 Okay, let's go ahead and get started. My name is Steve Lopez, I'm a professor of psychology and social work at the University of Southern California. I was here in UCLA for a while. The college is a professor of anthropology. And the two of us are the co-directors of a program called Culture, Brain and Mental Health and Development. And under that context, and it's funded through the foundation of psychocultural research, Dr. Mimi Yep-Wong works there with the foundation, and that's what supported bringing her today. So I have the pleasure of introducing them, and it gives me a great deal of pleasure to introduce Dr. John Olaf Johansson and Dr. Inga Joa, both traveled 24 hours to get back tomorrow. Is that true? Take 24 hours? Not in the air. Not in the air, yes. Okay. So Dr. Johansson is a professor of psychiatry at Stavanger University, and he's the director of research within the division of psychiatry at the Stavanger University Hospital. Dr. Inga Johansson is an associate professor within the Faculty of Social Sciences in the St. Anne University, and his training largely is in nursing and nursing science, and he received his Ph.D. in clinical medicine. And they, in part, are here to serve as consultants on the grant that my colleagues and I got at NIMH, and they, to actually carry out a community education campaign in the St. Fernando Valley, where Spanish would be Latinas, and the goal is to reduce the duration of untreated psychosis, the duration of untreated psychosis, and particularly among first episode psychosis. In other words, once the psychotic symptoms begin, how long does it take for them, these individuals, to come in to reach services? And past research has shown that the longer DUP, or duration of untreated psychosis, is associated with a poor clinical course, and poor treatment response, and also is associated with some structural and functional impairments of the brain. And so it recoups us to intervene early in the course of this illness. And exactly what Dr. Johansson and Dr. Joach had done is that they were the first to carry out a community education campaign and to demonstrate a significant reduction in the duration of untreated psychosis. Now, in a review paper, I think it was American Journal of Psychiatry 2011, they identified eight community education campaigns would be aimed to reduce the duration of untreated psychosis. And only two have been successful in doing so. And they are the first ones in doing this. And they, in fact, are the leaders in this field. In addition, I want to point out that they have a view of schizophrenia and they have a view of psychological treatments that, in my opinion, don't really mesh as well with my understanding of psychiatry, American psychiatry, and never. They see schizophrenia as a disorder that exists on a continuum, not a discreet clinical entity. Moreover, they believe strongly in psychological treatment for schizophrenia and other psychotic disorders. They recognize the importance of medication, but they put a lot of emphasis on psychological interventions. So their view of schizophrenia strikes me as a compassion of you, one that recognizes the diversity of the human spirit and celebrates the personhood of all, especially those with mental disorders. So I'm delighted, very delighted that the two of you have agreed to visit us here in Los Angeles and to share some of your insights and your important work to hear us here in UCLA. Thank you very much. Help me welcome them. Thank you, Steve, for your nice words and for the invitation. The pleasure is on our side to come to Los Angeles. Of course, it's exciting for people living in the far north to experience this weather and this very nice nature you have with the beaches and the hills. It reminds me of Tuscany in Italy. It's a beautiful place, so the pleasure is on our side. We will divide this in two, or maybe three, maybe four, we'll see. I will start, and Inge will follow after some time, and then maybe I will come back. I take off my jacket warm. So we are a little group, a small group, so you must feel free to ask questions while I'm talking. And how much time is it we have planned to use? One hour. One hour? Yeah, but you can take questions in between as well. Am I standing in? Okay, I'll maybe take this a little this way. Okay. So I'll take you through 20 years history, so to speak, and end up in 2012 when we finished and published the 10-year follow-up. So when we started out, we chose this as a symbol in a way of how early is it possible to intervene, and we ended up with the egg. We are now into ultra-high-risk research. That is prodromal research. So we have chosen the rooster for that line of research. I'm not sure if the rooster was before the egg. No? This is a 50 million Norwegian krona. That is 12, 13 million US dollars. I'll come back to that, what this is. Are we Sankja? So this is 50 million Norwegian krona. As I said, 12 million US dollars. Have you been to Norway? No one? You have. Where in Norway? Oslo. Oslo, of course. Bergen. Of course, Bergen is... You took the train. You took the train, yeah? Our Bergen is situated north of Stavanger and is our little larger brother. So we compete with Bergen all the time in Stavanger. Stavanger is situated on the southwest coast close to Scotland and Denmark. And it's a town with about... a town area of 250,000, so it's only a small part of a small part of Los Angeles, so to speak. But it's situated at the gateway for the fjords. So it's a kind of tourist location also. It's known for its wooden houses. It's the city in Europe with the largest amount of wooden houses, old wooden houses. And these houses are from 1600s, 1700s and so on. This is the old part of the town. It was... This is the harbour, part of it, and this is called Swords in Stone, or Swords in Mountain. In 872, Norway was gathered, is that what you say, to one kingdom and that happened just in a few or just five kilometers outside the city centre. We have the beaches as well, not as beautiful as yours. And this is... You shouldn't