"We don’t provide experimental treatment. We provide the kind of treatment we think people should be getting, and we organize it well."
Vinod Srihari, MD speaks from his office at Connecticut Mental Health Center (CMHC) about the continuing success of STEP—Specialized Treatment Early in Psychosis. STEP, a research clinic, serves patients ages 18 to 45 who have recently experienced their first psychotic break.
Srihari and his team are studying the effectiveness of STEP care against what researchers call "treatment as usual": care in the community outside the walls of CMHC. The clinic is in its sixth and final pilot year.
"The trends are very good," says Srihari. "STEP patients are doing better on every measure."
History & Structure
STEP began accepting patients in April 2006. It has enrolled 140 participants; of those, 85 have been treated at STEP and 55 randomized out for "treatment as usual."
STEP evolved out of the PRIME clinic (Prevention through Risk Identification, Management & Education), also based at CMHC. Researchers found that when at-risk patients did experience psychosis, it was difficult for them to access clinical care. Director Scott Woods, MD approached Srihari, a staff psychiatrist at CMHC, about setting up a clinic to meet the needs of this population. "There was a fair amount of literature about clinics for younger people with psychotic disorders,” Srihari recalls, “but there was not much being done in the US, and very little in the public sector. It seemed like a good opportunity to try something."
CMHC—a partnership between the State of Connecticut Department of Mental Health and Addiction Services (DMHAS) and Yale University Department of Psychiatry—is a publicly funded mental health center. Srihari and the CMHC leadership approached DMHAS about establishing a pilot early intervention clinic at CMHC.
DMHAS strongly supported the idea and made it possible for STEP to recruit and accept patients from all over Connecticut.
The Department also agreed that STEP could use DHMAS staff at CMHC to provide care. “We wanted to use existing resources reallocated from a public mental health center without hiring any additional staff,” says Srihari. “The vision was to build a clinic that could easily be replicated in ordinary community settings.” Grants from the Donoghue Foundation and the National Institute for Mental Health have supported STEP’s research.
The STEP Approach
Patients with early psychosis are notoriously difficult to engage. Often they and their families are not yet ready to accept a diagnosis of mental illness. The system itself presents barriers to care, such as complicated insurance parameters and long waits for appointments. Between hospitalizations, Srihari says, these patients often receive no care at all.
Left untreated, they lose valuable time. “Regardless of what it’s doing to your brain, the illness is causing all kinds of trouble with your social and psychological connections with family, friends, and the world,” Srihari explains. Early intervention aims to minimize the loss of weeks, months, and years that young adults need to build life-sustaining careers and relationships.
At STEP, clients receive recovery-oriented care delivered by highly skilled clinicians who have compassion for them and their families.
"We know he’s in good hands," says Henry Morris (a pseudonym), whose son has been a STEP client for three years. “Everybody who deals with him cares about him. They are very good with our son and take a personal interest in clients.”
When they receive a referral—usually from a hospital or emergency room—STEP clinicians visit with the patient and/or family within 24 hours, often at the psychiatric hospital. The meeting helps patients and families overcome their initial hesitancy about coming to STEP.
Like all clinical services at CMHC, STEP has a multi-disciplinary treatment team. Care is flexible and individualized. Re-entry to the clinic is easy for patients who disengage. Patients meet regularly with their primary clinician, usually a nurse or social worker, and meet their psychiatrist for periodic reviews and/or as requested. For clients who wish to work, STEP offers occupational and vocational services. For those who want to continue their educations, clinicians can help by serving as liaisons with schools.
The clinic offers Cognitive Behavioral Therapy (CBT) in a group setting. Clients meet once a week with two therapists to focus on improving social skills and surmounting the problems of daily living. Like everything at STEP, CBT is optional.
Clinicians encourage patients to make choices about their care. They also pay attention to the influence of culture, ethnicity, immigration and socio-economic status on patients’ access to and experience of care.
"These patients would be in our system anyway," says Debbie Fisk, PhD, STEP’s clinical supervisor. "Eventually they would come through CMHC’s doors, at which point their histories would be much worse. Because we get them early, we are able to help more."
Early intervention, Fisk explains, does not only prevent hospitalizations. It prevents incarcerations, homelessness, and family disintegration.
"We have an active family support program that we’re making an investment in continuing," she notes. "We’ve found that over time, our clients still have positive relationships with their families. The families are not exhausted, I think in part because we have been able to support them."
For Henry Morris and his wife, the family support group has been invaluable.
"When you’re in the situation there’s a lot of anger and guilt—you ask, what could I have done differently, and what can I do now." Morris recalls nights when, early in the course of his son’s illness, tension at home would escalate to the point of boiling over. He and his wife tried to talk to their son. He didn’t want to talk.
At STEP, Morris discovered that other parents were going through the same things.
For Srihari, educating family members about psychotic illness is rewarding. He chose psychiatry as his medical specialty because he was interested in the phenomenology of psychiatric illness and enjoyed spending time with patients.
"The subjective experiences that people with psychosis describe are alien to ordinary human experience," he says. "This can make their struggles difficult to appreciate by untrained observers."
These illnesses, he continues, induce behaviors for which patients are held responsible by society. Reframing the illness as a neurological disorder—a medical condition, not unlike diabetes—can bring relief to families stricken by a child’s unusual and sometimes self-injurious conduct.
Says Srihari, "We offer a different narrative to families that are obviously trying very hard to contain the behavior of their loved ones."
STEP patients show significant reduction in total days spent in the hospital during each hospitalization. (In the "treatment as usual" group, hospitalization days increased.) STEP clients' symptoms improve to a greater degree, and they score higher on "quality of life" and "global assessment of functioning" measures.
"Hospitalizations are costly events, so people who pay for them are interested in that outcome," says Srihari. "But the outcomes we’re most interested in are: are they living in a reasonably independent way? Are they working if they want to work? Or are they back in school?"
On those outcomes, STEP clients fare dramatically better: 60% are vocationally engaged, compared with less than 30% in the “treatment as usual” group.
While the research findings are strong enough to be called “statistically significant,” final outcomes will be reported when the clinic reaches its target enrollment in December of 2011. STEP’s success in reducing hospitalizations and improving vocational functioning argues for the clinic to continue beyond its pilot years. Srihari would love to increase outreach efforts, remove further barriers to access, and find a way to bill private insurance for patients who have it.
The STEP approach, he says, not only works for patients and families. It also makes sense for society. According to its September 2011 report on research findings, STEP’s goals “speak to the broader policy question of whether and how such services should be made available on a national scale” in real-world community mental health settings.
For Henry Morris and his son, the journey continues.
"You can’t predict the future," he reflects, "but my son has decided to stay on his meds. He’s doing that. We’ll take it day by day. From where he started to where he is now, there’s a huge change. He’s much better now…I don’t know where he will go. I like to think, all parents do, that he’ll go farther. We’ll see."
"I thank them every day," he says of the clinicians at STEP. "I don’t know where we’d be."