Implementing Coordinated Specialty Care for Early Psychosis: The RAISE Connection Program

Connection Learning Healthcare System Hub of the Early Psychosis Intervention Network: Program and Participant Characteristics

AIM

Connection Learning Healthcare System, one of the eight hubs of the National Institute of Mental Health funded Early Psychosis Intervention Network, supports uniform data collection, analysis, feedback and infrastructure development to promote a culture of continuous quality improvement across 25 Coordinated Specialty Care programs serving young people experiencing first episode psychosis and their families in Maryland and Pennsylvania. This first report describes the hub and its constituent programs, the approach for developing and implementing a hub-wide core assessment battery harmonised with the national battery, and preliminary program and participant characteristics.

METHODS

Our hub developed and implemented a computerised core assessment battery, administered every 6 months and developed an integrated system for managing and analysing data.

RESULTS

Between 1 January 2021 and 27 November 2023, 1059 participants were newly admitted to a hub program. The entire cohort (N = 1381) included newly admitted participants and those already in a program as of 1 January 2021. A total of 1245 complete assessment batteries were collected across all time points from 797 participants, with an additional 1920 partially completed batteries collected from 1319 participants. Data are uploaded to the National Data Coordinating Center, where our hub is the third largest data contributor. Descriptive information on programs and participants is provided.

CONCLUSIONS

As part of our learning healthcare system to improve clinical services and outcomes across two states, we have successfully implemented a standardised, computerised core assessment battery of essential characteristics and clinical outcomes. Successes, challenges and recommendations for data collection are provided. This paper will serve as a vital methodological resource for users of the unprecedented Early Psychosis Intervention Network national research database seeking to accelerate and improve early psychosis research.

Forging a learning health system for early psychosis: Insights from the academic community EPINET

Psychosis can lead to deleterious outcomes with multifaceted personal and societal costs, but the provision of intervention services early in the illness course positively influences disease trajectory. There has been a growing emphasis on innovation and expansion of first episode services (FES). Yet, such care has not universally delivered on the promise of meeting the needs of individuals with first-episode psychosis. The Academic Community Early Psychosis Intervention Network (AC-EPINET) is one of eight regional hubs envisioned by NIH to function as a learning healthcare system (LHS) to advance the quality of early intervention care. AC-EPINET spans three geographically distinct areas of the U.S. (Midwest: Indiana, Michigan, Ohio; Southeastern: Tennessee, Louisiana; and Northeastern: Connecticut, New York) with six academically oriented, community-facing FES' and an informatics site. Our goals were to strengthen existing services, expand them to collect common data elements within clinical workflows, leverage informatics, support practice-based research, and engage stakeholders to ultimately build a culture of continuous learning and quality improvement. We designed and implemented an infrastructure consisting of a centralized two-site administrative team supporting an inclusive steering committee, three work groups, and the six clinical sites. Common data capture at enrollment and consecutive six-month intervals was integrated into clinical workflows. An informatics workflow that included evidence-based benchmarked outcome visualization, for each site and across the entire network, was designed and deployed to enable shared learning and ongoing quality improvement efforts. Design and implementation lessons presented are relevant to LHS development and dissemination of FES quality improvement and research efforts.

Understanding Capacity to Treat First Episode Psychosis with a Hybrid Telemental Health Delivery Model: A Needs Assessment of Ohio Community Mental Health Centers

Coordinated specialty care (CSC) is considered the gold-standard treatment for individuals experiencing first episode psychosis (FEP). However, CSC teams are resource-intensive, motivating the development of a hybrid delivery approach where community mental health centers (CMHCs) collaborate with an academic medical center to deliver a mix of in-person and virtual services. To inform the development of this hybrid approach, a needs assessment was conducted, evaluating the existing capacity of Ohio CMHCs to treat FEP and identifying barriers to expanded use of telemental health. CMHC administrators throughout Ohio whose agencies primarily provide mental health services were surveyed using a novel instrument. A concurrent mixed methods approach combined multivariable analysis of cross-sectional survey data with thematic coding of responses to open-ended questions. The 56 responding CMHCs on average offered 10.96 of 17 services associated with CSC for FEP. Agency size was positively associated with number of service offerings, but rurality was not. Most agencies perceived gaps in their care for patients with FEP, particularly rural CMHCs. 75% believed that telemental health service expansion would benefit patients. Thematic analysis revealed three success factors for expanded telemental health usage: adapting care to virtual assessment, ensuring patient access, and adjusting workflows for virtual delivery. Responding CMHCs generally agreed that care for individuals with FEP could be improved and saw potential in expanded use of virtual services. Hybrid models may represent a valuable opportunity to overcome conventional barriers to CSC availability, but their development must account for current CMHC resource infrastructure and workflows.

Implementing a rapid-learning health system in early intervention services for psychosis: qualitative evaluation of its feasibility and acceptability

BACKGROUND

Heterogeneity in implementing essential evidence-based early intervention for psychosis services (EIS) components persists despite existing fidelity standards/guidelines in many countries. Rapid-learning health systems (RLHS) may remedy these challenges, improving service delivery through systematic data collection, analysis, feedback and capacity-building activities. SARPEP (Système Apprenant Rapide pour les Programmes de Premiers Épisodes Psychotiques) is the first Canadian RLHS for EIS. This paper presents qualitative findings from the mixed-method study that evaluated the feasibility and acceptability of SARPEP.

METHODS

We conducted six focus groups on the implementation of SARPEP with 25 participants from all SARPEP stakeholder groups; most were involved from project inception and throughout the 3-year implementation. The Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework (Glasgow, et al., 2019) and Lessard's dimensions for learning health systems guided data collection and deductive analysis.

RESULTS

Reach: focus group participants reflected SARPEP reach and included all stakeholders involved (six service users, two family members, four psychiatrists, six managers, seven team leaders) who shared their experiences.

EFFECTIVENESS

participants confirmed that SARPEP improved program capacity for data collection on core indicators and promoted evidence-based practices. Adoption: participants supported the selection of specific indicators and need to improve data-gathering technologies in the RLHS, even while challenges persisted regarding the integration of digital platform use by service users into routine care. Implementation and maintenance: all participants credited the RLHS with enabling mutual learning, self-reflection of programs and shared improvement of practices.

CONCLUSIONS

SARPEP contributes to promote evidence-based care and a sense of belonging within the Quebec EIS network.

Building a two-state learning healthcare system for persons with first episode psychosis

The Connection Learning Healthcare System (CLHS) represents a network of academic institutions, state behavioral health systems, and early psychosis specialty care programs in Pennsylvania and Maryland working together to provide the best evidence-based care for persons with first episode psychosis. Developing an integrated, two-state system required unification and harmonization of data collection, training, consultation, research, and dissemination activities. Here we describe the model that supported these efforts and our experience creating an active two-state learning healthcare system. We also review areas of ongoing attention and offer lessons learned.

Qualitative Evaluation of Acceptability and Feasibility of a Behavioral Intervention to Reduce Violence Among Young Adults with Early Psychosis

Young adults with early psychosis are at higher risk of violent behavior, but no studies have explored using CBT-based interventions to reduce violence in specialized early intervention services (EIS) settings. This study describes formative research about the acceptability and feasibility of the Psychological Intervention for Complex PTSD and Schizophrenia-Spectrum disorder (PICASSO) to reduce violence, using interviews with EIS participants and staff. Generated themes regarding acceptability included negative experiences of violence and the desire to control and minimize violence. Themes regarding feasibility raised concerns about time constraints, consistency of participation in the intervention, and implementation issues in the context of stigma related to both psychosis and perpetration of violence. Findings from this study suggest there is a need for an intervention addressing violence risk. If adequate resources are devoted to addressing implementation issues, a CBT intervention for violence like PICASSO appears both acceptable and feasible for EIS participants and staff.

