STEP LC - Overview of EIS for Schizophrenia - Session 1

Transcript

• 00:03Alright. So welcome, everyone, to
• 00:05the step learning collaborative's
• 00:07overview of
• 00:09early intervention services for schizophrenia
• 00:11course.
• 00:13We're so glad to have
• 00:14so many of you joining
• 00:15us.
• 00:17We wanted to start with
• 00:18some introductions.
• 00:21For those of you who
• 00:22I haven't met before, my
• 00:23name is Laura Yauveen Sykes.
• 00:25Professionally,
• 00:26I'm a clinical psychologist
• 00:28at the STEP program,
• 00:30and I'm also the director
• 00:31of our STEP learning collaborative.
• 00:33And then personally, I'm a
• 00:35family member of someone experiencing
• 00:37schizophrenia.
• 00:39And I'm so excited to
• 00:40be joined today and throughout
• 00:42the rest of the course,
• 00:43by doctor Vinod Srihari,
• 00:46a professor at the Yale
• 00:48School of Medicine in the
• 00:49department of psychiatry.
• 00:51He's the director,
• 00:53founder, and also a practicing
• 00:54psychiatrist
• 00:56at the STEP program and
• 00:57overall kind of visionary for
• 00:59our statewide for our hopes
• 01:00of a a statewide network
• 01:02of care.
• 01:03We're
• 01:05really excited to be joined
• 01:07by so many leaders,
• 01:09managers, and mental health, practitioners
• 01:11who are invested in the
• 01:12well-being
• 01:13of young people with recent
• 01:15onset psychotic disorders.
• 01:17So we're really eager and
• 01:19excited to get to know
• 01:20all of you better and
• 01:21build ongoing relationships with you.
• 01:24For the interest of time,
• 01:26we ask that everyone introduce
• 01:27themselves
• 01:28in the chat. Feel free
• 01:30to just type in your
• 01:31name,
• 01:32organization,
• 01:34and the role that you
• 01:35hold.
• 01:44So I'll take a couple
• 01:45minutes to just orient everyone
• 01:47to the course,
• 01:48before we get into the
• 01:50bulk of the content for
• 01:51today.
• 01:52So, again, this is our
• 01:54overview of early intervention services
• 01:56for schizophrenia,
• 01:59six week course.
• 02:00Here's the the overview of
• 02:02our next six sessions,
• 02:04which will be held on,
• 02:06upcoming Thursdays.
• 02:09We hope that,
• 02:11after participating, you all will
• 02:13leave with a foundation,
• 02:15a foundational knowledge in the
• 02:16research,
• 02:17evidence,
• 02:18and a clear understanding of
• 02:20the structures,
• 02:21processes, and outcomes that can
• 02:23guide,
• 02:24implementation
• 02:25of
• 02:26steps for early intervention service
• 02:28care pathway.
• 02:30We hope that this will
• 02:31enable you all to prepare
• 02:32your respective health care organizations
• 02:35to be able to participate
• 02:36in an emerging statewide system
• 02:38of care for individuals experiencing
• 02:41recent onset psychotic disorders.
• 02:45For those
• 02:46looking for additional information, you
• 02:48can find,
• 02:49a bit more in that
• 02:50course syllabus that Nina sent
• 02:52out to you all yesterday,
• 02:53and I'm also happy to
• 02:55to resend that in a
• 02:56a subsequent email.
• 03:01So before we dive into
• 03:02today's content,
• 03:03I wanted to take a
• 03:04moment to just orient you
• 03:06to the step learning collaborative.
• 03:08So for those of you
• 03:09who, haven't been familiar with
• 03:11this initiative,
• 03:13it's a workforce development and
• 03:15community education initiative
• 03:17to bolster provider capacity,
• 03:20to better serve folks, who
• 03:21are experiencing recent onset schizophrenia
• 03:24spectrum disorders across of our
• 03:26state of Connecticut.
• 03:28So
• 03:29when there's the overall goal
• 03:31and vision, which doctor Sriheri
• 03:33will talk about in more
• 03:34depth, but that we we
• 03:36imagine,
• 03:37we have an end goal
• 03:38of no matter which ZIP
• 03:40code an individual experiencing
• 03:43psychosis lives in, that they'd
• 03:44be able to rapidly
• 03:46access high quality care in
• 03:48our state of Connecticut.
• 03:50So over the past several
• 03:52years, the learning collaborative has
• 03:54provided various offerings,
• 03:56to different stakeholder groups.
• 03:58We have had a focus,
• 04:00for behavioral health providers.
• 04:02We've been developing this course
• 04:04that we're offering to you
• 04:05now.
• 04:06We've previously run,
• 04:08an early psychosis echo, which
• 04:10was focused on
• 04:12providers across the state bringing
• 04:13in different case discussions
• 04:15as well as,
• 04:17step kind of content experts
• 04:18offering brief didactics about best
• 04:21practices for early psychosis care.
• 04:24We periodically offer webinars
• 04:27for providers.
• 04:28And then we also,
• 04:30aim to serve and engage
• 04:32with the community and various
• 04:34stakeholders, so including
• 04:36family,
• 04:37and just other interested community
• 04:39stakeholders
• 04:39through different types of workshops,
• 04:41including,
• 04:42you know, learning strategies for
• 04:44talking with someone experiencing early
• 04:46psychosis,
• 04:48seminars to help kinda break
• 04:50the stigma or learn how
• 04:51to interact with mobile crisis
• 04:53teams during
• 04:55a crisis situation.
• 04:57And then we also maintain
• 04:58a variety of virtual resources
• 05:00and encourage you all to
• 05:02to check out our website
• 05:03if you haven't already at
• 05:04ctearlypsychosisnetwork
• 05:06dot org.
• 05:12So,
• 05:13this slide, which we hope
• 05:14you'll get become very well
• 05:16acquainted with over the next
• 05:18six weeks,
• 05:21this overview course is organized
• 05:23around the step service care
• 05:24pathway, which you can see
• 05:26outlined here.
• 05:28So each session well, today's
• 05:30kind of an, you know,
• 05:31introduction and overview, but each
• 05:32subsequent session will focus on
• 05:34one of these modules,
• 05:36that make up the step
• 05:38service care pathway.
• 05:40And as a reminder,
• 05:41the goal of the overview
• 05:42course would really be to
• 05:44support your understanding
• 05:45of the structures,
• 05:47processes, and outcomes that can
• 05:48guide implementation
• 05:50of such a care pathway.
