Maintaining Continuity of Care for First-Episode Psychosis Through Telehealth

For patients experiencing first-episode psychosis (FEP), specialty care in a dedicated setting is especially important to ensure consistent treatment engagement. How well does that specialty care translate to a telehealth setting?

Psych Congress Network recently spoke with Elisa Nelson, PhD, psychologist with the Department of Child and Adolescent Psychiatry & Behavioral Sciences at Children's Hospital of Philadelphia, Pennsylvania, and co-authors Monica Calkins, PhD, and Christian Kohler, PhD, about their study “Telehealth of Coordinated Specialty Care in Early Psychosis During COVID-19” recently published in the Journal of Clinical Psychiatry.

In Part 1 of this Q&A, Nelson et al. explains how pivoting to telehealth amid COVID-19 pandemic restrictions affected FEP patients, study aims, and which services might ultimately be best reserved for in-person care.

Stay tuned for Part 2 of this Q&A coming soon! In the meantime, visit our Telehealth Excellence Forum for more expert insights on how to improve patient outcomes remotely.

Brionna Mendoza, Associate Digital Editor, Psych Congress Network (PCN): What led you and your colleagues to investigate the feasibility of using telehealth to administer care to patients experiencing early psychosis?

Elisa Nelson, PhD, Monica Calkins, PhD, and Christian Kohler, PhD: When nationwide restrictions prevented in-person appointments during the emergence of COVID-19 in early 2020, we were faced with the sudden challenge to maintain young people with first-episode psychosis (FEP) in care. Coordinated specialty care (CSC) for FEP includes multiple services by a small team of providers, including psychotherapy, medication management, supported education and employment, peer support, and family education and support services. Persons with FEP do not fare as well in general outpatient settings. Rather, they benefit from a dedicated setting, and they are at high risk of dropping out of treatment (Kane et al. 2015). Untreated illness frequently leads to lack of social and occupational development and long-term disability (Perkins et al. 2005). To offer continued treatment we moved towards rapid implementation of telehealth services, and we were surprised at the level of remote engagement across services. As COVID-19 restrictions eased, we wanted to evaluate engagement across services before and during COVID-19 restrictions to determine the feasibility and potential effectiveness of continuing to offer telehealth options as part of FEP care.

Mendoza, PCN: Please walk us through the study methods and the most significant findings.

Nelson, Calkins, and Kohler: We evaluated total appointments; psychotherapy; medication management; employment and educational services completed; missed appointments rates; and new enrollment rates pre- (September 2219-February 2020) and post-COVID-19 (March 2020-July 2021). We also compared group attendance for our family psychoeducation groups before and during the pandemic.

Our rates of attendance and missed appointments remained stable across services (e.g psychotherapy, medication management and employment and educational services). Additionally, our rate of new enrollment remained steady before and during the pandemic, with a slight drop at the beginning of the pandemic that quickly rebounded. When we compared averages of attendance in our family support and education groups, we found a remarkable increase during COVID-19.

Mendoza, PCN: Were there some disease states that were more challenging to administer remote care to than others?

Nelson, Calkins, and Kohler: Overall, clinical symptoms did not appear to interfere with remote engagement. For a small number of individuals experiencing significant internal stimuli, such as hearing voices or disorganization, these symptoms may have impacted engagement but it is unclear whether this would have been less of a challenge in-person. In these situations, with the client’s consent, family members joined sessions to assist with engagement until in-person sessions were available.

Mendoza, PCN: Were there services that would have been more effectively administered in a hybrid or in-person setting?

Nelson, Calkins, and Kohler: Deciding on remote vs. in-person vs. hybrid visit models can be best determined by evaluating the individual’s needs. New intake evaluations are likely best in person since it is the providers first opportunity to meet the individual and foster engagement. Collateral interviews with family members for intake evaluations can readily be administered remotely, if the family is not able to come in person. Psychotherapy sessions lend themselves very well to telehealth, in particular when in-person sessions required (and still require) wearing masks for safety reasons.

Even without the mask mandate, telehealth psychotherapy represents a valuable option to provide treatment. Our group interventions in particular benefitted from the telehealth format. Our certified peer specialists and supported employment services maintained consistent contact with the individuals via phone and a HIPAA compliant video/audio platform. Including some in-person engagement for peer support is  beneficial since meeting in person and engaging in activity together can be so helpful in increasing purposeful activities and navigating social situations.

References

Perkins, D.O., Hongbin, G., Kalima, B., Lieberman, J.A. (2006). Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. The American Journal of Psychiatry, 162(10), 1785-1804. https://doi.org/10.1176/appi.ajp.162.10.1785

Kane, J.M., Robinson, D.G., Schooler, N.R., Mueser, K.T., Penn,D.L., Rosenheck, R.A.,…Heinssen, R.K. (2015). Comprehensive versus usual care for first episode psychosis: Two-year outcomes from the NIMH RAISE Early Treatment Program. The American Journal of Psychiatry, 142(4), 362-372. https://doi.org/10.1176/appi.ajp.2015.15050632

Elisa Nelson, PhD, is a psychologist in the Psychosis Evaluation and Recovery Center (PERC) at the University of Pennsylvania (UPENN) and the Children’s Hospital of Philadelphia (CHOP). She completed her post-doctoral training in Recovery-Oriented Cognitive Therapy (CT-R) for individuals with serious mental health conditions at UPENN. She has supported individuals in coordinated specialty care programs in the early stages of psychosis for several years. She is currently researching CT-R concepts and the effectiveness of this approach in coordinated specialty care programs, specifically ways CT-R can be adapted to support families.   

Monica Calkins, PhD, is Associate Professor of Psychology in the University of Pennsylvania Department of Psychiatry's Neurodevelopment & Psychosis Section (NDPS). After receiving her Bachelor’s degree from Temple University, she earned a Ph.D. in Clinical Science and Psychopathology Research at the University of Minnesota before joining Penn as a post-doctoral fellow, subsequently appointed to faculty. Her research focuses on phenotypic and biobehavioral risk factors for psychosis spectrum symptoms in young people. She is the Director of Clinical Research Recruitment and Assessment for NDPS and the Lifespan Brain Institute, Co-Director of the Pennsylvania Early Intervention Center (HeadsUp), and Associate Director of Penn’s Psychosis Evaluation and Recovery Center (PERC). 

Christian Kohler, MD, is Professor of Psychiatry and Neurology in the Neurodevelopment & Psychosis Section (NDPS), Department of Psychiatry of the University of Pennsylvania. After receiving his Doctorate in Medicine at Innsbruck University in Austria, he completed residency training in Psychiatry at Wright State University and in Neurology at the University of Cincinnati. After a NIMH-funded post-doctoral fellowship, he was appointed to faculty at the University of Pennsylvania. Dr. Kohler is the Clinical Director of the Neurodevelopment & Psychosis Section (NDPS), Director of Penn’s Psychosis Evaluation and Recovery Center (PERC) and Co-Director of the Pennsylvania Early Intervention Center (HeadsUp). His research has focused on emotion al processing in young persons with psychosis spectrum symptoms and, more recently, delivery of care during early psychosis.