BEST PRACTICE SPOTLIGHT
First Episode Psychosis
WELCOME
The Institute for Excellence in Behavioral
Health is excited to present its very first Best
Practice Spotlight to its readers. The goal of a
Best Practice Spotlight is to provide information
concerning new and upcoming evidence-based
programs and practices and Kentucky’s role in
their implementation.
This issue focuses on first episode psychosis, the
RA1SE study, and the use of the EASA model
to implement coordinated specialty care in
Kentucky. Kentucky’s Department for Behavioral
Health, Developmental and Intellectual
Disabilities (KDBHDID) uses Federal Mental
Health Block Grant funding to develop a number
of evidence-based and best practice programs
in Kentucky communities. Currently, one of
the focuses is on introducing early intervention
programs for individuals suffering from first
episode psychosis.
First Episode Psychosis
Each year approximately 100,000 young people
between the ages of 15 and 25 are affected by
a condition known as first episode psychosis
(FEP).
First episode psychosis is an alarming and
distressing experience. A person affected
by this condition may suddenly begin to
experience hallucinations, delusions, confused
thinking, changes in feeling, and behavioral
changes. These symptoms can be devastating
to a young person’s daily functioning and can
cause an array of struggles for the individual.
Psychosis is not only troubling for the
individual experiencing the symptoms,
but also for family members and clinicians
providing care and support. Authors for the
National Institute of Mental Health identified
challenges families and health care providers
encounter when interacting with an individual
experiencing psychosis. The challenging
behaviors include: engaging in irrational
behaviors, directing aggression toward self or
others, difficulty communicating and relating,
and conflicts with authority figures (Heinssen,
Goldstein & Azrin, 2014).
In the past, several barriers existed that may
have prevented someone experiencing FEP
from receiving beneficial treatment. A major
challenge for most individuals is confronting
the stigma of mental illness by telling someone
about their symptoms. Another barrier to
consider is the possibility of a client falling
through the cracks between child and adult
services. Sometimes services may not meet
the client’s developmental needs and service
providers may not be aware of the services/
supports available. Additionally, there has
been a significant lag between a client’s first
episode and when supportive services have
been provided.
For many years there has been a push to
eliminate barriers and improve services
for those battling FEP. Extensive work has
been conducted to develop effective services
designed specifically to treat first episode
psychosis. Two decades worth of data
recommends early interventions following the
first episode of psychosis. The goal is to close
the gap between when client first experiences
psychosis and when treatment is actually
provided. Reaching out to clients early has
proven to be effective in reducing symptoms
and improving client functional recovery
(Heinssen, Goldstein & Azrin, 2014).
In 2014, Congress allocated additional funds
to the Substance Abuse and Mental Health
Services Administration (SAMHSA) to support
evidence-based treatments for first episode
psychosis. Currently states must set aside 5
percent of their Mental Health Block Grant
(MHBG) to support this action.
The evidence-based approach for addressing
FEP is through Coordinated Specialty
Care (CSC) which is supported by the
research initiative Recovery After an Initial
Schizophrenia Episode (RA1SE).
RA1SE and CSC
RA1SE was launched in 2009 by the National
Institute of Mental Health (NIMH) with the
intent to discover methods which would
successfully establish coordinated specialty care
programs for FEP in the United States. The
goal of the RA1SE initiative is to provide the
information, resources, and tools necessary
for those wishing to implement CSC in their
community.
Coordinated specialty care is the central
focus of the RA1SE project and is described
as being a team-based, multi-element
approach to treating FEP. Although there are
similarities, coordinated specialty care should
not be confused with the increasingly popular
Assertive Community Treatment (ACT).
Coordinated specialty care sets itself apart from
ACT with two key differences: (1) CSC targets
a specific and younger population (those aged
15-25) who have recently been diagnosed and
(2) CSC sets expectations for a time-limited
treatment of 2-3 years (Heinssen, Goldstein &
Azrin, 2014).
