupImprovement among SA subgroup
No improvement in SZ subgroupNo improvement in SZ subgroup
LamotrigineLamotrigine; n = 34; 14 weeks; (; n = 34; 14 weeks; (TihonenTihonen
et al,et al, 03)03)
Improvement in positive and generalImprovement in positive and general sxsx
No improvement in negativeNo improvement in negative sxssxs
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Augmentation of Clozapine withAugmentation of Clozapine with
GlutamatergicGlutamatergic Agents*Agents*
Controlled Studies N = 7Controlled Studies N = 7
Consistently negativeConsistently negative
2 showed dose related worsening in2 showed dose related worsening in
negative symptomsnegative symptoms
1 showed advantage in negative symptoms1 showed advantage in negative symptoms
when added to typicals, but disadvantagewhen added to typicals, but disadvantage
when added to clozapinewhen added to clozapine
1 showed advantage in some cognitive1 showed advantage in some cognitive
measuresmeasures*Agents that stimulate*Agents that stimulate GluatamateGluatamate NMDA receptorNMDA receptor--mediatedmediated
activity, e.g.,activity, e.g., glycineglycine, D, D--serine, Dserine, D--cycloserinecycloserine; CX; CX--516516
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Augmentation of Clozapine with otherAugmentation of Clozapine with other
AntipsychoticsAntipsychotics
Controlled Studies N = 4Controlled Studies N = 4
SulprideSulpride; n = 28; 10 weeks;; n = 28; 10 weeks;
improvement in BPRS, SAPS, SANSimprovement in BPRS, SAPS, SANS(Shiloh et al,(Shiloh et al, 97)97)
3 studies with Risperidone3 studies with Risperidone
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Clozapine + RisperidoneClozapine + Risperidone
Controlled StudiesControlled Studies
Author /Author /
YearYear JournalJournal
NN
DurationDuration
(weeks)(weeks)
JagciogluJagcioglu
et al, 2005et al, 2005JJ ClinClin
PsychiatryPsychiatry3030 66
JosiassenJosiassen
et al, 2005et al, 2005AmerAmerJJ
PsychiatryPsychiatry4040 1212
Horner etHorner etal, 2006al, 2006
New Eng JNew Eng JMedicineMedicine
6868 88+ extension+ extension
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Primary Results:Primary Results: JosaiassenJosaiassen et alet al
Total
Symptoms(BPRS)
Positive
Sxs(BPRS)
Negative
Sxs(SANS)
JosiassenJosiassen et al, AJP, 2005et al, AJP, 2005
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Primary Results: Horner et al studyPrimary Results: Horner et al study
Total
Symptoms(PANSS)
Positive
Sxs(PANSS)
Negative
Sxs(PANSS)
Horner et al, NewHorner et al, New EnglEngl J Med, 2006J Med, 2006
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Clozapine + Risperidone Studies:Clozapine + Risperidone Studies:
Results and DifferencesResults and Differences
Author /Author /
YearYearFindings forFindings for
PrimaryPrimary
OutcomeOutcome
MeanMean
DoseDose
RispRisp..
SponsorSponsor
JagciogluJagcioglu
et al, 2005et al, 2005Benefit forBenefit for
PlaceboPlacebo5.15.1 IndustryIndustry
JosiassenJosiassen
et al, 2005et al, 2005Benefit forBenefit for
RisperidoneRisperidone4.44.4 IndustryIndustry
Horner etHorner et
al, 2006al, 2006NoNo
DifferenceDifference2.82.8 NonNon--
industryindustry
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Common Finding Across all 3Common Finding Across all 3
Risperidone + Clozapine StudiesRisperidone + Clozapine Studies
All found overall treatment effectAll found overall treatment effect
Benefit of treatment across all patientsBenefit of treatment across all patients
over timeover time
Be wary of open, uncontrolled studiesBe wary of open, uncontrolled studies
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So, what is a clinician to do?So, what is a clinician to do?
