Srivastava, Amresh

English

Scholarship@Western

Western UniversityScholarship@WesternPsychiatry Presentations Psychiatry Department10-22-2009Early Psychosis: A Novel Gateway for SuicidePreventionAmresh SrivastavaUniversity of Western Ontario, amresh.srivastava@sjhc.london.on.caFollow this and additional works at: https://ir.lib.uwo.ca/psychiatrypresPart of the Psychiatry and Psychology CommonsCitation of this paper:Srivastava, Amresh, "Early Psychosis: A Novel Gateway for Suicide Prevention" (2009). Psychiatry Presentations. 30.https://ir.lib.uwo.ca/psychiatrypres/30Early Psychosis:A Novel Gateway For Suicide Prevention Amresh SrivastavaThe University of Western OntarioE-mail: dr.amresh@gmail.comDeclarationNo stocks or bonds• Janssen Group• Eli Lilly• Astra Zeneca• Nicholas Piramal-Rosch• Pfizer• Sun Pharma- India• Consultant• Advisor• Drug trial coordinator• Research Investigator• Reviewer• Speaker• Educational GroupsWHO: Challenges and obstacles• Lack of awareness• Taboo in societies  • Reliability,  Reporting• Intervention from outside the health sector.  • Innovative, comprehensive multi-sectoralapproach, • Health and non-health sectors, • e.g. education, labour, police, • Justice, religion, law, • Politics, the  media.Young people: not as healthy as they seem  Suicide is the second largest cause of mortality in the 10-24 age group.  Lancet story, 15 September 2009 Contemporary Issues • Is there a correlation of early psychosis and suicide?• Does early intervention of psychosis prevent suicide as well?• Whether treatments for psychosis also work for suicide?• What is the public health implication of EI with respect to suicide prevention?Injuries both intentional & non intentional, by 2020 could rival infectiousdisease as a source for all ill health.1. Is there a correlation of early psychosis and suicide?Case • 16+ female ,  brought by her dad and step mother for  counseling.• Her mother had discussed 3 years about ‘suicidal ideation’  and  odd words on the eve of her X std.  exam. She was advised to bring her for assessment after the exams. • The clients  mother is on treatment for  schizophrenia for 15 years.• “When i saw the girl now  she was very depressed, dejected and • i called the parents  and told them that it could be schizophrenia or major depression needing medication.• The father got very angry with me. He told, "Doctor, I brought her for counselling to you. She was seen roaming with a boy  cutting classes. When i questioned, she insisted on going to hostel. Later in the night, she has slashed her forearm. Don't make her mad. Don't even tell her about medications”• our  psychologist  was to call her and convince her for assessment with a promise that she has no licence for drugging (medications) . • The psychologist went for a conference and called the girl only after 14 days. • The girl's mobile was not reachable. So she called her father who cried telling that the girl hung herself to death. He felt guilty that he did not listen to the Dr. Preventive psychiatryNeed for early Intervention across diagnosis  • EI opens up a window of opportunities:•Non-affective psychosis  cluster •Psychosis of schizophrenia spectrum disorder•Conversion to classical schizophrenia•Several conditions present as early psychosis enhancing opportunity to  treatWhy do people kill themselves?At best we can say, we do not know?Known causes of suicide Risk and causation of psychosis Cad Saude Publica. 2009 Sep;25(9):2064-74SuicideMental disorders : 71.9%depression (38.9%), psychoactive substances (21.9%), PTSD  (20.8%), alcohol abuse (17.7%), Schizophrenia (15.6%Mental IllnessCurrent MDD (27%),Schizophrenia SD (22%),   SUD  (16%). CMD 24%Psychiatr Serv. 2009 Aug;60(8):1135-8.90% have psychiatric illness (WHO)Psychosis• Mortality in schizophrenia X 2 to 3 times • lifetime risk of about 5%• 10%–15% of individuals die  by suicide ,  completed suicide (4% to 13%), • 20%–40% making suicide attempts, Having symptoms of psychosis does NOT mean having schizophrenia, it opens the window for intervention across a number of disorders!