"First Break" / Prodromal Psychosis Training

[Ishiguro]

With all necessary caveats about calling it a "first break" when symptoms are a long time coming...

I am a resident in a northeast academic program, and I'm interested in a career working with young people to manage and treat schizophrenia and psychotic illnesses. A first break clinic with clinical research would be a dream job (I'd be happy to just be able to make this type of work a significant part of my schedule, too). This seems best accomplished by doing a CAP fellowship (gain a better developmental perspective, get good at family work, have more time to hone some CBT skills) maybe followed by a schizophrenia fellowship.

I'm talking to mentors at my institution, too, but I wanted to see where people would recommend going for this type of work (that is, where to go for CAP). MGH has a first-break program, BIDMC has one (with Mass Mental Health), Columbia has something, etc. -- but I'm having a hard time figuring out which of these are really robust programs, and where else there might be deep expertise in this area. There are few child-trained people working in this area, from what I can tell, so it's difficult to know where a strong first-break program will really trickle into child training.

I know the northeast a little bit, but I'm open-minded about moving.

Thanks for your thoughts!

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[splik]

after the caveat why keep calling it a first break program, a term no one uses to describe these programs? Are you interested in first episode psychosis or the at-risk mental state, or both? I think these programs are only going to grow following the RAISE study, but the growth will be in community-based programs rather an ivory tower based ones. UCSF has an early psychosis program, OHSU has something like this, as does UC Davis, UCSD and Washington State (but not UW) has put some money into this too. I am sure there are many others too (I know hopkins and maryland have programs) but am most familiar with the west coast.

As you mentioned, these programs are usually run by general psychiatrists, I am not sure child psychiatry residency training is necessary or desirable if you don't want to work with kids (and of course most child psychiatry has nothing whatsoever to do with psychosis). Not sure you would have more time to hone your CBT skills, and you'd have less if you fasttracked (CBTp is basically a fad and not particularly help in patients early in the course of psychosis, supportive psychotherapy usually fares better in the studies; in fact CBT might actually make people worse in first-episode psychosis). Additionally, psychiatrists in these programs are not usually the ones doing CBT or family work.

Also these programs aren't just for young people. Psychotic symptoms can have first onset in the 20s, 30s, an 40s etc. Usually any older than that and you want a different kind of specialized program (which is where I come in).

Also the US is really a latecomer to this work. Pat McGorry in Australia is one of the big names, and there are also some important programs in the UK in London and Cambridge, as well as some other European Programs. The Canadians too have been doing interesting work here.

Another reason why "first break" is an inappropriate term, is that the majority of these ARMS patients don't even go onto develop schizophrenia - lots of affective psychosis, personality disorder, family systems pathology, substance abuse, PTSD, neurodevelopmental disorders, weirdo NOS, and occasionally zebras like Wilson's Disease, metachromatic leukodystrophy, Huntington's thrown into the mix too.

Why don't you arrange to spend your 4th year doing primarily clinical and research work in one of these services if it really interests you? Also what kind of research are you interested in? - clinical trials, psychotherapy, imaging, genetics, epidemiology? If you are interested in a research career then yes it would be a good idea to do a T32 or other fellowship related to early psychosis.

 

[clausewitz2]

If you just want another name of a likely program, Pitt definitely has a first episode of psychosis clinic that is very busy and has strict criteria for being seen. I have now referred many people there. It is definitely not all, or mostly kids though!

It strikes me that it is also an institution that is incredibly successful at getting grants funded and has a large number of people dedicated to psychotic disorders (and probably about fifty inpatient beds largely dedicated to the cohort of that population that does end up progressing to a primary psychotic disorder). The director of our other outpatient psychosis clinics has a dream to try and start an Open Dialogue pilot program for addressing this first episode population, speaking of therapeutic approaches that are not CBT, but not sure when that will get off the ground.

It's not Melbourne in terms of expertise, but nothing to scoff at.

 

[Ishiguro]

after the caveat why keep calling it a first break program, a term no one uses to describe these programs?

Fair! It was still used at my medical school (where there was an affiliated RAISE site) so I figured the term is still part of the broad parlance, and wasn't certain what language is being used elsewhere.