Many patients whose response is subMany patients whose response is sub--optimaloptimal
Science to serviceScience to service
gap goes bothgap goes both
waysways
It takes a while for science to catch upIt takes a while for science to catch up
to clinical practice for effectivenessto clinical practice for effectiveness
studies for complex approaches, e.g.,studies for complex approaches, e.g.,
polypharmacypolypharmacy
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Antipsychotic PolypharmacyAntipsychotic Polypharmacy
1950 1960 1970 1980 1990 2000
Chl
orprom
azin
e5
4
Clo
zapine
90*
Ris
perid
one9
4
Ola
nzap
ine9
6
Que
tiapin
e97
Ziprasi
done
01
Aripipr
azol
e0
2
Fluphen
azin
e59
Thio
ridazin
e5
9
Hal
operid
ol6
7
Era of First Generation APs
Man
yoth
ers5
6-70
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The Evidence PyramidThe Evidence Pyramid
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Sustained Use of 2 or more AntipsychoticsSustained Use of 2 or more Antipsychotics
Iowa Medicaid DataIowa Medicaid Data 1818--6464 yoyo
5
6
78
9
10
11
12
13
1415
90 91 92 93 94 95 96 97 98 99 '00
%
2 AP
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Antipsychotic PolytherapyAntipsychotic Polytherapy
35%
23%
17%
7%11%
0%5%
10%
15%
20%
25%
30%
35%
Denmark(1) Finland(2) Toronto (3) US VA(4) California(5)
polypharmacy rates
1. Peacock and Gerlach (1994) J Clin Psychiatry 55:44
2. Joffe et al (1996) Int Clin Psychopharmacol 11:265
3. Chong et al (2000) Psychiatric Services 51:250
4. Leslie and Rosenheck (2001) Med Care 39:923
5. Stahl (2002) pressented at NCDEU, Boca Raton, FL
Chronic APChronic AP--usersusers
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Chronic AP usersDaily Cost ofDaily Cost of AtypicalsAtypicals, FY 2000, FY 2000
$10.88
$17.57
$26.32
$0.00
$5.00
$10.00
$15.00
$20.00
$25.00
$30.00
$35.00
$40.00
$
AP monotherapy any AP polytherapy atypical polytherapy
*Mean SD
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Treatment resistanceTreatment resistance is not inherentlyis not inherently
dichotomousdichotomous
~ 20% of pts with schizophrenia have~ 20% of pts with schizophrenia havecomplete resolution of symptomscomplete resolution of symptoms
~ 30% have a clinically inadequate~ 30% have a clinically inadequate
responseresponse
What about the other 50%?What about the other 50%?
Source: R. Freedman, NEJM, 2003Source: R. Freedman, NEJM, 2003
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Clozapine is not a panaceaClozapine is not a panacea
AgranulocytosisAgranulocytosis
Weight gain / Metabolic syndrome / DMWeight gain / Metabolic syndrome / DM
TachycardiaTachycardia
HypersalivationHypersalivation
Seizures (dose related)Seizures (dose related)
Nocturnal enuresisNocturnal enuresis
Monitoring barriersMonitoring barriers
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Clozapine andClozapine and AgranulocytosisAgranulocytosis
Definition: ANC < 500/mmDefinition: ANC < 500/mm33
Risk estimated to be 1.3%Risk estimated to be 1.3% -- highest inhighest in
11stst 6 months6 months
Prior to 1989 in US:Prior to 1989 in US:
149 cases, 48 fatalities (32%)149 cases, 48 fatalities (32%)
19891989--19971997 with active monitoringwith active monitoring
Of >150,000 users in national registryOf >150,000 users in national registry
585 cases; 9 fatalities585 cases; 9 fatalities
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TopTop--downdown vs.vs. BottomBottom--upup
Approaches to EvidenceApproaches to Evidence--Based PracticeBased Practice
Top down:Top down:
Implementation of interventions thatImplementation of interventions that
have been repeatedly shown in rigoroushave been repeatedly shown in rigorous
studies to yield good outcomes instudies to yield good outcomes inspecific target populationsspecific target populations
BottomBottom--up:up: Practicing in anPracticing in an evidenceevidence--basedbased
mannermanner
IsIs EvidenceEvidence--BasedBased aa
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Newly Popularized Term?Newly Popularized Term?
