Results of a Coordinated Specialty Care Program for Early Psychosis and Predictors of 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.

Reimbursement for a Broader Array of Services in Coordinated Specialty Care for Early Psychosis

Despite the growing evidence supporting the benefits of coordinated specialty care (CSC) for early psychosis, access to this multimodal, evidence-based program in the United States has been hindered by a lack of funding for core CSC services and activities. The recent approval of team-based reimbursement codes by the Centers for Medicare and Medicaid Services has the potential to fund substantially more CSC services for clients with insurance coverage that accepts the new team-based billing codes. This streamlined and more inclusive billing strategy may reduce administrative burden and support the financial viability of CSC programs.

Measures of Social and Occupational Function in Early Psychosis: A Systematic Review and Meta-analysis

Deficits in social and occupational function are widely reported in psychosis, yet no one measure of function is currently agreed upon as a gold standard in psychosis research. The aim of this study was to carry out a systematic review and meta-analysis of functioning measures to determine what measures were associated with largest effect sizes when measuring between-group differences, changes over time, or response to treatment. Literature searches were conducted based on PsycINFO and PubMed to identify studies for inclusion. Cross-sectional and longitudinal observational and intervention studies of early psychosis (≤5 years since diagnosis) that included social and occupational functioning as an outcome measure were considered. A series of meta-analyses were conducted to determine effect size differences for between-group differences, changes over time, or response to treatment. Subgroup analyses and meta-regression were carried out to account for variability in study and participant characteristics. One hundred and sixteen studies were included, 46 studies provided data (N = 13 261) relevant to our meta-analysis. Smallest effect sizes for changes in function over time and in response to treatment were observed for global measures, while more specific measures of social and occupational function showed the largest effect sizes. Differences in effect sizes between functioning measures remained significant after variability in study and participant characteristics were accounted for. Findings suggest that more specific measures of social function are better able to detect changes in function over time and in response to treatment.

Putting measurement-based care into action: A mixed methods study of the benefits of integrating routine client feedback in coordinated specialty care programs for early psychosis

Background

Measurement-based care (MBC) is an effective tool in the delivery of evidence-based practices (EBPs). MBC utilizes feedback loops to share information and drive changes throughout a learning healthcare system. Few studies have demonstrated this practice in team-based care for people with early psychosis. This paper describes the development of a personalized feedback report derived from routine assessments that is shared with clients and clinicians as part of a MBC process.

Methods

We used a quasi pre-post comparison design with mixed methods to evaluate the implementation of a personalized feedback report at 5 early psychosis coordinated specialty care programs (CSC). We compared clients enrolled in CSC who did and did not receive a feedback report over the first 6 months of treatment. The sample included 204 clients: 146 who did not receive the feedback report and were enrolled over 2 years, and 58 who received the feedback report. A subset of 67 clients completed measures at both intake and 6-month follow-up, including 42 who received the report and 25 who did not. We compared the two groups with regard to self-reported symptoms, likelihood of completing treatment, and perception of shared decision making. We conducted qualitative interviews with 5 clients and 5 clinicians to identify the benefits and challenges associated with the personalized feedback report.

Results

People who received a personalized feedback report reported significant improvements in shared decision-making and had greater improvements over time in their intent to attend future treatment sessions. They engaged in more sessions for Supported Employment and Education (SEE), case management, and peer support, and fewer medication visits over the first 6 months of treatment. Both groups showed significant improvement in symptoms and functioning. Results from the qualitative analysis indicated that the experience of receiving the reports was valuable and validating for both patients and clinicians.

Conclusions

A personalized feedback report was integrated into standard of care for early psychosis programs. This process may improve shared decision-making, strengthen the likelihood to stay in treatment, and increase engagement in psychosocial interventions. We posit that this process facilitates strengths-focused discussions, enhances intrinsic motivation, and strengthens the therapeutic alliance.

"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.

Perspectives of young adults diagnosed with early psychosis using coordinated specialty care in Texas on substance use and substance use interventions

AIM

Despite known prevalence of substance use (SU) among young people experiencing early psychosis and increasing evidence for the relationship between certain substances (e.g., cannabis) and psychosis, there are no specialized interventions developed for effectively addressing substance use among young people participating in coordinated early psychosis services. This study elicited the perspectives of young people with early psychosis participating in Coordinated Specialty Care (CSC) programs about their substance use, including their motivations and concerns around their use, and their ideas on how to best support young people who are interested in reducing or quitting substance use.

METHODS

We recruited young adults (ages 18 to 30) from CSC programs across Texas through flyers sent to program staff inviting young persons willing to talk about substance use to engage in a 60-90 min person-centered, semi-structured, audio-recorded Zoom interview.

RESULTS

A total of 22 young adults were recruited and 18 completed an interview. Participants described mixed positive and negative responses to substance use, and while many understood the importance of discontinuing substance use, many expressed ambivalence related to social, contextual, mental and physical factors that motivated them to keep using. Participants desired practical substance use information, opportunities to explore their substance use ambivalence in supportive relationships, positive peer communities to support healthy choices, help engage, with work, school, and hobbies, and strategies for addressing psychological and physical pain that did not include substance use.

CONCLUSION

Study findings illuminate what motivates young people with early psychosis to initiate, continue, or cut back on substance use, and ideas for CSC practices for exploring substances and helping young people to reduce substance use.

The effect of duration of untreated psychosis (DUP) on the risk for hospitalization after admission to a first episode service

Engagement with a first episode-psychosis service (FES) reduces the risk of psychiatric hospitalization. However, the role of the duration of untreated psychosis (DUP) in impacting this outcome is disputed. This study aimed to examine whether DUP was an effect modifier of the post-FES reduction of risk of hospitalization, and to explore associations between patients' characteristics and hospitalization post-FES. Individuals aged 16-35 with recent onset (< 3 years) of non-affective psychosis, admitted to the Program for Specialized Treatment Early in Psychosis (STEP), a FES serving the Greater New Haven area, Connecticut, between 2014 and 2019 were included (N = 189). Medical records were queried from 2013 through 2020 for number and duration of psychiatric hospitalizations. Poisson regression models were used to estimate incidence rate ratios for hospitalization rates across all explanatory variables. Negative binomial regression was used to compare the length of stay (LOS) before vs after STEP enrollment. STEP admission was associated with a significant 90 % reduction in the frequency and duration of hospitalizations. This effect was moderated by DUP: with 30-day prolongations in components of DUP (supply, demand, and total) there was less reduction in hospitalizations and LOS after FES enrollment (p < .0001). Only DUP supply (time from first antipsychotic use to STEP admission) differentiated those who were hospitalized during the first year after STEP enrollment from those who were not (median: 35 vs. 15 weeks, p = .003). To fully harness the positive impact of FES on hospitalization, a detailed effort should be pursued to reduce all DUP components.