think we have the same weather as you. This is the one day we had sun last year. So, and this is probably the second day we had sun. So this is close by fjord, and it's actually in Norway's most visited tourist attraction. It's called the Pulpit. We used to live on sardines and canned sardines and sardines in oil. Nowadays, we live only on oil because it's the oil capital of Norway, and Norway's economy is fueled on oil from the North Sea. Yeah. This is the old state hospital we had, similar to what you have, I guess. This is the modern facility in town. I always show this when I give lectures. This is the incidence of mental disorders. And you see that the peak is 20 years, 20 years age when they present for treatment. And you can deduct a couple of years from that when they become ill. So the peak debut of all mental health disorders is about 17, 18 years. And 25% of all mental disorders have had their debut before the age of 25 years. So this is the picture that we are looking at when we are trying to do something with these disorders. We have had good cooperation with US all the time in our projects, and especially with Thomas McLean at Yale, who we got to know in the late 80s. And he had some bad experience with his patients, as you might know. Many of them didn't recover or go into remission. So he moved also approximately at the same time as us into this thought of trying to prevent this downward course that we thought we saw in many cases. This is what Steve talked about in a way. We look upon mental disorders as a continuum from normality to the final psychological breakdown, which is the psychosis. And in the start, you see these psychotic disorders, bipolar disorders, they don't... There's not much difference when it comes to the presenting symptoms in the early phases. It could be illustrated like this. And it's also, we think that the developing stages are these confusional states being in a way the final psychological breakdown. So this is the dimensional view when it starts with nervousness, depression, anxiety, and then it increases, and the psychological apparatus doesn't have the ability to cope with these increasing feelings in a way. And this is the view in most of Europe now these years, this dimensional view. It goes into the NICE guidelines, that is the UK guidelines and the Scandinavian guidelines. So this has in a way... We think this is a better way to look at it than this category, where you think you have separate illnesses with genes in a way determining this, whether you do anything or not. So this is how we picture it in the TIPS connection. And so that all mental disorders start with these things and then you have this domino effect stat that leads you into this breakdown in the end. And this is another way of picturing the same with the stages and development. And we are able, I guess, to intervene here and we want to move the treatment back in this illness development. So this is in Norwegian. I'll give you a couple of minutes to read through it. In Norwegian, duration of untreated psychosis is but these are the different stages that we deal with in the early psychosis development. We have duration of untreated psychosis, we have duration of psychosis, we have duration of untreated mental disorder and we have time to remission and so on and so on. There's something. Okay. His eyes on the late stages live in America. Yeah. This is one of my heroes, Harry Stack Sullivan. And he talked about and wrote about early intervention and the importance of that in American Journal of Psychiatry in 1927. We're getting close to 100 years ago. So it's not an original idea from Norway or Australia or Canada or whatever. He said that we see too many end states and too few pre-psychotic. He said it's never easy to say just when there's schizophrenic patients. So he talks about dimensionality. It's never easy to say just when the schizophrenic patient has crossed the line into actual psychosis. So there's always somebody who has discovered what you think you discover for the first time. As you might know and there's a lot of Hispanics here in Los Angeles. They think they discovered America. But this is the man who discovered America, Leith Ericsson, a Viking king. They settled in what they call Vineland. That is on Newfoundland for a couple of centuries before they were eradicated by the Indians. But actually Columbus used maps from them. There's many centers now. This is an old slide, but Ian Falun who lived and worked in Los Angeles for some time made important contributions to this and was a kind of pioneer on it. This is Australia, Epic and Pace, and Patrick McGorey, and Jane Edwards, and Alison Jung, and Jeffrey Lieberman also contributed to this thinking, and the Prime Pace Top, Prime is a Yale project. So we hope to contribute to prevention. And you are familiar with these concepts, so I won't bother you to go in details. But what we want to achieve, of course, would be primary prevention, and that is for the ultra-high-risk research. What I'm talking about today is secondary prevention, which means reducing prevalence or delaying onset and improving prognosis and so on. And that is what the TIPS project is about. Steve already told that the starting point, of course, is that we found out that duration of entry, we did some research in the beginning of the 90s, and we found out that duration of entry to psychosis in the Stavanger area was two years in mean and half a year in median. And that came as a kind of almost a shock on us, because we thought we had the best welfare system in the world, and was it possible that young people could go out there two years psychotic before they got the treatment they deserved? So we would like then to see if it's possible to reduce duration of entry to psychosis, and if that changes the long-term course. We did not a randomized controlled study. That's deemed unethical. So we did a quasi-experimental design. I'll come back to that a little more. So we did it with the Mülke Center trial comparing Stavanger region