STEP LC - Module B - Evaluation and Initiation of Treatment - Session 3

Transcript

• 00:00Everyone.
• 00:05Vance. So just to reorient,
• 00:07we're
• 00:08going back to module b,
• 00:11which is the
• 00:13module where we describe,
• 00:15and implement
• 00:18evaluation and treatment initiation and
• 00:20engagement,
• 00:22into care.
• 00:25So just some key concepts
• 00:26that we're gonna cover as
• 00:28part of this module. And,
• 00:31so I we make a
• 00:32distinction between differential diagnosis, and
• 00:34I think this will become
• 00:35clear
• 00:36in terms of, thinking about
• 00:38secondary causes of psychotic disorders.
• 00:41And once those are considered,
• 00:43we're mostly treating primary psychotic
• 00:45disorders for which
• 00:47we have an approach to
• 00:48structured assessment and case formulation
• 00:50that can inform,
• 00:52the treatment planning process. So
• 00:54I'll be presenting those two
• 00:55sections and then handing over
• 00:57to Laura to talk about,
• 00:59other important parts of this
• 01:01module
• 01:02wherein while we are doing
• 01:04this evaluation assessment, we're also
• 01:06simultaneously,
• 01:07of course,
• 01:08engaging the young person and
• 01:09their family into our model
• 01:10of care
• 01:12and providing support to the
• 01:13family. So,
• 01:14evaluation
• 01:15proceeds, of course, in parallel
• 01:17to the beginning of treatment.
• 01:19And as you heard previously
• 01:20in module c, that coordinated
• 01:23specialty care treatment is what
• 01:24follows upon this module b.
• 01:26But, of course,
• 01:27you can't really,
• 01:28evaluate,
• 01:29in in this situation without
• 01:31also providing
• 01:33necessary engagement and treatment.
• 01:37So I wanted to start
• 01:38with this this concept of
• 01:40secondary psychosis, and this is
• 01:41a term, you know, used
• 01:42across medicine,
• 01:44to to talk about syndromes
• 01:46that are secondary
• 01:48to
• 01:49primary causes, medical disorders.
• 01:52And they're, you know, not
• 01:54just in psychosis, but across
• 01:56mental illnesses,
• 01:58it has been a useful
• 01:59practice to
• 02:01think about these four different
• 02:03categories
• 02:03of what might be causing
• 02:06a mental illness.
• 02:08So
• 02:09delirium, which we won't be
• 02:11talking about a lot today,
• 02:12but is a situation of,
• 02:15unstable awareness, people who are,
• 02:17for a variety of reasons,
• 02:19related to
• 02:20unstable medical illnesses,
• 02:22may be in a confusional
• 02:23state, and in that state
• 02:25may have hallucinations
• 02:27and even paranoid delusions.
• 02:29And this is clearly secondary
• 02:31to the cause of the
• 02:32delirium, which once it's treated,
• 02:35say, if it's related to
• 02:36an uncontrolled infection or sepsis,
• 02:40the symptoms of psychosis
• 02:42remit completely, and the person
• 02:44does not have a chronic
• 02:45psychotic illness.
• 02:46They've merely suffered psychotic symptoms
• 02:48in the context of another
• 02:50medical disorder
• 02:51that's causing delirium.
• 02:54The the illnesses that can
• 02:56cause dementia, and we're speaking
• 02:57really here of elderly populations,
• 03:00not, our target population here,
• 03:02are often commonly associated with
• 03:05psychotic symptoms as well. So
• 03:06this is the individual with
• 03:08Alzheimer's dementia, for example,
• 03:10that may have frank delusions,
• 03:13misidentification,
• 03:15paranoid ideation, and even hallucinations
• 03:18that can be auditory or
• 03:20visual.
• 03:21And we all understand that
• 03:22these psychotic syndromes
• 03:24are not the primary psychotic
• 03:26or schizophrenia spectrum syndromes that
• 03:28we're speaking of here. But
• 03:29it's useful to think about
• 03:31this as a hierarchy of
• 03:32considering
• 03:34other secondary causes.
• 03:36There are the illnesses of
• 03:37known cause or ideology and
• 03:40mechanism, and they're often referred
• 03:41to as medical causes.
• 03:43I put that in inverted
• 03:44commas because in some respects,
• 03:47all mental illnesses
• 03:48are the result of some,
• 03:51mechanistic dysfunction in the brain.
• 03:54But we we speak of
• 03:56medical as really illnesses that
• 03:58we,
• 04:00have a better understanding of
• 04:01what the causes are
• 04:02and for which the treatments
• 04:04are specific and different than
• 04:05they are for chronic schizophrenia.
• 04:08And finally, substance abuse, which
• 04:10is which is something we
• 04:11commonly consider
• 04:12that may
• 04:13by itself, cause a psychotic
• 04:15syndrome
• 04:16and that we should think
• 04:17about before committing ourselves to
• 04:19thinking of the, illness as
• 04:21primary.
• 04:23So I don't expect that
• 04:24you can read the list
• 04:25on the right. It's just
• 04:26to make the point that,
• 04:27in fact, it's there are
• 04:28many, many medical illnesses that
• 04:30have been associated with psychotic
• 04:32symptoms.
• 04:34The list is actually
• 04:35even longer than this. The
• 04:37point here, of course, is
• 04:38that there are many rare
• 04:40causes,
• 04:41that the illnesses by themselves
• 04:43are very rare, and they
• 04:45sometimes can cause psychosis.
• 04:48And so there's a as
• 04:49is obvious from this long
• 04:50list, there's a limit to
• 04:51how many illnesses one can
• 04:53screen for. And so we
• 04:54often have
• 04:55family members
• 04:57who have a person with
• 04:58psychosis who request, for example,
• 05:00tests genetic tests or imaging
• 05:02studies
• 05:03in the hope that that
• 05:05we might discover
• 05:06a treatable illness.
• 05:08And certainly, some of these
• 05:09are very treatable.
• 05:12For example, thyroid disorders
• 05:14are very treatable,
• 05:16whereas
• 05:17prion diseases and endocrinopathies
• 05:19are not necessarily
• 05:20all as treatable.
