Well, hello, everyone, and welcome to our session this afternoon. My name is Abram Rosenblatt. I have the privilege of moderating this session today. I'm the vice president at Westat, and I have the great privilege of being the principal investigator for the IPNN National Data Coordinating Center, which is funded by and in partnership with NIMH. So our session today is on Advancing Early Psychosis Care in the United States, Addressing Inequities on Race, Culture, and COVID. Next slide, please. And we're focused on cognitive care and coordinated specialty care, federal and programmatic perspectives. Next, please. Here are our speakers. You can see them all listed here, and we'll go through each one one by one. Can we get the next slide, please? First speaker will be Christina West. She's a policy analyst with the Office of the Assistant Secretary for Planning and Evaluation, the Office of Behavioral Health, Disability, and Aging Policy. Ms. West was the project officer for the initial review of the Mental Health Block Grant Set-Aside, which I had the privilege of working with her on, for first episodes of psychosis and its implementation. She represented ASPE in a tri-agency effort with SAMHSA and NIMH to evaluate the Mental Health Block Grant Set-Aside, and she's currently collaborating with Westat and our team on a project to review transition services for clients graduating with coordinated specialty care. And I'm particularly delighted to have our colleague and friend Christina working with us on this panel. Next slide, please. Michael Birnbaum will be speaking after that, and he's an attending physician in the Department of Psychiatry at Zucker Hillside in New York. He's the program director for Northwell Health's Early Treatment Program, which is a clinical research initiative for adolescents and young adults in early stages of psychosis. His research is focused on psychotic disorders with an emphasis on early stages of illness, and he's currently exploring the role of social media, internet, and pathways to care for adolescents and young adults with psychotic disorders. Next slide, please. We're also honored to have David Penn joining us today. He's the Linda Wagner Martin Distinguished Professor of Psychology and Neuroscience at the University of North Carolina at Chapel Hill. He's published many, many papers in the areas of social cognition, treatment, and stigma and schizophrenia, and he was named as being in the top 1% of the most cited scientists in the world in psychology and psychiatry for an extended period of time. His research has been supported by NIMH, NARSOD, and the Stanley Foundation, and he was the lead author of the Individual Resiliency Training Manual that was used in the original RAISE ETP study, which was a pioneering study in the first episode in early psychosis. Next slide, please. And at the end, we'll have Nicholas Bukia joining us. He was born in Eugene, Oregon, from a Midwest farming class lady named Millie, whose name I'm afraid I won't be able to pronounce well, so I won't do that. He's of Austronesian descendant healing and fishing class named Frances Bukia, and he was raised as a Catholic and educated by the Jesuits. He's a survivor and explorer of a generational branding of schizophrenia, interested in community engagement to understand the role of the split mind in helping others through their own explanatory models. He helps promote occupational engagement and flow. We're very delighted to have Nicholas joining this panel today. As far as disclosures, you can see that there are just a couple here we just want to feature. Christina's views are not those of the U.S. Department of Health and Human Services of the United States. They're her own. Michael Birnbaum is disclosing ones with North Shore Therapeutic Consultants, David Penn, and Nicholas have no financial complex. So next slide, please. With that out of the way, I believe I'm going to turn it over now to Christina West. Christina. Hello, everyone, and it's a privilege to be here as part of this panel today. Next slide, please. So my talk today is on research that we did in transitions following coordinated specialty care and a little bit on the viewpoint that I'm coming from. So my office is within the Office of the Secretary at HHS, and our primary mission is to provide evidence-based advice on evidence-based policymaking. So for this work on coordinated specialty care, we've collaborated for a number of years now with SAMHSA and NMH. And this work is a result of this collaboration. Next slide, please. So we embarked on doing this because in my office, we do a lot of policy research. We look at best practices implemented in states for issues related to behavioral health, and specifically, I work on psychosis. And what we've been hearing from our colleagues in the field is that with the exponential growth in coordinated specialty care programs comes also the question of transitioning clients after they finish the program. And the most common treatment, and it's hard for clients to find treatments and providers that understand their needs post-coordinated specialty care. Studies, so most programs in the U.S. are two years long. Studies from outside the U.S. suggest, though, that participants who receive services for longer period of time beyond two years have better recovery outcomes, both more positive outcomes. And we also, so we knew that at the beginning of this work. We also knew that there are some programs within the U.S. that have attempted to design special programs for transitioning or have expanded their length of service. Next slide, please. And so we embarked on this work together with Westat to understand the range of existing approaches, the challenges and opportunities, and to really know more about, hopefully know more about how coordinated specialty services programs can be embedded into continuum of care. Next slide, please. And in order to do this, Westat did an environmental scan and case studies of nine sites. They represented a range of models, a range of transition services embedded, and they also included interviews with providers, with state agency representatives, and patients and parents, a small group of patients and parents. And from the environmental scan, you can see the resources listed on this slide included also two results from two NRI administered studies that included transition-related services questions. Next slide, please. These are the sites that were included in our study. We tried to have a geographically diverse sample. And one of the sites, the Duker Hill site, which my colleague, Dr. Ben Brown, will be talking about in a few minutes. Next slide, please. This is information that you can review probably after the presentation, but I did want to mention that the last four columns are describing the different range of approaches that sites have taken to transition services, whether it's extended, mid-step, down, or