Sleep Spindle Density as it relates to Positive Symptoms in Early Course Psychosis

Nataly Kaldawy (1), James Green (1), Nicolas Raymond (1), Finn Janak (1), Victor Zeng (1), Bengi Baran (2,4), Dan Denis (3), Robert Stickgold (1), Dara Manoach (4), Matcheri Keshavan (1)

1. Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA
2. Department of Psychological and Brain Sciences, University of Iowa
3. Department of Psychology, University of York, England
4. Sleep, Cognition, and Neuropsychiatry (SCAN) Lab, MGH

Abstract

Background: Schizophrenia and related psychoses are associated with deficits in sleep spindles during stage 2 non-REM sleep. How these sleep spindles relate to positive and negative symptoms of psychosis, however, is not well known. This study aims to understand the relationship between symptom severity of psychosis and sleep spindle density.
Methods: Data from 67 participants on the SPARCS sleep study was used, and participants were separated into EC (schizophrenia and related psychosis), FH (family high risk), and HC (healthy control) groups. Symptom severity of psychosis was measured using the PANSS and sleep spindle density was measured in spindles per minute using an EEG. We used a one-way ANOVA to assess the difference in sleep spindle densities between the three groups and multiple regression analyses to assess the difference between sleep spindle density and severity of psychosis.
Results: The EC group had significantly lower sleep spindle density than the FH and HC groups (F (2) = 4.71, p < 0.05). Multiple regression analyses demonstrated that PANSS Positive Symptoms (b = -0.08, p <0.05) and P6 (Suspiciousness/Persecution) (b = -0.29, p <0.05) were significantly predicted by sleep spindle density while adjusting for age and gender. PANSS Negative and General symptoms showed no correlation with spindle density.
Conclusion: These results show promise in conducting similar studies to further understand sleep spindles as a potential biomarker for schizophrenia. They also encourage further studies using structural and functional imaging to investigate the thalamus’ role in connecting sleep spindles to psychosis symptoms. Additionally, given the role of sleep spindles in memory consolidation, the relation between cognition, spindles, and psychotic symptoms needs to be further investigated. This research may improve the identification of early psychosis biomarkers, which may enhance accuracy of diagnosis and treatment, improving access and equity to effective early psychosis care.
Supported by NIMH grant MH MH107579

Psychosis Risk Screening Attitudes and Practices in College Mental Health Centers

Harini Suresh M.D. , James Green B.A., Isabela Pena, Colette Potts Ed.M., Michelle Friedman-Yakoobian Ph.D.

Beth Israel Deaconess Medical Center, Response to Risk Research

Abstract

Background: The onset of psychotic disorders occurs most commonly in late adolescence/early adulthood. Routine screenings by college mental health clinicians and increased familiarity with identifying symptoms of psychosis may lead to earlier intervention and therefore improved treatment outcomes.
Methods: Participants included college-affiliated mental health clinicians in Massachusetts. Prior to virtual conference attendance on 11/9/2022, they completed a pre-survey assessing confidence and familiarity with psychosis screening tools, identification of symptoms, and community referrals – all topics included in the subsequent training. Clinicians completed a post-survey in 2/2023. Pearson correlations assessed associations between variables in baseline, and paired samples t-tests analyzed whether familiarity, confidence, and number of students with full psychosis or risk for psychosis screened significantly improved 3 months after training.
Results: Forty-eight clinicians completed the pre-intervention survey, of which 29% identified as counselors, 25% as psychologists, and 25% as social workers. Private university clinicians made up 75% of the cohort. Mean years in practice was 3-5 years. Participants were more likely to screen for other mental health concerns (85%) than psychosis (42%). Overall familiarity with psychosis significantly increased for the 25 participants who responded to the follow-up survey (t(24) = 4.51, p < 0.001, d = 0.9), with a large effect size (d = 0.9) associated with timepoints. Confidence in providing care for individuals with psychosis did not significantly increase at three-month follow-up (t(24) = 0.29, p = 0.77).
Conclusions: Our results suggest that delivery of this educational intervention for college mental health clinicians may lead to improved familiarity with psychosis. Higher familiarity was associated with more routine clinical screening of students for psychosis/psychosis risk. New resources for referral for youth at-risk or experiencing psychosis may help increase clinician confidence (e.g., MPATH). Other limitations include a lack of control group, clinician drop-out rate (from pre- to post- intervention), and self-reporting bias.

Baseline Reports of Traumatic Experiences as Correlates of Symptom Severity in Naturalistic Psychiatric Treatment for Psychosis

Daphne Ying (1,2), Madison Natarajan (1,2,5), Heather Muir (1,2), Pegah Seif (1,2,3), Ananya Saluja (2), Kelsey Johnson (2), Iqra Imam (2), Nicolas Raymond (1,2,3), Oshin Kushwaha (1,2,3), Yusuf Sendil (1,2,3), Raquelle Mesholam-Gately (1,2),Margaret Guyer (5), Matcheri Keshavan (1,2,5), Paulo Lizano (1,2,3), Sarah Herold (1,2)

1. Advancing Services for Psychosis Integration and Recovery (ASPIRE) Clinic, Beth Israel Deaconess Medical Center
2. Department of Psychiatry, Harvard Medical School
3. Division of Translational Neuroscience, Beth Israel Deaconess Medical Center
4. Center for Early Detection Assessment and Response to Risk(CEDAR) Clinic, Brookline Center for Community Mental Health
5. Massachusetts Department of Mental Health

Abstract

Background: A history of trauma is associated with increased risk for psychosis, and individuals diagnosed with schizophrenia are 2.7 times more likely to have had adverse childhood experiences than healthy controls. Understanding a patient’s trauma history can provide important contextual information in understanding and treating their psychotic symptoms. Thus, it is important to elucidate the associations between trauma and psychosis in the naturalistic treatment of early psychosis patients. The present study aims to examine trauma rates within an early course psychosis clinic, whether traumatic life experiences are associated with baseline symptom severity, whilst considering which types of traumatic events are more strongly associated with psychosis symptoms. We hypothesize that sexual trauma will be most related to symptom severity compared to other types of trauma, as well as racial trauma for ethnic minorities.
Methods: Data was collected from intake assessments used in support of naturalistic early psychosis treatment across multiple MAPNET clinics. Intake assessments include various clinical measures including a self-report checklist of trauma (Life Events Checklist, LEC-5) and a measure of symptom severity (i.e., COMPASS-10, Colorado Symptom Index, and the Global Assessment of Functioning). Patients hold a variety of psychotic spectrum diagnoses, including schizophrenia spectrum disorders, affective psychoses, and substance-induced psychosis.
Results: As data collection is ongoing, analyses will be completed closer to the date of the conference. Means and standard deviations will be presented for both trauma experiences and psychosis symptoms to answer questions regarding descriptives. Additionally, a series of independent t-tests and chi-square analyses will be used to determine differences between trauma experiences as they relate to psychosis symptom severity.
Conclusions: Findings will help clarify the associations between trauma and psychosis symptom severity in naturalistic treatment for early psychosis. Incorporating trauma-informed psychosis interventions is one way in which clinics can foster a bio-psycho-social conceptualization of psychosis.