Medline Search ResultsMedline Search Results
EBPEBP == EvidenceEvidence--Based Practice (s)Based Practice (s)
EBT =EBT =
EvidenceEvidence
--Based Treatment (s)Based Treatment (s)
EBM =EBM = EvidenceEvidence--Based MedicineBased Medicine
YearsYears EBP or EBTEBP or EBT EBMEBM
Prior to 1990Prior to 1990 00 00
19901990 -- 19941994 88 22
19951995 -- 19991999 328328 3,5213,52120002000 -- 2005*2005* 1,3311,331 13,98913,989
*Last updated August (week 1), 2005*Last updated August (week 1), 2005
The Evidence Based Practice CycleThe Evidence Based Practice Cycle
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The Evidence Based Practice CycleThe Evidence Based Practice Cycle
Agree upon
and stick to
intervention
Modify
Intervention
systematically
Quantify and
review
priority
outcomes
regularly
Identify and
assess priority
outcomes
OptimizePriority
Outcomes
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Bottom Up EvidenceBottom Up Evidence--Based ApproachBased Approach
Clear agreement of priority outcomesClear agreement of priority outcomes(target signs / symptoms, and more)(target signs / symptoms, and more)
ClearClear a prioria priori endpoint (time)endpoint (time)
Assess barriersAssess barriers
Try to limit changes to one at a timeTry to limit changes to one at a time
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What are the priority outcomes?What are the priority outcomes?
According to who?According to who?
Symptoms?Symptoms?
Functional Status?Functional Status?
How related are those?How related are those?
Pathways from signs andPathways from signs and
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Pathways from signs andPathways from signs and
symptoms to functional outcomesymptoms to functional outcome
CognitionCognitionCognition+
+
+
NegativeSymptomsNegativeNegative
SymptomsSymptomsFunctionalOutcome
FunctionalFunctionalOutcomeOutcome
??
Positive
Symptoms
PositivePositive
SymptomsSymptoms
Green andGreen and NuechterleinNuechterlein,,
Schizophrenia Bulletin,Schizophrenia Bulletin, 19991999
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RecoveryRecovery OrientedOriented OutcomesOutcomes
a decent job, a place called home anda decent job, a place called home and
a date on Saturday nighta date on Saturday night
Charles G. CurieCharles G. Curie
Common reasons for suboptimalCommon reasons for suboptimal
response to pharmacologic treatmentresponse to pharmacologic treatment
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response to pharmacologic treatmentresponse to pharmacologic treatment
of schizophreniaof schizophrenia
NonNon
--compliancecompliance
Concurrent substance abuseConcurrent substance abuse
DemoralizationDemoralization -- lack of hope, purpose,lack of hope, purpose,connectedness and meaning in life;connectedness and meaning in life;
Problems associated with povertyProblems associated with poverty
Decision Tree with compliance as aDecision Tree with compliance as a
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Decision Tree with compliance as aDecision Tree with compliance as a
prioritypriority
Patient is need of an antipsychoticPatient is need of an antipsychotic
DisorganizationDisorganizationLack ofLack of
insightinsightRealistic to expect that person canRealistic to expect that person can
or will take the medication daily?or will take the medication daily?