• Suicidal behavior  may result from  discomfort with psychotic symptoms  • Previous attempts - significant predictors• Greatest risk:  younger and earlier in their course  Severe mood changes• Persistence of symptoms Untreated psychosis ▫ breakdown in relationships,▫ loss of family and social support, ▫ loss of employment or ▫ study interruption, ▫ denial of disease, ▫ depression, ▫ suicide, substance abuse and▫ violence. Risk of suicide and suicidal ideation in psychosis & At-Risk clients: Italian study Schizophr Res. 2009 Sep;113(2-3):145-50. Epub 2009 Jul 1Suicide in First episodeRobinson J Prevalence and predictors of suicide attempt in an incidence cohort of 661 young people with first-episode psychosis., Aust N Z J Psychiatry. 2009 Feb;43(2):149-57Rates of suicide in early psychosisPrior to contact During Death Aust N Z J Psychiatry. 2009 14.3% 8.7% 0.4%Acta Psychiatr.Scand. 2004 Feb;109(2):116-120 15% 2.9Harvey SB, Br J Psychiatry. 2008 11.3%Bertelsen M, Br J Psychiatry Suppl. 2007 67/547 in 5 yearsCan J Psychiatry. 2006 18.8%Acta Psychiatr.Scand. 2004 Feb;109(2):116-12 0 Can J Psychiatry. 2006 Jan;51(1):42-7. Suicidal behavior :Event precipitating the first treatment contact (9, 13)• Striking difference in suicide rates between first-episode and chronic schizophrenia patient groups,• First admissions have rates three times higher (1).• 15%–26% - at least one attempt by first treatment contact• 2%–11% - one more during their first year of treatment (7–9). • Seriousness of suicide attempts is high for patients with schizophrenia spectrum psychoses (3, 10). •What predicts suicidal behaviour in early psychosis?  Lifetime history of parasuicidebefore first admission Lower Positive And Negative Symptom Scale- positive subscores Longer duration of first admission   Longer duration of psychotic symptoms  Greater risk of being readmitted   Substance misuse     Prior attempts or ideation,  Severity of depressive symptoms and thought disorder, Lifetime substance abuse,   Younger age.   Early insight predictsActa Psychiatr Scand. 2001 May;103(5):347-54. Acta Psychiatr Scand. 2005 Dec;112(6):449-55 Challenges in clinical Practice of Suicide Behavior.Risk estimates • Risk ▫ Risk periods:  In-patient , Post-discharge▫ Risk candidates:  Borderline comorbidity, Schizophrenia, Previous attempts ▫ Risk situations:  Loss,  Disaster,  Recent trauma,  abuseRisk factors for suicide in young people a long-term follow-up study, A case-control studyNo Axis I or axis II diagnosis is free from risk of suicide.Psychiatric morbidity remains the major risk factor for suicide • Risk factors for suicide• Male gender, • Chronic illness with frequent relapses • Frequent short hospitalization, • Negative attitude towards treatment,• Impulsive behavior • Parasuicide • high pre-morbid IQ,• psychosis• depressionSchizophr Res. 2001 Mar 1;47(2-3):127-34 A schematic depiction of the putative key relationships between  information processing biases, schema and appraisal systemHigh suicide in recently discharged patients The first week   First day after discharge Risk factors :   history of self-harm,  Expressing clinical symptoms at last contact Suicide cases  1) More likely to have initiated their own discharge 2) Missed last appointment Less likely to die by suicide compulsory treatment    Enhanced levels of aftercare, What does Early intervention mean? Early intervention ProgramsOutside the Programs, advantage is lost?Neuronal development & Child abuse1.Chen TJ, Med Hypotheses. 2006;66(5):1043-4. 2.Anda RF,Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):174-86. 2005Childhood Experience & the Expression of Genetic Potential: What Childhood Neglect Tells Us About Nature and Nurture? 1, 2Risk for Schizophrenia Psychosis Suicide Cannabis J.Psychiatr.Res. 2008 Aug;42(10):822-826Acta Psychiatr Scand. 1999 Nov;100(5):389-95 Risk of Psychosis & Cannabis15/03/200831Reduced RiskIncreased RiskAdjusted odds ratio for any psychosis outcome according to ever use verses ‘Frequent use’ of Cannabis in individual studies at 95% CITheresa et al , Lancet, 2007Significant increase in frequent abusers A risk-vulnerability model for prevention of schizophrenia: Possibilities of preventive sites in process of ‘causation’Impact on brain and personality development15342Schizophrenia Spectrum Disorder & Liability Comorbid dirordersOpening up windows of opportunities for identification & treatment‘• To decide Need for medication• Medication trial = Medication free challenge• Ongoing functional decline• Suicide• Homicide or riskInterventions  Risk syndrome of Psychosis with suicide risk –an indication for APDPreventive Family intervention; Expressed Emotion (EE)• Predictive of psychotic relapse (Bebbington & Kuipers,1994)• ‘Not an artifact of patient morbidity’ (Leff and Vaughn,1995) • ‘Family intervention is recommended to reduce relapse risk’ (NICE, 2003)McGorry PD, Yung AR Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms, Arch Gen Psychiatry. 