Baseline Substance Use as a Correlate of Symptom Severity and Medication Adherence in Naturalistic Psychiatric Treatment for Psychosis

Caroline Harris (1,2,3), Heather Muir (1,2,4,5), Madison Natarajan (1,2,5), Pegah Seif (1,2,3), Ananya Saluja (2), Kelsey Johnson (2), Iqra Imam (2), Nicolas Raymond (1,2,3), Oshin Kushwaha (1,2,3), Yusuf Sendil (1,2,3), Raquelle Mesholam-Gately (1,2), Margaret Guyer (5), Matcheri Keshavan (1,2,5), Sarah Herold (1,2),Paulo Lizano (1,2,3)

1. Advancing Services for Psychosis Integration and Recovery (ASPIRE) Clinic, Beth Israel Deaconess Medical Center
2 Department of Psychiatry, Harvard Medical School
3. Division of Translational Neuroscience, Beth Israel Deaconess Medical Center
4. Center for Early Detection Assessment and Response to Risk(CEDAR) Clinic, Brookline Center for Community Mental Health
5. Massachusetts Department of Mental Health

Abstract

Background: Recent studies have found that those with psychosis who have used substances are more likely to develop schizophrenia-spectrum disorders than those who avoid substance use. Additionally, substance use in psychosis patients is correlated with medication non-adherence and increases in symptom severity. Moreover, studies examining substance use, medication adherence, and symptom severity in psychosis have largely been conducted in the context of clinical trials, as opposed to naturalistic settings for the treatment of early psychosis. Thus, it is important to elucidate the associations between these variables in the naturalistic treatment of early psychosis patients. The present study aims to examine the substance use rates within an early course psychosis clinic, and whether baseline current substance use frequency, duration, and type of substance are associated with baseline symptom severity and medication adherence.
Methods: Data was collected from intake assessments used in support of naturalistic early psychosis treatment across multiple MAPNET clinics. Intake assessments include various measures including measures of substance use (WHO ASSIST 3.0, Abbreviated), symptom severity (i.e., COMPASS-10, Colorado Symptom Index, and the Global Assessment of Functioning), and medication adherence. Patients hold varying psychotic spectrum diagnoses, including schizophrenia spectrum disorders, affective psychoses, and substance-induced psychosis.
Results: As data collection is ongoing, analyses will be completed closer to the date of the conference. Means and standard deviations will be presented for both substance use and psychosis symptoms to answer questions regarding descriptives. A series of independent t-tests and chi-square analyses will be used to determine the associations between frequency, duration, type of substance use and baseline psychosis symptom severity and medication adherence.
Conclusions: Findings will help clarify the associations between substance use, symptom severity, and medication adherence in naturalistic treatment for early psychosis, and thus, could inform decisions regarding inclusion of substance-focused intervention in coordinated specialty care programs for psychosis.

Hospitalization Rates in Early Psychosis: 48 Month Outcomes for Rural Coordinated Specialty Care and Community Care Programs

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

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

Abstract

Background: Hospitalization usage remains a significant contribution to overall health care costs in early psychosis, is associated with amplified symptom presentation, and can negatively impact treatment and intervention goals. However, hospitalization usage (and risk) has been shown to be markedly reduced in individuals who participate in coordinated specialty care programs (CSC) compared to usual care. Prevention and Recovery in Early Psychosis-West (PREP), a CSC for individuals living with early psychosis in Western MA, 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. Here we provide hospitalization rates data for individuals with early psychosis who participated in the PREP program and for those who received usual care over the past 48 months.
Methods: Descriptive analyses were used to explore demographic and inpatient psychiatric hospitalization rates (IPH) data from electronic health records for all PREP clients and usual care clients who received services for a minimum of three months between March 01, 2018, and March 31, 2022.
Results: Between 03/01/2018 and 03/31/2022 22% (n=78) of PREP clients had at least one hospitalization with an average IPH admission rate of 1.17 and a duration mean of 5.32 days, while 67% (n=30) of early psychosis individuals receiving usual care had at least one hospitalization with an average IPH admission rate of 2.20 and duration mean of 39.15 days.
Conclusion: Access to care and hospitalization usage remain robust challenges for young adults living with early psychosis in Western MA. However, in the past 48 months participants in the PREP program have demonstrated a markedly reduced overall IPH admission rate and duration compared to usual care. These data support the impact that a rural CSC can have on hospitalization usage in early psychosis when compared to usual care.

Examining Clinical and Social Predictors of Suicidal Ideation and Attempts in Individuals at Clinical High Risk for Psychosis (CHR-p)

Julia Pfluger, B.S. (1,2,3), James Green, B.A (1,2,3), Wenhui Qi (1,2,3), Claire Goods B.S. (1,2,3), Joey Rodriguez (1,2,3), Michelle West, Ph.D (2), Michelle Friedman-Yakoobian Ph.D (1,2,3)

1. Psychosis Research Program, Beth Israel Deaconess Medical Center, Boston MA
2. CEDAR Clinic/Brookline Center for Community Mental Health, Boston MA
3. Harvard Medical School Department of Psychiatry, Boston MA

Abstract

Background: Research demonstrates that individuals who experience psychotic symptoms are at higher risk for suicidal ideation (SI) or suicide attempt (SA). However, the relationship between suicide risk and clinical high risk for psychosis (CHR-p) has yet to be clarified. Previous literature suggests that psychosis and suicidality may be associated through hopelessness, minority stress associated with minority identity status, interpersonal connections, and direct effects. Our study aims to examine the prevalence and risk factors of suicidality in youth at CHR-p.
Methods: Participants (n = 140) included CHR-p clients at the Center for Early Detection, Assessment, and Response to Risk (CEDAR), who participated in a baseline clinical assessment between 2017 and 2022. Instruments used measured psychosis symptoms, suicidality, clinical covariates, social and role functioning, and demographics. Frequency analyses assessed the prevalence of lifetime SI and SA. T-test and Chi-square examined variables associated with SI and SA. Logistic regression was implemented to examine the predictive accuracy, sensitivity, and specificity of variables flagged with a significant association with SI and SA.
Results: Results suggested that 65% of participants at CHR-p endorsed lifetime suicidal ideation, while 22.2% had at least 1 lifetime suicide attempt. In addition, participants who endorsed lifetime suicidal ideation also had significantly more hallucinations (t(130) = 2.46), hopelessness (t(109) = 2.09), depression (t(109) = 3.87), and trauma severity (t(62) = 2.03). The only significant predictor in the logistic regression predicting lifetime suicide attempts was a trauma diagnosis (b = 1.4).
Conclusion: Our results suggest that clients who meet diagnostic criteria for CHR-p have high rates of SI and SA. In addition, our findings suggest that in our sample, a trauma diagnosis was the strongest predictor of a suicide attempt. Longitudinal research is needed to explore changes in suicidality over time.

Family member quality of life and loved ones with early psychosis and substance use

Patrick Kelly (1), Julie M. McCarthy (1,2)

1. Division of Psychotic Disorders, McLean Hospital, Belmont, MA

2. Department of Psychiatry, Harvard Medical School, Boston, MA

Abstract

Background: Families living with psychosis can experience lower quality of life. A loved one’s clinical status (e.g., psychiatric hospitalizations) may negatively impact family members’ quality of life, and substance use is one modifiable factor that is associated with increased likelihood of hospitalization. However, it is unclear the extent to which recent substance use and family members’ perceptions of a loved one’s substance use impact family members’ quality of life in early psychosis beyond recency of hospitalization, and the present project examines this question.
Methods: As part of a larger clinical trial, at baseline, family members (N = 23) of loved ones with early psychosis (<6 years) and recent alcohol or cannabis use (within the past 30 days) completed the World Health Organization Quality of Life BREF (WHOQOL-BREF) and questions about their loved one’s last hospitalization, past 30-day most problematic substance use, and perceived seriousness of such use. The WHOQOL-BREF includes physical, psychological, social relationships, and environmental domains. Linear regression models by domain characterized the relationship between loved ones’ past 30-day most problematic substance use, family’s perceived seriousness of substance use, and days since last hospitalization.
Results: Neither past 30-day most problematic substance use nor perceived seriousness of the loved one’s substance use predicted family members’ quality of life (p>.05). There was a trend relationship between more time since a loved one’s last hospitalization and better physical quality of life, but this was not significant (p=.087). The remaining quality of life domains were not significant.
Conclusion: Though substance use of a loved one with early psychosis continues to be a concern for clients, family, and clinicians, substances alone may not be a direct determinant of a family member’s quality of life. Instead, the potential consequences of substance use, such as hospitalization, may have greater influence on family members’ quality of life.

Validation of a brief psychosis screener in a population seeking help through the Massachusetts General Hospital Psychosis and Clinical Research Program

Cheryl Y. S. Foo, PhD* (1,2), Jacqueline Clauss, MD, PhD* (1), Lauren Utter, PsyD (1), Drew Coman, PhD (1), Michaela Newton, MA (1,3), Abigail Donovan, MD (1), Corinne Cather, PhD (1,2), Daphne Holt, MD, PhD (1)

1. Psychosis and Clinical Research Program, Department of Psychiatry, Massachusetts General Hospital 2. Center of Excellence for Psychosocial and Systemic Research, Department of Psychiatry, Massachusetts General Hospital
3. Clinical Psychology Department, William James College
*Authors contributed equally.

