Alcohol-related aggression: New therapies may result from Ohio State study
It takes an average of two years for someone with psychosis to receive appropriate care. This is most often due to the stigma associated with accessing mental health care, limited availability of specialized services for people with psychosis and misdiagnoses. The Early Psychosis Intervention Center (EPICENTER) at The Ohio State University aims to change that.
With early treatment, Nicholas Breitborde, PhD, believes many individuals can return to their pre-illness levels of well-being and functioning. In the future, intervention at the first sign of psychosis risk — before an illness begins — may even offer the opportunity to prevent psychosis altogether.
“The first few years of an illness set the stage for the long-term trajectory. It’s no different than any other health condition,” Dr. Breitborde says. “If you break your leg and get it treated today, it will heal much better than if you wait two years.”
Early psychosis intervention
EPICENTER works with youth and young adults with a recent onset of psychotic symptoms. Dr. Breitborde established and directs the EPICENTER — one of the largest specialized clinical programs for individuals with first-episode psychosis in the United States.
When treatment is delayed or unavailable, poor outcomes follow. People living with psychosis often:
- Experience physical health comorbidities such as diabetes and heart disease
- Drop out of school or quit work
- Live up to 15 years less than the average person
- See their social network dwindle
Early treatment is key to achieving life-changing results for people with:
- Bipolar disorder (with psychotic features)
- Major depressive disorder (with psychotic features)
- Schizoaffective disorder
- Schizophrenia
- Unspecified psychosis
“We have this unique window to get people in early, provide treatment and bend the curve of their course of illness,” Dr. Breitborde says.
Medications and other treatments can yield dramatic results when given at the first sign of psychosis.
Coordinated specialty care
Just as cancer is different in every patient, no one psychotic episode is the same. EPICENTER provides patients with a personalized menu of treatments combined with family education and support.
“Everyone walks in with unique strengths, goals and challenges, and we need to personalize their care,” Dr. Breitborde says.
This approach is called coordinated specialty care. The multi-component, evidence-based treatment menu can improve quality of life and social and clinical outcomes, says the National Institute of Mental Health. The five components of coordinated specialty care include:
- Case management
- Family education
- Medication management
- Psychotherapy
- Support employment and education
Family education plays a large role in patient recovery. The EPICENTER team works to help the helpers by showing them how to support their loved one and how to navigate the challenges that arise when a relative has psychosis.
Shared decision making for the long-term
Patients come to EPICENTER through a doctor’s referral after a crisis or through a self-referral. Often parents seeking help for their child find EPICENTER through an online search.
When family members call seeking help, the process begins with an assessment of the situation. The next step can be an on-campus visit or a referral to a more appropriate provider.
New patients undergo a thorough assessment of their symptomatic concerns and cognitive and social functions. Dr. Breitborde says the team wants to get a picture of what’s going on and the goals the person wants to work toward.
The care team, person with psychosis and family meet to discuss what’s occurring, what treatments are available and then build a care plan.
“We use shared decision making,” Dr. Breitborde says. “It’s our job to provide information so people can make an informed choice about what treatments they want to utilize.”
At EPICENTER, a person’s care plan is flexible and often changes over time as they accomplish a goal and move forward to achieve additional goals.
EPICENTER participants can rely on their care team to be with them for the long term. As they reach their treatment goals, they continue to see the same doctors and counselors. This honors the trust and relationships that are created during treatment.
Comprehensive treatment offerings
Many people receiving care at EPICENTER also struggle with other health and mental health conditions. This can include anxiety, depressed mood and elevated mood, as well as physical health issues or medication side effects.
The team provides comprehensive care to address all conditions and issues in a person’s treatment plan.
Some of the center’s additional treatment offerings for patients and families include:
- Metacognitive remediation therapy. Developed at the EPICENTER, this treatment improves cognitive abilities after first-episode psychosis. It’s common for people with early psychosis to experience a decline in memory, processing speed and other cognitive functions. For someone in college or at a first job, it’s hard to return to those settings if they can’t study or plan how to do their job.
- Peer support program. Many young adults with psychosis feel isolated. The center’s weekly peer support group lets people share experiences, aspects of their recovery and successes and find social support. “The group offers clear proof that recovery is possible,” Dr. Breitborde says.
- Primary care. A psychiatrist on staff is also a family medicine physician. They help address physical health needs that can arise. Having a doctor who understands the psychiatric and physical health aspects of care can optimize outcomes.
- Social skills group. Friendships and romantic relationships can be challenging. This group breaks down fundamental skills and helps people learn how to navigate new experiences through role play.
Expanding psychosis care while studying prevention options
The EPICENTER team partners with five community mental health agencies to help us provide coordinated specialty care for first-episode psychosis across Ohio. The five agencies serve 16 counties.
While staff at the EPICENTER can’t see everyone at the clinic, we can administer ongoing technical consulting and support to fellow providers. This partnership extends the same level of care available at the EPICENTER to hundreds of people, Dr. Breitborde says.
To spot a psychotic episode before it starts, EPICENTER launched a new clinic in 2018, in response to a call from the Substance Abuse and Mental Health Services Administration (SAMHSA).
“There is no standard of care for people at elevated risk for developing a psychotic disorder,” Dr. Breitborde says. “We want to see if we can develop care models to prevent psychosis from occurring in the first place.”
Supported by the SAMHSA and the Franklin County Alcohol, Drug and Mental Health (ADAMH) board, Dr. Breitborde and his team are studying methods of preventing psychosis. In Ohio, ADAMH boards are part of a county-operated, state-supervised behavioral health system. The boards plan, evaluate and fund mental health and addiction services and contract with providers.
The new clinic sees people showing the early warning signs of a burgeoning psychotic disorder. Providers administer low-intensity care and track people’s changes in symptoms and functioning.
If symptoms progress, more intense treatment is offered. Antipsychotic medication would be at the very high end of care, Dr. Breitborde says.
“Current data suggest that not everyone at risk for developing a psychotic disorder would benefit from antipsychotic medication,” he says. The EPICENTER team created a care model that shows treatment can begin before a psychotic episode occurs, with positive results.
The team is preparing a paper to share early research outcomes.
“We showed that the majority of people who participated in care at EPICENTER did not develop a psychotic disorder and experienced meaningful improvements in symptoms and functioning,” Dr. Breitborde says. “For many, we were able to help them return to their pre-risk level of mental health and functioning.”
This work is what Dr. Breitborde considers a new and encouraging frontier — figuring out how to prevent psychosis.
