#1Steve Sisolak Governor GREAT THE SEAL OF THE STATE OF Richard Whitley Director ALL FOR OUR COUNTRY NEVADA State of Nevada Department of Health and Human Services Early Treatment Program for Early Serious Mental Illness Division of Public and Behavioral Health Ruth Condray, Ph.D., Program Lead 10/14/2021 Helping people. It's who we are and what we do. OHN'S#2Agenda I. Overview II. Definitions 口 口 Early Serious Mental Illness Clinical Staging: Serious Mental Illness as a Dynamic, Emerging Process Social and Economic Burden of Serious Mental Illness Coordinated Specialty Care (CSC) for Early-Stage Schizophrenia Spectrum and Other Psychoses III. Access to Coordinated Specialty Care (CSC) Services for FEP in Nevada, 2021 V. Table 1: Participant Demographic and Clinical Characteristics IV. Frequently Asked Questions (FAQs) about CSC Services for FEP Outcomes-Driven Quality Control and Continuous Performance Improvement Effects of 1-year of Coordinated Specialty Care (CSC) for First Episode of Psychosis experienced by a Nevada Resident: Clinical Symptom and Social Functioning Outcomes 2#3I. OVERVIEW#4NEVADA Early Treatment Program for First Episode of Psychosis (FEP) Based on: The RAISE (Recovery After an Initial Schizophrenia Episode) Research Initiative, National Institute of Mental Health (NIMH) and the NAVIGATE Early Treatment Program for First Episode Psychosis Presenter: Ruth Condray, Ph.D., Program Lead, Nevada Early Serious Mental Illness/First Episode of Psychosis (ESMI/FEP) Program Background and Significance: Nevada Department of Health and Human Services recognizes the importance of building a statewide evidence- based program of early interventions to address early-stage psychotic disorders. Setting this priority follows recognition of key factors by national and international mental health communities and funding agencies: ✦ Historically, mental health services have focused on the later stages of serious mental illness (SMI), which has meant that interventions often occur only after things have reached a crisis and only after prolonged periods of untreated illness. ◆ Duration of Untreated Psychosis (DUP): The length of time that a person does not receive treatment for psychosis predicts the severity of his or her clinical outcome. Definition of DUP: Length of time between the onset of a psychotic disorder and the point when an individual enters treatment. ✦ Funding priority & guidance by SAMHSA have also been informed by: Advocacy efforts by clients and their family members urging Mental Health Systems to do more when people first experience ESMI/FEP. Societal & Economic Burden of Schizophrenia Psychosis, alone, was $155.7 billion in US in 2013, which included additional costs associated with unemployment, productivity loss because of caregiving, and direct health care. ✦ Goals of Program: Early interventions for early-stage psychosis may accomplish the following: Prevent or delay medical and psychological impairments, suicides and undesirable social circumstances (poverty and homelessness). Reduce the numbers of periods with severe symptoms. Improve social functioning and clinical outcomes. SAMHSA MH Block Grant funding, FFY 2020-2021: Minimum 10% set aside. Target Population: How many new cases of FEP occur each year? The median rate of new cases (incidence) each year for schizophrenia, one of the principal schizophrenia spectrum and other psychotic disorders, is estimated to be 15.2 per 100,000 population. First episodes show a peak onset between ages 15-25 years, although approximately 20% have an onset after age 40. Based on these estimates, the expected annual rate of new cases of schizophrenia in NV is approximately 300. Priorities: Statewide implementation of NAVIGATE, an evidence-based early treatment program of Coordinated Specialty Care (CSC) for individuals experiencing a first episode of psychosis, including: ✦ Northern Nevada Behavioral Health Region: Clinic Home, Carson Tahoe BH Services, Carson City, which