Evidence-Based Treatment forFirst Episode Psychosis - Part IIIRUMA BELLO, PHD CO-ASSOCIATE DIRECTOR AND CLINICAL TRAINING DIRECTORONTRACKNY

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Overview‣ Introductions

• The Basics‣ Tools and Strategies

• Identifying Psychosis• Using Shared Decision Making

‣ Q & A

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What is psychosis?‣ Psychosis occurs when a person loses contact with

reality. The word “psychosis” scares some people, but it actually describes an experience that many people have.

‣ Three out of every 100 people experience psychosis at some time in their lives, and most of them recover.

‣ FEP: refers to the first episode of psychosis

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The Basics: Psychotic Symptoms‣ Delusions

• False personal beliefs not subject to reason or contradictory evidence and not explained by culture or religion.

‣ Hallucination:• Perception of visual, auditory, tactile, olfactory, or gustatory

experiences without an external stimulus and with a compelling sense of their reality

‣ Disordered speech and behavior• Rapidly shifting between topics with not connection;

repeating the same things over and over• Inappropriate emotional responses, lack of impulse control,

behaviors that appear bizarre and lacking purpose

Initial Engagement & Assessment Strategies

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Engagement Strategies‣ Initial Call and in-person visit‣ Understand what they are seeking by learning what is

going on for them at this time.‣ What programs/kinds of treatment have they already

(recently) tried connecting with? What were the challenges?

‣ Provide information about services based on the above‣ Connect such exploration with detailed examples about

how your team might be able to help

‣ Common traps: Asking too many detailed questions in order to begin determining eligibility to receive services.

Self-determination‣ “Can be considered as the propensity for an individual to

act in a self-directed, self-regulated, autonomous way” (Field et al., 1998 pg. 2)

‣ Is respectful of people’s values and lived experience

‣ A fundamental tenant of personal recovery

‣ Associated with engagement in positive health behaviors such as increased medication and service adherence and other activities that promote wellbeing (Chang, 2011)

Empowering Interactions Promote Self-determination

Empowering Language Power Robbing Language

Can, could You shouldWhat have you considered? You needWhat are your options You mustWhat can you do? You can’tUp till now… No one can do that…Challenge, situation, concern ProblemAnd ButWhat other ways might work for you? It only works when…Some choices are… The best way is…Options to possibly consider are… Your only option is…What has worked for you in the past? My advice to you is…Some things that worked for me are… You can’t do that

Potential Challenges1) When a potential client is unable to identify

symptoms:Could be due to anosognosia: meaning the person is unaware of their own mental illness or can’t perceive it accurately

o Ask how they understood recent events (i.e. leading up to hospitalization, trouble with routine activities)

o Ask what changes they have noticed within themselves (i.e. relationships/work/school activities)

o Probe and build upon what they identified as changes in their life; use real examples/stories (i.e. some people have told me that it’s sometimes hard to leave the house…)

Potential Challenges continued

2) When there are different perspectives about treatment:

o Ask about what’s important to client (e.g. going back to school, enjoy hobbies as before, staying out of the hospital)

o Provide real examples from previous clients and how the team was able to help them (connect to the challenges identified)

o If onset was acute, and client does not believe it will happen again: validate this notion, while taking a wellness perspective (i.e. explore with the client how we can work together to help them maintain daily activities)

Potential Challenges continued

3) When family members are not aware of illness/treatment options:

o “My son is just lazy”– provide psychoeducationo “Is this happening because of drugs?”– provide some

context of biological and environmental factors o “Maybe she should just go to a state hospital/residential

facility”– explore caregivers’ concerns for client returning home; validate concerns, and offer real examples of how the team can help

Evaluation for Psychosis: Key Concepts‣ What are you trying to learn when assessing

presence of psychosis and etiology ?