Abstract

Background: Attenuated psychotic symptoms are relatively common and are associated with increased risk for a range of psychological disorders including, but not limited to, schizophrenia. In Massachusetts, only approximately 1-2% of individuals at clinical high risk for psychosis (CHR-P) receive treatment in specialized programs. Brief, low-burden screening measures are needed to identify individuals experiencing attenuated or early psychotic symptoms, which can facilitate timely referral to specialty psychosis treatment programs to promote better long-term symptom and recovery outcomes.
Methods: The MGH Psychosis and Clinical Research Program offers evaluation and treatment for individuals with psychosis-risk syndromes and primary psychotic disorders. A total of 312 individuals completed an online screening form that included the 7-item Adolescent Psychotic-Like Symptom Screener (APSS) between June 2021 and June 2023. We evaluated the performance of the APSS items against gold standard assessments of either CHR-P or primary psychotic disorder based on clinical diagnostic interviews and/or the Structured Interview for Psychosis-risk Syndromes (SIPS).
Results: 29 (9.3%) referrals were clinically indicated for a SIPS assessment for CHR-P. Based on SIPS criteria, 4 (1.3%) met criteria for psychotic disorder and 20 (6.4%) met criteria for CHR-P. Endorsement of at least one positive symptom on a two-item screener (auditory or visual hallucinations) derived from the APSS identified individuals with CHR-P or primary psychotic disorder with 79% sensitivity and 35% specificity, AUC = .61 [.50, .73], p = .066.  
Conclusion: A two-item version of the APSS was highly sensitive for identifying outpatients who meet criteria for CHR-P or psychotic disorder. Using this brief and simple psychosis screener in primary care, psychiatry outpatient settings, and referral pathways may facilitate early identification and intervention of a high-need clinical population.

Food for Thought: A Virtual Nutrition Outreach Program for People with Serious Mental Illness

Pooja Dutta, Marko Stojcevksi, Amy Cheung, Yumi Kovic, MD, Xiaoduo Fan, MD, MPH, MS

University of Massachusetts Medical School, Worcester MA

Abstract

Background: People living with serious mental illness (SMI), including those experiencing psychosis, have a markedly reduced life expectancy of 10 to 25 years. Unhealthy diet is a major risk factor and area for intervention. The COVID-19 pandemic further contributed to unhealthy eating due to increased isolation and limited access to healthy food choices. During this time, we piloted a virtual nutrition outreach program for people with SMI to equip them with practical cooking skills and nutrition knowledge in a supportive social setting.
Methods: Adult participants with SMI were recruited through a local mental health organization. A focus group session was conducted to assess participant food behaviors, knowledge, motivation, and attitudes about nutrition. This was followed by a series of three modules, each consisting of an education session paired with a hands-on cooking session. Participants joined sessions virtually using their own kitchen and cooking supplies. The program concluded with a final focus group. Brief surveys were conducted during focus group sessions and at the end of each module.
Results: Twelve members were enrolled in the program. Overall, the virtual program was well-received (4.4 out of 5). There was an average score of 3.4 on how likely members were to modify their lifestyle and practice healthier eating after participating in the program. They also reported an average of 4.4 on likelihood of participating in the program again, and the majority stated they would recommend the program (86.0%). In assessing virtual program design, most members preferred a hybrid format of virtual and in-person sessions (71.4%). Most members preferred small groups of 4-6 people (44.0%).
Conclusions: Virtual hands-on cooking sessions allowed participants to practice healthy food choices and cooking skills in their home environment. Future steps include refining the program curriculum and disseminating the program to additional mental health organizations in Central Massachusetts.

Social Vulnerability & Access to Care for Psychosis: A Geospatial Analysis of Clinics in MA

Iqra Imam (1,2), James Green (2,3), Kelsey A. Johnson (1,2), Emily Gagen (3,4), Henry White (3), Jessica Stern (3), Margaret E. Guyer (5), Matcheri Keshavan (1,3,4)

1. Massachusetts Psychosis Network for Early Treatment (MAPNET), Boston, MA
2. Beth Israel Deaconess Medical Center, Boston, MA
3. Brookline Center for Community Mental Health, Brookline, MA
4. Harvard Medical School Department of Psychiatry, Boston, MA
5. Massachusetts Department of Mental Health, Boston, MA

Abstract

Background: Each year in Massachusetts, approximately 2,000 people will experience a first episode of psychosis (FEP). Shorter duration of untreated psychosis (DUP) is associated with better clinical and functional outcomes. In Massachusetts there are thirteen Coordinated Specialty Care (CSC) programs, which are the leading evidence-based treatment for FEP. In addition, there are 24 Community Behavioral Health Center (CBHC) locations, which serve in locations where CSC may not be easily accessible. Resources including the Massachusetts Psychosis Access and Triage Hub (M-PATH) provide consultation and referral support for early psychosis. This project aims to understand where care is being provided and examine gaps in service availability.
Methods: Maps were created in ArcGIS using the 2020 Social Vulnerability Index (SVI) dataset from the Centers for Disease Control (CDC), MAPNET 2023 FEP clinic directory, Massachusetts CBHC locations, M-PATH outreach data, and 2019 census data. These visualizations included the locations of the CSC clinics and CBHCs in located in Massachusetts, the maximum capacities of the CSC clinics, referrals received by M-PATH, and indicators of social vulnerability.
Results: The Boston area had both the highest number of FEP clinics and the highest maximum clinic capacities compared to other regions of Massachusetts. SVI shows higher concentrations in Worcester, Springfield, and Brockton. M-PATH calls were primarily received from individuals in the Boston Area, with most calls for the 15-25 age group. Highest FEP incidence is in Middlesex and Essex County.
Conclusions: Proper access to CSC is imperative. These analyses indicate that the current capacity of CSC clinics in MA is lower than what is needed to serve the expected incidence of FEP, identifying a need for policy improvement to meet the needs of this underserved population. Targeting geo-mapping data to focus on variables which may affect access to care, such as social determinants of health, may be a critical step to identify inequities and ensure equitable access to care.

Impact of the COVID-19 Pandemic on First Episode Psychosis Services & Populations in Massachusetts

Ananya Saluja (1), Kelsey A. Johnson (1), Margaret Lanca (5), Dost Ongür (4,2), Raquelle I. Mesholam-Gately (1,2), Margaret E. Guyer (3), Matcheri S. Keshavan (1,2)

1. Beth Israel Deaconess Medical Center
2. Harvard Medical School
3. Massachusetts Department of Mental Health
4. McLean Hospital
5. Cambridge Health Alliance

Abstract

Background: The COVID-19 pandemic led outpatient psychiatric services to rapidly transition from in-person to telehealth services for first episode psychosis (FEP) patients receiving coordinated specialty care (CSC). Ongoing clinical data monitoring in CSC clinics by the Massachusetts Psychosis Network for Early Treatment (MAPNET) presents an opportunity to investigate the impact of a large-scale natural event – the pandemic – on patient characteristics and service utilization.
Methods: A common assessment battery was collected with 772 patients across 10 CSC clinics in Massachusetts from 1/2017 to 10/2022. Analyses assessed changes in gender, race, diagnosis, education level, service use, self-reported satisfaction with FEP care, symptom severity, quality of life, and functioning between pre-pandemic (1/2017-2/2020), early pandemic (3/2020-5/2021), and late pandemic (6/2021-10/2022) timepoints. Division into these stages was based on the initiation of COVID-19 lockdown procedures (3/2020) and widespread vaccine availability (6/2021) in Massachusetts.
Results: CSC clinics saw significantly more white and male patients in the early and late pandemic timepoints. New patients in these post-pandemic timepoints also showed decreased symptom severity and treatment engagement, as well as increased quality of life and social functioning. There were no significant changes in self-reported satisfaction with FEP services at 6 months. Change in symptoms at 6 month follow-up also did not differ between timepoints, indicating that treatment efficacy was not significantly impacted by the pandemic despite the significant change in patient demographics.
Conclusions: Results suggest that FEP patients who began CSC post-pandemic showed higher functioning, lower service utilization, and equal satisfaction with CSC interventions, and have notable implications regarding equitable access to care. Many of these trends have persisted even beyond the initial stage of the pandemic. These observations may suggest that those with more severe illness are accessing care less frequently; understanding this better will help to improve approaches to health care delivery.