Illness Phase as a Key Assessment and Intervention Window for Psychosis

The phenotype of schizophrenia, regardless of etiology, represents the most studied psychotic disorder with respect to neurobiology and distinct phases of illness. The early phase of illness represents a unique opportunity to provide effective and individualized interventions that can alter illness trajectories. Developmental age and illness stage, including temporal variation in neurobiology, can be targeted to develop phase-specific clinical assessment, biomarkers, and interventions. We review an earlier model whereby an initial glutamate signaling deficit progresses through different phases of allostatic adaptation, moving from potentially reversible functional abnormalities associated with early psychosis and working memory dysfunction, and ending with difficult-to-reverse structural changes after chronic illness. We integrate this model with evidence of dopaminergic abnormalities, including cortical D1 dysfunction, which develop during adolescence. We discuss how this model and a focus on a potential critical window of intervention in the early stages of schizophrenia impact the approach to research design and clinical care. This impact includes stage-specific considerations for symptom assessment as well as genetic, cognitive, and neurophysiological biomarkers. We examine how phase-specific biomarkers of illness phase and brain development can be incorporated into current strategies for large-scale research and clinical programs implementing coordinated specialty care. We highlight working memory and D1 dysfunction as early treatment targets that can substantially affect functional outcome.

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.

Recent substance use among clients with early psychosis and the potential to graduate from New Journeys

AIM

This study examined the relationship between recent substance use prior to intake and program graduation among young adults with early psychosis enrolled in coordinated specialty care.

METHODS

Participants (N = 248) were from New Journeys, a network of coordinated specialty care programs in Washington State. Recent (i.e., past 30 days) alcohol, cannabis, and other substance use was collected at intake and process data (e.g., contact) was collected by clinicians across a 2-year period.

RESULTS

At intake, 32% of participants reported alcohol use only, 26% cannabis use only, and 15% both alcohol and cannabis use. Participants who reported alcohol use only (p = .02), cannabis use only (p = .03), and any substance use (p = .02) had significantly lower chances of graduating from coordinated specialty care than individuals who do not use substances.

CONCLUSIONS

Unlike prior work, recent substance use influences clients' potential to graduate from New Journeys. Additional focus on the implementation of substance use treatment, with an emphasis on alcohol use, in coordinated specialty care programs is needed improve program completion rates.

User experiences of an American-adapted moderated online social media platform for first-episode psychosis: Qualitative analysis

Objectives

The current study sought to qualitatively characterize the experiences of American users in a recent open trial of the Horyzons digital platform.

Methods

In total, 20 users on Horyzons USA completed semistructured interviews 12 weeks after their orientation to the platform and addressed questions related to (1) the platform, (2) their online therapist, and (3) the peer workers and community space. A hybrid inductive-deductive coding strategy was used to conduct a thematic analysis of the data (NCT04673851).

Results

The authors identified seven prominent themes that mapped onto the three components of self-determination theory. Features of the platform itself as well as inter- and intra-personal factors supported the autonomous use of Horyzons. Users also reflected that their perceived competence in social settings and in managing mental health was increased by the familiarity, privacy, and perceived safety of the platform and an emphasis on personalized therapeutic content. The behaviors or traits of online therapists as perceived by users and regular contact with peers and peer support specialists satisfied users' need for relatedness and promoted confidence in social settings. Users also described aspects of Horyzons USA that challenged their satisfaction of autonomy, competence, and relatedness, highlighting potential areas for future iterations of the platform's content and interface.

Conclusions

Horyzons USA is a promising digital tool that provides young adults with psychosis with the means to access tailored therapy material on demand and a supportive digital community to aid in the recovery process.

Prediction Tool for Individual Outcome Trajectories Across the Next Year in First-Episode Psychosis in Coordinated Specialty Care

Importance

In coordinated specialty care (CSC) settings for people with a first episode of psychosis, the development of reliable, validated individual-level prediction tools for key outcomes may be informative for shared clinician and client decision-making.

Objective

To develop an individual-level prediction tool using machine-learning methods that predicts a trajectory of education/work status or psychiatric hospitalization outcomes over a client's next year of quarterly follow-up assessments. Additionally, to visualize these predictions in a way that is informative to clinicians and clients.

Design, Setting, and Participants

Individual-level data were collected for all patients enrolled in the OnTrackNY program at enrollment and at quarterly follow-ups using standardized forms. The OnTrackNY program, a network of CSC sites in New York State, provides person-centered, recovery-oriented, and evidence-based psychosocial and pharmaceutical interventions to individuals aged 16 to 30 years with recent-onset (<2 years) nonaffective psychosis. Although data collection is ongoing, data for this study were collected from October 2013 to December 2018, and the time frame for analysis was July 2020 to May 2021. Data were separated into a training/cross-validation set to perform internally validated model development and a separate holdout test set (~20% of the sample) for external validation. Random probability forest models were developed to predict individual-level trajectories of outcomes.

Exposures

Forty-three individual-level demographic and clinical features collected at enrollment in OnTrackNY, 25 of which were time-varying and updated at quarterly follow-up assessments, and 13 site-level demographic and economic census variables.

Main Outcomes and Measures

Individual-level education and/or employment status and psychiatric hospitalization trajectories at quarterly follow-up periods across the first 2 years of CSC.

Results

The total study sample consists of 1298 individuals aged 16 to 30 years and included 341 women (26.3%), 949 men (73.1%), and 8 (<1%) with another gender. Prediction models performed well for 1-year trajectories of education/work across all validation sets, with areas under the receiver operating characteristic curve (AUCs) ranging from 0.68 (95% CI, 0.63-0.74) to 0.88 (95% CI, 0.81-0.96). Predictive accuracy for psychiatric hospitalization 3 months ahead reached AUC above 0.70; moreover, predictions of future psychiatric hospitalizations at 6 months and beyond were consistently poor, with AUCs below 0.60. Given the good externally validated performance for predicting education/work, a prototype interactive visualization tool displaying individual-level education/work trajectories and related features was developed.

Conclusions and Relevance

This study suggests that accurate prediction tools can be developed for outcomes in people with first-episode psychosis, which may help inform shared clinician/client decision-making. Future work should study the effectiveness of its deployment, including proper communication to inform shared clinician/client decision-making in the context of a learning health care system. At present, more work is needed to develop better performing prediction models for future psychiatric hospitalizations before any tool is recommended for this outcome.

Established Outpatient Care and Follow-Up After Acute Psychiatric Service Use Among Youths and Young Adults

OBJECTIVE

This study explored follow-up after hospitalization and emergency room (ER) use for mental health among youths and young adults with private insurance.

METHODS

The IBM MarketScan commercial database (2013-2018) was used to identify people ages 12-27 with a mental health hospitalization (N=95,153) or ER use (N=108,576). Factors associated with outpatient mental health follow-up within 7 and 30 days of discharge were determined via logistic models with generalized estimating equations that accounted for state variation.

