The Wellness and Recovery after Psychosis (WRAP) Without Walls Program (WWW): Assertive Community Outreach for Young Adults with Substance Induced Psychosis (SIP) or Early Course Psychosis with Co-Occurring Substance Use Disorders

Ellie Reagan, BS (1), Anne Berrigan, LICSW (1), Thisara Jayasinghe (1), Abi Martin, PsyD (2), Emily Kline, PhD (2), Amy Yule MD (2), Hannah Brown, MD (2)

1. Boston Medical Center (BMC)
2. Boston Medical Center (BMC) and Boston University School of Medicine (BUSM)

Abstract

Background: A barrier to providing comprehensive, multi-disciplinary first episode psychosis (FEP) interventions to high-risk youth with substance induced psychosis or co-occurring FEP and a substance use disorder (SUD) is that programs are usually office-based. Many youth with substance induced psychosis or psychosis with co-occurring SUD have low motivation to change their substance use or engage in substance use and mental health treatment. Furthermore, urban youth of color and their families face systemic barriers to office-based treatment including limited resources for transportation, decreased access to technology for telemedicine visits, and less time during clinic hours to attend appointments due to work and other caregiving responsibilities. To address limitations associated with office-based care WRAP has expanded services to provide mobile, community-based multidisciplinary treatment through WRAP Without Walls (WWW). The WWW program is funded by a grant from the Jack Satter Foundation.

Methods: WWW was designed to treat youth under the age of 26 years with symptoms of psychosis and a substance use disorder. The WWW model is an adaptation of the Assertive Community Treatment model that provides community-based services including individual therapy, family psychoeducation, medication management, peer support, advocacy, and case management.

Results: In WWW’s first year, the program identified and interviewed 12 community stakeholders that work with youth with psychosis and/or frequent substance use to guide program design. The program also hired staff, identified referral sources, conducted a literature review to support staff training and treatment/service guides, and has piloted the program, now with 7 patients engaged in care.

Conclusions: The WWW pilot program will provide information and practice guidelines on how a hospital-based program can extend services into home and community settings. As a result, more young adults with co-occurring psychosis and SUD can be treated at a critical time in the course of their illness, and improve longitudinal outcomes.

Measurement-Based Care in Treatment for Psychosis: A preliminary study proposal

Heather Muir (1,2), Nicolas Raymond (1), Victoria Lisowski (1), Raquelle Mesholam-Gately (1,3), Shirley Yen (2,3), Paulo Lizano (1,3,4,5), Sarah Herold (1,3)

1. Advancing Services for Psychosis Integration and Recovery (ASPIRE) Clinic, Beth Israel Medical Center 2. Massachusetts Department of Mental Health
3. Department of Psychiatry, Harvard Medical School
4. Division of Translational Neuroscience, Beth Israel Deaconess Medical Center

Abstract

Background: Evidence suggests that mental health providers often overestimate the improvement rates of their patients and notably underestimate the deterioration rates for their caseload. Measurement-based care (MBC), the routine administration and use of outcome measures to inform treatment decisions, have been used to improve clinical decision-making and identify clinical strengths and weaknesses amongst clinicians. The benefits of using MBC for the average psychotherapy case have been established empirically by several systematic reviews and well-powered meta-analyses. However, only one MBC study has centered on psychosis patients, which demonstrated that the Patient Health Questionnaire-9 was the most routinely-administered measure. Thus, MBC in early psychosis programs is needed. The current proposal aims to elucidate the feasibility of implementing MBC for early psychosis patients, as well as determining whether therapist specific effects exist for this population.

Methods: Patients will be recruited from one of two study sites at Beth Israel Deaconess Medical Center or Massachusetts Mental Health Center, who are receiving naturalistic psychotherapy and meet criteria for a schizophrenia-spectrum or other psychotic disorder. Patients will be asked to complete a measure of psychosis symptomatology (i.e., Colorado Symptom Index), a measure of therapeutic alliance (i.e., Working Alliance Inventory), and a more general measure of distress (e.g., the Treatment Outcome Package) prior to each psychotherapy session.

Results: The nested data structure (patients within therapists) will be accounted for by using multilevel modeling to test whether there are between-clinician differences in effectiveness based on the Colorado Symptom Index and a global patient symptomatic/functional impairment index derived from the outcome tool.

Conclusions: Findings would elucidate the feasibility of implementing MBC for an early psychosis population in naturalistic treatment settings and identify whether clinician effects exist amongst this patient population. The findings from this study could inform future treatment-quality improvement.

A Brief Literature Review of Racial Differences in Psychosis Interventions

Cameron Wu (1), Heather Thibeau (2), Emily He (3)

1. University of California, Santa Cruz
2. Boston Medical Center
3. Clark University

Abstract

Background: Psychosis research has had recent advances in understanding risk factors for psychosis development and treatment engagement issues (e.g. long duration of untreated psychosis). However, disparities between racial groups in psychosis treatment uptake and in disengagement have suggested inadequate support to minority groups. Therefore, examining how treatment occurs in other countries in a post-COVID world can yield more information on racial disparities and potential ways to provide more equitable treatment.

Method: Medical and psychology databases (e.g. PubMED, PsychINFO) were searched for peer-reviewed articles on psychosis treatment and care. Articles selected for review were recently published (2018-2022) and included analyses of social determinants (e.g. racial and ethnic minority status, immigrant generational status).

Results: The literature suggests that experience of adversity can moderate the relationship between immigrant generational status and psychosis treatment engagement. There were relatively few investigations of disparities by racial and ethnic minority status and immigrant generational status in U.S. samples. Disparities in race do appear to be less significant in certain countries, where healthcare is less privatized and thus, more equitable.

Conclusion: By engaging with institutions outside of Massachusetts in examining the causes of racial disparities in psychosis treatment disengagement, a more equitable early intervention program can be implemented into the Early Intervention Roadmap for Psychosis in Massachusetts, promoting further international collaboration in tackling the disparity in psychosis treatment amongst racial groups.

Initial Development of the Massachusetts Psychosis Access and Triage Hub (M-PATH)

James Green B.A., Sydney Garner B.A., Emily Gagen Ph.D., Stephanie Trilling LICSW, Henry White M.D.

Massachusetts Psychosis Access and Triage Hub (M-PATH), of the Brookline Center for Community Mental Health, Brookline M.A.

Abstract

Background: Coordinated Specialty Care (CSC) has demonstrated efficacy in improving outcomes in CHR-p and FEP populations. To help support CSC service delivery, the augmentation of services using digital mental health interventions (DMHI’s) may be explored. This study aims to understand methods to implement and support technology into routine CSC care.

Methods: Clients and clinicians from a CHR-p clinic (CEDAR) and a FEP clinic (ASPIRE) participated in a quality improvement project exploring the feasibility of following the AACCS framework to implement mindLAMP, a flexible and evidenced-based DMHI. Digital navigators were used at each site to assist clinicians and clients to implement MindLAMP. To explore differences in implementation effectiveness associated with application format, a menu-style format was delivered at CEDAR, and a module approach was utilized at ASPIRE. Qualitative baseline and follow-up data were collected to assess specific implementation outcomes.

Results: Participants (n =5) included 3 white (60%), 2 (40%) males, 2 (40%) females, and 1 (20%) transgender with a mean age of 19.6 years old. Implementation outcome data revealed that clinicians and clients demonstrated high levels of access, connection, and sustainability of technology. Clients and clinicians reported significant variations in the types of clinical care they wished the technologies to support, ranging from case-management, exposure and response prevention, and measurement-based care. Differences in implementation styles revealed that clients are more responsive and engaged in the intervention when delivered in a module approach including a schedule for data collection and interventions.