with Oslo and Copenhagen. Copenhagen and Oslo did late intervention or usual intervention. A lot of good people working together. Many more could have been mentioned here. This is the design population, and we expected 300 cases through the first four years, and we got 301 cases. So it was first episode non-effective psychosis, age 15 to 65, and we had the same treatment program in all sides. So it's not a treatment study, it's a timing study, a study of the importance of the timing of the treatment. And these were the core elements in the treatment that we trained all the doctors and psychologists in across sides, psychotherapy, medication, multi-family groups. And the basics are educational information campaigns in the early sector and low-tracial, easy access services with active outreach detection teams, the case-finding teams. And we had extensive, and we still have, we do this, this is now a regular part of our services, we do this all the time, it's integrated in regular services. So we did a series of whole-page newspaper advertisements, radio, brochures, anything you can think of, ball pens, tie pins, cufflinks, disparages to the doctors, cups, anything of marketing you could think of, and we still do. And that's fun, that's part of the reward for us that we can use our imagination when it comes to what should we be up to now, in a way. We are like small boys when it comes to that. And we had courses and seminars for all teachers, counselors and for other persons in the schools, educational programs for teachers, videos illustrating early science and so on and so on. We had special information for the primary health services, educational seminars, brochures, rating manuals, videos, reminders and so on and so on. And you know this, of course, the importance of health literacy and training people and the publication in increasing the mental health literacy. And it's based on the works of Anthony Jorm from Australia. And we own a lot to the Australian groups. They have been pioneers in this, I would say. You know this, Wittgenstein-Stöck, which is the underlying idea. You cannot recognize what you haven't seen. And mental health promotion is, of course, also a crucial element here. And you have to address several levels, so to speak, to increase the health knowledge in the population. Yes, it has been said that the last thing a dweller in the deep blue sea would be likely to discover would be water. He would be conscious of its existence only if some accident brought into the surface. And these are young people. They don't recognize their feelings as something that bothers them. So they act out or they act in or they sit in their rooms playing with video games and so on. So our task is in a way to teach the population that you have feelings and your feelings are there to guide you, but they can also be a kind of burden. And you should look out for special feelings that could overburden you in a way. So effective health promotion programs should have a multi-level strategy as well as multiple access points. And this we learned from the US Department of Health and Human Services back in 1994. So it's not only in psychosis people seek help too late. It's in eating disorders, it's in bipolar disorders. It's a common problem for many of these disorders. And the reasons for this too late business are lack of knowledge in families, in patients and in helpers. And especially lack of knowledge about early signs, available help and outcome. And we discussed this earlier today in a small seminar. In mental health we are not trained or, as we have put it, we are not focused on results, what treatment results we achieve. I'm not sure do you know in Los Angeles what your treatment results are when it comes to first episode psychosis? What percentage should be in remission after one year in a first episode psychosis population? Usually when I give this talk to students, I say that you are not allowed to go out of this room before you know the answer to that. Because there are two questions patients and relatives ask. And that is what's wrong with my boy? And what's going to happen with my boy? What is the prognosis? And we can't answer that in psychiatry. Just think if you go to a surgical operation and you ask the surgeon, what are your results for this operation? And he says, I don't know. And psychosis is as serious as many somatic disorders. It's fear connected to these disorders. I'd like you now to think of what percentage in Los Angeles of first episode psychosis is in remission after one year. And we come back to that. Just figure it out for yourself. It's shame connected and there are thresholds out there. When I was a young resident, I always got a clap on my shoulder when I had been on duty or call and I had managed not to let any patient into my facility. That's not the situation anymore, luckily enough. So these are the early detection strategies that I've talked about. And in principle it looks like this. You have to have information campaigns and you have to have access to services, to decent services. It's unethical to do early intervention if you don't have a service that can receive these patients. I'll take you through some of the information and give you some examples now. Just since we are in the film capital of the world, this will go as fast as a film. Pay attention. Oh, somebody has turned on. Usually I turn this off. But this is part of the general health promotional work. We have a whole week every year called the Schizophrenia Days. It's more like a festival and also a professional congress. Europe's largest. And we inform the public on a regular basis on any kind of anti-stigma purpose. We have developed a lot of information material directed towards the general population. You can pay attention to this one. Just bear that in mind for later use, so to speak. This was the first whole page advertisement we had in 1996. It says in one aspect mental disorders are like somatic disorders. If health is provided early, then the chances to get well