MIRECC / CoE
VISN 5 MIRECC – Putting Recovery Into Practice
The mission of the VISN 5 MIRECC is to support and enhance the recovery and community functioning of Veterans with serious mental illness. Our integrated programs of research, education, and clinical training and consultation focus on the development, evaluation, and implementation of recovery-oriented evidence-based treatments and services for these Veterans.
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MIRECC News Spotlight: June 2020
VISN 5 MIRECC Fellow Publishes Study on Psychosis and Solitary Confinement
VISN 5 MIRECC Post-Doctoral Fellow in Mental Illness Research and Treatment, Arthur T. Ryan, and colleague, Jordan DeVylder1, recently published a study that supports a relationship between psychotic symptoms and a history of solitary confinement. They found that formerly incarcerated individuals who reported psychotic symptoms or a schizophrenia diagnosis in the past year were approximately 50% more likely to report having experienced solitary confinement while incarcerated than those without psychotic symptoms. These results are particularly important to bring to light as social isolation may be associated with the development and worsening of psychosis (Hoffman, 2007).
The researchers encouraged future studies to examine more clearly the nature of the relationship between psychosis and solitary confinement. For example, does psychosis precede solitary confinement, or does solitary confinement precede psychosis? Answering this type of question could be an important next step in protecting individuals from the potential discrimination of being placed in solitary confinement based on behaviors resulting only from their psychotic illness. Additionally, future research could support the development of less punitive methods for managing psychotic behaviors among incarcerated individuals.
Drs. Ryan and DeVylder used a dataset from the self-reported second Survey of Police-Public Encounters (SPPEII; DeVylder et al., 2018), which, among other things, assesses police violence exposure, mental health symptoms, and crime involvement. The individuals that participated in the study were located in Baltimore, Maryland and New York City, New York and reported a lifetime incarceration history (17.6%) consistent with other large-scale U.S. population research (Bonczar, 2003).
Think the VISN 5 MIRECC Fellows are an impressive bunch? We sure do! Interested in joining the ranks? See our Fellowship Program in Mental Illness Research and Treatment page for more information!
- Arthur T. Ryan , Jordan DeVylder , Previously Incarcerated Individuals with Psychotic Symptoms are More Likely to Report a History of Solitary Confinement, Psychiatry Research (2020), doi: https://doi.org/10.1016/j.psychres.2020.113064
- Bonczar, T.P., 2003. Prevalence of Imprisonment in the US Population, 1974–2001 (No. NCJ 197976). U.S. Department of Justice.
- DeVylder, J.E., Jun, H.-J., Fedina, L., Coleman, D., Anglin, D., Cogburn, C., Link, B., Barth, R.P., 2018. Association of exposure to police violence with prevalence of mental health symptoms among urban residents in the United States. JAMA Netw. Open 1, e184945. https://doi.org/10.1001/jamanetworkopen.2018.4945
- Hoffman, R.E., 2007. A social deafferentation hypothesis for induction of active schizophrenia. Schizophr. Bull. 33, 1066–1070. https://doi.org/10.1093/schbul/sbm079
1Graduate School of Social Service, Fordham University, New York, NY, USA
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.
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.
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.
OnTrackNY is a network of CSC programs located throughout New York State that offers specialized assessment and intervention for young adults experiencing early psychosis.
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.
For a complete list of early intervention programs and resources by state please use the following link:
- 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
- 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
- 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
- Saha S, Chant D, Welham J, McGrath J. A systematic review of the prevalence of schizophrenia. PLoS Med. 2005;2(5):e141. PMID: 15916472
- 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
- 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
- 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
- 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
- FEP citation
- Stahlman S, Oetting AA. Mental health disorders and mental health problems, active component, US Armed Forces, 2007-2016. MSMR. 2018;25(3):2-11.
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
Featured Educational Products
VISN 5 MIRECC Link: Coping with Psychiatric Medication Weight Gain Side Effects
The Link is a guiding link between VISN 5 MIRECC research outcomes and practice and treatment applications. It includes an overview of a research article and then links those findings to considerations for Veterans, Veteran Families and clinicians. Our first Link is Coping with Psychiatric Medication Weight Gain Side Effects. To visit the Link webpage click here.
Using the Guiding Principles of Recovery to Cope During Physical Distancing
This resource was developed to support Veterans, Veteran Families and Clinicians during the COVID-19 pandemic. Adapting to a national emergency and maintaining physical distancing can be challenging to mental health. This resource uses SAMHSA’s ten guiding principles of recovery to provide direction for how to cope, even in these challenging times. For more Resource E-Blasts on Recovery in SMI, click here.