other approach. Next slide. Next slide. So at the beginning of this work, WISTAT did a literature review and used the knowledge that they've gained from other work to really put together this typology of transitions following coordinated specialty care. So if you see the first type A is the standard coordinated specialty care program for two years that's been followed to services provided by community-based providers. Type B is when there is a separate step-down program. Usually services there are deeper down. They are not as intense. They're shorter duration. They could be a different set of services too, but they help clients transition to community-based services afterwards. Type C is extended-length CSC programs, which are basically embedding step-down type approaches. So for the last one year of participation, there is coordination of services and not such a high intensity. And then follows more extended-length, up to five years of programs. And finally, there are programs that do not have a limit and can keep patients for as long as they need to be in the program. Next slide, please. So program lead was one of the big things that came out from this work. And this is NRI, some findings from the NRI study that if you see from the orange and dark blue color circles, that most of the programs are two to two and a half years. But the rest of the programs in light blue, yellow, and gray are the programs that extend beyond two years and are close to 40%, which is good because in our study, we found that that flexibility and extended length seems to be preferred by providers. Next slide, please. Specifically, the providers that we interviewed and the patients seem to favor a three to five year program or a model that is more tied to the client's needs and does not have a set length. And I'm going to read, we have a few quotes here, I'm going to read just the first one. That four to five years gives a good sense of progress. You see growth happen. Two years feels too soon. Clients with slow progress don't make any headway. And then suddenly they have to start talking about discharge and termination. What we heard is that having this extended length program or step down program from the beginning puts patients at ease and takes away the pressure of having to adjust so soon. Also, it was shared with us that specifically because so many clients, CSE clients, are transitioning too. In the years between 16 and 19, there's a lot of physiological changes that occur. And there's also that big transition and leap between education-based child care services to the adult health care system. So having that extended length of three to five years and being able to provide support was reported as optimal for this population. Next slide, please. The other big thing that we found that's important in the facilitates transition, more seamless transition to services, is integration within agency. And so whenever programs, for example, the whole program in Minneapolis is part of a large hospital-based system. And so once clients finish CSE program, the community-based providers are literally across the whole. So it's easier to communicate between the two services and so providers can stay in touch. There is also the Epicenter program, which is part of the university-based system. So our providers, our community-based providers that take patients after CSE have access to their chronic health records, can follow, can get familiarized with the patient's progress in treatment. OnTrack Nashville is also a program that is part of a larger agency that provides services in 42 counties. And they do not have a step-down program. They are not extended-length program either, but their approach is in building collaboration with a number of community-based agencies. So there's two transition nature programs. There's an ACT team. There's a health link program that is a Medicaid program that provides care coordination that patients can also access in the transition period. And then finally, within integration, it's also the Certified Community Behavioral Health Clinics, which is a payment model that's also encouraging collaboration with an agency on state level, within agency collaboration and collaboration with other settings for all the clinics that participate. Most of the CCBHC clinics provide early intervention services, 60% of them. And two of the sites in our study, the Schutz and OnTrack Buffalo, use CCBHC funding to extend services. Beyond two years and provide transition services. Next slide. This is more of a background, but most of the, you know, about half of the sites did three or four clients for services within the same system. But the major issue in general, it's highlighted here again, is that lack of providers that are trained in the community to be able to adjust to the needs of early psychosis patients. Most of them are not familiar with evidence-based treatment with CBT for psychosis. They do not provide more than pharma. They don't provide much services beyond pharmacotherapy and are reluctant to accept clients with diagnosis with psychosis. Next slide, please. And so the solutions, as I mentioned earlier, are from the sites in our study, were to extend LEND beyond three years. Epicenter, for example, has five years standard CSB care, which is adjusted to the needs of the clients, some stage shorter. And then there is the site in EpicNOA, which is in New Orleans, that does not have defined limits of services. And that was very critical for their population because it's a very high need population with marginalized population, minority population with distrust of the healthcare system. So once they establish that connection with patients and earn their trust, they have the opportunity to keep them as long as needed. For the programs that have stepped down models, there were five sites in our study that had those, and they were very diverse. They could serve clients in the same location at the CSC program or a different location. They could provide the same set of services or a different set of services or more tapered down. The level, they could serve only CSC population or would serve also, for example, clients that have not met the criteria for CSC. They could be served in a step down in some locations. They varied by the ages that they can serve, whether they're time limited or have unspecified LEND, and whether they have same or different staff. Next slide, please. So in addition to having a step down extended service programs, there were other approaches, such as collaboration with transition age youth program, which was unique because those are programs that are tailored to serve transition age youth, very similar to coordinating specialty services programs. The other pattern that we noticed in a few of the sites is investment from the CSC staff in education and outreach with community mental health providers. So building that rapport in partnership with