1. Meeting the Needs of Individuals Experiencing Early Psychosis
Lisa Dixon, M.D., M.P.H.
Director , Center for Practice Innovations, NYSPI
Columbia University College of Physicians and Surgeons

2. Ryan 1

3. Outline
OnTrackNY—The big picture
The Rationale
The Model
The Dream

7. Start Small and Build Wisely
Provide technical assistance and training to other sites/agencies seeking to provide care for individuals experiencing early psychosis. Develop network of knowledge and experience
4 demonstration sites of full model to accrue information on feasibility, effectiveness and costs

8. Disease Burden across Age
Australian health study
Incident YLD rates per 1,000 population by age and broad disease grouping

9. Age 13-17 Any=40.3% in 12-Mo Any= 23.4% in 30 days
From: Prevalence, Persistence, and Sociodemographic Correlates of DSM-IV Disorders in the National Comorbidity Survey Replication Adolescent Supplement
Kessler et al Arch Gen Psychiatry. 2012;69(4): doi: /archgenpsychiatry
Age 13-17
Any=40.3% in 12-Mo
Any= 23.4% in 30 days : .

10. MH Prevalence /Service Use Gap greatest for young people
Hi Lisa It is from the Victorian Burden of Disease Study led by Dr Theo Vos Other authors of these studies here were Colin Mathers More recently the Australian Institute of Health and Welfare has published similar data and figures   The NCS Adolescent supplement is highly consistent but cuts off at 18 (Merikangas)   BW Pat 

11. Rationale: Why Early Treatment for Psychosis?
Optimal early treatment provides hope for enhanced recovery
Psychosocial approaches may minimize disability and impact biological changes
Pharmacological approaches may prevent illness progression or reduce side effects
Family and peer support may reduce the trauma of psychosis and promote empowerment

12. A Key Concept: The Duration of Untreated Psychosis (DUP)
Period of time between onset of psychotic symptoms and initiation of appropriate treatment
Two independent meta-analyses provide convincing evidence for an influence of DUP on early-course outcomes (
Two potential mechanisms:
“active morbid process” or neurotoxicity hypothesis
psychosocial “toxicity” of untreated psychosis
Marshall et al., Arch Gen Psych, 2005; Perkins et al., Am J Psych, 2005)

13. Time to Remission by Prior Duration of Psychosis
Cumulative % Responding to Treatment
Studies have confirmed that duration of untreated psychosis is a powerful predictor of course of illness in schizophrenia.
At every point in treatment, the shorter the duration of psychosis, the greater percentage of people who are in remission.
Weeks in Treatment
Loebel et. Al American Journal of Psychiatry Lieberman JA, et al Neuropsychopharmacology Perkins et. al American Journal of Psychiatry

14. Research Proof of Concept: A Study of Early Psychosis Linking the Mind and the Brain
Psychosocial Approaches have been demonstrated to alter brain changes.
CET  significant gray matter preservation
Specific gray matter improvements linked to specific improvements from CET
Eack et al. Archives of General Psychiatry 2010

15. The Challenge Reducing DUP
Providing the Right Treatment at the Right Time

16. Retrospective Reports of Duration of Untreated Psychosis
Wiersma 2000
Amminger 2002**
1 year
Malla 2002
Linszen
Verdoux 2001
Black 2001
Larsen 2000
Hoff 2000
Ho 2000
Drake 2000
Browne 2000
***in NY, we’re averaging about 1 year, and this is without much of a campaign/outreach.
If we wish to treat schizophrenia at its earliest manifestation, exactly how wide is the window of opportunity? Most clinicians first see the patient once symptoms of psychosis have become problematic, but, in many cases, this is not on the same date as when these symptoms initially manifested.
How wide is the typical time gap between the onset of psychotic symptoms and the clinical documentation of psychiatric illness? Exactly how long will the typical patient who is experiencing his or her first episode of schizophrenia remain untreated before being diagnosed?
The graph in this slide, from a review by Perkins, attempts to address this issue. It summarizes the results of 18 separate studies, published between 1992 and 2003, which reported the mean duration of untreated psychosis in first-time patients with schizophrenia. As illustrated here, a year 2000 study by Wiersma (second bar from the top) showed the shortest mean duration (approximately 12 weeks). In comparison, a 1996 study by Szymanski (second bar from the bottom) suggested that untreated psychosis had been present for over 160 weeks, or more than 3 years.
In general, however, the bulk of the evidence points to a middle ground of approximately 1 year. That is, the typical patient with schizophrenia probably experiences psychotic symptoms for approximately 1 year before diagnosis.
References: Perkins DO. Evaluating and treating the prodromal stage of schizophrenia. Curr Psychiatry Rep. 2004;6:
Barnes 2000
Robinson 1999*
McGorry 1996**
Larsen 1996
Szymanski 1996
Loebel 1992* 10 20 30 40 50 60 70 80 90
100
110
120
130
140
150
160
170
180
Weeks
Perkins DO. Curr Psychiatry Rep. 2004;6: [Courtesy of Diana O. Perkins, MD, MPH. University of North Carolina at Chapel Hill.]

