COMMENTARY

Saving Lives Through Early Psychosis Care

Drew Ramsey, MD; Lisa B. Dixon, MD MPH

Disclosures

September 12, 2019

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Drew Ramsey, MD: Welcome back. I'm Dr Drew Ramsey for Medscape and Columbia Psychiatry. Today we are here to talk about first-episode psychosis and effective interventions with Dr Lisa Dixon, a professor of psychiatry in our department. She heads up the OnTrackNY program and is the director of the Center for Practice Innovations. Dr Dixon, it's a pleasure to have you here with us.

Lisa B. Dixon, MD, MPH: Thanks. I'm glad to be here.

'Time of Hope' for First-Episode Psychosis

Ramsey: Let's start out by talking about first-episode psychosis. As a clinician and researcher, what should our colleagues in psychiatry think about in terms of how to be most effective?

Dixon: We're in a new world right now in schizophrenia care. When I was trained and, frankly, when my brother got sick with schizophrenia, there was not much in the way of hope. It was an illness where in some ways you were sentenced to a lifetime of disability. Because of developments in science, advocacy, and policy, it is exciting because we are living in a time of hope where we can deliver evidence-based approaches for young people who are early in the development of illnesses like schizophrenia.

We know we need to do two things. We need to get people treatment as early as possible after the onset of psychosis. We have to reduce the duration of untreated psychosis.

Ramsey: So often we meet a young individual and they are struggling with the reality testing or with some psychotic symptoms. It feels, as clinicians, that sometimes we're hesitant to say that word "psychosis" because it's not going to be a diagnosis that's filled with hope.

Dixon: Part of our job right now is to change that, to change the air, the ethos [around that]. We have to help people understand that people can live fulfilled lives. Of course we should always be careful before making any diagnosis or labeling any symptom. But we also need to recognize that if we leave psychotic symptoms untreated for an extended length of time, it could actually cause people to have a worse prognosis over time. There is a very robust association between duration of untreated psychosis and outcome; the longer the duration of untreated psychosis, the worse the short-term and long-term outcome. Not treating people could have a long-term impact. We have to do it right and we have to do it carefully. But we have to do it.

Interventions for Psychosis

Ramsey: Tell us about treating it right. When thinking about psychotic illnesses, medications are the first thing that usually pops into psychiatrists' heads. But that's just one piece of the type of intervention that you have evidence for.

Dixon: Right. What I'm going to be summarizing very briefly is the work of many investigators and the contribution of many people with schizophrenia and their families all over the world. This has been worked on in Australia, the United Kingdom, Canada, and the United States.

What do we know? We know that if we provide something that we in the United States call "coordinated specialty care," people do better. What is coordinated specialty care? It's a multi-element, team-based intervention. Of course, as psychiatrists, we start with medication. That is a critical part of the treatment. Prescribe the lowest effective dose of antipsychotic medications. And as psychiatrists and medical people, we need to watch overall health. These individuals come to us and they already have the beginnings of problems with metabolic issues and smoking, etc. But it is insufficient to do medication only; we have to work as a team with other clinicians and other providers.

What are the other elements? Again, this is evidence-based. We have individual cognitive-behaviorally oriented therapy to help people cope with what has happened to them, develop coping skills, address the trauma, and consider how they think about themselves—psychotherapy. We have family support and education. Families are the ones that often bring people to care. They are the ones who have noticed the problems and are supporting the individuals. Families need support. I can tell you from firsthand experience that it's a terrifying thing to happen to a family. Most people don't know what this is or what it's about. We provide case management. Sometimes people need help with their day-to-day lives, particularly if they are poor or don't have access to good housing, etc. We have individual therapy, family support and education, and case management.

Last, but certainly not least, is something that we call "supported employment and education." Someone works with the individual to help them stay in school if they are in school, stay in work if they are working, to the best of their ability. It may mean that someone taking a full course load in college maybe takes a few less courses. This support around employment isn't just blind to the issues and challenges and the heartbreak of sometimes dealing with psychosis. But we know that with the proper kinds of employment and education supports, people can stay on track.