community providers to improve seamless transition. And then some sites also use the step down period to help clients navigate community-based services to remove common barriers in transition. And one interesting solution was offered by the staff at Epicenter, which is not something that's been implemented, but as an idea I wanted to share today, which is a hybrid model of care for the last few months of participation in CSC program, where CSC providers and community prescribers provide services intermittently to win clients of CSC care and transition them more safely to the community. Next slide. Funding for transition services are not that different than funding from coordinating specialty care. And some sites, however, have used Medicaid waivers and flexibilities for the transition services specifically. For example, in Tennessee, they have a health link reimbursement model that's based on the federal health home model and was implemented earlier with state innovation grants with the Centers for Medicare and Medicaid Innovation. So this is a model that provides care coordination and connection to housing and other support services and was used by the site in Tennessee for transitioning clients out of CSC. And also in Minnesota, the CADI waiver, it's an HCBS waiver that provides care coordination and connection to services. But extended program length is linked with funding. And as an example, the Oregon Health Authority with additional funding. So the Oregon Health Authority is considering a bill to move from two to three year CSC program with additional funding incorporated. Next slide, please. When we did our study, we ended up doing it during COVID. It was not planned from the beginning, but that's how it worked out. So questions about COVID were added and also came up in the conversations. And I know there was a lot said yesterday and today about telehealth. I would just briefly say that the sites that we included in the study, the nine sites, reported seamless transition for telepsychiatry and therapeutic services. What was suffering more seemed to be the ancillary services, the coordination with support services, the peer support programs specifically, and parent support services. Groups that could not meet in person anymore had to meet online, but had to stop often because they had concerns about privacy. And so really the loss of centers, drop-in programs where patients can come without appointments and can meet alumni and get services is a challenge. Some programs actually have slowed or stopped transitioning. Clients during COVID, to make sure they stay in the program and receive services. And the other challenge that we saw is also in terms of team coordination. So teams had to adjust rapidly. They were used to being in the same office space and communicating, now had to communicate online. Next slide, please. So as conclusions, most programs are two to three years in length, but they are opportunities. They are best examples from sites that have designed either extended programs, designed step-down programs, or forged other relationships with community-based providers to facilitate transition. And more specific funding mechanisms for transitions could help spare these services. Next slide, please. So I want to acknowledge the team that worked on this. From Westat, the principal investigator was Abram Rothenblatt, project director was Tamara Daly, who also co-authored this presentation with me. And we had a team of national-level experts that advised this work as well. And I, from my name and the name of Joe Dubinis, as project officers, we are also very grateful for the support and mentorship we've received from Bob Heinzen and Susan Ezrin from NIMH on this and Steve Dutweiler from SAMHSA. There is going to be publication coming out of this in the next year, which will be published on the ASPE study I can include in the chat. Thank you. Hi, everyone. Michael Bierenbaum here. Thanks so much for having me. I am going to talk a little bit today about implementing a step-down program at the Zucker Hillside Hospital. I'm not going to be presenting data per se in the traditional sense, but I am going to be walking through the way that we moved from conceptualization to development and ultimately implementation of a step-down program at Zucker. Next slide, please. A little bit of context. The Zucker Hillside Hospital is a large psychiatric hospital with multiple inpatient and outpatient facilities. It's part of Northwell Health, which is a very large group of hospitals located largely in New York State. The Zucker Hillside Hospital exists within Queens. It provides care to a very diverse patient population. Queens is one of the most diverse populations in the world. We provide care across the lifespan from children to the elderly and provide a number of clinical and research opportunities. Next slide, please. The early treatment program, Northwell Health's Early Psychosis Intervention Clinic, began in 2013. I was recruited around that time to help develop the program. It is part of centers, which are specialty tracks within the outpatient department, providing evidence-based care for a number of psychiatric conditions. Prior to the early treatment program, there was a service by the name of the START program that provided some specialty care for folks with early psychosis. However, at around this time, the NIMH-funded RAISE trial was ending, recovery after initial schizophrenia episode. That helped support the established benefit of early intervention. We knew that we wanted to build something at Zucker that was based on RAISE principles to provide a coordinated specialty care delivered by a large multidisciplinary team. Next slide, please. I'm wondering if there was a slide before this. If not, sorry about that. Next slide, please. Forgive me. We started by setting up the parameters for who we'd like to serve at the early treatment program. We identified age ranges between 16 and 35, wanted to provide care for individuals who had a primary psychotic disorder with symptom onset within the past two years, ruling out folks who had below a certain threshold for IQ, autism spectrum disorder, and a non-primary psychotic disorder. Next slide, please. At around the same time, we received some exciting but complicating news that we would also be awarded funding from OnTrack New York to build a coordinated specialty care program at Zucker. So our initial challenge was thinking about how we were going to build a first episode psychosis program within a first episode psychosis program. Back in 2013, we were one of four pilot sites in New York State. We had about 25 participants enrolled in OnTrack New York within the larger early treatment program of about 250 participants. And since then, the OnTrack New York site or program rather has grown to a census of 75. For this particular talk, I'm going to talk about ETP and OnTrack as one first episode early