In early 2015, Mary* was in crisis. A sophomore attending the University of Maryland, she had to take leave of her studies because she started having some distracting and disturbing symptoms. Mary had hallucinations and experienced paranoia and delusional thoughts – she was experiencing the onset of psychosis.

She found help through a referral to the OnTrack Maryland team. The program, offered at Family Services, Inc., is designed for young adults who, like Mary, may be experiencing early symptoms of psychosis. It’s one of many programs throughout the country that received distinct funding and support from SAMHSA to address first-break psychosis.

Through a Congressional appropriations bill, SAMHSA is directed to set aside a percentage of Mental Health Block Grants to address serious mental illness, including psychosis. Linking specific funding to address specific mental health disorders began in 2015, as five percent of the amount allocated to each state.

As SAMHSA prepares for a second year of block grant set-aside funding to address psychosis, states are starting to report successful results and inspiring stories of recovery just as they consider how best to use the second year of set-aside budget. The 2016 set-aside increased from 5 percent to 10 percent, and must be used to address first-break psychosis, specifically.

Targeting Youth

With first-break episodes, the person living through the experience may have had a full and functional life until that point. With symptoms, however, psychosis can be intruding, distracting, and even disabling. Getting help early is essential to treat symptoms and provide support so that activities and relationships important to stability and wellness can stay intact.

“The majority of individuals with serious mental illness experience their first symptoms during adolescence or early adulthood, and there are often long delays between the initial onset of symptoms and a person receiving treatment,” said SAMHSA Administrator Kana Enomoto during her testimony to Congress last October. “The consequences of delayed treatment can include loss of family and social supports, reduced educational achievement, disruption of employment, substance use, increased hospitalizations, and reduced prospects for long-term recovery.”

When Mary first interacted with program staff, she had a flat affect, expressionless responses, and had internal thoughts that were distracting and disturbing. She had a hard time setting and achieving goals because she was shy and symptomatic. While she was guarded and seemed to have low self-confidence, when she expressed that she wanted a job, staff saw that as an opportunity to build trust with her so she would be open to other treatment supports.

One State’s Efforts

Understanding Psychosis

    As a mental disorder, schizophrenia and psychosis involve symptoms of delusions, hallucinations, disorganized thinking, impaired motor skills, lack of emotional expression, and a decreased ability to engage in day-to-day activities. While psychosis can be experienced at any age, most onset between the ages of 16 and 30. It is estimated that approximately 1 percent of the population in the United States will experience schizophrenia or psychosis at some point in their lifetime.

In Maryland the five percent set-aside of the Federal Block Grant was used to create Coordinated Specialty Care (CSC) teams that included a team leader, a supported employment and education specialist, a recovery coach, and a team psychiatrist, who work collaboratively with youth to identify, assess, and treat early psychosis. The teams, including OnTrack Maryland, were trained extensively to provide services and support to affected young adults and their families.

As with Maryland, many other states are using this team approach to provide wrap-around support for people experiencing first-break psychosis.

For Mary, the OnTrack Maryland team also used Cognitive Behavioral Therapy thought-restructuring techniques, individual therapy, and group therapy to address thought distortions and to manage anxiety and other symptoms Mary was experiencing.

She also connected with a supported employment and education specialist who worked with her to meet her goal to find work. Mary was coached through creating a resume, completing job applications, and practicing interview skills. Within a few months, she landed a job at a retail store where she is still employed. Mary also worked with a recovery coach to build social skills, particularly ways to develop communication skills needed when interacting with managers or customers. By working with the coach, she found it easier to ask for help, negotiate requests, and appropriately manage complaints.

Other States

While the State of Maryland used set-aside funding to build responsive community-based teams, it also expanded outreach and education to academic and behavioral health providers about first-break psychosis. Other states used the dedicated budget to create new programs and expand existing initiatives. Idaho, for instance, started a hospital-based pilot program to work with individuals experiencing serious mental illness; and in Virginia, the Department of Behavioral Health and Developmental Services (DBHDS) used this as an opportunity to learn about the CSC model and other helpful interventions.

“The five percent set-aside requirement, along with the information, resources, and technical assistance SAMHSA provided to the states, led us to focus our transition-age and young adult services initiative on CSC,” said Rhonda Thissen, MSW, Grant Manager of Virginia’s DBHDS. “This population is underserved and has significant unmet needs, and we are pleased to know that the set-aside is being increased.”

The Future

Congress increased the set-aside for the 2016 fiscal year to ten percent, with some changes. While the initial five percent set-aside in 2015 could be used to address serious mental illness and first-break episodes, the increased current funding may only be used for evidence-based programs that address the first episode of psychosis. The Recovery after an Initial Schizophrenia Episode (RAISE) research initiative, supported by the National Institute of Mental Health, found CSC to be an effective treatment to diagnose and treat first episode psychosis, which is why it is the recommended approach.

While CSC is used by many states, there is some flexibility in program design, implementation, and evaluation, as long as it is an evidence-based approach with a focus on first episode psychosis. The set-aside funds cannot be used for primary prevention or preventive intervention for individuals at risk for serious mental illness, but states can determine how best to use the remaining 90 percent of their mental health block grant.

In Maryland, the increase in the set-aside will likely enhance efforts to promote recovery support services, peer support specialists, and supported employment and education. “These support services enable individuals to choose, obtain, maintain, or advance within a community-integrated work and education environment,” said Cynthia Petion, Director of the Office of Planning at the Maryland Behavioral Health Administration. “Additional funding will further training and implementation support, particularly to develop tools to review, measure, and evaluate outcomes.”

For Mary, the benefits from her experience with the CSC team can be seen in how different her life looks now compared to one year ago. She is back at school and taking honors classes. With the treatment and support she received, she is balancing a new schedule that includes work, school, therapy, medication management, recovery coaching, job coaching, and a full family life – and she is dedicated to her ongoing recovery.

* Name changed to protect privacy.

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