Lisa Dixon, M.D., M.P.H. Director , Center for Practice Innovations, NYSPI Columbia University College of Physicians and Surgeons  Ryan 1 Outline OnTrackNY—The big picture The Rationale The Model The Dream Start Small and Build Wisely  4 demonstration sites of full model to accrue information on feasibility, effectiveness and costs  Provide technical assistance and training to other sites/agencies seeking to provide care for individuals experiencing early psychosis. Develop network of knowledge and experience Disease Burden across Age 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):372-380. doi:10.1001/archgenpsychiatry.2011.160 Age 13-17 Any=40.3% in 12-Mo Any= 23.4% in 30 days : . MH Prevalence /Service Use Gap greatest for young people 30 Prevalence Percent 25 Service Use 20 15 10 5 0 16-24 25-34 35-44 45-54 Age 55-64 65-74 75-85 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 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) Cumulative % Responding to Treatment Time to Remission by Prior Duration of Psychosis Weeks in Treatment Loebel et. Al. 1992 American Journal of Psychiatry Lieberman JA, et al. 1996 Neuropsychopharmacology Perkins et. al. 2005 American Journal of Psychiatry Research Proof of Concept: A Study of Early Psychosis Linking the Mind and the Brain CET  significant gray matter preservation Specific gray matter improvements linked to specific improvements from CET Eack et al. Archives of General Psychiatry 2010 The Challenge Reducing DUP Providing the Right Treatment at the Right Time Retrospective Reports of Duration of Untreated Psychosis Ho 2003 Wiersma 2000 Amminger 2002** Malla 2002 Linszen 1 year Verdoux 2001 Black 2001 Larsen 2000 Hoff 2000 Ho 2000 Drake 2000 Browne 2000 Barnes 2000 Robinson 1999* McGorry 1996** Larsen 1996 Szymanski 1996 Loebel 1992* 0 10 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Weeks Perkins DO. Curr Psychiatry Rep. 2004;6:285-295. [Courtesy of Diana O. Perkins, MD, MPH. University of North Carolina at Chapel Hill.] 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 % in Work or School Summary of Studies of Supported Employment for Individuals with First Episode Psychosis Rinaldi et al. First episode psychosis and employment: A review. Int Rev of Psych 2010 For how long is “early intervention” treatment needed? Over how long does benefit accrue? 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). Bootstrap Simulation Results on a Cost-Effectiveness Plane. Mihalopoulos C et al. Schizophr Bull 2009;35:909-918 © The Author 2009. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: [email protected]. Greater recovery and employment at 10 years in experimental condition 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 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 OnTrackNY: Overview  Grounded in Critical Time Intervention model  Most services provided in office, but capable of community outreach  Provide in youth-friendly space  Caseload 25-30 individuals 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 Connection Team Interventions Evidence-based Pharmacological Treatment Peer Support Supported Employment/Education Outreach/ Engagement Recovery Skills (SUD, Social Skills, FPE) Sshare Family Support/ Education Suicide Prevention Shared Decision Making Recovery Team Leader  Clinical 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 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 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 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 Recovery Coach  Social 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 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 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 maintenance medication relapse rate functional recovery 21% 18% 43% 40% 128 FEP patients dose reduction/discontinuation Baseline 18 months 7 years Wunderink et al., JAMA Psychiatry, in press 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        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 • • 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