• 05:54So we will talk about
• 05:55each of these. They include
• 05:56early detection,
• 05:58evaluation
• 05:59and initiation of treatment,
• 06:02continuing care
• 06:04in coordinated specialty care,
• 06:06and then lastly, care transition.
• 06:08So you can see that
• 06:09the most of the the
• 06:11sessions will align with one
• 06:12of these modules.
• 06:15So now I will hand
• 06:16it over to doctor Srihari
• 06:18who will lead us on
• 06:19an introduction to early intervention
• 06:21for schizophrenia in Connecticut.
• 06:26Thanks, Laura, and thanks everyone
• 06:28for putting in your names
• 06:30and roles on the chat.
• 06:31It's really great to see
• 06:32the diversity of expertise and
• 06:34also the different regions of
• 06:36the state that are represented.
• 06:39My task here is to
• 06:40cover some key concepts by
• 06:42way of introducing
• 06:44the rest of the sessions.
• 06:46And
• 06:48my goal here by the
• 06:49end of this session is
• 06:50to give you a sense
• 06:52of how we've constructed
• 06:54and
• 06:55tested the model of care
• 06:57that we've been providing at
• 06:58STEP.
• 06:59And as Laura mentioned, to
• 07:00help you think about ways
• 07:02in which this this might
• 07:03be relevant
• 07:04or which aspects of this
• 07:06might be relevant to your
• 07:07own organizations
• 07:09as we start thinking about
• 07:11partnering with, agencies across the
• 07:13state to improve,
• 07:15pathways to care and outcomes
• 07:17of treatment for early course
• 07:20schizophrenia.
• 07:21We can go to the
• 07:22next slide.
• 07:27So,
• 07:28as a as a review
• 07:31to describe maybe what our
• 07:33target illnesses
• 07:34are, we're speaking here about,
• 07:37syndromes.
• 07:38So these include
• 07:40subjective
• 07:41symptoms, but also signs that
• 07:43can be observed
• 07:44that typically fall into five
• 07:46clusters. The first that are
• 07:47often the most familiar
• 07:49even to non clinicians are
• 07:51the so called positive symptoms
• 07:52that sometimes get referred to
• 07:54as psychosis or psychotic symptoms.
• 07:56The reality distortion, delusions, hallucinations,
• 08:00and the kinds of disorganization
• 08:02that can be very evident
• 08:04even to
• 08:05an untrained,
• 08:06eye. So these are the
• 08:07positive symptoms.
• 08:09In the next slide,
• 08:11you will see a description
• 08:13here of the negative symptoms,
• 08:16maybe better described as
• 08:18signs that can be observed
• 08:20again that are an absence
• 08:22of what we would all
• 08:23count on as normal functioning.
• 08:25So a severe lack of
• 08:27motivation,
• 08:29lack of spontaneous speech. In
• 08:31many ways, the most disabling
• 08:33aspects of these illnesses,
• 08:35that can explain,
• 08:37long term dysfunction and morbidity.
• 08:40Interestingly,
• 08:41these symptoms
• 08:43or signs
• 08:45can,
• 08:46include a normal ability to
• 08:48enjoy pleasure,
• 08:50but
• 08:51do not,
• 08:52include an ability to anticipate
• 08:54or to plan ahead for
• 08:55this. And it often will
• 08:57present with someone whose parents
• 08:59might complain that the person
• 09:01is quite willing to join
• 09:02them in a recreational activity
• 09:04and appears to enjoy it,
• 09:05but will not initiate or
• 09:07or demonstrate any motivation to
• 09:10organize or plan it themselves.
• 09:11And you might imagine how
• 09:13this can be a huge
• 09:14source of social disability in
• 09:16a young adult,
• 09:17who is expected to be
• 09:19able to form their own
• 09:20social networks at that age.
• 09:22The next slide describes a
• 09:24couple of other at clusters
• 09:26that are less well
• 09:28appreciated.
• 09:30So the cognitive deficits,
• 09:32of these illnesses can be
• 09:33quite disabling as well,
• 09:35but are often subclinical.
• 09:37They're difficult to observe in
• 09:38usual clinical interactions,
• 09:40although they are, easily
• 09:42measurable in more detailed neuropsychological
• 09:45testing.
• 09:46And, again, like negative symptoms,
• 09:49explain much of the long
• 09:50term disability of these illnesses.
• 09:53And finally, the clusters that
• 09:55overlap significantly with mood disorders
• 09:58include
• 09:59dysregulations
• 10:00that look like depression and
• 10:01can also look like florid
• 10:03mania. And so in in
• 10:05these five clusters,
• 10:07I've described to you, a
• 10:08syndromal picture that is, I'm
• 10:10sure, familiar to to many
• 10:11of you
• 10:13that probably includes several different
• 10:15diseases that we currently
• 10:17today cluster as schizophrenia or
• 10:19the schizophrenias.
• 10:21I think the next slide,
• 10:23will will describe how we
• 10:25currently classify this in the
• 10:27DSM five. And,
• 10:31one,
• 10:32psychiatrist has described this as
• 10:33a field guide much like
• 10:36a a book that has
• 10:37pictures of birds that if
• 10:39one were to enter a
• 10:40forest, one could reliably identify
• 10:42and name them.
• 10:44And the point here, of
• 10:45course, is that they're quite
• 10:46reliable in that it helps
• 10:48us have a common language
• 10:49to describe,
• 10:51aspects of the syndromes.
• 10:53But, there has been,
• 10:55lately, a lot of good
• 10:57criticism that this might not
• 10:59quite carve things in the
• 11:00way that we would want
• 11:01to.
• 11:02So,
• 11:04we still find the distinction,
• 11:05though, between the non affective
• 11:07psychotic disorders that I'll now
• 11:09refer to as the schizophrenia
• 11:11from the affect of psychosis.
• 11:12And these are primary mood
• 11:14disorders
• 11:15that may also have
• 11:16positive symptoms or psychotic symptoms
• 11:19as part of their course.
• 11:20In our care model and
• 11:22in the evidence that that
• 11:24follows,
• 11:25I will mostly
• 11:27be referring actually exclusively to
• 11:29the non affective psychotic disorders
• 11:30or the schizophrenias.
• 11:32Next slide.
• 11:35Another feature to keep in
• 11:37mind is there
• 11:38that these are illnesses that
• 11:40typically onset in late adolescence
• 11:42or early adulthood.