Discussion: Utilizing specific case studies, these findings provide insights to guide implementation of technologies supporting CSC care. This study demonstrates the importance of technology to provide autonomy for clients in and clinicians in their use, the utility of a digital navigator in training and implementation, and that technologies are best implemented when they are versatile, rather than complex.

What does 988 mean for Early Psychosis Programs?

Monica Luke

Abstract

This poster session will describe the main components of a fully implemented 988 behavioral health response system as envisioned by Congress with input and guidance from Crisis Now and the National Association of State Mental Health Program Directors (NASMHPD). The implementation is being driven nationwide with deep readiness and financial support from SAMHSA.

Background: 988 is a new three digit number replacing the 1-800-CALL2TALK suicide prevention lifeline starting on July 16, 2022. The 988 Suicide and Crisis Lifeline is designed with a three-pillar approach: • Someone to Call – 24x7x365 access to trained crisis counselors • Someone to Respond – Mobile Crisis Teams with clinicians and peer support specialists • Safe Place to Go – Crisis Stabilization Units, Peer respite and other community based supports preferred over hospitalization

Conclusion: This poster session will outline the opportunity presented by the 988 Lifeline to improve access to Coordinated Specialty Care as early as possible during, or immediately after, a first episode of psychosis. By creating strong linkages with both the crisis call center and the mobile crisis teams, we can ensure early referral for an evaluation for CSC during a first episode event.

About Monica Luke: Monica Luke is a mental health advocate and founder of The Living Assistance Fund (LAF) focusing on financial barriers to accessing mental health care. Activities include legislative advocacy, parity enforcement and creative approaches to expanding payment models and commercial insurance coverage. Monica has written several articles about the importance of 988, given multiple trainings for NAMI Massachusetts on the topic of 988 and informed several municipalities in the Commonwealth on 988. Monica works closely with an emergency response team in Cambridge, HEART.

Brain morphometry points to emerging patterns of psychosis, depression, and anxiety vulnerability over a 2-year period in childhood

T. G. Vargas (1), V.A. Mittal (2)

1. Northwestern University Psychology Department, Evanston, IL
2. Northwestern University Department of Psychology, Department of Psychiatry, Department of Medical Social Sciences, Institute for Policy Research, and Institute for Innovations in Developmental Sciences, Evanston, IL

Abstract

Background: Gray matter morphometry studies have lent seminal insights into the etiology of mental illness. Existing research has primarily focused on adults and then, typically on a single disorder. Examining brain characteristics in late childhood, when the brain is preparing to undergo significant adolescent reorganization and various forms of serious psychopathology are just first emerging, may allow for a unique and highly important perspective of overlapping and unique pathogenesis.

Methods: A total of 8645 youth were recruited as part of the Adolescent Brain and Cognitive Development study. Magnetic resonance imaging scans were collected, and psychotic-like experiences (PLEs), depressive, and anxiety symptoms were assessed three times over a 2-year period. Cortical thickness, surface area, and subcortical volume were used to predict baseline symptomatology and symptom progression over time.

Results: Some features could possibly signal common vulnerability, predicting progression across forms of psychopathology (e.g. superior frontal and middle temporal regions). However, there was a specific predictive value for emerging PLEs (lateral occipital and precen- tral thickness), anxiety (parietal thickness/area and cingulate), and depression (e.g. parahip- pocampal and inferior temporal).

Conclusion: Findings indicate common and distinct patterns of vulnerability for varying forms of psychopathology are present during late childhood, before the adolescent reorganiza- tion, and have direct relevance for informing novel conceptual models along with early prevention and intervention efforts.

The Support, Treatment, and Resilience (STAR) Program for Youth at Clinical High-Risk for Psychosis

Halle R. Singer (a) , Zachary B. Millman (a,b*), P. Esra Guvenek-Cokol (a,b), Hyun Jung Kim (a,b), Dost Öngür (a,b) , Emily E. Carol (a,b)

a. Psychotic Disorders Division, McLean Hospital
b. Department of Psychiatry, Harvard Medical School

Abstract

Background: Early intervention of psychosis has increased nationwide resulting in a recent increase in clinics that treat initial stages of psychotic disorders. The Support, Treatment, and Resilience (STAR) clinic was established in 2019 at McLean Hospital in response to the need for services specifically for youth at Clinical High Risk (CHR) for psychosis. The clinic’s mission is to provide high-quality, insurance-based, outpatient care to youth ages 14-25 at increased risk for psychosis through utilization of a flexible CHR framework and stepped care model.

Methods: Information related to client referrals, intakes, psychosis risk assessments, and discharges were tracked to evaluate effectiveness in recruiting CHR youth, the clinical need for STAR’s services in the community, and progress as a growing clinic.

Results: From fall 2019-spring 2022, the STAR clinic received 121 referrals and 38 (31.4%) were evaluated with the Structured Interview for Psychosis-risk Syndromes (SIPS). 34 (28.1%) youth presented with psychosis risk symptoms following assessment and received ongoing STAR clinical services. 83 (68.6%) referrals were not evaluated with the SIPS due to not meeting inclusion criteria. Each year, the STAR clinic has experienced a 50% increase in intakes. There has been a total of 16 clinic discharges thus far, and 50% of discharged clients transitioned to later-stage psychopathology.

Conclusion: Results suggest the clinical need for the STAR clinic’s specialized CHR services. Three factors may contribute to the on-going success of the STAR clinic: (1) the program’s placement within a tertiary psychiatric hospital, (2) utilization of a flexible CHR inclusion framework and treatment model, and (3) providing insurance-based clinical care. The STAR clinic’s goal is to continue its contribution to early intervention of psychosis and help support Massachusetts’s statewide system of services for early psychosis through ongoing integrated clinical data collection.

A Multi-Stage Exploration of Equity and Access to Care Disparities in Clinical High-Risk Psychosis (CHR-P) Through a Referral Lens

Joey Rodriguez (1,2,3,4), James Green B.A. (1,2,3,4), Michal Musikavanhu B.A. (1,2,3,4), Claire Goods (1,2,3,4) B.S. Olivia Aveson M.S. (1,2,3,4), Pilar Tucker M.A. (1,2,3,4), Isabel Brown (1,2,3,4), Wenhui Qi (1,2,3,4), Michelle Friedman-Yakoobian Ph.D. (1,2,3,4)

1. Psychosis Research Program, Beth Israel Deaconess Medical Center, Boston MA
2. Harvard Medical School Department of Psychiatry, Boston MA
3. Center for Detection Assessment, and Response to Risk (CEDAR), Brookline Center for Community Mental Health, Brookline, MA
4. Response to Risk Research, Massachusetts Mental Health Center, Boston MA

Abstract

Background: Based on previous research exploring First Episode Psychosis (FEP) incident rate in the 2016 Massachusetts All-Payer Claims Database, it is estimated that 4,544 individuals experience symptoms consistent with Clinical High-Risk for Psychosis (CHR-p) in Massachusetts every year. Previous studies demonstrated an association between duration of untreated psychosis and treatment outcomes. Given the limited resources of CHR-p care, this study seeks to explore if demographic characteristics of individuals such as age, race, and gender identity are associated with access to care, and duration of undertreated CHR-p symptoms. These demographics are examined to identify possible inequities in access to care to better inform equitable practice.

