Jo Smith Worcestershire EI Service Study day

9th June 2011

Crow et al (1986): first-admission patients with SZ with DUP > 1y more likely to relapse than those with DUP < 1y

Longer DUP is associated with:◦ Psychosocial decline (Jones et al, 1993)◦ Prolonged morbidity (Wyatt et al, 1997)◦ Increased treatment costs (Moscarelli et al,

1991)◦ Worse course and outcome (Helgason, 1990;

Haas et al, 1998; Larsen et al, 2000; Altamura et al., 2001; Black et al., 2001; Malla et al., 2002)

◦ Increased duration of the acute episode (Loebel et al, 1992; McGorry et al, 1996)

The’ critical period’ hypothesis proposes that in the early phase of a psychosis there is:

◦ A plateau effect of psychopathology and disability◦ The development of influential biological,

psychosocial and cognitive factors◦ The beginnings of desynchrony between clinical

and social functioning

A shorter DUP gives a longer critical period within which to intervene and influence these processes

Prevention of neurobiologically “toxic” effect of psychosis (Wyatt et al, 1997) ◦ Recent work does not support this (Hoff et al,

2000; Fannon et al, 2000; Normal et al, 2001)

Prevention of psychosocially toxic effect of psychosis◦ Some evidence in support of this

For every patient seen within specialist psychosis (including EI) Services

Collect quarterly from 1st April 2011 First quarter return delayed to September 2011

to allow information system set up Relevant information to be taken from referrals

database on ‘M’ drive to be reported as part of NMHDS return from Trust Information Dept

Expansion from current single DUP rating (in months) to include 5 additional data points:

Prodrome psychosis date:◦ Date at which first noticeable change in behaviour or mental state prior to

emergence of full blown psychosis

Emergent psychosis date:◦ Date at which there was evidence of a positive psychotic symptom for the patient

regardless of its duration ( symptom would rate 4 ‘moderate’ or above on PANSS)

Manifest psychosis date:◦ Date at which a positive symptom has lasted for a week for the patient (usually 7

days after the date of the first psychotic symptom)

Psychosis prescription date:◦ Date the patient was prescribed anti-psychotic medication

Psychosis treatment start date:◦ Date the patient commenced prescribed anti psychotic medication and was

compliant for at least 75% of time during subsequent month (using clinical judgement and usually same as date of psychosis prescription)

Commonly defined as the time interval between onset of definite positive psychotic symptoms and first appropriate treatment (usually defined as first anti-psychotic treatment but where not on medication can use engagement and treatment in an EI service)

Singh et al: Nottingham Onset Schedule (NOS) DUP measurement version identified ‘psychosis onset’ as comprising:◦ Prodrome (MHMDS:‘Psychosis Prodrome’ date)◦ First psychotic symptom (MHMDS:‘Emergent Psychosis’

date)◦ Definite Psychosis (MHMDS:‘Manifest Psychosis’ date)

Prodrome

First psychotic symptom

Definite diagnosis

Prodrome: Date at which the first noticeable changes in behaviour or mental state occurred before the emergence of frank psychotic symptoms. Prodromal symptoms usually include trouble sleeping, poor attendance/performance at school/work, withdrawal from friends/family, attenuated psychotic symptoms (suspiciousness, whisperings or occasionally hearing name called, slight confusion in thinking). There should be a clear deterioration in functioning from previous levels and no return to premorbid functioning following onset of prodromal symptoms.

  First Psychotic symptom: Date at which there is first clear evidence for

the presence of a positive psychotic symptom (delusion, hallucination or thought disorder) which would score 4 or more (moderate or above) on PANSS, regardless of its duration.

  Definite Diagnosis: Date at which there is clear evidence of a positive

psychotic symptom (delusions, hallucinations, first rank symptoms, catatonic symptoms or negative symptoms) that has lasted for at least one week. This date is usually the date 7 days after the date of onset of the first psychotic symptom.

DUP = length of time between:Date at which a positive psychotic symptom has lasted for a week for the patient, usually 7 days after onset of first psychotic symptom (manifest psychosis date)Date commenced prescribed antipsychotic medication and thereafter was compliant for 75% of time during subsequent month (psychosis treatment start date)

DUI= length of time between:Date of onset of non specific changes in behavior or mental state prior to emergence of a positive psychotic symptom which would be rated as 4 ( moderate or higher) on PANSS (prodrome psychosis date)Date commenced prescribed antipsychotic medication and thereafter was compliant for 75% of time during subsequent month (psychosis treatment start date)

Simple concept, can be more difficult in reality Sources of information:

◦ Client◦ Family/significant others report◦ Medical notes◦ Assessment measures (mental state assessment,

premorbid adjustment scale, pathways to care etc) Should calculate DUP within 3 months of acceptance onto

caseload Construct timeline of major life events and changes in

thoughts, behavior and feelings (similar to constructing a relapse signature timeline)

Can use early signs cards or a checklist of common symptoms and changes as prompts/cues to jog memory

Beginning the interview: Explain that you already know something about how this illness started, and that you now want to get some more details to ensure that you have things in the correct sequence or order. e.g."I am interested in finding out more about how you felt and what happened to you at each stage of your illness. I'm particularly interested in getting a clear idea of how you felt in the early stages, before it became quite obvious to you and your family that there was something definitely wrong with you."

