Dipartimento di Scienze mediche e Sanit Pubblica Universit

  • Slides: 60
Download presentation
Dipartimento di Scienze mediche e Sanità Pubblica Università di Cagliari S. C. Clinica Psichiatrica

Dipartimento di Scienze mediche e Sanità Pubblica Università di Cagliari S. C. Clinica Psichiatrica AOU Cagliari Recovery: quanto e come è possibile Bernardo Carpiniello

Schizophrenia: two ways to conceptualize the disorder “Two conceptualizations of serious mental illness- the

Schizophrenia: two ways to conceptualize the disorder “Two conceptualizations of serious mental illness- the “broken brain” and the “recovery model”- have dominated recent attempts to understand treat severe and persistent mental disorders such as schizophrenia…” Lieberman J et al, Psych Serv, 2008, 59: 487 -496

Recovery “ …a more hopeful view of the course of illness emerges from the

Recovery “ …a more hopeful view of the course of illness emerges from the recovery movement, which emphasizes developing a meaningful life beyond illness…» Lieberman J et al, Psych Serv, 2008, 59: 487 -496

Il recovery secondo la prospettiva dei pazienti

Il recovery secondo la prospettiva dei pazienti

“processo unico, profondamente personale di cambiamento dei propri atteggiamenti, valori, sentimenti, obiettivi, abilità e/o

“processo unico, profondamente personale di cambiamento dei propri atteggiamenti, valori, sentimenti, obiettivi, abilità e/o ruoli. Rappresenta una modalità di vivere una vita soddisfacente, carica di speranza e ricca di spunti pur con le limitazioni causate dalla malattia. La ripresa coinvolge lo sviluppo di nuovi significati e scopi della propria vita, al di là degli effetti catastrofici della malattia mentale”. Anthony, 1993

“ Mental health recovery is a journey of healing and trasformation enabling a person

“ Mental health recovery is a journey of healing and trasformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice, while striving for achieve his or her full potential” National Consensus Statement on Mental Health Recovery Definition, Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration (SAMHSA)

Il recovery secondo la prospettiva dei clinici

Il recovery secondo la prospettiva dei clinici

Targets of treatments in schizophrenia Recovery Clinical Stabilization/Adequate Functioning/Well being Absence of significant Remission

Targets of treatments in schizophrenia Recovery Clinical Stabilization/Adequate Functioning/Well being Absence of significant Remission Symptoms /clinical sta bilization Response Significant improvement of symptoms

Recovery is possible “ Now is accepted that recovery is possible, even to the

Recovery is possible “ Now is accepted that recovery is possible, even to the extent of full absence of all symptoms and disabilities and that optimal recovery should be a goal for people with schizophrenia, although not all the individual with the illness will make significant progress toward this goal” Harvey P. D, Bellack AS, Toward a terminology for functional Recovery in Schizophrenia: Is Functional Remission a Viable Concept? Schiz Bull, 35, 300 -6, 2009

 • Multidimensionalità (ed eterogeneità dei criteri di valutazione) del «recovery» dal punto di

• Multidimensionalità (ed eterogeneità dei criteri di valutazione) del «recovery» dal punto di vista clinico

“Recovery encompasses both symptom remission and functiontal elements such as cognition, social functioning and

“Recovery encompasses both symptom remission and functiontal elements such as cognition, social functioning and quality of life” Luecht S, Lasser R, The concept of remission and recovery In Schizophrenia, Pharmacopsychiatry, 39: 161 -70, 2005

“ There are multiple elements of recovery. These include freedom from troubling psychotic symptoms

“ There are multiple elements of recovery. These include freedom from troubling psychotic symptoms and relapses, satisfaction with life and daily activities and suitable functioning in everyday life” Harvey P. D, Bellack AS, Toward a terminology for functional Recovery in Schizophrenia: Is Functional Remission a Viable Concept? Schiz Bull, 35, 300 -6, 2009

 • Remission of symptoms • Engagement in productive activity (Work, school) • Independent

• Remission of symptoms • Engagement in productive activity (Work, school) • Independent management of day-to-day needs • Cordial family relations • Recreational activities • Satisfying peer relationships Liberman RP, Recovery from disability. Manual of psychiatric Rehabilitation, Am Psych Publishing, Washington DC, 2008

Clinical Models of Recovery unidimensional RECOVERY Sustained (long term) Symptoms’ Remission

Clinical Models of Recovery unidimensional RECOVERY Sustained (long term) Symptoms’ Remission

Clinical Models of Recovery Bidimensional Symptoms Remission recovery Functional Remission

Clinical Models of Recovery Bidimensional Symptoms Remission recovery Functional Remission

Clinical Models of Recovery Tridimensional Well Symptoms Remission recovery Functional Remission being /Qol

Clinical Models of Recovery Tridimensional Well Symptoms Remission recovery Functional Remission being /Qol

ng so bei cia lc ll og n iti We on Clinical Models of

ng so bei cia lc ll og n iti We on Clinical Models of Recovery Pluridimensional recovery ve iti gn oc o Ne ur l /Qo sy mp to m s Symptoms Remission Functional Remission

 • Eterogeneità dei dati sul recovery: i dati più ottimistici degli studi meno

• Eterogeneità dei dati sul recovery: i dati più ottimistici degli studi meno recenti

Recovery «……long-term outcome studies…. consistenlty show heterogeneity, with many patients improving and in some