17. Treatment for First Episode Schizophrenia
Multi-element treatments Dominant (CBT, Social Skills Training, Family Psychoeducation, Medication, IPS)
OPUS (symptoms, substance abuse, satisfaction)
Lambeth Early Onset (LEO)(readmissions)
Grawe et al. (2006)-Norway (“excellent” outcome (composite)
Guo et al. (2010)-China(multiple outcomes)
Single-element treatments (Less evidence)
Family psychoeducation
Cognitive Behavioral Therapy

18. Summary of Studies of Supported Employment for
Individuals with First Episode Psychosis
% in Work or School
Note the importance of a focus both on education and employment
Rinaldi et al. First episode psychosis and employment: A review. Int Rev of Psych 2010

19. For how long is “early intervention” treatment needed?
Over how long does benefit accrue?
COMMENT
No difference in 5 year as compared to 2 year clinical outcomes
However still underpowered to detect moderate rather than large effects
Social benefits maintained eg independent living and hospital readmission rates
This study (the OPUS trial) is the largest
randomized clinical trial comparing the intensive early-intervention program (OPUS) with standard
treatment (community mental health centers) for patients
experiencing their first episode of psychosis8 and the
first to report outcome after 5 years of follow-up. The intensive
early-intervention program consisted of ACT, psychoeducational
family treatment, and social skills training.
The experimental treatment was carried out for 2 years.
The intensive early-intervention program has shown significant
positive effects on psychotic and negative symptoms,
secondary substance abuse, treatment adherence, success
with lower dosages of antipsychotic medication, and
a higher satisfaction with treatment after 2 years of treatment. 4

22. a specialized model of early psychosis intervention with timely and assured care during the early illness period produces better longer term clinical and functional outcomes at one third of the cost of standard adult mental health services
Specialized programmes delivering timely and assured care during the early illness period give better clinical and functional outcomes at a third of the cost of standard public mental health services
Investment in early intervention programmes provides excellent value for money and should be considered as an additional stream of care within the specialist mental health services…

23. 8-Year Follow of Early EPPIC Cohort (N=32) Compared to Concurrent Historical Controls (N=33)
Individuals in EPPIC had
lower levels of positive psychotic symptoms (P = .007),
were more likely to be in remission (P = .008)
had a more favorable course of illness (P = .011)
Fifty-six percent of the EPPIC cohort were in paid employment over the last 2 years compared with 33% of controls (P = .083).
Schizophr Bull Sep;35(5): Epub 2009 Jun 9.
Is early intervention in psychosis cost-effective over the long term?
Mihalopoulos C, Harris M, Henry L, Harrigan S, McGorry P.

24. Bootstrap Simulation Results on a Cost-Effectiveness Plane.
Mihalopoulos C et al. Schizophr Bull 2009;35:
© The Author Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please

25. Early intervention did not increase costs and was highly likely to be cost- effective when compared with standard care.