• 05:22So, there are limits to
• 05:24how much we could screen
• 05:25for any of these. And
• 05:26with very rare illnesses,
• 05:28it's actually very challenging to
• 05:30effectively
• 05:31diagnose and and screen for
• 05:33them unless you have a
• 05:34very high index of suspicion,
• 05:36either from your history or
• 05:38from your exam.
• 05:40And and there is the
• 05:41the reality, though, that missing
• 05:43some of these illnesses can
• 05:44be high stakes. And some
• 05:45of you may have heard
• 05:46of the well publicized case
• 05:47of,
• 05:48Susan Callan who Susanna Callan,
• 05:51sorry, who wrote about
• 05:52her illness. I believe the
• 05:54book was called Brain on
• 05:55Fire, and this was a
• 05:57a rare,
• 05:59autoimmune disorder that can manifest
• 06:01as psychosis.
• 06:03Thankfully, it doesn't look a
• 06:05lot like schizophrenia. It often
• 06:07presents with psychosis, but also
• 06:08with a lot of other
• 06:09obvious
• 06:10signs of severe,
• 06:13you know, physiological
• 06:15collapse, you know, blood pressure
• 06:17problems and so on that
• 06:19often, land people in the
• 06:20ICU.
• 06:22But there is, of course,
• 06:23a risk that some of
• 06:24these individuals could be mistaken
• 06:25as having primary psychosis
• 06:28and not given the the
• 06:29treatment that will really make
• 06:30a difference. And so
• 06:33it's it's worthwhile thinking, and
• 06:34and I bring this up
• 06:35often that,
• 06:37the medical providers, especially in
• 06:39a coordinated specialty care team,
• 06:42have the, the responsibility
• 06:44and the obligation in many
• 06:45ways to keep their eyes
• 06:46open for,
• 06:48rare and high stakes diagnoses
• 06:50even while understanding that these
• 06:52are actually quite rare and
• 06:53there's
• 06:54there are potential costs to
• 06:56doing unnecessary screening tests,
• 06:59for these.
• 07:01So,
• 07:02given that that I've set
• 07:03it up in this way,
• 07:04it might seem very daunting
• 07:06to us to proceed around
• 07:07differential diagnosis, which is by
• 07:09which I mean, considering whether
• 07:11there are any medical etiologies
• 07:13that are causing the psychotic
• 07:14illness.
• 07:16And this slide is from
• 07:18a paper reference below that's
• 07:21that describes really a a
• 07:23pragmatic approach.
• 07:24So the way we think
• 07:26about this in step,
• 07:27in in amongst our
• 07:30medical providers is
• 07:32to really think about
• 07:34which disorders,
• 07:36are common and which typically
• 07:38can present with psychosis. So
• 07:40that's box a.
• 07:41And you might think here
• 07:43about
• 07:44amphetamine abuse, cocaine abuse, and
• 07:46even cannabis abuse that,
• 07:49are quite common and can
• 07:51commonly
• 07:52include psychosis within their presentation.
• 07:56In box b are,
• 07:58illnesses that are common, but
• 07:59very, very rarely present with
• 08:02psychosis.
• 08:03So,
• 08:04you know, these are, for
• 08:05instance, ill thyroid disorders that
• 08:08are quite common, hypothyroidism.
• 08:11But they can present they
• 08:12can have psychosis, but it's
• 08:13not a common presentation
• 08:15of hypothyroidism,
• 08:16for example.
• 08:17In box c are the
• 08:18uncommon disorders, but that when
• 08:20they do occur, they often
• 08:22have psychosis. And these are
• 08:23very rare for us to
• 08:24see, but there are syndromes
• 08:26like, twenty two q eleven
• 08:28deletion syndromes. It's also called
• 08:30belocardiofacial
• 08:31syndrome.
• 08:32And more than a third
• 08:33of individuals with this will
• 08:35have psychotic symptoms as part
• 08:36of their presentation. So you
• 08:38might even describe that as
• 08:39not just a genetic, but
• 08:41a psychotic disorder.
• 08:43But they're very uncommon. And,
• 08:45when they do present with
• 08:46psychosis, they require different ways
• 08:48of managing and treating those
• 08:50individuals.
• 08:51And then finally, box d,
• 08:53which is that they're very
• 08:55rare. And when they do
• 08:56happen, psychosis is very rarely
• 08:58associated with it. And these
• 08:59are disorders we rarely see
• 09:01in the clinic.
• 09:03They they might include disorders
• 09:04like Wilson's disease, for example,
• 09:06a a
• 09:08couple metabolism disorder that is
• 09:10very rare just in the
• 09:11general population.
• 09:12And when it does occur,
• 09:14very rarely, psychosis part of
• 09:15the picture, but it can
• 09:16happen.
• 09:17And one needs to be
• 09:18educated about these illnesses so
• 09:20that
• 09:22the the person trying to
• 09:24distinguish what's going on at
• 09:26least has those illnesses in
• 09:27mind when they're thinking about
• 09:28what's what's happening with individual
• 09:30patients.
• 09:31So at step, we have,
• 09:33based on this previous slide,
• 09:35a sort of list of
• 09:36tests that we generally,
• 09:39collect,
• 09:40during the evaluation. And often,
• 09:42many of these tests are
• 09:43routinely done in
• 09:45emergency rooms and inpatient units.
• 09:47So
• 09:48we we often when we
• 09:50admit the person to our
• 09:51clinic, if they've been recently
• 09:52admitted,
• 09:53we're just collecting those tests
• 09:55that have not been collected.
• 09:57We aren't necessarily repeating a
• 09:58lot of blood work that
• 09:59the person has already gone
• 10:01through.
• 10:02I'm happy to talk more
• 10:03specifically about certain tests, but
• 10:04it's actually
• 10:06not a very long list,
• 10:07and it's often covered by
• 10:08many routine blood draws that
• 10:10are done.
• 10:12And some of these tests
• 10:13are not necessarily for differential
• 10:14diagnosis.