• 11:44There is a difference between
• 11:46the genders,
• 11:47and,
• 11:49there there has been some
• 11:51evidence that there may be
• 11:52another spike in the onset
• 11:54of of psychosis
• 11:56around the perimenopausal
• 11:57period in females, although this
• 11:59has come under some,
• 12:01critique as well. But the
• 12:03main point here is that
• 12:04this emerges at a time
• 12:06for most people between their
• 12:08late teens and early twenties.
• 12:10That is a particularly vulnerable
• 12:12period for
• 12:13development in general in a
• 12:15time when people are leaving
• 12:16home for college,
• 12:19or beginning relationships
• 12:21or beginning jobs. And so
• 12:23these illnesses can be uniquely
• 12:25disruptive because of the time
• 12:26at which they tend to
• 12:27emerge. Next slide.
• 12:31Oh,
• 12:32yeah. We you can,
• 12:34this is to make the
• 12:35the point I was trying
• 12:36to make earlier, which is,
• 12:38more recent studies that are
• 12:40depicted on top right suggests
• 12:42that
• 12:43the incidence
• 12:45in females
• 12:46might actually be spread out
• 12:47a lot more than previously
• 12:49recognized.
• 12:50And the other,
• 12:51fact that's emerging is that
• 12:53most,
• 12:54early intervention clinics like ours
• 12:56should expect to see a
• 12:57preponderance of males and just
• 12:59because of the nature of
• 13:01the age of onset of
• 13:03these illnesses.
• 13:05Next
• 13:06slide.
• 13:08So,
• 13:10although there are,
• 13:12concerns about the way we
• 13:14categorize these illnesses,
• 13:16the category of the schizophrenia
• 13:17is still very useful. And
• 13:19in some ways, the slide
• 13:20describes,
• 13:21why.
• 13:23We know a lot about
• 13:24this cluster of syndromes, which
• 13:26is that they tend to
• 13:27have a period,
• 13:29of what we call the
• 13:31premorbid period where there are
• 13:32no discernible symptoms or signs
• 13:35of any illness.
• 13:37So unlike disorders of very
• 13:39early neurodevelopment
• 13:40like autism where typically a
• 13:42clinical diagnosis can be made
• 13:44before the age of four
• 13:45or five and sometimes sooner,
• 13:48the early period,
• 13:50in individuals who will go
• 13:51on to have schizophrenia tends
• 13:52to be remarkable for being
• 13:55without any evidence of abnormalities
• 13:57that are at least detectable
• 13:59with our current, instruments.
• 14:01But for most individuals who
• 14:02end up with a psychotic
• 14:04episode that's in the slide
• 14:06marked as a first episode,
• 14:08there is a period prior
• 14:09to that of the so
• 14:10called prodrome,
• 14:12which is sometimes difficult to
• 14:13distinguish from the
• 14:15challenges of normal development at
• 14:17the time and becomes clear
• 14:19often only in retrospect when
• 14:21family members will say, well,
• 14:23actually, there was this time
• 14:24in middle school when and
• 14:26so on. So
• 14:27this is an active area
• 14:28of research to try to
• 14:30disentangle
• 14:31normal development from what is
• 14:33actually a high risk period
• 14:35for psychosis.
• 14:36But at the first episode
• 14:37is when it becomes,
• 14:40apparent and clear and clinically,
• 14:43reliable
• 14:44or or which is to
• 14:45say that clinicians can reliably
• 14:47detect the presence of an
• 14:49illness, that will benefit from
• 14:51treatment.
• 14:52Unfortunately, what follows after that
• 14:54is the jagged yellow line
• 14:56for most patients, and that's
• 14:58meant to signify
• 14:59repeated relapses,
• 15:01often rehospitalizations,
• 15:03periods when individuals are in
• 15:05and then out and then
• 15:06in and then out of
• 15:08care. And over those first
• 15:09three to five periods, which
• 15:11is called the critical period,
• 15:13most of the decline in
• 15:15functioning begins to accumulate.
• 15:17It is a time when
• 15:19individuals will often lose
• 15:21various forms of connection to
• 15:23their community. They might drop
• 15:25out of high school or
• 15:26college. They might lose an
• 15:27important relationship.
• 15:29They might lose their jobs.
• 15:31They may even become homeless.
• 15:33They may become entangled with
• 15:35the criminal justice system. And
• 15:36it's also a period that's
• 15:38at that's of highest risk
• 15:40for suicide,
• 15:42which is much higher than
• 15:43the risk for any kind
• 15:44of aggression, although it is
• 15:46also a period of highest
• 15:47risk for aggression against others.
• 15:50It's also a period when
• 15:51substance use might emerge as
• 15:53a comorbidity.
• 15:54And so this period has,
• 15:57brought a lot of interest
• 15:59from investigators
• 16:00for several decades now as
• 16:02an opportunity
• 16:04appeared in which
• 16:05if we could organize our
• 16:07interventions and deliver them in
• 16:08a way that's acceptable to
• 16:10young individuals,
• 16:11we might prevent much of
• 16:13the morbidity that accumulates over
• 16:14these first three to five
• 16:15years,
• 16:17which would mean that the
• 16:18plateau, which is the the
• 16:20right end of the yellow
• 16:21line where people usually end
• 16:23up, might be lifted and
• 16:25higher, ideally close to where
• 16:27the premorbid line is, but
• 16:28much higher than it is
• 16:29today.
• 16:31And substantially, this is the
• 16:33goal of early intervention services
• 16:35now around the world to
• 16:37deliver,
• 16:38the best treatments we can,
• 16:40organized in the best way
• 16:41we can, and as rapidly
• 16:43as we can after the
• 16:44first episode
• 16:45to lift that plateau and
• 16:47avoid a lot of the
• 16:48unnecessary morbidity
• 16:50and even mortality during this
• 16:52early phase of the illness.
• 16:54So this is the effort
• 16:56to not just improve the
• 16:57quality of care during the
• 16:59critical period, but to also
• 17:00reduce the DUP or the
• 17:02duration of untreated psychosis. The
• 17:04time from psychosis onset to
• 17:06the initiation
• 17:07of,
• 17:08what we would all consider
• 17:09to be best practice care.
• 17:11The two white lines,
• 17:13a and c that you
• 17:15can see are meant to
• 17:16signify that there is heterogeneity.
• 17:18There are some individuals who
• 17:19have a first episode, and
• 17:20as far as we can
• 17:21tell, do not have another.