27. Greater recovery and employment at 10 years in experimental condition

29. Governing Principles
Disability: Limiting disability is the central focus; disability influenced by treatment and environment
Recovery: Core value of empowerment and a personal journey in which the individual acquires the skills and personalized supports necessary to optimize recovery
Shared decision-making: Shared decision-making facilitates recovery and provides a framework within which the preferences of consumers can be integrated with provider recommendations for available treatments

30. OnTrackNY: Overview Multi-disciplinary team
Multi-element (e.g., psychiatric care and medications, case management, supported education/ employment, skills and substance abuse treatment, family support, suicide prevention)
Individualized approach
Developmentally flexible 30

31. OnTrackNY: Overview Grounded in Critical Time Intervention model
Most services provided in office, but capable of community outreach
Provide in youth-friendly space
Caseload individuals

32. Team Composition FT Team Leader (Master’s-level clinician)
FT Supported employment/supported education specialist
FT Clinician for Outreach/Enrollment and Recovery Coach (self-management, substance abuse, family)
.30 Psychiatrist
0.20 Nurse 32

33. Connection Team Interventions
Sshare
Peer Support
Evidence-based
Pharmacological
Treatment
Supported
Employment/Education
Outreach/
Engagement
Recovery
Recovery Skills
(SUD, Social Skills, FPE)
Family Support/
Education
Suicide Prevention
Shared Decision Making

34. Team Leader Clinical Leadership Administrative Leadership
Initial Engagement and Outreach
Direct Ongoing Emotional and Practical Support
Care Management
Psychotherapy
Working with Families
Administrative Leadership
Coordinating Referral and Intake
Coordinating Treatment Planning Process and Activities (Safety, Wellness, and Transition Plans)
Coordinating and Supervising Activities of Team Members

35. Supported Employment and Education: IPS
Completely integrated in team function
Working with family and supports
Balance and align work and school goals
Competitive Employment
Systematic job development
Rapid individualized job search based on client preference
Ongoing job supports
Education
Direct contact with teachers, principals, administrators
Help with financial aide

36. Supported Employment and Education: IPS
Wide range of employment from Wall Street to Main Street
School participation included high school, technical school and college
Part time and full time education and employment observed
Younger population with limited work experience and training
Shorter term jobs, internships normative

37. Recovery Coach Types of sessions Individual, group, family ed
Content of sessions
Introductory, planning, coaching/training, supportive
Types of strategies
Social skills training, coping skills training, substance abuse treatment, re-engaging with the community, psycho-education
Location of session
Office/clinic, home, community

38. Recovery Coach Social Skills Training Coping Skills Training
Communication skills (“Social Networking”)
Friendship and dating skills (“Relating and Dating”)
Assertiveness skills (“Expressing Yourself”)
Conflict management skills (“Keeping Cool”)
Coping Skills Training
Anxiety, stress, depression
Substance Abuse Treatment
Heavy Use/Episodic Use/Substance Abuse
Substance Dependence
Re-engaging with the community
Pleasant activities, activities with other people
Psycho-education
As needed around topics of interest to consumer, monthly family meetings

39. Psychopharmacologic Treatment
Medication decisions guided by principles of shared decision making. Not all patients choose to take medication.
Antipsychotic medication as first line treatment
Use of evidence-based algorithm that accounts for variability in therapeutic response, side effect sensitivity, adherence, diagnostic uncertainty
Add mood stabilizers or antidepressants if mood symptoms to do not resolve with antipsychotics

40. Medication strategies to promote functional recovery
New evidence suggests that minimizing antipsychotic load during the recovery phase allows for optimal functional recovery, despite the increased risk of relapse
128 FEP patients
dose reduction/discontinuation
maintenance medication
relapse rate
21%
43%
functional recovery
18%
40%
Baseline
18 months
7 years
Wunderink et al., JAMA Psychiatry, in press

41. KEY MESSAGES
Positive symptom control is a desirable means to an end, but must not be the sole or dominant target or goal of care
If becomes the sole target then outcomes can be worse not better
Other outcomes crucial and must have serious interventions to target them: “F words”
Functioning: Vocational Intervention
Fulfillment: Positive Psychology
Financial: Work and financial planning
Fun: Positive Psychology
Family: Peer support
Fysical health: Preventive medical care
Focus on other syndromes esp anxiety, depression, PTSD, SUD and PD: Specialised interventions
Maximum personal choice also crucial

42. Conclusions
Providing effective early treatment is an imperative, not just an option
Need to consider communication, outreach, and pathways to referral
Treatment requires rethinking of our current treatment structure and components, but models exist
OnTrackNY will provide model and work to assist local efforts in creating evidence-based approaches to this important challenge

43. “The future ain’t what it used to be”
The Dream
Youth Mental Health: An International Field
Early Intervention: A Fundamental Feature of Mental Health Care
“The future ain’t what it used to be”
Yogi Berra