RESULTS

Of those hospitalized, 42.7% received follow-up within 7 days (67.4% within 30 days). Of those with ER use, 28.6% received follow-up within 7 days (46.4% within 30 days). Type of established outpatient care predicted follow-up after hospitalization and ER use. Compared with people with no established care, the likelihood of receiving follow-up within 7 days was highest among those with mental health and primary care (hospitalization, adjusted odds ratio [AOR]=2.81, 95% confidence interval [CI]=2.68-2.94; ER use, AOR=4.06, 95% CI=3.72-4.42), followed by those with mental health care only (hospitalization, AOR=2.57, 95% CI=2.45-2.70; ER use, AOR=3.48, 95% CI=3.17-3.82) and those with primary care only (hospitalization, AOR=1.20, 95% CI=1.15-1.26; ER use, AOR=1.22, 95% CI=1.16-1.28). Similar trends were observed within 30 days of discharge.

CONCLUSIONS

Follow-up rates after acute mental health service use among youths and young adults were suboptimal. Having established mental health care more strongly predicted receiving follow-up than did having established primary care. Improving engagement with outpatient mental health care providers may increase follow-up rates.

A Scoping and Systematic Review of Employment Processes and Outcomes for Young Adults Experiencing Psychosis

Young adults who experience psychosis want to work but are less likely to be employed than their peers. Sixty two studies relating to young adults with psychosis and employment were reviewed following a systematic search of five databases: CINAHL, PsycINFO, MEDLINE, SCOPUS and EMBASE. Publication date ranged from 1973 to 2019 with > 70% between 2010 and 2019. Intervention was considered in 29 papers; critical appraisal revealed 90% of these had moderate to good methodological quality with only three RCTs. Of 11 intervention types "Early Intervention" and "Individual Placement and Support" were most common; both demonstrating positive impact on obtaining employment. The review identified minimal participant perspectives and great variability in: terminology used; the reporting of participant attributes; intervention characteristics and ways employment outcomes were measured. Employment processes identified were preparing for, seeking, obtaining, keeping and re-obtaining employment, with current research efforts focused on obtaining work. More focus is required on keeping and re-obtaining employment.

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).

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.

Structural Racism and Inequities in Incidence, Course of Illness, and Treatment of Psychotic Disorders Among Black Americans

Psychotic disorders (e.g., schizophrenia, schizoaffective disorder) are a leading cause of morbidity and premature mortality and an overlooked health inequity in the United States. European data indicate inequities in incidence, severity, and treatment of psychotic disorders, particularly for Black communities, that appear to be primarily attributable to social adversities. The dominant US narrative is that any observed differences are primarily a result of clinician bias and misdiagnosis. We propose that employing the framework of structural racism will prompt European and US research to converge and consider the multifaceted drivers of inequities in psychotic disorders among Black Americans. In particular, we describe how historical and contemporary practices of (1) racialized policing and incarceration, and (2) economic exploitation and disinvestment, which are already linked to other psychiatric disorders, likely contribute to risks and experiences of psychotic disorders among Black Americans. This framework can inform new strategies to (1) document the role of racism in the incidence, severity, and treatment of psychotic disorders; and (2) dismantle how racism operates in the United States, including defunding the police, abolishing carceral systems, and redirecting funds to invest in neighborhoods, housing, and community-based crisis response and mental health care. (Am J Public Health. 2022;112(4):624-632. https://doi.org/10.2105/AJPH.2021.306631).

Rates of Inpatient and Emergency Room Use Before and After Discharge Among Medicaid Enrollees in OnTrackNY

OBJECTIVE

This study examined hospital and emergency room (ER) use among Medicaid enrollees before and after discharge from OnTrackNY, a coordinated specialty care program for recent-onset psychosis.

METHODS

Medicaid claims data were linked to program data. Inpatient hospitalization, inpatient days, and ER visits were assessed in the 6 months prior to OnTrackNY enrollment and 6 months prior to and after discharge. The sample consisted of 138 participants with continuous Medicaid enrollment during the study.

RESULTS

Inpatient visits significantly declined from the pre-OnTrackNY enrollment period to the predischarge period (β=-1.23, standard error [SE]=0.22, p<0.001), did not significantly change in the first 6 months after discharge (β=0.19, SE=0.26, p=0.48), and remained significantly lower than before OnTrackNY enrollment (β=-1.05, SE=0.20, p<0.001). Similar patterns were observed for inpatient days and ER use.

CONCLUSIONS

ER and hospital use declined during OnTrackNY participation and did not significantly change in the first 6 months after discharge.

Implementation of NAVIGATE for first episode psychosis in Israel: Clients' characteristics, program utilization and ratings of change

OBJECTIVE

NAVIGATE is a comprehensive treatment program for first episode psychosis developed and implemented in the US that has been found to be effective. The purpose of the present study was to describe the first initiative of NAVIGATE's implementation outside the US, and to present data collected in Israel from the first two clinics focusing on NAVIGATE clients' characteristics, components utilization and retrospective clinician ratings of change.

METHODS

Administrative data for 61 NAVIGATE clients in Israel and retrospective ratings of NAVIGATE clinicians were analysed.

RESULTS

The duration of untreated psychosis was 4.4 months (SD = 6.8). Clients were mostly referred to NAVIGATE from psychiatric hospitals (n = 29, 50.9%) and community mental health agencies (n = 20, 35.1%). The individualized resiliency training (IRT) component had the highest client utilization rate (n = 53, 98.1%) with a monthly average of M = 2.32 sessions (SD = 2.75). Clinicians' retrospective ratings indicated that 66% of the clients (n = 33) had improved in at least one life domain, with the most common improvement in employment (n = 28, 56%), recovery (n = 24, 50%), and symptoms severity (n = 23, 47%).

CONCLUSIONS

Our findings reveal that NAVIGATE can be implemented outside the US within a different social and cultural context and different mental health system. The utilization rates of the program components and clinicians' retrospective ratings indicated positive change among most of NAVIGATE clients, pointing to the potential value of NAVIGATE above and beyond different countries and health systems.

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.

Insurance Status and Continuity for Young Adults With First-Episode Psychosis

OBJECTIVE

Insurance status and continuity may affect access to and quality of care. The authors characterized patterns of and changes in insurance status over 1 year among people with first-episode psychosis (FEP), comparing insurance patterns with adults of similar age in the general population.

METHODS

Longitudinal data on insurance status and predictors of insurance status among adults with FEP were obtained from RAISE-ETP (Recovery After an Initial Schizophrenia Episode-Early Treatment Program) study participants with complete 1-year data (N=288). The frequencies of insurance status and transitions are presented. Bivariate comparisons were used to assess the impact of the comprehensive coordinated care intervention in RAISE-ETP on insurance changes. These data were compared with contemporaneous longitudinal data in the 2011 Medical Expenditures Panel Study.