began enrolling clients in FEB 2019. + Clark Behavioral Health Region: Clinic Home, UNLV/Mojave Counseling, Las Vegas, which began enrolling clients in FEB 2020. + Washoe Behavioral Health Region: Clinic Home, UNR SOAR Program, Reno, which was launched in August, 2021. Coordinated Specialty Care (CSC) is provided by a multi-disciplinary team of mental health professionals whose clinical expertise span biological, psychological and social work domains. Recovery-oriented interventions involve clients, multi- disciplinary team members and family members. CSC feasibility and efficacy have been demonstrated for community mental health settings, as well as for rural and low-density population regions. The evidence-based NAVIGATE program for FEP involves a manualized protocol of four core interventions (https://raiseept.org/): Pharmacotherapy & Primary (Medical) Care Coordination (RX & PCC); Individual Psychotherapy-Individual Resiliency Training (IRT); Family Education (Family ED; Supported Employment & Education (SEE). Assertive Case Management and Peer Support Services are also provided. NAVIGATE Program of Coordinated Specialty Care (CSC) for FEP PEER Support CASE Mgt RX & PCC IRT Client Relatives TX Team FAMILY ED SEE#5II. DEFINITIONS#6What is Serious Mental Illness (SMI)? What is Early Serious Mental Illness? Serious Mental Illness (SMI) includes: (1) any diagnosable mental, behavioral, or emotional disorder other than a developmental or substance use disorder defined by current, accepted diagnostic systems (e.g., Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5)), and (2) serious functional impairment. Annual average rate of early serious mental illness was 25,000 individuals, ages 18-25, in Nevada for each year during 2018 and 2019 (SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2018 and 2019). Early Serious Mental Illness (ESMI) involves a diagnosis of SMI (e.g., schizophrenia spectrum disorder; affective disorder with and without psychosis; anxiety disorder), and Early SMI refers to the recent onset of a Serious Mental Illness. Early SMI refers to the initial period of time following the onset or beginning of a serious mental disorder (e.g., first episodes; multiple-episode illnesses with an onset during the past 1-2 years; etc.). First Episode of Psychosis (FEP) includes schizophrenia spectrum and other psychotic disorders that appear during the early stages of the clinical course (e.g., first episodes; multiple-episode illnesses with an onset during the past 1-2 years; etc.). Individuals diagnosed with FEP represent a sub-group of the Early Serious Mental Illness (ESMI) population. Median rate of new cases (or incidence) each year for schizophrenia is estimated to be 15.2 per 100,000 population (McGrath et al., 2008).#7Serious Mental Illness (SMI) as a Dynamic, Emerging Process adapted from: McGorry P.D., et al., (Aug 2010): Clinical Staging. The Canadian Journal of Psychiatry, Vol 55, p. 489. Internalizing Major Depressive Episode Major Depressive Disorder Externalizin g Pervasive Psychological Disturbances Hypomanic Episode Schizo- phreniform Disorder Bipolar Psychosis Disorder Early Stage: mild, non-specific signs & symptoms 1 1 Mid-to-Late Stages: full disorders, moderate to severe symptoms Early-Stage Mild Signs and Symptoms: Internalizing Signs/Symptoms: Pervasive Psychological Disturbances: Externalizing Signs/Symptoms: Anxious, Depressive, Somatic Cognition, Perception, Affect, Language, Social relationships Impulsive, Disruptive conduct, Substance misuse/abuse#8What is the Social and Economic Burden of Serious Mental Illness (SMI)? The economic burden for Schizophrenia alone is steep-an estimated $155.7 billion for the United States in 2013, with additional excess costs associated with unemployment and productivity loss due to caregiving (Cloutier et al., J Clin Psychiatry, 2016; 77:764-771). Similarly, the economic burden for Bipolar I Disorder is precipitous- an estimated $202.1 billion for the United States in 2015, which corresponds to an average of $81,559 per individual (Cloutier et al., J Affective Disorders, 2018; 226:45-51).