Advancing care for people at risk for psychosis within a large hospital system in New York City

       
(L to R): Shaynna Herrera, PhD, Rachel Jespersen, LMSW, Michael Jacobs, MA, Cheryl M. Corcoran, MD and Yulia Landa, PsyD

Early identification and intervention shows promise for improving the lives of young people with psychosis. Research demonstrates that the sooner a person receives treatment for psychosis, the greater the likelihood of their recovery. For approximately 80 percent of people with psychosis, there is a one- to two-year period preceding the development of psychosis in which people begin to experience attenuated psychotic symptoms and social and functional declines. One way to facilitate early intervention is by targeting people who are exhibiting these early signs of being at clinical high risk for psychosis (CHR).

While there have been significant advances in identifying CHR individuals over the past 20 years, there are barriers at the individual and systemic level that hinder the successful identification and implementation of services for CHR individuals: young people are often disengaged from therapeutic services; many clinicians are not trained to recognize and assess for the early signs of psychosis; and empirically supported interventions and programs for CHR individuals are limited. A dedicated group of clinicians and researchers at the Mount Sinai Health System in New York City are working to address these barriers and improve the identification, engagement and treatment of CHR youth.

Identification. Better detection strategies are needed to improve identification of CHR individuals in order to engage them in services aimed at restoring functioning as early as possible. Yulia Landa, PsyD, assistant professor of psychiatry at the Icahn School of Medicine at Mount Sinai, received National Institute of Mental Health (NIMH) funding to implement systematic screening and assessment for psychosis-risk and psychosis throughout the Mount Sinai Health System with the aim of improving early identification of CHR and First Episode Psychosis (FEP) cases and rapid referral to specialty care. The central goal of this project is to investigate whether this detection approach can substantially reduce the duration of untreated psychosis.

As part of this study, all new patients ages 12-30 entering six Mount Sinai Outpatient Clinics are screened at intake with the Prodromal Questionnaire-Brief Version (Loewy, Pearson, Vinogradov, Bearden, & Cannon, 2011). Those who screen positive are then administered the Structured Interview for Psychosis-Risk Syndromes (SIPS; Miller et al., 2003) by a clinician who has been trained and certified in SIPS to determine if the patient meets criteria for a psychosis-risk syndrome or a first episode of psychosis. Currently, over 70 Mount Sinai clinicians have been trained and certified in SIPS administration and over 40 young people have been screened. This challenging mission would not be possible without the unwavering support of the chair of the department of psychiatry, Rene Kahn, MD, PhD, who is dedicated to advancing identification and care for people with psychosis-risk and psychosis across the entire Mount Sinai Health System.

Engagement. Once CHR individuals are identified, it is important to effectively communicate information about psychosis-risk to individuals and their families as this may facilitate treatment engagement and rapid treatment following psychosis onset. Shaynna Herrera, PhD, a postdoctoral fellow at Icahn School of Medicine at Mount Sinai, received funding from the American Psychological Foundation (APF) to evaluate a psychoeducation intervention specifically for CHR youth and their families. The intervention, titled “BEGIN: Brief Educational Guide for Individuals in Need,” aims to provide education about the CHR condition to patients and their families, improve attitudes about treatment, and reduce stigma. This pilot study will determine the potential for BEGIN to enhance treatment engagement for CHR youth and reduce the duration of untreated psychosis for those who eventually develop psychosis.

Treatment. In order to provide a full range of services to CHR individuals once they have been identified and engaged in treatment, Cheryl Corcoran, MD, recently launched the Coping with Unique Experience (CUE) program at Mount Sinai. CUE is a clinical and research program where CHR youth can receive clinical services and participate in clinical research. One service that will be offered to families of CHR youth is the Group and Family-Based Cognitive Behavioral Therapy Prevention Program (GF-CBT) developed by Yulia Landa, PhD. The GF-CBT Prevention Program aims to facilitate psychosocial recovery, decrease symptoms, and prevent transition to psychosis in CHR youth (Landa et al., 2016).  GF-CBT teaches strategies for regulating emotions and reducing biased information processing in order to prevent the formation of delusional beliefs. The involvement of family members in the program is designed to support, encourage and maintain use of these skills at home. Family members are trained via simulated-patient-actor to respond to their loved one’s symptoms and concerns, and to reinforce the CBT skills learned in time-limited therapy. GF-CBT recipients have shown statistically significant decreases in attenuated-psychotic symptoms (APS), paranoid ideation, negative symptoms, depression, cognitive biases, and improvements in functioning. Family members have shown significant improvements in use of CBT skills, enhanced communication with their offspring, and greater confidence in their ability to help (Landa et al., 2016). GF-CBT is currently being implemented in three community mental health centers (CMHCs) in Missouri through the Missouri State Department of Mental Health as part of a SAMHSA-funded System of Care Community Enhancement for Early Signs and Symptoms (SOC-CESS) program. Together, these efforts by clinicians and researchers at Mount Sinai to identify, engage, and treat people at risk for psychosis have the potential to positively influence the course of a young person’s psychotic illness.

APA Convention

We look forward to sharing more about these research and clinical services for CHR individuals at the APA Annual Convention in August 2018. We will be holding a two-part skills-building session entitled “I Can Feel Better: Facilitating Recovery in Youth at Clinical High Risk” on Thursday Aug. 9, 2018 at 10:00 a.m. Landa and Herrera will be joined by Rachel Jespersen, LMSW, the program coordinator of the Mount Sinai CBT for the Treatment and Prevention of Psychosis Program, and Michael Jacobs, MA, a professional actor and clinical psychology doctoral student, to teach skills for the engagement and treatment of CHR youth. Part I of this session is a didactic session in which audience members will learn important skills for the engagement and treatment of CHR youth through the BEGIN psychoeducation intervention and GF-CBT program. Part II will immediately follow in the Div. 18 suite, a more intimate setting where we will hold a practicum session using innovative training methods. Attendees will be able to practice their clinical skills for working with CHR youth with Mr. Jacobs, who will simulate a CHR patient. We highly encourage everyone to attend and we look forward to seeing you there!

Research reported in this publication was supported by the Sidney R. Baer Foundation, American Psychological Foundation, and National Institute of Mental Health of the National Institutes of Health under Award Number R34MH115463.

References

Landa, Y., Mueser, K. T., Wyka, K. E., Shreck, E., Jespersen, R., Jacobs, M. A., … Walkup, J. T. (2016). Development of a group and family-based cognitive behavioural therapy program for youth at risk for psychosis. Early Intervention in Psychiatry, 10(6), 511-521.  doi:10.1111/eip.12204

Loewy, R. L., Pearson, R., Vinogradov, S., Bearden, C. E., & Cannon, T. D. (2011). Psychosis risk screening with the Prodromal Questionnaire--brief version (PQ-B). Schizophrenia Research, 129, 42-46. doi:10.1016/j.schres.2011.03.029

Miller, T. J., McGlashan, T. H., Rosen, J. L., Cadenhead, K., Cannon, T., Ventura, J., … Woods, S.    W. (2003). Prodromal assessment with the Structured Interview for Prodromal Syndromes and the Scale of Prodromal Symptoms: Predictive validity, interrater reliability, and training to reliability. Schizophrenia Bulletin, 29(4), 703-715.