Identify a few anchor dates and related key events that stand out as remembered clearly, and that have some relationship to any part of the onset. Start with either the clearest or the first anchor date or event and ask, e.g."At that time.. [quote it] ..how did you feel?"Did you feel that anything was wrong with you?""What sort of experiences were you having?""In what ways were you different from your normal self at that time?""What happened next?" etc

Initial, open-ended questioning: If you already have completed a psychiatric history use an introductory statement like; “ You’ve told me that you knew that the Mafia were following you and were going to harm you. That started about 2 weeks before Christmas. Now what I want us to think about is what was going on and how you were feeling leading up to this “.If not, spend the first part of the interview finding out about the subject's positive psychotic symptoms and dating their origin.

Use open-ended questions:“Take me back to when you were feeling well and things were going OK for you, what happened first ….what was the first thing that you noticed had changed” Once the presence of a symptom has been confirmed, dates can be clarified with direct questioning if necessary. It is useful to repeat back to the client the information elicited, to ensure accuracy:“ You remember enjoying your holiday in Cyprus in August, but about two weeks after starting back at sixth form in September you describe feeling very worried and down in the dumps about your work load. This preoccupied you so much that it stopped you getting to sleep until 3am. Is that correct?”.

Using common symptom checklists (list or early signs card sort): Explore all relevant non-psychotic symptoms with direct questions if necessary:

“ We’ve been through things in detail but I’d just like to make sure we haven’t missed anything so I’m going to ask you a few specific things. Have you had the feeling of being restless, not being able to settle?”

Thinking Mood Behaviour

Unusual ideas Feels unreal/empty/not right Restless, can't settle

Poor concentration Moodiness , anxiety, tension Argues more

Forgetful/ confused Feels tired Avoids people, stays in more

'Something wrong' Feels empty/tense/irritable Seeks reassurance

New interests such as Low mood/ emotional withdrawal Seems preoccupied/frightened

philosophy, religion, occult etc. Worries more Neglects hygiene/ appearance/ hobbies

Unusual fears Elated, unduly cheerful Speech muddled, and unclear

Suspicious /paranoid Hostile, aggressive Agitation/ Inappropriate behaviour

Jealousy/Guilt   Unpredictable/ rigid routine

Grandiose   Deterioration in work/school performance

Obsessional   Poor sleep/appetite

Perception   Mannerisms, posturing

Derealisation, depersonalisation   Ritualistic behaviour

Perceptual distortions    

)

Be flexible in your interview technique depending on the client: sometimes it may be easier working gradually backwards from when the first positive symptom was apparent to the beginning of the prodrome.

Dates will very often be vague despite trying to pin people down to birthdays, Xmas, summer holidays or important events in their lives.

Around the beginning, middle or end of a month will very often be the closest estimate and often subjects will not be able to be this specific.

‘Summer’ is taken as June, July and August, ‘Autumn’ as September, October, November, ‘Winter’ as December January and February and ‘Spring’ as March, April or May. ‘Mid summer’ would therefore be July, ‘mid winter’ January etc.

Symptoms may be fluctuating and intermittent. Prodromal symptoms may start and then remit for a time. The start of the episode will be from where symptoms begin and original baseline functioning is never resumed despite symptoms waxing and waning.

Information from the interview can now be used to date onset of: Prodrome : date of onset of non-psychotic symptoms prior to emergence of definite first psychotic symptom (rated as 4 ‘moderate’ or above on PANSS)Emergent psychosis : date when an unequivocal first positive symptom has been present, regardless of duration of the symptomManifest psychosis: date at which there is clear evidence of a positive psychotic symptom that has lasted for at least one weekStart of Psychosis Treatment: date the patient commenced prescribed anti psychotic medication and was compliant for at least 75% of time during subsequent month

These dates can then be used to calculate both DUP and DUI

When estimating dates:

Use 1st July if only have the year15th of the month if only know the month1st January for beginning of the year31st December for end of the year25th December for Christmas etc.

5th Feb 2000: Mum’s birthday Things OKMarch 2000 Not sleeping/poor concentrationMay 2000: left armyJune 2000 Smoking cannabis3rd August: my birthday Things not too badSeptember 2000: working as a joinerMid September 2000 Poor motivation/missing workOctober 2000: fell out with friends Anxious/arguments with friendsNovember 2000: Arguing at work/paranoid19th December 2000: sacked from job Fight with boss/lost jobChristmas 2000New Years Day 2001 Hearing voices5th February 2001: mum’s birthday Thought food poisoned/ paranoid/ got into fightLate March 2001: Mum took me to GP Prescribed antidepressantsMid April 2001: saw GP Referred to Consultant Psychiatrist16th April: outpatient appointment Prescribed Olanzepine 20mg nocte

On basis of the timeline example:◦ What is the ‘psychosis prodrome date’?◦ What is the ‘emergent psychosis’ date?◦ What is the ‘manifest psychosis’ date?◦ What is the ‘psychosis prescription’ date?◦ What is the ‘psychosis treatment’ start date?◦ What is the DUP?◦ What is the DUI?

5th Feb 2000: Mum’s birthday Things OK

March 2000 Not sleeping/poor concentration

May 2000: left army

June 2000 Smoking cannabis

3rd August: my birthday Things not too bad

September 2000: working as a joiner

Mid September 2000 Poor motivation/missing work

October 2000: fell out with friends Anxious/arguments with friends

November 2000: Arguing at work/paranoid

19th December 2000: sacked from job Fight with boss/lost job

Christmas 2000

New Years Day 2001 Hearing voices

5th February 2001: mum’s birthday Thought food poisoned/ paranoid/ got into fight

Late March 2001: Mum took me to GP Prescribed antidepressants

Mid April 2001: saw GP Referred to Consultant Psychiatrist

16th April: outpatient appointment Prescribed Olanzepine 20mg nocte

DUP=16/4/2001- 8/1/2001= 88 days (3 months 8 days)

DUI = 16/4/2001- 15/9/2000= 223 days (7 months)