MIRECC / CoE

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Schizophrenia affects approximately 0.25%-0.64% of the population nationally.^1-5 There are many treatments that can help individuals living with schizophrenia manage symptoms and lead full and rewarding lives.^6-8 Veterans living with schizophrenia can connect with programs that provide evidence-based interventions and a full range of supportive services - such as Psychosocial Rehabilitation and Recovery Centers (PRRC) - at VAs across the country. Recovery is possible – Veterans living with schizophrenia can pursue their goals, engage in meaningful experiences, and live the lives of their choosing.

Schizophrenia often begins when people are in their late teens or early twenties. Approximately 100,000 young adults (age 16-35) experience a first episode of psychosis each year.¹ Among active military personnel, there are approximately 1,150 incident cases of psychosis each year.¹⁰ When a young person first experiences psychosis, they and their families are often scared, confused, and unsure of what is going on. In many cases, young adults and their families do not know where to go for help which leads to months or years of incorrect diagnosis and treatment. This time between first symptoms of psychosis and engaging in treatment is referred to as duration of untreated psychosis. Research shows that longer duration of untreated psychosis is associated with poorer prognosis, including greater symptoms, poorer quality of life, reduced social functioning, and worse response to treatment.^11-12 This underscores the great need for rapid diagnosis and referral to effective care for young adults experiencing a first episode of psychosis.

Over the last decade there has been a national effort to develop, test, and implement evidence-based treatments for young adults experiencing first-episode psychosis and their families. Coordinated Specialty Care (CSC) is a recovery-oriented treatment program for people with first episode psychosis. CSC is a multi-element approach that offers a range of evidence-based interventions within a framework of collaboration and shared decision making. The goal of CSC treatment is to help young adults experiencing first-episode psychosis and their families understand psychosis, engage in personalized interventions to manage symptoms, play an active role in the treatment process, and determine the best ways to pursue recovery. Investigators at the VISN 5 MIRECC and the University of Maryland School of Medicine have been active in developing interventions that are included within CSC and in training clinicians to provide them with fidelity. This and similar work in other states has increased the capacity of mental health systems to identify and provide treatment to young adults experiencing first-episode psychosis and their families.^13-17

Although there are a growing number of CSC programs across the U.S. civilian community, resources for military personnel and Veterans remain limited. Heather Wastler, MS, a psychology intern at the VA Maryland Health Care System/University of Maryland School of Medicine Psychology Internship Consortium who is pursuing research with Dr. Alicia Lucksted at the VISN 5 MIRECC, has spearheaded a project to identify programs within VA that are targeted to the treatment of Veterans experiencing first-episode psychosis. As highlighted above, early detection and intervention for psychosis can have a profound impact on clinical outcome and recovery.^13-17 The highly structured nature of the military and VA affords the unique opportunity for early detection,¹⁹ yet very little is known about pathways to care, engagement, and the unique treatment needs of this population. Here we present a summary of the findings regarding specialty care for early psychosis in military and VA treatment settings.

The Balboa Naval Hospital, located in San Diego California, houses the only CSC program across the Department of Defense and the Veteran Healthcare Administration. Using a team-based approach, this program uses recovery-oriented psychotherapy, shared decision-making medication management, family psychoeducation, and supported employment/education to help service members transition from military service to the VA. This program serves Navy and Marine active duty service members, leaving Army, Air Force, Coast Guard, and National Guard personnel and all veterans experiencing a first episode of psychosis without specialty care. For more information about this program please contact the PTP Office at 619-532-5808.

Dr. Jason Peer, The Local Recovery Coordinator at the Baltimore VA Medical Center, suggests that VA mental health programs may need to be delivered more flexibly to meet the unique treatment needs of this population, as young veterans might be less likely to engage in intensive treatment programs such as the PRRC and MHICM. At the same time, the VA has the potential to capitalize on its existing resources to create CSC programs to meet the needs of young veterans with psychosis. Dr. Amy Wilson, Local Recovery Coordinator at the Edith Nourse Rogers Memorial VA, provides a leading example through the Specialized Team for Early Engagement and Recovery (STEER). Working closely with the inpatient unit, OIF/OEF team, assessment clinics, and vocational services at her VAMC, Dr. Wilson and her team use the CSC model to provide specialized care for Veterans’ experiencing early psychosis. For more information about the STEER program please contact Dr. Amy Wilson at Amy.Wilson8@va.gov or 781-687-3017.

As the VA continues to work towards improving care for Veterans experiencing early psychosis, it is important for clinicians to know what resources for evidence-based treatment exist in community settings and what opportunities there are for training in the CSC model. The following list includes resources for clinicians who are interested in learning more.