#9III. Access to Coordinated Specialty Care (CSC) for FIRST EPISODE of PSYCHOSIS in Nevada, 2021#10Coordinated Specialty Care (CSC) for Early Serious Mental Illness involving First Episode of Psychosis Nevada, 2019-2021 Beginning in 2017, the State selected the evidence-based NAVIGATE Early Treatment Program of Coordinated Specialty Care for First Episode of Psychosis for implementation throughout Nevada. Selection was based on the following factors: The efficacy and feasibility of the NAVIGATE Early Treatment Program for implementation within community mental health settings and in rural and low-density population regions in the United States were demonstrated by clinical trial: Clinical Trials registration: NCT01321177: An Integrated Program for the Treatment of First Episode of Psychosis (RAISE ETP), http://www.clinicaltrials.gov/ct2/show/NCT01321177 The personalized medicine framework of the NAVIGATE Early Treatment Program, which uses targeted therapies from multiple specialties to treat a specific diagnostic category of complex and serious mental illness—the schizophrenia spectrum and other psychotic disorders. The clinical treatment design of the NAVIGATE Early Treatment Program, which is compatible with an outcomes-driven methodology for achieving quality control and continuous performance improvement. For example, medical, psychological and psychosocial assessments are administered continuously (monthly, bi-monthly, quarterly, annually) to evaluate the clinical and functional status of patients, as well as to monitor the efficacy of specialty care interventions and the fidelity of program implementation with the evidence-based protocol. The National NAVIGATE Training Team of experts who were involved in the National Institutes of Health Clinical Trial (RAISE Research Initiative) were available to provide training, guidance and ongoing consultation to states and community-based providers in the implementation of the NAVIGATE Early Treatment Program for First Episode of Psychosis.#11Access to Coordinated Specialty Care Services for First Episode Psychosis in Nevada, 2021 The current status of access to evidence-based coordinated specialty care for residents experiencing first episode of psychosis in Nevada is summarized by state statute-defined behavioral health region (below) and by the demographic and clinical characteristics of clients who have been served to date in Table 1 (below). 1. Northern Behavioral Health Region: Carson Tahoe Health, Behavioral Health Services, Carson City, Nevada was the first site selected to implement the Nevada NAVIGATE early treatment program of CSC to serve individuals experiencing first-episode psychosis and living in Carson City and the counties of Churchill, Douglas, Lyon and Storey. The Carson Tahoe FEP Program opened its doors in February 2019 and is active and ongoing. 2. Clark Behavioral Health Region: University of Nevada, Las Vegas/Mojave Counseling, Las Vegas, Nevada was the second site selected to implement the Nevada NAVIGATE early treatment program of CSC to serve individuals experiencing first-episode psychosis and living in Clark County and the portion of Nye County that is south of the 38th parallel of north latitude (NRS 433.314). The UNLV/Mojave Counseling FEP Early Treatment Program opened its doors in February 2020 and is active and ongoing. 3. Washoe Behavioral Health Region: University of Nevada, Reno, School of Medicine, Department of Psychiatry and Behavioral Sciences, Reno, Nevada was the third site selected to implement the Nevada NAVIGATE early treatment program of CSC to serve individuals experiencing first-episode psychosis and living in Washoe County. The University of Nevada, Reno First Episode of Psychosis Program began accepting patients in August 2021.