WELCOME TO THE 2017 CIT INTERNATIONAL CONFERENCE

Integrating CIT and Early Intervention for Serious Mental Illness: New Partnerships for Better Community Outcomes Robert K. Heinssen, Ph.D., ABPP Division of Services and Intervention Research National Institute of Mental Health 2017 CIT International Conference Ft. Lauderdale, FL 18 August 2017

Disclosures I have no personal financial relationships with commercial interests relevant to this presentation The views expressed are my own, and do not necessarily represent those of the NIH, NIMH, or the Federal Government

CIT is more than training Major Sam Cochran (Retired), CIT International

Schizophrenia Facts ~2.5 million U.S. citizens are affected Typical onset between ages 16-30 Symptoms include altered perceptions, thinking, and disorganized behavior Unemployment, homelessness, and incarceration are common People with schizophrenia die 8-10 years earlier than other people

Treatment Delays are Common The time between the onset of psychotic symptoms and initiation of treatment is typically 1-3 years in the U.S. Lengthy treatment delays are associated with negative outcomes Poorer response to antipsychotic medications Poorer symptomatic and functional outcomes

Early Intervention Matters Rapid remission of positive symptoms Lower rates of psychiatric re-hospitalization Decreased substance use Improved social and vocational functioning Increased quality of life

Recommended Practices Research-supported interventions Low-dose antipsychotic medications Cognitive and behavioral psychotherapy Family education and support Educational and vocational rehabilitation Team-based, person-centered care Shared decision-making Strong community partnerships Twin goals are to reduce DUP and provide EIS to promote long term recovery and reduce disability. Bird et al. (2010). Early intervention services, cognitive-behavioral therapy and family intervention in early psychosis: systematic review. British Journal of Psychiatry, 197:350-356

Coordinated Specialty Care Service User Medication/ Primary Care Cognitive Behavioral Psychotherapy Family Education and Support Case Management Supported Employment and Education

National Early Intervention Programs, 2008 10

http://www.nimh.nih.gov/RAISE

RAISE Studies RAISE Early Treatment Program RAISE Connection Program John Kane Nina Schooler Delbert Robinson Lisa Dixon Jeffrey Lieberman Susan Essock Howard Goldman

RAISE by the Numbers 2 Studies 22 States 36 Sites 134 Providers TX UT MT CA AZ ID NV OR IA CO KS WY NM MO MN NE OK SD WA AR ND LA IL OH FL GA AL WI VA IN MI MS KY TN PA NC SC WV NJ ME NY VT MD NH CT DE MA RI Phase-specific specialty care for First Episode Psychosis vs. TAU Representative patients, providers, and community clinics Focus on clinical and functional recovery, cost of care, societal benefits Early deliverables on DUP, guideline-concordant pharmacotherapy, medical comorbidity in FEP, and implementing CSC in public mental health systems 2 Studies 22 States 36 Sites 134 Providers 469 Participants

RAISE Findings After 2 years, Coordinated Specialty Care was superior to usual community care on: Quality of life Symptomatic improvement Involvement in work or school Cost-effectiveness CSC worked better for patients with shorter duration of untreated psychosis DUP is the interval between the onset of psychotic symptoms and initiation of antipsychotic treatment Kane JM, Robinson, DG, Schooler, NR, et al. (2016). Comprehensive versus usual community care for first episode psychosis: Two-year outcomes from the NIMH RAISE Early Treatment Program. American Journal of Psychiatry, 173(4):362-372. Kane, Robinson, Schooler, et al., 2016

RAISE Take Home Message

Typical Pathways to Care CMHC Police/Crisis Services Emergency Department Inpatient Unit School Counselor PC Physician Onset of Symptoms Help Seeking Referral to CSC Program 1-3 year delay!