Oral SGAOral SGA
Long Acting SGA or FGALong Acting SGA or FGA
YESYES NONOCognitiveCognitive
ImpairmentImpairmentCostCost
Can identify andCan identify and
address barriers?address barriers?YESYES
NONO
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Other EvidenceOther Evidence--Based ApproachesBased Approaches
A host of nonA host of non
--pharmacologicalpharmacological
interventions have beeninterventions have beendemonstrated to be effective indemonstrated to be effective in
schizophreniaschizophrenia
? Role of psychiatrists in these? Role of psychiatrists in these
interventionsinterventions
EvidenceEvidence--Based Practices forBased Practices for
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EvidenceEvidence Based Practices forBased Practices for
SchizophreniaSchizophrenia
Assertive Community TreatmentAssertive Community Treatment
Supported EmploymentSupported Employment
Integrated Treatment for CoIntegrated Treatment for Co--OccurringOccurringSubstance AbuseSubstance Abuse
Family PsychoFamily Psycho--educationeducation
Illness Management and RecoveryIllness Management and Recovery
Cognitive Behavioral TherapyCognitive Behavioral Therapy
Ch i P di d M d l fChanging Paradigms and Models of
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Changing Paradigms and Models ofChanging Paradigms and Models of
understanding and treating schizophreniaunderstanding and treating schizophrenia
19501950ss AsylumAsylum Neurobiological /Neurobiological /
PsychodynamicPsychodynamic
19601960ss DeDe--institutionalizationinstitutionalization
19701970ss Comm. Mental HealthComm. Mental Health BioBio--psychosocialpsychosocial
19901990ss Managed CareManaged CareNeurobiologicalNeurobiological
19801980ss Revolving DoorRevolving Door
20002000ss Recovery?Recovery? Holistic?Holistic?
The message to individuals withThe message to individuals withschizophrenia:schizophrenia:
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schizophrenia:schizophrenia:
Prior to DeinstitutionalizationPrior to Deinstitutionalization
Either pull yourself up by theEither pull yourself up by the
bootstraps and get with it, or, if youbootstraps and get with it, or, if you
cancant, and no one in your family can,t, and no one in your family can,
we have a place you can spend yourwe have a place you can spend yourlife.life.
Its your faultIts your fault its your familyits your familys faults fault
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The messageThe message 7070s and 80s and 80ss
You have a serious mental illness.You have a serious mental illness.
These are medical illnesses that affectThese are medical illnesses that affect
the brain, and have to be managed asthe brain, and have to be managed as
such.such.
There are effective treatmentsThere are effective treatments
It is not your faultIt is not your fault it is not yourit is not your
familyfamilys faults fault
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The Message: 80The Message: 80s and 90s and 90ss You have an incurable mental illness. ItYou have an incurable mental illness. Its not yours not your
fault; itfault; its not your familys not your familys fault. Its fault. Its a chemicals a chemical
imbalance.imbalance.
The only thing that will help that is the right chemicals.The only thing that will help that is the right chemicals.
Whatever you do, donWhatever you do, dont work. Its way too stressful,t work. Its way too stressful,
and may interfere with your taking medications andand may interfere with your taking medications and
making appointments. Your career from now on is tomaking appointments. Your career from now on is to
be a psychiatric patient.be a psychiatric patient.
It is our responsibility to take care of you. Just doIt is our responsibility to take care of you. Just do
what we say, and wewhat we say, and well make sure you have almostll make sure you have almost
enough money to survive.enough money to survive.
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The Message Now?The Message Now?
YouYouve got a mental illness.ve got a mental illness.
Lots of us doLots of us do some more severe,some more severe,
others lessothers less
Now, lets move onNow, lets move on together.together.
What will it take for you to thrive?What will it take for you to thrive?
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The PresidentThe Presidents New Freedom Commission ons New Freedom Commission on
Mental HealthMental Health
Cover Letter for the Interim ReportCover Letter for the Interim Report
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Cover Letter for the Interim ReportCover Letter for the Interim Report
October 29, 2002October 29, 2002
Mental Health SystemMental Health System
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RecoveryRecovery&&
ResilienceResilience
Mental HealthMental Health
& Health& Health
(1)(1)
Consumer /Consumer /
Family DrivenFamily Driven
(2)(2)
EliminateEliminate
DisparitiesDisparities
(3)(3)
EarlyEarlyInterventionIntervention
(4)(4)
EvidenceEvidence--BasedBased
PracticesPracticesTraining / ResearchTraining / Research
(5)(5)
TechnologyTechnology
&&
InformationInformation
(6)(6)
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Key Recovery ConceptsKey Recovery Concepts
HopeHope
Personal ResponsibilityPersonal Responsibility
Self AdvocacySelf Advocacy
EducationEducation
SupportSupport
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RecoveryRecovery Other PerspectivesOther Perspectives
Recovery involves the development ofRecovery involves the development of
new meaning and purpose in onenew meaning and purpose in ones lifes life
as one grows beyond the catastrophicas one grows beyond the catastrophic
effects of mental illnesseffects of mental illness
Anthony, WA: Recovery from mental illness: the guidingAnthony, WA: Recovery from mental illness: the guidingvision of the mental health service system in the 1990vision of the mental health service system in the 1990ss.