Well-Space: Peer Specialist Fidelity Criteria and Practice in First-Episode Psychosis

Stephen J. Fedele (1), Lisa Charland (1), Allison Nelson-Eliot (1), and Michael Murphy (1,2)

1. McLean Hospital,
2. Harvard Medical School

Abstract

McLean Hospital’s Well-Space Program, a peer-led initiative that works in conjunction with McLean OnTrack, a first episode program (FEP), hosts in-person and virtual groups along with providing vocational support for young adults ages 18-30 who have experienced psychosis. Within the literature on peer work, there is limited consensus on standardized practices and measures for assessing fidelity criteria. This also varies from state to state. Maintaining effectiveness and adherence to peer principles while also having a clear sense of best practices can become more difficult when fidelity measures are not established. However, there is a contingent of peer providers who assess that too narrowly defining the role can also be overly constraining to the work and detract from some of the capabilities of peers. Our aim is to research current fidelity criteria and compose some pillars, report on Well-Space’s adherence to fidelity criteria, indicate how and why we deviate from it as peer providers, and explore how this can improve the quality of care we are providing as peer specialists.

Pathways to Possibility: An Equitable and Accessible Referral System for Early Psychosis Intervention

Rebecca Wlcek BA (1), James Green BA (1), Henry White MD (1), Kelsey Johnson MPH (2), Iqra Imam MPH (2), Emily Gagen PhD (1,3)

1. Massachusetts Psychosis Access and Triage Hub (M-PATH), of the Brookline Center for Community Mental Health, Brookline MA
2. Massachusetts Psychosis Network for Early Treatment (MAPNET) Boston, MA
3. Harvard Medical School, Cambridge, MA

Background: Recent estimates suggest 1,136 first episodes of psychosis (FEP) per year. Longer duration of untreated psychosis (DUP) is associated with negative outcomes. Coordinated specialty care (CSC) programs have demonstrated efficacy in improving outcomes for FEP. To equitably serve our diverse population and increase access to care in the state, the Massachusetts Psychosis Access and Triage Hub (M-PATH) was created to improve access to specialized FEP services.
Method: M-PATH is a statewide service that offers support to clients, family members, and providers. Stakeholders can contact M-PATH to receive an initial screening for psychosis, consultation, and/or referrals to community resources and CSC. Check-ins with clients and family members throughout the referral process ensure continuity of support. Providers are offered ongoing consultation to support the development of a community workforce delivering "psychosis-informed care". Demographic information is collected at baseline, while outcomes and needs are collected at 1-month. Demographic and program performance data were analyzed using descriptive statistics. Data is presented between 1/1/2023 - 6/30/2023 to demonstrate feasibility in improving access to FEP care.
Results: 30 clients and families and 35 providers contacted M-PATH. Client’s self-referring had an average age of 28.5 (17.99), families 23.94 (9.5), and providers 18.96 (7.57). 70.6% of referrals were white, 17.6% Black or African American, and 5.9% Asian. 31.7% were female, 60% male, 5% transgender, and 3.3% non-binary. On average for FEP clients, time between the 1st contact with M-PATH and an appointment at a CSC clinic was 35.42 days. 44.6% of service recipients were referred to FEP programs, 10.8% referred to CHR-p clinics, 12.3% of providers were supported to continue care.
Discussion: M-PATH's model demonstrates promising speeds of access to care for clients (~35.42 days vs. 140 days). In addition, M-PATH’s model of care demonstrates potential to improve equitable access, reduce DUP, and identify barriers for care.

Sociodemographic Predictors of Substance Use in College Students with Schizophrenia Spectrum Disorders, and Impact on Resiliency

Ashley Mack MS (1), Luisa Camacho MPH (1), Hannah E. Brown MD, (1,2) Brittany Gouse MD MPH (1,2)

1: Wellness & Recovery After Psychosis Program, Boston Medical Center, Boston, MA
2: Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA

Abstract

Background: Structural inequities at the neighborhood level negatively impact access to care and targeted interventions are necessary to reduce these barriers. In the metro-Boston area, systemic factors such as housing discrimination perpetuate racial segregation. Here, we explored individual sociodemographic characteristics across area-level socioeconomic (SES) strata among young adults with psychosis receiving care at an urban, safety-net hospital.
Methods: We used an electronic-medical record derived repository (ACCESS) of all visits with a schizophrenia spectrum disorder (SSD) billing code. The analytic sample included patients ≤ to 30-years old with at least one SSD-related visit between 2015-2022. Neighborhood socioeconomic deprivation was defined by connecting individual-level EMR demographics to U.S. Census data and American Community Survey Data. Sociodemographic differences were compared across SES Social Vulnerability Index (SVI) quartiles using chi-squared tests.
Results: Among 1,197 patients, 67.2% were male, 56.5% were non-Hispanic Black, and 87.7% were English speaking. The median SVI for the cohort was 0.76 (IQR: 0). A higher proportion of non-Hispanic Black and Hispanic patients resided in census tracts that were more socioeconomically vulnerable than 75% of census tracts across Massachusetts than non-Hispanic white patients (62.5% non-Hispanic Black vs. 55.6% Hispanic vs. 24.1% non-Hispanic white, p<.001).
Conclusions: The majority of young adults with psychosis served at BMC reside in highly socioeconomically disadvantaged neighborhoods. Further, a significantly higher proportion of non-Hispanic Black and Hispanic patients resided in the census tracts in the lowest SES strata in the state compared to their non-Hispanic white counterparts. Additional resources are critically needed to mitigate structural inequities at the neighborhood level in pursuit of health equity in Massachusetts.

Prospective Relationships between Social Functioning and Insight in Recovery After a First Episode of Psychosis

Cheryl Y. S. Foo, PhD (1), Corinne Cather, PhD (1), Kim T. Mueser, PhD (1,2)

1. Center of Excellence for Psychosocial and Systemic Research, Department of Psychiatry, Massachusetts General Hospital;
2. Center for Psychiatric Rehabilitation, Department of Occupational Therapy, Boston University, Boston, MA, USA

Abstract

Background: Impairments in insight and social relationships are characteristic features of schizophrenia associated with worse outcomes. The NAVIGATE program is an evidence-based early intervention service (EIS) for first-episode psychosis (FEP) that improves psychiatric symptoms and social functioning to a greater extent than usual care. Little is known about the temporal relationships between improvements in symptoms and social functioning over the course of treatment.
Methods: We conducted cross-lagged panel analyses using structural equation modeling to evaluate the reciprocal associations between social functioning and insight, a strong correlate of positive symptom severity, among individuals with FEP (aged 15-40) receiving the first year of comprehensive early intervention (NAVIGATE; n=223) versus usual community care (CC; n=181) in a nationwide cluster randomized controlled trial (RAISE-ETP study). Participants completed clinical assessment, including of insight (single PANSS item) and social functioning, at baseline, 6- and 12-months.
Results: Across all participants, controlling for significant covariates, race and treatment group, baseline and 6-month social functioning was associated with subsequent improvements in insight, but not vice versa. When this relationship was evaluated separately in the NAVIGATE and CC groups, it was apparent in NAVIGATE, but not in CC. In the NAVIGATE group, controlling for race, 6-month social functioning was significantly associated with 12-month insight (β = -.157, p = .03) and baseline social functioning showed a marginally significant association with later insight (β = -.121, p = .07).
Conclusion: Improvement in social functioning was associated with subsequent improvement in insight, but not vice versa, in the first year of treatment following an initial episode of psychosis. Better social relationships may provide greater exposure to and understanding of others’ perspectives, which may foster greater insight into illness and self. Findings have clinical implications, suggesting that enhancing social functioning in early stages of intervention for FEP may have secondary positive effects in improving insight into psychotic illness and treatment needs.