The role of netrin G1-netrin-G-ligand-1 in schizophrenia

Schizophrenia (SCZ) is a chronic psychotic disorder that profoundly alters an individual's perception of reality, resulting in abnormal behavior, cognitive deficits, thought distortions, and disorientation in emotions. Many complicated factors can lead to SCZ, and investigations are ongoing to understand the neurobiological underpinnings of this condition. Presynaptic Netrin G1 and its cognate partner postsynaptic Netrin-G-Ligand-1 (NGL-1) have been implicated in SCZ. This review article emphasized the structure and expression of Netrin G1/NGL-1 in the brain, its dysregulation in SCZ patients, and its role in synaptic plasticity, synaptic interaction, learning and memory, microglia neurotrophic activity, and possible signaling between Netrin G1/NGL-1, postsynaptic density protein 95, and cyclin-dependent kinase-like 5 in synaptic morphogenesis. Pharmaceutical targets and the potential use of Netrin G1/NGL-1 as treatment targets or biomarkers for SCZ were also discussed.

Prevalence and Clinical Correlates of Suicidal Ideation and Attempts in Individuals at Clinical High Risk for Psychosis

BACKGROUND

Individuals with psychosis symptoms are at high risk for suicidal ideation and attempts. The prevalence and correlates of suicidal ideation and attempts in clinical high risk for psychosis (CHR-P) have yet to be clarified. This study reports on the prevalence and clinical correlates of suicidal ideation and attempts in a clinical CHR-P sample.

METHOD

Participants (n = 135) included CHR-P clients at a CHR-P community specialty clinic, who participated in a clinical assessment between 2017 and 2022. Assessments measured attenuated psychosis symptoms, suicidal ideation and attempts, clinical covariates, and functioning. Frequency analyses assessed the prevalence of lifetime suicidal ideation and attempts and t-test and Chi-square identified clinical correlates. Logistic regression assessed the relationship between significant clinical correlates and lifetime suicide attempts.

RESULTS

Sixty-five percent of participants at CHR-P endorsed lifetime suicidal ideation, while 22.2% reported at least one lifetime attempt. Correlates for lifetime suicidal ideation included self-reported gender expansive identity, hopelessness, depression, trauma, obsessive compulsive symptoms, insight: reflectiveness, trauma diagnoses, mood disorder diagnoses, and perceptual abnormalities/hallucinations. Significant correlates for lifetime suicide attempts included self-reported hopelessness, depression, trauma diagnosis and mood disorder diagnosis.

CONCLUSION

CHR-P clients are at a higher risk for suicidal ideation and attempts compared to the general population. Correlates of suicidal ideation and attempts may be diagnostically heterogeneous and therefore interventions should be tailored to specific clinical needs. Clients with trauma-disorder diagnoses may be at highest risk for suicidal ideation and attempts. Continued intervention and longitudinal research is needed to clarify causal risk factors and establish evidence-based treatments for suicidal ideation and attempts in CHR-P.

Preventing disease progression in schizophrenia: What are we waiting for

Despite research advances and progress in health care, schizophrenia remains a debilitating and costly disease. Onset occurs typically during youth and can lead to a relapsing and ultimately chronic course with persistent symptoms and functional impairment if not promptly and properly treated. Consequently, over time, schizophrenia causes substantial distress and disability for patients, their families and accrues to a collective burden to society. Recent research has revealed much about the pathophysiology that underlies the progressive nature of schizophrenia. Additionally, treatment strategies for disease management have been developed that have the potential to not just control psychotic symptoms but limit the cumulative morbidity of the illness. Given the evidence for their effectiveness and feasibility for their application, it is perplexing that this model of care has not yet become the standard of care and widely implemented to reduce the burden of illness on patients and society. This begs the question of whether the failure of implementation of a potentially disease-modifying strategy is due to the lack of evidence of efficacy (or belief in it) and readiness for implementation, or whether it's the lack of motivation and political will to support their utilization. To address this question, we reviewed and summarized the literature describing the natural history, pathophysiology and therapeutic strategies that can alleviate symptoms, prevent relapse, and potentially modify the course of schizophrenia. We conclude that, while we await further advances in mental health care from research, we must fully appreciate and take advantage of the effectiveness of existing treatments and overcome the attitudinal, policy, and infrastructural barriers to providing optimal mental health care capable of providing a disease-modifying treatment to patients with schizophrenia.

Suicidality among clients in a network of coordinated specialty care (CSC) programs for first-episode psychosis: Rates, changes in rates, and their predictors

BACKGROUND

People experiencing their first episode of psychosis have high risk of suicide, and programs specializing in early psychosis have not always achieved reduced risk. The present study analyzes patterns of suicide ideation, self-harm, and suicide attempts within the Connection Learning Healthcare System of 23 early psychosis programs in Pennsylvania and Maryland that follow the Coordinated Specialty Care treatment model.

METHOD

People with first episode psychosis (n = 1101) were assessed at admission and every six months using a standardized battery that included self-reported past-month ideation and clinician-reported past-six-month ideation, self-harm, and suicide attempts.

RESULTS

At admission, there were 28 % rates of self-reported past-month suicide ideation and 52 % rates clinician-reported past-six-month suicide ideation, 23 % rate of clinician-reported self-harm, and 15 % rate of attempts. After the first six months of treatment there were significantly lower rates of clinician-reported suicidality (with reductions of at least 77 %), and after the first year of treatment there was significantly lower self-reported ideation (with approximately 54 % reporting lower past-month ideation). Changes were not accounted for by differential early discharge. A range of psychosocial variables predicted within- and between-subject variability in suicidality. Social and role functioning, depressive symptom severity, and a sense of recovery were significant within-subject predictors of all four measures of suicidality.

CONCLUSIONS

Compared to admission, we observed substantially lower rates of suicidality within the first year of treatment for clients with first episode psychosis in Coordinated Specialty Care. Reductions were predicted by some of the variables targeted by the treatment model.

Fidelity to Common Elements of Coordinated Specialty Care: Outcomes of Clients With First-Episode Psychosis

OBJECTIVE

The present study examined whether clients enrolled in coordinated specialty care (CSC) programs for first-episode psychosis (FEP) across 22 states and territories showed improved clinical and functional outcomes and assessed whether program- or client-level predictors were associated with client outcomes. The study included CSC programs that subscribe to a variety of models, including Early Assessment and Support Alliance, OnTrack, and NAVIGATE.

METHODS

Deidentified demographic and outcome data were collected from clients (N=770) receiving CSC services in 36 programs at the time of program entry and every 6 months for up to 18 months. Programs participated in fidelity assessment by using the First-Episode Psychosis Services Fidelity Scale, version 1.0, developed for the study and based on the components of the CSC model defined by NIMH. Additional program-level variables assessed during the study included staff turnover rate and time spent on CSC services.

RESULTS

Across programs, clients experienced improved symptoms, higher quality of life, and improved social and role functioning. Of note, participants from high-income families had greater improvement in role functioning than participants from low-income families. Higher levels of fidelity predicted reduced symptoms and improved social functioning. Having a CSC team lead with time dedicated to the program was also associated with greater improvements in clients' symptoms and social functioning.

CONCLUSIONS

Clients showed improvements, regardless of program or demographic characteristic. Program-level findings suggest that fidelity to the core components of CSC is important for improving client outcomes across a range of specific program models.

Perspectives on the implementation and collaborative facilitation of an intervention to engage young adults in psychiatric rehabilitation

OBJECTIVE

Increasing service user involvement and collaboration with providers has become an important facet of the recovery movement. This study explored perspectives on the implementation and delivery of an intervention (Just Do You [JDY]) designed to improve treatment engagement among marginalized young adults diagnosed with serious mental illnesses.

METHOD

Informed by the Consolidated Framework for Implementation Research (CFIR), we conducted in-depth interviews (N = 11) with nine participants that included agency leaders, clinical providers, and researchers involved with the planning, delivery, and evaluation of JDY. We used grounded theory coding techniques and constant comparison to develop themes that capture the data on implementation and collaboration related to the delivery of JDY.