• 10:16They're, to allow us to
• 10:17get a baseline, for example,
• 10:19on a person's
• 10:20fasting glucose and lipid profile
• 10:22because we know that these
• 10:24variables get worse and sometimes
• 10:26because of the antipsychotic
• 10:28medications we use. So it's
• 10:29helpful to have a baseline
• 10:31to track this and respond
• 10:32if these variables
• 10:34are going in the wrong
• 10:35direction.
• 10:38I put some principles on
• 10:39the right. I mean, number
• 10:40one is probably the most
• 10:41important for differential diagnosis, which
• 10:43is when someone who you
• 10:45think
• 10:45has does not have a
• 10:47medical cause and is likely
• 10:49falling in the schizophrenia spectrum,
• 10:51group of illnesses,
• 10:53it's important to keep an
• 10:54open mind. And some hints
• 10:56that this may not be
• 10:58schizophrenia,
• 10:59might be that the person
• 11:00doesn't respond to treatment as
• 11:01you expect.
• 11:02They have more repeated relapses.
• 11:05They their symptoms,
• 11:08are such that they,
• 11:11are unusual in a variety
• 11:12of ways that might include
• 11:14visual hallucinations rather than the
• 11:15typical auditory hallucinations.
• 11:18The point, though, of course,
• 11:19is there's there's no specific
• 11:21clinical picture that gives away
• 11:23what the diagnosis is.
• 11:26Many different disorders look the
• 11:28same in terms of their
• 11:29psychotic symptoms, and so it
• 11:31often requires be having an
• 11:33open mind and repeating
• 11:34and revisiting elements of the
• 11:36history to understand whether you
• 11:38may have missed something at
• 11:39the initial assessment.
• 11:41And, of course, we test
• 11:42for common disorders. So, for
• 11:44example, we test for b
• 11:45twelve deficiency,
• 11:47not because we think it's
• 11:48a common cause of psychosis,
• 11:50but it's cheap to test
• 11:51for, and it's very easy
• 11:52to treat. And so we
• 11:54screen for it and,
• 11:56and check for that.
• 11:59I I've mentioned this already
• 12:00as a but what revisiting
• 12:02as a principle is that,
• 12:05sometimes the test to really
• 12:07rule out a very rare
• 12:09condition like, for example, Wilson's
• 12:11disease
• 12:12might be a liver biopsy.
• 12:14And I bring this up
• 12:15because,
• 12:17we never
• 12:18we we often cannot do
• 12:19the definitive test
• 12:21just because we're worried we
• 12:22might miss something. The test
• 12:24itself has risks.
• 12:25So the only reason to
• 12:26do that is if you
• 12:27have a very high suspicion
• 12:29that this might be Wilson's
• 12:31disease, and it often requires
• 12:33consultation with a hepatologist to
• 12:35decide whether it's worth doing
• 12:36the definitive test,
• 12:38because it fits the clinical
• 12:40picture, which would then drive
• 12:41different treatment.
• 12:44We also, of course, test
• 12:45for rare but treatable disorders.
• 12:47I mentioned this. And then
• 12:48I I've already covered five,
• 12:50which is we do testing
• 12:51to check baseline risk,
• 12:54as part of our of
• 12:55our so called medical workup.
• 12:58So this can take effort,
• 13:00time, and discussion within a
• 13:01team, and it requires
• 13:04continued,
• 13:05will a continued willingness to
• 13:07revisit,
• 13:08and not prematurely close on
• 13:10what might be going on.
• 13:11So having said all of
• 13:13that, much of the time,
• 13:14the most common causes of
• 13:16psychosis,
• 13:17that is box a on
• 13:19the top left that you
• 13:20may recall,
• 13:21are in fact the so
• 13:22called primary psychotic disorders.
• 13:24And by primary, we mean
• 13:26not the best or the
• 13:27the top of the list,
• 13:28but really, there is no
• 13:30known secondary cause for the
• 13:32psychosis.
• 13:33It's not different from what,
• 13:35what most of us,
• 13:38refer to as high blood
• 13:39pressure or hypertension. It's often
• 13:41called primary hypertension, which is
• 13:43to say,
• 13:44we don't know what causes,
• 13:46high blood pressure, but we
• 13:47do know how to treat
• 13:48it effectively.
• 13:49And every once in a
• 13:50while, we discover the hypertension
• 13:52is related to a specific
• 13:54kidney disorder,
• 13:56which can be treated in
• 13:57a different way from general
• 13:59hypertension.
• 14:00But as with primary hypertension
• 14:02with primary psychosis,
• 14:04we're really talking about,
• 14:06the top left box, which
• 14:07are non affective psychotic disorders.
• 14:10So
• 14:12I should say there are
• 14:13two categories, the non affective
• 14:14and the affective psychoses.
• 14:17The non affective psychotic disorders
• 14:19are what can also be
• 14:20referred to as the schizophrenia,
• 14:22and you'll see a list
• 14:23of
• 14:24terms below that.
• 14:26I don't regard these really
• 14:27as different diagnoses.
• 14:29So these are just different
• 14:30ways to classify,
• 14:32individuals who have very overlapping
• 14:35syndromal features.
• 14:37Sometimes it makes a difference
• 14:38to treatment.
• 14:40For example, individuals with delusional
• 14:41disorder
• 14:43will typically present with just,
• 14:45delusions and not much else,
• 14:48and they present specific challenges
• 14:50in terms of treatment.
• 14:51But in the main, all
• 14:53the other,
• 14:54terms in that box
• 14:56are regarded by most,
• 14:58specialists as just versions of
• 15:00the same kinds of,
• 15:02syndromes
• 15:03that probably represent many different
• 15:05diseases,
• 15:06but it's practical at this
• 15:07point to put them together
• 15:09and provide treatment because they
• 15:10have many common,
• 15:12needs and respond to many
• 15:13of the same treatments we
• 15:14currently have.
• 15:16The affective psychoses are the
• 15:19ones that disorders that have,
• 15:21are primarily mood disorders
• 15:23that may also have psychotic
• 15:24features.