RESULTS

The RAISE-ETP experimental intervention did not significantly change insurance status. At baseline, levels of uninsurance (47%) and public insurance (31%) were higher among RAISE-ETP participants than among a similar age group in the general public (29% and 13%, respectively). Insurance transitions were common among people with FEP, although 79% of those with public insurance at baseline also had public insurance at 1 year. Of studied RAISE-ETP participants, 60% had a period of uninsurance during the year studied.

CONCLUSIONS

Compared with a national sample, people with FEP were more likely to use public insurance but still had high persistence of 12-month uninsurance. That over half of the RAISE-ETP participants had a period of uninsurance suggests that more research is needed on whether these periods affect treatment continuity and medication adherence.

Sociodemographic, clinical and help-seeking characteristics of homeless young people with recent onset of psychosis enrolled in specialized early intervention services

AIM

To examine differences in demographic, clinical, social, functional and help-seeking characteristics of homeless vs housed individuals enrolled in specialized early intervention teams in the United States.

METHODS

Participants comprised 1349 individuals enrolled across 21 teams. Teams report individual-level data including homelessness status at admission. Bivariate differences between homeless and housed participants were analysed using Wilcoxon-rank, chi-square, Fisher-exact and t tests, as appropriate.

RESULTS

Approximately 5% of participants were homeless at admission. Homeless participants were less likely to be enrolled in school and/or employed (12.2% vs 43.4%); to have more involvement in the legal system (23.0% vs 6.2%); and to have had a more restrictive pathway to care, than housed participants.

CONCLUSIONS

Homeless young people with recent-onset psychosis have a substantially greater need for a diversity of services for psychosocial needs. Homeless individuals may also have a more adverse pathway to care and directed outreach to engage this population may be needed.

Adapting coordinated specialty care in the post-COVID-19 era: study protocol for an integrative mixed-methods study

BACKGROUND

Coordinated Specialty Care (CSC) programs provide evidence-based services for young people with a recent onset of a psychotic disorder. OnTrackNY is a nationally recognized model of CSC treatment in New York state. In 2019, OnTrackNY was awarded a hub within the Early Psychosis Intervention Network (EPINET) to advance its learning health care system (LHS). The OnTrackNY network is comprised of 23 CSC teams across New York state. OnTrack Central, an intermediary organization, provides training and implementation support to OnTrackNY teams. OnTrack Central coordinates a centralized data collection protocol for quality improvement and evaluation of program fidelity and a mechanism to support practice based-research. OnTrackNY sites' breadth coupled with OnTrack Central oversight provides an opportunity to examine the impacts of the COVID-19 crisis in New York State, and supplementary funding was awarded to the OnTrackNY EPINET hub in 2021 for that purpose.

METHODS

This project will examine the implications of modifications to service delivery within the OnTrackNY LHS during and after the COVID-19 crisis. We will use the Framework for Reporting Adaptations and Modification-Enhanced (FRAME) to classify systematically, code, and analyze modifications to CSC services and ascertain their impact. We will utilize integrative mixed methods. Qualitative interviews with multi-level stakeholders (program participants, families, providers, team leaders, agency leaders, trainers (OnTrack Central), and decision-makers at the state and local levels) will be used to understand the process of making decisions, information about modifications to CSC services, and their impact. Analysis of OnTrackNY program data will facilitate examining trends in team staffing and functioning, and participant service utilization and outcomes. Study findings will be summarized in a CSC Model Adaptation Guide, which will identify modifications as fidelity consistent or not, and their impact on service utilization and care outcomes.

DISCUSSION

A CSC Model Adaptation Guide will inform CSC programs, and the state and local mental health authorities to which they are accountable, regarding modifications to CSC services and the impact of these changes on care process, and participant service utilization and outcomes. The guide will also inform the development of tailored technical assistance that CSC programs may need within OnTrackNY, the EPINET network, and CSC programs nationally.

TRIAL REGISTRATION

NCT04021719 , July 16th, 2019.

Defining and Addressing Gaps in Care for Obsessive-Compulsive Disorder in the United States

OBJECTIVE

Obsessive-compulsive disorder (OCD) can be a chronic and disabling illness with a lifetime prevalence of 2%, twice that of schizophrenia. Although effective treatments exist, OCD often remains underdetected and undertreated.

METHODS

The authors performed a scoping review of the literature (of articles in PubMed and PsycINFO published from January 1, 2000, to February 1, 2020) to define gaps in OCD diagnosis and treatment among U.S. adults. Interventions at the patient, clinician, and health care system levels used to address these gaps are described, and promising approaches from around the world are highlighted.

RESULTS

Of 102 potential studies identified in the search, 27 (including five non-U.S. studies) were included. The studies revealed that lack of clinician and patient knowledge about OCD and misdiagnosis contributes to its underdetection. Suboptimal prescribing of selective serotonin reuptake inhibitor medications and limited use of exposure and response prevention, as a first-line psychotherapy, contribute to OCD undertreatment. Digital health technologies show promise in increasing OCD detection and delivery of evidence-based care and in ensuring continuity of care (including during the COVID-19 pandemic).

CONCLUSIONS

Given the significant rates of disability, morbidity, and mortality associated with OCD, addressing gaps in OCD care will reduce the U.S. burden of mental illness. Further research is needed to determine how the use of digital health technologies can increase the detection and management of OCD.

The impact of neighbourhood crime on mental health: A systematic review and meta-analysis

BACKGROUND

Growing evidence indicates that the residential neighbourhood contributes to the complex aetiology of mental disorders. Although local crime and violence, key neighbourhood stressors, may be linked to mental health through direct and indirect pathways, studies are inconclusive. This systematic review and meta-analysis aimed to synthetize the evidence on the association between neighbourhood crime and individual-level mental health problems.

METHOD

We searched 11 electronic databases, grey literature and reference lists to identify relevant studies published before September 14, 2020. Studies were included if they reported confounder-adjusted associations between objective or perceived area-level crime and anxiety, depression, psychosis or psychological distress/internalising symptoms in non-clinical samples. Effect measures were first converted into Fisher's z-s, pooled with three-level random-effects meta-analyses, and then transformed into Pearson's correlation coefficients. Univariate and multivariate mixed-effects models were used to explore between-study heterogeneity.

RESULTS

We identified 63 studies reporting associations between neighbourhood crime and residents' mental health. Pooled associations were significant for depression (r = 0.04, 95% CI 0.03-0.06), psychological distress (r = 0.04, 95% CI 0.02-0.06), anxiety (r = 0.05, 95% CI 0.01-0.10), and psychosis (r = 0.04, 95% CI 0.01-0.07). Moderator analysis for depression and psychological distress identified stronger associations with perceived crime measurement and weaker in studies adjusted for area-level deprivation. Importantly, even after accounting for study characteristics, neighbourhood crime remained significantly linked to depression and psychological distress. Findings on anxiety and psychosis were limited due to low number of included studies.