Law Enforcement Involvement 29% of persons with MI have police contact along the pathway to care 14-58% of persons with FEP are incarcerated before receiving care Incarceration after psychosis onset can delay treatment by ~2 years 29% rate of police involvement in pathway to MH care (US studies) – Livingston, 2016. Psychiatric Services, 67:850-857. 14% prior incarceration – 45% of FEP patients had police/ambulance contact – Anderson et al., 2013. Soc Psychiatry and Psychiatr Epidemiol, 48:125-136 57% of FEP patients had prior incarceration – Broussard et al., 2013 58% of FEP patients had prior incarceration – Ramsay et al., 2011. J Am Acad Psychiatry Law, 39:57-64 59% of FEP patients had prior incarceration – Ramsay et al., 2014. Psychiatric Services, 65(6):758-764 Median treatment delay for those incarcerated during the duration of untreated psychosis was >2 years longer than those not incarcerated during DUP – Ramsay et al., 2014. Psychiatric Services, 65(6):758-764 Anderson et al; 2013; Broussard et al, 2013; Livingston, 2016; Prince et al, 2007; Ramsey et al, 2011; Ramsey et al, 2014

Safe and effective resolution of mental health crises Natural Partners CSC Leaders CIT Leaders Safe and effective resolution of mental health crises Common goals of: (1) resolving mental health crises safely; (2) linking individuals in crisis to appropriate mental health services; (3) diverting individuals from the criminal justice system, when appropriate.

CSC Team Leader Role Assertive community outreach Cultivate referral network Create strong partnerships and interagency agreements Facilitate access to CSC care Identify first episode psychosis cases early Shorten duration of untreated psychosis Prevent traumatic experiences Cultivate referral networks; facilitate access to care; outreach to patients and family members; coordinate clinical services among team members; provide ongoing clinician supervision

Outreach to Community Partners CMHC Police/Crisis Services Emergency Department Inpatient Unit School Counselor PC Physician Onset of Symptoms Help Seeking CSC Team Leader CSC goal: <12 weeks

Crisis Intervention Team Leader Seek out local CSC Team Connect with Team Leader Create a strong partnership and interagency agreements Encourage cross training Resolve mental health crises safely Link individuals to CSC mental health services Divert from CJ system, when appropriate

New Federal Funding Accelerates Implementation of Evidence-Based Care for First Episode Psychosis Dates and Milestones July, 2009 RAISE studies begin December, 2013 RAISE feasibility study completed January, 2014 H.R. 3547 ($25M set-aside for FEP) April, 2014 NIMH/SAMHSA provide guidance to states December, 2014 H.R. 88 ($25M set-aside for FEP) October, 2015 RAISE clinical trial completed CMS coverage of FEP intervention services December, 2015 H.R. 2029 ($50M set-aside for FEP) RAISE = Recovery After and Initial Schizophrenia Episode. States’ status is based on: November 2014 review of states’ revised FY14 CMHBG program plans submitted in response to the 5% set-aside for FEP treatment programs. 2015 updates to state plans from GA, ME, and MN about new FEP initiatives related to the set-aside initiative. Plans submitted to SAMHSA in 2015 for the FY2016-FY2017 set-aside initiative. Plans downloaded from https://bgas.samhsa.gov/ Mental Health Block Grant Plans: https://bgas.samhsa.gov/

States with CSC Programs, 2016 TX UT MT CA AZ ID NV OR IA CO KS WY NM MO MN NE OK SD WA AR ND LA IL OH FL GA AL WI VA IN MI MS KY TN PA NC SC WV NJ ME NY VT MD NH CT DE MA RI

CSC Programs after RAISE, 2016 2008 2014 2016 2018

Finding Local CSC Programs http://strong365.org/get-strong/find-help/

Summary Treatment delay worsens outcomes in serious mental illness Early intervention improves symptoms, functioning, and quality of life in FEP Law enforcement officers are often key agents in directing pathways to care To achieve common goals, CSC and CIT leaders must engage actively over time Many of the ~200 CSC clinics nationwide overlap with the 2,646 local CIT programs

Acknowledgements NIMH RAISE Team Susan Azrin Amy Goldstein Beth Bowers Joanne Severe Michaelle Scanlon Beth Bowers Yancy Bodenstein Denise Juliano-Bult Laura Seiss

Thank You! Robert K. Heinssen, Ph.D., ABPP Director, Division of Services and Intervention Research National Institute of Mental Health Room 7141, Mail Stop 9629 6001 Executive Blvd. Bethesda, MD 20892-9629 E-mail: rheinsse@mail.nih.gov Direct Voice:  301-435-0371 Division Fax:  301-443-4045

The Heinssen Boys