RESULTS

Two broad themes emerged: (a) collaboration between the clinician and person with lived experience and (b) collaborative culture within and between organizations. Findings capture how collaboration occurred between providers within the clinical encounter (e.g., combined strengths of clinicians and peers) and within and between organizations, clustering around several CFIR domains (e.g., inner setting, process, characteristics of individuals, intervention characteristics). Findings speak to the importance of a "culture of collaboration" in which collaboration is occurring across multiple levels of an organization to support the delivery and implementation of JDY.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

JDY can complement other collaborative approaches given its focus on improving initial engagement. Findings point to the perceived benefits of interventions that are facilitated by a clinician and a person with lived experience along with how their combined expertise can support recovery. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Observed Trajectories of Cannabis Use and Concurrent Longitudinal Outcomes in Youth and Young Adults Receiving Coordinated Specialty Care for Early Psychosis

Cannabis use is present and persistent in young adults with early psychosis receiving Coordinated Specialty Care (CSC) in the United States. While CSC programs are effective in improving quality of life, helping individuals reach goals, and promoting recovery, cannabis use may limit the extent of these improvements. This study extended upon previous findings to examine trajectories of cannabis use among individuals with early psychosis. The sample consisted of 1325 CSC participants enrolled for more than one year at OnTrackNY and followed up to two years, categorized into three groups: no use, reduced use, and persistent use. Baseline demographic and clinical differences were compared across groups and associations between clinical and psychosocial outcomes at 12 months and 24 months were examined across groups. Of the sample, 40 % remained persistent users over two years while 12.8 % reduced their use. At baseline, persistent users were younger (p = 0.011), more likely to be male (p < 0.001), had lower education levels (p = 0.019), and were more likely to have had past legal issues prior to admission (p < 0.001) than non-users. At 2 years, persistent users had significantly worse symptom scores than non-users (p = 0.0003) and reduced users (p = 0.0004). These findings highlight the presence of persistent cannabis use being common in this population and the need to improve substance use treatment offered to allow more CSC participants to achieve improved outcomes.

Identifying Individuals With Early Psychosis in Jail: Lessons Learned for Coordinated Specialty Care Services

OBJECTIVE

This study sought to establish the feasibility of a two-component intervention embedded within a jail setting that would detect detainees with early psychosis and connect them to coordinated specialty care (CSC) in the community upon release.

METHODS

The two components of the intervention were a targeted educational campaign for correction officers and a specialized early engagement support service to facilitate jail discharge planning. Jail detainees with early psychosis were referred to the project and assessed for positive and negative symptoms, substance use, and duration of untreated psychosis (DUP). During a 24-month period, 25 individuals were referred, of whom eight were eligible and interviewed.

RESULTS

The sociodemographic and clinical characteristics of the jail detainees were similar to those of individuals in hospital settings. The median DUP was 36 weeks. One of the eight detainees with early psychosis was successfully referred to CSC; for the other detainees, social or criminal legal factors precluded referral.

CONCLUSIONS

A targeted educational campaign for correction officers and a specialized early engagement support service can be implemented in a jail setting, and referrals can be facilitated. Success of the campaign may depend on having dedicated liaisons within the jail setting (e.g., among correctional health staff) as well as liaisons in local CSC programs and leadership. Changes in the law and policy environments (e.g., criminal legal system reform) and changes in organizational practices and processes for corrections, correctional health, and local CSC programs (such as those made during the COVID-19 pandemic) require ongoing collaborations.

Implementation of an Adapted Fidelity Scale for Pennsylvania Coordinated Specialty Care Programs for First Episode Psychosis

Coordinated Specialty Care (CSC) is an evidence-based model for early intervention of first episode psychosis (FEP). Monitoring fidelity to CSC models is essential for proper evaluation of program outcomes and quality improvement. To address variability across CSC programs and fidelity assessment-associated burden, an adapted fidelity scale was developed and implemented statewide in Pennsylvania. This report describes the design and preliminary performance of the adapted scale. The Pennsylvania FEP Fidelity Scale (PA-FEP-FS) assesses adherence to the CSC model by focusing on essential model components of other established fidelity scales, in tandem with program evaluation data. Initial data from fourteen PA-FEP sites from 2018 to 2021 were examined as preliminary validation. Assessment-associated burdens and costs were also estimated. PA-FEP-FS captured essential components of CSC models and proved feasible for implementation across varying program structures, while minimizing burden and cost. Programs utilized annual feedback as CSC benchmarks, evidenced by increased scores over time. PA-FEP-FS provides a model for adapting CSC fidelity scales to meet state- or local-level requirements while reducing assessment burdens and costs that may be associated with existing scales.

Community- and Program-Level Predictors of Funding Streams Used by Coordinated Specialty Care Programs

OBJECTIVE

Although coordinated specialty care (CSC) is an effective service model to address first-episode psychosis, CSC is not widely accessible in the United States, and funding for this service model often remains challenging. The authors examined whether community- or program-level factors predict the use of public and private funding streams in a national sample of 34 CSC programs in 22 U.S. states and territories.

METHODS

As part of a larger mixed-methods study, CSC program leaders completed a brief questionnaire regarding funding sources. Statistical modeling was used to examine program- and community-level predictors of the use of funding sources.

RESULTS

Most CSC programs (20 of 34, 59%) reported that Mental Health Block Grant (MHBG) set-aside funds accounted for more than half of their total funding, and 11 of these programs reported that these funds contributed to >75% of their funding. Programs ≤5 years old were more likely to rely on MHBG set-aside funds. Programs in Medicaid expansion states were more likely to rely on Medicaid funding than programs in nonexpansion states. Programs in higher-income service catchment areas used more state funds than did those in lower-income areas, and among programs in lower-income service catchment areas, those that were >4 years old were more likely than those ≤4 years old to rely on state funds other than Medicaid.

CONCLUSIONS

CSC programs remain largely dependent on MHBG set-aside funding. Some programs have diversified their funding streams, most notably by including more Medicaid and other state funding. A more comprehensive funding approach is needed to reduce reliance on the MHBG set-aside funds.

"Everything Changed, Would You Like Me to Elaborate?": A Qualitative Examination of the Impact of the COVID-19 Pandemic on Community Participation Among Young Adults with Early Psychosis and Their Families

OnTrackNY provides early intervention services to young people with early psychosis throughout New York State. This report describes the impact of the COVID-19 pandemic on community participation of OnTrackNY program participants and their families. Thirteen participants and nine family members participated in five focus groups and three individual semi-structured interviews. Data were analyzed using a summary template and matrix analysis approach. Major themes highlight the negative impacts of the pandemic with reports of decreased socializing or using online means to connect, unemployment, challenges with online learning and a decrease in civic engagement. Positive impacts include more time to deepen connections with family and valued friendships and engage in activities that promote wellness and goal attainment. Implications for coordinated specialty care programs include adapting services to promote mainstream community integration and creating new strategies for community involvement of young people within a new context brought forth by the pandemic.

Expanding Early Psychosis Care across a Large and Diverse State: Implementation Lessons Learned from Administrative Data and Clinical Team Leads in Texas

The U.S. is facing an unprecedented youth mental health crisis. Translating the findings from mental health intervention trials into large scale, accessible community-based services poses substantial challenges. Examination of state actions as a result of research-informed federal policy to improve youth access to quality mental healthcare is necessary. This mixed-methods study examines the implementation of evidence-informed multidisciplinary coordinated specialty care (CSC) for first-episode psychosis (FEP) services across Texas. The study explores CSC service model components, site location and participant characteristics, and implementation barriers. This cross-sectional study analyzes State of Texas public mental health administrative data from 2015 to 2020, including CSC site (n = 23) characteristics and CSC participant (n = 1682) demographics. Texas CSC site contracts were compared to OnTrackNY, a leading CSC model in the U.S. for CSC service element comparison. In-depth interviews with CSC Team Leads (n = 22) were analyzed to further understand CSC service elements and implementation barriers using qualitative content analysis. CSC was implemented across three waves in 2015, 2017, and 2019-serving 1682 participants and families. CSC sites were located in adult mental health programs; approximately one third of CSC participants were under 18 years. CSC implementation challenges reported by Team Leads included: staff role clarification, collaboration and turnover, community outreach and referrals, child and adult service billing issues, and adolescent and family engagement. Study findings have implications for large state-wide evidence-based practice implementation in transition-to-adulthood community mental health.

Care Pathways and Initial Engagement in Early Psychosis Intervention Services Among Youths and Young Adults

Importance

Broad efforts to improve access to early psychosis intervention (EPI) services may not address health disparities in pathways to care and initial engagement in treatment.