• 17:24And we don't know much
• 17:25about them because they tend
• 17:26to not accumulate
• 17:28around clinical sites and even
• 17:30research centers. But there is
• 17:32a small minority of individuals
• 17:34who may not require ongoing
• 17:36care, and we still don't
• 17:37know how to predict who
• 17:39those will be.
• 17:40And there is another small
• 17:42minority, eight to nine percent,
• 17:43certainly less than ten percent,
• 17:45who are refractory
• 17:47to our current treatments. And
• 17:49what I mean by that
• 17:50is that we don't yet
• 17:51have good enough treatments to
• 17:53improve their symptoms,
• 17:55and often their level of
• 17:56functioning,
• 17:57but are deserving of our
• 17:59care and are often the
• 18:00individuals who are overrepresented
• 18:03in,
• 18:04community mental health centers and
• 18:05chronic care centers
• 18:07and who require assistance with,
• 18:09activities of daily living, with
• 18:11housing, and so on.
• 18:14You can go to the
• 18:14next slide,
• 18:17Laura. Oh, I I think,
• 18:18this just rehearses what I
• 18:19already said. So,
• 18:22we can go to the
• 18:23next slide.
• 18:26This is to make the
• 18:27point again that there is
• 18:28a lot of prognostic heterogeneity,
• 18:30and, these are individuals
• 18:34on the left,
• 18:36Ellen Sachs, John Nash, and
• 18:37Cecilia who
• 18:39whether or not they had
• 18:40an illness are extraordinary individuals
• 18:42who happen to be afflicted
• 18:44with a psychotic illness and
• 18:45have, either written about it
• 18:47or presented about it in
• 18:49ways that have improved all
• 18:50of our understandings of this
• 18:51illness.
• 18:53And on the bottom right
• 18:54is just to make the
• 18:55point that that,
• 18:56old image of,
• 18:58Felix Garcia, this is a
• 19:00flamenco dancer who was a
• 19:01friend of the painter Picasso,
• 19:04reflects a,
• 19:05is not reflective really
• 19:08of the course of most
• 19:09people with schizophrenia.
• 19:11However, it still occupies
• 19:14much of the public imagination
• 19:15and media representations of psychosis.
• 19:18As I mentioned, it's less
• 19:19probably than ten percent of
• 19:20individuals
• 19:22who will not respond to
• 19:23currently available treatments.
• 19:26But all too often, there's
• 19:27a a nihilism
• 19:29about what is possible for
• 19:30these individuals.
• 19:32And it's why I've presented
• 19:33these pictures from a time
• 19:35when we had really no
• 19:37evidence based interventions for people
• 19:39with these illnesses, and that
• 19:40is not the case anymore.
• 19:42Next slide.
• 19:45This is just to make
• 19:46the point that in usual
• 19:47systems of care,
• 19:50the most recent review suggest
• 19:52that less than one third
• 19:53will recover, and the definition
• 19:56of recovery here was quite
• 19:57stringent. It was returning to
• 19:59their premorbid level of functioning.
• 20:01But if one were to
• 20:02expand the notion of recovery
• 20:04to include,
• 20:06living a meaningful life in
• 20:07the community, having work or
• 20:09school, family, and engagement,
• 20:11that number is actually considerably
• 20:13higher,
• 20:14but much depends on the
• 20:15quality of access and the
• 20:17quality of care provided in
• 20:18the critical period to be
• 20:20able to reach higher levels.
• 20:22These illnesses are very costly,
• 20:24And as many of us
• 20:26will probably intuitively understand,
• 20:29the initial costs are driven
• 20:31by so called direct health
• 20:32care costs, emergency room visits,
• 20:35inpatient hospitalizations.
• 20:37But in fact, over the
• 20:38life course, the largest source
• 20:40of costs are indirect, and
• 20:41these are
• 20:43the cost of losing someone
• 20:44to the labor market who's
• 20:45not able to contribute to
• 20:47the economy.
• 20:48The cost of family caregiving,
• 20:50for example, individuals who have
• 20:51to leave work,
• 20:53or work less in order
• 20:54to care for a young
• 20:55individual with a poorly, managed
• 20:57or poorly treated illness.
• 20:59And by way of comparison,
• 21:01since these numbers can seem
• 21:02quite abstract,
• 21:04far more common affective illnesses,
• 21:06including depressive disorders,
• 21:09are not much lot greater
• 21:11in terms of cost than
• 21:13schizophrenia spectrum disorders that are
• 21:15far less common. And it's
• 21:16just to make the point
• 21:17that these illnesses
• 21:19amongst the serious mental illnesses
• 21:21punch well above their weight
• 21:23in terms of the burden
• 21:24they exact on individuals,
• 21:26on families, and on society
• 21:27at large.
• 21:28And so it's well worth
• 21:30our efforts to improve the
• 21:32outcomes that we can get
• 21:33from
• 21:34delivering what we know works
• 21:36to individuals in a timely
• 21:38way that's also acceptable to
• 21:40them. And that's mostly what
• 21:41I'll be following up to
• 21:43present evidence on,
• 21:45going forward. So we can
• 21:46go to the next slide.
• 21:51So yes. So they're they're
• 21:52distressing. They're disabling. They're costly.
• 21:55This idea of thinking of
• 21:57them as chronic illnesses of
• 21:58the young, I find useful.
• 22:01Most chronic illnesses like diabetes,
• 22:03for example,
• 22:05and congestive heart disease,
• 22:09usually onset later on. These
• 22:11are illnesses of of late,
• 22:13and middle age.
• 22:16Serious mental illnesses of which
• 22:17psychotic disorders are are one
• 22:19are different in that they
• 22:20strike individuals at a time
• 22:22of otherwise peak physical health.
• 22:25But they are often chronic,
• 22:27and they require
• 22:29attention,
• 22:30not least because they're striking
• 22:32individuals who are usually not
• 22:34in medical care for other
• 22:36reasons. They're often,
• 22:38have have stopped seeing their
• 22:39pediatricians
• 22:40and are not yet seeing
• 22:42their internists,
• 22:44but in fact, do need
• 22:45attention for illnesses that if
• 22:46not treated well will result
• 22:48in chronic disability that rivals
• 22:51and sometimes exceeds many other
• 22:52chronic medical illnesses.
• 22:55So now we we can
• 22:56move on to talk about
• 22:57good news and the opportunities
• 22:58we have. We can go
• 22:59to the next slide.