NIMH Recovery After an Initial Schizophrenia Episode (RAISE):
RAISE is a large-scale research project initiative designed to examine coordinated specialty care treatments for individuals experiencing a first episode of psychosis. RAISE offers resources and manuals for successful implementation of CSC-model treatment.
https://www.nimh.nih.gov/health/topics/schizophrenia/raise/index.shtml

OnTrackUSA:
OnTrackUSA is part of the NIMH RAISE initiative to implement CSC teams across the United States. This program provides manuals, web-based resources, and consultations for training programs and agencies interested in implementing CSC.
https://practiceinnovations.org/OnTrackUSA

Maryland Early Intervention Program (Maryland EIP):
The Maryland EIP Network is a group of providers and programs participating in Maryland’s statewide effort to provide CSC services for individuals experiencing early psychosis.
https://marylandeip.com/

OnTrackNY:
OnTrackNY is a network of CSC programs located throughout New York State that offers specialized assessment and intervention for young adults experiencing early psychosis.
https://ontrackny.org/

Early Assessment and Support Alliance (EASA):
EASA is a network of programs and providers across Oregon who focus on early assessment, identification, and treatment for adolescents and young adults who are experiencing early signs of psychosis.
http://www.easacommunity.org/

For a complete list of early intervention programs and resources by state please use the following link:
http://www.easacommunity.org/files/Early_Psychosis_Intervention_Program_Directory.pdf

Bibliography

1. McGrath J, Saha S, Chant D, Welham J. Schizophrenia: a concise overview of incidence, prevalence, and mortality. Epidemiol Rev. 2008;30:67-76. PMID: 18480098
2. Kessler RC, Birnbaum H, Demler O, Falloon IR, Gagnon E, Guyer M, Howes MJ, Kendler KS, Shi L, Walters E, Wu EQ. The prevalence and correlates of nonaffective psychosis in the National Comorbidity Survey Replication (NCS-R). Biol Psychiatry. 2005;58(8):668-76. PMID: 16023620
3. Wu EQ, Shi L, Birnbaum H, Hudson T, Kessler R. Annual prevalence of diagnosed schizophrenia in the USA: a claims data analysis approach. Psychol Med. 2006;36(11):1535-40. PMID: 16907994
4. Saha S, Chant D, Welham J, McGrath J. A systematic review of the prevalence of schizophrenia. PLoS Med. 2005;2(5):e141. PMID: 15916472
5. Moreno-Küstner B, Martín C, Pastor L. Prevalence of psychotic disorders and its association with methodological issues. A systematic review and meta-analyses. PLoS One. 2018;13(4):e0195687. PMID: 29649252
6. Dixon LB, Dickerson F, Bellack AS, Bennett M, Dickinson D, Goldberg RW, Lehman A, Tenhula WN, Calmes C, Pasillas RM, Peer J. The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophrenia bulletin. 2009;36(1):48-70. https://doi.org/10.1093/schbul/sbp115
7. Buchanan RW, Kreyenbuhl J, Kelly DL, Noel JM, Boggs DL, Fischer BA, Himelhoch S, Fang B, Peterson E, Aquino PR, Keller W. The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. FOCUS. 2012;10(2):194-216. https://doi.org/10.1093/schbul/sbp116
8. Kreyenbuhl J, Buchanan RW, Dickerson FB, Dixon LB. The schizophrenia patient outcomes research team (PORT): updated treatment recommendations 2009. Schizophrenia bulletin. 2009;36(1):94-103. https://doi.org/10.1093/schbul/sbp130
9. FEP citation
10. Stahlman S, Oetting AA. Mental health disorders and mental health problems, active component, US Armed Forces, 2007-2016. MSMR. 2018;25(3):2-11.
11. Perkins DO, Gu H, Boteva K, Lieberman JA. Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. American journal of psychiatry. 2005;162(10):1785-804. https://doi.org/10.1176/appi.ajp.162.10.1785
12. Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Archives of general psychiatry. 2005;62(9):975-83. https://doi.org/10.1001/archpsyc.62.9.975
13. Marino L, Nossel I, Choi JC, Nuechterlein K, Wang Y, Essock S, Bennett M, McNamara K, Mendon S, Dixon L. The RAISE connection program for early psychosis: secondary outcomes and mediators and moderators of improvement. The Journal of nervous and mental disease. 2015;203(5):365. https://doi.org/10.1097/NMD.0000000000000293
14. Kane JM, Schooler NR, Patricia Marcy BS, Correll CU, Brunette MF, Mueser KT, Rosenheck RA, Addington J, Estroff SE, Robinson J, Penn DL. Original research the RAISE early treatment program for first-episode psychosis: Background, rationale, and study design. J Clin Psychiatry. 2015;76(3):240-6. https://doi.org/10.4088/JCP.14m09289
15. Kane JM, Robinson DG, Schooler NR, Mueser KT, Penn DL, Rosenheck RA, Addington J, Brunette MF, Correll CU, Estroff SE, Marcy P. Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE early treatment program. American Journal of Psychiatry. 2015;173(4):362-72. https://doi.org/10.1176/appi.ajp.2015.15050632
16. Nossel I, Wall MM, Scodes J, Marino LA, Zilkha S, Bello I, Malinovsky I, Lee R, Radigan M, Smith TE, Sederer L. Results of a coordinated specialty care program for early psychosis and predictors of outcomes. Psychiatric Services. 2018;69(8):863-70. https://doi.org/10.1176/appi.ps.201700436
17. Dixon LB, Goldman HH, Srihari VH, Kane JM. Transforming the treatment of schizophrenia in the United States: The RAISE initiative. Annual review of clinical psychology. 2018;14:237-58. https://doi.org/10.1146/annurev-clinpsy-050817-084934
18. Hann MC, Caporaso E, Loeffler G, Cuellar A, Herrington L, Marrone L, Yoon J. Early interventions in a US military FIRST episode psychosis program. Early intervention in psychiatry. 2018;12(6):1243-9. https://doi.org/10.1111/eip.12709

