An Evidenced-/based approach to Treatment- Resistant Schizophrenia Flaum

8/13/2019 An Evidenced-/based approach to Treatment- Resistant Schizophrenia Flaum

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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


Failure of firstFailure of first


Use anotherUse another


(other than(other thanclozapine)clozapine)

Choice of specificChoice of specific


Failure of secondFailure of second

antipsychoticantipsychoticUse clozapineUse clozapine



(other than(other thanclozapine)clozapine)

Failure of thirdFailure of third

antipsychoticantipsychoticUse clozapineUse clozapine

Failure of clozapineFailure of clozapineAugmentAugment

clozapineclozapine

Failure of clozapineFailure of clozapineaugmentationaugmentation


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


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*


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


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

Documents

An Evidenced-/based approach to Treatment- Resistant Schizophrenia Flaum