intervention program, but there are slight differences between the two. Specifically, the funds provided by OnTrack allowed us to think really creatively in how we provide care. We were able to offer individualized and dedicated employment and education supports to every person in the OnTrack program. We were able to explore community-based services, and they were in fact encouraged. There was a higher staff to participant ratio. We were able to hire a peer mentor to start delivering peer services. There were additional opportunities for mentorship and supervision for the staff beyond what was already being provided at Zucker. And we were really able to start thinking about space and environmental considerations in order to create a space that felt unique and youth-friendly and less clinical. So, as in some illustrative examples, here's me as soon as you walk into the ETP. We hired somebody to create a mural on the wall, and to the right is our waiting area. Again, we tried to create something that felt special and unique and create an environment that felt a little bit less clinical. Next slide, please. Just a few more slides about ETP. I know this isn't to talk about first-episode psychosis per se, but I wanted to provide a little bit of context and also the program that we were hoping to emulate when we were thinking about our step-down service. But everybody who's enrolled in the ETP or OnTrack New York program at Zucker is offered multi-day intakes, starting off with a clinician and a prescriber, followed by a structured diagnostic interview, neuropsychological testing, symptom rating scales that are repeated throughout care, medication management, individual and group therapy, family therapy, education and employment supports, cognitive remediation for folks who want it, need it, peer advocacy services, and employment and education supports. Next slide, please. Here's the team, the ETP team, consisting of psychiatrists, psychologists, social workers, trainees, many of whom are also involved in the development and implementation of our step-down program. Next slide, please. And the last slide about the early treatment program, in addition to those traditional services, we also offer a number of other creative interventions and therapeutic opportunities like pizza and game nights, video game group, yoga group, our ETP garden illustrated here. This was done in conjunction with participants at ETP, an annual talent show, monthly movie night, annual holiday party, and an annual peer presentation, which just occurred this past Tuesday. Next slide, please. So, despite building this really nice service, we were aware that there were ongoing challenges. And specifically, we would often get referrals for individuals that we were unable to accept due to our strict inclusion eligibility criteria. Our discharge options were also limited. We didn't really have that many places that we could or wanted to send folks who were graduating from ETP. The discharge processes were often inconsistent, and it wasn't quite clear who was going to be referred where and when. And we also knew that there were concerns about our ability to sustain gains and enhance gains, especially after all the work that was done by participants and families and clinicians at the early treatment program. So, we really wanted to think creatively about what we can do and how we can change these issues. Next slide, please. We set out to build a specialized step-down service for folks who were graduating ETP. That was our primary goal. We also wanted to build a program that could provide early episode care for folks who fell out of our inclusion criteria, who would be able to receive similar interventions, but unfortunately were ineligible for ETP. And so, we built the BOOST program, Better Outcomes Through Ongoing Specialized Treatment. Coming up with the name was probably our biggest challenge. This was done in collaboration with several participants of the early treatment program and was a topic of conversation for many weeks in groups until we finally came up with the name BOOST. It launched in 2019, and we've grown to about 60 participants so far in the past year. Next slide, please. So, much like the way we set up the early treatment program, we started by simply asking ourselves, who did we want to serve? And we set up the following parameters. Essentially, we wanted to work with folks between the ages of 18 and 40. So, we increased the upper limit of the inclusion criteria as far as age goes, compared to the early treatment program. Again, we wanted to provide care for folks with a primary psychotic disorder, kept our rule-outs. The main difference is that we removed the duration of symptom criteria. So, no longer did people need to have less than two years of symptoms in order to be eligible for the BOOST program, our step-down program. Next slide. Thank you. And so, once we had the name, we had the parameters, our next challenge was, well, who was going to provide the care? How are we going to create a service? And the biggest challenge here is that we didn't have any additional funds. We didn't have an opportunity or resources to hire additional staff. We realized that we needed to build the program into existing operations with existing resources. And we set out to build a specialty track within the outpatient department. And our first task was identifying interested clinicians. We simply gauged interest. We wanted to find people who were particularly passionate, and excited about this opportunity. And as much as possible, we tried to overlap with existing ETP clinicians, many of whom are not full-time staff at ETP, but work at various other places within the hospital. And over a couple of weeks to months, we created a small and cohesive group of clinicians who would serve as the BOOST team. Our first request from administration was relatively small. But what we asked to do here is, instead of randomly assigning participants once they graduated the early treatment program to the outpatient clinic, we now ensure that eligible people for BOOST were referred specifically to our small and cohesive team. And these would be the folks who would provide the ongoing care. The next request that was asked and approved by administration was to create a weekly team meeting. Of course, a critical component to early intervention, and we assume a critical component to a step-down service as well. And since inception, the weekly team meetings have grown, and now we're incorporating residents and trainees to participate in that process. Next slide, please. So, now that we had the name, and the parameters, and the team, we started thinking about what services we'd be able to offer. Again, we were not in a position to be able to offer any services that were not fundable. We didn't have any additional resource to build this program, and so we started with existing resources. Things that were already