#12Table 1: Participant Demographic and Clinical Characteristics Characteristic NEVADA NAVIGATE Early Treatment Program for FEP, 2021 Enrollment: 2019 2021 (N=37) for reference: NIMH RAISE Early Treatment Program for FEP, 2014 Enrollment: 2010 2012 (N=223) (Kane et al., 2015, ajp.psychiatryonline.org) Continuous Factors Mean (SD) Age (Yrs., at Enrollment) 20.8 (4.5) Categorical Factors N (%) Sex (at birth) Male Female Race Mean (SD) 23.2 (5.2) N (%) 173 (78) 25 (68) 50 (22) 12 (32) 18 (49) 138 (62) White 8 (22) 63 (28) African American 3 (7) 22 (10) Other 8(22) 55 (25) Hispanic#13Table 1 continued Characteristic Categorical Factors NEVADA NAVIGATE Early Treatment Program for FEP, 2021 Enrollment: 2019 2021 (N=37) N (%) for reference: NIMH RAISE Early Treatment Program for FEP, 2014 Enrollment: 2010 2012 (N=223) (Kane et al., 2015, ajp.psychiatryonline.org) N (%) Marital Status Presently married 1 (3) 14 (6) Widowed, divorced or separated 2 (5) 14 (6) Never married 34 (92) 195 (87) Current Residence Independent Living 2 (5) 40 (18) Supported or structured 2 (5) 7 (3) Family, parents, grandparents or sibling 32 (87) 158 (71) Homeless, shelter or other 1 (3) 18 (8)#14Table 1 continued Characteristic NEVADA NAVIGATE Early Treatment Program for FEP, 2021 Enrollment: 2019 2021 (N=37) for reference: NIMH RAISE Early Treatment Program for FEP, 2014 Enrollment: 2010 2012 (N=223) (Kane et al., 2015, ajp.psychiatryonline.org) Categorical Factors Patient's Education Some college or higher N (%) N (%) 3 (8) 71 (32) Completed high school 18 (49) 75 (34) Some high school 15 (40) 67 (30) Some or completed grade school 1 (3) 9 (4) Mother's Education Some college or higher 3 (8) 102 (46) Completed high school 6 (16) 60 (27) Some high school or grade school 1 (3) 27 (12) No school or unknown 27 (73) 34 (15)#15Table 1 continued Characteristic NEVADA NAVIGATE Early Treatment Program for FEP, 2021 Enrollment: 2019 2021 (N=37) for reference: NIMH RAISE Early Treatment Program for FEP, 2014 Enrollment: 2010 2012 (N=223) (Kane et al., 2015, ajp.psychiatryonline.org) Categorical Factors N (%) N (%) Education & Employment Activity Current Student 8 (22) 35 (16) Currently Working 9 (24) 28 (13) Type of Insurance Private 7 (19) 55 (25) Public 29 (78) 61 (27) Private/Public Combination 1 (3) 0 Uninsured Missing data 0 0 104 (47) 3 (1)#16Table 1 continued Characteristic Categorical Factors SCID-5/DSM-5 diagnosis 1 Schizophrenia Schizoaffective Disorder NEVADA NAVIGATE Early Treatment Program for FEP, 2021 Enrollment: 2019 2021 (N=37) N (%) For reference: NIMH RAISE Early Treatment Program for FEP, 2014 Enrollment: 2010 2012 (N=223) (Kane et al., 2015, ajp.psychiatryonline.org) N (%) 17 (46) 113 (51) 43 (19) 8(22) 5 (13) 43 (19) 1 (1) 0 Schizophreniform Disorder Brief Psychotic Disorder Other Specified Schizophrenia Spectrum 7 (19) and Other Psychotic Disorder Lifetime Alcohol Use Did not meet criteria Met abuse criteria Met dependence criteria Unknown 23 (10) 31 (84) 134 (60) 4 (11) 36 (16) 0 53 (24) 0 2(5) 1 Structured Clinical Interview for DSM-5 Disorders/DSM-5#17Table 1 continued Characteristic NEVADA NAVIGATE Early Treatment Program for FEP, 2021 Enrollment: 2019 2021 (N=37) For reference: NIMH RAISE Early Treatment Program for FEP, 2014 Enrollment: 2010 2012 (N=223) (Kane et al., 2015, ajp.psychiatryonline.org) Categorical Factors Lifetime Cannabis Use Did not meet criteria Met abuse criteria Met dependence criteria Unknown Prescribed one or more antipsychotics at Enrollment Yes Number of prior hospitalizations 0 6 (16) 1 15 (40) 2 > = 3 7 (19) 8 (22) Unknown 1 (3) N (%) N (%) 16 (43) 137 (61) 39 (18) 17 (46) 2 (5) 47 (21) 0 2(5) 34 (92) 182 (82) 54 (24) 106 (48) 37 (17) 24 (11) 0#18IV. FREQUENTLY ASKED QUESTION (FAQ): How Does COORDINATED SPECIALTY CARE WORK for ESMI/FEP?