Methods: Quality assurance data was analyzed from the Center for Early Detection, Assessment and Response to Risk (CEDAR), a specialty clinic for youth at CHR-p. Demographic data was examined to explore frequency of age, gender, race, and referral source at four stages along the intake process (referrals, pre-screening, evaluation, and intake). Race/ethnicity was examined at evaluation and intake. Frequencies and percentages were analyzed and compared to U.S. Census data to examine differences that may indicate inequities.

Results: Clients had a mean age of 17 years, were female (41%) and typically white (64.60%). Results suggest racial disparities (Suffolk County= 55.1% white residents, CHR-p care= 64.60% white (n=51) at evaluation and intake and gender disparities at original referral. Most frequent successful referrals were taken from community agencies (28%) (n=72). Most frequent ineligibility after pre-screening (n=675) was due to a FEP (61%).

Conclusions: Results show significant differences in gender/racial demographics when comparing U.S census bureau data to clinic quality assurance data. Future research may explore cultural beliefs about mental health, individuals' socio-economic-status, and technological accessibility at each stage of care to continue to understand factors that may contribute to accessing CHR-p and impact the length of untreated CHR-p symptoms.

Baseline Clinical Insight and Cognitive Functioning as Correlates of Treatment Engagement in Naturalistic Psychiatric Treatment for Psychosis

Victoria Lisowski (1), Heather Muir (1,2), Ali Sendil (1), Kelsey Johnson (1), Nicolas Raymond (1), Raquelle Mesholam-Gately (1,3), Matcheri Keshavan (1,2,3), Sarah Herold (1,3), Paulo Lizano (1,3,4)

1. Advancing Services for Psychosis Integration and Recovery (ASPIRE) Clinic, Beth Israel Deaconess Medical Center,
2. Massachusetts Department of Mental Health,
3. Department of Psychiatry, Harvard Medical School,
4. Division of Translational Neuroscience, Beth Israel Deaconess Medical Center

Abstract

Background: Over 50% of psychosis patients lack clinical insight into their illness. Poorer insight is associated with worse psychotic symptomatology and cognitive decline. Moreover, studies examining clinical insight and cognition in psychosis have largely been conducted in the context of clinical trials, but not in naturalistic settings for the treatment of early psychosis. Thus, it is important to elucidate the associations between insight, cognition, sociodemographic, and treatment outcomes in the naturalistic treatment of early psychosis patients. The present study aims to examine whether patients with higher versus lower baseline clinical insight differ in their treatment engagement.

Methods: Data was collected from intake assessments (starting September 2021) used in support of naturalistic early psychosis treatment at Beth Israel Deaconess Medical Center. Intake assessments include a self-report measure of clinical insight (BIS; Birchwood Insight Scale) and a brief neuropsychological assessment (BACS; Brief Assessment of Cognition in Schizophrenia), among other clinical tools. Patients (N >11) have a mean age of 26, and hold a variety of psychotic spectrum diagnoses, including schizophrenia spectrum disorders, major depression, or substance-induced psychosis.

Results: As data collection is ongoing, analyses will be completed closer to the date of the conference. However, the BIS total scores will be median-split to derive an index of high versus low baseline clinical insight. Independent t-tests and chi-square analyses will be used to determine whether high versus low clinical insight groups significantly differ in their baseline sociodemographic, cognitive functioning, and treatment engagement (i.e., medication adherence, attended follow-up appointments). In a small subset of individuals, longitudinal changes in insight and cognition will be examined.

Conclusions: Findings will help clarify the associations between clinical insight, cognitive functioning, and treatment engagement in naturalistic settings for patients with early psychosis and, thus, could inform treatment within this population, such as metacognitive therapy.

Individual and Neighborhood-level Predictors of Repeat ED Visits in Early Psychosis at an Urban Safety Net Hospital

Brittany M. Gouse MD, MPH (1,2) Samantha LaMartine PsyD (2), Luisa Camacho MPH (2), Madison R. Boschulte (2), Hannah E. Brown MD (1,2)

1. Department of Psychiatry, Boston University School of Medicine
2. Department of Psychiatry, Boston Medical Center

Abstract

Background: Repeat emergency department (ED) visits for treatment of psychosis are a significant driver of morbidity early in illness course. We investigated both individual and neighborhood-level sociodemographic predictors of risk of repeat psychosis-related ED visits.

Methods: We retrospectively evaluated electronic medical records of individuals 18-35 years-old who had at least one ED visit between 3/1/2019-2/28/2021 with an International Classification of Disease 10 code of F20-F25. EMR data was crosswalked to Census tract and American Community Survey data to calculate socioeconomic status (SES) metrics. Chi-square and independent samples T-tests were conducted to compare demographics between individuals with or without at least one repeat ED visit. Poisson regression was used to model number of repeat ED visits across sociodemographic factors.

Results: Of the 477 included individuals, 187 (39.2%) individuals had at least one repeat ED visit. Mean neighborhood percentile percentage of persons below poverty (0.77 vs 0.69, p=.001), without high school diploma (0.75 vs 0.67, p=.001), and SES social vulnerability index score (0.75 vs 0.66, p=.002) were higher among individuals with repeated ED visits compared to those with a single ED visit. While there were no sex differences, there was an association between race/ethnicity and repeat visits (Χ2(4) = 17.43, p=.002), with a higher proportion of Black (46.7%) compared to Latinx/Hispanic (29.9%) and white (28.6%) individuals with at least one repeat ED visit. Compared to white individuals, Black individuals had a higher rate of repeat ED visits (IRR 1.92 95% CI, 1.4–2.8; p <.001).

Conclusions: This work highlights disparities in repeat ED visit risk based on race/ethnicity and neighborhood-level SES among individuals with early psychosis and highlights the urgent need for targeted community interventions.

PREP West Clinical Data Measurement: Findings from the current MAPNET Assessment Battery data collection process

John Knutsen, PhD (1,2), Cassidy Lewis, BA (2), Betty DeAngelis, LICSW (2), Melissa Weise, LICSW, PhD (2, 3)

1. Department of Psychology, Harvard University, Cambridge, MA
2. ServiceNet Inc., Northampton, MA
3. School of Social Work, Smith College

Abstract

Background: The Prevention and Recovery in Early Psychosis West (PREP-W) program is a Department of Mental Health (DMH)-licensed, and McLean Hospital’s Laboratory for Early Psychosis (LEAP) Center affiliate, coordinated specialty care (CSC) program for individuals living with early psychosis. Located in Holyoke, MA, PREP-W provides intensive, comprehensive, evidence-based outpatient milieu treatment for young adults to stabilize their lives, recover, and resume developmentally appropriate social and role functioning in their communities. PREP-W also practices clinical measurement-based care by collecting and sharing standardized data as a Massachusetts Psychosis Network for Early Treatment (MAPNET) partner using baseline and routine six-month follow-up assessments with clients until discharge. Here we provide updates on collecting client assessment data at PREP-W over the past 12 months, highlighting successes and challenges of collecting these data in a large underserved rural community setting.

Methods: Descriptive analyses were used to explore data from electronic health records for all PREP-W clients who received services in the past year. As we are at the 11-month mark for assessment collection, we specifically examined client demographics and who received the MAPNET assessment battery at baseline, and 6-months.

Results: Of the 54 active clients between 09/01/2021 and 09/01/2022, no clients have received the 12-mo follow-up assessment. Ten (19%) received a baseline and 6-mo, 10 (19%) clients received the baseline only, and 34 (62%) have not been given the baseline or 6-mo.

Conclusion: PREP-W has successfully continued to perform clinical measurement-based care, using an in-depth quantitative assessment battery to help measure client progress. However, the program was recently further challenged with assessment collection as a rural CSC clinic due to collection protocol changes, limited resources, and reduced clinician time to support data collection efforts. Increased resource efforts, development with local and regional academic partners, and staff support will help improve collection outcomes and subsequent care.