Objective

To understand factors associated with referral from acute hospital-based settings and initial engagement in EPI services.

Design, Setting, and Participants

This retrospective cohort study used electronic medical record data from all patients aged 16 to 29 years who were referred to a large EPI program between January 2018 and December 2019. Statistical analysis was performed from March 2022 to February 2023.

Exposures

Patients self-reported demographic information in a structured questionnaire. The main outcome for the first research question (referral source) was an exposure for the second research question (initial attendance).

Main Outcomes and Measures

Rate of EPI referral from acute pathways compared with other referral sources, and rate of attendance at the consultation appointment.

Results

The final study population included 999 unique patient referrals. At referral, patients were a mean (SD) age of 22.5 (3.5) years; 654 (65.5%) identified as male, 323 (32.3%) female, and 22 (2.2%) transgender, 2-spirit, nonbinary, do not know, or prefer not to answer; 199 (19.9%) identified as Asian, 176 (17.6%) Black, 384 (38.4%) White, and 167 (16.7%) other racial or ethnic groups, do not know, or prefer not to answer. Participants more likely to be referred to EPI services from inpatient units included those who were older (relative risk ratio [RRR], 1.10; 95% CI, 1.05-1.15) and those who identified as Black (RRR, 2.11; 95% CI, 1.38-3.22) or belonging to other minoritized racial or ethnic groups (RRR, 1.79; 95% CI, 1.14-2.79) compared with White participants. Older patients (RRR, 1.16; 95% CI, 1.11-1.22) and those who identified as Black (RRR, 1.67; 95% CI, 1.04-2.70) or belonging to other minoritized racial or ethnic groups (RRR, 2.11; 95% CI, 1.33-3.36) were more likely to be referred from the emergency department (ED) compared with White participants, whereas participants who identified as female (RRR, 0.51 95% CI, 0.34-.74) had a lower risk of ED referral compared with male participants. Being older (odds ratio [OR], 0.95; 95% CI, 0.90-1.00) and referred from the ED (OR, 0.40; 95% CI, 0.27-0.58) were associated with decreased odds of attendance at the consultation appointment.

Conclusions and relevance

In this cohort study of patients referred to EPI services, disparities existed in referral pathways and initial engagement in services. Improving entry into EPI services may help facilitate a key step on the path to recovery among youths and young adults with psychosis.

Community-based family peer navigator programme to facilitate linkage to coordinated specialty care for early psychosis among Black families in the USA: A protocol for a hybrid type I feasibility study

BACKGROUND

Approximately 70% of Black/African American family members report no contact with mental health providers prior to initial diagnosis and the receipt of services for early psychosis. Black families often encounter barriers and experience delays on the pathway to coordinated specialty care programmes for early psychosis.

METHODS AND ANALYSIS

This mixed-methods study will (1) develop and refine a family peer navigator (FPN) for Black families designed to increase access and engagement in coordinated specialty care and (2) pilot-test FPN for Black families with 40 family members with loved ones at risk for psychosis in a randomised trial to assess the acceptability and feasibility. Families will be randomised to FPN (n=20) or a low-intensive care coordination (n=20). Other outcomes include proposed treatment targets (eg, knowledge, social connectedness), preliminary impact outcomes (time to coordinated specialty care programmes, initial family engagement), and implementation outcomes (acceptability, feasibility, appropriateness).

ETHICS AND DISSEMINATION

Ethics approval has been obtained from Washington State University Institutional Review Board and informed consent will be obtained from all participants. This study will establish an innovative culturally responsive FPN programme and implementation strategy, and generate preliminary data to support a larger hybrid effectiveness-implementation trial. Study findings will be presented at conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05284721.

Evaluating and sustaining Coordinated Specialty Care for a recent onset of psychosis in non-academic-affiliated community mental healthcare settings

PURPOSE

To improve sustainability of Coordinated Specialty Care (CSC) for a recent onset of psychosis, a better understanding is needed regarding how non-academic-affiliated community mental health centers blend CSC service elements and select key performance metrics to evaluate their approach.

METHODS

A quality and evaluation team embedded within a large community mental health center partnered with CSC site leadership to implement CSC and design a program evaluation strategy informed by CSC research literature. Clinical, family, vocational, and psychiatry services participation, exits, key performance indicators, and standardized measures were examined for participants (n = 47) enrolled for 12-months.

RESULTS

Mean service participation was 55 h (SD = 23.5) in the first 12-months (approximately 4.70 h/month). All participated in clinical; 87% in psychiatry; 67% in vocational; and 57% in family services. Sixty-one percent had planned service exits; 39% had unplanned exits. Across the 12-months, 83% were employed or in school; 72% were not psychiatric hospitalized.

CONCLUSIONS

CSC participation and outcomes were similar to the limited research examining both together. Understanding service participation and provider adjustments to sustain CSC is critical in community mental healthcare settings that rely on fee-for-service billing mechanisms. Findings have implications for national CSC data harmonization and sustainability efforts.

The Patient Journey of Schizophrenia in Mental Health Services: Results from a Co-Designed Survey by Clinicians, Expert Patients and Caregivers

BACKGROUND

The Patient Journey Project aims to collect real-world experiences on schizophrenia management in clinical practice throughout all the phases of the disorder, highlighting virtuous paths, challenges and unmet needs.

METHODS

A 60-item survey was co-designed with all the stakeholders (clinicians, expert patients and caregivers) involved in the patient's journey, focusing on three areas: early detection and management, acute phase management and long-term management/continuity of care. For each statement, the respondents expressed their consensus on the importance and the degree of implementation in clinical practice. The respondents included heads of the Mental Health Services (MHSs) in the Lombardy region, Italy.

RESULTS

For early diagnosis and management, a strong consensus was found; however, the implementation degree was moderate-to-good. For acute phase management, a strong consensus and a good level of implementation were found. For long-term management/continuity of care, a strong consensus was found, but the implementation level was slightly above the cut-off, with 44.4% of the statements being rated as only moderately implemented. Overall, the survey showed a strong consensus and a good level of implementation.

CONCLUSIONS

The survey offered an updated evaluation of the priority intervention areas for MHSs and highlighted the current limitations. Particularly, early phases and chronicity management should be further implemented to improve the patient journey of schizophrenia patients.

A Scoping Review of Measures Used in Early Intervention Services for Psychosis

OBJECTIVE

The early intervention service (EIS) model for psychosis has been implemented with increasing frequency; yet, improving outcomes across domains for all patients remains challenging. Measurement-based care can strengthen outcomes by optimizing interventions and promoting alignment with standards, but it is still not widely deployed in EIS. The authors conducted a scoping review by systematically identifying and synthesizing measures used in EIS related to purpose (i.e., to assess patients, families, and programs), domains (e.g., symptoms, quality of life), and reporting perspectives (of patients, families, and clinicians).

METHODS

EMBASE, MEDLINE, PsycINFO, CINAHL, and Cochrane Library databases were searched for pertinent literature published between 2000 and 2020. Two reviewers independently screened titles, abstracts, and full texts and extracted data. Measures were classified as clinician-reported outcome measures (CROMs), patient-reported outcome or experience measures (PROMs/PREMs), or family-reported outcome or experience measures (FROMs/FREMs).

RESULTS

In total, 172 measures of 27 domains were identified from 115 articles. Nineteen measures had been used to assess programs on fidelity, service engagement, and satisfaction; 136 to assess patients on duration of untreated psychosis, symptoms, functioning, quality of life, and others; and 17 to assess families on coping and burden, background, and others. Sixty percent were CROMs, 30% were PROMs/PREMs, and 10% were FROMs/FREMs.

CONCLUSIONS

Greater inclusion of PROMs and FROMs is needed because they align with the EIS philosophy of patient and family engagement and may improve shared decision making and outcomes. A comprehensive, meaningfully synthesized archive of measures can advance measurement-based care, services research, and data harmonization in early psychosis.