#19IV. Frequently Asked Question about Coordinated Specialty Care for ESMI/FEP What will an early treatment program of coordinated specialty care provide for my teenage son/daughter who has been diagnosed with psychosis? The early treatment program of coordinated specialty care (CSC) for FEP is provided by multi-disciplinary teams of mental health professionals whose expertise span biological, psychological and social domains. Recovery-oriented interventions involve clients, CSC Team members and, when appropriate, family members and significant others. This program is manualized and includes four core interventions (April 2020, Revised Versions: https://navigateconsultants.org/manuals/): Core Treatment Interventions: Pharmacotherapy & Primary (Medical) Care Coordination 1) 2) Individual Resiliency Training 3) 4) Family Education Program Supported Employment and Education Social Support Services are also provided: 1) Case Management 2) Peer Support Services. The wheel-and-spoke model (below) shows the configuration of individuals and treatment components that comprise the Nevada NAVIGATE Early Treatment Program for First Episode of Psychosis.#20Nevada Evidence-based Early Treatment Program of Coordinated Specialty Care for First Episode of Psychosis, 2017-2021 Psycho- pharmacology & Primary Care PEER Support CASE Mgt CLIENT FAMILY TX Team Supported Employment & Education Resilience- focused Psychotherapy FAMILY Education#21Core Treatment Component #1: Evidence-based Psychopharmacological Treatment & Primary Care Coordination PEER Support Psycho pharmacology & Primary Care Resilience- focused Psychotherapy CLIENT CASE Mgt FAMILY TX Team Supported Employment & Education FAMILY Education#22Core Treatment Component #1 Psychopharmacological treatment for first-episode psychosis typically begins with a low dose of a single antipsychotic medication, and includes monitoring Psychopharmacology for clinical symptoms, side effects and attitudes and Primary Care Coordination about medication at each visit. Emphasis is given to managing cardio-metabolic risk factors (smoking, weight gain, hypertension, dyslipidemia, and pre- diabetes). Prescribers maintain close contact with primary care providers to ensure optimal medical monitoring and intervention for risks related to cardiovascular disease and diabetes.#23Core Treatment Component #2: Evidence-based Individual Resiliency Training (IRT) PEER Support Psycho- pharmacology & Primary Care Resilience- focused Psychotherapy CLIENT CASE Mgt FAMILY TX Team Supported Employment & Education FAMILY Education#24Core Treatment Component #2 Resilience- focused Psychotherapy NAVIGATE Individual Resiliency Training (IRT) includes 13 modules: 8 modules that are foundational for treating FEP; and 5 modules that focus on problem areas which may create challenges for recovery and health. Primary goals include: Promotion of recovery by identifying clients' strengths and resiliencies; Enhancing clients' management of their own illness; and Teaching skills to facilitate clients' functional recovery and to attain and maintain personal wellness. Standard Modules are provided to all and include the following topics: 1) Orientation 2) Assessment & Initial Goal Setting 3) Education about Psychosis 4) Healthy Lifestyles 5) Developing a Wellness Plan 6) Processing the Psychotic Episode 7) Developing Resiliency (Standard Sessions) 8) Building a Bridge to Your Goals Individualized Modules are tailored to each client's specific needs & goals and include the following topics: 9) Dealing with Negative Feelings 10) Coping with Symptoms 11) Substance Use 12) Having Fun and Developing Good Relationships 13) Developing Resiliency (Individualized Sessions)#25Core Treatment Component #3: Evidence-based Family Education Program PEER Support Psycho- pharmacology & Primary Care Resilience- focused Psychotherapy CASE Mgt CLIENT FAMILY TX Team Supported Employment & Education FAMILY#26Core Treatment Component #3 FAMILY EDUCATION The Family Education Program teaches relatives and other supportive individuals about psychosis and its treatment. The goal is to strengthen family members' abilities to help in their patient's recovery. If possible, and with the patient's agreement, family members and other supportive individuals are included in all phases of their patient's treatment planning. Participation of a family member or guardian is required for patients who are 17 years and younger. The goals of family education services are to reduce the burden on the patient's relatives and supportive others and to help relatives and supportive others acquire the needed knowledge and interpersonal skills to adapt to their new circumstances and to support their patient's recovery.