Caregivers’ Mental Health in Early Course Psychosis

Emily R. Kline, PhD, Heather Thibeau, BA, Bediha Ipekci, PhD, Brooklyn Landis, Vicky Zheng, Nelsie Berberena, PsyD, Hannah E. Brown, MD

Boston University Chobanian
Avedisian School of Medicine, Boston, MA
Boston Medical Center, Boston, MA

Abstract

Background: Caregiving in psychotic disorders is associated with high levels of stress and burden and may also impact caregivers' own social and occupational functioning. Because caregivers play crucial roles in initiating treatment, facilitating rehabilitative activities, and ensuring treatment adherence for individuals with psychotic disorders, their wellness may be a significant and overlooked component of early psychosis intervention. The aim of the current study is to describe the characteristics of family caregivers who participated in the Motivational Interviewing for Loved Ones clinical trial and the impact of their loved one's psychosis on their own mental health.
Methods: Participants (n = 71) were recruited from 2020-2021 to a study offering communication skills training to family caregivers of individuals with early-course psychosis. Participants provided demographic information, completed the Perceived Stress Scale, and were assessed by a clinician using the adjustment disorder module of the Structured Clinical Interview for the DSM-5.
Results: Most participants (66%) were mothers of an individual with early-course psychosis, though fathers (28%), siblings (3%), and extended family members (2%) were also represented. The vast majority endorsed offering their loved one emotional support (97%), financial support (92%), advice or information (93%), and assistance with obtaining medical and mental health care (77%). Eighty-two percent reported a moderate or high level of stress. A substantial minority (35%) met criteria for a diagnosis of adjustment disorder relating to their loved one’s psychotic illness and an additional 8% reported that the circumstances exacerbated a previous diagnosis of depression, anxiety, or trauma related disorder. They described sleeplessness, loss of control, worry, guilt, sadness, relationship difficulties, and career disruptions. Adaptive coping strategies included prayer, compartmentalization, and researching potential solutions.
Conclusions: Caregivers reported significant personal anguish around the time of their child’s first episode of psychosis. Caregiver mental health is worthy of attention

Exploration of Neighborhood Deprivation and Patient -level Demographics of Young Adults Receiving Care for Psychosis: Implications for Health Equity

Brittany Gouse MD MPH, (1,2) Tithi Baul MPH, (1,3) Elijah Boliver MPH, (1) Luisa Camacho MPH, (1) Jennifer Lancet MBA, MS, CPS, (1) Nandini Agarwal MPH, (1,3) Toshiaki Komura BS, (1) Hannah Brown MD (1,2)

1: Wellness & Recovery After Psychosis Program, Boston Medical Center, Boston, MA
2: Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
3: Evaluation Research Center, Department of Psychiatry, Boston Medical Center, Boston, MA

Abstract

Background: Structural inequities at the neighborhood level negatively impact access to care and targeted interventions are necessary to reduce these barriers. In the metro-Boston area, systemic factors such as housing discrimination perpetuate racial segregation. Here, we explored individual sociodemographic characteristics across area-level socioeconomic (SES) strata among young adults with psychosis receiving care at an urban, safety-net hospital.
Methods: We used an electronic-medical record derived repository (ACCESS) of all visits with a schizophrenia spectrum disorder (SSD) billing code. The analytic sample included patients ≤ to 30-years old with at least one SSD-related visit between 2015-2022. Neighborhood socioeconomic deprivation was defined by connecting individual-level EMR demographics to U.S. Census data and American Community Survey Data. Sociodemographic differences were compared across SES Social Vulnerability Index (SVI) quartiles using chi-squared tests.
Results: Among 1,197 patients, 67.2% were male, 56.5% were non-Hispanic Black, and 87.7% were English speaking. The median SVI for the cohort was 0.76 (IQR: 0). A higher proportion of non-Hispanic Black and Hispanic patients resided in census tracts that were more socioeconomically vulnerable than 75% of census tracts across Massachusetts than non-Hispanic white patients (62.5% non-Hispanic Black vs. 55.6% Hispanic vs. 24.1% non-Hispanic white, p<.001).
Conclusions: The majority of young adults with psychosis served at BMC reside in highly socioeconomically disadvantaged neighborhoods. Further, a significantly higher proportion of non-Hispanic Black and Hispanic patients resided in the census tracts in the lowest SES strata in the state compared to their non-Hispanic white counterparts. Additional resources are critically needed to mitigate structural inequities at the neighborhood level in pursuit of health equity in Massachusetts.

The Impact of Certified Peer Specialists as Teachers to Families

Nicole Cerundolo (1), Jacqueline Dow (1), Rahel Bosson (2), Yale Hicks (3), Zachary Millman (1), Matthew Moseman (4), Dost Öngür (1,5), Nathaniel Peter VanKirk (5,6),Emily Carol (1,5), Steve Fedele (7)

1. Division of Psychotic Disorders, The LEAP Center, McLean Hospital;
2. Medical Director of PACT, McLean Hospital;
3. (CPS) Program Coordinator of Waverly Place, McLean Hospital;
4. (CPS) PACT Team, McLean Hospital;
5. Department of Psychiatry, Harvard Medical School;
6. OCD Institute, Office of Clinical Assessment and Research (OCAR), McLean Hospital;
7. (CPS, IPS) Program Coordinator of WellSpace, McLean Hospital

Abstract

Background: There has been a rise in certified peer specialists (CPSs) in mental health services over the past fifty years. These individuals with lived experience of mental health conditions have received training to work in clinical organizations, providing support to individuals with mental illness. Peers offer practical advice, assistance, resources, and recovery stories grounded in their unique perspectives. However, peers remain an underutilized resource in working with family members of individuals with psychosis. Given their impact in patients’ recovery, increasing family members exposure and interactions with CPS could have a significant impact on their outlook regarding mental health and recovery.
Methods: Our aim was to assess the impact CPS-led teaching sessions held for families. The project itself was organized by a peer specialist. Family members of loved ones with psychosis (n=42) completed a feedback survey following open discussion. Survey questions assessed the impact of this session on their understanding of mental health conditions, their belief in the possibility of recovery, and their ability to support a loved one with a severe mental health condition. Thematic analyses identified key motivations and overarching impressions from these sessions.
Results: Approximately 19% of survey respondents had no prior knowledge of peer specialists, and 38% of respondents attended the session specifically to hear the perspective of a peer specialist. Primary takeaways included strategies to support family members in recovery, newfound hope for the future recovery of their loved ones, a greater appreciation for peer specialists as a resource, and a deeper understanding of beneficial interventions.
Conclusions: We expect to find a significant positive impact of peer-led discussions, particularly for those lacking prior experience working with peers. This preliminary analysis will serve to illustrate the importance of peer services for families, and the impact that a single peer-led event can have on a family member’s relationship with mental illness.

Enhancing Psychosis Assessment and Intervention in Primary Care: Collaborative Initiative with Psychosis Experts

Sohenga C. Depestre PsyD (1,2), Samantha LaMartine PsyD (1,2,3), Hannah Brown MD (1,3), Cara Fuchs PhD, MPH (1,2)

1: Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
2: Integrative Behavioral Health, Boston Medical Center, Boston, MA
3. Wellness & Recovery After Psychosis Program, Boston Medical Center, Boston, MA

Abstract

Background: The Support, Treatment, and Resilience (STAR) clinic at McLean Hospital was established in 2019 as an outpatient program for youth at clinical high-risk (CHR) for psychosis. STAR’s mission is to provide high-quality, insurance-based, outpatient care while serving as a hub for training and research on the high-risk stages of illness. We previously reported STAR’s referral and clinical activities through 2021. Here we provide updates on recent clinic developments including referral progress, clinical services, training, and research, highlighting years 2022 and 2023.
Methods: Frequencies of client referrals, intakes, consultations, and discharges are reported and compared across 2022 and 2023 with further updates at the time of presentation. Additional metrics of clinic growth are reported including staff additions, clinical programming, training opportunities, and affiliated research grants.
Results: In fall 2022, STAR initiated a consultation service to complement its active treatment program and added five new professional staff and trainees. In 2022, the number of referrals, evaluations, and clients who met CHR criteria once assessed were 29, 7, and 4, respectively. In 2023, these numbers are 39(34.48% increase), 20(184.71% increase), and 12(200% increase). 14 additional clients received ongoing treatment through STAR in 2023; to date, 7(35%) of 20 discharged clients since the clinic opened have transitioned to psychosis. STAR also began a new psychotherapy group, established a longitudinal clinical monitoring battery, and obtained numerous federal and local research and service awards. Conclusions: The STAR clinic continues to grow in terms of community impact and there continues to be a need for these services. Referrals are increasing and clinical services are expanding. The clinic is providing valuable training opportunities for psychology and psychiatry trainees and supports several promising research studies focused on CHR youth. Moving forward, standardized longitudinal data collection will provide valuable insights into the clinical course and treatment of this population.