increases. Something like that. So we had school campaigns, courses and seminars for teachers, educational programs as I've said, videos, information brochures. This is a headmaster in the most prestigious high school in the area. It was a whole page advertisement in our largest newspaper. And the only purpose of this is to get the attention of the other headmasters. This is high school graduates. In Norway we have special programs for the high school graduates because we know that everyone looks up to the graduates who want to become a graduate. They party for one month when they have graduated. So it's a dangerous period for some of them. But this attracts the attention of all the other pupils in the high school. So you don't have to go and teach all the high school pupils. There is knowledge in the last year, but the others are curious then. This says young people these days. And we have buses, advertisements going around. It has shown you that. This is also back to 1996. You remember that film? When people have information campaigns about mental disorders and so on, they come up with this old film. As I heard it, even back when it was made in 1960, they couldn't get the patients to play themselves because it was so exaggerated. I don't know. So we had a whole series of contrasting elements here. We say this is the myth and this is reality. These were the people working in the TIPS project back in 1996. So if I brought a picture of them now you would see that they have become older. This is from the school information. The school of life could put you on harder tests than any exam. I go through this lit fast. These are images that we use. Why are you so sad? Why are you so silent? Why are you so angry? When somebody you know becomes silent, they usually have a story to tell. When somebody you know disappears, they usually have a need to be seen. When somebody you know is irritated, they usually have their reasons. This was the program for all schools in Norway now. It's called What's Wrong with Monika? I traveled to the US on a couple of occasions when Bill Clinton was president. He usually made people smile and was coincidental. So these are the information campaigns for primary health services which also is a target group. This should illustrate that you have to have multiple targets with your information to succeed. And then you have to repeat and repeat and repeat. So then what happened when we did this? As I said, the goal was to reduce the duration of in-freedom psychosis. That was the first goal. And this was what happened. We had an historical control with Median 26 weeks. It went down to five weeks in Median. And compared to the Oslo and Copenhagen with detection as usual, they had 16 weeks. And even 16 weeks is short in this connection. We wanted to see if we had some impact on attitudes and knowledge in the population. And so we have done regular opinion polls. And we managed to get up. This isn't research because it could be confounding factors, other things also contributing. But there was a significant shift in knowledge and attitudes in the population. So Inge, now it's your turn. I will try to tell you a bit more about this early detection team and how people go into the system and how this referral system functions. And then go over to say more how has these campaigns and the low threshold detection team had its impact on the DUP over some years. So as Jan Ola said, the core purpose of the low threshold detection team was to have an easy access into the specialized healthcare system in Norway. In order to get access or be treated in the mental health system, you have to go to your GP and he has to write up a referral and it goes to the hospital into an intake team and time will go on. And in order to have the possibilities to take these first episode patients straight into the system and have a short DUP, we had to make a system going around the GPs. So we set up these low threshold detection team where anyone could call if they suspected that themself, a relative, anyone they know or care for could have been such causes under development. So anyone could call. They would be assessed within 24 hours after the call and if there were any need for help from our system, we would provide that. So I'll show you some of these referrals and how they are. This is a table over the first 10 years to the detection team where we had 5,000 referrals. People usually use the phone but they could also send us a mail or a letter but the main route into the detection team is that they first take a telephone call. 5,000 for tenure gives us annual 500 calls. That would give us two calls per day to the one who is at call. And out of these 5,000, about 30% were anonymous. You could call us on an anonymous basis just to discuss. Most of the referrals were about regarding men. And we did the PAMPS interview for close to 40% of these referrals. What we first do on the phone is more kind of a telephone triage. The people staffing the detection team are psychiatric nurses with long clinical experience. They've been working in the acute department so they would know how a psychotic patient will present at clinics. And the first telephone interview will try to get a view of what is happening with this young person. And if we had any suspicion that there could be a psychosis under the development we would offer a first assessment. And it's better to take one too much than one too few. And we are not obliged to have the patient coming into the system. If they wanted us to do a home visit we would go home. If the teacher called we would go to the school. Or even to the GP's office anywhere where it was wanted. Many when they called and we would say you can come today or tomorrow morning they would perhaps say well tomorrow I'm going to school and can I do it on Friday I'm off then. So the 24 hour rule is okay. We managed to take all patients in by that. If they called us on Friday afternoon they would have to wait until Monday and we would tell them if there was a crisis under development they