Improving Access to Psychiatric Care for Teens

with Mood and Anxiety Disorders:

London’s First Episode Mood & Anxiety Program

November 1, 2013

When psychiatrist Dr. Elizabeth Osuch first joined the

London Health Sciences Centre in 2005 as the Rea Chair of

Affective and Anxiety Disorders, the mandate of her position

was to conduct functional brain imaging research on mood

and anxiety disorders.

Dr. Osuch wanted to identify brain changes resulting directly

from these disorders as opposed to other factors associated

with long-term mental illness, such as medication use or

social isolation. As such, she began to study individuals

aged 16 to 30 who were in the early stages of depression.

As her research progressed, she realized that the youth

participating in her study were unable to quickly access the

psychiatric care they needed. Some of the younger

participants would end up on waiting lists for psychiatrists

that were one to two years long. Others would wind up

cycling in and out of the emergency department or would be

referred to adult psychiatric facilities, neither of which Dr.

Osuch viewed as user-friendly options for youth

experiencing symptoms of mood or anxiety disorders.

So, Dr. Osuch expanded her research program to include

clinical care and health care delivery evaluation research for

youth with mood and anxiety concerns. With this change, the

First Episode Mood & Anxiety Program (FEMAP) was born

in 2006. At full capacity, the program sees about 250 new

youth per year. Through FEMAP, youth with mood or anxiety

disorders in the London-Middlesex region are able to directly

and rapidly access psychiatric care without a physician’s

referral.

Program Details

Currently, FEMAP aims to improve access to treatment for

London-Middlesex youth aged 16 to 25 experiencing early-

stage mood and anxiety concerns who have not been

treated for these symptoms for more than 18 months. Also,

through ongoing research, the program is advancing

knowledge of mood and anxiety disorders and models of

care.

FEMAP Psychiatrist and Program Founder Dr. Elizabeth

Osuch.

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FEMAP is part of the London Health Sciences Centre’s Adult

Mental Health Services and the Schulich School of Medicine

and Dentistry at Western University.

FEMAP is modeled in part after London’s Prevention and

Early Intervention Program for Psychoses (PEPP), a

longstanding community-focused mental health program of

the London Health Sciences Centre and Western University

that provides rapid assessment and comprehensive

treatment for individuals experiencing their first episode of

psychosis.

At FEMAP, rapid access to care is achieved through three

defining features of the program:

1. Youth Can Self Refer

First, youth with mood or anxiety concerns can self-refer to

FEMAP. Dr. Osuch explains that being able to directly

contact the program without requiring a physician’s referral is

crucial for meeting the needs of youth with mental health

issues.

“One of the things that we were finding, especially for

students who are not from here and who don’t have a family

doctor or don’t know how to access a family doctor, was that

it was a long and complicated process to get in to see a

psychiatrist,” Dr. Osuch says. “It’s a very circuitous route for

youth to get psychiatric care if they have to first receive a

referral from another physician. We decided that this isn’t

user-friendly for young people – they should be able to just

pick up the phone and get in to see somebody about their

concerns, who can determine what sort of treatment they

might need. This self-referral piece is a really important part

of FEMAP’s model.”

In addition to self-referrals, FEMAP accepts referrals from

other health care providers, such as family physicians,

inpatient hospital services, or social workers. In these cases,

the youth must have a conversation with the FEMAP intake

worker before an appointment is made, to ensure that the

youth is motivated and interested in receiving treatment.

2. Youth-Friendly Setting

A second key feature of FEMAP is that the program is

discreetly located in a renovated house in the community

rather than in a hospital. Dr. Osuch explains that hospital

settings can be intimidating to youth, especially those

experiencing symptoms of anxiety or depression. FEMAP’s

private, house-based setting is well-suited to the target

population, offering a quiet, comfortable, and welcoming

environment.

3. First Contact Involves Clinical Staff

Third, when a young person first comes to FEMAP they

receive an in-person assessment with the program’s social

worker. This ensures that the first person taking personal

information from the youth is knowledgeable about

psychiatric conditions and is skilled at engaging youth. This

approach facilitates follow-through with services and is

therapeutic in itself, as the initial assessment is often the first

time the youth has shared their personal story about their

illness with a professional.

FEMAP’s staff includes an addictions counsellor, a

psychologist, a family therapist, a social worker, and three

psychiatrists (including Dr. Osuch). FEMAP offers a range of

services designed to provide client-centred care to youth

with mood and anxiety concerns, including individual and/or

family psychotherapy, medication prescription and

monitoring, and substance abuse counselling.

FEMAP also has a resource library for youth and parents to

explore at their leisure, allowing them to read and learn more

about mood and anxiety disorders, substance use, and

coping strategies. This resource library houses a SMART

board with a computer projector for meetings so that FEMAP

staff can communicate effectively with one another about

complex topics.

Providing rapid access to services and

meeting clients’ specific needs

At intake, FEMAP’s social worker assesses the youth to find

out what kind of distress they’re having, what kind of

services they might need, and whether FEMAP is the right

place for them. The clinical team then collaboratively

develops a preliminary care plan based on the individual

youth’s needs. This client-centred approach allows FEMAP

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to offer tailored treatments that address the youth’s specific

issues, including, for example, co-occurring mental health

issues, substance use problems, and history of trauma.

