Optimizing Care in a Team Setting: A Program for People With Schizophrenia

CASE REPORT

[[{"type":"media","view_mode":"media_crop","fid":"33260","attributes":{"alt":"Optimizing Care in a Team Setting: A Program for People With Schizophrenia","class":"media-image media-image-right","id":"media_crop_4126118454266","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3504","media_crop_rotate":"0","media_crop_scale_h":"137","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; width: 155px; height: 143px;","title":"© marrishuanna/shutterstock.com","typeof":"foaf:Image"}}]]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.

SacEDAPT

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).

Medication management

Patients have regular (ie, more than once-monthly) appointments with a psychiatrist. The goal is to find a medication (if appropriate) that alleviates symptoms with the fewest adverse effects. The physician also addresses the challenges of medication adherence, provides psychoeducation about medications, and adjusts and/or switches medications as needed.

Case management and individual support

Case managers identify the patient’s unique needs and recovery goals, which are used to develop a treatment plan that addresses both symptoms and functional challenges. The case manager provides a variety of patient services, ranging from case management (eg, linking the patient to community resources) to individual and family therapy. Most patients meet with their case manager weekly or biweekly, and the close relationship that frequently forms between patients and their case manager serves as a cornerstone for the work that is done in the clinic. Typical topics for therapy include coping skills for symptoms, medication adherence, avoiding alcohol and cannabis, keeping a regular schedule, and identifying early warning signs of relapse.

Peer partner advocacy

Unlike the clinicians, the peer partner has received a diagnosis of a mental illness and can therefore relate to the patient on a more personal basis. He or she provides support, serves as an advocate, assists in problem-solving strategies, and speaks on behalf of the patient in clinical settings when the patient is not present (eg, in team meetings). In addition, the peer partner provides direct services to patients and families, targeting both mental health and functional treatment goals, and assists patients in accessing benefits and community services. For many parents, the thought of a diagnosis of a psychotic disorder in their child is a terrifying prospect. The peer partner provides an alternative and realistic vision of the future in which their child attends college, obtains a job, and has a fulfilling life.

Symptom management group

These loosely structured, weekly drop-in groups for patients older than 18 years provide support to improve illness understanding, develop stress and symptom management techniques, and enhance communication and problem-solving skills. Meetings include didactic presentations of psychoeducational information and spontaneous interactions between group members. Common topics include coping skills, social skills, perceptions about medications, and healthy habits.

Weekly skills group

This weekly CBT-based group is designed to meet the unique needs of younger children (aged 12 to 17 years). Youths learn effective coping skills to manage distressing thoughts, symptoms, school stress, and social stress. A key aspect of CBT is learning that changing the patient’s perception of an event can enable him to change his reaction to an event.

Substance Abuse Management group

The work of this weekly drop-in group is based on the Psychiatric Rehabilitation Consultants Substance Abuse Management (SAM) module.⁴ The goal of the group is to teach skills for substance abuse relapse prevention (eg, identifying early warning signs of impending use) and ways to identify and engage in healthy habits and pleasures. This is done through a mixture of didactic training of basic concepts and skills and structured discussion among attendees.

Supported education services

Supported education services help patients to successfully return to school or begin an educational program. Like symptom reduction, functional improvement is a key part of treatment, and getting back to work and school is a key component in recovery for most patients. Our goal is to help patients gain knowledge about how education can help them reach their goals and become independent. The services are frequently provided in the community, and the supported education specialist meets with the patient and his family, the clinical staff, and appropriate school staff to develop educational goals and objectives, identify appropriate programs, assist with registration and logistics, and strengthen organizational skills.

Supported employment services

Supported employment services include vocational rehabilitation that assists patients (and their families) in finding and keeping a job that pays a competitive wage, capitalizes on personal strengths, and provides the support necessary to be successful in the workplace. These services are typically provided in the community, within the patient’s home, school, or workplace, to improve everyday functioning and to help patients achieve their goal of recovery. Specialists help patients access vocational resources, create or update a résumé, strengthen interviewing skills, find and keep a job, and manage personal finances.

Family support group

Patients who thrive are those who have the most support from their families, and families that thrive are the ones that enlist the most support from the clinic. The family support group is a monthly unstructured drop-in group for caregivers only, led by a psychiatrist and clinician and, as often as possible, the peer partner. The purpose of this group is to support the caregivers and provide them with an opportunity to ask about their loved one’s symptoms and prognosis or to discuss their fears and frustrations. It also provides an opportunity to create a network with other parents and family members who are in similar circumstances.