offered at the clinic included medication management, individual therapy, group therapy, and family therapy. So, our next request from administration was simply to create a new group. That was relatively easy to get approved. What was harder was sort of thinking about what would be unique and different about this group, and that's something that we're still working on. We're still trying to understand, but some thoughts were that a large focus within the early treatment program was about education, school, relationships, and work. And at this next stage in development in a young person's life, there really needed to be a heavy focus on independent living skills. And so, that's something that we're hoping to explore at the BOOST program. Next slide, please. All right, and beyond simply the types of services, a critical component was a shared treatment philosophy, so that the clinicians who were providing care within the BOOST program shared the same conceptualization of what early intervention was all about, and more specifically, that recovery was possible, that clinicians would work on identifying personal goals, understanding personal recovery, that shared decision-making would be a critical component, and that this would very much be a team-based approach where clinicians and patients and families were all working together towards a shared goal. Next slide, please. So, here is how we set up the parameters and the boundaries between the three programs. Essentially, here on the left, we have the first episode psychosis program. Within a first episode psychosis program, folks who are eligible for OnTrack New York are defined as individuals between the ages of 16 and 30 who have had a symptom onset within the past year, and that is essentially a two-year program. ETP, we enroll folks who are between the ages of 16 and 35 who've had two years since symptom onset, and we're viewing this first episode psychosis program as a five-year program. In the BOOST program, we eliminated the age, sorry, the symptom cut-off. We've expanded the age range to 18 and 40, and we haven't yet identified how long the BOOST program is going to continue, potentially indefinitely, although that's something that we still need to work out. Next slide, please. We are in the process of applying for grants to be able to expand and enhance the services that we are providing in the BOOST program, and that's that we are providing in the BOOST program to include things that aren't traditionally reimbursable. We'd like to continue with what we're already doing at ETP, for example, neuropsychological evaluations and rating scales, cognitive remediation. We'd very much like to offer peer advocacy, education, employment supports, and we'd also really like to be able to think about our environment, social events, and space considerations. But here, too, the question becomes, how do we differentiate this program from ETP? We don't necessarily want to just extend the early treatment program. We want to create something that is unique and special and delivers the necessary services for individuals at this time. Next slide, please. Here's my last slide. I just wanted to finish off with some ongoing areas of inquiry, things that we still don't know but want to figure out, is how do we best prepare someone for transfer between these services? How do we decide who, what, and when? And ultimately, what are the essential services to a healthy step-down program? How do we differentiate a first-episode psychosis program from a step-down program? What are the unique elements? And what happens post-BOOST? I think that we're all under the assumption that people are not going to stay in a step-down program forever, but what is the next stage beyond that? And ultimately, what is the role of technology? That's something that I'm particularly passionate about. I haven't really had a chance to talk about that today. I know David Penn is going to be talking a little bit about it in his talk, but I think that there's a real potential here to leverage technology to improve the things that we do in both the early treatment program and BOOST, our step-down program. And that's my last slide. Thank you very much for listening. I think I'm up. Hopefully, everyone can hear me okay. Greetings from Durham, North Carolina. My name is David Penn. We are a tad behind, so I may end up talking kind of quickly and just to try to get us caught up a little bit. I'm going to talk about Horizons USA. Let's see. Oh, they are advancing slides for me. So if you could advance the next slide, please. As Michael mentioned, I'm going to talk about some technology that may be relevant. Post-discharge, and I believe my colleague who developed this technology may have spoken already at the conference, Mary Alvarez. When we think about young people with first-episode psychosis, there are a number of challenges that they face. These include what you might think of as a social network crisis. As you can see here, they're much more likely to have no confidants in terms of friends. They tend to be of lower social rank, lower in the social hierarchy. They tend to have a number of days per week with no meaningful contact with others. This tends to be more due to the fact that they have fewer friends, despite the fact that they stay in contact with family. And as Christina talked about, and so did Michael, there's time limited support, and the time limited support could have an impact on long-term recovery. Next slide, please. So this is a term that Mario Alvarez, who developed the technology, calls Generation Next. And some of the questions that come up are, can we reduce the social impact of first-episode psychosis and develop sophisticated interventions that utilize the social environment? Second, can we sort of turn things around and have interventions that focus on well-being, personal strengths, and not only on correcting symptoms? Third, can we bring about long-term recovery for young people with first-episode psychosis so that they will not end up returning to the mental health system at some time in the future? Next slide. I told you I was going to move kind of quickly here. How do we reach people who have moved on from coordinated specialty care, but still need ongoing support? And I think Michael and Christina both talked about the importance of step-down services. We see in our clinic, which is the OASIS program in Chapel Hill, North Carolina, that there are people that are phasing out, but they still want to have some sort of connection to the program. And then finally, how do we extend the reach of conventional treatment services? So we can think about conventional treatment services as the classic bricks and mortar. How do we extend that beyond our catchment area? Next slide, please. So one way of doing it is potentially via social media and digital interventions. And I should make very clear for everyone that I am a clinical