To be accepted into a CSC program for
treatment related to first episode psychosis, the
recommended inclusion criteria listed by the
National Alliance on Mental Illness (NAMI) is
as follows:
• Age range: 15-25 years
• Diagnosis: schizophrenia, schizoaffective
and schizophreniform disorders,
delusional disorder, psychosis not
otherwise specified (NOS)
• Duration of psychotic symptoms >1 week
and <2 years
• Ability to speak and understand English
• Anticipated availability to participate in
programming for 1 year
• NAMI also included a list of exclusion
criteria which include:
• Other diagnoses associated with psychosis
• Substance-induced disorder
• Psychotic affective disorder (e.g., major
depressive or manic episode with
psychotic features)
• Psychotic disorder due to a general
medical condition
• Medical conditions that impair function
independent of psychosis
• Intellectual disability
An essential characteristic of coordinated
specialty care is its collaborative and recoveryoriented approach (Heinssen, Goldstein &
Azrin, 2014). All members of the treatment
team work together toward a common goal
IN THIS ISSUE
Welcome to Best Practice
Spotlight
• Understanding First Episode
Psychosis
• Introducing the RA1SE Study and
Coordinated Specialty Care
• Discussing Kentucky’s
Implementation of Coordinated
Specialty Care with Support
from the Early Assessment and
Support Alliance (EASA) Model,
Including Updates on Two CSC
Start-Ups in KY
•
Issue #1: First Episode Psychosis 1
and, when applicable, supportive relatives
of respective clients are included in the
process. Understanding this collective effort
is imperative if CSC is to be implemented
successfully.
This article will briefly discuss the general
components of a CSC team but detailed
manuals for start-up ventures are available on
the National Institute of Mental Health website
(www.nimh.nih.gov).
Coordinated specialty care programs tend to
possess four to six team members, all sharing a
caseload of 30-35 clients. Each team member
is thoroughly trained in the principles of phasespecific care designed precisely for treating
clients affected by FEP (Heinssen, Goldstein &
Azrin, 2014). Teams may also opt to include
a team member with lived experience of
psychosis, as these individuals can directly
relate to consumers and create a more
welcoming environment for incoming clients.
An important aspect of CSC teams is the
frequent communication that takes place
among all professional participants. Weekly
meetings serve several purposes including:
focusing on all client’s recovery goals and
needs, increasing team confidence, and
improving program reliability (Heinssen,
Goldstein & Azrin, 2014). Frequent contact
is beneficial in keeping all providers informed
of client treatment concerns and recovery
progress.
There are six key roles that must be attended
to when developing a CSC team. These roles
include: team leadership, case management,
supported employment and education (SEE),
psychotherapy, family education and support,
and lastly, pharmacotherapy and primary care
coordination.
Several programs across the United States use
the basic framework of CSC to implement
early intervention programs for the treatment
of first episode psychosis. Programs may
slightly differ from one another but certain
core characteristics remain such as being
team-based, multi-element, collaborative and
recovery-oriented. Figure 1 briefly discusses
the four main programs functioning across
the country, including the model providing
consultation to Kentucky: the Early Assessment
and Support Alliance (EASA).
The EASA Model
In the early 2000’s, several countries gathered
to create the International Early Psychosis
Association. The intent was to create a forum
where countries could share their program
ideals and knowledge regarding early psychosis.
One major outcome of this meeting was
the development of the foundation of early
psychosis intervention strategies. Support for
early interventions for FEP began to spread
2
Issue #1: First Episode Psychosis
Programs Treating FEP across the US
(Figure 1)
• Early Assessment and Support
Alliance (EASA) (Oregon) – The first
statewide effort in the United States
to provide systematic early psychosis intervention for adolescents and
young adults. There are established
EASA programs or programs being
implemented in licensed public
mental health centers serving 32 of
Oregon’s 36 counties, reaching 94
percent of Oregon’s population.
• RA1SE Early Treatment Program
– CSC programs in 17 community
clinics located in urban, suburban,
and rural settings across the United
States.
• RA1SE Connection – CSC programs
in New York City, NY and Baltimore,
MD. Each team consists of four staff
members for a target caseload of 25
clients. A licensed clinician serves
as a full-time team leader.
• OnTrackNY (Yonkers, NY) – The
RA1SE connection program model
was modified to increase flexibility
and to allow for staff time to do CSC
outreach and evaluations for eligibility. CSC teams serve between
30-35 clients and require two FTE
licensed staff members who cover 4
roles: team leader, recovery coach,
primary care manager, and outreach
and recruitment coordinator. The
team leader must be fulltime.
internationally, eventually making its way to the
United States. Oregon is a pioneer in the field
with a well-established system in place to treat
clients experiencing psychosis.