Family advocacy and support

The family advocate supports family members of persons who have a serious mental illness. He or she acts as a mentor to families with a loved one who is in the prodromal phase of mental illness. The advocate’s goals are to educate families regarding mental health, suicide prevention, and reducing stigma and discrimination, and to assist them in locating and accessing community resources.

Multifamily groups

The bimonthly multifamily groups use a structured group format based on the PIER treatment model.¹ The main goals are to promote education on how to cope with symptoms, understand the path to recovery, and prevent relapse. These groups increase understanding about psychotic illnesses, improve stress management and communication skills within the family, and help patients and their families develop problem-solving skills.

Life after SacEDAPT

SacEDAPT is a 2-year program, so the process of transitioning patients to community care occurs quickly. The clinic was formed in part to address the unique and often unmet needs of young patients who might otherwise slip through the cracks of the traditional mental health system. With early and consistent treatment, these patients can maintain stability and avoid the revolving door of chronic hospitalization and incarceration.

At SacEDAPT, clinicians work on identifying where in the community patients would like to be referred and then complete a “warm hand-off” with the new treatment provider. The patient remains actively engaged in the clinic until he is established with the new provider, which may require several months. SacEDAPT team members connect with the new clinic to make the transition as smooth as possible, sharing relevant information about medications and treatment recommendations.

CASE VIGNETTE

Michael, a 21-year-old, was referred for services in the clinic after he was arrested for causing significant property damage to local buildings. While in jail, he attempted suicide and made odd and unusual statements about the reasons for his behaviors. He had exhibited changes in his behavior for several months before his arrest, dating back to his father’s suicide. Following his father’s death, Michael began to believe the FBI was after him and his car was bugged; as a result, he tore all the upholstery out of his car. He also began digging and collecting rocks, telling family members they were gold and jade and explaining that the white parts of the rocks were messages from his father.

During his intake assessment, Michael endorsed a belief that his father was inside of him and controlling his actions; he demonstrated significant paranoia and frequent ideas of reference. He explained that he was able to think in a “symbolic manner,” and was able to see patterns that conveyed messages to him.

Michael had a history of significant substance abuse, including alcohol, cannabis, LSD, bath salts, MDMA, nitrous oxide, and cocaine, among others. At intake, he had been sober for 2 months, yet he still remained quite symptomatic.

On intake, Michael was linked with a psychiatrist and his case manager/therapist; he immediately started taking part in the multifamily group, substance abuse management, and the symptom management group sessions. These group sessions in combination with medications were a key aspect of his recovery. He eventually achieved sobriety, although it was a long process. He and his grandmother engaged in the multifamily group on a regular basis and worked through some difficult interpersonal issues that were affecting his recovery. Michael also had productive individual therapy appointments that helped him develop coping skills to manage his symptoms and gain insight into his illness.

By the end of his first year, he was hired for a nearly full-time job at the mall, and he was branching out socially. He continued to engage in the clinic, and by the end of his second year, he had formed a social group with peers from the symptom management group that met once or twice monthly in the community for various social activities.

Michael’s psychotic symptoms continued to improve to the point of being “easily dismissible” at the time of his discharge. He still described seeing symbols on occasion but also stated that he knew they didn’t mean anything, and thus he was able to ignore them. He no longer presented with paranoia, ideas of reference, or thoughts of being controlled.

Michael graduated from the program and decided on a career in mental health advocacy, as a result of the impact the clinic had had on him. He continues to engage in his own mental health services in the community and takes his medication on a regular basis. He has also become involved with the National Alliance on Mental Illness and is learn-ing how to be a patient advocate.

Conclusion

By having high expectations for our patients and by intervening early, we have been able to create a new face of mental illness. Our expectation-one that is shared freely with incoming patients and their families-is that the patient WILL get better. Although the future may not turn out exactly as imagined, it can still be fulfilling. SacEDAPT provides hope for patients and their families when things look dark, and when they are better, we help them access the services and tools that they need to stay healthy and lead a productive life.

Disclosures:

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.

References:

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.

4. Shaner A, Eckman T, Roberts LJ, Fuller T. Feasibility of a skills training approach to reduce substance dependence among individuals with schizophrenia. Psychiatr Serv. 2003;54:1287-1289.