psychologist who thinks that one-on-one individual or group interventions are the way to go. I have been introduced to social media digital interventions, and I'm trying not to be a dinosaur because I think there's a lot of potential not to replace face-to-face interactions, which I think is the most important thing, but to supplement or augment them in some cases. Next slide. I'm going to mention this very quickly. The people that develop this intervention are on my right, Mario Alvarez, and on the left of the woman is John Gleason. They're both psychologists in Melbourne. I'm the one, the good-looking guy in that group with my glasses and a T-shirt. And the gentleman in the middle, many of you may notice, is Bob Heinsohn. And the person to his left is our program director, Sylvia Sade at the OASIS program. OASIS was the second first-episode program in the United States, and a lot of it is due to the successes due to Sylvia. This is when John and Mario were down in North Carolina giving a workshop on horizons, and Bob Heinsohn was kind enough to come down to also be part of that. Next slide. What Mario and John developed is something called moderated online social therapy, and it has the following components. It includes things such as a peer-to- peer online social network, the sort of thing you would see in the newsfeed and Facebook. There's both moderation from mental health professionals and from peers. There is, and I'm making sure that, oops, sorry. I'm trying to notice the chat, and I probably shouldn't. There's also therapeutic content, and these novel models of psychotherapy include things such as mindfulness, positive therapy, and they're also delivered not only in terms of text and audio, but the use of comics, because young people don't always tend to be more visual than older people. And finally, there are strengths-based approaches. So the idea is have clients identify their strengths first. This is something that obviously many of you in the audience likely already do. Have people identify their strengths first, and then use those strengths to help tailor treatment for them. Next slide. I could try to describe most to you, but what I'd like to do is show a brief video, and this is developed by the team out in Melbourne, Australia, and it's a four-minute video providing an overview of what MOST is. I think it will come on in any minute now. Welcome to MOST, a lovable, engaging, evidence-based digital mental health platform for young people, delivering access to clinical and peer community support when and where they need it most. Let's take a quick look at how the platform works. When a young person logs on to MOST for the first time, they'll come through to an intelligent onboarding process. This process will ask young people about themselves, and MOST will use this information to tailor a personalized therapy journey based on the user's individual strengths and interests. MOST has a strong focus on meeting young people's clinical needs, but we also place a strong emphasis on empowering people to identify and build upon their personal character strengths. MOST does this by asking people to answer an evidence-based strength survey, which identifies people's top five personal strengths and appropriate therapy journeys. These personalized therapy journeys are instrumental in helping young people find therapeutic direction that's built on science that works, that can help them in the long term and in moments of need and connect them to a virtual support network of other young people who get it. When young people finish the onboarding process they'll come through to their personalized homepage for the first time. They'll see their suggested guided therapy journey. The journeys are a way to stay on track with their therapy and young people will be further supported by a most clinical therapist. Guided therapy journeys are mapped against a clinical evidence-based treatment model. For example, the social anxiety guided therapy is mapped against cognitive behavioral principles that address maladaptive thoughts, feelings and behaviors that maintain social anxiety symptoms over time. Each guided journey comprises of approximately eight tracks. Each address a particular theme associated with the maintenance of clinical symptoms. For example, there's a track to help drop safety behaviors in a social anxiety therapy journey, a track on managing worry within the general anxiety journey, a track to short circuit rumination within the depression journey and effective ways to manage tricky interpersonal situations within the social functioning journey. As young people complete their journeys they can collect things that have been helpful in the past or could help in the future and save them in a toolkit. The toolkit becomes their personal therapy library. As well as specific therapy journeys, young people can use the explore function to browse content on specific issues and to find a range of specific coping strategies and tools in the moment. Depending on clinical need there's a flexible communication tool that allows for live text chat and asynchronized messaging between the therapist and the young person. All communication is logged on the system. In the back end therapists can work with young people to modify and tailor this content depending on their needs. This could include moving relevant tracks forward to their encounter earlier in the therapeutic journey or turning off and on content within the track itself. The final most platform feature is our community news feed. This is an online social space that encourages connection between members of the platform. The young person centered space provides an opportunity to share stories, experiences and mental health strategies that have worked for them. A safe relaxed online social environment where young people can truly be themselves. We could probably go back to the slideshow at this point. Oh thank you, wow. So if you bear with us as we're making the transition to, here we go. So as you can see there's multiple components of Horizons. Oh pardon me, I'm sorry to confuse everyone. So the platform itself is called Most. Most is the platform that drives a variety of different digital interventions. So the platform itself is called Most. Most is the platform that drives the one for young people with psychosis is called Horizons. And as you could see here, it has a number of team members which includes the clients. There are Horizons therapists. We've used graduate students as well as professionals, peer support specialists and SCE specialists. Next slide please. Next slide. How does Horizons fit with Coordinated Specialty Care? Well Christina and Michael talked about this. I thought Christina's presentation was really eye-opening that you see anywhere from two to three years of specialized services for young people. But then after that there's a period where there's going to be no services. People are going