#27Core Treatment Component #4: Evidence-based Supported Employment and Education (SEE) PEER Support Psycho- pharmacology & Primary Care Resilience- focused Psychotherapy CASE Mgt CLIENT FAMILY TX Team Supported Employment & Education FAMILY Education#28Core Treatment Component #4 Supported Supported Employment and Education (SEE) services are an integral part of the Coordinated Specialty Care (CSC) services developed for FEP. Employment and Education SEE specialty staff assist in a recovering person's return or initial entry to work or educational settings, and facilitate the efforts of clients to achieve expected vocational and educational goals. SEE specialty staff work to integrate vocational and mental health services, and to function as a CSC Team liaison with educators and employers.#29Social Support Services Components: Case Management Services and Peer Support Services PEER Support Psycho- pharmacology & Primary Care Resilience- focused Psychotherapy CLIENT CASE Mgt FAMILY TX Team Supported Employment & Education FAMILY Education#30V. OUTCOMES-DRIVEN QUALITY CONTROL and CONTINUOUS PERFORMANCE IMPROVEMENT#31Effects of 1-year of Coordinated Specialty Care for First Episode of Psychosis: Clinical Symptom and Social Functioning Outcomes Clinical symptom and social functioning outcomes data (de-identified and with signed informed consent) are presented (below) to show the clinical course and treatment response to the Nevada NAVIGATE Early Treatment Program of Coordinated Specialty Care for one patient (Patient A), in his 20s, who was diagnosed with early-stage schizophrenia based on the Structured Clinical Interview for DSM-5 Disorders (SCID-5/DSM-5, American Psychiatric Association, 2013). To date, Patient A has received one (1) year of coordinated specialty care (CSC) services provided by the Nevada NAVIGATE Early Treatment Program for FEP. The optimal length of CSC services established for this population is a minimum of two (2) years. Patient A is therefore considered to have reached the midpoint of the optimal length of CSC services determined for the NAVIGATE Early Treatment Program.#32Patient A: Number of Coordinated Specialty Care (CSC) Services Received by Service Type during Year 1. Patient A received a total of 28 coordinated specialty care services during Year 1. Psychopharmacology (n=12) and Individual Resiliency Training (n=11) services were provided monthly. (Source: Nevada NAVIGATE Early Treatment Program for First Episode of Psychosis.) Number of Services Received (Total = 28) 14 12 10 80 6 4 2 Patient A: Coordinated Specialty Care Services Received by Service Type, Year 1 0 I. Psycho- pharmacology II. Individual Resiliency Therapy III. Family Psycho- Education CSC Services, Year 1 12 11 2 IV. Supported Employment & Education 3#33Patient A: Adherence to Medication Regimen by Frequency of Psychopharmacology Services at Baseline and across 11 Months. Patient A reported full adherence to the medication regimen prescribed for his treatment, beginning with the first month of Psychopharmacology services and continuing through the next 11 months of Year 1. (Source: Nevada NAVIGATE Early Treatment Program for First Episode of Psychosis.) Frequency 2.5 1.5 0.5 0 1 2 Patient A: Adherence to Medication Regimen by Frequency of Psychopharmacology Services, Year 1 -0.5 Bas 2 3 4 5 6 7 8 9 10 11 1 e- mo mo mo mo mo mo mo mo mo mo mo line S S S S S S S S S S Number of Psychopharmacology Services 1 1 1 1 1 1 1 1 1 1 1 1 Number of days patient did NOT take medication. 