The relationship of therapeutic alliance to quality of life for people with serious mental illness: A pilot study based on lived experience

Raquelle Mesholam-Gately (1,2,3), Emily Parsons (4), Christian Rosa-Baez (5), Nathan Schwirian (5), Linda Larson (5), Peter Durning (5), Dan Johnston (5), Vera A. Muñiz-Saurré (5), Charles Stromeyer (5), Matcheri Keshavan (1,2,3)

1. Massachusetts Psychosis Network for Early Treatment (MAPNET), Beth Israel Deaconess Medical Center, Boston, MA
2. Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Boston, MA
3. Department of Psychiatry, Harvard Medical School, Boston MA
4. OASIS Program, University of North Carolina at Chapel Hill, Chapel Hill, NC
5. Peer Advisory, Advocacy & Research Council, Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Boston, MA

Abstract

Background: The therapeutic alliance in mental health care is associated with better symptomatic and functional outcomes, as well as increased treatment adherence and satisfaction with care. There are, however, few instruments measuring therapeutic alliance for those with serious mental illness (SMI) that have specifically been developed in collaboration with researchers and people with lived experience. Guided by lived experience expertise, his study examined the relationship between therapeutic alliance and quality of life in SMI.
Methods: This project represented a partnership between researchers, clinicians and those with lived experience of SMI in the Peer Advisory, Advocacy & Research Council (PAARC; formerly Consumer Advisory Board) at the Psychosis Research Program of the Massachusetts Mental Health Center (MMHC) Public Psychiatry Division of Beth Israel Deaconess Medical Center, Boston, MA. People with SMI (N=76) between the ages of 20-76 receiving outpatient care at the MMHC and other MA DMH mental health facilities in the Boston area provided data for this project. Participants were asked to complete a 1 hour interview with researchers and PAARC members. Interviews involved questionnaires developed by the research team about the therapeutic allaince (Treatment Relationship Inventory; TRI) and subjective quality of life (a modified version of the World Health Organization Quality of Life Assessment; mWHO-QOL). Internal reliability of the TRI, including its subscales, was calculated with Chronbach’s alpha. Associations between survey ratings were measured with Spearman’s correlations. Nonparametric partial correlations were conducted to consider the potential confounding influence of select sample characteristics on the survey associations.
Results: The TRI was found to be highly reliable for all 30 items comprising the total score (α = .94), as well as for each of the subscales. Total average scores for the TRI and mWHO-QOL were significantly and positively correlated (rs=.41, p<.001). Subsections within the TRI (clinician relationship, emotional climate, interpersonal continuity, mutual trust) and the total average score for the mWHO-QOL were also significantly correlated (range of rs=.31 to .40; all ps <.01). Subsections within the mWHO-QOL (physical, cognitive, emotional) and the total average score for the TRI were similarly significantly correlated (range of rs=.24 to .36; all ps <.05). Most specific subsections between the instruments also showed significant correlations. Controlling for age, gender and treatment background characteristics via separate nonparametric partial correlation analyses did not change the significant association between TRI and mWHO-QOL total average scores. Comparable significant findings were shown when just analyzing an adolescent and young adult subset of the sample (N=16; aged 20-34).
Conclusions: These findings suggest that a strong therapeutic alliance is related to better quality of life in people with SMI. Additionally, certain aspects of the therapeutic alliance and quality of life have a stronger association than others. Further research can help to elucidate the predictive nature of therapeutic alliance on quality of life in early phases of illness, particularly psychosis, and inform more effective approaches to early intervention by targeting aspects of therapeutic alliance early in treatment. Moreover, applying these novel scales, and with it the expertise of lived experience, in future assessments of therapeutic alliance will provide further insights into the impact of collaborative approaches to conceptualizing, developing and providing recovery-oriented mental health services.

Using Implementation Science to Operate as a Learning Health System to Improve Outcomes in Early Psychosis

Bo Kim (1,2), Margaret Guyer (1,3), Matcheri Keshavan (1,4)

1. Harvard Medical School
2. VA Boston Healthcare System
3. Massachusetts Department of Mental Health
4. Beth Israel Deaconess Medical Center

Abstract

Background: Early interventions are well understood to improve psychosis outcomes, but their successful implementation remains limited. This work introduces a three-step roadmap for advancing the implementation of evidence-based practices to operate as a learning health system, which can be applied to early interventions for psychosis and is intended for an audience that is relatively new to systematic approaches to implementation.
Methods: The roadmap is grounded in implementation science, which specializes in methods to promote routine use of evidence-based innovations. The roadmap draws on learning health system principles that call for commitment of leadership, application of evidence, examination of care experiences, and study of health outcomes. Examples are discussed for each roadmap step, emphasizing both data- and stakeholder-related considerations applicable throughout the roadmap.
Results: Early psychosis care is a promising topic through which to discuss the critical need to move evidence into practice. Despite remarkable advances in early psychosis interventions, population-level impact of those interventions is yet to be realized. By providing an introduction to how implementation science principles can be operationalized in a learning health system and sharing examples from early psychosis care, this work prompts inclusion of a wider audience in essential discourse on the role that implementation science can play for moving evidence into practice for other realms of psychiatric care as well.
Conclusions: The proposed roadmap can serve as a conceptual guiding template and framework through which various psychiatric services can methodically pursue timely implementation of evidence-based interventions for higher quality care and improved outcomes.

Insights from the STAR Program at McLean Hospital: Creating a Standardized Clinical Assessment Battery for a Clinical High Risk for Psychosis (CHR-p) Early Intervention Program

Joey Rodriguez (1,2,3,4), Halle R. Singer (1), P. Esra Guvenek-Cokol (1,2), Hyun Jung Kim (1,2), Tamara Welikson (1,2), Lola Nedic (3), Dost Öngür (1,2), Zachary B. Millman (1,2), Emily E. Carol (1,2)

1. Psychotic Disorders Division, McLean Hospital, 115 Mill Street, Belmont, MA 02478
2. Department of Psychiatry, Harvard Medical School, 25 Shattuck Street, Boston, MA 02114
3. Psychosis Research Program, Beth Israel Deaconess Medical Center,
4. Northeastern University, Boston

Abstract:

Background: Clinical assessment batteries are a core component of measurement-based care within learning healthcare systems. Early intervention services (EIS) for early psychosis in Massachusetts have established a learning healthcare approach that utilizes integrated clinical assessments to systematically inform individualized care and program development. While EIS are becoming increasingly common for treatment of individuals at clinical high risk for psychosis (CHR-p), the field lacks guidance on standardized symptom and treatment monitoring. Developing a standardized clinical assessment battery for CHR-p EIS that emphasizes a bi-directional feedback loop between clinic and client may (1) augment treatment planning, (2) enhance response monitoring, and (3) improve understanding of clinical profiles and outcomes in CHR-p populations.
Methods: The purpose of this clinical QI project was to assess current assessment batteries utilized across local CHR-P and First Episode Psychosis EIS to inform the development of a STAR clinical assessment battery. The QI project was organized in three phases: (1) program identification and assessment battery collection; (2) comparison of assessments across batteries; (3) identification of gaps and solution prototyping.
Results: Six assessment batteries were collected . Seventy-one measures were identified and compared. Gaps lacking clear guidance in assessment batteries were identified. Notable gaps include: (1) assessment battery organization; (2) client perception of consultation; (3) influences of social media ; (4) perception of discrimination and stigma; (5) ambivalence towards medication adherence ; (6) identity formation. Proposed solutions to these gaps will be explored.
Conclusion: The results of this QI project provide preliminary insights into assessment battery standardization and suggest solutions for current gaps that inform a learning healthcare approach to CHR-p care. Additionally, the results highlight the primacy of client-clinic collaboration in shaping EIS for CHR-p. Future steps hope to inform guidelines that deepen the learning healthcare approach for outpatient specialized care in CHR-p populations, improve clinical utility, and support state-wide alignment.

