Janine Ward

Medium term follow-up of a randomized controlled trial of interventions for young people at ultra high risk of psychosis

Valid criteria to identify young people who are believed to be at ultra high risk (UHR) of developing a psychotic episode were developed over the last decade. The first randomized controlled trial of treatment in a UHR cohort indicated that specific pharmacotherapy and psychotherapy delayed onset of disorder, and possibly reduced incidence. This paper reports results of follow-up of that trial. 41 of the 59 (69.5%) participants in the original study agreed to follow-up. No differences were found in transition rate, level of symptomatology or functioning between participants who received a combination of psychological treatment and anti-psychotic medication compared to those who received supportive therapy alone. A significant proportion of both treatment groups reported moderate levels of psychiatric morbidity and a continuing need and desire for care at this follow-up. Low levels of hospitalisation were noted for those who did progress to psychosis. Conclusions that can be drawn from this exploratory study are limited by the relatively small number of participants in the original study and the failure to follow-up the entire cohort. Although participants may have been treated too briefly to result in enduring positive effects, there appear to have been some cost savings in inpatient mental health treatment required after the end of the trial for individuals in both treatment groups who developed psychosis.

The proximal prodrome to first episode mania – a new target for early intervention

OBJECTIVE Affective psychoses and bipolar disorders have been neglected in the development of early intervention strategies. This paper aims to gather current knowledge on the early phase of bipolar disorders in order to define new targets for early intervention. METHODS Literature review based on the main computerized databases (MEDLINE, PUBMED and PSYCHLIT) and hand search of relevant literature. RESULTS Based on current knowledge, it is likely that an approach aiming at the identification of impending first-episode mania is the most realistic and manageable strategy to promote earlier treatment. During the period preceding the onset of the first manic episode, patients go through a prodromal phase marked by the presence of mood fluctuation, sleep disturbance, and other symptoms such as irritability, anger, or functional impairment. Additionally, various risk factors and markers of vulnerability to bipolar disorders have been identified. CONCLUSIONS In the few months preceding first-episode mania, patients go through a prodrome phase (proximal prodrome) that could become an important target for early intervention. However, considering the low specificity of the symptoms observed during this phase, criteria defining high-risk profiles to first-episode mania should also include certain risk factors or markers of vulnerability. While more research is needed in high-risk groups (e.g., bipolar offspring), retrospective studies conducted in first-episode mania cohorts could provide valuable information about this critical phase of the illness.

The initial prodrome to bipolar affective disorder: prospective case studies

BACKGROUND The initial prodrome to bipolar disorder has received very little attention to date, with most of the available data only addressing the prodrome to relapse. This study presents several prospective case studies of the initial prodrome to bipolar affective disorder. METHODS Three patients are presented who developed bipolar disorder during their treatment at the Personal Assessment and Crisis Evaluation Clinic (PACE). They were prospectively interviewed over a 12-month period using standard clinical research interviews. RESULTS These patients met the criteria for bipolar disorder by the end of the treatment period. Depressive symptoms were the main reason for their first clinical presentation, with mania developing at a later date. Other comorbidities were observed before they were diagnosed with bipolar disorder. LIMITATIONS The generalisability of our findings was constrained because of the small sample size. Furthermore, our findings are likely to be influenced by the intake criteria used at PACE, a clinic that primarily aims at identifying patients at risk of psychosis rather than bipolar disorder. CONCLUSION Our study provides information about the initial prodrome to bipolar disorder, which has previously been neglected in research studies. We found there were no prodrome features that clearly distinguished between patients who go on to develop bipolar disorder and those who develop schizophrenia. We hope our prospective data will be the starting point for subsequent studies, with the aim of applying these findings to developing suitable preventative interventions for bipolar disorder.

S05-04 - Conceptual aspects and recent data on the prodrome to first episode mania

Background Little is known about the early phases of bipolar disorders (BPAD) and most of current knowledge derives from putative “high-risk” studies conducted in populations of bipolar off-spring; such information may therefore be relevant only to a subgroup of at-risk subjects. Methods Retrospective assessment of the phase preceding the emergence of mania and of premorbid characteristics of patients treated for a first episode of psychotic mania. The collected data was used mainly to generate hypotheses. Results Before onset of a first episode of psychotic mania, patients go through a phase of change from previous mental state where they present mood symptoms, sleep disruption and general functional decline. These clinical manifestations are likely to have low specificity. However, their occurrence in patients presenting certain risk factors or markers of vulnerability that were identified at a relatively high prevalence in our sample, may be an indicator of impending first episode mania. Limitations This is a retrospective study, in a small sample of patients presenting with psychotic mania. Criteria identified need therefore to be validated in larger prospective studies. Conclusions Early identification of patients at risk to develop a first episode of psychotic mania is unlikely to be possible on the basis of symptoms alone. However, the occurrence of certain clinical characteristics in patients who have risk factors or markers of vulnerability to BPAD may be a sign of impending first episode mania.

05-05 Cost-effectiveness of a preventive intervention for young people at ultrahigh risk of developing psychosis.

Background: Despite considerable interest and investment in early psychosis services over the past one to two decades, scant attention has been paid to the economic evaluation of such services. A 1-year evaluation of the cost-effectiveness of the Early Psychosis Prevention & Intervention Centre (EPPIC) model in Melbourne, Australia, concluded that EPPIC was a dominant intervention compared with historical care in that it was cheaper and more effective; however, no published studies have evaluated the longer term effects of a model of early intervention in terms of both outcomes and costs. This study aims to examine whether the cost savings and benefi ts associated with EPPIC persist beyond the 1-year timeframe. Methods: The study used a historical control design. A sample of 51 participants who presented to EPPIC in 1993 was individually matched (on age, sex, diagnosis, premorbid adjustment and marital status) with 51 participants admitted to the precursor service (the ‘preEPPIC’ service) between 1989 and 1992. Participants were followed up at 1 year, then again approximately 8 years after inception. A representative subsample of 65 participants was interviewed at 8-year follow-up. Data describing psychiatric service use, medication type, duration and dosage were collected by means of interviews with patients and informants, electronic databases and medical records. Standard economic methods will be used to evaluate the two interventions. Results: The results will compare the costs, benefi ts and incremental cost-effectiveness of the two interventions. Conclusion: This study will help answer whether the EPPIC model of care maintains ‘value for money’ over a longer period. 05-05