CONCLUSIONS

Neighbourhood crime is an important contextual predictor of mental health with implications for prevention and policy. Area-based crime interventions targeting the determinants of crime, prevention and service allocation to high crime neighbourhoods may have public mental health benefits. Future research should investigate the causal pathways between crime exposure and mental health, identify vulnerably groups and explore policy opportunities for buffering against the detrimental effect of neighbourhood stressors.

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.

Association of Follow-Up After an Emergency Department Visit for Mental Illness with Utilization Based Outcomes

Follow-up within 30 days of an emergency department (ED) visit for mental illness is a new and widely-used quality measure. However, no empirical evidence validates associations between follow-up and subsequent utilization based outcomes. Using Massachusetts all payer claims data, we identified insured individuals with an ED visit for mental illness. Multivariate regression analysis estimated associations between follow-up within 30 days after an ED visit for mental illness with costs, hospitalizations, and additional ED visits in 180 days following the index visit. 63,814 index ED visits were included (56.5% female, mean [SD] age 38.0 [12.1] years, 48% Medicaid covered). 31% of index ED principal diagnoses were for major depressive disorder, 3% schizophrenia, 5% bipolar disorder, 34% anxiety disorder, 0.6% post-traumatic stress disorder, 8% other psychoses, and 19% other mental illness diagnoses. Only 33% of patients had a follow-up visit for mental illness within 30 days. Adjusted regression analyses show timely follow-up is associated with increased costs in the 180 days after (average marginal effect = $1622; 95% confidence interval [CI] 1459, 1786), an increased probability of inpatient hospitalization (2.7 percentage points; 95% CI 0.021, 0.032), and a small reduction in the probability of at least one additional ED visit (- 1.7 percentage points; 95% CI - 0.026 to 0.009). Overall follow-up rates are low; follow-up within 30 days of an ED visit for mental illness is associated with increased costs and increased probability of hospitalization in the follow-up period. It is not known whether increased rates of utilization improve patient outcomes, potentially by receiving appropriate more intensive care.

Applying Implementation Drivers to Scale-up Evidence-Based Practices in New York State

Mental health authorities in several states, often working with academic partners, have played important roles in disseminating evidence-based practices (EBPs) for adults diagnosed with serious mental illness. This work has been facilitated by intermediary organizations that work directly with providers to implement EBPs. This report uses two case studies to describe how the Center for Practice Innovations (CPI), an intermediary organization, has used the Active Implementation Research Network’s nine implementation drivers to successfully implement EBPs across the large state of New York. One case study focuses on supported employment and the second on integrated treatment for co-occurring mental health and substance use conditions. We provide these case studies to illustrate how intermediary organizations can use implementation science to organize and select effective support strategies to disseminate and implement a range of EBPs within a state system.

Computational Mechanism for the Effect of Psychosis Community Treatment: A Conceptual Review From Neurobiology to Social Interaction

The computational underpinnings of positive psychotic symptoms have recently received significant attention. Candidate mechanisms include some combination of maladaptive priors and reduced updating of these priors during perception. A potential benefit of models with such mechanisms is their ability to link multiple levels of explanation, from the neurobiological to the social, allowing us to provide an information processing-based account of how specific alterations in self-self and self-environment interactions result in the experience of positive symptoms. This is key to improving how we understand the experience of psychosis. Moreover, it points us toward more comprehensive avenues for therapeutic research by providing a putative mechanism that could allow for the generation of new treatments from first principles. In order to demonstrate this, our conceptual paper will discuss the application of the insights from previous computational models to an important and complex set of evidence-based clinical interventions with strong social elements, such as coordinated specialty care clinics (CSC) in early psychosis and assertive community treatment (ACT). These interventions may include but also go beyond psychopharmacology, providing, we argue, structure and predictability for patients experiencing psychosis. We develop the argument that this structure and predictability directly counteract the relatively low precision afforded to sensory information in psychosis, while also providing the patient more access to external cognitive resources in the form of providers and the structure of the programs themselves. We discuss how computational models explain the resulting reduction in symptoms, as well as the predictions these models make about potential responses of patients to modifications or to different variations of these interventions. We also link, via the framework of computational models, the patient's experiences and response to interventions to putative neurobiology.

Stigma of Treatment Stages for First-Episode Psychosis: A Conceptual Framework for Early Intervention Services

Early intervention services (EIS; in the United States, Coordinated Specialty Care) can lead to substantial improvements in psychiatric symptoms and social functioning for individuals with first-episode psychosis who engage in treatment. Nevertheless, stigma associated with early intervention services can limit their full potential benefits by preventing or reducing participation. Drawing from Corrigan's "why try" model positing relationships between public and self-stigma, engagement in treatment services, and the EIS treatment model, this article proposes a framework that delineates how distinct forms of stigma are linked to given stages of treatment engagement in first-episode psychosis. We identify three phases of engagement: (1) community outreach, which has associations with public stigma; (2) the referral and evaluation process, which primarily has associations with self-stigma; and (3) EIS, which have associations with self-stigma and its psychosocial consequences. For each phase, we describe evidence-based strategies typically provided by EIS programs, using OnTrackNY as an exemplary model, to illustrate potential linkages in our conceptual framework. By specifying how distinct forms of stigma are associated with EIS treatment stages, this framework is intended to guide EIS programs in explicitly addressing stigma to optimize recovery of individuals with first-episode psychosis.

Association of Insurance Status With Provision of Recommended Services During Comprehensive Postpartum Visits

IMPORTANCE

Improving care during the postpartum period is a clinical and policy priority. During the comprehensive postpartum visit, guidelines recommend delivery of a large number of assessment, screening, and counseling services. However, little is known about services provided during these visits.

OBJECTIVE

To examine rates of recommended services during the comprehensive postpartum visits and differences by insurance type.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 20 071 093 weighted office-based postpartum visits (645 observations) with obstetrical-gynecological or family medicine physicians from annual National Ambulatory Medical Care Surveys from December 28, 2008, to December 31, 2016, and estimated multivariate regression models to calculate the frequency of recommended services by insurance type, controlling for visit, patient, and physician characteristics. Data analysis was conducted from November 1, 2019, to September 1, 2020.

EXPOSURES

Visit paid by Medicaid vs other payment types.

MAIN OUTCOMES AND MEASURES

Visit length and binary indicators of blood pressure measurement, depression screening, contraceptive counseling or provision, pelvic examinations, Papanicolaou tests, breast examinations, medication ordered or provided, referral to other physician, and counseling for weight reduction, exercise, stress management, diet and/or nutrition, and tobacco use.