A systematic review of persons of color participation in first episode psychosis coordinated specialty care randomized controlled trials in North America

The population of persons of color (POC) are increasing in the United States. Unfortunately, POC are significantly impacted by serious mental illness; psychosis represents a mental health disparity among POC. Fortunately, first episode coordinated specialty care (CSC) is an effective treatment for individuals who are in the early phases of a psychotic disorder. This systematic review of the literature examined POC inclusion rates in randomized controlled trials (RCT) examining First Episode Psychosis (FEP) programs. Our review yielded seven articles that met inclusion criteria. Our findings were mixed-researchers conducting RCTs on FEP programs did an excellent job including African American participants suggesting that findings from RCTs on FEP programs may generalize to African American participants. Regarding Latines, they were broadly underrepresented in RCTs on FEP CSC. Based on the data, we cannot definitively conclude to what extent findings from RCTs on FEP CSC generalize to Latines although results from studies that included a reasonable number of Latines offer promising results. Asians were overrepresented in three of the seven studies included in this review; thus it seems that the findings from RCTs on FEP CSC generalize to the Asian population in the United States.

State Mental Health Authority Level of Involvement in Coordinated Specialty Care Clinics and Client Outcomes

OBJECTIVE

State mental health authorities (SMHAs) in all U.S. states and territories administer the Mental Health Block Grant (MHBG) set-aside funding for first-episode psychosis. Funds support implementation of coordinated specialty care (CSC) programs. The authors investigated the relationship between the level of SMHA involvement with CSC programs and clinical outcomes of clients in these programs.

METHODS

As part of a mixed-methods study of 34 CSC programs, SMHAs from 21 states and one U.S. territory associated with the 34 CSC programs participated in a 1-hour interview (between November 2018 and May 2019) focused on SMHA involvement in administration of MHBG set-aside funds and the SMHA's ongoing relationship with funded CSC programs. SMHA involvement was rated on a scale of 1 to 5, with 5 indicating the highest involvement. Client outcome data were collected at the 34 study sites over an 18-month period. Multilevel random-effect modeling was used, controlling for response propensity (propensity score), client demographic variables, and program-level covariates (i.e., fidelity score, staff turnover rates, service area urbanicity, and number of clients enrolled).

RESULTS

Clients in CSC programs with SMHAs that were the most involved (level 5) had significantly improved symptoms, social functioning, and role functioning, compared with clients in programs with which SMHAs were least involved (level 1).

CONCLUSIONS

The findings suggest that increased SMHA involvement in CSC programs is relevant for positive client outcomes. Levels of first-episode psychosis funding doubled in 2021 and 2022, and it is important to identify how SMHAs affect the success of CSC programs and the individuals served.

Prevalance and course of tobacco use among individuals receiving coordinated specialty care for first-episode psychosis

AIM

Tobacco use is decreasing among the general population, but persistent use among individuals in treatment for first-episode psychosis (FEP) remains a problem. This study aimed to measure the prevalence and course of tobacco use and explore the associations between tobacco use and clinical outcomes in a FEP sample located in New York State (NYS).

METHODS

Participants (N = 870) were from the OnTrackNY system of coordinated specialty care clinics in NYS. Participant data were collected at admission to the program and at every 3 months of follow-up using standardized forms based on reports from clients, client families and chart review. Course of tobacco use was categorized into four groups: no-use, cessation, persistent and initiation over 1 year of follow-up.

RESULTS

The prevalence of tobacco use was 12.8% at baseline and 19.9% at 1-year follow-up. Only 3.8% of tobacco users stopped by 1 year follow-up, and 4.9% initiated use. Urbanicity of clinic location (p < .001); age at admission (p = .044); gender (p = .015); ethnoracial group (p = .007); baseline education/employment status (p = .004); and baseline use of any non-tobacco substances (p < .001), including alcohol (p < .001) and cannabis (p < .001), were associated with tobacco course. Findings suggest an association between tobacco use and reduced improvement in symptoms.

CONCLUSION

Despite a lower prevalence of tobacco use among OnTrack participants than in other comparable samples, tobacco cessation was minimal and more individuals initiated tobacco use than ceased over the course of follow-up. Efforts to implement tobacco cessation interventions in coordinated specialty care are warranted, since tobacco use is associated with poor health outcomes.

The neurobiology of duration of untreated psychosis: a comprehensive review

Duration of untreated psychosis (DUP) is defined as the time from the onset of psychotic symptoms until the first treatment. Studies have shown that longer DUP is associated with poorer response rates to antipsychotic medications and impaired cognition, yet the neurobiologic correlates of DUP are poorly understood. Moreover, it has been hypothesized that untreated psychosis may be neurotoxic. Here, we conducted a comprehensive review of studies that have examined the neurobiology of DUP. Specifically, we included studies that evaluated DUP using a range of neurobiologic and imaging techniques and identified 83 articles that met inclusion and exclusion criteria. Overall, 27 out of the total 83 studies (32.5%) reported a significant neurobiological correlate with DUP. These results provide evidence against the notion of psychosis as structurally or functionally neurotoxic on a global scale and suggest that specific regions of the brain, such as temporal regions, may be more vulnerable to the effects of DUP. It is also possible that current methodologies lack the resolution needed to more accurately examine the effects of DUP on the brain, such as effects on synaptic density. Newer methodologies, such as MR scanners with stronger magnets, PET imaging with newer ligands capable of measuring subcellular structures (e.g., the PET ligand [11C]UCB-J) may be better able to capture these limited neuropathologic processes. Lastly, to ensure robust and replicable results, future studies of DUP should be adequately powered and specifically designed to test for the effects of DUP on localized brain structure and function with careful attention paid to potential confounds and methodological issues.

Ethnic identity, stress, and personal recovery outcomes among young adults with serious mental health conditions

OBJECTIVE

Serious mental illnesses (SMI) often occur during early adulthood, just as young people are developing important aspects of their identity that can affect their recovery. Positive ethnic identity development is associated with stress coping and psychological well-being in young people. But, there is limited research to indicate how individual experiences of belonging and attachment to one's ethnic group influence personal recovery processes among young adults living with SMI.

METHOD

Young adults living with SMI (95% identified as ethnic/racial minorities) were recruited from four outpatient psychiatric rehabilitation programs (N = 83). Multivariate regressions were used to examine relationships between predictors (demographics, psychiatric symptomatology, ethnic identity) and the dependent variables (perceived stress and personal recovery).

RESULTS

A stronger, more developed ethnic identity and fewer depressive symptoms were associated with higher ratings of personal recovery. Increases in psychiatric symptoms predicted increased perceived stress. Post hoc analyses showed that Black, Latino/a, and multiracial study participants' ethnic identity ratings were similar to those of same ethnic/racial group of young adults without SMI.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Ethnic identity development could be a significant psychosocial factor shaping mental health recovery among minority young people living with SMI. Several factors associated with psychological well-being among ethnic and racial minority youth may account for this, including adaptive coping, social support, and a buffering effect against racism. Our findings indicate that assessing and developing a young person's ethnic identity-related strengths and resources as a means for improving the personalization of recovery services and enhancing the quality of care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Depression Mediates the Relationships between Hallucinations, Delusions, and Social Isolation in First-Episode Psychosis

Social isolation is common among individuals with schizophrenia spectrum and other psychotic disorders. Research indicates that social isolation relates to poorer mental health outcomes, depression, and negative symptoms, with less known about its relationship with positive symptoms. This study examined depression as a mediator in the relationships between positive symptoms (i.e., hallucinations and delusions) and social isolation among an early treatment phase sample in the United States. Data were obtained from the Recovery After an Initial Schizophrenia Episode project of the National Institute of Mental Health's Early Treatment Program. Participants (N = 404) included adults between ages 15 and 40 in a first episode of psychosis. Data were analyzed using structural equation modeling in Mplus (Version 8). The study showed that delusions (b = .095, SE = 0.04, p < .05) and hallucinations (b = .076, SE = 0.03, p < .01) were directly related to depression, and that both delusions (b = .129, SE = 0.06, p < .05) and depression (b = .254, SE = 0.09, p < .05) were directly related to social isolation. Findings of this study determined that depression functioned as a mediator in the relationships between positive symptoms and social isolation. Targeting psychosis symptomatology and depression in treatment, improving social skills and social support networks, and considering the role of stigma in social isolation are of great importance in the prevention of poorer mental health outcomes.