That is why we gave OnTrackNY its name. We have to deal with substance use issues, we have to deal with suicide prevention. But the bottom line is, no one of these treatments, no one of these components is more important than the other. We have to deliver the package, and we do it using shared decision-making. Individuals can work with the clinical teams and sort of figure out [what they are capable of doing at that time.] For example, they may say, "I don't think I can do the supported employment education today, but maybe next month."

All of these treatments are offered, and then there is dialogue and conversation to try to help engage people. The most important thing when providing care to young people with early psychosis, and their families, is engaging them. When this happens, people often don't know what it is; they don't recognize it and they have no experience with it. They don't wake up saying, "I think I better go see a psychiatrist." That is not how it happens at all.

We have to go to where the person is psychologically, emotionally, and sometimes actually physically and make treatment something that they actually want. Again, we do that by listening, empowering, trying to help understand, and trying to provide care for the problem that the person thinks they have. They may not think they have a problem with psychosis or schizophrenia. They may think that their most pressing issue is that they are having a problem with their girlfriend, or they are not doing as well in school. We need to try to offer this package of services, but the dialogue has to be engaging, delivered, and offered in the context of how the person defines the problem. We have to listen.

Resources for Providers

Ramsey: You mentioned that programs like OnTrackNY now exist around the country. For clinicians who are interested or want to do a more robust job of offering a multimodal set of services, how can they access some of this information, and is funding available?

Dixon: As a result of all of these players and participants in this new movement coming together (eg, researchers, advocates, and government), the federal government added money to the community mental health block grant for every state. Every state has additional new money that needs to be used to provide evidence-based early psychosis services. So, for all of the psychiatrists listening from whatever state they are in, a first-episode psychosis program or approach is being developed now. Different states are at different phases of development. We've tried to make this available throughout New York State.

Ramsey: Can you share a little bit about that experience? Because we have watched your program ramp up over just a few years. Last I heard, you are reaching thousands of families across the entire state. How did you do that so quickly?

Dixon: We did it with the support of the Office of Mental Health and New York State city counties. Money that came through the block grant, as well as additional state dollars, were put into building programs in different communities.

My group at OnTrack Central is tasked with providing training and ongoing monitoring so that the program is delivered in an evidence-based way. This program is staffed by clinicians, psychiatrists, social workers, and psychologists. Now we have peers on each team in different communities throughout the state. Everybody delivering these services loves it. It's so rewarding, because you see people recovering to some extent before your eyes. Obviously, there is a heterogeneous response to this intervention—not everybody gets well. It's so satisfying when you see someone who was struggling and in pain who, 3 months later, is going to the prom or graduating from high school or college. It teaches the clinicians that we can do this with our patients and their families. We can do this.

Ramsey: Peer support is such a great commonsense way to help engage patients, and it strikes me that it gives an opportunity for patients who get into recovery from their psychotic illnesses to potentially give back and help.

Dixon: The promise and opportunities afforded by having peers on the team is something that we are even just now beginning to realize. Certainly, for many individuals, the opportunity to talk to somebody who has been through it, who can tell them how they coped, and can reflect a little bit on their experience is especially valuable in early psychosis care. We know that this is not just in first episode but throughout the treatment system.

Ramsey: We've talked about early psychosis and the ways clinicians can do a better job. Intervene early and get help in developing or engaging in multimodal systems of care that provide a real robust set of wraparound services. It sounds like there is more funding for this than there ever has been. There are certainly breakthroughs happening in psychosis and schizophrenia research, but there has been another breakthrough in terms of the services and the coordination of services that can be employed by psychiatrists to get their patients fully into recovery.

Dixon: If you Google "early psychosis program" and whatever state you live in, I guarantee that something will come up that you can use to make a referral and learn what is happening in your own community.

Ramsey: Thank you, everyone, for joining us. If you have questions about coordinated care, go to Google or check out the Center for Practice Innovation, Twitter, or the great journal that Dr Dixon is the editor of, Psychiatric Services. She is a great person to keep track of if you take care of this patient population.

I'm Dr Drew Ramsey for Medscape and Columbia Psychiatry. We'll see you soon.

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