2002 Oct;59(10):921-8 The First Episode Can Be the Best Episode!2. Does early intervention of psychosis prevent suicide as well?Early detection of the first episode of schizophrenia and suicidal behavior.   Melle Study 1. Suicidal behavior is present in the early phases of psychotic disorders   2. Precedes the first treatment contact. 3. The rate of severe suicidality (plans or attempts) was significantly higher in subjects from communities without the early detection program,  4. May reduce suicidality risk at first treatment contact.5. Beyond the decrease in duration of untreated psychosis.Am J Psychiatry. 2006 May;163(5):800-4. The power of clinical contact in life-and-death situationsCommunity with EI Community without EIRates of suicidalideation & attempt56% 39%Previous attempt 16% 5%Decrease in Rates after first clinical contact Similar Similar SUD High LowSuicidal behaviors Low High• early detection and intervention have the potential of reducing one of the most dangerous and permanent complications of schizophrenia. Earlier Intervention Improves the Chances of Recovery!3.Whether treatments for psychosis also work for suicide?EI: The role of the   Case Manager:Do Antipsychotic Drugs Influence Suicidal Behavior in Schizophrenia? • First Hypothesis: Negative Influence▫ Depressive Symptoms Related to  Extrapyramidal Side Effects EPS, depressogenic effect• Second Hypothesis: Positive Influence▫ Specific effect on suicide, e.g. Clozapine, but can it be applied to suicide across diagnosis, NOT clear• Third Hypothesis: No Influence ▫ Lindenmayer et al.suggest that suicidality may represent a separate symptom domain that is related to, but independent of, depression or psychosisIncrease in suicide Attempt rate when Atypical Antipsychotic Therapy is Interrupted.• Drug dispensing and Hospital discharge databases in The Netherlands (N=865 K)• Patients with schizophrenia (n=603)  interruption of 30+ days in Tx (n=204)• Relative risk increased by 4.2 times ( 95%CI: 1.7-10.1) Herings RM, Erkens JA Pharmacoepidemiol Drug saf. 2003;12;423-424Medication Compliance • The Quebec data -- significant association between • good versus poor compliance and a • decreased risk of death and • suicideClin Ther. 2006 Nov;28(11):1912-21Treatment effects for Suicide • Increased overall suicide mortality in bipolar disorder• Zurich Cohort, n=406, 1959-1997Adopted from Angst et al 2002 ***Treatment of suicidality in schizophrenia.Meltzer HY.2001• Insight  • less severe cognitive impairment  • feelings of hopelessness. • Typical neuroleptic drugs: No evidence. • evidence suggest that clozapine, reduces ▫ the suicide attempt▫ completion rates in schizophrenia and schizoaffective disorder,▫ perhaps by as much as 75-85%. • Other atypical antipsychotic drugs may have a similar effect, but direct evidence is lacking. Ann N Y Acad Sci. 2001 Apr;932:44-58; • Improvement in positive and negative symptoms, • Reduced (EPS), • Direct antidepressant action, • Improved cognitive function, and • Improved compliance may contribute to reduced suicidality. Clozapine has been approved byUS FDA for suicide in schizophreniaFeb,2003Adding Lithium or Anticonvulsants to Antipsychotics for the Treatment of Schizophrenia: Useful Strategy or Exercise in Futility? June 2009 JCP• Lithium is perhaps the best-known mood stabilizer, • A  Cochrane review of  RCTs  concluded that, despite some evidence supporting the efficacy of lithium augmentation among 11 studies testing this, Overall results were inconclusive.Leslie Citrome, M.D., M.P.H. ,AMERICAN SOCIETY OF CLINICAL PSYCHOPHARMACOLOGY Meltzer & Baldessarini, 20034. What is the public health implication of EI with respect to suicide prevention?Management of psychosis & suicide Effective interventions* Strategies involving restriction of access to common methods of suicide, such as firearms or toxic substances like pesticides, have proved to be effective in reducing suicide rates;  .