‣ Pertinent symptoms of psychosis ‣ Establishing date of onset‣ Substance use history‣ Presence and/or history of mood episodes‣ General Medical Conditions

Psychotic Disorders

(Sami, Shiers, Latif, & Bhattacharyya, 2017)

Which of these examples constitutes enduring psychosis?

Alex‣Last summer I started feeling like people on the subway were watching me. First it was just on certain trains that I take to go to school, and then it was all the time. I think they were thinking bad things about me– it was whenever I wore blue, that meant something bad to them, and I knew it because they would blink at me in a certain pattern. It became harder to do the things I was doing because I couldn’t take trains to get anywhere...

Kevin‣Last winter my best friend said I should start watching this TV show that he really likes. At first I liked it, but then I started wondering if the people on the show were talking about me or maybe trying to say something to me. For example, I was breaking up with my girlfriend, and all of a sudden the TV couple would also break up. It was weird, but after watching it more I just realized that it was part of the story and didn’t have anything to do with me...

Assessing Psychotic Symptoms‣ Delusions*

• Referential; Persecutory; Grandiose; Somatic; Control (thought insertion/withdrawal); Thought broadcasting (mind being read)

‣ Hallucinations• Auditory; Visual; Tactile; Gustatory; Olfactory

‣ Disorganized thinking (formal thought disorder)/ Disorganized behavior

‣ For each positive symptom, determine• Impact• Intensity, frequency, and context• *Degree of conviction (lack of insight must be present to

meet threshold symptoms for delusions)

Evaluation: Date of Onset‣ Identify which psychotic symptoms met threshold

criteria for frank psychosis

‣ Create timeline for each psychotic symptom• Helpful to understand prodromal phase (assess

functioning and impairment)• Confirm the absence of symptoms before the earliest

date• Correlate psychotic symptoms with any applicable

substance use, mood episodes, trauma history, and/or major life events (occurring prior to onset)

Sample Assessment Timeline

08/2015:Moved out of

state for college

Fall 2015: Continued smoking

marijuana (about

once per week)

Jan 2016: Coursework

became more

difficult; dropped all extracurricular activities

Feb 2016:

Wanted tostay home more, not

interested in talking to others,

deactivated Facebook, stopped emailing

friends back home

April 2016: Went to ER for anxiety;

Saw a therapist on

campus twice for

anxiety; no meds,

stopped going for therapy

Jul 2016:Began feeling

like others were

talking about me,

felt like TV was

talking to me

August 2016: Moved back

home for Summer

Sept 2016: increased

cannabis (daily use) used to

"slow down the thoughts";

taken to ER by parents, 1st

hospitalization

‣ What’s their story?‣ Working backwards from recent incidents (e.g.

hospitalization).‣ Working forward from high school/college/employment

benchmarks.‣ Integrating information from multiple sources (e.g. family

members, medical records), without losing sight of hearing from the individual.

‣ Using non-clinical language

Assessment Engagement Strategies: Our Approach

Shared Decision-Making in FEP

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Recovery: One Possibility

Shared Decision-Making (SDM)“The process of interacting with patients who wish to be

involved in arriving at informed, values-based choices when 2 or more medically reasonable treatment options have features that patients value differently.”

O’Connor AM et al. Health Affairs 2004; (web exclusive): 63-72.

“…a mechanism to decrease the informational and power asymmetry between doctors and patients by increasing patients’ information, sense of autonomy, and/or control over treatment decisions that affect their well-being.”

Charles C et al. Soc Sci Med 1997; 44: 681-692.

What is Shared Decision-Making?

The best kind of informed consent process

A model of decision making in which a provider and individual receiving care move from initial preference to informed preferences through a process of supported deliberation

It acknowledges:• 2 experts in the room

It can help to clarify an individual’s values and preferences for decision-making

Key Characteristics of SDM‣ Clear decision to be made ‣ Decision-making preference evaluated ‣ Information presented in usable format‣ Information provides range of evidenced-based

alternatives ‣ Information includes strength of evidence ‣ Procedure to weigh options ‣ Decision that is at least clear, if not agreed upon

by all parties

SDM in Practice‣ Tom is a 24 y/o man recently referred to the Team

following a first hospitalization for psychosis

• Treated with risperidone in the hospital, with good response, well-tolerated

• Tom returns for his 3rd mtg with you and reports that he no longer wants to take medication

→ How would you approach a shared decision-making process with Tom?