RESULTS

A total of 20 071 093 weighted comprehensive postpartum visits to office-based family medicine or obstetrical-gynecological physicians were included (mean patient age, 29.7 [95% CI, 29.1-30.3] years). Of these visits, 34.3% (95% CI, 27.6%-41.1%) were covered by Medicaid. Mean visit length was 17.4 (95% CI, 16.4-18.5) minutes. The most common procedures were blood pressure measurement (91.1% [95% CI, 88.0%-94.2%]), pelvic examinations (47.3% [95% CI, 40.8%-53.7%]), and contraception counseling or provision (43.8% [95% CI, 38.2%-49.3%]). Screening for depression (8.7% [95% CI, 4.1%-12.2%]) was less common. When controlling for visit, patient, and physician characteristics, the only significant difference in visit length or provision of recommended services based on insurance type was a difference in provision of breast examinations (14.7% [95% CI, 8.0%-21.5%] for Medicaid vs 25.6% [95% CI, 19.4%-31.8%] for non-Medicaid; P = .02).

CONCLUSIONS AND RELEVANCE

These findings suggest that receipt of recommended services during comprehensive postpartum visits is less than 50% for most services and is similar across insurance types. These findings underscore the importance of efforts to reconceptualize postpartum care to ensure women have access to a range of supports to manage their health during this sensitive period.

Predictors of Early Discharge From Early Intervention Services for Psychosis in New York State

OBJECTIVE

Although specialized early intervention services (EISs) for psychosis promote engagement in care, a substantial number of individuals who receive these services are discharged from care earlier than expected. The main goal of this study was to examine predictors of early discharge in a large sample of individuals enrolled in an EIS program in the United States.

METHODS

This cohort study (N=1,349) used programmatic data from OnTrackNY, an EIS program that delivers evidence-based interventions to youths across New York State experiencing a first episode of nonaffective psychosis. The main outcome was "early discharge," which was operationalized as discharge prior to completing 12 months of treatment. Cox proportional hazard regression models were used to assess the association between sociodemographic, clinical, and support system predictors and early discharge.

RESULTS

The estimated probability of discharge before 1 year was 32%. Participants who at baseline had poor medication adherence, had no health insurance, were living alone or with nonparental family, or were using cannabis were at higher risk of leaving services within the first 12 months after enrollment. Individuals with higher social functioning were at lower risk of being discharged early from OnTrackNY, but those with higher occupational functioning were at a higher risk.

CONCLUSIONS

Predictors of early discharge from EISs largely overlapped with previously identified predictors of poor prognosis in early psychosis. However, the association between early discharge and high occupational functioning indicates that trajectories leading up to discharge are heterogeneous.

Measuring The Lifetime Costs Of Serious Mental Illness And The Mitigating Effects Of Educational Attainment

Serious mental illness (SMI) is a disabling condition that develops early in life and imposes substantial economic burden. There is a growing belief that early intervention for SMI has lifelong benefits for patients. However, assessing the cost-effectiveness of early intervention efforts is hampered by a lack of evidence on the long-term benefits. We addressed this by using a dynamic microsimulation model to estimate the lifetime burden of SMI for those diagnosed by age twenty-five. We estimated that the per patient lifetime burden of SMI is $1.85 million. We also found that a policy intervention focused on improving the educational attainment of people with SMI reduces the average per person burden of SMI by $73,600 (4.0 percent)-a change driven primarily by higher lifetime earnings-or over $8.9 billion in reduced burden per cohort of SMI patients. These findings provide a benchmark for the potential value of improving educational attainment for people with SMI.

Trajectories of occupational and social functioning in people with recent-onset non-affective psychosis enrolled in specialized early intervention services across New York state

BACKGROUND

Despite the benefits of early intervention services for the initial stages of psychosis ongoing impairments in functioning are common.

AIMS

To identify 1-year trajectories of occupational and social functioning in individuals enrolled in OnTrackNY, a statewide program offering early intervention services for recent-onset psychosis in community settings.

METHOD

We included 937 persons with recent-onset psychosis enrolled at 19 programs across New York State. Demographic, social and clinical data was collected at program entry and at 3, 6, 9 and 12 months. We used growth mixture models to identify occupational and social functioning trajectories and examined the association between trajectory class, baseline factors and symptoms during 1-year follow-up.

RESULTS

Four distinct trajectory classes of occupational and social functioning were identified. The converging (58.0%) class had disparate levels of functioning at baseline (low occupational, higher social) which eventually converged. The other classes had high-stable (14.8%), moderate-stable (17.8%) and low-improving (9.4%) trajectories. Female gender, educational attainment and private insurance status were significantly associated with the trajectory characterized by higher functioning, while living alone, homelessness, a longer period from psychosis onset to program enrollment, a schizophrenia diagnosis and cannabis use at enrollment were associated with the poorest trajectory. The differences in severity of symptoms by trajectory class diminished over time.

CONCLUSIONS

Trajectories of occupational and social functioning showed substantial variation, but overall, remained stable or improved during 1-year follow-up. The relationship between symptoms and occupational and social functioning attenuated after the acute treatment phase.

Persistent cannabis use among young adults with early psychosis receiving coordinated specialty care in the United States

Persistent cannabis use among young adults with first episode psychosis (FEP), even those receiving early intervention services, has been associated with poor outcomes. In the United States (US), Coordinated Specialty Care (CSC) has been shown to be more effective at reducing symptoms, improving quality of life and increasing involvement in work or school, compared to typical care for FEP. However, little is known about the prevalence, course and outcomes for cannabis use in this real-world, clinical setting. This study examined the prevalence, course and outcomes of cannabis use categorized into three groups: no use, reduced use, and persistent use, among a sample of 938 CSC participants enrolled for at least 1 year. Prevalence of cannabis use was 38.8% at admission and 32.8% of the sample had persistent cannabis use at 1 year. At baseline, persistent cannabis users were more likely to be male (p < .001), white, non-Hispanic and black non-Hispanic (p = .001), have worse symptoms as measured by the GAF (p < .001), increased suicidality (p = .024), violent ideation (p = .008), and legal trouble (p = .006) compared with non-users. At 1 year, persistent users maintained worse symptoms compared with non-users (p = .021) while those who reduced use had significant improvement in symptoms compared with persistent users (p = .008). This study suggests that cannabis use is common among young adults enrolled in a CSC program in the US and that persistent cannabis users may have worse outcomes while reducing cannabis use may improve outcomes. These findings highlight the potential impact of secondary prevention in this population through reduction in cannabis use.

Changing levels of local crime and mental health: a natural experiment using self-reported and service use data in Scotland

Background

This study contributes robust evidence on the association between mental health and local crime rates by showing how changing exposure to small area-level crime relates to self-reported and administrative data on mental health.

Methods

The study sample comprised 112 251 adults aged 16–60 years, drawn from the Scottish Longitudinal Study, a 5.3% representative sample of Scottish population followed across censuses. Outcomes were individual mental health indicators: self-reported mental illness from the 2011 Census and linked administrative data on antidepressants and antipsychotics prescribed through primary care providers in the National Health Service in 2010/2012. Crime rates at data zone level (500–1000 persons) were matched to the participants’ main place of residence, as defined by general practitioner patient registration duration during 2004/2006, 2007/2009 and 2010/12. Average neighbourhood crime exposure and change in area crime were computed. Covariate-adjusted logistic regressions were conducted, stratified by moving status.