* There is compelling evidence indicating that adequate prevention and treatment of depression and alcohol and substance abuse can reduce suicide rates, as well as follow-up contact with those who have attempted suicideWHOIs it possible to reduce ‘suicidality’?• Reducing suicide is a World Health Organization priority. • Risk reduction programs in general youth populations and the U.S. Armed Forces have given indications of positive results• Positive effects on suicide rates of educating general practitioners about patients with depression• ‘Defeat depression’ program Royal college of Psychiatrists UKSuccessful Treatment OptionsPoor  AwarenessContinuous EducationAssessment,Care Plan, Discharge Plan,Risk Management &Transfer of careDocumentationPrevention of Suicide in Psychotic Disorders:General principles and strategies.A survey of general practitioners' knowledge of symptoms and epidemiology of schizophrenia.GPs had a fair theoretical knowledge of schizophrenia symptoms, but underestimated the prevalence and the risk of suicide. Eur Psychiatry. 2006 Jun;21(4):238-44. Early Intervention program offers opportunity for suicide preventionCan early detection of psychosis prevent suicidal behavior? [Am J Psychiatry. 2006] Review of early intervention, 2006, 2009Cochrane Review• Treating people presenting  with prodromal symptoms of schizophrenia provides any benefits??? • Ethical issues are less intense in FEP• Little evidence: ▫ Intervention in FEP ▫ Support the ‘standard care’. (NICE2002) as well.▫ Phase specific treatment of FEP• Family therapy is effective.• No evidence from clinical trials to support early detection of patients in their ﬁrst episode of psychosis.• It is premature to implement wide-spread treatment programs   Marshall M, Rathbone J : Early Intervention for psychosis (Review) Copyright © 2009The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.• Case managers,• Key contacts, awareness• Education• Low stigma • Risk factors, mental illness• Early age Identification Treatment Monitoring Prevention Opportunities from early psychosis  and the health systems  ‘Care needs to reach where people live, where problems arise’Mental health in primary care • Treatment gap• Enhances access • Mental and physical health problems are interwoven • Burden of mental disorders• Affordable and cost effective• Generates good health outcomes Common mental disorders Severe mental disordersPrimary CareCentre of preventionRadical reform in Primary careProactive prevention • Almost 90% of suicides occur - DSM-IV diagnosis of a major mental health disorder, • 83% of these patients have at least one contact with a medical practitioner within 1 year of completed suicide• More than 60% have had contact within 1 month, • Physician education has been a valid target in suicide prevention strategies. • Physician education has been shown to increase the detection rate and prescription of antidepressant medication in the community,  Need for paradigm shift in preventionGateway for prevention: Crisis help line: Mumbai experience • Study of suicidal ideation  (2341, N= 15.4%) • DSM-IV, • 25%, had schizophrenia, • 17%, had depression • 13% had personality disorder,   • 7% had diagnosis of addiction.  • Rest 38% clients had no Axis I or Axis II diagnosis  •• Suicide in Schizophrenia• 5-14% die• 14-18% attempt before first contact• 25% make at least one attempt • 50% contemplate suicide •Shrivastava A, sarkhel G, Iyer S, Kelkar C, Rao S, Experience with mental health helpline inmatropolis community, Indian j. Psychiatry 1999,41:84-85Future of mental health lies in primary careFuture of primary care lies in mental health Primary Care Institutional supportvoluntary and social  support( CMHA, ODSP, HOOUSING)Consequences of missed opportunities.Suicide prevention is  aboutbreaking the barriers

Early Psychosis: A Novel Gateway for Suicide Prevention

https://ir.lib.uwo.ca/cgi/viewcontent.cgi?article=1027&amp;context=psychiatrypres

Early Psychosis: A Novel Gateway for Suicide Prevention

Abstract

Similar works

Full text

Available Versions

Scholarship@Western

Scholarship@Western