to be discharged. And Horizons potentially could fit in at that point after people are discharged from Coordinated Specialty Care. Next slide please. Next slide please. So what we did is we decided in collaboration with Mario and John to pilot Horizons in the United States. Our first step was not to do it for discharged people. We just wanted to see can we do it in the United States? So we did it with people in our program who tended to be in the program for a couple of years and were sort of transitioning out. So these were not people that were discharged. Next slide please. For the purposes of time let's go past this slide. It's just a funny slide. You can just see that there's some Australian jargon that make no sense to non-Australians. So we had to actually translate that into American jargon. Next slide. We conducted a brief pilot study in the U.S. Next slide please. This is a study that was recently published in Early Intervention in Psychiatry. This was conducted over three months at three Coordinated Specialty Care clinics in the state of North Carolina. And our main goal was can we do this in North Carolina? What is it, you know, what does it look like? Obviously there was a lot of modifications in terms of the content, not only in terms of the jargon, but also if they were referring to clinics in Melbourne, we had to update that. Next slide. Next slide, sorry. And next please. The study aims were first to examine the feasibility and accessibility of horizons. Second, assess the impact of horizons on the primary outcomes of loneliness and perceived social support. And then finally explore the relationship between engagement and higher horizons and treatment outcomes over time. Next slide. I'm going to, I'm just going to mention there was 26 people recruited from three clinics. They were mainly male, mainly Caucasian, early 20s, and most of them had a diagnosis of schizophrenia, schizoaffective disorder. Next slide. Next slide. What I want you to see here in the slide is we looked at when people entered the study at baseline. We actually looked at their baseline characteristics for people that were more engaged in horizons based on their logins versus people that were less engaged. And what's highlighted in bold is the differences between the high engaged and the low engaged at baseline. And what you can see here is that people that were more engaged in the platform of baseline had lower social support and tended to have both more positive emotions and more negative emotions. Next slide. Keep in mind, this is a very low sample size study. I'm going to cut to the chase and say that when we looked at our treatment outcomes, UCLA is a loneliness scale. SPS is a social support scale. Those are effect sizes, baseline to mid-treatment, baseline to post-treatment, baseline to follow-up. We saw some signal in terms of people showing reductions in loneliness by mid-treatment, but by post-treatment that sort of, that didn't, wasn't sustained. We didn't see much of an impact on social support. What we did see an impact on is a reduction in depression as a secondary outcome and reduction in psychotic symptoms as a secondary outcome. Next slide. And I'm almost finished because I want to make sure we have enough time. The last thing we looked at was how do changes in engagement relate to changes in outcomes? So if you could go back one, if you don't mind, go back one more. Okay. There's different ways of being engaged. The bottom half of the panel focuses on engagement that involves things like interacting with other people on the platform. The way to engage on the top is really more just in terms of have you logged on or are you completing steps or actions in your therapeutic journey? So if you can click next, what you can see here is an improvement in psychological wellbeing was associated with greater posts, greater comments, more engagement with other people. Another click, please. We see also a greater improvement in positive emotions and a greater decrease in negative emotions. Again, interacting more with people on the network. Next click. Similar pattern with depression. Next click. One more. And then finally, you see some limited pattern of improvement in psychological wellbeing with an increased number of logins. And next click and final click is some pattern for reduction in loneliness predominantly when interacting with others. Next slide. Last thing I want to say, and by the way, the highlights in blue, you can ignore them. We looked at qualitative data. We just asked people right from one to five, how easy was Horizons? How much did you enjoy it? How helpful was it? And you can see that people that were more engaged, this is no big surprise, tended to have more favorable opinions of Horizons than people that were less engaged. They also stated in qualitative feedback that they really enjoyed the community and they enjoyed being able to have positive interactions with others. At the time, there was not a smartphone application for this. So that was an area of improvement. And they also said they wanted more people in the network. We only had 15 to 20 at any one time. Next slide. In conclusion, Horizons we felt like was feasible. People seemed to like it. It seemed to us that it's not a one size fits all intervention. In fact, it almost feels like multiple interventions. Some people do the therapeutic journeys. Some people, you know, are more just like, just want to log on and interact with others. And it's clear that engagement in the platform is variable. Future Future directions, we're doing a statewide implementation and in all the first episode programs in North Carolina, we're actually making a part of the peer support program. So it's kind of being housed there. And then my colleague who just spoke right before me, Michael Birnbaum, Mario Alvarez, Lisa Dixon, who many of you know, and myself have a NIMH R01 grant under submission, under review to evaluate Horizons in a large multi-site randomized controlled trial in the United States. Next slide and final slide. Just acknowledgements to my, the first author, Kelsey Ludwig, Mario and John, the first episode programs in North Carolina, and also an unrestricted gift from the Australian Catholic University so that we can conduct this study. Thank you so much for your time. I apologize for going quickly. Hello, everyone. Welcome to the ESA community. I am a representative of ESA. I've been a part of their Young Adult Leadership Council since 2013. And let me just back up a bit. ESA is a first episode psychosis organization, treatment organization. I actually went through ESA, but I'll spare you my own narrative. And I've been with them since 2010. Again, the YALC, the Young Adult Leadership Council since 2013. And I went through ESA from 2010 to that 2013. And I've stuck around with them ever since because, well, as we all know, first episode psychosis programs are a necessity to build