Growth of Coordinated Specialty Care in the United States With Changes in Federal Funding Policies: 2014-2018

OBJECTIVE

In 2014, the number of coordinated specialty care (CSC) programs in the United States greatly expanded. The proliferation of CSC programs was likely due in part to the availability of Mental Health Block Grant (MHBG) set-aside funds for treatment of first-episode psychosis. This study aimed to explore the characteristics of CSC programs across 44 states, the District of Columbia, and three U.S. territories that received funding through the MHBG set-aside program in 2018.

METHODS

Leadership at 88% (N=215) of the 244 MHBG-funded CSC programs identified through state mental health authorities participated in an online survey.

RESULTS

Overall, 69% of the CSC programs were initiated after 2014. More than 90% of programs included services that were consistent with federal guidance. CSC programs showed variability in training received, program size, and enrollment criteria.

CONCLUSIONS

The results of this study emphasize that clear federal guidance can help shape national CSC implementation efforts, although decisions at the state and local levels can influence how implementation occurs. The strategy of states administering federal funds for CSC may be adapted for the rollout of other behavioral health interventions. Future studies could investigate factors that may shape national dissemination efforts, such as leadership within the state, funding, availability of programs established before the influx of funding, and considerations about sustainability after the funding is no longer available.

OnTrack Chile for people with early psychosis: a study protocol for a Hybrid Type 1 trial

BACKGROUND

Substantial data from high-income countries support early interventions in the form of evidence-based Coordinated Specialty Care (CSC) for people experiencing First Episode Psychosis (FEP) to ameliorate symptoms and minimize disability. Chile is unique among Latin American countries in providing universal access to FEP services through a national FEP policy that mandates the identification of FEP individuals in primary care and guarantees delivery of community-based FEP treatments within a public health care system. Nonetheless, previous research has documented that FEP services currently provided at mental health clinics do not provide evidence-based approaches. This proposal aims to address this shortfall by first adapting OnTrackNY (OTNY), a CSC program currently being implemented across the USA, into OnTrackChile (OTCH), and then examine its effectiveness and implementation in Chile.

METHODS

The Dynamic Adaptation Process will be used first to inform the adaptation and implementation of OTCH to the Chilean context. Then, a Hybrid Type 1 trial design will test its effectiveness and cost and evaluate its implementation using a cluster-randomized controlled trial (RCT) (N = 300 from 21 outpatient clinics). The OTCH program will be offered in half of these outpatient clinics to individuals ages 15-35. Usual care services will continue to be offered at the other clinics. Given the current COVID-19 pandemic, most research and intervention procedures will be conducted remotely. The study will engage participants over the course of 2 years, with assessments administered at enrollment, 12 months, and 24 months. Primary outcomes include implementation (fidelity, acceptability, and uptake) and service outcomes (person-centeredness, adherence, and retention). Secondary outcomes comprise participant-level outcomes such as symptoms, functioning, and recovery orientation. Over the course of the study, interviews and focus groups with stakeholders will be conducted to better understand the implementation of OTCH.

DISCUSSION

Findings from this study will help determine the feasibility, effectiveness, and cost for delivering CSC services in Chile. Lessons learned about facilitators and barriers related to the implementation of the model could help inform the approach needed for these services to be further expanded throughout Latin America.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov NCT04247711 . Registered 30 January 2020.

TRIAL STATUS

The OTCH trial is currently recruiting participants. Recruitment started on March 1, 2021, and is expected to be completed by December 1, 2022. This is the first version of this protocol (5/12/2021).

Feasibility and Utility of Different Approaches to Violence Risk Assessment for Young Adults Receiving Treatment for Early Psychosis

This pilot study examined violence risk assessment among a sample of young adults receiving treatment for early psychosis. In this study, thirty participants were assessed for violence risk at baseline. Participants completed follow-up assessments at 3, 6, 9 and 12 months to ascertain prevalence of violent behavior. Individuals were on average 24.1 years old (SD = 3.3 years) and predominantly male (n = 24, 80%). In this sample, six people (20%) reported engaging in violence during the study period. Individuals who engaged in violence had higher levels of negative urgency (t(28) = 2.21, p = 0.035) This study sought to establish the feasibility, acceptability, and clinical utility of violence risk assessment for clients in treatment for early psychosis. Overall, this study found that most individuals with early psychosis in this study (who are in treatment) were not at risk of violence. Findings suggest that violent behavior among young adults with early psychosis is associated with increased negative urgency.

Virtual Technology's Critical Role in Sustaining Coordinated Specialty Care in Texas During the COVID-19 Pandemic

OBJECTIVE

This report examined challenges and adaptations to sustaining multidisciplinary team-based coordinated specialty care (CSC) for early-onset psychosis during the COVID-19 pandemic in Texas.

METHODS

In June 2020, team leaders from 23 Texas CSC sites participated in semistructured phone interviews about CSC implementation barriers and adaptations. Transcripts were analyzed with thematic analysis.

RESULTS

CSC implementation barriers included difficulty delivering critical CSC components (i.e., community education and vocational exploration) and client recruitment limitations. Virtual technology integration (i.e., texting and videoconferencing) largely sustained CSC outreach, service delivery, and client engagement. However, sites faced virtual competency and accessibility issues, exhaustion from virtual technology use, lack of structural support, and unanticipated disengagement.

CONCLUSIONS

The surveyed sites rapidly integrated virtual technology into CSC delivery. This integration promoted CSC engagement during the pandemic, especially in rural areas, and increased insight into what resources and policies are needed to sustain virtual technology use among community mental health providers.

Evaluating Educational and Employment Services for Young People With Psychiatric Conditions: A Systematic Review

OBJECTIVE

The authors conducted a systematic review of studies evaluating vocational interventions for young people with psychiatric conditions to determine the extent to which services were adapted for young people and whether services promoted gains in postsecondary education and employment.

METHODS

Five databases (PubMed, PsycINFO, Web of Science, Academic Search Premier, and ERIC) were searched. Sources eligible for inclusion were controlled studies published between 2000 and mid-2020 that evaluated a vocational intervention and examined postsecondary educational or employment outcomes for youths or young adults (ages 14-35 years) with psychiatric conditions.

RESULTS

Ten studies met the inclusion criteria. Several of the studies evaluated services that were adapted for young people, including through the incorporation of educational supports. The most consistent finding was that services based on the individual placement and support (IPS) model improved employment outcomes more effectively than did comparison approaches and treatment as usual. Fewer studies assessed educational outcomes, and they yielded mixed results; however, recent findings from a controlled trial indicate that an enhanced IPS intervention that included well-specified supported education and skills training led to significantly superior outcomes in both education and employment.

CONCLUSIONS

These results provide support for the efficacy of IPS-based services to improve employment outcomes among young people with psychiatric conditions and suggest that adapting IPS to include comprehensive educational supports and skills training may be important for efforts to improve postsecondary educational outcomes. Additional well-controlled intervention studies that examine educational and longer-term outcomes should further inform the development and delivery of vocational services for this population.

The History of Coordinated Specialty Care for Early Intervention in Psychosis in the United States: A Review of Effectiveness, Implementation, and Fidelity

Coordinated Specialty Care (CSC) is a multidisciplinary team approach to providing care for young and emerging adults having their first episode of psychosis. CSC programs have expanded rapidly throughout the United States going from 12 programs in 2008 to over 160 programs a decade later. The purpose of this historical review is to document the process and conditions that led to the accelerated dissemination of these programs across the country. CSC models began in the US in the early 2000s, but nationwide expansion followed the 2008 Recovery After an Initial Schizophrenia Episode trial. As programs have grown, debates have risen about fidelity to CSC models. The challenges facing CSC programs today include lack of evidence on what are the core components of CSC and how fidelity monitoring relates to positive client outcomes.

Developing a theoretical framework for persistent cannabis use among young adults with first episode psychosis

AIM

Cannabis use is common among individuals with first episode psychosis (FEP) and persistent use is associated with worse outcomes. The purpose of this qualitative study is to identify factors pertaining to onset of cannabis use and persistent use among young adults with early psychosis receiving coordinated specialty care (CSC) in the United States and begin to develop a theoretical framework to drive further study and hypothesis testing and inform the approach to treatment of cannabis use disorder in this setting.