SDM: Team Talk–Starting the Conversation‣ “What is important to you? What are your goals and

priorities? What would you like treatment to help with?”

• Elicit the individual’s goals, priorities and preferences for treatment

SDM: Team Talk‣“I want you to know that we have a number of choices we can consider. Let’s work as a team to figure out what would be best for you”:

• Continue the medication at this dose• Lower the dose• Raise the dose• Switch to another formation (e.g. long-acting injectable)• Switch to a different medication• Taper off the medication

SDM: Options Talk‣“Let’s review the pros and cons of each option”:

• Consider and discuss potential benefits and side effects of each option

• Provide information so it is easily understood• Consider decision aid

SDM: Options Talk‣“If we stop the medicine, your side effects will go away.”

‣“Research suggests that about 80% of people who stop medicine will

have symptoms return the following year.”

‣“If symptoms return, usually they will respond to medication again, but

occasionally they do not.”

‣“If symptoms return they might interfere with school or work, and there is

a chance you may have to go back to the hospital.”

‣“We have other options too: dose reduction, med switch”

SDM: Decision Talk‣Let’s review what matters most to you and think together

about how these options might fit into your goals and

priorities for treatment.”

‣“Is there anyone else you’d like to involve in the decision

about medication- a family member or anyone else?”

‣“I will share my recommendation with you, but I will support

you whatever decision you make.”

Navigating “Duty to Care” and “Dignity of Risk”

Duty to Care Dignity of Risk

• Legal responsibility to do no harm

• Doesn’t mean we have to protect program participants from themselves but rather protect them from abuse from the mental health system

• Every person has the right to take risks

• Learn• Make mistakes• Live life as they choose

Ove

rpro

tect

Neglect

Guiding Principle:Would a person not in my care be allowed to make

this decision on their own?

Resources‣ www.ontrackny.org

References‣ Sami, M. B., Shiers, D., Latif, S., and Bhattacharyya, S.

2017. Early psychosis for the non-specialist doctor. BMJ. 357, j4578.

‣ Chang, L. 2011. An interaction effect of leisure self‐determination and leisure competence of older adults’ self‐rated health. Journal of Health Psychology. 17(3): 324‐332.

‣ Field, S., Martin, J., Miller, R., Ward, M. and Wehmeyer, M. 1998. A practical guide for teaching self‐determination. Reston, VA: Council for Exceptional Children

Additional Resources‣ NYC Start

• https://www1.nyc.gov/site/doh/health/health-topics/crisis-emergency-services-nyc-start.page

‣ Outpatient programs/clinics• Lenox Hill Early Treatment Program & Long Island Jewish Hospital

Early Treatment Program• https://www.northwell.edu/behavioral-health/programs-services/early-

treatment-program‣ Mount Sinai clinical and research program for youths 12-30

• www.icanfeelbetter.org‣ Center for Prevention and Evaluation Cope

• https://www.columbiapsychiatry.org/research-clinics/prodromal-clinic-center-prevention-and-evaluation-cope

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Upcoming OfferingsThe Supervisor’s Role in Supporting Professional Development of the Supervisee (Dr. Tony Salerno)

Thursday, February 27 - 12:00 PM

Family Driven Care Learning Community (FDC LC): Informational Webinar (CTAC Clinical and Peer Team)

Friday, February 28 - 12:00 PM

Legal Options for Kinship Caregivers (Gerard Wallace, Esq. & Ryan Johnson)

Tuesday, March 3 - 12:30 PM

Learn more at ctacny.org

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