Anna was visiting a friend in another city when strange things began to happen. She saw things that looked real, but later didn't seem real at all. She was so troubled by what she described as not feeling like herself that she woke her friend; together, they called Anna's parents. "She started to cry," says Anna's dad. "She was talking about things, but we didn't know where they were coming from." The early psychosis A softspoken, pretty young woman, Anna returned home the next day. After picking her up at the airport, her parents noticed that Anna was doing programs in Atlantic things like stopping in front of posters and tracing all the letters. In the days Canada offer to treat that followed, Anna became afraid of talking on the phone. "I live on the phone," she says. "It was kinda weird." While watching television, she thought people at the very first the actors were talking about her. Something was happening to Anna that was separating her from the world she once knew. signs of problems The family's doctor saw Anna immediately. His early diagnosis was a first episode of psychosis, signs of which include withdrawal from usual activities, a persistent decline in ability to handle everyday activities, anxiety, irritability, Photography by Perry Jackson unusual or bizarre behaviour, attention problems. Although this sounds dire, if given a chance, the brain can often heal itself. The prognosis is promising if symptoms are treated early, a philosophy that programs in the Atlantic region are taking to heart.
Health In At lantic Canada •
ic Canada • Spring 200
Nova Scotia Early Psychosis Program team members, from left to right, Who and when?
front row: Diana Bennett, Diane Piccott, Alisa Stevens, Dr. Zenovia Psychosis strikes three in every 100 Ursuliak, Jill Torraville. Back row: Dr. Heather Milliken, Margie Crown, Kim Good, Dr. Michael Teehan.
people, in every corner of the world, in every walk of life. Although the usual age range is 16 to 30, it can occur as early as 14 years of age.
What else might it
A first episode of psychosis can be a
see people within the week. Nobody sits on a result of substance use, a side effect waiting list.
of medication, or a symptom of a Instead, the intake person sets up an medical condition, including bipolar assessment appointment with a psychiatrist disorder, post-partum depression and nurse. Other members of the care team and dementia. The only way to -- psychologists, occupational therapists, social know what a first episode heralds is workers, an education coordinator – are involved to watch what happens, and treat as the need arises. The team gathers as much information as possible and starts to work on a treatment plan in conjunction with the client, and, in some case, with the family and friends.
Clients are offered medication, support, education, and cognitive-behaviour therapy. Since psychosis is a sign of a distressed brain, treatment generally begins there, with anti-psychotic medication. The research evidence suggests that the earlier people start anti-psychotics, the better their chances. Still, clients are bleak about medication. Because of their severe side effects, older antipsychotics, such as chlorpromazine, have not been used much for the past Cannabis conundrum
Some of the people who call upon the health care
system with symptoms of psychosis have recently used
cannabis; a few are heavy cannabis users. Although this
has led people to assert that cannabis causes psychosis,
there is no evidence of that.
There is a connection, though. A UK team recently conducted a meta-analysis (an analysis of many studies) of cannabis research and concluded that use increases the risk of psychosis by approximately 40%. The greater the use, the greater the risk: upwards of 200%. These and other results suggest that, in some people, cannabinoid receptors aren't working properly, and that That wasn't always the case. The prevailing Some regions have even built the approach that problem is part of a larger problem. However, that view for many, many years was that no one into health policy. Nova Scotia, for instance, remains a question.
recovered from psychosis, and if they did, they enacted a Standard of Care for Early Psychosis What isn't a question is genetics. Since a great many never had it in the first place. In the 1970s in 2004, laying out the importance of treating people use cannabis, and only a few develop psychosis, and '80s, attitudes started to shift. More effort as soon as possible. Newfoundland and New researchers in the UK, US, Ireland, and New Zealand and funding were going into research that Brunswick have taken the same approach, if not combined forces to look at genetic vulnerability. They explored the outcomes of earlier treatment, the policy route. found that people with a specific mutation of the gene the mechanisms of psychosis, risk factors, What that means is that in those three catechol-O methyltransferase were most likely to have causes. The best guess about cause is that it's an provinces, anyone with concerns about a psychotic symptoms and to develop schizophrenia if they interaction between genetic vulnerability and first episode of psychosis can seek treatment used cannabis. People without the specific structure were environment, which might mean viral exposure without a referral, and get help quickly. at no greater risk. during pregnancy, exposure to substances In Halifax, the Nova Scotia Early Psychosis Since there is – as yet – no genetic test designed for such as amphetamines, stress and so on. No Program (NSEPP) sees people immediately. at-home use, the best advice health care professionals matter the cause, researchers have found that The Fredericton Mental Health Centre Early can give people is to abstain, until 21, at least. That's early intervention improves the changes of full Prevention Program sees people within 48 when the brain finishes developing, and may not be as recovery from psychosis, a finding that clinicians hours. The St. John's Psychosis Intervention Early vulnerable to environmental assaults. -JM are incorporating into their treatment approach. Recovery program, at Waterford Hospital, will Spring 2008 • LIVING Healthy In Atlantic Canada
The NSEPP's educational booklet.
PEI manages early intervention through family doctors and hospital emergency room.
decade. The side-effect profile of the newer anti-psychotics – clozapine, olanzapine, quetiapine, and risperidone – is not as brutal, although there are still risks such as hyperglycemia (high blood sugar) and diabetes. "There is still no utopic medication," says Dr. Zenovia Ursuliak, a staff psychiatrist with NSEPP.