METHODS

Participants were ages 16-30 years with early psychosis attending a CSC program in New York State. Interviews were conducted in December 2018. Coding and analysis was conducted in Atlas.ti and themes were identified via a thematic analysis approach.

RESULTS

Thirteen individuals completed the interview. The mean age in years was 20.7 and the majority were male (n = 10). Almost half (46%) were Black, non-Hispanic and 39% were Hispanic. Seven participants indicated they were currently using cannabis and six participants indicated they had stopped for at least 6 months at the time of the interview. Several themes emerged including the influence of family and social norms, motivating factors for persistent use and for reduced use or abstinence, and ambivalence regarding the impact of cannabis use on mental health.

CONCLUSION

A theoretical framework emerged which may help identify future research in this area and inform the approach to treatment of cannabis use disorder in this setting.

Social work training to reduce duration of untreated psychosis: Methodology and considerations of a web-based training for community providers

AIM

Outcomes for individuals with psychotic disorders can be improved through early intervention services; however, identification continues to be a major problem in connecting individuals with these services. Social workers form a vast majority of the human service and mental health workforce in the United States and therefore have the potential to play a unique role in identifying and referring those who may benefit from specialty early intervention services.

METHODS

The current article describes the methodological design, implementation, and participant recruitment procedures of a large-scale, web-based training program for social workers promoting identification and referral of individuals with emerging symptoms of a mental illness with psychosis in the context of a randomized clinical trial.

RESULTS

The web-based study enrolled 1384 individuals. More than half of study participants enrolled within the first 3 months of the 14-month recruitment period. Completion of all study components was achieved by 959 individuals (69% of total enrolled), and completion status did not vary significantly by gender, ethnicity, or facility at which the individual was employed. Completion rates varied by race, such that participants identifying as White were more likely to complete the study, while those identifying as Black were less likely.

DISCUSSION

The results suggest the feasibility of using a web-based training program to engage social workers in early psychosis identification practices. Challenges related to encouraging participants to complete the training and lessons learned during the study recruitment are discussed.

Impact of the COVID-19 Pandemic on the Employment and Educational Outcomes of Individuals in a First-Episode Psychosis Clinic

OBJECTIVE

A central objective of early psychosis therapy is to restore social functioning (e.g., through employment and education). Employment and educational outcomes during the COVID-19 pandemic were examined in a well-defined cohort of patients receiving care in an early psychosis clinic.

METHODS

Data were extracted from the electronic health records of 128 patients receiving care at McLean Hospital's first-episode psychosis (FEP) clinic between January 1 and September 21 in 2019 and 2020. Using a generalized linear model with a Gaussian distribution and robust standard errors, the authors compared the average changes in the weekly employment and education proportions before and after COVID-19 lockdowns with the same changes in 2019.

RESULTS

Employment losses among patients with FEP were greater than among the general population and persisted through the end of follow-up. In 2020, average employment after a stay-at-home order was instituted was 33% lower than before the order compared with the change in employment during the same period in 2019. The effect was stronger among men and those who identified as non-White, were age <21 years, or did not have a college education. Although educational engagement recovered in the fall of 2020, it still remained below the 2019 levels.

CONCLUSIONS

Employment disruptions were major and persistent among the FEP population, which might affect short- and long-term outcomes. Innovative approaches are needed to help patients transition to remote employment, file unemployment claims, and use online hiring platforms to ameliorate the indirect effects of the COVID-19 pandemic.

Inpatient Early Intervention for Serious Mental Illnesses Is Associated With Fewer Rehospitalizations Compared With Treatment as Usual in a High-volume Public Psychiatric Hospital Setting

OBJECTIVE

High-acuity publicly funded inpatient psychiatric settings usually feature short lengths of stay and high readmission rates. This study examined the influence of an early intervention program for serious mental illnesses (SMI) on readmissions at 6 and 12 months postdischarge at a high-volume, urban public inpatient psychiatric hospital.

METHODS

The Early Onset Treatment Program (EOTP) is a cost-free, 90-day inpatient multidisciplinary service intervention program for uninsured patients who are within 5 years of SMI onset, funded as a pilot program by the Texas state legislature. Rehospitalization rates at 6 and 12 months were extracted from electronic medical records for EOTP participants (n=165) and comparison patients matched on demographics and diagnosis (n=155). The comparison group received treatment as usual at the same psychiatric hospital. Group re-admission rates were compared using logistic and Poisson regression analyses.

RESULTS

Group membership was a significant predictor of rehospitalization (P<0.0001) at both 6 and 12 months. Expressed as 1/odds ratio (OR), the EOTP group was less likely to readmit once and more than once at 6 months postdischarge (1/OR=3.82 and 4.74, respectively) compared with the non-EOTP group. The EOTP group was also less likely to readmit once and more than once at 12 months postdischarge (1/OR=2.96 and 3.51, respectively).

CONCLUSIONS

The results suggest that participation in the EOTP service in this high-acuity setting was significantly related to reduced likelihood of rehospitalization at 6 and 12 months. Several variables may account for this observation, including length of stay, longer medication adherence, environmental stability, and more individualized and extensive psychotherapy treatment.

Implementation case study: Multifamily group intervention in first-episode psychosis programs

AIM

Family interventions are a core component of first-episode psychosis (FEP) treatment; however, low implementation rates are consistently reported. As such, work is needed to understand the factors impacting real-world treatment delivery. The present paper describes the implementation of the McFarlane-model multifamily psychoeducational groups (MFG) in established FEP early intervention programs within a single state. The aims were to examine (a) training participation and implementation of MFG, (b) barriers and facilitators to implementation, and (c) modifications made to MFG.

METHODS

Practitioners from six established FEP early intervention programs received in-person training and ongoing consultation in MFG. Training participation data were obtained via attendance and implementation outcomes were obtained from practitioner reports. Fifteen months following the initial training, practitioners reported on clinic-specific barriers, facilitators, and modifications across four categories (context, intervention, practitioner, and recipient).

RESULTS

Twenty-three practitioners across six clinics received in-person training and were offered ongoing consultation to support implementation. Difficulties in starting MFG were salient as the earliest group was run 7 months after the initial training, thereby resulting in low overall frequency of groups. A number of barriers spanning context, intervention, practitioner, and recipient domains were noted, the majority of which were clinic-specific. Despite challenges, practitioners identified several facilitators and made modifications to the intervention and its delivery in service of implementation.

CONCLUSIONS

Results from this implementation case study highlighted the challenges of delivering MFG in real-world FEP early intervention programs. Further, this paper emphasizes the value in identifying and addressing clinic-specific factors when implementing MFG.

The impact of manic symptoms in first-episode psychosis: Findings from the UK National EDEN study

OBJECTIVE

The extant literature is inconsistent over whether manic symptoms in first-episode psychosis (FEP) impact on its development and trajectory. This study addressed the following: (1) Does Duration of Untreated Illness (DUI) and Duration of Untreated Psychosis (DUP) differ between FEP patients with and without manic symptoms? (2) Do manic symptoms in FEP have an impact on time to remission over 1 year?

METHODS

We used data from the National EDEN study, a longitudinal cohort of patients with FEP accessing early intervention services (EIS) in England, which measured manic, positive and negative psychotic symptoms, depression and functioning at service entry and 1 year. Data from 913 patients with FEP (639 without manic symptoms, 237 with manic symptoms) were analysed using both general linear modelling and survival analysis.

RESULTS

Compared to FEP patients without manic symptoms, those with manic symptoms had a significantly longer DUI, though no difference in DUP. At baseline, people with manic symptoms had higher levels of positive and negative psychotic symptoms, depression and worse functioning. At 12 months, people with manic symptoms had significantly poorer functioning and more positive psychotic symptoms. The presence of manic symptoms delayed time to remission over 1 year. There was a 19% reduced rate of remission for people with manic symptoms compared to those without.

CONCLUSIONS

Manic symptoms in FEP are associated with delays to treatment. This poorer trajectory persists over 1 year. They appear to be a vulnerable and under-recognised group for poor outcome and need more focussed early intervention treatment.