Resilience Evaluation-Social Emotional Training (RE-SET) at Massachusetts General Hospital (MGH): Establishing a Clinical High Risk for Psychosis Program from the Ground Up

Jacqueline Clauss, MD, PhD (1,2), Lauren Utter, PsyD, Drew Coman, PhD (1,2), Michaela Newton, MA (1,3), Abigail Donovan, MD (1,2), Daphne Holt, MD, PhD (1,2)

1. Department of Psychiatry, MGH, Boston, MA
2. Harvard Medical School, Boston, MA,
3. William James College, Newton, MA

Abstract

Background: Individuals are identified as being at clinical high risk for psychosis (CHR-P) based on the presence of brief or attenuated psychotic symptoms. These individuals are typically adolescents or young adults and many of them also struggle with comorbid diagnoses, such as major depression, anxiety disorders, PTSD, and autism spectrum disorder.

Methods: The RE-SET program at MGH was established in 2021 to provide early identification, treatment, and ongoing research in CHR-P. Potential clients between the ages of 12-30 were evaluated. Prior to initial diagnostic evaluation with a psychiatrist, potential clients completed a series of measures to describe their symptoms, including the Prodromal Questionnaire-Brief (PQ-B), State-Trait Anxiety Inventory (STAI), and Beck Depression Inventory-II (BDI-II). Following initial diagnostic evaluation, if there was concern for attenuated or brief psychotic symptoms, clients completed the Structured Interview for Psychosis-Risk Syndromes with a clinical psychologist. Finally, clients, client’s family, and their current treaters if available, were provided feedback from the evaluation and recommendations for further treatment.

Results: RE-SET received 68 referrals in its first year of operation, 29 clients were seen for initial evaluation, and eight clients were enrolled in ongoing care. Clients were on average 18.2y (range: 13.6 – 25.3) at the time of initial evaluation. On average, clients seen for initial evaluation endorsed 8.9 psychotic-like experiences on the PQ-B (SD: 6.6, out of 21 possible), had moderate depression symptoms as measured by the BDI-II (mean + SD: 21.9 + 16.2), and severe anxiety symptoms as measured by the STAI (mean + SD: 44.3 + 10.0).

Conclusions: MGH has established a new CHR-P program for early identification, treatment, and ongoing research. As has been reported elsewhere, clients present with significantly elevated symptoms in multiple domains. They benefit from tailored psychiatric interventions sometimes most appropriately provided within a CHR-P program or other forms of ongoing specialized care.

Implementation and Improvement Suggestions for Digital Technologies in Coordinated Specialty Cares for First Episode Psychosis (FEP) and Clinical High Risk for Psychosis (CHR-p)

Claire Goods, BS, James Green, BA, Joey Rodriquez, Michal Musikavanhu, BA, Isabel Brown, Wenhui Qi, Ananya Saluja, BA, John Tourous, MD

1. Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center
2. Harvard Medical School Department of Psychiatry, Boston, Massachusetts.

Abstract

Background: Coordinated Specialty Care (CSC) has demonstrated efficacy in improving outcomes in CHR-p and FEP populations. To help support CSC service delivery, the augmentation of services using digital mental health interventions (DMHI’s) may be explored. This study aims to understand methods to implement and support technology into routine CSC care.

Methods: Clients and clinicians from a CHR-p clinic (CEDAR) and a FEP clinic (ASPIRE) participated in a quality improvement project exploring the feasibility of following the AACCS framework to implement mindLAMP, a flexible and evidenced-based DMHI. Digital navigators were used at each site to assist clinicians and clients to implement MindLAMP. To explore differences in implementation effectiveness associated with application format, a menu-style format was delivered at CEDAR, and a module approach was utilized at ASPIRE. Qualitative baseline and follow-up data were collected to assess specific implementation outcomes.

Results: Participants (n =5) included 3 white (60%), 2 (40%) males, 2 (40%) females, and 1 (20%) transgender with a mean age of 19.6 years old. Implementation outcome data revealed that clinicians and clients demonstrated high levels of access, connection, and sustainability of technology. Clients and clinicians reported significant variations in the types of clinical care they wished the technologies to support, ranging from case-management, exposure and response prevention, and measurement-based care. Differences in implementation styles revealed that clients are more responsive and engaged in the intervention when delivered in a module approach including a schedule for data collection and interventions.

Discussion: Utilizing specific case studies, these findings provide insights to guide implementation of technologies supporting CSC care. This study demonstrates the importance of technology to provide autonomy for clients in and clinicians in their use, the utility of a digital navigator in training and implementation, and that technologies are best implemented when they are versatile, rather than complex.

COVID-19 Vaccination in a First Episode Psychosis Clinic

Jacqueline F. Dow, MPH (1), Dost Öngür, MD, PhD (1,2), Emily E. Carol, PhD (1,2)

1. Schizophrenia and Bipolar Disorder Program, McLean Hospital, Belmont, MA
2. Department of Psychiatry, Harvard Medical School, Boston, MA

Abstract

Background: The CDC has identified that people with schizophrenia spectrum and mood disorders may be more likely to become ill from COVID-19; therefore, vaccination is important in this population. However, studies have indicated higher rates of vaccine declination among those with psychotic disorders. Therefore, the aim of this secondary data analysis was to examine COVID-19 vaccination, hesitancy, motivation, and related items in a coordinated specialty care (CSC) first episode psychosis (FEP) clinic.

Methods: FEP patients in an outpatient CSC clinic (N=64) reported demographics, COVID-19 vaccination status, hesitancy, and vaccine motivation. Clients were aged 18 to 37 (M=24.27, SD=4.03) and had a clinician-reported primary psychotic disorder diagnosis (51.56% bipolar disorder, 10.94% schizophrenia, 15.63% schizoaffective disorder, 3.13% other non-affective psychoses, 6.25% major depressive disorder, 1.56% substance-induced psychosis). Descriptive statistics examined all self-reported COVID-19 measures except vaccination status motivation. Separate qualitative thematic analyses examine vaccine status motivation.

Results: Nearly all individuals with self-reported COVID-19 vaccination status available (n=62) indicated that they had received at least one dose of a COVID-19 vaccine (95.16% total: 1.69% one dose only, 50.85% fully vaccinated, 47.46% vaccinated with dose unknown). Of vaccinated clients with a completed booster item (n=30), 86.67% had received at least one booster. Only three individuals were entirely unvaccinated against COVID-19. Unvaccinated clients indicated greater vaccine hesitancy (M=58.33, SD=14.43) than the vaccinated clients (M=11.67, SD=23.57). Few patients indicated that a friend or loved one was hospitalized (7.94%), treated in the ICU (3.17%), or passed away (1.59%) from COVID-19.

Conclusion: This sample of FEP patients had very high rates of COVID-19 vaccination and on average, low vaccine hesitancy. Further research should examine these variables across a larger FEP sample as well as the effects of engagement in CSC on vaccination and other aspects of physical health in those with FEP.