Despite the kinder side-effect profile, compliance is often difficult. This is especially the case in the beginning, when the medication may not have begun to work. "Part of the illness is a lack of insight that they may need medication," says Maureen Penny, the nurse coordinator for St. John's PIER program. When the brain is chemically unbalanced, it takes a while to get it back on track. "It won't happen overnight, which we had hoped would happen," says Anna. Another client reassured Anna that she would return to her former self, having done so herself. That gave Anna the hope she needed to continue. The medication worked. "Each week we could see a little bit of the old Anna shining through," says her dad. Her mom saw Anna's sense of humour returning. Anna herself realized she could talk on the phone again, for at least a few minutes. She was on her way back.
For families, the first intervention is education. Many parents, siblings and friends are deeply Standing: Jill Torraville and Patricia Cosgrove. distressed and often blame themselves. At the Seated: Margie Crown and Dr. Zenovia Ursuliak.
NSEPP, education sessions cover what psychosis is, symptoms, causes, treatment, community
When the brain
is chemically unbalanced, it takes a while to get it back on track.
supports, and recovery. "Information is so key," they're encouraged to maintain contact with says Margie Crown, education co-ordinator at their family doctor, and to seek help quickly if NSEPP, "and people get support from each other. anything goes awry.
Everyone feels so isolated." But does this approach to psychosis Clients begin the education sessions make any difference? As laid out by policy, as early as possible. "If they're not stable, program evaluation is built into the NSEPP. they can't take in information or talk about Team members continually monitor program readiness," says Crown. "It's essential that effectiveness by collecting physical health everyone gets information on the illness, on measures, depression symptoms, family reports what they can do to recover and help with the and the like. According to recent findings, the process. The goal is to manage the illness with majority of patients with first-episode psychosis a circle of support." were symptom-free at the one-year follow-up Once clients are able, cognitive-behaviour mark. There is as yet no data on how people therapy is helpful. It teaches people how are doing at five years or 10 years, although to channel thoughts and behaviours in a those studies are underway. Anna, for one, has positive direction, including how to disregard recovered. She finished high school, went to hallucinations, and manage stress and any culinary school and now works at a resort in the other concerns they may have. If willing Atlantic provinces. "Life is great," she says, her and able, clients can attend group therapy. eyes sparkling once again.
A wellness recovery program, which was Attention recently has focused on people piloted at the NSEPP under the direction of Dr. who are at high risk of psychosis, because Ursuliak, is designed to help with the recovery of family history, a decline in functioning, phase. It includes healthy eating, exercise, and psychotic symptoms that come and go. stress management and the like. Given the "If there is a strong family history and some side effects of the anti-psychotic medication, evidence of decline, it warrants an assessment healthy lifestyle is vital, especially in combating at the very least," says Dr. Sabina Abidi, a child The NSEPP's Diane Piccott.
the weight gain associated with some of the and adolescent psychiatrist who has a cross drugs. After going two years without another appointment to the NSEPP and the IWK Youth incidence of psychosis, clients can decide to Psychosis Team. The hope is that support, medication can be offered early enough to stop taking medication. Whether they do or not, education, cognitive-behaviour therapy, and prevent, or at least delay, a first break. To identify what makes people vulnerable to psychosis, researchers at the IWK and the NSEPP are set to study young people who have sought help. Not normal teenage stuff
Dr. Abidi says it's hard to say whether anxiety, The myth of teenage angst is that teenagers are supposed to be disturbed, and that this disturbance is normal. The idea depression and extreme distress are signs of began with Dr. G. Stanley Hall, a psychiatrist who loved opera, and borrowed from a Wagnerian concept when he wrote vulnerability. "It depends on the individual case. about the "storm and stress" of adolescence. Researchers in the 1960s, who set out to prove Dr. Hall right, found that We often see adolescents with such symptoms most teenagers didn't experience substantial storm and stress. Only 15% to 20% of adolescents had problems such who do not develop a psychotic illness." Dr. Abidi as social phobia, anxiety and depression, in response to stress. "Many of the mental disorders that onset in the teen is running a study of ultra high-risk people in years do not occur in response to an environmental event," says Dr. Stan Kutcher, professor of psychiatry at Dalhousie Cumberland County; the study is one of the first University and holder of the university's Sun Life Financial Chair in Adolescent Mental Health. "None occur due to the research collaborations between the IWK and normal stresses and strains of being a teenager." the Capital District Health Authority. Dr. Abidi's According to Dr. Kutcher, for most teenagers (60%), things go well. During adolescence, the brain renovates, objective is to better understand what the getting rid of stuff (pruning back cells) and putting new things in (creating neural links). Although a disruption during pre-onset stage of psychosis looks like, and what this process can increase the risk of depression, psychosis, anxiety disorders, and anorexia nervosa, most teens develop helps prevent or delay it. "In five to 10 years, with smoothly. Dr. Kutcher says that because of the confusion created by this myth of teenage angst, family and friends may similar research, we'll be better informed." assume that disturbances are normal and ignore the health problems of someone they love. Emotional, psychological, developmental bumps, if they last any length of time, are signs of a distressed brain and call for medical attention. - JM For more information about Anna and her family, as wel as information about the NSEPP, go to www.e-earlypsychosis.ca Spring 2008 • LIVING Healthy In Atlantic Canada
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