Implementing Coordinated Specialty Care in CMHC Youth and Young Adults with Severe Mental Illness: Preliminary Outcome Assessment

This study assessed impact of Coordinated Specialty Care (CSC), expanded to include both first episode psychosis (FEP) and severe mental health disorders (e.g., depression, bipolar disorder, trauma) in youths attending Community Mental Health Centers (CMHCs). Eligible youth and young adults (ages 16-26 years, N = 201) were recruited from two CMHCs and assessed every 6 months. Paired sample t-tests were performed comparing pre- and post-treatment observations. Statistically significant decreases from pre to post were found in sad and anxious feelings and in days hospitalized for psychiatric emergency and increases were found in subjective health ratings and employment status. This preliminary assessment supports the effectiveness of expanded inclusion criteria for participation in the CSC model.

Financing Early Psychosis Intervention Programs: Provider Organization Perspectives

OBJECTIVE

The authors aimed to identify prominent financing approaches for coordinated specialty care (CSC) of patients with first-episode psychosis, alignment or misalignment of such approaches with sustained CSC implementation, and CSC provider perspectives on ideal payment models.

METHODS

Semistructured interviews were conducted with informants from CSC provider organizations. Purposeful sampling of CSC program directors, team leaders, and other administrators from a national e-mail Listserv was supplemented by snowball sampling via participant recommendations. Interview data from 19 CSC programs in 14 states were analyzed by using an integrated (inductive and deductive) approach to derive themes.

RESULTS

The results indicated that financing approaches to CSC were patchwork and highly varied. Three major sources of funding were cited: insurance billing (largely fee for service [FFS] to Medicaid and private insurance), set-aside funding from the federal Mental Health Block Grant (MHBG) program, and state funding. The findings revealed limited coverage and restrictive rules associated with FFS insurance billing that were misaligned with CSC implementation. The grant nature of MHBG and other public funding was seen as a threat to long-term CSC sustainability and deployment. CSC stakeholders endorsed a bundled-payment approach by public and private payers and supported tying payment to client outcomes to reflect CSC's recovery orientation.

CONCLUSIONS

Reliance on FFS insurance billing and public funding is likely to be unsustainable. Additionally, FFS billing is misaligned with CSC goals. Because of the diversity in CSC programs, populations, and existing funding mechanisms and rules, payer-provider collaboration will be essential in designing a bundled-payment model that meets local needs.

The utility of a fidelity measure to monitor implementation of new early psychosis services across Australia

AIM

Early psychosis delivery models have proliferated worldwide, but there is limited research into establishing model fidelity. In this context, this article aims to describe the development and implementation of a fidelity tool in a national network of early psychosis services across Australia-the headspace Early Psychosis program.

METHODS

Following a detailed consultation process, and based on the Australian Early Psychosis model, an 80-item Early Psychosis Prevention and Intervention Centre Model Integrity Tool (EMIT) was developed along with predefined thresholds for fidelity. The tool was used to assess adherence to the model in six clusters of service sites across Australia. Ratings on the EMIT were informed by interviews with site staff and young people receiving the service, routinely collected data and site policies and procedures.

RESULTS

All six clusters of headspace Early Psychosis programs participated in five fidelity assessments across a period of two and a half years. In the initial two visits, the average fidelity score was in the 'low' fidelity range (i.e., <75%). By the fifth fidelity visit, the network average improved to 92.35%, reflecting 'superior' fidelity.

CONCLUSIONS

Results of the longitudinal fidelity assessments indicate the successful implementation of the Australian Early Psychosis model across the headspace Early Psychosis program. Utilisation of ongoing fidelity assessments has proved an effective method to improve and maintain adherence to the model.

mHealth for Young Adults with Early Psychosis: User Preferences and Their Relationship to Attitudes About Treatment-Seeking

A long duration of untreated psychosis reduces benefits of early intervention for early psychosis. Digital technologies have potential to encourage help-seeking and reduce barriers to care. Because of high rates of smartphone ownership, mobile health (mHealth) interventions may be particularly well-suited to increase access. There is a lack of available information on the specific features that may be most appealing to young adults with early psychosis. The present study remotely recruited 77 young adults with psychosis and surveyed their interest in mHealth features, delivery modalities, and attitudes toward treatment. Overall, respondents reported high utilization of digital health and high interest in psychosis-specific mHealth. They expressed the highest interest (ordered by mean score by item) in information about medications and side effects (n = 69, 89.6% reporting being “interested” or “very interested”), managing stress and improving mood (n = 67, 89.3%) and symptoms of psychosis (n = 66, 88%), as well as in tracking changes in symptoms (n = 70, 90.9%), and goals (n = 66, 86.9%). They also reported high interest in content being delivered as text (n = 69, 89.6%) and also in communicating directly with providers. Respondents were less interested in social features, and those with most negative attitudes toward help-seeking had particularly low interest in features related to disclosing symptoms to others. These results suggest mHealth may have potential to engage individuals with early psychosis, and that the most effective strategies may be those that are most straightforward, including direct psychoeducational information.

Cost Utility of cognition-enhancing interventions for individuals with first-episode psychosis: a naturalistic evaluation

Background

Although effective treatments are available to address the cognitive deficits experienced by individuals with first-episode psychosis, provision of such treatments within Coordinated Specialty Care (CSC) programs is rare. One factor that may contribute to this is uncertainty about the cost implications of providing cognitive-enhancing treatments within the American mental healthcare system. The aim of this study is to complete a naturalistic evaluation of the cost utility of incorporating two different cognitive-enhancing interventions within an American CSC program.

Methods

Participants included 66, predominately white (75.38%), individuals with first-episode psychosis (19 women and 47 men) with a mean age of 22.71 years. Quality adjusted life years (QALYs) and cost of care were tracked among these individuals during their participation in a CSC program. These data were compared among three groups of participants during their first six months of care: (i) individuals who participated in metacognitive remediation therapy (MCR), (ii) individuals who participated in computerized cognitive remediation (CCR), and (iii) individuals who participated in no cognitive-enhancing intervention.

Results

Participation in MCR, but not CCR, was associated with larger gains in QALYs than participation in no cognitive-enhancing intervention within a CSC program. Moreover, data support the cost utility of MCR as compared to CCR or no-cognitive enhancing intervention within a CSC program. Conversely, CCR did not appear to be a cost-effective addition to CSC services.

Conclusions

Our results highlight the potential cost utility of incorporating MCR within CSC programs for individuals with first-episode psychosis. However, given study limitations, these results should be interpreted cautiously until replicated by large, randomized controlled trials.

Trial Registration ClinicalTrials.gov Identifier NCT01570972, registered April 4, 2012, Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT01570972?term=breitborde&draw=2&rank=6.

Violence risk assessment for young adults receiving treatment for early psychosis

AIM

Although the absolute risk of violence is small for individuals with mental illnesses, a specific subgroup of individuals who appear to be at increased risk for violence includes young people experiencing emerging or early psychosis. Prior research has identified risk factors for violence in this population, though no prior studies using a formal risk assessment tool have been identified. This study used the Historical Clinical Risk Management-20, version 3 (HCR-20) to identify risk of future violence among a sample of young adults with early psychosis and relevant predictors of risk unique to this population.

METHODS

The HCR-20 was administered to a sample of young adults with early psychosis (N = 53) enrolled at one OnTrackNY site, part of a statewide program providing early intervention services to young adults presenting with a first episode of non-affective psychosis. A Confirmatory Factor Analysis (CFA) was conducted to explore the relative importance of the HCR-20 items for this population.

RESULTS

The average age of participants was 21.9 years (SD 3.6 years) and most were male (69.8%, n = 37). Most patients were assessed to be at low risk for future violence based on the Case Prioritization summary risk rating (67.9%, n = 36). The CFA identified 4 items that were not of relative predictive value in identifying the risk of violence in this sample: history of substance use (item H5), history of major mental disorder (item H6), living situation (item R2), and personal support (item R3).

CONCLUSION

This study presents a formal approach to assessing violence risk in a population at elevated risk of violence, demonstrates the feasibility of using a standardized risk assessment tool in early intervention services, and identifies factors of particular importance associated with predicting violence in this population. Future research should implement violence risk assessment with a structured tool such as the HCR-20 and assess its accuracy in predicting future violent behavior in this setting.