• 23:01I I wanted to spend
• 23:02this introductory session,
• 23:05presenting some of the evidence,
• 23:07which
• 23:07I'm assuming many of you
• 23:09may already be familiar with.
• 23:11But I think it's useful
• 23:12to talk a little bit
• 23:12about why it is,
• 23:14we believe this care pathway
• 23:16that we've developed at step
• 23:18represents,
• 23:19good evidence for what might
• 23:21improve these outcomes and lift
• 23:22that platter over time.
• 23:24Next slide.
• 23:27So this is to, describe
• 23:29the current state of of
• 23:30practice in Connecticut.
• 23:32Some of you may know
• 23:33of the Prime Clinic, which
• 23:35is our sister clinic here
• 23:36at Yale and also based
• 23:38at CMHC like STEP, which
• 23:40is focused on this period
• 23:41before the onset of the
• 23:43first episode.
• 23:44And this is in the
• 23:45main, a very active and
• 23:47exciting research enterprise in which
• 23:49many of us are involved
• 23:51to both try and develop
• 23:53better ways to predict who
• 23:55will turn out to have
• 23:56a psychotic illness and then
• 23:57to find ways to intervene
• 23:59to either delay or prevent,
• 24:01the onset of these illnesses.
• 24:03This is obviously,
• 24:05these are these are not
• 24:06interventions that are are yet
• 24:08ready for implementation,
• 24:09But we hope in the
• 24:10future to be able to
• 24:12have evidence to be able
• 24:14to engage in this kind
• 24:15of preventative,
• 24:16initiative.
• 24:18The the current,
• 24:19state of the art in
• 24:20terms of delivery
• 24:21begins after the first episode
• 24:24where steps early intervention service
• 24:26seeks to both reduce delays
• 24:28and also improve
• 24:30the quality of care
• 24:32and thereby improve outcomes.
• 24:34And then, of course, we
• 24:35have many excellent,
• 24:38service providers for chronic psychosis
• 24:40care across the state.
• 24:43And based on on data
• 24:45published from around the world,
• 24:47it appears that under usual
• 24:48systems of care that do
• 24:50not have early intervention services,
• 24:53most individuals
• 24:54begin to really engage with
• 24:55regular outpatient care
• 24:58in in the period of
• 24:59a plateau all the way
• 25:00to the right. That is
• 25:01to say, after after a
• 25:03time in which they've already
• 25:05lost
• 25:06much of the psychosocial
• 25:07function,
• 25:09that in the usual course
• 25:10of care, they will begin
• 25:12to recover very, very slowly
• 25:14over time. So the usual
• 25:15course of these illnesses is
• 25:17actually one of recovery,
• 25:19not deterioration.
• 25:20However, the recovery,
• 25:22begins from much lower plateau
• 25:24and proceeds often very slowly,
• 25:26depriving many of these individuals
• 25:28of the highest level of
• 25:29functioning
• 25:30and the most,
• 25:32the highest quality of life
• 25:33and social engagement they could
• 25:34have had
• 25:36if they had been,
• 25:37given often
• 25:39substantially the same kinds of
• 25:40treatment earlier in the course
• 25:42of the illness. And we'll
• 25:43I'll say more about this,
• 25:45in the upcoming,
• 25:46slides.
• 25:49This is a a summary
• 25:51slide that I'll provide a
• 25:52little more detail on. But,
• 25:54the good news is that
• 25:56both early detection that is
• 25:58simply
• 25:59providing care earlier without necessarily
• 26:02enriching the care in any
• 26:03way has a durable effect
• 26:05on outcome that's measurable ten
• 26:07and even twenty years later.
• 26:09And this was based on
• 26:10a study done in Norway
• 26:12where,
• 26:13outpatient care that will be
• 26:14very recognizable to all of
• 26:16us was just delivered much,
• 26:17much earlier after psychosis onset.
• 26:21Also, there is, more evidence
• 26:23because these are studies that
• 26:25are somewhat easier to do
• 26:27that even if one did
• 26:28not reduce,
• 26:29the duration of untreated psychosis,
• 26:31that is to say without
• 26:33early detection,
• 26:34simply improving the quality of
• 26:36care,
• 26:37after
• 26:39individuals
• 26:40self present or are referred
• 26:42to to outpatient services can
• 26:44also improve outcomes. And I've
• 26:46listed some of the studies
• 26:47for those who would like
• 26:48to to look up the
• 26:49references.
• 26:50The OPUS trial in the
• 26:51United Kingdom,
• 26:53I'm sorry, in Denmark, the
• 26:55Lambert study in the United
• 26:56Kingdom. And then in the
• 26:57US, the first two studies
• 26:59that,
• 27:00tested
• 27:02a specialized
• 27:03team based approach to care,
• 27:04which was our clinic in
• 27:06step, and then the RAISE
• 27:08studies that did this over
• 27:10twenty two different
• 27:12sites across the US.
• 27:14All are showing consistently
• 27:16improvements in outcome measured at
• 27:18two years after initiation of
• 27:20treatment. I can go to
• 27:21the next slide.
• 27:24So a little more about
• 27:25us.
• 27:26We
• 27:27planned a pragmatic trial,
• 27:30that ran from two thousand
• 27:31seven to two thousand thirteen,
• 27:33and we we built it
• 27:35so that it would recruit
• 27:36very broadly. We provide interventions
• 27:38that we thought would be
• 27:39feasible at a place like
• 27:40CMHC
• 27:41in ambulatory,
• 27:43clinics,
• 27:44and we measured outcomes that
• 27:45we thought would be most
• 27:46relevant for,
• 27:48the the kinds of,
• 27:49evaluations that these services should
• 27:52be subjected to.
• 27:55The clinic is based at
• 27:56CMHC, which as many of
• 27:57you may know is a
• 27:58public academic collaboration.
• 28:01And
• 28:02we,
• 28:03when we initiated the service,
• 28:06decided,
• 28:07to in to be as
• 28:08inclusive as possible
• 28:10across
• 28:11barriers
• 28:12of insurance,
• 28:13and catchment. So step,
• 28:15then as it does now,
• 28:17admits individuals,
• 28:19whether or not they have
• 28:20private or public insurance.
• 28:23And, initially, we admitted individuals
• 28:25anywhere in the state. They
• 28:26didn't have to be in
• 28:27the catchment of CMHC.