Heterogeneity of clinical symptomatology among pediatric patients at clinical high risk for psychosis (CHR-P)

L. Sophia Rintell (1), Devon Carroll (1,2), Joseph Gonzalez-Heydrich (1,3) Eugene D’Angelo (1,3)

1. Department of Psychiatry & Behavioral Sciences, Boston Children’s Hospital, Boston, MA
2. College of Nursing, University of Rhode Island, Providence, RI
3. Department of Psychiatry, Harvard Medical School, Boston, MA

Abstract

Background: Clinical heterogeneity within the Clinical High Risk for Psychosis (CHR-P) population is a barrier to advancement of research on early identification and treatment. A possible cause may be the broad criteria for CHR-P, particularly the presence of at least one attenuated positive symptom as rated on the Structured Interview for Prodromal Symptoms (SIPS). CHR-P individuals, however, present with several symptoms, not limited to positive symptoms. The SIPS captures this range with the categories of Positive, Negative, Disorganization, and General symptoms. The purpose of this study is to investigate the utility of the non-positive (N, D, and G) symptoms as rated by the SIPS for risk assessment among youth with CHR-P.

Methods: Participants were 40 CHR-P youth ages 7-18 (M=12.78) who were evaluated with the SIPS and met criteria for Attenuated Positive Symptom Syndrome. Upon caregiver consent, SIPS ratings were used in this analysis.

Results: On average, participants endorsed 9.42 (SD=3.28) negative, disorganization, and general symptoms, in addition to an average of 2.78 (SD=1.12) positive attenuated symptoms. Mean total severity of symptoms was 36.32 (SD= 16.56) out of 114. Average severity per symptom was 1.91 (SD=0.87) out of 6. The most common symptoms were Perceptual Abnormalities/Hallucinations (P4), Avolition (N2), Trouble with Focus and Attention (D3), and Dysphoric Mood (G2). Number and severity of symptoms were similar across gender and age. The positive symptom sum was significantly correlated to each negative and general symptom, but only one of the disorganization symptoms: D3.

Conclusions: We sought to improve our understanding of the clinical heterogeneity within CHR-P youth by examining their prevalence and severity of clinical and attenuated symptoms. Improved understanding of the heterogeneity in this population is necessary as it could lead to advances in screening, predictive modelling, improved symptom monitoring, and targeted prevention and treatment of CHR-P individuals.

Gaps in Clinical Access for Individuals with a New Onset Psychotic Disorder: A Spatial Analysis

Shruti Bahukudumbi, Kelsey Johnson (MPH)

Abstract

Background: First episode psychosis (FEP), or the first time a person experiences a psychotic disorder, is a debilitating condition for which early intervention improves longer-term outcomes. Intervention within the first 2 to 5 years can limit the negative effects of psychotic symptoms, lower the risk of relapse, preserve psychosocial skills and facilitate a rapid recovery. 1,2 Many individuals face challenges in accessing psychosis specialty clinics and other mental health services because of out-of-pocket costs, transportation difficulties, lack of appointment availability, disparities in access to care, and social stigma. 3,4 This project utilizes data from the Massachusetts Psychosis Network for Early Treatment (MAPNET) program at Beth Israel Deaconess Medical Center to identify the extent of reach of psychosis specialty programs in Massachusetts. This study aims to (A) Identify the proximity of patients with new onset psychotic disorders to existing psychosis specialty clinics in order to locate gaps in treatment provision and (B) Identify the socio-economic breakdown of patients with new onset psychotic disorders to identify potential demographics that are being systematically under- served.

Methods: Deidentified data obtained was from 2016-2021, primarily from MASS.GOV, CENSUS tracts, and the MAPNET database. All categories were converted from point to vector data. Tabular data was geocoded using Zip Codes and XY coordinates. Dot-density maps were created to visualize the spatial spread of exist- ing psychosis-specialty programs in proximity with the population distribution in Massachusetts. Further maps are being created to depict the drive-time to psychosis-specialty programs, and locations of upcoming clinics.

Biomarkers/Biotypes, Course of Early Psychosis and Specialty Services (BICEPS)

Efim Oykhman (1), Paulo Lizano (1), Roscoe Brady (1), Gautami Shashidhar (1), Jenny Jang (1), Walid Yassine (1), Victor Zeng (1), Brett Clementz (2), Elliot Gershon (3), Sarah Keedy (3) Godfrey Pearlson (4), Dost Ongur (5), Eve Lewandowsky (5), Carol Tamminga (6) , Matcheri Keshavan (1)

1. Beth Israel Deaconess Medical Center, Boston, MA
2. University of Georgia, Athens, GA
3. University of Chicago, Chicago, IL
4. Yale University, New Haven, CT
5. McLean Hospital, Boston MA
6. University of Texas Southwestern Medical Center, Dallas, TX

Abstract

Background: There is increasing evidence that early intervention for psychosis in coordinated specialty care (CSC) services improves outcomes and lives. The outcome of early course psychosis (EP) is heterogeneous, ranging from early full recovery to treatment resistance and functional decline from the onset of illness. This heterogeneity limits our ability to predict individual level outcomes needed for treatment planning and for tailoring the type, duration and intensity of therapeutic interventions. Biomarkers as well as clinical and demographic features, early in the illness can predict outcome, but taken individually, their prognostic value is limited.

Methods: Our Bipolar-Schizophrenia Network for Intermediate Phenotypes (BSNIP) consortium has recently developed, replicated and validated a biomarker (EEG, eye movement testing, and neurocognition) based categorization (Biotypes 1, 2 and 3) in a trans-diagnostic sample of cases with idiopathic psychosis (schizophrenia, schizoaffective disorder, or bipolar disorder with psychosis), ranging from 18-35 years of age. In this study, we will leverage this categorization, along with clinical and biomarker data to predict illness trajectory and outcome during follow-up at 1, 6 and 12 months in 320 EP patients across CSC clinics at the five B-SNIP sites.

Results: First, we will characterize outcome trajectories and Biotype structure in EP. Our available data indicate the Biotype structure will be the same in EP as in our large sample. Second, we will investigate the predictive value of the nine bio-factors and the three Biotypes identified by B-SNIP for symptomatic and functional outcome. We predict that the EP population will manifest distinct outcome clinical trajectories (good, intermediate and poor) and will have a Biotype structure similar to that seen in chronic psychosis subjects, i.e., Biotypes 1, 2 and 3) (hypothesis 1). Biotype-3, and Biotype-2 cases, will have the best outcomes (defined both categorically, and dimensionally, using symptomatic, cognitive and functional measures); Biotype-1 will have the worst outcomes to CSC treatment, across all target time points (hypothesis 2). Notably, Biotype-1 and Biotype-2 cases will have the same level of cognition function at baseline. Finally, we will investigate the predictive value of clinical (such as diagnosis, illness duration, substance abuse, and treatment adherence), and biomarker (including neuroimaging) features in a multi-variate model and will develop a feasible biomarker battery and predictive algorithm for application in community CSC sites across 5 sites nationally nation-wide. BIDMC will serve as the coordinating site and will be supported by the Ontrack program at MCLean and MAPNET.

Conclusion: Our goal is to provide to the field a means for predicting success of EP cases in CSC treatment to improve clinical practice and to enhance efficient use of available treatment resources.

Prevention and Recovery in Early Psychosis West (PREP-W): Early-Stage Outcomes from the Psycho-Social Well-being Scale (PSWS)

John Knutsen, PhD (1,2), Cassidy Lewis, BA (2), Betty DeAngelis, LICSW (2), Melissa Weise, LICSW, PhD (2, 3)

1. Department of Psychology, Harvard University, Cambridge, MA
2. ServiceNet Inc., Northampton, MA
3. School of Social Work, Smith College

Abstract

Background: Prevention and Recovery in Early Psychosis West (PREP-W), located in Holyoke MA, is a rural community-based coordinated specialty care (CSC) clinic for young adults living with early psychosis. PREP-W’s comprehensive and recovery-oriented program includes routine standardized multidisciplinary global assessment of clients using the Psycho-Social Well-being Scale (PSWS). The PSWS is a reliable and valid multidimensional tool to help monitor and evaluate client wellbeing and inform the treatment process (O’Hare et al., 2002). The clinician rated five-point 12-item scale, conducted at client intake and routinely thereafter, includes the following domains: cognitive functioning, emotional functioning, impulse control, substance abuse, coping skills, health, recreational activities, living environment, immediate and extended social networks, activities of daily living, and work satisfaction. We propose to present findings on the first 12 months of PSWS assessment for all current PREP-W clients who have participated in the program for at least one year.

