Pioneering Coordinated Specialty Care Programs for First-Episode Psychosis

Coordinated Specialty Care (CSC) is a collaborative, team-based, recovery-oriented approach to the treatment of first-episode psychosis (FEP) which integrates medical, psychosocial and rehabilitative elements that strive to improve functional and clinical outcomes, particularly for those with a shorter duration of untreated psychosis (DUP).^1,2

Strategies for implementing CSC in community clinics in the United States³ have enabled its adoption in 37 States, with over 130 clinics offering evidence-based care for FEP.⁴

Scaling up OnTrackNY CSC in New York

The omission of the word “psychosis” is deliberate to encourage engagement

Lisa Dixon, Professor of Psychiatry at the Columbia University Medical Center, NY, leads OnTrackNY, which was set up 5 years ago.

OnTrackNY describes itself as an innovative treatment program for individuals who have had unusual thoughts and behaviors, or who have started hearing or seeing things that others don’t.⁵

The omission of ‘psychosis’ in the description is deliberate to avoid stigmatization and encourage engagement, said Professor Dixon.

Eligibility is limited to individuals within 2 years of onset of FEP, and they are discharged after 2 years. However, one size does not fit all, and some participants would benefit from intervention for more than 2 years, said Professor Dixon.

Over the 2-year intervention period, the rate of hospitalization decreases and the percentage of individuals in work or at school increases to 70%

As a result of its success – monitoring and measurements show that over the 2-year intervention period, the rate of hospitalization decreases and the percentage of individuals in work or at school increases to 70% – OnTrackNY has been scaled up throughout New York; and Professor Dixon explained that it was important to “begin with the end in mind.”

Thirteen programs are now in place, and over 1007 participants with a mean age of 21 years had enrolled to March 2018 – 73% were male, 83% lived with family, 6% were homeless, and average time since onset of psychosis was 7.7 months.

Challenges in scaling up have included setting up the outreach initiatives, changes in the service context, finance, staff turnover, and non-performing programs, which have been closed.

Potential for use of online and social media in CSC

Patterns and variables associated with mental health can be identified using machine learning

Michael L. Birnbaum, Program Director, Early Treatment Program (ETP), Zucker Hillside Hospital, Queens, NY, described his work to identify and engage those with early psychosis effectively and ethically using the Internet and a social media platform.

He explained that social media status updates reveal symptoms of depression and predict later binge drinking, and that changes in social media activity can signal the onset of a depressive episode. Psychotic relapses are associated with significant linguistic shifts, with increased swearing, use of the first-person pronoun and negative content.

Social media status updates reveal symptoms of depression and predict later binge drinking, and that changes in social media activity can signal the onset of a depressive episode

Patterns and variables associated with mental health can be identified using machine learning, Professor Birnbaum said. Based on language data, a computer can differentiate:

• individuals with psychosis from healthy controls with 80% accuracy
• individuals with psychosis from individuals with depression with 70% accuracy

Research is ongoing as Professor Birnbaum and his team continue to learn more about their online participants.

Media, outreach and rapid-access approaches are feasible

Vinod Srihari, Director of the STEP (Specialized Treatment Early in Psychosis) Program, Connecticut Mental Health Center, New Haven, CT, told the audience that STEP’s interim results for lowering DUP are promising.

STEP includes an early psychosis clinic, and is involved in research, training, and mental health policy initiatives. It hosts the MindMap public education campaign.⁶

Analysis of features of the STEP program shows that media, outreach and rapid-access approaches are feasible additions to CSC, Dr Srihari said. Outreach is a key component for engagement, traditional media remains an important communication channel, and digital media initiatives show promising results.

Integrating a computerized decision support system to optimize medication

Delbert Robinson, Professor of Molecular Medicine and Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, NY, has analyzed the use of a secure, web-based, computerized decision support system (COMPASS) to help guide individualized treatment. It was developed for the NIMH RAISE-ETP (Recovery After an Initial Schizophrenia Episode Early Treatment Program) for the NAVIGATE trial.*¹

COMPASS was acceptable for participants and enables optimization of medication for individuals with FEP, he said.

Future strategies for CSC

It is never too late for early intervention, and progress is being made

Patrick McGorry, Professor of Youth Mental Health, University of Melbourne, Australia set up the pioneering Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia in the 1990s.

Professor McGorry explained that mental health reform is taking place worldwide – in Canada, US, UK, Ireland, France, Denmark, The Netherlands, Israel, Australia, New Zealand – and that it is now time to develop CSC further by:

• Widening the channel to mental health interventions for clinical high risk syndrome for psychosis to delay onset and ameliorate impact
• Reducing DUP to weeks
• Identifying early treatment resistance
• Providing comprehensive holistic care to address physical health, sexual health, substance abuse, and include family and vocational interventions
• Extending care to 5 years for a significant subgroup
• Augmenting care online using a social media-based interactive mental health recovery platform such as MOST (moderated online social therapy)⁷

Professor McGorry added that challenges to implementing these improvements include devolved commissioning, poor model fidelity, weak and patchy financial models, pressure to diffuse the model across lifespan and the diagnostic spectrum, professional resistance to key evidence-based elements, and mobilizing political will.

It is never too late for early intervention, he said, and progress is being made.

*For further information about the RAISE study, click here