Results

In addition to average crime exposure during follow-up, recent increases in crime (2007/2009–2010/2012) were associated with a higher risk of self-reported mental illness, among ‘stayers’ aged 16–30 years (OR=1.11; 95% CI 1.00 to 1.22), and among ‘movers’ aged 31–45 years (OR=1.07; 95% CI 1.01 to 1.13). Prescribed medications reinforced these findings; worsening crime rates were linked with antidepressant prescriptions among young stayers (OR=1.09; 95% CI 1.04 to 1.14) and with antipsychotic prescriptions among younger middle-aged movers (OR=1.11; 95% CI 1.01 to 1.23).

Conclusion

Changing neighbourhood crime exposure is related to individual mental health, but associations differ by psychiatric conditions, age and moving status. Crime reduction and prevention, especially in communities with rising crime rates, may benefit public mental health.

Coordinated Specialty Care Discharge, Transition, and Step-Down Policies, Practices, and Concerns: Staff and Client Perspectives

OBJECTIVE

In recent years, optimizing the process of transition and discharge from coordinated specialty care (CSC), a program that provides early intervention in psychosis, has emerged as an important focus area for program administrators, clinicians, and policy makers. To explore existing CSC policies and practices and to understand frontline provider and client views on discharge, the authors conducted a comprehensive analysis of staff and client interview data from the Mental Health Block Grant 10% Set-Aside Study.

METHODS

Data from 66 interviews with groups of CSC providers and administrators representing 36 sites and 22 states were analyzed, as well as data from interviews with 82 CSC clients at 34 sites. Transcripts were coded by using systematic content analyses.

RESULTS

Analyses of data from providers and administrators showed the heterogeneity of CSC program practices and strategies regarding discharge and highlighted a range of concerns related to postdischarge service accessibility and quality. Analysis of data from client interviews reflected the heterogeneity of transition challenges that clients confront. A significant number of participants reported concerns about their readiness for discharge.

CONCLUSIONS

CSC discharge policies and practices vary across CSC programs and states. Frequent clinician and client concerns about optimal program length, transition, and postdischarge services highlight the importance of sustained policy and research efforts to develop evidence-informed practice guidelines and possible modifications to the time-limited CSC model that currently dominates the field.

Protocol for the development and validation procedure of the managing the link and strengthening transition from child to adult mental health care (MILESTONE) suite of measures

Background

Mental health disorders in the child and adolescent population are a pressing public health concern. Despite the high prevalence of psychopathology in this vulnerable population, the transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) has many obstacles such as deficiencies in planning, organisational readiness and policy gaps. All these factors contribute to an inadequate and suboptimal transition process. A suite of measures is required that would allow young people to be assessed in a structured and standardised way to determine the on-going need for care and to improve communication across clinicians at CAMHS and AMHS. This will have the potential to reduce the overall health economic burden and could also improve the quality of life for patients travelling across the transition boundary. The MILESTONE (Managing the Link and Strengthening Transition from Child to Adult Mental Health Care) project aims to address the significant socioeconomic and societal challenge related to the transition process. This protocol paper describes the development of two MILESTONE transition-related measures: The Transition Readiness and Appropriateness Measure (TRAM), designed to be a decision-making aide for clinicians, and the Transition Related Outcome Measure (TROM), for examining the outcome of transition.

Methods

The TRAM and TROM have been developed and were validated following the US FDA Guidance for Patient-reported Outcome Measures which follows an incremental stepwise framework. The study gathers information from service users, parents, families and mental health care professionals who have experience working with young people undergoing the transition process from eight European countries.

Discussion

There is an urgent need for comprehensive measures that can assess transition across the CAMHS/AMHS boundary. This study protocol describes the process of development of two new transition measures: the TRAM and TROM. The TRAM has the potential to nurture better transitions as the findings can be summarised and provided to clinicians as a clinician-decision making support tool for identifying cases who need to transition and the TROM can be used to examine the outcomes of the transition process.

Trial registration

MILESTONE study registration: ISRCTN83240263 Registered 23-July-2015 - ClinicalTrials.gov NCT03013595 Registered 6 January 2017.

OnTrackNY's learning healthcare system

Worldwide, early intervention services for young people with recent-onset psychosis have been associated with improvements in outcomes, including reductions in hospitalization, symptoms, and improvements in treatment engagement and work/school participation. States have received federal mental health block grant funding to implement team-based, multi-element, evidence-based early intervention services, now called coordinated specialty care (CSC) in the USA. New York State's CSC program, OnTrackNY, has grown into a 23-site, statewide network, serving over 1800 individuals since its 2013 inception. A state-supported intermediary organization, OnTrackCentral, has overseen the growth of OnTrackNY. OnTrackNY has been committed to quality improvement since its inception. In 2019, OnTrackNY was awarded a regional hub within the National Institute of Mental Health-sponsored Early Psychosis Intervention Network (EPINET). The participation in the national EPINET initiative reframes and expands OnTrackNY's quality improvement activities. The national EPINET initiative aims to develop a learning healthcare system (LHS); OnTrackNY's participation will facilitate the development of infrastructure, including a systematic approach to facilitating stakeholder input and enhancing the data and informatics infrastructure to promote quality improvement. Additionally, this infrastructure will support practice-based research to improve care. The investment of the EPINET network to build regional and national LHSs will accelerate innovations to improve quality of care.

Preliminary Evaluation of Washington State's Early Intervention Program for First-Episode Psychosis

OBJECTIVE

Early intervention programs are designed to address the needs of youths experiencing first-episode psychosis (FEP). Washington State developed New Journeys, a network of coordinated specialty care programs for FEP. In this study, the authors have outlined components of the New Journeys model and preliminary findings since its initial implementation.

METHODS

Youths and young adults diagnosed as having psychosis (N=112) completed measures at and after intake on a range of mental health assessments and functional outcomes for the first 12 months of treatment. Administrative data including state-funded emergency department and psychiatric hospitalizations were assessed 24 months before and after intake. Generalized estimating equations were used to assess change over time on multiple measures of mental health status.

RESULTS

Compared with their condition at intake, clients had significant decreases in symptoms of anxiety (β=-2.48, p<0.001), psychotic experiences (β=-3.37, p<0.05), and clinician-rated psychotic symptoms (β=-1.47, p<0.05) during treatment. Additionally, quality of life (β=-5.95, p<0.001) and school attendance (odds ratio=1.42, p<0.05) significantly improved during treatment. Administrative data indicated that postintake, clients were less likely to visit the emergency department for psychiatric reasons (β=0.22, p<0.05), utilize community psychiatric inpatient services (β=0.31, p<0.001), and utilize public assistance (β=0.71, p<0.05) compared with 24 months before intake.

