December 1st, 2013

Beyond the black box

Benefits of early intervention highlighted

It’s time for everyone embedded in the behavioral health world to “move out of the treatment black box,” develop a broad range of early interventions and take a more public health approach to mental illness. Those views among many others were presented by Arthur Evans, Ph.D., commissioner, Philadelphia Department of Behavioral Health and Intellectual Disabilities, during the Kennedy Forum’s inaugural conference in October held in Boston.

Evans, formerly a deputy commissioner and director of managed care at Connecticut’s Department of Mental Health and Addiction Services, was among panelists at a session about prevention and intervention strategies in a changing healthcare climate.

Evans emphasized that people with mental illnesses, including schizophrenia have the potential to recover and lead productive lives. He said that Connecticut and Pennsylvania are among states “re-orienting” to a recovery mode and resources should be shifted to accommodate individuals during “preclinical” points in their conditions.

With prevention as its primary focus, PRIME (The Prevention Through Risk Identification, Management and Education) program at Yale School of Medicine is one example of that effort at work. The research clinic identifies at-risk individuals for psychoses and collaborates closely and shares staff and faculty with a program called STEP (Specialized Treatment Early in Psychosis). STEP, a Yale/Connecticut Mental Health Center partnership founded in 2006, serves individuals in the initial stages of psychotic illness and attempts to minimize their decline and condition’s severity through symptom alleviation and reintegration into the community.

Jessica Pollard, Ph.D., STEP’s new clinical director and an assistant professor in the department of psychiatry at Yale, says that on average, 40 to 60 patients are in the census and they are followed for a few years through their illness. Emphasis is placed on engaging the patient and gearing treatment and support specifically to meet each individual’s needs.

“We meet the patients where they’re at,” Pollard says. “We try to get them through the doors if they are reluctant to come in. We want them to be comfortable and stick with us.” While STEP’s key elements include cognitive behavioral therapy, medical management, family education, supported employment, psycho/social groups and more, Pollard says that some individuals may only need one or two of those strategies to be successful. “We don’t try to force patients to adhere to a strict structure. We go with what works for them.”

Although progress has been made, Evans said, there are still significant challenges including increasing public awareness and garnering financial support. He suggested creating health promotion strategies similar to the way medical health crises are addressed. For example, hand washing and other tips are given to try to prevent the flu rather than waiting until an epidemic occurs. “What can we do to ameliorate so people don’t need treatment or develop very significant illnesses?” he asked. “The absence of pathology is health. Not being sick does not equal healthy.”

The fact that STEP is part of the public health system as well as an academic institution makes it unique, Pollard says. She adds that early intervention programs must be translatable into any mental health setting. Creating a balance between research and access to “real world” services is crucial.

Also, collecting cost and utilization data is important, Pollard says, in part, because it can be used in “pitches” to policy makers and other budget controllers.

To receive financial and legislative support, a stronger argument must be made about the “economics of prevention,” said William Beardslee, M.D., director of the Prevention Intervention Project at Judge Baker Children’s Center in Boston, another panelist.

“There’s a payoff to early intervention. It’s cost effective,” Beardslee said. “If you make a business case and prove early intervention is less expensive, it will be a no brainer and have a life of its own.” “It will gain bipartisan support,” Evans agrees.

Making a case for the “real world implications” of identifying and addressing psychoses early is key to garnering support, says Abigail Donovan, M.D., director of the First Episode and Early Psychosis Program (FEPP) at Massachusetts General Hospital.

“If you give the gold standard level of care when patients are young, you can expect better functional outcomes. They can contribute to the work force and have meaningful relationships. You can prevent the downstream effects of homelessness and joblessness,” Donovan says.

For the past decade, FEPP has provided specialized evaluation, treatment, support and education for people experiencing psychosis for the first time or who have been diagnosed with a psychotic disorder of recent onset (within one year).

From 2012-2013, 71 new patients from around the country and internationally used the services, with an additional 30 to 40 people receiving on-going care, Donovan says. A lack of access to treatment and insurance reimbursement for critical aspects of it are still among the challenges that restrict early intervention from becoming the norm, Donovan says.

Brandon Staglin, believes that philanthropic support is available for mental health issues. Staglin, another panelist, is communications director for the Staglin Family Vineyard and the International Mental Health Research Organization. Staglin said he “lives” preventive education programs. After suffering a psychotic break, he was diagnosed with schizophrenia in 1990 and received treatment shortly afterwards. Staglin spoke about the benefits of non-pharmaceutical treatment including stress reduction and CBT.

Staglin and his family have raised more than $100 million to fund research. He feels that a powerful way to reduce stigma is for people with mental health conditions to interact with others and share their first hand experiences.

By Susan Gonsalves

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