• 15:26And in most, of the
• 15:28world,
• 15:28early intervention clinics, coordinated specialty
• 15:31care are really targeted at
• 15:33non affective psychotic disorders, which
• 15:35I'll refer to as schizophrenia
• 15:37or the schizophrenias.
• 15:39There's some clinics that do
• 15:40also admit people with affective
• 15:42psychoses.
• 15:43Most of this occurs because
• 15:45early in the course of
• 15:46the illness, it's hard to
• 15:47tell the two apart.
• 15:49And at Step as well,
• 15:50we sometimes admit somewhere in
• 15:52the range of, you know,
• 15:53five to ten percent of
• 15:54our sample ends up having
• 15:56really a bipolar disorder with
• 15:58psychotic features
• 15:59or major depression with psychotic
• 16:01features.
• 16:02And when that happens, we
• 16:03continue caring for them for
• 16:04a period of time and
• 16:05then refer them elsewhere.
• 16:07So the the main focus
• 16:09of coordinated specialty care is
• 16:10really,
• 16:11tailored to the needs of
• 16:13people with the schizophrenia.
• 16:18To make the point, I
• 16:19found this in a in
• 16:20a textbook, but I think
• 16:21makes the point really well
• 16:22is when it comes to
• 16:22these schizophrenias,
• 16:25like many other primary mental
• 16:26illnesses,
• 16:27it's very likely that these
• 16:29are many different diseases, by
• 16:31which I mean that they
• 16:32have many different causes and
• 16:34probably different mechanisms.
• 16:36And so like the different,
• 16:38tributaries to the Mississippi River,
• 16:41if you were to find,
• 16:42these these individuals earlier along
• 16:45in their,
• 16:47illness development,
• 16:48they might actually look quite
• 16:50different from each other, and
• 16:51there might be possibilities to
• 16:53intervene that would look very
• 16:54different from our current treatment
• 16:55models.
• 16:56But as it stands now
• 16:57in twenty twenty three, we're
• 16:59really treating individuals closer to
• 17:01New Orleans. They all look
• 17:02this they all look very
• 17:04similar, that the syndromes all
• 17:06fall within the schizophrenias
• 17:08even though we are aware
• 17:09that how they got there
• 17:11might have been quite different.
• 17:13And that at some point
• 17:14in the future, we might
• 17:16be dividing these syndromes up
• 17:18that more closely match to
• 17:20how they began,
• 17:22and that we might, in
• 17:23the end, provide treatments earlier
• 17:25on
• 17:26further up,
• 17:27the
• 17:28the course of the river
• 17:30that are more specific to
• 17:31those causes.
• 17:32But but where we are
• 17:33now really is providing treatment,
• 17:36at the syndrome level
• 17:38closer to the bottom,
• 17:40when the river meets the
• 17:41gulf.
• 17:42The good news is that
• 17:43we can do a lot
• 17:43of good even with that
• 17:45kind of treatment that's offered,
• 17:47But it's important to know
• 17:49that
• 17:50people will arrive with very
• 17:51different presentations, a very different
• 17:53mix of,
• 17:55symptoms
• 17:56will respond differently to treatment,
• 17:59some very, very well, some
• 18:01moderately well, and some not
• 18:02so well.
• 18:04And so it's important, I
• 18:05think,
• 18:06to also in formulating
• 18:08their their difficulties, be able
• 18:10to to
• 18:11to look at the case
• 18:12from different lenses, from different
• 18:14perspective, which is what I
• 18:15mean by being multilingual,
• 18:18thinking being able to think
• 18:19about the effects of ongoing
• 18:21substance use
• 18:22separately from the possible effects
• 18:24of trauma
• 18:25while also treating,
• 18:27a
• 18:28a disease that's, likely a
• 18:29psychotic illness,
• 18:31with the treatments that are
• 18:32specific for that.
• 18:35So this is my last
• 18:36slide, and I'm not since
• 18:37this is a high level
• 18:39presentation,
• 18:41I'm not gonna get into
• 18:42much more detail except to
• 18:44say that in the clinic
• 18:45at the three month point
• 18:47after every individual has entered
• 18:49care,
• 18:50we have a case.
• 18:51We have a meeting amongst
• 18:52all the clinicians
• 18:54where we very deliberately try
• 18:55to answer
• 18:56at least four different kinds
• 18:58of questions about each individual
• 18:59patient. And the first is
• 19:00really, what does the person
• 19:02have? And this refers really
• 19:04to what I mentioned earlier
• 19:06around differential diagnosis
• 19:07and then classification
• 19:09of the primary psychotic illnesses
• 19:11that they have. So assuming
• 19:12that
• 19:13we've,
• 19:14considered and temporarily ruled out
• 19:16the secondary causes,
• 19:18while we keep paying attention
• 19:20to their to the possibility
• 19:21that we may have missed
• 19:22something, we proceed to treat
• 19:24a primary
• 19:25psychotic illness,
• 19:26and we treat it much
• 19:27as as we would treat
• 19:28many other diseases with treatments,
• 19:30including medications and psychosocial treatments
• 19:33that seek to address the,
• 19:36disease related morbidity and sources
• 19:38of disability.
• 19:40But we also take on
• 19:41other lenses, which is,
• 19:44for example, if a person
• 19:45is continuing to to abuse,
• 19:47cannabis,
• 19:48it it requires something other
• 19:50than a disease perspective to
• 19:51consider this behavior, which is
• 19:54often driven by cravings.
• 19:56That's a learned behavior that
• 19:58with repetition over time becomes
• 19:59habituated
• 20:00and needs to be addressed
• 20:02in a behavioral approach, which
• 20:04essentially in the end will
• 20:06which aims to stop the
• 20:07behavior or at least limit
• 20:08the risk dramatically.
• 20:11We also consider,
• 20:13who the person is,
• 20:14dimensionally, by which I mean,
• 20:17their personality traits that will
• 20:19could make a huge difference
• 20:20to how they might both
• 20:21manage their illness, but also
• 20:23respond to stressors in their
• 20:24environment,
• 20:25but also their level of
• 20:27cognitive development,
• 20:30which can determine, for example,
• 20:32what kinds of
• 20:33stresses,
• 20:35what kinds of educational
• 20:37opportunities, what kinds of psychotherapeutic
• 20:39approaches
• 20:40may or may not be
• 20:41appropriate given their their level
• 20:43of functioning.