CONCLUSIONS

New Journeys clients experienced improved clinical and functional outcomes during their first year of treatment, and rates of state-funded service utilization decreased during their treatment.

Community Interventions to Promote Mental Health and Social Equity

(Reprinted with permission from Current Psychiatry Reports (2020) 21: 35).

Service Use Following First-Episode Schizophrenia Among Commercially Insured Youth

OBJECTIVE

To investigate patterns of mental health service and antipsychotic use following a first-episode schizophrenia (FES) and to examine the role of the treatment setting in which individuals are first diagnosed.

METHOD

Analysis of de-identified administrative claims data from the OptumLabs Data Warehouse was used to identify 1450 privately insured youth and young adults aged 14 through 30 with FES from January 1, 2011 through December 31, 2015. Regression analysis was used to estimate the use of mental health services during the year following FES, by type of service and by site of index diagnosis.

RESULTS

In the year following FES, 79.7% of youth received outpatient mental health services and 35.8% filled a prescription for antipsychotic medication. Among service users, mean outpatient visits were 15.9 and mean antipsychotic fills were 8.3. Youth who received an index diagnosis of FES in an inpatient setting were more likely to fill an antipsychotic medication than youth with FES in other settings. Youth who received an index diagnosis of FES during a specialty mental health outpatient visit had greater use of outpatient mental health than youth who received their diagnosis during a primary care visit.

CONCLUSIONS

Despite evidence-based guidelines supporting outpatient psychosocial care and antipsychotic treatment for FES, one-fifth of this cohort did not use outpatient services and the majority did not fill any prescriptions for antipsychotic medications during the year following FES. Our findings provide renewed urgency to ongoing efforts to accelerate early identification and care coordination for youth with FES.

Early Detection and Preventive Intervention in Schizophrenia: From Fantasy to Reality

Scientific progress in understanding human disease can be measured by the effectiveness of its treatment. Antipsychotic drugs have been proven to alleviate acute psychotic symptoms and prevent their recurrence in schizophrenia, but the outcomes of most patients historically have been suboptimal. However, a series of findings in studies of first-episode schizophrenia patients transformed the psychiatric field's thinking about the pathophysiology, course, and potential for disease-modifying effects of treatment. These include the relationship between the duration of untreated psychotic symptoms and outcome; the superior responses of first-episode patients to antipsychotics compared with patients with chronic illness, and the reduction in brain gray matter volume over the course of the illness. Studies of the effectiveness of early detection and intervention models of care have provided encouraging but inconclusive results in limiting the morbidity and modifying the course of illness. Nevertheless, first-episode psychosis studies have established an evidentiary basis for considering a team-based, coordinated specialty approach as the standard of care for treating early psychosis, which has led to their global proliferation. In contrast, while clinical high-risk research has developed an evidence-based care model for decreasing the burden of attenuated symptoms, no treatment has been shown to reduce risk or prevent the transition to syndromal psychosis. Moreover, the current diagnostic criteria for clinical high risk lack adequate specificity for clinical application. What limits our ability to realize the potential of early detection and intervention models of care are the lack of sensitive and specific diagnostic criteria for pre-syndromal schizophrenia, validated biomarkers, and proven therapeutic strategies. Future research requires methodologically rigorous studies in large patient samples, across multiple sites, that ideally are guided by scientifically credible pathophysiological theories for which there is compelling evidence. These caveats notwithstanding, we can reasonably expect future studies to build on the research of the past four decades to advance our knowledge and enable this game-changing model of care to become a reality.

NYC START: A New Model for Securing Community Services for Individuals Hospitalized for First-Episode Psychosis

OBJECTIVE

The New York City (NYC) Board of Health amended the city's health code to require hospitals to report to the Department of Health and Mental Hygiene when individuals ages 18-30 are hospitalized for first-episode psychosis (FEP). This study examined the implementation of NYC START, a program that meets patients hospitalized with FEP to offer a voluntary, 3-month critical time intervention provided by social workers and peer specialists to connect individuals to appropriate community mental health services after discharge.

METHODS

Service logs completed by program staff were summarized to determine the mean number of contacts received per client per week, types of services provided by social workers and peer specialists, survival analyses of time to discharge from NYC START, and connection rates with community mental health services.

RESULTS

Of the 285 clients who accepted NYC START services in 2016, 87% attended an initial mental health appointment after hospital discharge and 78% completed at least 3 months of the program. Consistent with the program model, contacts were most frequent in clients' first week in NYC START, with a mean of 2.5±1.4 contacts, 1.9 of which were with social workers and 0.5 of which were with peer specialists. Social workers provided a mean of 17.3±4.4 client-specific activities per week, and peer specialists provided a mean of 8.5±3.5.

CONCLUSIONS

NYC START serves as a critical time intervention to connect people hospitalized with FEP to community mental health treatment.

Understanding the implementation of coordinated specialty Care for Early Psychosis in New York state: A guide using the RE-AIM framework

AIM

Consistent evidence shows that early interventions for individuals with psychosis lead to improvements in symptoms, social functioning and treatment satisfaction. These results, combined with the allocation of specific funds for early psychosis services, have contributed to the emergence and dissemination of coordinated specialty care for early psychosis in the United States. Despite the rapid growth of such services across the country over the last 5 years, implementation processes are not yet well understood. We employ the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework to describe processes, achievements and challenges of an early psychosis program called OnTrackNY that has been implemented in New York State.

METHODS

OnTrackNY is a coordinated specialty care program that delivers early intervention services that include both medications and psychosocial interventions to youths experiencing a first episode of non-affective psychosis. By drawing on outcome and care process data that are collected quarterly from all OnTrackNY sites, we describe the status of each RE-AIM dimension regarding OnTrackNY implementation followed by an evaluation of both achievements and shortcomings.

RESULTS

In general terms, OnTrackNY has shown to be a scalable and sustainable model for addressing early psychosis, reaching and providing recovery-oriented services to a large population in need.

CONCLUSION

Despite its advancements, a series of limitations pose challenges to the implementation and maintenance of the model including, but not to, the lack of incentives for coordination of services, the fragmentation of child and adult services, and concerns about financial sustainability.

Estimated Staff Time Effort, Costs, and Medicaid Revenues for Coordinated Specialty Care Clinics Serving Clients With First-Episode Psychosis

As coordinated specialty care for first-episode psychosis is implemented nationally, questions arise regarding financial sustainability. To address this, New York State undertook a time study in which 13 coordinated specialty care sites reported all activities provided to 75 randomly selected Medicaid clients with first-episode psychosis over a 2-week period. The average estimated cost was $1,375 per client per month, yet under optimal billing conditions, estimated revenues were only $662 per client per month, or 48% of the costs. These results underscore the need for continued subsidies and novel payment schemes for coordinated specialty care.

Community Interventions to Promote Mental Health and Social Equity

PURPOSE OF REVIEW

We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions.

RECENT FINDINGS

There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.