Methods: Descriptive analyses will be used to explore demographic data and statistical analyses will be used to examine PSWS data, focusing on outcomes across three timepoints: T1 intake (baseline), T2 (first assessment after intake, ~6-mo), and T3 (second assessment after intake, ~12-mo).

Results: Approximately 50 active clients between 09/01/2021 and 09/01/2022 have the PSWS at three timepoints. Multiple analyses will be conducted to help answer the following questions: Are the T1 global scores on the PSWS at the group and individual level different from T2 and T3? Are the T1 individual domain scores on the PSWS at the group and individual level different from T2 and T3?

Conclusion: Findings will inform clinicians and clients about client psychological and social wellbeing at intake and after approximately 6- and 12-months of treatment, and further support the treatment process and program evaluation at PREP-W.

From Evidence-Based Practices to Social Media: How Utilizing Instagram Can Disseminate Motivational Interviewing Skills

Heather Thibeau (1), Emily Barnard (1), Jada Gibbs (1), Bediha Ipekci (1,2), Emily Kline (1,2)

1. Department of Psychiatry, Boston Medical Center
2. Boston Univeristy School of Medicine

Abstract

Background: Motivational interviewing (“MI”) is an evidence based practice in which open communication is utilized to elicit change in the client. It is primarily used clinically in substance abuse treatment, but has shown efficacy in other contexts. Family caregivers of individuals with first episode psychosis and other mental health difficulties represent a population that could benefit from MI training. Pilot studies show that this approach is feasible and beneficial. However, pilot research participants expressed concerns about the need for ongoing MI training in order to continue to use and improve their skills. Therefore, the study team turned to social media to disseminate MI skills and concepts on an open-access platform.

Methods: The study team created an Instagram account to share MI skills by posting concept flashcards as well as short videos illustrating the use of MI skills in family contexts. Instagram analytics, as well as a focus group to elicit qualitative feedback from account followers, will be used to improve the account’s performance and generate further ideas for posts and reels.

Results: The Instagram page @learnaboutmilo has created over 30 posts. The account has 253 followers and receives an average of 500 profile views per week. Reels demonstrating the skills or explaining their application appear to generate the most user engagement, with one video viewed over 10,000 times.

Conclusion: Demonstrating evidence-based communication tools on a free social media platform democratizes access to this knowledge. Instagram is one of several potential venues. We believe translating evidence based practices into easy-to-consume media is essential for dissemination. Our next step is to conduct a focus group to obtain specific feedback and recommendations from followers.

Young Adult Perspectives on Communication with Family and Clinical Providers During First Episode Psychosis Treatment

Bediha Ipekci, PhD (1,2); Heather Thibeau, BA (1); Jada Gibbs, MPH (1); Emily Kline, PhD (1,2)

1. Department of Psychiatry, Boston Medical Center
2. Boston University School of Medicine

Abstract

Background: Treatment non-adherence among individuals who experience first-episode psychosis (FEP) is highly prevalent. Coordinated, multidisciplinary intervention care may deter high dropout rates, and family involvement is a strong proponent of this type of intervention. We asked young adults who recently experienced their first episode of psychosis to share their opinions and experiences of communication with their family and their treatment team.

Methods: Young adults were recruited who had an onset of psychosis within the past 5 years and were between 18-35 years of age. Using a semi-structured interview, participants were asked questions about what treatment they were involved in, how much their family is involved with treatment and their opinions on communication with their treatment team and their family. Research staff then coded to find important themes.

Results: Frequency analysis of the interviews revealed (1) a robust engagement with treatment is influenced positively by therapeutic alliance and clinical benefit and negatively by structural barriers and interpersonal barriers; (2) expectations from family include a deeper understanding of psychosis and current psychological condition of the individual with psychosis; and (3) the quality of communication with family is impacted by the caregiver’s response to the individual’s varying needs for respect, privacy, autonomy, and care.

Conclusion: Listening to young adults’ opinions on their experiences can provide insight into what type of support best facilitates treatment adherence. The results suggest that family-focused interventions that target enhancing communication and interpersonal dynamics between caregivers and young adults might support treatment engagement and the general well-being of the youth. The results also revealed that positive patient-provider relationships, prioritizing therapeutic alliance with a crucial focus on a non-judgmental, caring, and respectful approach, are another key element to treatment engagement.

Family Member Perceptions of Substance Use in Loved Ones with Psychosis

Julie M. McCarthy (1,2), M. Grace Shinners (1), Edoardo N. Bianchi (1), Kim Mueser (3), Roger Weiss (1,4), Dost Öngür (1,2)

1. Division of Psychotic Disorders, McLean Hospital, Belmont, MA
2. Department of Psychiatry, Harvard Medical School, Boston, MA
3. Center for Psychiatric Rehabilitation, Departments of Occupational Therapy and Psychological and Brain Sciences, Boston University, Boston, MA
4. Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA

Abstract

Background: The impact of substance use affects people living with psychosis and their families. Family members may have concerns about their loved one’s substance use given that such use increases the risk for treatment dropout and rehospitalization. However, limited data exist on how families of people with early psychosis and substance use perceive their loved one’s substance use.

Methods: Participants were 20 family members of a loved one with a history of substance use in the past 90 days and psychosis first onset in the past 6 years. Family members completed a functional analysis with a research study coach as part of a pilot feasibility clinical trial on Community Reinforcement and Family Training for Early Psychosis (CRAFT-EP). Functional analysis qualitative data were analyzed using a thematic analysis approach to identify patterns of substance use, internal and external triggers, as well as short-term positive consequences, and long-term negative consequences of substance use.

Results: Family members reported that cannabis was the most commonly used substance among loved ones with psychosis. Self-medicating or relieving negative emotions, such as anxiety and stress, were key internal triggers for substance use. The most frequent external triggers included evening/nighttime use at home. Short-term positive consequences often involved experiencing positive emotions, relaxation, and a sense of freedom. Long-term negative consequences of greatest concern to families were tensions with friends/acquaintances, damage to their loved one’s brain, and fear of future job consequences.

Conclusions: Family members can identify concerns and empathize with reasons their loved ones may continue using substances despite the risks associated with psychosis. Developing healthy behaviors as alternatives to promote positive emotions, relaxation, and a sense of freedom may important targets when addressing substance use among people living with early psychosis.

Family Involvement in First-Episode Psychosis Treatment of Sexual and Gender Minority Patients

Nicole Cerundolo (1) and Vivian Nye (1), Jacqueline Dow (1), Alyssa Williamson (2), Kelsey Johnson (2), Emily Carol (1, 3), Dost Öngür (1, 3)

1. Division of Psychotic Disorders, The LEAP Center, McLean Hospital
2. Massachusetts Psychosis Network for Early Treatment (MAPNET), Beth Israel Deaconess Medical Center
3. Department of Psychiatry, Harvard Medical School

Abstract

Background: Family involvement in first-episode psychosis (FEP) treatment is associated with improved mental health outcomes (e.g., lower relapse rates and better treatment adherence). The onset of psychosis typically occurs in late adolescence or early adulthood, when many individuals are still reliant on their families for housing and financial support. Sexual and gender minority (SGM) youth report lower levels of parental support and worse mental health outcomes than their non-SGM peers, but family involvement in FEP treatment has not been studied in SGM patients. Given this disparity, we hypothesized that SGM patients would report significantly lower rates of family involvement.