• 20:44And finally, of course, the
• 20:46the narrative perspective, which is
• 20:47the consideration
• 20:48of their own story,
• 20:50the kinds of developmental
• 20:52challenges or deprivations they may
• 20:55have suffered, the effect of
• 20:56often in many of our
• 20:58patients' current,
• 20:59social determinants,
• 21:01poverty,
• 21:04and how this might be
• 21:05incorporated into,
• 21:06their an approach to treatment
• 21:08that empowers them to take
• 21:09advantage of the clinic, but
• 21:11also resources in the community
• 21:13to maximize their own,
• 21:15functioning.
• 21:16And we we try to
• 21:17take a very holistic approach
• 21:19in formulating, which includes
• 21:22data, obviously, from patients and
• 21:24family members as we all
• 21:25do in clinical care. But
• 21:27we also have structured assessments
• 21:29from trained raters at baseline
• 21:31and periodically in the course
• 21:33of treatment
• 21:34that, for example, use symptom
• 21:36scale that can sometimes give
• 21:37you information that is not
• 21:39transparent in the clinical interaction.
• 21:42So what I mean by
• 21:43that is that a trained
• 21:45rater who doesn't have a
• 21:46treatment relationship with your patient
• 21:48will sometimes be able to
• 21:50get the patient to,
• 21:51acknowledge
• 21:52symptoms that they may not
• 21:54acknowledge to you either because
• 21:55they want to
• 21:58please you and they have
• 21:59a feel a sense of
• 22:00pressure to say that things
• 22:02are better given all the
• 22:03efforts you're making on their
• 22:04behalf.
• 22:05Or you might be conversely
• 22:07motivated not to ask them
• 22:08or record
• 22:09symptoms
• 22:11in in the kind of
• 22:14spirit of a therapeutic relationship
• 22:16where it sometimes may be
• 22:17difficult
• 22:18to keep scratching and asking
• 22:19about disturbing symptoms when
• 22:21the patient prefers to talk
• 22:23about something else. So these
• 22:24structured assessments can be very,
• 22:26illuminating,
• 22:27and supplement the clinical assessments.
• 22:30And then, of course, we
• 22:31also try to get increasingly
• 22:33responses to self report surveys
• 22:36where sometimes individuals are willing
• 22:38to acknowledge,
• 22:39substance use, for example, to
• 22:41a survey wherein they may
• 22:43not be willing to do
• 22:43this face to face with
• 22:44a clinician.
• 22:46We also have a a
• 22:47a new scale we piloted
• 22:49to assess caregiver burden that's
• 22:50directed family members
• 22:52to try to understand whether
• 22:53the clinic's efforts are helping
• 22:55to reduce that as well.
• 22:57So
• 22:58I think this is my
• 22:59last slide, and I'm I'm
• 23:00happy to, maybe take questions
• 23:02in the end. But if
• 23:02there are questions now as
• 23:03well, feel free to to
• 23:05speak up.
• 23:07Laura, this is you.
• 23:09Great. Thank you so much,
• 23:11doctor Shrieri.
• 23:16So now that, we've really
• 23:18spoken about the assessment and
• 23:20and evaluation piece, remember module
• 23:22b has a a couple
• 23:24different goals going on. We're
• 23:25we're simultaneously
• 23:27evaluating and learning
• 23:29as much as we can
• 23:30as quickly as we can
• 23:31about the individuals coming into
• 23:33the clinic.
• 23:35But at the same time,
• 23:35we're initiating treatment and offering
• 23:37help,
• 23:39with some goals that are
• 23:40outlined here. So,
• 23:41again, a lot of different
• 23:43things to be,
• 23:44to be holding on to
• 23:46and throughout treatment, but also
• 23:47in this early stage.
• 23:49And some of them listed
• 23:50here, we don't need to
• 23:51go through all of them.
• 23:52But but as I mentioned,
• 23:53trying to gain an understanding
• 23:55of the person and their
• 23:56situation
• 23:57as quickly as we can.
• 23:59We do that from, you
• 24:00know,
• 24:01meeting with them, pulling from
• 24:02different sources,
• 24:04as Vinod mentioned.
• 24:06A really key aspect of
• 24:07this
• 24:08acute slash engagement phase,
• 24:12would be in trying to
• 24:13ensure safety.
• 24:14We know the we've previously
• 24:15spoken about the increased risk,
• 24:18during that critical period,
• 24:20and it can persist into
• 24:21to the initiation of treatment.
• 24:23So a real focus on
• 24:25risk mitigation. So reducing the
• 24:27risk of suicide and violence,
• 24:29and focusing on that both
• 24:31with work with the individual
• 24:33and with family or other
• 24:35supportive context is a is
• 24:36a key aspect of this.
• 24:39We'll certainly
• 24:40wanna be doing our best
• 24:42to, be reducing the delay
• 24:44to effective treatment.
• 24:45And so,
• 24:47as we know, pharmacotherapy
• 24:48is a first line treatment,
• 24:50for primary psychotic disorders. So
• 24:53as we had talked about
• 24:54previously and kinda what's entailed
• 24:56in some of the the
• 24:58care pathway, it it is
• 24:59essential that,
• 25:00a prescriber is, you know,
• 25:02present very early on in
• 25:03treatment and that there's not
• 25:04a big delay to being
• 25:06able to meet with a
• 25:06prescriber.
• 25:08Of course, not every individual,
• 25:12will
• 25:12will there be implications
• 25:14for antipsychotic medication nor will
• 25:16they make the choice,
• 25:18to to utilize them. But
• 25:20it it's important that the
• 25:22the multidisciplinary
• 25:23team kind of is present
• 25:24and,
• 25:25both the primary clinician
• 25:27and
• 25:28a per provider are meeting
• 25:30with, the individual,
• 25:32early on and as quickly
• 25:33as possible in the beginning
• 25:35of treatment.