shouldn't wait until Monday but go to the emergency room. When we see them face to face the assessment is consisting about that we are doing a pants interview. Do you know the pants? Yeah. So that's just a symptom description. Giving us a fairly good idea if this is a psychosis yes or no. And the outcome of the interview is that we will then if there were psychotic episodes we would give the person an offer about fast treatment within the system. We had this kind of guarantee that within a week you will be given a therapist at our outpatient clinic. And if needed if they were really sick then we would just take them into the hospital at once. Most of these referrals they were not about psychosis. Many would have anxiety problem, eating disorder, self-harm, trauma and if there were any mental health problem uncovered in these assessments we would see too that the patient provided decent help in the system. The Norwegian psychiatric treatment system is offered to its public and very few people, especially with severe mental disorder is treated in a private system. We have private psychiatrist and private psychologist but they mostly treat milder disorders like anxiety or depression. And who are using our services? And luckily more than half of the referrals to this low threshold detection team came from either the patients themselves, close to 30% of the referrals came from patients themselves, the families and then it's the mother who is the key referer and the friends and fathers. The general practitioners and other people in the first line services they provided about 10% of the referrals and the school, the teachers, they provided close to 10% of the referrals and we have others who will cover our outpatient clinics giving us a call about a patient that we already started treatment with and then they saw that there were some psychotic symptoms that they could refer to us. So the system seems to function and we still have it on the same way so since 2007 to now we added more 500s per year to this cohort. When the TIP study stopped in the end of 1991 because that was a Norwegian research council that provided the funding for the study, luckily Jan Ula and other wise persons in our system they had done it so that the low threshold team had become a part of the clinical services in our system so that part were carried on but the funding for these information campaigns they were stopped and that gave us an opportunity to see what are the impact of the information campaigns in relation to the reduction of TIP that we had seen over the four years. So I was given a scholarship for doing a PhD or a grant for doing a PhD just investigating that and I will give you some examples of what we found for the years from 2002 and the next two years what happened with the DUP when the information campaign stopped in our system. So these are the figures that we have told you about in the pre-TIPs period in 1992 or 1993 the DUP was in Maine close to two years in the yarn of 26 years during the TIPs period it was decreased to five weeks and 26 weeks in Maine and what happened the next years was that the DUP went up again it didn't become as bad as the years before but when we stopped the campaign the median was close to or similar to the one in our control sites in the TIPs period and out of that we concluded that maybe that the information campaigns or communication campaigns are a vital part of the early detection strategy key component and we have studied these referrals to the low threshold detection team over the years and we also saw what happened to these referrals and over the four years of the DUP these are about three months periods over the four months over the four years in the TIPs study we got a decreasing number of referrals it would take you a year or two to cover a large community you should visit all the GPs you should visit all the schools you should have campaigns over and over again so it would take some time before you have these referral rates at a steady level but when we stopped it decreased again close to the level that we had in the first two years and we saw that especially that the referrals from the GPs and the schools decreased and we had more first episodes coming through the emergency care units in our hospital so you need to keep on doing these things you have to have you set out this pathway you have to go on and kind of stop another thing that you might want to know is that the DUP among the adolescents is longer than among the adults so we looked into and saw how did these persons look like they had their onset of psychosis before they were 18 compared to the persons who were older than 18 when the psychosis started and what we saw is that the DUP among the youngest were 16 weeks in our cohort compared to six weeks among the adolescent and that tells us something about that we should especially target the youth and mental health system youth and adolescent system within our services many, many young people they will start off being treated in our adolescent departments and the psychotic symptoms is not recognized among the therapists so we have to bring attention to that department in particular so they don't develop a long DUP so what we concluded when I did my dissertation was that in order to achieve a fully effective strategy for the early detection of first episode psychosis you need both the information campaign and the low threshold detection teams nothing now and how does the DUP look in our region now by 2013 the DUP was close to 7 weeks in our cohort so it's still short but not as short as we had in the end of this very intensive period but we aim for getting it down to 4.5 weeks Janula still varies and we have published the DUP through 15, 17 years in an article in schizophrenia research early intervention I think so this is also official policy now to do early intervention this is Benedetto Saratieno who was director for Dragons mental health issues in WHO who points to the advantages of prevention in this aspect and the same there's a WHO