VISN 5 MIRECC investigators have been presenting their work at different meetings throughout the fall.

In June, Dr. Alicia Lucksted presented a poster at the Psychiatric Rehabilitation Association’s 41st Annual Wellness and Recovery Summit in Denver on her qualitative analysis of interview data to understand how people with serious mental illness respond to and get impacted by stigma over their lives and what wisdom those experiences offer that might help others in similar circumstances. Recently, Dr. Lucksted also gave a presentation on Veterans, mental health, and stigma as part of the Pro Bono Counseling Project Military Program Workshop which was focused on Veterans mental health.
View poster. View slides.

In September, Dr. Letitia Travaglini and Lorrianne Kuykendall, MA presented a poster at the International Association for the Study of Pain, World Congress 2018 in Boston. The poster focused on results from a qualitative study examining chronic pain experiences and management among Veterans with bipolar disorder. The poster presenting findings on the relationships between chronic pain and mood symptoms; the degree to which pain and mood affect functioning; Veterans’ thoughts about the pain-mood connection and how it translates into treatment; and the way in which mental health stigma affects access to and receipt of pain management.
View poster.

Drs. Samantha Hack and Amy Drapalski attended the 34th annual meeting of the International Society for Traumatic Stress Studies in Washington, DC. Dr. Hack presented a poster on her work exploring clinical behaviors that support patient-centered communication with recent Veterans with stress-related disorders.
View poster.
Dr. Drapalski presented a poster describing the work of her team piloting of an intervention to reduce internalized stigma in Veterans with PTSD.
View poster.

Drs. Amanda Peeples and Anjana Muralidharan presented their work at the annual scientific meeting of the Gerontological Society of America in Boston. Dr. Peeples presented a poster on her work studying barriers, facilitators, and preferences for mental health treatment engagement among Vietnam-era Veterans with PTSD and a delivered presentation on these Veterans’ conceptualizations of recovery.
View poster. View slides.
Dr. Muralidharan gave a presentation on the progress of her team in developing a peer coaching program to promote supervised fitness training for older Veterans with psychotic disorders.
View slides.

Dr. Peter Phalen presented a poster at the annual meeting of the Association for Behavioral and Cognitive Therapies in Washington DC on his work examining relationships among personal beliefs, experiences, and stigma toward individuals who hear voices. He and colleagues at Indiana University-Purdue University also presented their work on mortality following naloxone encounters with emergency medical services at the American Public Health Association’s 2018 Annual Meeting & Expo in San Diego.
View poster. View presentation abstract.

Contact any of these investigators with questions or for more information.

Presented in part by VISN5 MIRECC Fellow, Letitia Travaglini, PhD.

This 45 minute podcast is part of the Complex Clinical Decisions in Psychopharmacology Series from SAMHSA’s Recovery to Practice (RTP) Program. In the podcast, national experts discuss the current research and clinical practices around managing chronic pain in individuals with serious mental illness (SMI), and reinforce the need for person-centered and strengths-based approaches to help better manage pain and improve functioning and quality of life in individuals with SMI.

Additional Presenters: Jennifer Murphy, PhD; Robert McCarron, DO; Amber Guererro, LMFT. Discussant: Curley Bonds, MD.

Listen to the podcast.

Download a transcript of the podcast.