Evaluating Fidelity of Coordinated Specialty Care in First Episode Psychosis Clinics Across Massachusetts

Elizabeth S. Eberlin (1), Kelsey Johnson (2), Michael Stephanski (3), Donald E. Addington (4), Dost Ongur (5,6), Kim T. Mueser (7), Daphne J. Holt (1,6), Nicole R. DeTore (1,6)

1. Department of Psychiatry, Massachusetts General Hospital
2. Beth Israel Deaconess Medical Center
3. Massachusetts Department of Mental Health
4. Department of Psychiatry, University of Calgary
5. Department of Psychiatry, McLean Hospital
6. Department of Psychiatry, Harvard Medical School
7. Center for Psychiatric Rehabilitation, Boston University

Abstract

Background: Coordinated specialty care (CSC) programs are now the gold standard of care for those with a first episode of psychosis (FEP) in the United States. Many sites however differ in their adoption of CSC programing and thus it is unclear how many CSC components are delivered to fidelity. This study aimed to better understand how FEP programs in Massachusetts adhere to the overall CSC model, and more specifically to the supported education and employment (SEE) component. This study also examined how fidelity differed by the setting type, community mental health centers (CMHC) versus hospital affiliated programs.
Methods: This ongoing study conducted fidelity assessments utilizing two standardized fidelity scales: the FEP Services Fidelity Scale 1.0 (FEPS-FS), which measures fidelity to CSC, and the Individual Placement & Support Fidelity Scale for Young Adults (IPS-FS), which measures fidelity to SEE only. Fidelity across 11 Massachusetts community FEP sites was assessed, 64% were CMHC (n=7) and 36% (n=4) were hospital-affiliated.
Results: A total of 9 sites have completed the fidelity assessments. Sample-wide, the average fidelity of FEP-sites to the CSC model was 94.4%, per the FEPS-FS (good-high; m=170, sd=6.90, range=49-148; highest possible score=180). On the IPS-FS, FEP-sites averaged 76.6% fidelity to the IPS-employment model (fair, m=95.71, sd=24.60, range=49-120; highest possible score=125) and averaged 86.9% fidelity to the IPS-education model (good; m=43.43, sd=11.10, range=21-50; highest possible score=50). There were no statistically significant differences between site-types (CMHC versus hospital-based) using t-tests, on performance on the FEPS-FS (t=0.715, df=4, p=.514), the IPS-FS employment scale (t=1.45, df=5, p=.208), and the IPS-FS education scale (t=1.381, df=5, p=.226).
Conclusion: The results showed that Massachusetts FEP programs delivered high-quality services through the CSC model, with some room for improvement specifically regarding SEE services. Overall, these findings meet national standards, comparing favorably to prior work assessing fidelity of FEP programs nationwide (MHBG 10% set-aside study).

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

Efim Oykhman (1), Lola Nedić (1), Josie Kolstad (5), Jintian Luo (5), Paulo Lizano (1), Roscoe Brady (1), Gautami Shashidhar (1), Jenny Jang (1),Walid Yassine (1), Victor Zeng (1), Iqra Imam (1), Ananya Saluja (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 psychosis spectrum disorders (schizophrenia, schizoaffective disorder, bipolar disorder with psychosis, etc.), 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 B-SNIP chronic population 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 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. 

First Year of WRAP Without Walls: Assertive Community Outreach for Young Adults with Substance-Induced Psychosis or Psychosis with Co-Occurring Substance Use Disorders

Ellie Reagan, BS (1,2), Anne Berrigan, LICSW (1,2), Nicholas Fisher (1), Agata Bereznicka, MPH (1), Emily Kline, PhD (1,2), Hannah E. Brown, MD (1,2), Amy Yule, MD (1,2)

1: Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
2: Wellness & Recovery After Psychosis Program, Boston Medical Center, Boston, MA

Background: Adolescents and young adults experiencing psychosis and substance use often have low motivation to engage in substance use or mental health treatment. In addition, young people and their families face systemic challenges in accessing office-based treatment including limited resources for transportation, restricted access to technology for telemedicine visits, and less availability to attend appointments due to work and family responsibilities. In its second year of operation, the WRAP without Walls (WWW) program has succeeded in overcoming many of the engagement barriers to provide mobile, community-based multidisciplinary treatment to a diverse population of teens and young adults living with psychosis and substance use.
Methods: Data on WWW program participants gathered from the BMC electronic health record system (EHR) were analyzed to provide a description of program engagement in the program’s first year of operation (6/1/22 through 7/31/23). The WWW program, an adaptation of the Assertive Community Treatment model, provides the following community-based services to young people in Boston: individual therapy; family support and psychoeducation; medication management; peer support and advocacy; and case management.
Results: EHR and patient-reported data provide demographic and diagnostic information of the population engaged in WWW program services. Data also show the range of services to which individuals have been referred, or engaged in during the program’s first year. These services include individual therapy; meetings with family and community supports; psychopharmacology treatment; case management; and peer recovery support.
Conclusions: Through the development and execution of a multidisciplinary mobile treatment team, a diverse cohort of young people with psychosis and substance use have engaged in an array of services in home and community settings. Further work on the WWW model will provide information and practice guidelines on engaging and treating young people at a critical point in their development.

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

Halle R. Singer (a) , Joey Rodriguez (a,c), P. Esra Guvenek-Cokol (a,b), Hyun Jung Kim (a,b),Dost Ongur (a,b), Tamara Welikson (a,b), Emily E. Carol (a,b), Zachary B. Millman (a,b)

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

Abstract

Background: The Support, Treatment, and Resilience (STAR) clinic at McLean Hospital was established in 2019 as an outpatient program for youth at clinical high-risk (CHR) for psychosis. STAR’s mission is to provide high-quality, insurance-based, outpatient care while serving as a hub for training and research on the high-risk stages of illness. We previously reported STAR’s referral and clinical activities through 2021. Here we provide updates on recent clinic developments including referral progress, clinical services, training, and research, highlighting years 2022 and 2023.
Methods: Frequencies of client referrals, intakes, consultations, and discharges are reported and compared across 2022 and 2023 with further updates at the time of presentation. Additional metrics of clinic growth are reported including staff additions, clinical programming, training opportunities, and affiliated research grants.
Results: In fall 2022, STAR initiated a consultation service to complement its active treatment program and added five new professional staff and trainees. In 2022, the number of referrals, evaluations, and clients who met CHR criteria once assessed were 29, 7, and 4, respectively. In 2023, these numbers are 39(34.48% increase), 20(184.71% increase), and 12(200% increase). 14 additional clients received ongoing treatment through STAR in 2023; to date, 7(35%) of 20 discharged clients since the clinic opened have transitioned to psychosis. STAR also began a new psychotherapy group, established a longitudinal clinical monitoring battery, and obtained numerous federal and local research and service awards. Conclusions: The STAR clinic continues to grow in terms of community impact and there continues to be a need for these services. Referrals are increasing and clinical services are expanding. The clinic is providing valuable training opportunities for psychology and psychiatry trainees and supports several promising research studies focused on CHR youth. Moving forward, standardized longitudinal data collection will provide valuable insights into the clinical course and treatment of this population.