Psychosocial Rehabili tation Journal 16: 11Psychosocial Rehabili tation Journal 16: 11--23, 199323, 1993
RecoveryRecovery Definition used in theDefinition used in the IllnessIllness
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RecoveryRecovery Definition used in theDefinition used in the IllnessIllness
Management and RecoveryManagement and Recovery ToolkitToolkit
Recovery occurs when people withRecovery occurs when people with
mental illness discover, or rediscover,mental illness discover, or rediscover,their strengths and abilities fortheir strengths and abilities forpursuing personal goals and develop apursuing personal goals and develop a
sense of identity that allows them tosense of identity that allows them togrow beyond their mental illnessgrow beyond their mental illness
Source: Mueser et al, Illness Management andSource: Mueser et al, Illness Management and Recovery:Recovery:
A Review of the ResearchA Review of the Research
Psychiatric Services 53: 1272Psychiatric Services 53: 1272--1284, 20021284, 2002
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"The introduction of recovery into our"The introduction of recovery into our
national mental health dialogue isnational mental health dialogue isnothing short of revolutionary."nothing short of revolutionary."
A. Kathryn Power, M.Ed.A. Kathryn Power, M.Ed.
Director, Center for Mental HealthDirector, Center for Mental Health
Services, SAMHSAServices, SAMHSA
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ConclusionsConclusions Schizophrenia, by definition, tends to be a chronicSchizophrenia, by definition, tends to be a chronic
and persistent illnessand persistent illness
Medications are a key part of the solution, but forMedications are a key part of the solution, but for
most, they are not the only part of the solutionmost, they are not the only part of the solution
The effectiveness literature will always lag behindThe effectiveness literature will always lag behind
efficacy studies and can only guide us so farefficacy studies and can only guide us so far
An evidenceAn evidence--based approach should be pursuedbased approach should be pursued
There are many other highly effective interventionsThere are many other highly effective interventions
Psychiatrists may need to rethink their rolePsychiatrists may need to rethink their role
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Q and AQ and A
Contact information:Contact information:
[email protected]@uiowa.edu
319319--353353--43404340
www.icmentalhealth.orgwww.icmentalhealth.org
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Core Principles of 6 EBPCore Principles of 6 EBPss
Supported Employment: CoreSupported Employment: Core
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principlesprinciples
Eligibility is based on consumer choiceEligibility is based on consumer choice
Supported employment is integratedSupported employment is integratedwith treatmentwith treatment
Competitive employment is the goalCompetitive employment is the goal
Job search starts soon in the processJob search starts soon in the process
FollowFollow--along supports are continuousalong supports are continuous
Consumer preferences are importantConsumer preferences are important
Assertive community treatmentAssertive community treatment
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core principles (1)core principles (1)
Services are targeted to a specific group ofServices are targeted to a specific group of
individuals with severe mental illnessindividuals with severe mental illness
Rather than brokering services, treatment,Rather than brokering services, treatment,
support and rehabilitation services aresupport and rehabilitation services areprovided directly by the ACT teamprovided directly by the ACT team
Team members share responsibility for theTeam members share responsibility for theindividuals served by the teamindividuals served by the team
The staff to consumer ratio is small (~ 1:10)The staff to consumer ratio is small (~ 1:10)
Assertive community treatmentAssertive community treatment
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core principles (2)core principles (2) The range of treatment and services isThe range of treatment and services is
comprehensive and flexiblecomprehensive and flexible
Interventions are carried out in vivo ratherInterventions are carried out in vivo ratherthan in hospital or clinic settingsthan in hospital or clinic settings
There is no arbitrary time limit on receivingThere is no arbitrary time limit on receivingservicesservices
Treatment, support and rehabilitation servicesTreatment, support and rehabilitation servicesare individualizedare individualized
Services are available on a 24Services are available on a 24--hour basishour basis
