Rehab Rounds : Psychosocial Rehabilitation Early After the Onset of Psychosis

To help young people like Phillip attain their goal, comprehensive programs must be developed to address the unique needs of people in the early stages of recovery from psychotic disorders (2,3,4). Clients in the Nova Scotia early-psychosis program have an initial diagnostic assessment with a psychiatrist who sees each of them as often as necessary, based on their changing clinical condition. In general, clients are seen by the psychiatrist weekly or biweekly for initial medication adjustments and then less often.

During the initial assessment, family members also meet with the psychiatrist and with the clinical nurse specialist. The clinical nurse specialist provides support to the family and monitors the client's clinical progress. The clinical nurse specialist also provides the family with 24-hour access to urgent care through a telephone pager system and establishes links to the community mental health team in the client's own community through a liaison nurse. Through the liaison nurse, clients have access to psychiatric social work and occupational therapy services and to community support programs from the community mental health center.

In the first year of the early-psychosis program (1996-1997), the clinical activities for 45 clients were supported by a core program staff of a psychiatrist-director who works half time with the program, a senior psychiatric resident, and a clinical nurse specialist. In the second year the program expanded to serve 90 clients, and another half-time psychiatrist and a nurse were added to the staff.

In designing the early-psychosis program, we identified and implemented five major program components: an attitude of hope, optimism, and respect; early treatment with effective antipsychotic medications used in a way that minimizes side effects; psychoeducation and counseling about the personal meaning of having a psychotic disorder; help in returning to vocational and educational activities; and involvement of families as key members of the treatment team.

As we worked individually with young people, we heard them asking, "Are there other people like me, who are going through the same experiences?" When we replied that there were, they were surprised. They had thought they were the only ones. When we asked them whether they would like to meet others with similar experiences, they said yes.

We brought together several clients to help us design a group program. They recommended that group sessions should be kept simple and should be designed to encourage informal discussion. They suggested that a professional be present at the sessions and that the sessions be held biweekly.

The early group meetings had a remarkable degree of openness and sharing about psychotic experiences. Several people said that they had not realized what their symptom experiences had been about until they had heard others talk about them in the group.

As the group progressed, the discussion shifted from past psychotic experiences to the issues of returning to school and work. Here it became evident that some people had moved further than others along the path of recovery. Those who were back at work were able to encourage others by providing role models. After several months, group members embarked on a project to develop a videotape about the group that would serve as an introduction to prospective members. The young people participated in filming and editing and contributed interviews and original music. The completed videotape is now used routinely with people newly referred to our program and is available from the authors.

Clients are made aware of the peer support group if program staff determine that the group environment would not be overly stressful. Participation is purely voluntary. In most cases, clients are ready to participate in the group within the first 12 weeks of treatment. In the 24 months that the peer group program has existed, 40 clients have chosen to participate in it.

In the first two years of operation, the program fully assessed 115 clients with early schizophrenia and schizophrenia-spectrum disorders. The symptom severity and general level of functioning of all clients entering the program were rated using standardized scales and were reassessed after three, six, 12, and 24 months in the program, as well as whenever a significant clinical change occurred.

Because the program has been active for only two years, long-term outcome data are only now becoming available. At six months, 68 percent of clients achieved a full remission of positive symptoms, and an additional 22 percent achieved significant symptom reduction. These results were sustained for clients who were in the program for at least one year. Hospital readmission rates for all clients have been less than 20 percent per year.

As is well known, recovery of social and occupational functioning requires a longer period of time than symptom reduction. Our experience has been that functional outcomes are strongly influenced by the age of the client and the level of functioning achieved before the onset of psychosis. Clients who were under age 19 when they entered the program (20 percent of all clients) almost all lived with their family of origin. Most of these families reported that their ill relative showed improved functioning at home and an ability to continue with his or her education. Most clients who were over 27 years old (20 percent) had established some degree of social and occupational independence to which they were able to return. However, many clients who were between age 19 and 27 had not yet left home or developed a consistent work situation, often due to prodromal dysfunction or an extended period of untreated psychosis. This group appears to have less success in recovering social and occupational functioning and will require more intensive psychosocial rehabilitation.

Dr. Whitehorn is a coordinator of the Nova Scotia early psychosis program and a member of the Research and Community Education Group, Nova Scotia Hospital, P.O. Box 1004, Dartmouth, Nova Scotia, Canada B2Y 3Z9. Dr. Lazier formerly was senior psychiatric resident with the early-psychosis program. Dr. Kopala is director of the Nova Scotia early-psychosis program and professor and director of research in the department of psychiatry at Dalhousie University in Halifax, Nova Scotia. Robert Paul Liberman, M.D., and Alex Kopelowicz, M.D., are editors of this column.