Improving Accuracy of Screening for Clinical High-Risk for Psychosis in an Adolescent Population Seeking Help through the MGH Resilience Evaluation-Social Emotional Training (RE-SET) Program

Jacqueline Clauss, MD, PhD* (1), Cheryl Y. S. Foo, PhD* (1,2), Lauren Utter, PsyD (1), Drew Coman, PhD (1), Michaela Newton, MA (1,3), Kamila Bhiku (1,2), Julia London (1,2), 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:

Introduction: Young people with brief or attenuated psychotic symptoms may meet criteria for the clinical high-risk state for psychosis (CHR-P), a syndrome associated with enhanced risk for developing psychotic disorders and other impairing psychiatric illnesses. The MGH Resilience Evaluation-Social Emotional Training (RE-SET) program provides evaluation, prognostic assessment, and preventative treatment for CHR-P individuals (ages 12-30). CHR-P’s high comorbidity and overlap in clinical features with other psychiatric symptoms presents challenges for early and accurate identification of CHR-P. Improving identification of CHR-P individuals could facilitate more timely referrals and reduce evaluation burden.

Method: Family members, clinical providers, or patients self-referring to RE-SET completed a screening form assessing patient’s lifetime behaviors, psychiatric diagnosis, psychiatric service use, and the Adolescent Psychotic-like Symptom Screener (APSS). Prior to a two-part clinical evaluation, eligible patients and their caregivers completed a battery of measures of symptoms of psychosis, anxiety, attention, and mood; traumatic experiences; social functioning; caregiver burden; and developmental history. Following an initial diagnostic evaluation, if there was evidence for attenuated or brief psychotic symptoms, clients the completed the Structured Interview for Psychosis-Risk Syndromes, a gold-standard assessment to determine CHR-P status. We used hierarchical logistic regression to determine predictive ability and incremental validity of clinical risk factors to detect CHR-P status.

Results: 98 help-seeking adolescents (mean age: 18.1; SD: 4.1) were assessed. 24 (24.5%) met CHR-P criteria. Referrals had high rates of psychiatric comorbidity at time of referral: 73.5% had at least one reported psychiatric diagnosis and 62.2% had been treated with a psychotropic medication. Evaluated patients (n=43) reported moderate levels of perceived stress, loneliness, and depression, and severe anxiety symptoms, consistent with the transdiagnostic nature of this population. Referrer-reported decline in social functioning in the past year (OR=6.54, p=.038), autism spectrum disorder (ASD) diagnosis (OR=16.21, p=.026), and endorsing at least two APSS items (OR=9.52, p=.011) predicted CHR-P status (model R2= .43, p = .008). Self-reported hours awake per day improved prediction of CHR-P over the above variables (OR=4.41, p=.016; model ΔR2 = .306, p=.002).

Conclusions: Potential CHR-P individuals present with high diagnostic complexity and significant clinical need. A recent decline in social functioning, an ASD diagnosis, attenuated symptoms, and less sleep are significant risk factors for CHR-P status; screening and evaluation of CHR-P can be improved with greater attention to these factors.

Falling through the Cracks: Perspectives from local leaders on substance use and psychosis treatment for youth

Christina Freibott MPH (1), Thisara Jayasinghe (2), Ellen Reagan B.S. (1), Daisy Perez MPH (1), Anne Berrigan LICSW (1), Emily Kline PhD (1,2) Hannah Brown, M.D. (1,2) Amy Yule, M.D. (1,2)

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

Abstract

Background: Substance Induced Psychosis (SIP) requires early intervention in youth to improve prognosis. The Assertive Community Treatment (ACT) model has been used to treat severe mental illness in adults who have struggled to engage in typical treatment. However, this model has not been adapted to treat youth in an urban setting who struggle to engage in typical office based treatment. The objective of this study was explore local leaders experiences and perspectives with substance use and psychosis treatment (“leaders”) when adapting and implementing the ACT model to treat and engage urban youth with SIP.
Methods: Purposeful sampling was used to recruit leaders who interact with youth with SIP for semi-structured interviews to understand barriers and facilitators in adapting the ACT model to treat urban youth with SIP. Interviews were recorded, transcribed, and de-identified. Using the software NVivo, de-identified interviews were deductively coded using the Consolidated Frameworks for Implementation Research (CFIR). Themes emerged from deductive coding that were identified and agreed upon by a three person coding team.
Results: Eleven interviews were completed with 14 leaders. The four themes included: 1). A patchwork of systems attempts to catch youth early on, but often does not, 2). The inability to simultaneously address mental health and substance use concerns complicates how youth and their families engage in care, 3). An ideal program would be flexible in all the ways the current system is inflexible, centering treatment around youth and families, and 4). Factors important in tailoring a community-based program to serve under-resourced and historically marginalized urban youth.
Conclusion: Urban youth with SIP are a unique and vulnerable population. When designing a community based program to support their engagement in treatment it is imperative to take a patient centered approach that accounts for their symptoms, setting, and individually tailored how care is presented.

The Revenue Stream Can Now Flow: Billing Codes approved for Coordinated Specialty Care for FEP

David Shern, Brenda Jackson, Ken Farbstein

Abstract

Coordinated Specialty Care programs for Early Psychosis (CSC-EP) have struggled financially, despite the strong evidence base for their effectiveness. They’ve had to piece together funding for their teams from philanthropic donations, some fee-for-service reimbursement, temporary grants, the Community Mental Health Services Block Grant, and sometimes state contracts. Now the Centers for Medicare and Medicaid (CMS) has approved two team-based HCPCS [Medicaid] billing codes, which just became effective October 1, 2023. This poster will depict the next steps of the full adoption of the billing codes until provider teams can get routinely reimbursed for their CSC-EP. The poster will also portray the pathway that led to CMS approval.