• 28:30And we also,
• 28:31admitted individuals who were sixteen
• 28:33and seventeen years old in
• 28:35order to capture the the
• 28:37widest range of individuals who
• 28:39were truly in the first
• 28:40episode of these illnesses.
• 28:42Next slide.
• 28:45This is just a a
• 28:46reference slide for those who
• 28:48want to look back later
• 28:49on the design of the
• 28:50trial.
• 28:51The point,
• 28:52here was that while the
• 28:54initial studies
• 28:56in Denmark and the UK
• 28:58had tested a very intensive
• 29:00approach to treatment, essentially, act
• 29:02level care
• 29:04where clinician to patient ratios
• 29:06were ten or or twelve
• 29:07to one. I'm sorry. Patient
• 29:09to clinician ratios were ten
• 29:10or twelve to one. What
• 29:12we tested here was a
• 29:13pragmatic study where, clinicians at
• 29:16CMHC were often carrying
• 29:18a patient loads of anywhere
• 29:19from forty to fifty individuals,
• 29:22of whom a subset were
• 29:23first episode psychosis patients.
• 29:26And we randomized
• 29:28all
• 29:32people presenting this to either
• 29:34come into care at step
• 29:35or to be randomized to
• 29:36the kind of care they
• 29:37would ordinarily get depending on
• 29:39their insurance status. So a
• 29:40significant number were referred out
• 29:42into the community if they
• 29:44had commercial insurance,
• 29:45while those who were eligible
• 29:47for CMHC care received care
• 29:49elsewhere in other teams in
• 29:50the building.
• 29:52Next slide.
• 29:55So this is a summary
• 29:56slide of our outcomes, which
• 29:57we have published for those,
• 29:59who wanna look at the
• 30:00details
• 30:01of the design and the
• 30:02results.
• 30:03But I'm presenting here just
• 30:04the two main outcomes. The
• 30:06pairs of,
• 30:08bars on the left
• 30:09are hospitalization
• 30:11outcomes
• 30:13and describe how both in
• 30:15step and in usual treatment,
• 30:16there was a reduction in
• 30:17hospitalization
• 30:18as you might expect when
• 30:20individuals enter care. But the
• 30:22reduction in step was significantly
• 30:24greater
• 30:25over the first year.
• 30:26And interestingly,
• 30:28on the outcomes that patients
• 30:29and families cared more about,
• 30:31which is
• 30:31vocational engagement, so were they
• 30:34engaged in at least part
• 30:35time school or work or
• 30:36better,
• 30:38the fraction of individuals
• 30:39who remained,
• 30:41in the labor
• 30:42force was significantly higher in
• 30:44step. So only eight percent
• 30:47had essentially dropped out and
• 30:48stopped looking for work or
• 30:49school, whereas this number was
• 30:51up to a third
• 30:53in people in usual care,
• 30:54which is striking given that
• 30:56these were typically individuals in
• 30:58their early twenties.
• 31:00Next slide.
• 31:04For those who are interested
• 31:05in the in the costs,
• 31:07we I am showing here
• 31:08a slide describing
• 31:09the drive the biggest driver
• 31:11of direct cost, which is
• 31:12hospitalization.
• 31:13And on the left is
• 31:14a steady reduction
• 31:16every six months after entry
• 31:18into step, compared to the
• 31:20six months prior.
• 31:22This occurred as well in
• 31:24usual treatment, which again is
• 31:26a finding when individuals begin
• 31:28care early in the course,
• 31:29but it was not nearly
• 31:30as dramatic and remained quite
• 31:32high even one year after
• 31:34entry into usual care.
• 31:38Next slide.
• 31:40So it's hard slide to
• 31:41see all the results, but
• 31:42the the main point to
• 31:43make here is that,
• 31:45in a review of ten
• 31:47experimental studies from around the
• 31:49world of which STEP was
• 31:51one,
• 31:52The data suggests in this
• 31:53review that
• 31:55these kinds of specialty early
• 31:57intervention services
• 31:59have positive effects on a
• 32:00variety of outcomes, including symptoms,
• 32:03psychiatric hospitalization,
• 32:05and also global functioning and
• 32:07measures of quality of life.
• 32:08So,
• 32:10the effects the positive effects
• 32:12of receiving care within these
• 32:14specialty teams are pervasive,
• 32:16and big enough in size
• 32:18to be worthy of an
• 32:19investment,
• 32:21by health care services.
• 32:23Next slide.
• 32:28Another review. And,
• 32:30here again, the focus was
• 32:32on the risk of relapse
• 32:33or readmission,
• 32:35offered variety of studies from
• 32:36around the world. And STEP
• 32:38was with its focus really
• 32:40in the US on reducing
• 32:41relapse and rehospitalization,
• 32:44given
• 32:44how expensive and disruptive these
• 32:46can be, was a positive
• 32:48outlier and, again, demonstrating a
• 32:50reduction,
• 32:52in favor of our model
• 32:53of care versus usual treatment.
• 32:56And, again, I've left the
• 32:57reference there for those who
• 32:58want to look at the
• 32:58details. Thanks, Laura. You can
• 33:00go to the next slide.
• 33:03So,
• 33:04just a summary of sort
• 33:05of the evolution and to
• 33:06make the point that,
• 33:08while the idea of doing
• 33:09early intervention
• 33:10is not new,
• 33:12in fact, it goes back
• 33:13to the nineteen hundreds when,
• 33:16these illnesses were first described.
• 33:18It was in two thousand
• 33:20and five when two
• 33:22experimental studies demonstrated
• 33:24that
• 33:25these kinds of services can
• 33:27have a significant
• 33:28impact on outcomes.
• 33:31It took another ten years
• 33:32before we were able to
• 33:34adapt and replicate those studies
• 33:36in the US.
• 33:38And since then,
• 33:40we have good good data
• 33:42on costs
• 33:43and,
• 33:44the the health economic benefits
• 33:46of investing in these kinds
• 33:48of services
• 33:49for these patients.
• 33:50So we have data on
• 33:52efficacy,
• 33:53on effectiveness, which is the
• 33:55more real world question.
• 33:57We have data on cost,
• 33:59and the and whether the
• 34:00investments made are are worth
• 34:02it. I think the big
• 34:03question
• 34:04now,
• 34:05especially in the US is,
• 34:06can these models that have
• 34:08demonstrated impact,
• 34:09be scaled across community settings?