“For example, we might decide that a youth needs to see our

addictions therapist before they see a psychiatrist. In fact,

our data show that about half of the youth we see are at

moderate to high risk for an addiction issue, and that’s after

we’ve screened out youth that are presenting with addiction

as their primary concern, in which case we refer them to a

more appropriate service,” explains Dr. Osuch.

The waitlist at FEMAP is minimal, with youth typically seeing

a psychiatrist within four to six weeks. There is no limit on

the number of sessions that youth can receive. The average

duration of treatment is about nine sessions, although some

youth require only a few sessions while others are with the

program for years.

Data collected between 2009 and 2012 as part of a research

study of their program show that, on average, the client base

is 19 years old, with around 60% being female. While nearly

40% of their clients are referred by physicians or other health

practitioners, around 60% are self-referrals. In all, FEMAP

accepts 73% of all referrals, and refers 27% to other health

practitioners that would better meet the client’s needs.

Advancing knowledge of models of mental

health care delivery and functional brain

changes

Ongoing research is also a core component of Dr. Osuch’s

work at FEMAP, where she is conducting two programs of

research.

1. Health systems evaluation research

The first is a series of health systems evaluation projects

designed to assess FEMAP’s ability to help youth with mood

and anxiety disorders recover through early intervention.

This involves two stages, the first of which is complete and

the second of which is ongoing.

The first stage of the evaluation showed FEMAP’s ability to

conduct community outreach and receive appropriate

referrals from youth and other sources, such as health care

providers and family members. It also showed that the

program connected these youth with needed services, either

at FEMAP or from other health care providers. Some of the

results from this phase of the research have been published

in scientific journals, while others are currently in the process

of being written up for publication.

For the second stage of the evaluation, Dr. Osuch and her

colleagues are assessing FEMAP’s ability to help youth

recover by looking at the client’s symptoms, their level of

functioning, and their satisfaction with treatment before and

after receiving services at FEMAP.

As part of this evaluation research, Dr. Osuch and her

colleagues also hope to complete a cost-utility analysis to

show the economic impact of early treatment for mood and

anxiety disorders. Early results are promising, and Dr. Osuch

hopes that the findings will help ensure FEMAP’s longevity in

the London-Middlesex mental health care system. She also

hopes that positive evaluation outcomes will help the

program become a model of mental health care delivery for

youth that can be used in other health care systems across

the province and beyond.

“One of the things we want to propose with the cost utility

analysis is that if these young people are not treated, they

could end up coming in and out of the emergency

department for years down the road,” says Dr. Osuch.

“We’re trying to prevent that from happening. And I think it’s

quite possible to prevent that from happening. People get

better when they’re younger, and people get better when

they’re treated based on their clinical needs.”

2. Functional brain imaging research

Dr. Osuch’s other main research program involves studying

functional brain changes associated with mood disorders.

For instance, she and her colleagues are looking at

connections between depression and self-injurious

behaviour, the pathophysiology of the brain in mood

disorders with and without regular marijuana use, and brain

imaging of bipolar disorder compared to unipolar depression.

This research has been well received by clients.

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“The participating youth are often excited about the

suggestion that we may eventually be able to show there’s

something going on with their brains and it’s not ‘all in their

heads’,” says Dr. Osuch. “It validates for them that they are

suffering from a medical condition, a real illness with a

pathophysiological basis.”

Learnings and Challenges

FEMAP has evolved in some ways over time, based on their

experience. For instance, the program originally accepted

clients aged 16 to 30. However, Dr. Osuch began to see that

people in their late 20s who were experiencing the first

episode of a mood or anxiety problem were dealing with very

different life issues than younger clients. Moreover, the older

clients in this age range had access to other adult mental

health programs in the community. To focus services on

those who would benefit most from early services and for

whom accessing services was particularly challenging, Dr.

Osuch decided to narrow the program’s age range to 16 to

25 year olds.

Another key lesson learned is the importance of having a

multi-disciplinary team.

“I don’t think you can run a program for this age group

without considering the addictions piece. I also don’t think

you can do it without the family piece,” says Dr. Osuch. “A lot

of young people are still highly reliant on their families, so it

is important to take into consideration the family context of

the problems the youth are experiencing in order to move

them towards recovery. For example, a parent could be

unintentionally engaging in behaviours that are enabling the

youth in a way that isn’t helping them recover, so it could be

that bringing the parent into the equation is critical to

addressing the youth’s issues.”

Notably, parents or other family members are only involved

in clinical treatment at FEMAP if the youth provides written

consent. Otherwise, services provided are entirely

confidential and youth do not need to include their parents in

treatment in order to access the program, as mandated by

law.

The main challenge the program has faced, and continues to

face, is unstable funding. The majority of staff members are

available only a few days a week, and most are on “soft

money,” such as private donations. Donations not only help

support the staff complement, they have also funded the

program’s resource library and other much-needed

equipment and resources.

Despite these challenges, Dr. Osuch remains a strong

advocate of the need for early intervention programs for

mood and anxiety issues.

“My experience with this program is that it’s incredibly

needed and it’s incredibly valued by the people who use the

service. It’s also incredibly rewarding for us to treat these

young people and it’s rewarding for the young people who

are able to get their lives back,” she says.

More information about the program can be found on their

website – FEMAP – or by calling them at 519-646-6000,

extension 65178.

Author:

Andrea Flynn

November 1, 2013