consensus statement encouraging people to do early intervention I won't go through that now in detail just point to the fact the same with World Psychiatric Association have made a statement about this so the evidence builds and it's now should be part of how we develop the services and this is preemptive psychiatry it's not preemptive warfare when I have this I'm always thinking about Donald Rumsfeld was that his name who introduced this concept preemptive warfare the man with no regrets DUP is now a national what you say maybe performance measure we call it quality indicator because it's so closely associated or correlated with long-term outcome that it's a result indicator and every county in Norway has to report on their DUP on a regular basis just to see how they perform in that and in Denmark too and it's in some regions in Canada and so on so it's spreading it's an important measure for how we meet young people with serious mental disorders so there will be no early intervention without information and low threshold easy access so I'll give you now some of the long-term outcome results how it's constructed you know now this was the first main result reduction of DUP at baseline it becomes a kind of win-win-win situation because we get the patients earlier the patients get help earlier in the illness development and the stress on them and the families is reduced and they are less ill when they come that's good for the patient and it's good for us as therapists as well it makes the therapy easier and it's good for society because we save a lot of money on this and effort so yeah that's the same in a way we managed to identify and then this is also important very important I would say the two-year outcome did it last for two years these beneficial effects well as you see there are no difference on the positive component and the reason is that the positive symptoms disappear in most of the groups anyway during the first first years but the negative component and this is the important this is the really important thing when it comes to the long-term outcome it increased the differences increased up to two years the same for the depressive component and for the cognitive component so this is the conclusion after two years it's not the final conclusion but you have these lowest levels of cognitive, depressive and negative symptoms it was not explained by confounders we have some very strict statisticians working with us so they don't allow us to do anything that we can't account for and we already then said that maybe we have succeeded in doing a kind of secondary prevention at least up to two years but would this last well once again suicidal behavior was reduced and was almost a 50% difference between the early sites and the later sites and Inge Melle who works with us in Oslo this article was in the American Journal of Psychiatry and in an editorial in the same edition the editor said that this was a kind of paradigm shift in reflect so we were pleased with that of course so five years would it then be the same after five years we did follow up on 73% of the original group what happened was that overall the dropouts were more symptomatic especially in the late detection area and we controlled for all the time we controlled for the consumption so to speak of health service inpatient days outpatient visits and so on and medication user medication and so on and it's the same the treatment is the same between the different sites so you see that the early detection patients had more friends and better scores on the pan's negative scale even at five years five years and treatment lasted for two years so compared with the Opus study in Denmark if you haven't seen that I recommend you to read that they did the same treatment as us but they didn't achieve early intervention and they had good results at two years but it disappeared at five years when they didn't continue the treatment but it didn't disappear here and the only difference between the two projects is that we intervene early and they intervene at one year yeah this was what I just said about the Opus treatment so some conclusions by 2011 just repetition of what I said I guess it is possible to reduce the it is possible to influence the populations help seeking behavior it requires easy access and active outreach the notion that specialists health services should be overwhelmed by referrals if you have this active send us cases attitude that didn't hold at all you still have to drag people into the services it's not like when you open the gates to the psychiatric facility then people are banging on your door you get people younger they are less ill better functioning at three months one year, two year and five years less suicidal I've said that and we find young males with long dupes that's a special challenge so what happened at ten years then just keep this short we hoped of course that this level of symptoms should be lower still and we hoped for a higher level of remission and recovery in the early detection area that would be we thought the final evidence that this was important the sample I think I have a better one on that one as you know now this is the baseline sample and this is these are the main outcome measures that we use your family with those I guess and this is how it developed we managed to find 73 out of 140 at ten years in the not early detection and 101 out of 141 in the early detection sector but we had the biased we had the biased attrition rate with at ten years the best patients best functioning patients disappeared in the early detection sector and the worst patients disappeared or didn't didn't contribute in the non early detection sector so how would that influence our results one could ask well this all ended up and is summarized in an article in American Journal of Psychiatry in April 2012 you I ask you to bear in mind this here so our information campaigns ended up on the front page in American Journal of Psychiatry we were very pleased with that that was a nice gesture and this was the