• 34:13And I list a few
• 34:14states in the US that
• 34:15have led on statewide
• 34:17implementations
• 34:18of these models of care.
• 34:19And we're very excited to
• 34:21be
• 34:24thinking and hopefully launching
• 34:26a Connecticut
• 34:27based response that,
• 34:29under this learning collaborative,
• 34:32will I hope emerge over
• 34:33the next few years where
• 34:34we can deliver on improved
• 34:36access
• 34:37and treatment outcomes,
• 34:39for these individuals.
• 34:41Next slide.
• 34:43So I wanted to say
• 34:44a little bit about,
• 34:48a study we did at
• 34:50at STEP,
• 34:51to improve
• 34:53access to care,
• 34:55both in terms of the
• 34:56duration of untreated psychosis, but
• 34:58also the quality of the
• 34:59pathways,
• 35:00to care.
• 35:02And we,
• 35:03completed what is the first
• 35:05US experimental test of an
• 35:07early detection,
• 35:09campaign that that was targeting
• 35:12ten towns around step to
• 35:13reduce delays to care. The
• 35:15campaign was called mind map,
• 35:16and you can see here
• 35:17a couple of the,
• 35:19sort of pictures of of
• 35:21participants who helped us in
• 35:22the campaign.
• 35:23Next slide.
• 35:28The
• 35:29the study was,
• 35:31a replication of of a
• 35:32previous study in Norway, which,
• 35:35is the only other
• 35:36study now that has demonstrated
• 35:39a reduction in the duration
• 35:40of untreated psychosis
• 35:42across an entire community.
• 35:44And
• 35:45like the Norwegian study,
• 35:47we had a site which
• 35:49was STEP in Southern Connecticut
• 35:51where we
• 35:52ran a campaign to reduce
• 35:53delays to care. And we
• 35:55had a control site,
• 35:56which was a a clinic
• 35:58much like ours in Metropolitan
• 36:00Boston,
• 36:02which provided very similar care,
• 36:04but unlike us did not
• 36:05run an early detection campaign.
• 36:08And the idea here was
• 36:09to be able to demonstrate
• 36:10that the campaign was responsible
• 36:12for
• 36:13the improvements in Pathways to
• 36:14Care and DUP,
• 36:16and this wasn't some other,
• 36:19unrelated variable either in terms
• 36:21of
• 36:22changes in health care policy
• 36:24or insurance coverage that could
• 36:26explain these these differences between
• 36:28the sites.
• 36:30Next slide.
• 36:33So the the campaign that
• 36:34we ran that some of
• 36:35you may have heard of
• 36:36included three major components. One
• 36:38was, focused on the public,
• 36:40using social and mass media.
• 36:42The another leg was focused
• 36:44on professionals,
• 36:46primary care and behavioral health
• 36:48care agencies,
• 36:50who would be referral sources
• 36:51to our clinic.
• 36:53And the third was really
• 36:54a
• 36:55performance improvement
• 36:57approach to reduce wait times
• 36:58at our front door and
• 36:59bring people into care rapidly
• 37:02after they were referred to
• 37:03us. Next slide.
• 37:06There's here are some
• 37:08pictures really of the various
• 37:10kinds of messaging we used
• 37:12in social and mass media.
• 37:13Top left is our website
• 37:14we had developed.
• 37:16Top right is a description
• 37:17of our care model,
• 37:19and then various messages that
• 37:20we put out in media,
• 37:22to increase awareness, but also
• 37:24to increase referrals of individuals
• 37:27to our service. Next slide.
• 37:32On the top is,
• 37:33we use skins on local
• 37:35buses to
• 37:37transmit our message that people
• 37:39could call a referral number
• 37:41and,
• 37:42be provided information
• 37:44and an active assistance to
• 37:46enter into care in our
• 37:47clinic.
• 37:48We were on local TV
• 37:49and local newspapers.
• 37:51Go to the next slide.
• 37:55And
• 37:56in our professional outreach and
• 37:57detailing, we identified several distinct
• 37:59sectors in our region
• 38:01that we did outreach,
• 38:04to and also then conducted
• 38:07frequent detailing interactions, phone calls,
• 38:09and visits to people's workplaces
• 38:12to inform them about the
• 38:13work in our clinic and
• 38:14to encourage them to refer
• 38:16individuals to us, as soon
• 38:17as possible.
• 38:19Next slide.
• 38:21Some pictures of our campaign
• 38:23launch top right with,
• 38:25with leadership
• 38:26from the state, including the
• 38:28Department of Mental Health, the
• 38:30governor's office, our own department,
• 38:32and then many public events
• 38:34in which we were involved
• 38:35to
• 38:36interact with the public, educate
• 38:38them, and then enable them
• 38:39to make rapid referrals to
• 38:40our service.
• 38:42Next slide.
• 38:45So this is, I I
• 38:46could say a lot more
• 38:47about the details of the
• 38:48campaign. This is sort of
• 38:49the bottom line is that
• 38:50we were able to
• 38:52have
• 38:52the duration of untreated psychosis
• 38:55across ten target towns in
• 38:57our region.
• 38:58I give them in different
• 38:59units for people who prefer
• 39:01thinking in days versus weeks.
• 39:03But by way of context,
• 39:04our reduction from ten to
• 39:06five months was very similar
• 39:08in size to
• 39:09the the the study in
• 39:11Norway.
• 39:12And we know from the
• 39:13largest study in the US
• 39:15that
• 39:16the average or median DUP
• 39:18is closer to seventy four
• 39:20weeks. So while we started
• 39:22off,
• 39:24in our region
• 39:25at less than that about
• 39:26forty five weeks,
• 39:29we were able to reduce
• 39:30it considerably,
• 39:31and we are
• 39:33happily now publishing
• 39:35results showing that this reduction
• 39:37translated
• 39:38to improved presentations
• 39:40to our clinic
• 39:41and also,
• 39:43improvements in outcomes six months
• 39:45and a year later.
• 39:47You can go to the
• 39:48next slide.
• 39:51Oh, and and I put
• 39:51this up here also because
• 39:53we learned many lessons
• 39:55about,
• 39:56the pathways to care, the
• 39:58the the routes that people
• 40:00took on
• 40:02their way to our clinic,
• 40:04through
• 40:05questions we asked of them
• 40:06and their family members and
• 40:07referral sources.