Oregon’s Early Assessment and Support
Alliance (EASA) was created by the MidValley Behavioral Care Network, an
intergovernmental mental health managed
care organization in charge of publicly
funded mental health services under the
Oregon Health plan. EASA started providing
community level early psychosis interventions
in 2001, and was the first systematic integration
of population-wide early psychosis intervention
to the public mental health system in the
United States (Sale & Blajeski, 2015). As of
2007, EASA has been implemented statewide
using specific practice guidelines and has begun
the process of fidelity and evaluation.
EASA’s mission is to “Keep young people with
the early signs of psychosis on their normal
life paths by building community awareness
and offering easily accessible, effective
treatment and support.” The program has
set itself apart from other early intervention
teams by focusing on early detection and
community education while incorporating
multidisciplinary professionals and using
evidence-based practice. The program seeks to
support individuals experiencing FEP as they
complete their education, enter adult roles and
employment options, live in a safe and positive
environment, and participate in healthy social
groups while promoting positive well-being.
Participation in an EASA program requires the
following:
• Ages 12 – 25;
• Experienced FEP within the last 12
months; or
• Experiencing early at-risk symptoms of
psychosis
Kentucky’s Involvement
The need for early interventions is evidenced
by the facts listed in Figure 2. In previous
years, Kentucky has seen more than 900
individuals enter psychiatric facilities to treat
schizophrenia or related illnesses. Kentucky
saw a need to develop special programs
dedicated to early interventions for FEP, which
might also allow Kentuckians to receive the
best treatment available while remaining in
their communities. Kentucky’s Department
for Behavioral Health, Developmental and
Intellectual Disabilities responded by traveling
to Oregon to gain further insight as to how the
EASA model provided quality community care
for first episode psychosis. KDBHDID was
impressed by Oregon’s system and chose EASA
developers as consultants for CSC start-up sites
in Kentucky.
Kentucky’s start-up sites are located in two
regional community health centers: Mountain
Comprehensive Care Center and Cumberland
River Behavioral Health. The MCCC area
encompasses Prestonsburg and surrounding
counties, while the CRBH services Corbin and
contiguous counties.
The programs based in Kentucky have yet
to develop a name and currently use Early
The Facts (Figure 2)
• Psychotic disorders affect about 1% of
the US population over 18 years old
• There are 3 million adults living in
Kentucky
• About 30,000 Kentuckians will be
affected with a psychotic disorder
this year
• In 2013, 918 young adults with
schizophrenia or a related illness
entered Kentucky’s adult psychiatric
facilities
Number of Young Adults by Hospital:
Appalachian Regional Hospital: 168
Central State Hospital: 237
Eastern State Hospital: 294
Western State Hospital: 219
Total: 918
KEY COMPONENTS OF CSC IN KY (Figure 3)
Specialized Training in FEP
Ensures all new hires are competent in the structure and goals of CSC. Training also
emphasizes the vision of recovery for those with FEP. Thorough training materials are
available on the National Institute of Mental Health website (www.nimh.nih.gov).
Active Outreach and Engagement
Outreach specialists are utilized to connect the program to clients by developing a
number of valuable pathways. Relationships are key so institutions know to contact
the program to refer potential candidates for treatment.
Services Provided in Flexible Locations
A mobile outreach approach is adopted which differs greatly from traditional care
modalities. This method allows the program to reach out to clients in a variety of
settings to provide the essential care necessary for recovery. It is also beneficial
for the program to allow for a 24-hour on-call service for those clients who may be
experiencing crisis situations.
Acute Care During and Following
FEP
The structure of CSC teams allows for the acute care during and following the event
of FEP. Clients have frequent contact with all team members concerning their care.
Team members also maintain frequent communication among each other to ensure all
members are up-to-date on treatment and recovery goals. The previously discussed
mobile outreach and on-call personnel provide the consumer with the attentiveness
necessary to handle emergencies.