• 25:37Certainly, as with any therapeutic
• 25:39relationship and an engagement phase,
• 25:42really working on alliance building
• 25:44and engagement, which I'll talk
• 25:45about some more specific strategies
• 25:47on the next couple slides.
• 25:50We wanna,
• 25:51be finding ways to identify
• 25:52treatment goals and align with
• 25:54the young person
• 25:55and the family. A lot
• 25:56of times, there's there's quite
• 25:57a bit of treatment ambivalence
• 25:59with young young folks in
• 26:01general and then folks experiencing,
• 26:04symptoms of psychosis. It's it's
• 26:05not uncommon that,
• 26:07there is that treatment ambivalence
• 26:09or lack of
• 26:11illness awareness that,
• 26:13might make it difficult to
• 26:14for them to engage actively,
• 26:17in a clinic like Step.
• 26:20Another
• 26:21important piece,
• 26:23of this early engagement is
• 26:24is really
• 26:26mobilizing and empowering the family
• 26:27or the support system if
• 26:29the young person is agreeable
• 26:30to that. So I know
• 26:32we discussed
• 26:33a bit more in detail
• 26:34what the family support and
• 26:36education element of care looks
• 26:38like. But again, this is
• 26:39really important to also try
• 26:41to do early on.
• 26:42And
• 26:43it can look a lot
• 26:44of different ways, but at
• 26:45minimum,
• 26:46someone from the clinic kind
• 26:47of connecting
• 26:49with the identified family or
• 26:50support people,
• 26:52orienting them to care,
• 26:54helping them with, partner with
• 26:56you in that mitigation of
• 26:57risk,
• 26:59by,
• 27:00informing them of just, you
• 27:01know, practical strategies of when
• 27:03to initiate emergency services,
• 27:05what type of collateral and
• 27:07information is helpful to report
• 27:09to the clinical team, and
• 27:11how they can do that,
• 27:12how they can reach you,
• 27:14who they can reach after
• 27:15hours.
• 27:16So a lot of different
• 27:17elements.
• 27:18And then it can lead
• 27:19into the kind of more
• 27:20sustained treatment where you're you're
• 27:22teaching skills and problem solving
• 27:24and other communication strategies with
• 27:26the family. But we really
• 27:28view them as,
• 27:29and, you know, when I
• 27:30say family, I mean that
• 27:31broadly, whoever is a supportive
• 27:32person to the young person,
• 27:35but really view them as
• 27:36key team members,
• 27:38in in engagement and throughout
• 27:40treatment.
• 27:42So on the next slide,
• 27:44we'll talk a little bit
• 27:45more about
• 27:46just engagement.
• 27:48So
• 27:49I go a little bit
• 27:50more in-depth here, but
• 27:51what is engagement? Right? There's
• 27:53there's not really a consensus,
• 27:55in the early intervention
• 27:57field or,
• 27:59in the kind of therapy
• 28:00field in general. So there's
• 28:01a lot of different ways
• 28:02that one might measure it.
• 28:04Sometimes it's just,
• 28:06measured by frequency, clinical attendance,
• 28:08or actual contact,
• 28:11treatment adherence. Is this person
• 28:14engaged, and are they taking
• 28:15their prescribed medications?
• 28:17Are they meeting, the duration
• 28:19of the treatment recommendation?
• 28:21Sometimes there's a bit more
• 28:22higher level assessment of engagement
• 28:24as their
• 28:25treatment acceptance,
• 28:27or recognition of a need
• 28:29for help,
• 28:31or it needs to be
• 28:31addressed.
• 28:32Sometimes this can be measured
• 28:34by,
• 28:35different types of ratings about
• 28:37strength of the therapeutic alliance
• 28:39or
• 28:40overall kind of consumer or
• 28:42client satisfaction.
• 28:43So a lot of different
• 28:44ways to think about this
• 28:46complex phenomenon.
• 28:48At step, we we also
• 28:49we kinda look at it
• 28:50a lot of different ways.
• 28:51We do do at minimum
• 28:53the the utilization kinda way,
• 28:55like, have we been in
• 28:56contact with this person? But
• 28:57it certainly goes beyond that.
• 28:59Like, is this person,
• 29:01you know, kind of invested,
• 29:02willingly engaged?
• 29:04How are we connecting with
• 29:05them?
• 29:06So on the next slide,
• 29:09talk a little bit about,
• 29:11you know, the flip side
• 29:12of engagement and this,
• 29:14this this pretty big problem
• 29:16of disengagement.
• 29:17And so in early intervention
• 29:20programs,
• 29:21disengagement
• 29:22rates are pretty wide ranging
• 29:24here. So you can see
• 29:25that range from twelve to
• 29:26fifty three percent.
• 29:28I think a lot of,
• 29:30a lot of times we're
• 29:30we're sitting around thirty percent.
• 29:32I'm not sure what step
• 29:33is is currently at,
• 29:37or on the lower end
• 29:38of of that range. But,
• 29:40it's it's certainly a pervasive
• 29:42problem in early psychosis and
• 29:44early intervention programs.
• 29:47What a recent meta analysis
• 29:48has showed is that,
• 29:50there's certain factors that we
• 29:52know that can predict
• 29:54a higher level of disengagement.
• 29:56And so it's helpful to
• 29:58look out for those and
• 29:59to be aware, especially if
• 30:00you're engaging with someone early
• 30:02on and you notice that
• 30:03they might have some of
• 30:04these characteristics
• 30:06or be in some of
• 30:07these contexts that it might
• 30:08it might involve
• 30:10more or different types of
• 30:11engagement efforts. So some of
• 30:13the known factors predicting
• 30:14disengagement is a lack of
• 30:16family support.
• 30:17So all the more reason,
• 30:19if we can, to kind
• 30:20of,
• 30:22mobilize and empower,
• 30:24family or support person involvement.
• 30:27But, again, they can be
• 30:27helpful in a a variety
• 30:29of ways, emotionally, financially, but
• 30:31also really just practically
• 30:33helping a young person get
• 30:35to an appointment, helping remind
• 30:37them if there's any organizational
• 30:39time management
• 30:41difficulties or
• 30:42sometimes that nudge when there's
• 30:44ambivalence
• 30:45is enough to kinda keep
• 30:46someone engaged.