Methods: We conducted a secondary analysis of data collected for quality improvement across several coordinated specialty care (CSC) clinics in Massachusetts. The sample included N=430 FEP patients (SGM-identifying = 4.9%, mean age = 23). Survey questions assessed self-reported demographic information, past family involvement in care (operationalized as yes/no), and preference for family involvement (restricted/unrestricted/none). Patients identifying as non-cisgender and/or non-heterosexual in the demographics questionnaire comprised our SGM subsample. Data were drawn from patients’ most recent reports with complete responses regarding family involvement.

Results: A chi-squared test of independence indicated that family involvement in care is significantly lower in SGM patients, X² (1, N = 430) = 39, p < .001. Additionally, we provide descriptive statistics summarizing SGM and non-SGM patients’ preference for family involvement in care.

Conclusions: In our sample, SGM patients reported less family involvement in care than non-SGM patients. This preliminary analysis highlights a need for further research into the relationships between SGM identity, psychosis, and family involvement in care. Such research could elucidate how CSC can be tailored to meet the unique clinical needs of SGM patients and their families.

Well-Space: Peer Led Interventions for Young Adults with Psychosis and First Episode Care

Stephen J. Fedele (1) and Michael Murphy (1,2)

1. McLean Hospital
2. Harvard Medical School

Abstract

Aim: Coordinated specialty care (CSC) is a collaborative-team based approach that has been shown to be helpful for patients with first-episode psychosis. Peer support is an important component of CSC. Here, we describe the development and implementation of peer-led group programming (McLean WellSpace) that was loosely affiliated with a CSC (McLean OnTrack). We discuss how we adapted this program to the challenges imposed by COVID-19.

Methods: WellSpace was developed to have minimal barriers to entry other than a self-reported history of recent onset of psychosis. It is free for participants with minimal restrictions about who may attend. WellSpace and WellSpace groups are largely administered by peer specialists who align with the recovery movement. WellSpace has been a virtual program since March 2020.

Results: McLean WellSpace participants include many people who are not patients of McLean OnTrack, suggesting that such programs may have greater reach than standard medical programs. We transitioned to virtual programming and saw average group attendance and unique participants increase during the pandemic.

Conclusions: Our experience suggests that peer-led group programming for first-episode psychosis is well-accepted by patients, including many who are not engaged with a CSC. This may be related to our efforts to minimize barriers to entry and our peer-led, non-medical orientation.

Conceptualizing High Functioning in Individuals who Experience First- Episode Psychosis: A Look at Coordinated Specialty Care Clinics

Ananya Saluja (1), Kelsey A. Johnson (1), Raquelle Mesholam-Gately (1, 2) Matcheri Keshavan (1, 2)

1. Psychosis Research Program, Massachusetts Mental Health Center, Beth Israel Deaconess Medical Center, Boston, MA
2. Harvard Medical School, Boston, MA

Abstract

Background: The term “high-functioning” has come to connote an individual with a chronic disability or illness who functions at a higher level than others with the same condition. Although “functioning” often receives grim and stigmatizing prognoses in psychosis, particularly compared to disorders such as depression and anxiety, Coordinated Specialty Care (CSC) has demonstrated efficacy in improving symptoms and functioning in individuals who have experienced psychosis. This study analysis examines the conceptualization of and contributors to functioning in a real-world sample of FEP clients.

Method: Data from the Massachusetts Psychosis Network for Early Treatment (MAPNET) were analyzed to explore how factors such as age, gender, race, education, medication, school or work involvement, disability benefits, diagnosis, trauma, and substance use may affect or predict functioning in FEP. Global Social Functioning, Occupational Functioning, and the Brief Assessment of Cognition in Schizophrenia (BACS) were analyzed to determine mean levels of functioning, both social and neurocognitive, for individuals who have experienced a first episode of psychosis.

Results: Participants (n = 556) included individuals of varied ages, genders, and racial identities. We report on variables which predict higher vs. lower functioning, as well as results pertaining to mean levels of social/occupational and cognitive functioning.

Discussion: High functioning, especially in the context of conditions such as depression and anxiety, has been conceptualized in a manner which ties into the productivity of an individual. However, functioning for individuals in FEP treatment is measured using social, occupational, and cognitive domains. The results from this study provide insight into functioning, both high and low, for people who have experienced a first episode of psychosis, and aim to broaden our conceptualization of "high functioning" psychosis. These data have important implications on the ways in which CSC can be used to improve symptoms and functioning, and which variables are considered risk factors.

Coordinated Specialty Care (CSC) Billing Strategy Guide for Massachusetts

Iqra Imam, MPH, Elaine Marshal, JD, MPH, Kelsey A. Johnson, MPH, Monica Luke, Michelle Freidman-Yakoobian, PhD, Matcheri Keshavan MD, Raquelle Mesholam-Gately, PhD

Abstract

Background: Coordinated Specialty Care (CSC) is an evidence-based treatment model that addresses psychotic disorders early in order to reduce psychiatric hospitalizations for people with first-episode psychosis (FEP). With CSC, a multi-disciplinary team with licensed and non-licensed mental health specialists work with a person with a psychotic disorder to create and deliver an individualized treatment plan. However, there is no established payment model for necessary elements of CSC, which results in key services unable to be billed to insurance. The leads to economic burden placed on patients and their families, and clinics that struggle to provide CSC.

Methods: In order to address these issues, the Massachusetts Psychosis Network for Early Treatment (MAPNET) developed a guidebook of strategies to fund CSC using a team-based payment model, which would allow for teams to receive a flat rate for all the encompassing services.

Results: There are five critical questions to consider in order to advocate for a more comprehensive CSC billing system include: (1) Why pay for CSC? (2) What services are included in CSC? (3) How much does CSC cost? (4) How is CSC paid for? (5) How can we implement a new CSC billing model? The biggest hurdle to cross is how to implement the standardized billing for CSC. Strategies to promote implementation include employer advocacy, private insurance adoption, enforcing mental health parity laws, and developing legislation and regulation.

Conclusion: This guide identifies key resources and strategies to implement a sustainable payment model for CSC in MA and beyond. We outline next steps for MA towards this model, including a thorough assessment of CSC program costs.

Barriers and Facilitators to Work and School Motivation in First Episode Psychosis

Nicole R. DeTore, PhD. (1,2) Oyenike Balogun-Mwangi, PhD. (3) Miriam Tepper, MD. (4)
Corrine Cather, PhD. (1,2) Margaret Lanca, PhD. (2,5) Kim T. Mueser, PhD. (6,7) & Zlatka Russinova, PhD (6)

1. Department of Psychiatry, Massachusetts General Hospital
2. Department of Psychiatry, Harvard Medical School
3. Department of Psychology, Salve Regina University
4. Department of Psychiatry, Columbia University
5. Department of Psychiatry, Cambridge Health Alliance
6. Center for Psychiatric Rehabilitation, Boston University
7. Department of Occupational Therapy, Boston University

Abstract

Background: Despite targeted interventions, work and school outcomes in first episode psychosis (FEP) remain low, still often only reaching 50%. Amotivation has been identified as one of the strongest predictors of poor work or school functioning in FEP, with this lack of motivation often beginning immediately following illness onset. Motivation has been shown to be an essential aspect of work and school outcome and should therefore be an intervention target, though little is understood about the specific barriers and facilitators impacting motivation in those with FEP.

