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Friday, October 21, 2016

Catching Psychosis Early

From the APA Monitor
by the American Psychological Association

By Heather Stringer
October 17, 2016

Psychologists are at the forefront of helping young people at risk of mental health crisis.


Brian Malmon seemed to be thriving at Columbia University. He was on the dean’s list, president of his a cappella singing group and sports editor for the college newspaper. But friends began to notice subtle changes in his behavior. Sometimes he seemed unusually withdrawn. During his senior year he visited the student health center, and a counselor noted signs of anxiety, stress and depression.

Malmon returned home to Maryland and met with a psychiatrist, who learned that he had been hearing voices since his freshman year. Malmon had been living with psychosis but told no one. He was diagnosed with schizoaffective disorder and withdrew from school to move home. He started taking medication and seeing a psychotherapist, but struggled deeply with the fact that his life had been put on hold while his peers were graduating from college.

He died by suicide at age 22.

"The most salient emotion I experienced was a deep belief that if Brian’s friends had known what he was experiencing and if he had felt comfortable reaching out for help, his life would be so different," says Alison Malmon, Brian’s younger sister. The experience led her to found a national young adult mental health advocacy group called Active Minds.

Malmon died in 2000. Since then, awareness of the importance of early intervention in psychosis has been elevated to the national agenda. Between 2000 and 2009, the National Institute of Mental Health (NIMH) started directing more funding to early psychosis research because studies were uncovering better strategies to identify individuals at risk—and there was mounting evidence about the consequences of delaying treatment once psychotic symptoms appeared, says Robert K. Heinssen, Ph.D., director of the NIMH Division of Services and Intervention Research.

"Previous studies showed that when treatment was delayed, people experiencing a first episode of psychosis did not respond as well to initial intervention and that long-term recovery was impaired," says Heinssen. Then in 2014, the federal government specifically designated funding for programs aimed at helping people after their first episode of psychosis. That year, Congress set aside an additional 5 percent of state mental health block grant money for these programs, and in 2016, the grant money set aside doubled to 10 percent.

"The earlier someone gets into care the better their outcome," says Rachel Loewy, Ph.D., associate professor in the department of psychiatry at the University of California, San Francisco. The symptoms of psychosis often start during the late teens or early 20s, she says. "These young adults are not only dealing with symptoms of a mental disorder but also the fact that the changes are happening at a critical time in their lives when they are developing their identities."

Psychologists at the Forefront

In a study published in 2015, researchers found that the median duration of untreated psychosis (DUP) was 74 weeks among participants. The people in the study represented 21 states throughout the country and had sought treatment in community clinic settings (Psychiatry Services, 2015).

"These data are extremely important because it represents a starting point in understanding DUP and how it is related to treatment outcomes," says Carina Iati, Psy.D., a clinical psychologist in the Prevention and Recovery in Early Psychosis program at the Massachusetts Mental Health Center.

Iati was interested in finding ways for clients to access treatment earlier. She and Rachel Waford, Ph.D., a former colleague from Emory University, discussed the issue and realized that people who knew their patients often noticed changes and wanted to help, but didn’t know how. Those people included family members, friends, teachers, police, coaches and guidance counselors.

There is mounting evidence about the consequences of
delaying treatment once psychotic symptoms appear.
The earlier someone gets into care, the better.

In an effort to educate non-clinicians about how to intervene and help young people who may be experiencing psychosis, Iati and Waford, a clinical psychologist at Emory, developed the "Psychosis Response Guide: How to Help Young People in Psychiatric Crisis."

The book, published this year, covers the warning signs of psychosis, such as isolation from friends and activities, academic struggles, irritability, substance use and lack of self-care such as bathing, eating or sleeping. While some of these behaviors may be common in adolescents, people suffering from psychosis will feel like the changes are happening to them involuntarily rather than by choice, Iati says.

The guide also explains how to have a conversation with someone about getting help. It’s important to understand that people dealing with psychosis may feel that the world has become scary and perceive things differently, Iati says.

"If someone believes the government is watching him or her, our gut reaction is to explain that this isn’t happening," she says. "But we ask people to avoid confronting delusional content. It’s more constructive to affirm that this sounds terrifying, and suggest talking to someone about their fears."

Coordinated Specialty  Care

Although early intervention is critical, equally important is the right kind of treatment. A first episode of psychosis typically results in a brief inpatient hospitalization with high doses of medication, followed by long-term outpatient treatment, Loewy says.


Traditionally, outpatient community mental health clinics provide patients with a case manager and medication, often at the same high doses of drugs that were used in the hospitalization, which can lead to intolerable side effects, she says.

"Patients on these high doses may suffer from lack of motivation and lower energy, fuzzy cognition and weight gain, and consequently they stop taking the medication," she says.

A more effective treatment strategy includes a coordinated combination of interventions, including individual or group therapy, pharmacological treatment, family support and education, and support in returning to work or school. This multidisciplinary approach has proven successful in Australia, England and other countries, but it wasn’t until recently that the National Institute of Mental Health dedicated funding to evaluate the effectiveness of this strategy in the United States.


Many other countries have the advantage of a single-payer health insurance system, which makes it easier to fund early psychosis programs, says Kim Mueser, Ph.D., executive director of the Center for Psychiatric Rehabilitation at Boston University. To explore whether these programs could be adapted to the U.S. health-care context, the NIMH launched an initiative called "Recovery After Initial Schizophrenia Episode" or RAISE.