Recovery «……long-term outcome studies…. consistenlty show heterogeneity, with many patients improving and in some cases achieving substantial remission…” Lieberman J et al, Psych Serv, 2008, 59: 487 -496

RECOVERY RATES ACCORDING TO BROAD DIAGNOSTIC CRITERIA (DIAGNOSIS AND EVALUATIONS)

RECOVERY RATES ACCORDING TO BROAD DIAGNOSTIC CRITERIA (DIAGNOSIS AND EVALUATIONS)

 • Eterogeneità dei dati sul recovery: i dati meno ottimistici degli studi più

• Eterogeneità dei dati sul recovery: i dati meno ottimistici degli studi più recenti

Remissione sintomatologica, funzionale, soggettiva 24 mesi in 2960 pazienti Remissione sintomatologica Remissione funzionale Benessere

Remissione sintomatologica, funzionale, soggettiva 24 mesi in 2960 pazienti Remissione sintomatologica Remissione funzionale Benessere soggettivo % NO NO NO 35, 08 SI NO NO 11, 12 NO SI NO 7, 19 NO NO SI 8, 30 SI SI NO 4, 37 SI NO SI 18. 86 NO SI SI 2. 24 SI SI SI 12. 84 Lambert et al. J Clin Psychiatry 2006; 67: 1690 -1697

Recovery rates in recent studies using different criteria for “recovery” 22. 4 19 12.

Recovery rates in recent studies using different criteria for “recovery” 22. 4 19 12. 8 10

24 months recovery rates (SOHO Study) 55 47, 2 42, 2 45 Patients (%)

24 months recovery rates (SOHO Study) 55 47, 2 42, 2 45 Patients (%) 35, 1 35 26, 6 25 12, 8 15 5 0 Symptoms Functioning Subjestive wb Lambert et al. J Clin Psychiatry 2006; 67: 1690 -1697 Clinical+Functional Absence of remssion

26

26

24 Months recovery rates 100 90 80 70 60 50 40 30 20 10

24 Months recovery rates 100 90 80 70 60 50 40 30 20 10 0 recovery rates recovered Carpiniello unpubl data 2016 not recovered

 • Quanto dura nel tempo il recovery ? • La schizofrenia comporta tassi

• Quanto dura nel tempo il recovery ? • La schizofrenia comporta tassi di recovery diversi rispetto alle altre psicosi? • Esistono differenze di genere nei tassi di recovery?

Grossman L, et al

Grossman L, et al

Grossman L, et al

Grossman L, et al

Carpiniello et al

Carpiniello et al

Cagliari Remission-Recovery Study 24 Months Recovery Rates Recovery criteria Males Females Total Clinical+ function.

Cagliari Remission-Recovery Study 24 Months Recovery Rates Recovery criteria Males Females Total Clinical+ function. remission+ Well being 6. 3% 18. 8% 9. 8% p=. 045 Carpiniello unpubl data 2016

 • I tassi di recovery sono diversi se si considerano i soli pazienti

• I tassi di recovery sono diversi se si considerano i soli pazienti all’esordio?

Revier CJ et al

Revier CJ et al

Lambert M, et al

Lambert M, et al

Lambert M, et al

Lambert M, et al

Wunderink L et al

Wunderink L et al

Cumulative Recovery Rates per year in FEP patients Yrs upper Cumulative lower confidence rates

Cumulative Recovery Rates per year in FEP patients Yrs upper Cumulative lower confidence rates (%) confidence limits 95% 3 9. 7 3. 7 15. 8 4 12. 3 5. 4 19. 1 5 13. 7 6. 4 20. 9 Robinson DG et al. Am J Psychiatry. 2004; 161: 473 -479.

Albert N et al

Albert N et al

Albert N et al

Albert N et al

Austin SF et al

Austin SF et al

Austin SF et al

Austin SF et al

Recovery: evidenze meta-analitiche

Recovery: evidenze meta-analitiche

When deciding the recovery criteria, we acknowledged the recommendations of using multidimensional definitions, including

When deciding the recovery criteria, we acknowledged the recommendations of using multidimensional definitions, including at least 2 domains, one related to clinical remission and another related to broader social functioning outcome, and persistence of good outcome for a minimum of 2 years.

16%

16%

Perché i tassi di recovery sono tuttora bassi e non sembrano essere migliorati nel

Perché i tassi di recovery sono tuttora bassi e non sembrano essere migliorati nel tempo?

Mucci A et al It is increasingly acknowledged that the alleviation of schizophrenia symptoms

Mucci A et al It is increasingly acknowledged that the alleviation of schizophrenia symptoms obtained with available treatments is not accompanied by a parallel improvement of patients' functional impairments The relationship between symptoms and functioning is modest: individuals with relatively severe symptoms may function moderately well, while patients with mild symptoms may not function adequately in their daily activities From 30% to 70% of people with schizophrenia do achieve symptom remission, but the percentage of patients showing adequate functioning in real life is remarkably lower Symptomatic remission contributes to improved functioning in real life, but is not sufficient to attain it.

Galderisi S et al

Galderisi S et al

Galderisi S et al

Galderisi S et al

Galderisi S et al

Galderisi S et al

Epidemiol Psych Soc, 2008, 17: 331 -348

Epidemiol Psych Soc, 2008, 17: 331 -348

Epidemiol Psych Soc, 2008, 17: 331 -348

Epidemiol Psych Soc, 2008, 17: 331 -348

Green CA et al

Green CA et al