2 ☐ 0 0 0 0 。。 0 。。。 0 0#34Patient A: Severity of Positive Symptoms of Psychosis at Baseline and across 11 Months. Prescriber ratings were performed to evaluate the presence and severity of positive symptoms of psychosis (COMPASS Clinician Rating Form) that were reported by Patient A at baseline and across 11 months of NAVIGATE Coordinated Specialty Care (CSC) services. COMPASS Clinician Rating Form (anchor points): 0=Not Present, 1=Very Mild, 2= Mild, 3-Moderate, 4-Moderately Severe, 5-Severe, 6-Extremely Severe. (Source: Nevada NAVIGATE Early Treatment Program for First Episode of Psychosis) Patient A: Positive Symptoms of Psychosis, Year 1 Prescriber ratings: Presence and Severity 5.5 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 -0.5 Base- line (0) 1 mo 2 mos 3 mos 4 mos 5 mos 6 mos 7 mos 8 mos 9 mos 10 mos 11 mos Suspiciousness 4 1 2 0 0 1 2 1 0 0 0 0 Hallucinations 4 5 4 4 2 2 4 4 3 3 2 1#35Patient A: Severity of Unusual Thought Content and Conceptual Disorganization at Baseline and across 11 Months. Prescriber ratings were performed to assess the presence and severity of unusual thought content and conceptual disorganization (COMPASS Clinician Rating Form), which are linked to disturbances in cognition that are commonly associated with psychosis. NOTE: Graph lines are superimposed when severity levels of symptoms are identical. COMPASS Clinician Rating Form (anchor points): 0=Not Present, 1=Very Mild, 2= Mild, 3-Moderate, 4-Moderately Severe, 5=Severe, 6=Extremely Severe. (Source: Nevada NAVIGATE Early Treatment Program for First Episode of Psychosis) 4.5 Patient A: Unusual Thought Content and Conceptual Disorganization, Year 1 Prescriber-ratings: Presence and Severity 4 3.5 3 2.5 2 1.5 1 0.5 Z 0 -0.5 Base- line 10 11 1 mo 2 mos 3 mos 4 mos 5 mos 6 mos 7 mos 8 mos 9 mos mos mos (0) Unusual Thought Content 4 3 4 2 1 1 1 Conceptual Disorganization 1 0 2 2 1 1 2 02 0 0 1 0 0 0#36Patient A: Severity of Negative Symptoms Associated with Psychosis at Baseline and across 11 Months. Prescriber ratings were performed to evaluate the presence and severity of two negative symptom domains, avolition/apathy and asociality/low social drive (COMPASS Clinician Rating Form) for Patient A at baseline and across 11 months of NAVIGATE Coordinated Specialty Care services. NOTE: Graph lines are superimposed when severity levels of symptoms are identical. COMPASS Clinician Rating Form (anchor points): 0=Not Present, 1=Very Mild, 2= Mild, 3-Moderate, 4-Moderately Severe, 5-Severe, 6=Extremely Severe. (Source: Nevada NAVIGATE Early Treatment Program for First Episode of Psychosis) Patient A: Negative Symptoms Associated with Psychosis, Year 1 Prescriber ratings: Presence and Severity 5.5 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 -0.5 Base-line 1 mo 2 mos 3 mos 4 mos mos 6 mos 7 mos 8 mos 9 mos 10 mos 11 mos (0) Avolition 5 3 3 2 2 0 3 2 1 0 1 0 -Asociality 4 2 4 3 2 1 2 2 1 0 1 0#37Patient A: Severity of Mood Symptoms at Baseline and across 11 Months. Prescriber ratings were conducted to evaluate the presence and severity of symptoms of Depressed Mood and Elevated/Expansive Mood (COMPASS Clinician Rating Form) that were reported by Patient A at baseline and across 11 months of NAVIGATE Coordinated Specialty Care Services. NOTE: Graph lines are superimposed when severity levels of symptoms are identical. COMPASS Clinician Rating Form (anchor points): 0=Not Present, 1=Very Mild, 2= Mild, 3-Moderate, 4-Moderately Severe, 5=Severe, 6=Extremely Severe. (Source: Nevada NAVIGATE Early Treatment Program for First Episode of Psychosis) Prescriber ratings: Presence and Severity 3.5 3 2.5 2 1.5 15 1 0.5 0 Patient A: Mood Symptoms, Year 1 -0.5 Base- 10 11 line 1 mo 2 mos 3 mos 4 mos 5 mos 6 mos 7 mos 8 mos 9 mos mos mos (0) Depressed Mood 0 1 1 0 0 3 0 0 0 0 0 0 Elevated/Expansive Mood 0 0 0 0 0 0 0 0 0 0 0 0#38Patient A: Severity of Anxiety Symptoms and Suicidal Ideation and Behavior at Baseline and across 