The team is assertive in engaging individualsThe team is assertive in engaging individualsin treatment and monitoring their responsein treatment and monitoring their response
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Integrated dual disorders treatmentIntegrated dual disorders treatment
More than half of all adults with MIMore than half of all adults with MI
have cohave co--occurring substanceoccurring substance
abuse problemsabuse problems
Recovery from both is more likelyRecovery from both is more likely
when MH and SA treatments arewhen MH and SA treatments are
combinedcombined
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Integrated dual disorders treatmentIntegrated dual disorders treatment Integrated servicesIntegrated services
Clinicians provide MH and SA servicesClinicians provide MH and SA servicesconcurrentlyconcurrently
StageStage--wise treatmentwise treatment
Individualized treatment approach: differentIndividualized treatment approach: differentstages focused on at different phases of recoverystages focused on at different phases of recovery
AssessmentAssessment
Motivational treatmentMotivational treatment
Substance abuse counselingSubstance abuse counseling
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Family psychoeducationFamily psychoeducation
A method of working in partnershipA method of working in partnership
with families to help them developwith families to help them develop
increasingly sophisticated andincreasingly sophisticated and
beneficial coping skills for handlingbeneficial coping skills for handling
problems posed by mental illness inproblems posed by mental illness in
their family, and skills for supportingtheir family, and skills for supporting
the recovery of their loved on.the recovery of their loved on.
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Family Psychoeducation Involves:Family Psychoeducation Involves:
Joining with consumers and theirJoining with consumers and their
familiesfamilies
Education about the illness and usefulEducation about the illness and useful
coping skillscoping skills
ProblemProblem--solving strategies forsolving strategies for
difficulties caused by illnessdifficulties caused by illness
Creating an optimal environment forCreating an optimal environment forrecovery from mental illnessrecovery from mental illness
Creating social and support groupsCreating social and support groups
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Illness Management and RecoveryIllness Management and Recovery
Weekly sessions where practitionersWeekly sessions where practitioners
help consumers* develop personalizedhelp consumers* develop personalizedstrategies for managing mental illnessstrategies for managing mental illnessand achieving personal goalsand achieving personal goals
Individual or group formatIndividual or group format
33
6 months6 months
Designed for people who have hadDesigned for people who have hadsymptoms of schizophrenia, bipolarsymptoms of schizophrenia, bipolar
disorder, major depressiondisorder, major depression
Illness Management and Recovery:Illness Management and Recovery:
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Session ContentSession Content
Recovery strategiesRecovery strategies
Practical facts aboutPractical facts aboutthe 3 disordersthe 3 disorders
StressStress--vulnerabilityvulnerabilitymodel and treatmentmodel and treatmentstrategiesstrategies
Building socialBuilding socialsupportssupports
Using medicationsUsing medications
effectivelyeffectively
Reducing relapsesReducing relapses
Coping with stressCoping with stress
Coping withCoping with
problems andproblems andsymptomssymptoms
Getting your needsGetting your needs
met in the mentalmet in the mentalhealth systemhealth system
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Does CBT work?Does CBT work?
Randomized controlled trials conducted inRandomized controlled trials conducted in
UK, using BeckUK, using Becks model of Cognitive Therapys model of Cognitive Therapy
Studies primarily address medicationStudies primarily address medication--
refractory symptoms; not CBT as a standrefractory symptoms; not CBT as a stand--
alone treatmentalone treatment
General finding that symptom reductions ofGeneral finding that symptom reductions of
about 25about 25--30% occur in 60% of pts.30% occur in 60% of pts.
Effect sizes average .65; .93 at followEffect sizes average .65; .93 at follow--upup
CBT now mandated by British Health TrustCBT now mandated by British Health Trust
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SnowballSnowball EffectEffect
Psychotic
Exacerbation
PsychoticPsychotic
ExacerbationExacerbationSleep
Disturbance
SleepSleep
DisturbanceDisturbance