community. And this needs to continue. Community needs to continue to be built. And so without further ado, let's move on to the next slide. So as I said, ESA is needing community engagement, first and foremost. So what is community engagement? As we all know, it can look like education. It can look like employment, leisure, it can look like employment, leisure, work. And I also wanted to back up and acknowledge David Penn's success in not only including peer supports in the awesome virtual therapy, but also including supported education specialists. Because we need a variety of multidisciplinary teams to come together to think of how to treat psychosis, how to treat loneliness, and how to build that community like we have all been addressing. So is community for all, even the ill? Well, I think we all know that many people have gone on from their psychosis to live with things such as bipolar disorder, schizophrenia, as I have schizophrenia, to live and not only just survive, but thrive to continue to become things such as film screen actors, your casual chess players, lawyers, computer scientists, and really hit home the point that there are many different philosophies of life. And if we can all come together to acknowledge some of our lonelinesses, as David puts it so brilliantly, then we can integrate societally. Next slide, please. Isis Perspectives. I think it's a C in terms of Christina's classification, because it's a two to three year program. I stumbled with the three year because it hasn't actually been granted its additional funding. But as we mentioned earlier, through the OHA, it might get that additional funding, fingers are crossed. Isis accepts all forms of insurance, no doubt. Some of our population is very poor and come from not poor in terms of spirit, but societally labeled poor by having little money. And so we all know the stigma that comes with being of a lower social denominator. And so Isis accepts all forms of insurance, no doubt. And I love that Michael's, I suppose, boombastic swagger in terms of the New York psychosis organization that he's been working on. That is just amazing. Isis promotes, forgive my, as I'll occasionally say, Isis promotes a culture of life outside of the clinic. Isis uses radical acceptance and understanding to meet clients where they are. Isis promotes wellbeing and safety for its community members, realizing that the people of Isis are valuable society members. People with mental illness are more likely to be victims of abuse and violence than to commit such acts, as we all know. Next slide, please. How do we continue with Isis after graduation? So all of the people on the Young Adult Leadership Council have asked this about themselves. What are we to do post-graduation, post-Isis? Well, we have to stay involved. Well, we have to stay involved. How best to stay involved? Through our local Young Adult Leadership Council. Next slide, please. This council, it's a group of young people with lived experience and their allies. It helps to shape the direction of Isis. Emphasizing participatory decision-making, as we all know, is crucial to giving people the volition to choose where they want to go. But we all know this. We've come a long way from giving people the treatment of locking them in a mental hospital forever. We are preaching to the choir. Community outreach is the way. Advocating for change. We like to do that. We like to get out to our local legislators, our local artistic shows, film even. There's a Bad Taste video production that narrates suicidal awareness. Next slide, please. More of what goes on inside YELC. Teamwork. Dreams. Some may say world peace. Maybe that's, you know, so far out there. Some may say more equitable services. Which I think is beautiful when it comes to, again, David's use of comics. Because a lot of the time, it's all put in some jambly, mambo-jumbo jargon that we can't understand. Whether it's called world peace or more equitable services, comics put things into layman terms so people can understand. The whole translation of psychosis is important. Which is probably unique for everyone, as I've come to terms with my own story as it's different from other people's stories. So, we're not all the same. Steps. Determine the difference between a friend and a siloed support. What is a pure support and what's a friend? Who knows, like, at the moment? Who knows, you know? They're pretty close. What is a pure support and what's a friend? Who knows, like, at the moment? Who knows, you know? They're pretty close. I mean, clarification of the difference between a friend and a pure support is important. Clarifying boundaries, setting ground rules. Next slide, please. So, this is maybe an example of what goes on in Michael's and David's and Christina's worlds, as well as mine. Transitioning from provider-consumer relationship to mutual colleague relationship. Client, are we friends? Professional, please know that while I admire your genuine interests in video games, and I, too, share that interest, it is important for us to remain, maintain a clinical relationship within ESA with the expectation that we all care for you on the team. In this capacity, I am your friend, but my ties are to the ESA community. It is important for you to continue to find natural support outside of ESA, who will be there for you where ESA cannot. You can email me any time of day or feel free to text me during your work hours from 11 to 7. Client, can I still contact you after I'm done with services? I prefer if we maintain a professional work relationship. You can maintain a relationship with ESA via our Young Adult Leadership Council. There, we may work together, but I'd like to maintain our boundaries as colleagues. Client, client, I understand. Next slide, please. Now, this gets at the heart and soul of what we've defined as, for a long time, of treating people as if we're animals that can't be related to, because we often deny some of the struggles of our own. A lot of the time, we give advice that won't apply as water does apply to most things, as water will also apply to us. So, there's a way to give advice that helps everyone, such as the positive smiles that David so elegantly put, comic smiles. I noticed one of the things in the origin things was also, there was a category for most love. That was a category. We're not talking like most agitated or most on a scale of negativity. Are you this negative or that negative? No, we're talking about the strengths. How much do you love? How happy can you be while maintaining the relationships and the groundedness and those around you to be able to communicate and still engage in occupations? So, don't be afraid to relate.

advancing early psychosis care

United States

inequities

COVID

transitions

coordinated specialty care

transition services

step-down program

digital mental health platform

peer-to-peer online social network

community engagement