As part of the RAISE initiative, Mueser helped to develop and study a treatment psychosis called NAVIGATE. This program includes individualized pharmacological treatment, family psycho-education and resilience-focused individual therapy. The program also provides supported employment or education. This involves assistance with searching for a job or educational setting and follow-up support to facilitate success in school and the workplace. Counselors also work with patients to determine how to disclose their psychiatric disorder.

"In this program, the primary goal is helping people get their lives back in order and achieve goals," Mueser says. "They have a right to the same kind of life that we do, but unfortunately our current system gives them the opposite message."

For example, colleges and universities make it difficult for patients to go back to school by imposing strict requirements for students who return with serious mental illnesses. "It’s my opinion that schools do this because they have a disproportionate concern over safety, and they don’t realize that people with a first episode of psychosis who have received treatment pose little risk to others," Mueser says.

But the NAVIGATE program can help, Mueser’s research has found. In a study of 404 patients who had experienced one episode of psychosis, overall quality of life scores increased about 31 percent over two years for those who went through NAVIGATE compared with 18 percent for those who received usual community care. The quality-of-life scale included interpersonal relationships, engagement in community activities and sense of purpose and motivation.


The NAVIGATE participants’ involvement in school or work also increased 58 percent during the study, compared with a 6.1 percent increase for community care participants (The American Journal of Psychiatry, 2016).

Quick Facts About Psychosis

  • 100,000 - Number of Americans who have a first onset of psychosis each year
  • 74 weeks - The duration of untreated psychosis for the subjects in the NIMH RAISE study across 21 states
  • 39 - Percentage of the subjects who were not receiving medication consistent with guidelines in terms of agent or dose at the time of enrollment into the RAISE trial
Source: NIMH

As a result of the recent increase in state mental health block grant funding for early psychosis, the number of clinics that offer this type of specialized care for psychosis will be increasing dramatically in the coming years, Loewy says. "This is a really exciting area to get involved in for psychology students in graduate school," she says. "It’s fulfilling to impact someone’s life at a critical stage."

At present, most clinics support these programs by combining Medicaid reimbursement with mental health block grant funds. There are some clinics, however, that also accept private insurance, Heinssen says. As more facilities implement this new model of care, NIMH’s next goal is to evaluate outcomes for patients and whether the programs are consistent with the coordinated specialty care model.


Transitioning Back to College

Henry (who preferred not to give his last name) was one college student who found specialized services three months after his symptoms escalated in 2015. Early in his freshman year, he started having psychotic delusions that he had evolved to a superior race. He believed he was a rap music star on par with Eminem and slept little. He couldn’t stop creating new songs for anyone he met—friends and strangers—and eventually found himself on a roof during a party. His friends contacted campus protective services. Henry was diagnosed with bipolar I disorder.

He started a 15-week program for college students with serious mental illness at Boston University called Niteo. The program reflects the NAVIGATE model, and is specifically geared for college students. Henry is learning such wellness strategies as the importance of maintaining a sleep schedule, avoiding substance use, and managing the stresses of an academic environment given his bipolar disorder.

"Before the program, I felt lost and regret about how I’d been acting, but now I fully accept my situation," he says. "I’m not going back to the same school, but I’m going to a university closer to home with good academic and athletic programs. I believe I will be able to succeed there."


Who is at risk?

While early intervention is the frontier in psychosis care now, some psychologists are leading research efforts aimed at identifying risk factors early enough to possibly prevent psychosis in the future. Elaine Walker, Ph.D., a professor of psychology and neuroscience at Emory University, is studying patients who exhibit prodromal symptoms—symptoms that precede the onset of psychosis.


For example, someone experiencing a prodromal symptom may hear a voice calling his or her name when no one is there, but attribute it to his or her imagination, Walker says.

"Once someone crosses the threshold to thinking the voices or visions are real, then they have moved into the category of having mental illness," Walker says.

Studies have shown that only about one-third of people who experience prodromal symptoms of psychosis go on to develop the disorder. Another third continue to have prodromal symptoms but do not escalate to psychosis, and one-third stop experiencing symptoms altogether, Walker says.

She is working with investigators who are part of the North American Prodrome Longitudinal Study to understand which people with these early signs are most at risk of developing a psychotic illness. They discovered that brain volume in the cortex decreased more in participants who eventually developed psychosis than those who did not (Biological Psychiatry, 2015).


Other research groups have found decreases in the volume of the hippocampus. These individuals also had differences in brain electrical activity, and elevated biomarkers of neuro-inflammatory processes, Walker says. The researchers also found evidence that exposure to stress and trauma was associated with a greater likelihood of developing a psychotic illness (Biological Psychiatry, 2013).

Proven Treatment Strategy

A combination of interventions, such as therapy, medications, family support and education, and support in returning to work or school appears most effective.

"We are trying to understand the underlying neural mechanisms so we can shed some light on the causal factors and maybe even prevent psychosis," Walker says.

For now, though, early intervention after the onset of psychosis is gaining momentum, and Walker hopes psychologists can continue to disprove the myth that the outlook is dismal for people with this disorder.

"I work with young people every day with psychosis and see them make huge strides," Iati says. "They go back to school and work and reconnect with friends, and start to enjoy life again."

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