11 Months. Prescriber ratings were conducted to evaluate the presence and severity of symptoms of Anxiety/Worry and Suicidal Ideation/Behavior (COMPASS Clinician Rating Form) that were reported by Patient A at baseline and across 11 months of CSC Services. NOTE: Graph lines are superimposed when severity levels of symptoms are identical. COMPASS Clinician Rating Form (anchor points): 0=Not Present, 1=Very Mild, 2= Mild, 3-Moderate, 4-Moderately Severe, 5-Severe, 6=Extremely Severe. (Source: Nevada NAVIGATE Early Treatment Program for First Episode of Psychosis) Patient A: Anxiety Symptoms and Suicidal Ideation and Behavior, Year 1 Prescriber ratings: Presence and Severity 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 -0.5 Base 2 3 4 5 6 7 8 9 10 11 -line 1 mo mos mos mos mos mos mos mos mos mos mos (0) Anxiety/Worry 1 3 0 1 4 3 Suicidal Ideation/Behavior 0 0 0 0 0 0 0 0 NO 2 0 0 0 0 0#39Patient A: Social and Occupational Functioning at Baseline and across 11 Months. Clinician ratings were performed to evaluate the psychological, social and occupational functioning of Patient A at baseline and across 11 months of NAVIGATE Coordinated Specialty Care (CSC) services (American Psychiatric Association (2000): Social and Occupational Functioning Assessment Scale, (SOFAS).). This scale provides ratings for social and occupational functioning that is influenced by mental and physical health factors and on a continuum in 10-point increments from superior functioning (SOFAS = 100) to grossly impaired functioning (SOFAS < 20). (Source: Nevada NAVIGATE Early Treatment Program for First Episode of Psychosis.) 80 80 70 60 60 50 Patient A: Social and Occupational Functioning, Year 1 40 40 30 Clinician ratings: Social and Occupational Functioning 20 20 Baselin e (0) 1 mo 2 mos 3 mos 4 mos 5 mos 6 mos 7 mos 8 mos 9 mos 10 mos 11 mos SOFAS 20 60 50 65 65 60 65 63 70 60 60 62 10 10 0#40Clinical Symptoms and Level of Social Functioning Following One Year of Coordinated Specialty Care Services: Summary and Conclusions Outcomes-Driven Quality Control and Continuous Performance Improvement: Clinical symptom and social functioning outcomes data (de-identified and with signed informed consent) were presented (above) to show the clinical course and treatment response for one client who was diagnosed with early-stage schizophrenia and who received one (1) year of coordinated specialty care (CSC) services provided by the Nevada NAVIGATE Early Treatment Program for First Episode of Psychosis. Year 1 is considered to be the midpoint for the optimal length of two (2) years of CSC services established for this evidence-based protocol. Assessments of clinical symptoms and level of social and occupational functioning were conducted monthly for this client throughout his participation in coordinated specialty care services. Following twelve (12) months of CSC services, this client showed improvements in the positive symptoms of psychosis (suspiciousness and hallucinations), and in the cognitive disturbances (unusual thought content and conceptual disorganization) and negative symptoms (avolition and asociality) associated with psychosis. Mood and anxiety symptoms also improved. Finally, this client's level of social and occupational functioning at Month 12 showed gains over the level of functioning observed at the time of his enrollment in the NAVIGATE Program (Baseline). The initial conclusion concerning the impact of the NAVIGATE Early Treatment Program of CSC for this client with early-stage schizophrenia is one of conservative optimism. Coordinated specialty care services for FEP appear to have been an effective intervention for advancing the recovery process for this client who had experienced a recent first episode of psychosis of the schizophrenia spectrum type.#41Questions? 41#42THANK YOU!#43Contact Information Ruth Condray, Ph.D. Nevada Division of Public and Behavioral Health Bureau, Behavioral Health Wellness and Prevention [email protected] 43