second time actually we were we were written about in an editorial in American Journal of Psychiatry as well in that issue and this long term follow up showed and this is the important figure here that if you come from the early intervention sector that is if you have a medium of four weeks versus 16 weeks that is the only difference four weeks versus 16 weeks then the odds ratio that you should be fully recovered 10 years is 2.5 and the biased attrition rates say that this is an underestimation of the difference how big that is we don't know of course but it's closer to three I would say so this is the main 10 year follow up finding so this is another cake celebrated and this is Inge celebrating 10 year they used to smoke but it's quit now so we got about 15 minutes of fame perhaps was it 10 anyway that passes so what we hope is that this research should have an impact on the service system to the benefit of young persons drifting into a serious could be condition and this is the 50 million Norwegian crew now and this is the cost of one case of chronic psychotic disorder 12 million euros maybe I'm not sure how much but that's what it will cost you in Europe and we hope we have contributed to the more evidence based treatment we hope we contribute to what we call result consciousness in the services that we could answer these two important questions that the patients and relatives ask us what's wrong with my son and what will his future be and I ask you to think of a number what is the remission rate for first episode psychosis within how many of the 100 patients you receive in Los Angeles would be out of the psychotic state within one year what you should expect is at least 70 percent should be in remission the best facilities in Europe they achieve 85 percent remission rate for first episode psychosis within one year we had 67 percent after one year and close to 80 after two years so that is the answer when you go to the psychiatric surgeon you don't say I don't know so tips we have been operating for 20 years and there will be a big international conference in Stalanga with all the major contributors in the field in November Steve will be one of those and yeah and this is also this thinking this dimensional thinking staging is a central part it's a proven ideology in a way in the new guidelines in Norway, in the UK in Australia and in Canada and so on so we have left this category thinking and the category of thinking and there's a conference a world conference on early intervention in Tokyo 17 to 19 November 2014 in the IEPA International Early Psychosis Association that's a good place to be and connect you want to learn more about the tips ideas you go to that homepage and this is what we don't want to do this is where we don't want to be we want to be up there and preventing people from falling into the river of life thank you for your attention time for questions and also stay for wine and cheese and fruit as well yeah I can this is not the treatment research program because the treatment is the kind of constant factor so but what we provide is what we now provide in the national guidelines in Norway, Denmark UK and other countries as the core treatment for first episode psychosis would be some kind of psychotherapy on a regular basis for at least two years that would be CBT in some cases we give that the grade A in our recommendations and we give psychodynamic psychotherapy the grade B you shouldn't go into an acute phase in psychotic phase with psychodynamic psychotherapy but we think there are ample evidence that what you do should be psychodynamically informed and in many cases if the patients want it it should be provided we recommend that was psychotherapy we recommend family work in some cases usually multi-family groups but also single family groups after a certain recede and medication but we stress the fact that you shouldn't over-medicate I think we have over-medicated patients for many decades now you should only give medicine so you don't give them side effects usually it shall go down and especially for young persons you must not mediate so you frighten them away from getting treatment that old in a way so it's a low dose very low dose strategy and that's we think that's evidence based when it comes to prodromal states at risk states we have the only negative recommendation you should not mediate you can mediate on a clinical basis if you see that it's escalating and you have a kind of imminent psychological breakdown so that's a recommendation and then we have recommendations for what we call milieu therapy and we say that these patients should be in milieus wards homes, group homes or whatever that is that are suited for patients with this kind of vulnerability in a way so you shouldn't place these patients in wards with a high level of aggression they need low aggression they need structure and we use a scale called ward atmosphere scale to measure the in wards and home likes and so on and the recommendations say that every unit that handles psychotic patients should do this every second year just to monitor if you have a suitable milieu for your patient and then we I could talk about this music therapy evidence based grade A all these patients those with a more chronic should be given the possibility of music therapy because that has been in a cock grain review and it ended up with a grade A and then you have IPS in the video everything so these are the elements now it's in Norway now there's a lot of projects starting on that because when we did these guidelines we didn't find anything when it comes to psychosis and exercise we found some general articles and research around it so now I know that many places are you into that okay yeah that's good yeah yeah I had to cut down because I have 20 slides on the stigma and how it has developed and so on and it's been a very positive development so I would say there are a kind of negative stigma maybe in 20% of the population and 80% have good attitudes now much better than if you go back 20 years so we do