The development of antipsychotic medication has led to dramatic changes in the treatment of psychotic disorders. Medication rapidly became a crucial part of treatment in the second half of the 20th century. Yet many patients do not obtain the recovery that they and their families hope for through medication treatment alone. Over time, the need for more comprehensive and early treatment has become clear, but how to create a system of care that addresses this need has remained a challenge.
In this article, we discuss the structure of our multidisciplinary team and our focus on meaningful recovery—medication management is only one part of treatment. A specific case example illustrates how our team works with patients to offer comprehensive treatment and the types of outcomes we commonly see.
The Early Diagnosis and Preventative Treatment (EDAPT) Clinic (an outpatient facility) was founded at the University of California at Davis in 2004; the objective is to provide early intervention for patients aged 12 to 25 years who are at high risk for a psychotic disorder or in whom a psychotic disorder has recently developed. The EDAPT Clinic has since collaborated with Sacramento County to form the SacEDAPT Clinic, a partnership that allowed for expansion of services.
Through initial funding from the Robert Wood Johnson Foundation, the SacEDAPT Clinic was able to replicate and implement key elements of the Portland Identification and Early Referral (PIER) program. PIER was developed to provide early detection and intervention in children, adolescents, and young adults at risk for psychosis. The program aims to intervene during the prodromal phase and thus reduce the incidence of psychotic disorders.1 Staff who use the PIER model are trained in identifying prodromal symptoms and creating an infrastructure that provides rapid referral for treatment and services.
At SacEDAPT, the treatment team consists of a psychiatrist, a case manager, a family advocate, a peer partner, a clinic coordinator, and the supported education and employment specialist. All costs associated with the program are covered by Sacramento County, at no cost to the patient.
The recovery-based approach provides services for 2 years, with a goal of reducing and managing symptoms and supporting patients’ success through appropriate education and employment opportunities. To reduce stigma and increase help seeking, the community is educated on the nature of mental illness and the positive impact of early intervention. At-risk individuals are identified and provided comprehensive evidence-based treatment that focuses on patient self-determination and family support as the path toward recovery.
Patient intake procedures
The clinic coordinator screens patients during a lengthy telephone interview, followed by a thorough intake assessment (2 to 3 hours) to determine the appropriate diagnosis. Assessments of psychosocial functioning also determine which patients need targeted treatment. Patients and members of their families are asked to complete a health questionnaire, and patients complete either the Structured Clinical Interview for the DSM-IV Disorders,2 for those who appear to have already had their first psychotic break, or the Structured Interview for Prodromal Syndromes,3 for patients at high risk for a psychotic disorder. On the basis of the assessments and the clinical interview, the patient is given a provisional diagnosis, and a decision is made as to whether the services in the clinic are appropriate for the patient.
Once a patient is accepted, a medication intake appointment with a psychiatrist allows for a thorough assessment of symptoms and presentation and a treatment history is obtained. Medications are discussed as well as the treatment process and how treatment goals will be achieved.
During a welcome appointment with the clinician who conducted the intake assessment, patients and their families receive handouts that outline all of the services in the SacEDAPT Clinic and psychoeducational materials on managing troubling symptoms, recommended readings, and helpful community resources. If time permits, they are introduced to other treatment team members.
The treatment team
TheSacEDAPT clinical team meets on a weekly basis to review all patients and discuss the effectiveness of treatment plans as well as patient concerns and success stories. These meetings provide internal continuity of care, allow for the sharing of information, and ensure that team members are working cohesively to help patients achieve treatment goals and recover. In addition, community providers and other community resources may meet with the clinical team to share useful information (eg, services, benefits).
Ms DuBe is Clinical Coordinator in the department of psychiatry and behavioral sciences at the University of California at Davis, Sacramento. Dr Wadell is Associate Physician in the department of psychiatry and behavioral sciences and Medical Director of early psychosis programs at the University of California at Davis. The authors report no conflicts of interest concerning the subject matter of this article.
1. McFarlane WR, Cook WL, Downing D, et al. Portland identification and early referral: a community-based system for identifying and treating youths at high risk of psychosis. Psychiatr Serv. 2010;61:512-515.
2. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version. Washington, DC: American Psychiatric Press, Inc; 1996.
3. McGlashan TH, Miller TJ, Woods SW, et al. Instrument for the assessment of prodromal symptoms and states. In: Miller TJ, Mednick SA, McGlashan TH et al, eds. Early Intervention in Psychotic Disorders. Dordrecht, the Netherlands: Kluwer Academic Publishers; 2001:135-149.
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