• 40:09And this network graph is
• 40:10just a visual display of
• 40:12a significant,
• 40:13number of people who came
• 40:15to us where from the
• 40:16the time of the onset
• 40:17of symptoms
• 40:18to the first help seeking
• 40:20individual, which is often the
• 40:21family member,
• 40:23pathways, as you can see,
• 40:24often ran first to the
• 40:26ED, the emergency department, and
• 40:28then an inpatient unit, and
• 40:30then across,
• 40:31the graph to STEP. But
• 40:33there were, of course, myriad
• 40:34other ways in which people
• 40:35might,
• 40:36seek help multiple times from
• 40:39many different actors in a
• 40:40local network before they are
• 40:42routed to a clinic like
• 40:43STEP in a region. So
• 40:44it it illustrates, I think,
• 40:45what many of you, I'm
• 40:47sure, have already heard in
• 40:48the histories of your patients
• 40:50that,
• 40:51go getting to care and
• 40:53finding out where to go
• 40:54to care can be quite
• 40:55a torturous journey that can
• 40:57take a lot of
• 40:59interactions, involve many different members
• 41:01of a local community
• 41:03who can all be organized,
• 41:06to help improve
• 41:08and hasten these pathways,
• 41:10but who can also
• 41:11present in some ways in
• 41:13their own way as
• 41:14barriers or sources of delay
• 41:17if they do not understand
• 41:18what they're confronting and cannot
• 41:20cooperate to help a person,
• 41:22access care quickly.
• 41:24Next slide, please.
• 41:28So to summarize,
• 41:29I I have rushed through
• 41:31a lot of,
• 41:32work done over now almost
• 41:34fifteen years, but,
• 41:36the good news is that
• 41:37we have been able to
• 41:38demonstrate
• 41:40utilizing
• 41:40tools that, we believe exist
• 41:43and are available to all
• 41:44of us
• 41:45to improve both the outcomes
• 41:46of care that is the
• 41:47quality,
• 41:48but also
• 41:50reduce delays and improve access
• 41:52pathways
• 41:53within this defined catchment,
• 41:56around step.
• 41:58And we think that this
• 41:59partnership
• 42:00that allowed us to,
• 42:02apply for grants and test
• 42:04these models of care
• 42:07has greater relevance for other
• 42:09regions of the state. And
• 42:10so this is really the
• 42:11question that we are confronting,
• 42:13and we hope to work
• 42:14with all of you around
• 42:16whether we can leverage this
• 42:17to improve access and outcomes
• 42:19statewide.
• 42:21I think I have just
• 42:22one more slide.
• 42:25So we think of what
• 42:26we've done in these ten
• 42:28towns,
• 42:29around step as a kind
• 42:31of prototype or a model
• 42:32that we've been running now
• 42:33since twenty fifteen.
• 42:35And the different modules that
• 42:37Laura,
• 42:38initially outlined and will be
• 42:40returning to in this seminar
• 42:43really describe the care pathway
• 42:45that we have constructed
• 42:46that we have announced
• 42:48seeking to deliver to every
• 42:51eligible individual in these ten
• 42:53towns.
• 42:54And in trying to do
• 42:55this, we see our early
• 42:57intervention service as really an
• 42:59integrator
• 43:00of the activities of all
• 43:01these different
• 43:03stakeholders
• 43:04across education,
• 43:06criminal justice, social welfare,
• 43:09to both engage them in
• 43:10helping us improve
• 43:12access pathways to our service
• 43:14in the region,
• 43:15but also assisting us as
• 43:17they go through care in
• 43:18terms of serving as resources
• 43:20for, our patients,
• 43:22as they receive our care
• 43:23in these modules and then
• 43:25transfer back to community based
• 43:27care,
• 43:28close to where they live
• 43:29in the region.
• 43:32I think we have another
• 43:34slide. Oh, yes. So
• 43:36so,
• 43:37this is something we'll return
• 43:38to in the last session
• 43:40of the course.
• 43:42These sessions are primarily to
• 43:43introduce you to our care
• 43:44pathway
• 43:45and to have you understand,
• 43:48why and how we do
• 43:49what we do at STEP.
• 43:51And, of course, then to
• 43:52consider
• 43:53to what degree this is
• 43:55relevant to improving care across
• 43:57the state.
• 43:59And we think of the
• 44:00learning health collaborative
• 44:01as
• 44:02a vehicle to engage with
• 44:04all of you in this
• 44:05partnership.
• 44:07This map here,
• 44:09has color coded the five
• 44:11different regions across the state
• 44:12that, Demus defines.
• 44:15And based on census data
• 44:17and epidemiologic
• 44:18studies,
• 44:19we have,
• 44:20tried to guesstimate how many
• 44:22new cases of psychosis
• 44:24we might expect in each
• 44:25region based on the age
• 44:27distribution
• 44:28of the populations.
• 44:29So on the bottom left
• 44:31is the example of region
• 44:32two where STEP is,
• 44:34where we can get a
• 44:35rough estimate of about ninety
• 44:37four cases a year, which
• 44:39would mean close to about
• 44:40three hundred cases that would
• 44:42be eligible
• 44:43for a an early intervention
• 44:45service that took individuals
• 44:47within the first three years,
• 44:48say, of psychosis onset.
• 44:51The red,
• 44:53icons
• 44:54are all the local mental
• 44:55health agencies, the lead mental
• 44:57health agencies, and which we
• 44:59see as the regional experts
• 45:01on behavioral health services across
• 45:03the state that we're hoping
• 45:04to partner with to think
• 45:06through how we can
• 45:07adapt and disseminate
• 45:10this this prototype model really
• 45:13to,
• 45:14improve
• 45:15both access and care outcomes
• 45:18for all individuals,
• 45:19no matter where they happen
• 45:21to be in the state.
• 45:23That's that's the the,
• 45:25ambition of,
• 45:26the learning how collaborative over
• 45:28the long term. And we're
• 45:29hoping over the next few
• 45:30sessions to give you
• 45:33a more granular sense of
• 45:34how we actually provide care
• 45:37at step in these ten
• 45:38towns and improve access.
• 45:40So you'll be in a
• 45:41position to think about how
• 45:42you might think about this
• 45:44in your own region,
• 45:46where
• 45:47your agencies,
• 45:49really are the key node,
• 45:51for
• 45:52potentially
• 45:53organizing care in the region,
• 45:55but certainly delivering care to
• 45:56these individuals.
• 45:58So I
• 45:59I think we're good for
• 46:01time, hopefully, for enough questions,
• 46:02but I'll stop there.