the regular follow up on that and so does the central governmental offices in Norway as well health directorate so it's better but it comes back if you stop this information if you stop it then it comes back so it's a challenge it's not much work I'm serious it is not much work we have one person working with this public relation and all people wanting to do this the work we have done we have taken a lot of what they have done in Australia you are English speaking they have all this in English in Australia in the UK and in Canada for example the only thing you have to do is to do it on a regular basis so it demands a kind of funding we use let's say 100,000 dollars in this marketing every year for a population of 350,000 people something like that we wouldn't use more money if the population was 2 million or something like that that's less than our local store spend on advertising for cheap coke or cheap bread in upcoming weekend it's not a lot of money how often do we in this cohort or whatever I wouldn't know that I'm sorry I don't know that I'm not sure it could be possible to look into that but I wouldn't know that it is of course a risk factor for the population it is that's been proven but we talked about that earlier the habitability it's the same as when it comes to poverty in a way it's transmitted like it's not connected to genes to a high degree like we thought I could have talked about genes also but the relative risk for if you have some mutation on 10,000 alleles that small points on the genes is about 1.2 compared to the normal population and these points on these alleles are the same in schizophrenia and bipolar and that has contributed to strengthen the view that these are dimensions not separate disorders so yeah yeah we don't have exact data for that but these school programs in every high school on a continuous basis so the young people would talk about and it's not particularly aimed at psychosis the topics in these lessons for the for the young people there are more about mental health and anxiety these more common so in the general population there are more awareness of of where to seek help what the mental health problem is some years ago our prime minister he went into a depression and needing clinical attention and he was on a sick leave for a while and when he came back to work and told about this of course that has a major impact among in the population but we don't have exact numbers for it but still there are stigma among young people they will tell us in our focus groups that when we provide these brochures they should be in a small format so they could stick it in the pocket they shouldn't be like big big like this so they show everyone that I am so of course they were all still shame and fear and yeah psychologist she wrote an article in the Norwegian psychological journal about and she looked into the word of schizophrenia used in in papers and so but because there's a double meaning and you turn schizo for that and schizo for various reasons and she has done some of this yeah and it's an important thing to follow well we have something we call schizophrenia days kind of big event the four or five thousand people attending each year and we mix theater art exhibition concerts and we also have a big professional conference attracting twelve hundred thirty hundred people on a regular basis and we have information for the public popular lectures and so on and it's kind of mental health it's serious and it's called the schizophrenia days and some years ago we have different themes every year it's not only about schizophrenia it's about any topic in mental health in a way that we started out with schizophrenia and we thought that's become brand now but we it's a kind of paradox because we want to get rid of the schizophrenia name in psychiatry because it's hundred years old it's outdated it don't describe what what we see so I think all over the world people are looking for better concepts to describe these disorders and also to to a larger extent to focus on the subjective experience and so on so our goal is is to make schizophrenia as you say part of the everyday language so so I'm happy with the news the journalist and so on when they say it's a schizophrenic position and it's it's coming into the daily language could think that that could be stigmatizing but in the end I think it will we will end up with schizophrenia describing just what it is that you have to in a way thoughts or meanings that stands against each other and we have to develop new concepts for our diagnosis in a way that better describes what this is so we are looking for that but haven't found it a Danish psychiatry called his name is Lars Tugel he passed away a year ago he developed a very nice system that he called LTHR LTH3R which should be similar to DSM3R and L was for Lars and TH was for Togo and 3 was that was his third try and R was that was revised anyway he described 12 different states within what we usually call psychosis emphasizing the subjective different subjective experiences so we have to come back to where we were metal disorders are about feelings that are too strong to be handled by the psychological defenses so to speak and if it overwhelms the psychological defenses then you get a kind of electrical breakdown that we call psychosis confusional states yeah that's right I think we are in second place in the world or something like that no it's not bad could be better though so that would be a position but I'm not sure yeah if you read that suicide rate was high yeah yeah yeah we have some drug abuse and we have a very high overdose mortality and how come and of course a rich society I guess we are maybe the richest country in the world the capital besides maybe a small state in the Saudis Arabia or something like that and there's a lot of not a lot of but there still is of course child abuse there's violence in the homes and so on and yeah so you don't eradicate those factors even if a country is rich and the majority is happy so me sometimes it varies