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Lisa Dixon, M.D., M.P.H. Director, Center for Practice Innovations, NYSPI Columbia University College of Physicians and Surgeons Slide 2 Ryan 1 Slide 3 Outline OnTrackNYThe big picture The Rationale The Model The Dream Slide 4 Slide 5 Slide 6 Slide 7 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 Slide 8 Disease Burden across Age Slide 9 . 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 : Any=40.3% in 12-Mo Any= 23.4% in 30 days Any=40.3% in 12-Mo Any= 23.4% in 30 days Age 13-17 Slide 10 MH Prevalence /Service Use Gap greatest for young people Prevalence Service Use Slide 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 Slide 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) Slide 13 Loebel et. Al. 1992 American Journal of Psychiatry Lieberman JA, et al. 1996 Neuropsychopharmacology Perkins et. al. 2005 American Journal of Psychiatry Time to Remission by Prior Duration of Psychosis Weeks in Treatment Cumulative % Responding to Treatment Slide 14 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 Slide 15 The Challenge Reducing DUP Providing the Right Treatment at the Right Time Slide 16 Retrospective Reports of Duration of Untreated Psychosis Perkins DO. Curr Psychiatry Rep. 2004;6:285-295. [Courtesy of Diana O. Perkins, MD, MPH. University of North Carolina at Chapel Hill.] Loebel 1992* Szymanski 1996 Larsen 1996 McGorry 1996** Robinson 1999* Barnes 2000 Browne 2000 Drake 2000 Ho 2000 Hoff 2000 Larsen 2000 Black 2001 Verdoux 2001 Linszen Malla 2002 Amminger 2002** Wiersma 2000 Ho 2003 Weeks 0 102020 3030 4040 5050 6060 7070 8080 9090 10 0 11 0 12 0 13 0 14 0 15 0 16 0 17 0 18 0 1 year Slide 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 Slide 18 Rinaldi et al. First episode psychosis and employment: A review. Int Rev of Psych 2010 Summary of Studies of Supported Employment for Individuals with First Episode Psychosis % in Work or School Slide 19 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 For how long is early intervention treatment needed? Over how long does benefit accrue? Slide 20 Slide 21 Slide 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 Slide 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). Slide 24 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: journals.permissions@oxfordjournals.org. Slide 25 Early intervention did not increase costs and was highly likely to be cost- effective when compared with standard care. Slide 26 Slide 27 Greater recovery and employment at 10 years in experimental condition Slide 28 Slide 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 Slide 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 Slide 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 25-30 individuals Slide 32 Team Composition FT Team Leader (Masters-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 Slide 33 Sshare Connection Team Interventions Recovery Supported Employment/Education Family Support/ Education Evidence-based Pharmacological Treatment Suicide Prevention Recovery Skills (SUD, Social Skills, FPE) Peer Support Outreach/ Engagement Shared Decision Making Slide 34 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 Slide 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 Slide 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 Slide 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 Slide 38 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 Slide 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 Slide 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% Baseline18 months7 years Wunderink et al., JAMA Psychiatry, in press Slide 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 Slide 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 Slide 43 Youth Mental Health: An International Field Early Intervention: A Fundamental Feature of Mental Health Care The future aint what it used to be Yogi Berra