• 30:48We know that
• 30:50higher substance use as well
• 30:52as living alone, again, so
• 30:54there
• 30:55be potentially less less family
• 30:57involvement with someone living alone,
• 30:59when there's lower medication adherence,
• 31:02And then a variety of
• 31:03social determinants of mental health,
• 31:05such as homelessness
• 31:06can, lead to
• 31:08increased disengagement rates. So,
• 31:10you know, there can be
• 31:11a variety of although these
• 31:13present
• 31:14quite a bit of challenges,
• 31:16recognizing the importance of some
• 31:17of those social determinants of
• 31:19health and doing whatever you
• 31:20can kind of case management
• 31:22or practically
• 31:23to try to support a
• 31:24person to help them be
• 31:26able to access,
• 31:28important treatment
• 31:29can be really can be
• 31:30really helpful and kind
• 31:33of supporting overall engagement.
• 31:35And so on the next
• 31:36couple of slides,
• 31:37I'm gonna talk about here
• 31:39some strategies, you know, that
• 31:41we use. And I'm sure,
• 31:42you know,
• 31:44these are familiar to to
• 31:45many people,
• 31:47working with this population or
• 31:49working as clinicians in general,
• 31:51but things that we found
• 31:52are particularly helpful for young
• 31:54folks
• 31:55and particularly helpful for folks
• 31:57experiencing,
• 31:58early psychosis.
• 31:59So right away, we wanna
• 32:01try to find some common
• 32:02ground. Right? And
• 32:04so orienting around shared goals,
• 32:08and also giving support right
• 32:10away. Like, establishing yourself as
• 32:12a potentially useful person
• 32:14or resource can be helpful.
• 32:15Sometimes that's
• 32:17I need a ride
• 32:18to the appointment or something
• 32:20and there's such a barrier
• 32:21or I need this paperwork
• 32:22filled out for my job
• 32:23and that's all I care
• 32:24about is that
• 32:25getting this this leave paperwork
• 32:27filled out for my job.
• 32:28And so
• 32:29prioritizing things, you know, that
• 32:31that are important
• 32:33to a young person in
• 32:34the family to the best
• 32:34of your ability can really
• 32:36help,
• 32:37with that therapeutic alliance, especially
• 32:39early on in aligning over
• 32:41shared goals.
• 32:43A lot of
• 32:44times,
• 32:45the
• 32:46you know, I would say
• 32:47the the minority minority of
• 32:49our folks kinda come in
• 32:51saying like, hi. I I'm
• 32:52experiencing psychosis. I think I
• 32:54have schizophrenia.
• 32:55Help me
• 32:56prevent that from happening again.
• 32:58We certainly have folks who
• 33:00present like that in our
• 33:01clinic.
• 33:02And there's a a lot
• 33:03of heterogeneity as we've discussed.
• 33:05But a lot of times,
• 33:07we're orienting with folks around
• 33:08a shared goal of getting
• 33:10back on track.
• 33:12And that often
• 33:14means kind of, hey. This
• 33:15is
• 33:16whatever has happened to me,
• 33:17this stress, this hospitalization
• 33:20has really gotten in the
• 33:21way of my school. I
• 33:22had to take a medical
• 33:23leave or I lost my
• 33:24job or
• 33:25my relationships are strained, and
• 33:27that's what I care about.
• 33:28Like, that's what you can
• 33:29help me with, doctor Sykes.
• 33:30And so aligning around that,
• 33:32finding what's important,
• 33:34and trying to find that
• 33:35common ground of courses,
• 33:37can be very helpful and
• 33:38really helpful with,
• 33:40early engagement report building and
• 33:42and finding ways to kinda
• 33:43get at the underlying causes
• 33:45potentially of those disruptions in
• 33:47social and role functioning, which
• 33:48very well may be,
• 33:50symptoms of psychosis.
• 33:53You can also get some
• 33:54you know, we we wanna
• 33:55be helpful early on. We
• 33:56we wanna help our folks,
• 33:57but and so sometimes getting
• 33:59relief,
• 34:00from distressing symptoms early on,
• 34:02sometimes someone will be like,
• 34:03I just I can't sleep
• 34:04or I'm so stressed out.
• 34:06And so sometimes there's a
• 34:07a medication or a distress
• 34:09tolerance coping skill that you
• 34:10can offer right away
• 34:12that can give someone some
• 34:14some quick relief,
• 34:16and again, can support kind
• 34:17of buy in with treatment
• 34:19in an ongoing way.
• 34:21We certainly find it helpful
• 34:22to go slow.
• 34:24Again, everyone's presenting
• 34:26differently,
• 34:28but we certainly were in
• 34:30this engagement phase for with
• 34:31some of our folks for
• 34:32for quite a while. And
• 34:33it it can take a
• 34:34while to, for folks to
• 34:36kinda build build trust, feel
• 34:37comfortable disclosing information about their
• 34:40symptoms and experiences or what's
• 34:42going on.
• 34:43There might be fear of
• 34:45being rehospitalized
• 34:46if someone had previously had
• 34:48a a hospital admission.
• 34:51So a lot of different
• 34:52things to consider and a
• 34:53lot of kind of this
• 34:54this therapeutic dance of,
• 34:56you know, maybe testing something
• 34:58out, seeing how it lands.
• 34:59And if you need to
• 35:00retreat, you retreat. If you
• 35:01feel like you can kinda
• 35:02keep pushing forward and and
• 35:03pursuing a topic,
• 35:05you can do that.
• 35:07Another, you know, important just
• 35:09practical aspect of working
• 35:12with, young folks with early
• 35:13psychosis or young folks in
• 35:15general,
• 35:16I think, is being able
• 35:18to be flexible,
• 35:19to the extent that your
• 35:20clinic or organization can be
• 35:22flexible of
• 35:23you know, with rescheduling
• 35:25things and not necessarily having,
• 35:26like, a
• 35:28a three no show and
• 35:29you're out policy or,
• 35:31you know, being able to
• 35:32be assertive with your reminders
• 35:34and engagement. We find all
• 35:35of those things really helpful,
• 35:37and we find that
• 35:38having access to a clinic
• 35:40cell phone and a way
• 35:41to text young people is
• 35:43an essential piece,
• 35:44of this type of engagement.