Step-Down Services and Support
Programs differ on the continuity of care following FEP with some programs limiting
their time to 2 years, while others recommend 5 years (Heinssen, Goldstein & Azrin,
2014). EASA participants progress through 5 phases with the last two phases focusing
on future planning. Phase 4 highlights transition and Phase 5 collaborates with clients
post-graduation. For more information on all phases visit: www.easacommunity.org/
easa -services
Fidelity Monitoring
Fidelity monitoring should answer 3 key questions concerning CSC implementation:
1. Are CSC team members implementing interventions as intended?
2. Are providers delivering what was promised in the service contract?
3. Have CSC services achieved desired clinical and functional outcomes for clients?
(Heinssen, Goldstein & Azrin, 2014)
Interventions for First Episode Psychosis as
an interim descriptor. Eventually it is the
program’s wish to speak with young people and
their families to discuss name possibilities. This
conjoint effort will result in a title that appeals
to a younger population.
Treating first episode psychosis using a CSC
framework in Kentucky is an up and coming
venture and the programs are in the earliest
stages of development. Funding to start-up
sites began in July 2015 but neither site will
begin to provide services until January 2016.
A six month period was set aside so planning
and training could take place, along with
community conversation to inform potential
stakeholders about the program’s goals and
services.
Throughout this six month period the basic
components of CSC in Kentucky have been
cultivated, closely following guidelines
developed by EASA. Figure 3 discusses
these components in more detail. These key
elements are essential for any program to
operate smoothly and Kentucky has carefully
included each component in the program
design. Operation only occurs if each program
is staffed by the appropriate personnel. Key
roles for CSC programming in Kentucky is
further discussed in Figure 4. Kentucky will
ensure each role is successfully fulfilled before
accepting clients into treatment.
Carefully assembled programs and teams will
allow the programs to achieve many milestones.
Kentucky’s goals closely match those of other
CSC programs across the country by striving
to provide quality early interventions for those
who are at risk or those who are developing
first episode psychosis. Historically, the gap
between the onset of first episode psychosis
and when the consumer received treatment has
been too long. Kentucky plans to change this
pattern by connecting individuals to treatment
as soon as possible.
KENTUCKY UPDATES
2015 Planning Year
• All CMHCs have designated at least
one child services and one adult
services key contact for Early Interventions for First Episode Psychosis
Programming for their region.
• Stakeholder planning meetings were
held regarding implementation of
CSC.
• DBHDID selected two CMHCs as startup sites (Mountain Comprehensive
Care Center and Cumberland River
Behavioral Health).
• The two start-up sites were allowed
six (6) months of planning.
• Tamara Sale and Dr. Ryan Melton at
EASA will provide overall technical
assistance to Kentucky concerning
the implementation of CSC. RA1SE
and OnTrack NY will also be used as
Involving the community in the process is
one of the most effective ways to provide
quality care for first episode psychosis. A key
component of CSC programming is engaging
with the community. It is realized early on
that if the programs are to be successful, the
community must understand the program
objectives. Kentucky has already made great
strides in connecting programs with the
community.
•
consultants on an as needed basis.
Dr. Cathy Batscha from UofL will
provide technical assistance around
clinical issues for this population.
2016 Implementation Year
• Meetings held in September 2015
introduced community partners to
CSC and provided training to program
staff on CBT for psychosis.
• DBHDID/IPOP will generate a report
through existing data collection efforts that will begin to capture data
related to youth and young adults
with, or at risk of FEP.
• DBHDID will provide technical assistance, training and ongoing support
to the two start-up sites. Additional
statewide trainings and support will
also be held for the remaining regions
in order to ensure success.
Issue #1: First Episode Psychosis 3
At this stage of development, Kentucky has
developed multiple community partnerships
and created an implementation team.
Stakeholder planning meetings were held
regarding implementation and in September of
2015, community partners were introduced to
coordinated specialty care. Upon introduction
to CSC, an overview of CBT for psychosis was
provided to each program’s staff. Additionally,
all community mental health centers have
designated at least one child services and one
adult services key contact in their region to
connect potential clients to early interventions
for FEP.
out: http://www.nasmhpd.org/content/information-guide-steps-and-decision-points-starting-early-psychosis-program
Want Additional Information?
Helpful Sites:
• The National Alliance on Mental Illness
discusses first episode psychosis in more
detail: https://www.nami.org/Learn-More/
Mental-Health-Conditions/Related-Conditions/Psychosis/First-Episode-Psychosis
Ultimately, Kentucky plans to see early
interventions for first episode psychosis spread
across the state. Individuals have been busy
laying the necessary groundwork to expand
coordinated specialty care for FEP beyond the
initial start-up sites. Currently, Kentucky is
targeting to achieve state-wide implementation
within six years.