Method: A total of 40 participants were recruited from two FEP programs located in Boston, Massachusetts to complete a qualitative assessment. Inclusion criteria included 1) 18 years of age or older; and 2) diagnosis of a primary psychotic disorder within 5 years of onset. The qualitative interview utilized a guide consisting of open-ended questions covering: 1) plans for work or school; 2) how those plans have changed since diagnosis; 3) motivation enhancers; and 4) de-motivators. Notes were taken during each interview and all interviews were audio taped, then transcribed verbatim. Using a thematic analyzing approach, all transcripts were coded individually by three PhD level psychologists.

Results: Our findings revealed that participants were faced with several barriers that decreased their motivations for work and school including a) mental health symptoms; b) mental health treatment; c) awareness of functional limitations; and d) fear of relapse. Conversely, participants described several motivational facilitators for work and school: a) mental health symptoms; b) mental health treatment; and c) positive attitudes about mental health. Direct participant quotes accurately describe each domain.

Conclusion: These findings elucidate the underlying motivators and demotivators of those with FEP in concerns to returning to or continuing with work or school goals. This information is critical to the development and dissemination of interventions targeting functional outcome.

Implementation of Psychosis Risk Documentation in Adolescent Behavioral Health Referrals

Julia A. Plumb, BS (a), Kelsey A. Johnson, MPH (b), Kristen A. Woodberry, MSW, PhD (c,d), & Lydia A. Shrier, MD, MPH (a,e)

a. Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, MA
b. Massachusetts Psychosis Network for Early Treatment (MAPNET), Beth Israel Deaconess Medical Center, Boston, MA
c. Maine Health Institute of Research, Portland, ME
d. Department of Psychiatry, Tufts University School of Medicine, Boston, MA
e. Department of Pediatrics, Harvard Medical School, Boston, MA

Abstract

Background: Early detection of and intervention in psychosis is associated with improved outcomes for patients with serious mental illness. Routine screening in adolescent/young adult primary care may help to identify psychotic symptoms earlier than current strategies relying on clinician initiative. The present study evaluated the utility of adding psychosis screening items to a behavioral health consult documentation template.

Methods: Psychosis screening items were added to a standardized electronic medical record template used by behavioral health clinicians for same-day consults in an adolescent/young adult medical clinic. Items addressed observation or disclosure of hallucinations, delusions, and family history of psychosis, and whether symptom presence was elicited by direct provider inquiry about psychosis. We conducted a retrospective chart review of consults from November 2019 – November 2020, and summarized completion and endorsement of the psychosis screening items with descriptive statistics.

Results: Data were collected from 418 behavioral health consults, representing 313 patients (78% female; mean age 19.2). Roughly one in four consults (28%; n=116) included any responses to psychosis items; 72% (n=302) had no documentation. Of the 116 consults with documentation, 22% (n=26) were fully completed. Direct provider inquiry about psychosis was reported in 51% (n=59) of consults with psychosis risk documentation. Among consults that reported direct provider inquiry, 20% (n=12) indicated at least one psychosis risk factor, representing 10 unique patients. For three (33%) patients, this was an initial identification of psychosis risk.

Conclusions: Despite inclusion of psychosis screening items on the consult template, most behavioral health consults did not include medical record documentation of psychosis risk assessment. Documentation of direct clinician inquiry into psychosis risk was associated with identification of previously unidentified psychosis risk factors. Additional systematic efforts, including feedback on documentation, are needed to increase psychosis risk screening and early detection during behavioral health consults in adolescent/young adult primary care.

Adverse Life Events by Immigrant Generational Status in a FEP Sample in Massachusetts

Emily He (1), Heather Thibeau (2), Emily Kline (2,3), Matcheri Keshavan (4,5)

1. Clark University
2. Boston Medical Center
3. Boston University School of Medicine
4. Beth Israel Deaconess Medical Center
5. Harvard Medical School

Abstract

Background: There is a higher incidence of psychosis in first-and second-generation immigrants to countries with predominantly white/European populations, this might be linked to disproportionate exposure to childhood and adult adverse experiences. This suggests that immigrant generational status may be a proxy for difficult life circumstances which contribute to an individual’s psychosis vulnerability in addition to biological and heritable risk factors. Utilizing clinician written case reports of intake interviews may provide insight to difficult life experiences for individuals experiencing early psychosis.

Methods: Research staff coded (N=70) case reports collected for a longitudinal U.S. study on outpatient psychosis specialty care specifically recruited from Boston, MA First Episode Psychosis clinics. Twenty-eight parent themes were identified with additional subthemes. The themes reflect life events related to changes in mental health status/symptomatology, pathways to care, or adverse life experiences. Frequency of the themes was analyzed by immigration status (N=36 born in the USA, N=14 1st generation, N=20 2nd generation).

Results: Frequency analysis reveals that the top common theme among the entire sample was substance misuse (51.4%). When broken up into immigration status, different themes emerged and commonly endorsed themes occurred at different frequencies.

Discussion: Identifying adverse life experiences for individuals with early psychosis can provide insight into common stressors that can contribute to psychosis development and its treatment. Adverse life experiences may further impact engagement with care and timely treatment. Additionally, identifying variation in adverse life experiences by immigrant generational status can provide context for understanding disparities that disproportionately impact those belonging to minority groups.

The Support, Treatment, and Resilience (STAR) Program for Youth at Clinical High-Risk for Psychosis

Halle R. Singer (a), Zachary B. Millman (a, b*), P. Esra Guvenek-Cokol (a,b), Hyun Jung Kim (a,b), Dost Öngür (a,b), Emily E. Carol (a,b)

a. Psychotic Disorders Division, McLean Hospital
b. Department of Psychiatry, Harvard Medical School

Abstract

Background: Early intervention of psychosis has increased nationwide resulting in a recent increase in clinics that treat initial stages of psychotic disorders. The Support, Treatment, and Resilience (STAR) clinic was established in 2019 at McLean Hospital in response to the need for services specifically for youth at Clinical High Risk (CHR) for psychosis. The clinic’s mission is to provide high-quality, insurance-based, outpatient care to youth ages 14-25 at increased risk for psychosis through utilization of a flexible CHR framework and stepped care model.

Methods: Information related to client referrals, intakes, psychosis risk assessments, and discharges were tracked to evaluate effectiveness in recruiting CHR youth, the clinical need for STAR’s services in the community, and progress as a growing clinic.

Results: From fall 2019-spring 2022, the STAR clinic received 121 referrals and 38 (31.4%) were evaluated with the Structured Interview for Psychosis-risk Syndromes (SIPS). 34 (28.1%) youth presented with psychosis risk symptoms following assessment and received ongoing STAR clinical services. 83 (68.6%) referrals were not evaluated with the SIPS due to not meeting inclusion criteria. Each year, the STAR clinic has experienced a 50% increase in intakes. There has been a total of 16 clinic discharges thus far, and 50% of discharged clients transitioned to later-stage psychopathology.

Conclusion: Results suggest the clinical need for the STAR clinic’s specialized CHR services. Three factors may contribute to the on-going success of the STAR clinic: (1) the program’s placement within a tertiary psychiatric hospital, (2) utilization of a flexible CHR inclusion framework and treatment model, and (3) providing insurance-based clinical care. The STAR clinic’s goal is to continue its contribution to early intervention of psychosis and help support Massachusetts’s statewide system of services for early psychosis through ongoing integrated clinical data collection.