Life Skills Learning And Readiness for Resilient Youth (LARRY): a day treatment program for teens with serious emotional disturbance

Kimberley Hurdle-Carter (1), Olivia Naya (1), Rebecca Stocker (1), Daryn Lowe (1), Rachael Lauterbach (1), Tarshe Derival (1), Emily Kline (3, 4), Melanie Schanche (2), Kimberly Irving (2), Charlene Zuffante (3), Cynthia Berkowitz (2, 5)

1. Riverside Community Care, Somerville, MA
2. Massachusetts Department of Mental Health Metro Boston Region Child, Youth, and Family Team, Boston, MA
3. Massachusetts Department of Mental Health Central Office, Boston, MA
4. Boston Medical Center, Boston, MA
5. Boston University School of Medicine, Department of Psychiatry, Boston, MA
6. UMass Chan School of Medicine, Department of Psychiatry. Worcester, MA

Abstract

Background: Recent decades have seen the development of intensive biopsychosocial treatment innovation for early psychosis and clinical high risk. Adolescents experiencing psychosis may present with significant social isolation and disengagement from school and other structured, age-appropriate settings. Given the significant numbers of youth who have new onset psychosis and clinical high risk for psychosis as well as psychosis beginning in early life, we have recognized the need to develop a similar program that provides a recovery-oriented milieu for adolescents. Life Skills: LARRY is a previously established, successful day treatment program for adolescents with significant emotional struggles who can benefit from a daytime milieu. When a third Life Skills setting opened in Somerville, the Metro Boston Child Youth and Family team collaborated with Riverside Community Care to give this team specialization in treatment of emerging psychosis - early psychosis, clinical high risk, and psychosis beginning in early life.
Methods: Admissions to Life Skills LARRY were tracked from 2020 to present via chart review. For each youth, the primary diagnosis, whether the youth had experienced psychosis, and non-diagnostic presenting concerns were recorded. Concerns were categorized as: school refusal, substance use, self-harm or suicide risk, social isolation, aggression toward others, and conflict with family.
Results: We will present the number of admissions each year of the program including the number with a primary psychotic disorder, those with psychosis symptoms, and their chief presenting concerns. We will describe the treatment model in the process of development.
Conclusions: Life Skills LARRY seeks to treat emerging psychosis primarily by providing a socially supportive therapeutic milieu model. Those with primary psychoses as well as psychosis symptoms can benefit from the model. The LARRY team provides the therapeutic milieu as well as psychoeducation, social skills training, and motivational interviewing. Clinicians focus on referring teens to specialized early psychosis treatment teams that can offer specialized pharmacotherapy and continue treatment over years. We are developing a collaboration with the Wellness and Recovery After Psychosis (WRAP) program at Boston Medical Center that will emulate the coordinated specialty care treatment model.

An Exploration of Disparities in Telemedicine in Early Intervention Services

Samantha LaMartine PsyD (1,2), Beshaun Davis, PhD (3), Rachel Oblath PhD (1,2), Daisy Perez MPH (1,2), Luisa Camacho MPH (2), Hannah E.Brown MD (1,2), Emily Kline, PhD (1,2)

1. Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
2. Wellness & Recovery After Psychosis Program, Boston Medical Center, Boston, MA
3. Department of Psychiatry, University of Maryland School of Medicine, College Park, MD

Abstract

Background: In the early stages of psychotic disorders, limited self-awareness often leads to poor treatment adherence, more hospitalizations, and increased symptom severity. While coordinated specialty care has proven effective, it usually requires in-person sessions . Although the COVID-19 pandemic created an environment where telemedicine became an accepted alternative, its effectiveness in treating early stages of psychosis is not yet well-studied. This is a significant gap, as those who are newly diagnosed have distinct needs and may be ambivalent about receiving care. Furthermore, unequal access to technology could potentially make telemedicine less effective . These concerns are especially relevant for minoritized populations, who are more likely to be diagnosed with severe mental illness, more prone to slide into poverty following the diagnosis and experience higher dropout rates from in-person care. This study aims to address the existing gaps in understanding the feasibility and effectiveness of telemedicine as a treatment approach for early psychosis among Latinx and Black individuals.
Methods: This study will use Consensual Qualitative Research to allow data-driven categories to emerge. Researchers will recruit 10-15 Black or Latinx adults to share their telemedicine experiences. Multiple judges will analyze the interviews to reach a consensus on the data interpretation, and an auditor will counteract groupthink. The findings will be organized into themes.
Results: Recruitment for this study is ongoing. Preliminary data will present quotes and initial themes from interviews conducted to date, focusing on patient preferences for telehealth versus traditional therapy and potential barriers to utilizing telehealth services.
Conclusions: Depending on the outcomes, the study could offer valuable insights for improving care and engagement in this vulnerable population. Future steps may include optimizing telemedicine platforms to cater to these specific needs and addressing technological barriers to access.

CHAMPioning Reverse Integration Model in a Community Mental Health Center

Caitlin Mulligan (1,2), Niharika Brungi (1), Liana Raberg (1), Sarah Maclaurin (1,2)

1. Freedom Trail Clinic of North Suffolk Community Services
2. Massachusetts General Hospital, Department of Psychiatry

Abstract

Background: Outpatient mental health (MH) clinics are often the primary and most consistent point of contact with medical providers for underserved populations like those with Serious Mental Illness (SMI) and patients experiencing homelessness. People with SMI on average die up to 25 years earlier than the general population due to medical co-morbidity and limited access to preventative medical care1. The relationship between mental health and medical conditions are often bidirectional, therefore, addressing both conditions is crucial for improving a person’s overall quality of life and well-being.
Methods: Between April 2022 and March 2023, 140 patients met with a registered nurse or nurse practitioner to complete Comprehensive Health Assessment and Medical Prevention Screening (CHAMPS), an assessment that covers a wide range of preventative health and mental health screenings. Obtaining these results created an opportunity for cross-disciplinary collaboration with primary/specialty care, thus improving care coordination, patient education and access to care.
Results: 90 individuals (65%) were current or former smokers and 29 (51.72%) of those eligible completed lung cancer screening. 45 individuals had completed screening for colorectal cancer at the time of the assessment and of those remaining who were eligible, an additional 29 (93.10%) completed with assistance. 28 individuals completed breast cancer screening and 5 individuals completed prostate cancer screening with an additional 6 after the assessment. 128 individuals had primary care physicians and 32 appointments were scheduled for follow up at the time of assessment.
Conclusions: Reverse Med-Psych Integration in an outpatient community mental health clinic for underserved populations is feasible and effective. Addressing mental health concerns alongside medical conditions improves adherence to recommended treatment plans and improves overall health. This can result in reduced hospitalizations, emergency room visits, and better long-term health outcomes.

Predictors of Prolonged Length of Stay Among Young Adults Presenting to the Emergency Department with Psychosis

Elijah E. Boliver MPH (2), Brittany Gouse MD MPH (1,2), Tithi D. Baul, MPH (1-3), Luisa Camacho MPH (2), Jennifer Lancet, (MBA, MS, CPS2), Temitope Ogundare MD (1,2), Nandini Agarwal MPH (1,3), Hannah Brown MD (1,2)

1: Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
2: Wellness & Recovery After Psychosis Program, Boston Medical Center, Boston, MA
3. Evaluation Research Center, Department of Psychiatry, Boston Medical Center, Boston, MA

Abstract

Introduction: The emergency department (ED) is a common pathway to treatment for individuals experiencing psychosis. Prolonged ED length of stay (LOS) is associated with significant declines in quality and timeliness of care. We examined factors associated with prolonged LOS within an urban, safety-net hospital among young-adult patients experiencing psychosis.
Methods: We analyzed ED visits among young adults, age 18-30 with a schizophrenia spectrum disorder billing code between 03/01/2019-02/28/2021. We conducted bivariate analyses to determine associations between demographic characteristics and prolonged LOS (defined as ED LOS > 24 hours). We conducted multivariable regression analyses to measure the association between prolonged LOS and markers for acuity (physical restraint, parenteral medication, inpatient hospitalization, and substance use screening).
Results: Among 637 patients, 69.9% were male, mean age of 26-years (SD=3.1). There was a significant association between race/ethnicity and prolonged LOS (p=0.027); a higher proportion of non-Hispanic Black patients (67.5%) had prolonged LOS compared to non-Hispanic white patients (6.7%). Multivariable regression analyses showed that compared to patients without prolonged LOS, patients with prolonged LOS had higher odds of being physically restrained (aOR: 4.79; 95%CI: [2.45, 9.37]; p<0.001) and receive parenteral medication (aOR: 1.88; 95%CI: [1.02, 3.46]; p=0.044).
Conclusions: ED LOS > 24-hours may represent a risk factor for iatrogenic trauma early in the course of psychosis due to increased possibility of physical restraint use and parenteral medication. Early negative experiences with the mental health system may increase duration of untreated psychosis. Further work is critically needed to better understand driving factors for prolonged LOS in Massachusetts to inform policy changes such as increased funding for inpatient psychiatric services.