• 35:45Most of our folks don't
• 35:46wanna answer the phone or
• 35:48listen to voice mails, and
• 35:49so kind of checking in,
• 35:51not not tons of clinical
• 35:52information, but but trying to
• 35:54engage and remind folks via
• 35:55text seems to be a
• 35:56really helpful strategy.
• 35:58And then, of course, throughout
• 36:00all of this, you're using
• 36:00your, you know, therapeutic
• 36:03skills of,
• 36:05that are central to a
• 36:06lot of different evidence based
• 36:08psychotherapies
• 36:09including CBT for psychosis where
• 36:11you're you're aiming to be
• 36:12normalizing and curious in your
• 36:14interactions,
• 36:15withholding judgment,
• 36:16really trying to understand
• 36:19what how the young person
• 36:20and family are understanding what
• 36:22is going on for them
• 36:23and trying to come to
• 36:24a shared understanding.
• 36:25And in that, you're, especially
• 36:27if someone's experiencing active
• 36:30delusional beliefs
• 36:31or hallucinations or other positive
• 36:33symptoms,
• 36:34remembering not to,
• 36:36be confrontational about that or
• 36:38necessarily directly challenging that.
• 36:41You can, you know, validate
• 36:43and and help someone understand
• 36:45that you're not, you know,
• 36:46scared by their experiences when
• 36:47they do disclose,
• 36:49and in fact that you've
• 36:50you've heard many people
• 36:52talk about similar things before.
• 36:53All of those things can
• 36:54really help,
• 36:56with the relationship.
• 36:57And then a little bit
• 36:59more on the next slide.
• 37:03So there's there's actually a,
• 37:06a term for this called
• 37:08befriending,
• 37:09A strategy a kind of
• 37:10therapeutic strategy for engagement,
• 37:12which,
• 37:13sometimes we have to use
• 37:14varying amounts of. As I
• 37:15mentioned, a lot of heterogeneity
• 37:17in this population,
• 37:19sometimes folks need a lot
• 37:20of engagement in befriending, and
• 37:22sometimes other folks can kinda
• 37:24really skip
• 37:25right ahead to
• 37:26much more active,
• 37:29or more direct discussions of,
• 37:31their symptoms and and therapeutic
• 37:33content.
• 37:35But with without going into
• 37:36too much detail, befriending is
• 37:37is basically what it sounds
• 37:39like. We're using
• 37:41strategies to kind of get
• 37:42to know the person, but
• 37:44talk about safe topics.
• 37:46So here, if you're you're
• 37:47noticing someone is particularly guarded.
• 37:49Right? So maybe you suspect
• 37:50that they're
• 37:51experiencing some active paranoia or
• 37:53active symptoms or internal preoccupation
• 37:56that might be impacting their
• 37:58presentation in the room with
• 37:59you or their ability to
• 38:00trust a provider or maybe
• 38:02they had a
• 38:03a traumatic involuntary hospitalization.
• 38:06Just just so many factors
• 38:08that can add to the
• 38:09already,
• 38:11the the preexisting challenges that
• 38:13might that folks might experience
• 38:15when interacting with a mental
• 38:16health provider. So if you
• 38:18notice you're kinda getting a
• 38:19lot of resistance,
• 38:20really engaging and spending some
• 38:22time in a befriending state,
• 38:24where you're
• 38:26you're getting to know them,
• 38:27you're getting to know their
• 38:28interest, trying to set positive
• 38:29memories. Maybe you switch up
• 38:31what the therapy is looking
• 38:32like. You might
• 38:35name of cards,
• 38:36have some type of other
• 38:37shared experience
• 38:39together. We've, you know, we've
• 38:40done a lot of different
• 38:41things over the years. A
• 38:42little bit has changed since
• 38:44of the initiation of some
• 38:46of the hybrid model with
• 38:47telehealth, but, you know, going
• 38:49for walks with with patients
• 38:51or finding other ways,
• 38:52to help folks feel more
• 38:54comfortable,
• 38:55can be really important, especially
• 38:57if there's, a lot of
• 38:58treatment ambivalence.
• 38:59And just, of course, again,
• 39:01keeping in mind that
• 39:03many folks with experiencing a
• 39:05first episode of psychosis
• 39:07may have had a period
• 39:09of social withdrawal,
• 39:11prior to this,
• 39:12and they may not have
• 39:13shared information about these symptoms
• 39:15with anyone.
• 39:16Or as I mentioned, they
• 39:17might be experiencing active
• 39:19positive symptoms,
• 39:20that might be contributing to
• 39:22their distrust
• 39:23of a therapist.
• 39:24So,
• 39:25just, you know, taking your
• 39:26time to kinda get to
• 39:27know them.
• 39:28Doesn't mean that you can't
• 39:30ask directly about symptoms. And
• 39:31as I mentioned, an important,
• 39:35goal is always that risk
• 39:36mitigation and assessing safety. So
• 39:38we're we're still asking those
• 39:39questions, but we're also supported
• 39:41by the multidisciplinary
• 39:43team where perhaps,
• 39:44you know,
• 39:46if it's implicated, the
• 39:48the prescriber or other team
• 39:50one team member might step
• 39:51in and ask some more
• 39:52of these questions.
• 39:53As doctor Shrihari mentioned, having,
• 39:56folks conduct regular assessments
• 39:59such as the pans or
• 40:00other things
• 40:01might get at symptoms that
• 40:03are not being disclosed in
• 40:04the therapy session.
• 40:07But you're still getting that
• 40:09information, able to kind of
• 40:10put it all together as
• 40:11the team while,
• 40:12kind of preserving the the
• 40:14therapeutic alliance and,
• 40:16making sure that we're not
• 40:17missing anything.
• 40:20So I believe that is
• 40:21all we have for plan
• 40:23slides.