Mobile Applications for Schizophrenia Treatment

Bridget Dwyer, John Torous (MD), Elena Perlmutter

Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School

Abstract

Background: Common barriers among schizophrenia treatment include medication non-adherence and lack of access to clinically relevant psychoeducation and tools for daily symptom management. Additionally, early-onset schizophrenia is associated with poorer clinical outcomes, higher rates of treatment resistance, and diagnostic delay among providers. Mental health applications have the potential to target the aforementioned barriers and increase access to care for individuals experiencing psychosis, including those with early-onset psychotic symptoms. However, the marketplace for clinically relevant, schizophrenia-specific applications is limited. A 2022 study revealed that of the 537 schizophrenia-specific applications available to download, only six were deemed clinically relevant. More specifically, the marketplace for youth experiencing psychosis is even more limited.
Methods: In order to deliver higher quality, more accessible care to individuals experiencing psychosis and specifically target youth demographics, it is necessary to build clinically relevant apps that are publicly available to download from the Apple and Android marketplaces. While research efforts surrounding app development are evident, adaptation from research to marketplace should be facilitated.
Results: Such applications should incorporate reminders to promote medication adherence, research-backed psychoeducation, and sustainable interventions to aid in daily symptom management, such as personalized toolkits. Features of personalized tool kits should include but not be limited to: journaling, meditating, goal-setting, and mood/symptom/sleep/exercise/ tracking.
Discussion: While digital interventions have the potential to transform mental healthcare and access to psychosis treatment, significant efforts toward implementation must be considered beforehand. In order to support its scalability, there must be concomitant workforce training and a clinically supported infrastructure.

Comprehensive Clinical Assessment in Rural Massachusetts: 24 Month MAPNET Data Collection Outcomes

Cassidy Lewis, BA (1), Betty DeAngelis, LICSW (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: Located in Holyoke, MA, Prevention and Recovery in Early Psychosis-West (PREP) is a Department of Mental Health (DMH)-licensed coordinated specialty care (CSC) program for individuals living with early psychosis. PREP 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. To further support evidence-based treatment and care, and state-wide early psychosis collaboration efforts, PREP 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 over the past two years, 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 clients who received services in the two years. As we are at the 23-month mark for assessment collection, we specifically examined client demographics and who received the MAPNET assessment battery at baseline, 6-, 12-, and 18-months.
Results: For the 59 clients enrolled at PREP between 09/01/2021 and 09/01/2023: 18-mo follow-up assessment n=7 (12%); 12-mo n=2 (3%); 6-mo n=12 (20%); and baseline n=19 (32%). Eighteen (44%) clients have been discharged, and 8 of the 41 (19.5%) active clients have not received the assessment battery at any timepoint.
Conclusion: Competent clinical measurement-based care continues to be carried out at PREP using a comprehensive quantitative assessment battery to help measure client progress. As a CSC clinic in rural MA, however, limited resources, decreased clinician time, and staffing challenges hampers data collection. Heightened resource allocation efforts, continued development with local and regional academic partners, and increased staff support will help improve collection and subsequent care.

Sexual and Gender Minority Reporting in First-Episode Psychosis Outpatient Care

Jacqueline F. Dow, MPH (1) , Tamara Welikson, PhD (2,3), Tithi Baul, MPH (4,5), Kelsey A. Johnson, MPH (6), Hannah Brown, MD (4,5), Dost Öngür, MD, PhD (1,3), Brittany Gouse, MD, MPH (4,5)

1. Schizophrenia and Bipolar Disorder Program, McLean Hospital, Belmont, MA
2. Psychotic Disorders Division, McLean Hospital, 115 Mill Street, Belmont, MA
3. Department of Psychiatry, Harvard Medical School, 25 Shattuck Street, Boston, MA
4. Department of Psychiatry, Chobianian and Avdesian School of Medicine at Boston University
5. Wellness and Recovery After Psychosis Research Program, Boston Medical Center, Boston, MA
6. Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA

Abstract

Background: Sexual and/or gender minorities (SGM) have increased rates of social adversities and adverse mental health outcomes such as suicide. To our knowledge, there is a paucity of prior work describing the SGM population engaged in first episode psychosis (FEP) care. Here, we aim to describe the proportion of FEP clients in Massachusetts who self-identify as a member of an SGM group.
Methods: We performed a cross-sectional analysis of baseline demographic data collected 3/2016-11/2022 through the MAPNET/EPINET core assessment battery (CAB) from 11 FEP clinics in Massachusetts. Gender identity and sexual orientation were self-reported, and sex assigned at birth was either self-reported or collected through chart review. These sexual orientation/gender identity (SOGI) data were analyzed using descriptive statistics.
Results: In this cohort of 750 young adults (mean age of 23.6), 16 individuals identified as a gender minority (2.14%), 14 individuals identified as non-binary (1.87%), and 2 individuals identified as another gender (0.27%). Additionally, 25 individuals identified as a sexual minority (3.3%), 7 individuals identified as gay/lesbian (0.93%), 16 individuals identified as bisexual (2.1%), and 2 individuals identified as another sexual orientation (0.27%). Further analyses will evaluate the missingness of these data.
Conclusions: The proportion of clients captured through the current MAPNET/EPINET CAB identifying as a member of an SGM group is lower than what has previously been reported in population-based studies. Further work is needed to understand if this assessment is underrepresenting this population. Improvements to the collection of SOGI measures are imperative in understanding the need for SGM-affirmative support in FEP settings. Our next step is to describe the proportion of sites capturing SOGI data over time given the lack of standardization in timing of collection of this variable across FEP programs.