First Episode Psychosis: A Review of NIMH’S White Paper

The National Institute of Mental Health’s White Paper on evidenced-based programs for first episode psychosis (FEP) suggests treatments which are not currently in place in Western Kentucky.  At the time of this article review, twenty states currently have evidence based FEP programs, but Kentucky is not one of them.  The Recovery After an Initial Schizophrenia Episode program (RAISE) is an NIMH initiative to investigate early community treatment of FEP, and the RAISE paper discusses an evidence-based model for treatment of FEP that might be beneficial for the State of Kentucky to adopt.

States implementing evidence-based FEP programs provide services that are driven by treatment teams and specific to the developmental tasks of young adulthood. Since a majority of patients experience their first episode of psychosis (FEP) between 15-25 years old, programs are targeted toward teen and early adult populations. Within these evidence-based models, research notes that patients experiencing FEP are in the process of acquiring the social, relational, academic, and vocational skills upon which the rest of their adult life may be built upon—so disruption in this normal developmental process can be catastrophic. The lack of development in these vital areas then contributes to accumulated disability for people with psychotic disorders. The work of other states and countries has provided two decades of research to draw upon guiding program development in the United States This research strongly supports early intervention’s ability to stop the accumulated disability in young people who develop psychotic disorders.

Coordinated Specialty Care (CSC) is the model that has been implemented in other countries and in some areas of the United States. CSC has the potential to mitigate and possibly even stop the damage caused by psychotic disorders. Some elements of the CSC framework exist in Western Kentucky, making the development and implementation of a CSC program a reasonable goal. Other RAISE programs have been embedded into existing healthcare services. CSC resembles the Assertive Community Treatment (ACT) model in some ways but very much differs in others. The presence of ACT teams and community mental health centers may be a starting framework for CSC.

Additional components of CSC include assertive case management, Individual Resiliency Training (IRT) model based psychotherapy, family education and support, supported employment and education services, and low doses of select antipsychotics. CSC emphasizes a youth driven structure, a relationship with a primary staff member, and small caseloads for staff. CSC is a team driven approach involving the patient and family members. Collaborative treatment planning helps to increase compliance with treatment.  CSC emphasizes shared decision-making and a therapeutic alliances with patients in order to maintain engagement in the program over time.  One CSC staff member is always identified as the patient’s principal care manager.

CSC strives to bridge the gap between hospitalization and engagement in outpatient services. Referred individuals may be interviewed for eligibility while hospitalized and ‘in reach’ services provided.  This gives patients a chance to form an alliance with CSC staff prior to discharge. The CSC program then contacts the patient no less than 7 days after discharge to begin program entry. Since there is heavy emphasis on a person-centered, therapeutic alliance approach, primary clinicians should be a first point of contact. Research supports care of up to 5 years post-onset of FEP in order to maintain gains made in treatment. Maintaining engagement over a 5 year period requires a strong collaborative alliance with patients and families.  CSC programs should engage in strong outreach activities to schools, emergency rooms, jails and police departments, youth care agencies and any agency in their catchment area having contact with youth.  The outreach program must have expertise in relationship formation in order to maintain collaborative relationships with other community agencies and bridge the gaps in care for FEP.

The youth driven structure of CSC means that all aspects of the program need to be tailored to adolescents and young adults.  Reception and treatment areas of clinics should be decorated with youth in mind. Some CSC programs have separate waiting areas within existing healthcare clinics to facilitate a comprehensive youth-centered environment. Trends for adolescent and youth populations change more quickly than adult populations, and this should be taken into account when creating the clinic environment. Reception staff should be trained in dealing with youth and their families. Experienced mental health clinic receptionists may have more experience assisting adults with chronic mental illness versus youth experiencing FEP. CSC staff must be highly motivated to work with the complexities of FEP youth and their families. Flexibility is an absolute must. Weekend and evening appointments are necessary with this population in order to accommodate and encourage work and academic schedules. FEP peers who can help direct the youth friendliness of the clinic may provide valuable insight to clinic staff.

CSC provides a comprehensive, evidence based model of FEP treatment. Western Kentucky could benefit greatly from such a program serving youth. CSC programs are likely to decrease the cost of utilization of other community resources including state psychiatric hospitals, medical facilities and criminal justice resources. Infrastructure within current community mental health exists making development and implementation of CSC  feasible.

http://www.nimh.nih.gov/health/topics/schizophrenia/raise/nimh-white-paper-csc-for-fep_147096.pdf

Rain Blohm, MS
WKPIC Doctoral Intern