Lisa Dixon, MD, MPH

Professor of Psychiatry

Columbia University Medical Center

New York State Psychiatric Institute

NIMH RAISE Projects

• RAISE-ETP: Cluster Randomized Trial

comparing clients (N= 223) at 17 sites

randomized to Navigate vs at 17 sites

randomized to usual care (N=181) for two

years

• RAISE-IES: Connection Program delivered

in two sites (Baltimore and NYC)(N=65).

Assess outcomes, engagement, develop

materials to scale up

Two Key Scientific Findings

• Longer duration of untreated psychosis

(DUP) is associated with poorer short

term and long term outcome

• DUP is the time between onset of psychosis

and specified treatment (e.g., antipsychotics

or CSC)

• Treatment with coordinated specialty care

(CSC) is associated with better outcomes

Coordinated Specialty Care

Clinical Services• Case management, Supported

Employment/Education, Psychotherapy,

Family Education and Support,

Pharmacotherapy and Primary Care

Coordination

Core Functions/Processes• Team based approach, Specialized training,

Community outreach, Client and family

engagement, Mobile outreach and Crisis

intervention services, Shared decision makinghttp://www.nimh.nih.gov/health/topics/

schizophrenia/raise/coordinated-specialty-care-for-first-

episode-psychosis-resources.shtml

Challenges

• Financing

• Workforce Development

• Community Activation: Getting the Word

Out

• Fidelity and Measuring Outcomes

• Youth/Consumer Involvement

H.R. 3547, 113th CongressJanuary 17, 2014

• Increased Community Mental

Health Block Grant (CMHBG)

program by $24.8M

• Funds allocated for first

episode psychosis (FEP)

programs

• NIMH and SAMHSA to

develop guidance for States

regarding effective programs

for FEP

Financing Early Psychosis Programs

http://www.medicaid.gov/federal-policy-guidance/federal-policy-guidance.html

“RAISE-ETP, RAISE-IES, and STEP demonstrate convincingly (1) the feasibility of first episode psychosis specialty care programs in U.S. community mental health settings; (2) that young people with psychosis and their family members accept these services; and (3) that CSC results in better clinical and functional outcomes than typical treatment.”

Financing Early Psychosis Programs

Consolidated Appropriations Act,

2016: Mental Health Block Grants

$50,000,000 increase over FY 2015 for the Mental

Health Block Grant program

Increases the set-aside to 10 percent

SAMHSA directed to continue its collaboration with

NIMH to ensure that funds from the set-aside

are only used for programs showing strong

evidence of effectiveness and targets the first

episode of psychosis.

http://docs.house.gov/billsthisweek/20151214/CPRT-114-HPRT-RU00-SAHR2029-AMNT1final.pdf.

Financing• Need to develop strategies to pay for CSC

regardless of disability status and insurance

• Current funding typically blend of block grant,

Medicaid, state support, other grants, private

insurance

• Specific service components not typically

covered (e.g., SEE, outreach)

• Challenge of uncertain future of ACA and

Medicaid

Workforce Development• Child providers less familiar with

psychosis, but comfortable with family

and developmental perspective

• Adult providers comfortable with

psychosis, but not with families and

development

• Unlearn disability expectation

• Practice shared decision making

• CSC OnDemand in development

Community Activation: Reduce

DUP

Onset of Symptoms

Help Seeking

Referral to Mental Health

Services (Could receive criterion

treatment in MHS)

Referral to EIS

Current System

Mental

Health

Clinic

Help

seeking

ER/I

PPolice

Stigma

Lack of Knowledge

Distrust

Poor Insight

Insidious Onset

Dropout from

Care

Referral from GP

Lack of Access

Unaffordability

and Inefficiency of

health care

Compton M, Broussard B: Current Psych Reviews 2011, 7, 1-11

Individual

with FEP

FEP

Onset/Illness

Factors

Family

Members

Misattribution

Stigma

Self-reliance

13

Cloud of Uncertainty

➢Cause of symptoms

➢Level of severity

➢Appropriate treatment

➢Connecting with care

Ambiguity around: Ambivalence toward:

➢Mental illness

➢Appropriate treatment

➢How to find treatment

Lack of knowledge of:➢ Level of necessary concern

➢ Need for treatment

➢ Acknowledgement

of a mental health problem

➢ Enlisting outside help

What is happening?

Who and when to tell?

Where and when to go?

What to do?

What are the options?

14

Individual

with FEP

FEP

Onset/Illness

Factors

Family

Members

Misattribution

Stigma

Self-reliance

Shorter

DUP

Longer

DUP

He

alth

Se

rvic

e F

acto

rs

Interpersonal Connections

Quality of Care

Family Involvement

Care Transitions

15

Strategies to Reduce DUP:

Enhance…• Recognition of psychotic symptoms

• Referral to mental health treatment

• Diagnosis of a psychotic disorder

• Referral to a CSC program

• Enrollment in a CSC program and/or

initiation of CSC treatment

• Engagement in CSC services

Strategies to Reduce DUP

• “Supply side” approaches targeting

clinical and community systems

• Training primary care physicians and nurses,

school and college counselors, emergency

department staff, police, and mental health

“generalists” to recognize signs of early

psychosis, and the improvement of referral

networks to fast-track the initiation of FEP

care.

Strategies to Reduce DUP

• Demand side approaches targeting people with

FEP and their family members, friends,

caregivers and others close to the affected

individual

• improve recognition of early symptoms, help-

seeking, access, and engagement in care for

persons with FEP and/or youth at high clinical risk for

psychosis, through education, decision-support

systems, and other tools, including social marketing,

social media and social networking.

Fidelity and Measuring Outcomes

• Need strategy/tool to ensure programs

being delivered as intended and achieving

expected outcomes

• Evolving model without existing well-

tested fidelity tool; need scalable

approach; several being developed

• Availability of PhenX toolkit for

psychometrically sound outcome

measures

Youth/Consumer Involvement

• Need youth input into oversight and

development of programs

• EASA Young Adult Leadership Council

• Sussex NHS trust early intervention

service: Youth Advisory council and Youth

Research Council

• OnTrackNY just started Youth Advisory Board

• Peer support within programs

Challenges

• Financing

• Workforce Development

• Community Activation: Getting the Word

Out

• Fidelity and Measuring Outcomes

• Youth/Consumer Involvement