pp lezing 3 m. van der gaag 30-5-13
TRANSCRIPT
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The effects of prevention: the EDIE-NL study and meta-
analytical outcomes Hoe eerder, hoe beter 30 mei 2013, Den Haag
Mark van der Gaag
STATISTICAL POWER IS THE ISSUE IN
PREVENTION RESEARCH
PLAYING TRICKS WITH EPIDEMIOLOGY
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Extended Psychosis Phenotype: 61 cohorts Prevalence 7.2% Incidence 2.5% Persistence 2-5 years 20-30% Transition rate 7.4%
0.6% 20-30% 10%
Transition rate, success rate, and Number Needed to Treat Van Os, J., & Delespaul, P. (2005). Toward a world consensus on prevention of schizophrenia. Dialogues Clin Neurosci, 7(1), 53-67.
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IT IS ALL ABOUT SAMPLE
ENRICHMENT
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EDIE
Help-seeking for a co-morbid axis 1 or 2 disorder Young people 14-35 years of age (18-35 in The
Hague) Psychotic-like experiences (Prodromal
Questionnaire, Rachel Loewy) Decline in functioning SOFAS<55
EDIE TRIAL 2008-2012
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Acknowledgements Early Detection and Evaluation Intervention
David van den Berg Petra Bervoets Nynke Boonstra Marion Bruns Sara Dragt Saskia van Es Sarah Eussen Gitty de Haan Mischa van der Helm Martijn Huijgen Helga Ising Lianne Kampman Rianne Klaassen Don Linszen Aaltsje Malda
Carin Meijer Julia Meijer Roeline Nieboer Dorien Nieman Bianca Raijmakers Judith Rietdijk Marleen Rietveld Nadia van der Spek Annelies van Strater Tinie van de Tang Zhenya Tatkova Jenny van der Werf Swanny Wierenga Lex Wunderink Annemieke Zwart
Alison Yung Tony Morrison Paul French Lucia Valmaggia Rachel Loewy Pim Cuijpers Niels Smits Kees Korrelboom ZonMW grant
PSYCHOLOGICAL MODEL
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Goals of CBT in UHR
‘Manage’ external risk factors à education and behavioural control
Prevent catastrophising and delusional interpretations to PLEs à CBT for current concerns à Reduce selective attention and avoidance à Metacognitive awareness of risky thinking styles and ways to handle and cope with cognitive biases and PLEs
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Risk management Ø No cannabis or other drugs Ø Keep attending school and work Ø Share thoughts and convictions with others and discuss these
RESULTS 12
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Parnassia Psychiatric Institute & PsyQ Haaglanden, The Hague
MHS Leiden, Child and Adolescent Department Academic Medical Centre & PsyQ Amsterdam MHS Friesland, Leeuwarden and province
Flowchart of patients
Results of CBTuhr intervention
TAU = State of the art treatment for co-morbid disorder
CBTuhr add-on to TAU
10 transitions
22 transitions
Patient status at 18-month follow-up
The Chi-square linear-by-linear association is significant: Chi2 (df=1)=4,266, p=.039
The NNT to prevent a transition was 9 The NNT to bring a patient into remission was 7
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ECONOMIC COSTS 17
Cost Utility Analysis Voorlopige uitkomsten, nog aan verandering onderhevig
-10.000
-7.500
-5.000
-2.500
0
2.500
5.000
7.500
-0,15 -0,10 -0,05 - 0,05 0,10 0,15 0,20
Add
ition
al c
osts
(€)
Additional effects
NE: more effective and more expensive 26.1 %
NW: less effective and more expensive 10,9%
SW: less effective and less expensive 11,5%
SE: more effective and less expensive 51.6 %
Cost Uitility Analysis Voorlopige uitkomsten, nog aan verandering onderhevig
CBT uhr Effect: 0.60 Costs: € 6.734
TAU Effect: 0.57 Costs: € 7.445
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Incremental Cost Effectiveness Ratio Incr effectiveness: 0.03 Incr costs: - € 710 ICER: - € 21.747 Median: - € 14.650
Results Cost Utility and Cost Effectiveness Analyses
CBT uhr is cost-effective:
• Increased health QALYs for reduced costs • Reduced psychotic transitions for reduced
societal costs • Reduced psychotic transitions for reduced
health costs 20
META ANALYSIS 21
Preventing a first episode of psychosis: meta-analysis of randomized controlled prevention trials of 12 month and longer-term follow-ups
Mark van der Gaag1,2, Filip Smit1,3, Andreas Bechdolf4, Paul French5, Don H
Linszen6, Alison R Yung7, Patrick McGorry7, Pim Cuijpers1,3 1) VU University and EMGO Institute of Health and Care Research, Amsterdam, The
Netherlands 2) Parnassia Psychiatric Institute, The Hague, The Netherlands 3) Trimbos Institute, Utrecht, The Netherlands 4) Department of Psychiatry and Psychotherapy, University of Cologne, Germany 5) University of Manchester, Manchester, United Kingdom 6) Academic Medical Center of the University of Amsterdam, The Netherlands 7) University of Melbourne, Australia.
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Study name Statistics for each study Risk ratio and 95% CI
Risk Lower Upper ratio limit limit Z-Value p-Value
McGorry, 2002 0,542 0,226 1,298 -1,374 0,169McGlashan, 2006 0,425 0,168 1,076 -1,806 0,071McGorry, 2012a 0,760 0,285 2,026 -0,549 0,583Amminger, 2008 0,177 0,042 0,750 -2,350 0,019Nordentoft, 2006 0,264 0,079 0,888 -2,152 0,031Bechdolf, 2012 0,054 0,003 0,913 -2,023 0,043Morrison, 2004 0,207 0,046 0,941 -2,039 0,041Addington, 2011 0,128 0,007 2,350 -1,385 0,166McGorry, 2012b 0,742 0,278 1,982 -0,594 0,552Morrison, 2012 0,700 0,274 1,788 -0,745 0,456Van der Gaag, 2012 0,473 0,226 0,988 -1,993 0,046
0,463 0,334 0,642 -4,616 0,000
0,01 0,1 1 10 100
Intervention Control
Study name Statistics for each study Risk ratio and 95% CI
Risk Lower Upper ratio limit limit Z-Value p-Value
McGorry, 2002/70,753 0,387 1,465 -0,836 0,403
Nordentoft, 20060,566 0,278 1,153 -1,567 0,117
Bechdolf, 2012 0,103 0,014 0,783 -2,197 0,028
Morrison, 2004/70,622 0,250 1,543 -1,025 0,305
Morrison, 2012 0,769 0,349 1,697 -0,650 0,516
0,635 0,438 0,919 -2,405 0,016
0,01 0,1 1 10 100
Favors Experimental Favors Control
Results
Early detection and indicated prevention are about to become an evidence-based intervention
CBT that showed a transition reduction of 48% and a NNT of 13 in five RCTs with 672 subjects
CBT uhr is cost-effective: increased health for
reduced costs
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MARK VAN DER GAAG PhD
HEAD OF PSYCHOSIS RESEARCH PARNASSIA PSYCHIATRIC INSTITUTE, DEN HAAG PROFESSOR OF CLINICAL PSYCHOLOGY AT VU UNIVERSITY, AMSTERDAM
Thank you for your attention!
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