To your question, I'm certainly curious about ARMS, but I think I'm most interested in working in first episode psychosis. RAISE brought attention to early intervention, of course, and at least where I am there's been an increase in funding and interest for this work, but I'm having a hard time figuring out where early intervention is really happening on the ground. Thanks for the West Coast tips!-- that's where my knowledge is pretty fuzzy.

Your points are well-taken about initial psychotic symptoms occurring in older adults and diversity of eventual diagnosis. I still do think child training might have a lot to contribute here (for the reasons mentioned previously, but also because of the fact that psychotic-symptoms-not-becoming-schizophrenia are also present in many illnesses seen in child psychiatry). I like working with kids and families, anyway, so it wouldn't be a thing to be endured.

The US *is* a latecomer! I've wished for some time that I could spend part of my training abroad. One of the hardest things about being fairly isolated in adult inpatient psychiatry has been feeling that I meet lots of patients many, many years into living with schizophrenia, but I have relatively little sense of what early intervention really looks like, or how much to expect of a properly executed recovery model.

I'll scratch "first break" from my vocabulary now.

 

[Ishiguro]

If you just want another name of a likely program, Pitt definitely has a first episode of psychosis clinic that is very busy and has strict criteria for being seen. I have now referred many people there. It is definitely not all, or mostly kids though!

It strikes me that it is also an institution that is incredibly successful at getting grants funded and has a large number of people dedicated to psychotic disorders (and probably about fifty inpatient beds largely dedicated to the cohort of that population that does end up progressing to a primary psychotic disorder). The director of our other outpatient psychosis clinics has a dream to try and start an Open Dialogue pilot program for addressing this first episode population, speaking of therapeutic approaches that are not CBT, but not sure when that will get off the ground.

It's not Melbourne in terms of expertise, but nothing to scoff at.

Ah, so helpful! Thanks!

 

[SmallBird]

With all necessary caveats about calling it a "first break" when symptoms are a long time coming...

I am a resident in a northeast academic program, and I'm interested in a career working with young people to manage and treat schizophrenia and psychotic illnesses. A first break clinic with clinical research would be a dream job (I'd be happy to just be able to make this type of work a significant part of my schedule, too). This seems best accomplished by doing a CAP fellowship (gain a better developmental perspective, get good at family work, have more time to hone some CBT skills) maybe followed by a schizophrenia fellowship.

I'm talking to mentors at my institution, too, but I wanted to see where people would recommend going for this type of work (that is, where to go for CAP). MGH has a first-break program, BIDMC has one (with Mass Mental Health), Columbia has something, etc. -- but I'm having a hard time figuring out which of these are really robust programs, and where else there might be deep expertise in this area. There are few child-trained people working in this area, from what I can tell, so it's difficult to know where a strong first-break program will really trickle into child training.

I know the northeast a little bit, but I'm open-minded about moving.

Thanks for your thoughts!

Yale has a very robust clinical, research and training program in this area. The PRIME clinic has developed some of the key instruments for assessing prodromal psychosis, and many of our residents do rotations there, as well engage in research. The other clinic is the STEP clinic, which is the early psychosis clinic. It's an already large program with several million dollars in NIH funding and significant support from the state of Connecticut. I published a paper based on research with this population, and it's a popular site for residents to do both clinical work and research.

Typically, people in this area are not child psychiatrists, although I've heard many directors of early psychosis programs emphasize how they would see value in having people with developmental perspectives.

 

[HarryMTieboutMD]

Yale has a very robust clinical, research and training program in this area. The PRIME clinic has developed some of the key instruments for assessing prodromal psychosis, and many of our residents do rotations there, as well engage in research. The other clinic is the STEP clinic, which is the early psychosis clinic. It's an already large program with several million dollars in NIH funding and significant support from the state of Connecticut. I published a paper based on research with this population, and it's a popular site for residents to do both clinical work and research.

Typically, people in this area are not child psychiatrists, although I've heard many directors of early psychosis programs emphasize how they would see value in having people with developmental perspectives.

Without having read extensively on the subject, I would think having CAP training would be crucial to understanding these patients. I think one of psychiatry's biggest problems now is the chasm between CAP and adult psychiatry, when really, most adult illnesses have manifestations in childhood, with SCZ being the prototype for "high genetic risk architecture combined with environmental stressors" IDing these patients before obvious symptom onset and intervening seems to be the direction the leaders in the field are going: https://www.ncbi.nlm.nih.gov/pubmed/26939910