REFERENCES
Heinssen, R.K, Goldstein, A.B & Azrin, S.T.
(2014). Evidence-based treatments for first
episode psychosis: Components of coordinated specialty care. Retrieved October 27, 2015.
Check it out: http://www.nimh.nih.gov/health/
topics/schizophrenia/raise/nimh-white-papercsc-for-fep_147096.pdf
PROJECT
LEADERSHIP
Leaders should be experienced and able to provide ongoing
guidance to other team members. Major tasks include managing team functions and coordinating key services.
OUTREACH
SPECIALIST
These specialists are the community’s link to the program
providing services. Specialists maintain connections within
the community so individuals may be referred to treatment
for FEP.
CASE MANAGEMENT
Case managers maintain frequent contact with clients and
family members. Case managers remain flexible, meeting a
client in his/her environment if needed. Tasks include: assisting the client in problem solving, offering practical solutions
to problems, and coordinating social services.
SUPPORTED
EMPLOYMENT &
EDUCATION (SEE)
SEE employees meet with clients to determine the client’s
educational and employment goals. If the client expresses an
interest, the SEE specialist strives for rapid placement for the
client.
PSYCHOTHERAPY
Emphasis is placed on resilience training, illness and wellness
management, and the development of general coping skills.
FAMILY EDUCATION
& SUPPORT
Aims to teach relatives or alternative support systems about
psychosis and its treatment. Those in a client’s life are then
more capable to aide in the client’s recovery.
PHARMACOTHERAPY Evidence-based pharmacologic approaches guide medication
& PRIMARY CARE
selection and dosing for first episode psychosis. Providers pay
COORDINATION
close attention to cardiometabolic risk factors and maintain
close contact with primary care providers (Heinssen, Goldstein & Azrin, 2014).
Sale, T. & Blajeski S. (2015) Steps and decision points in starting an early psychosis
program. NASMHPD Publications. Check it
• Melissa Runyon
BH Program Administrator
502-782-6187
[email protected]
•
For additional material on the RA1SE research project, visit the National Institute
of Mental Health website. Link to informational RA1SE page: http://www.nimh.
nih.gov/health/topics/schizophrenia/raise/
raise-questions-and-answers.shtml
Visit the Early Assessment & Support
Alliance website to gain further insight
into the model providing consultation to
Kentucky programs: http://www.easacommunity.org/
TEAM MEMBER ROLES (FIGURE 4)
An early success has been Kentucky’s ability
to provide thorough education to CMHC’s
regarding early interventions and its benefits.
The programs’ wish is to reach out not only
to CMHC’s but also to those living in the
community to provide quality education
concerning first episode psychosis. The desired
outcome of community education efforts is to
greatly reduce the stigma surrounding mental
illness.
Kentucky Division of Behavioral Health
• Janice Johnston, LCSW
BH Program Administrator
502-782-6170
[email protected]
•
PEER SUPPORT
Peer support is fulfilled by individuals who have personally experienced psychosis. These individuals can offer their wisdom
to newcomers and create a sense of understanding and hope.
OCCUPATIONAL
THERAPY
Assist clients to identify and improve cognitive and sensory
issues. Occupational therapists break down tasks, pinpoint
adjustments and develop routines (Sale & Blajeski, 2015).
CONTACT INFO
Kentucky’s Start-Up Sites
Cumberland River Behavioral Health
• Samantha Reid
[email protected]
• Angela Silva
[email protected]
Mountain Comprehensive Care Center
• Angela Parker
[email protected]
• Rachel Ratliff
[email protected]
Institute for Excellence in Behavioral
Health
Louis Kurtz, M.Ed.
Interim Director
229 Mattox Hall
521 Lancaster Avenue
Richmond, Kentucky, 40475
Office: 859-622-7281
Fax: 859-622-8609
[email protected]
[email protected]
The Institute for Excellence in Behavioral Health is a contracted initiative of the Department for Behavioral Health, Developmental and
Intellectual Disabilities in partnership with the Training Resource Center at Eastern Kentucky University.
4
Issue #1: First Episode Psychosis