Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today to highlight the Early Psychosis Treatment Program at Northwestern Memorial Hospital is Dr. Yu Jenny Zhang. She's an Assistant Professor of Psychiatry and Behavioral Sciences at Northwestern Medicine.

Dr. Zhang, it's a pleasure to have you join us today. As we get into this topic, and it's such an interesting topic, I'd like you to tell us a little bit about yourself. You started as a resident at Northwestern Memorial Hospital. What about your experience, the team, and the behavioral health program motivated you to stay on and join us in attending?

Dr Yu(Jenny) Zhang: Well, hi, Melanie, and thank you so much for having me. So, there were quite a few reasons as to why I chose to stay on at Northwestern as faculty after residency. Probably the most significant reason was the opportunity to continue working with the Recovery from Early Psychosis Program, or REP for short. Also, Northwestern Startup Package gave me a certain amount of protected time to do quality improvement research with the program, which was quite appealing.

Before I get into that, I do want to talk about why REP is so important to me. Before getting to work with REP during my later years of residency, I had the impression that psychotic illnesses were these devastating conditions that would inevitably rob an individual of many of the facets of life the rest of us find fulfilling, such as the ability to connect with others, having meaningful friendships and romantic relationships, supporting oneself independently, and pursuing a dream career. It really wasn't until REP that I came to see how function in these different areas of life can be preserved or restored with early intervention. It was very meaningful to be part of this as a resident and in many ways the whole person approach that REP takes with its participants has shaped the way that I work with all of my patients.

Melanie Cole, MS: Well, thank you so much for that, Dr. Zhang. I'd like you to expand a little on early psychosis as the criteria for a diagnosis. Please speak about how it's defined. And while you're speaking to other providers, give us some signs for primary care providers to be on the lookout, things that they might notice in their practice.

Dr Yu(Jenny) Zhang: So, some obvious signs of psychosis would be if a person is responding to internal stimuli, talking to someone who isn't there, talking to themselves, endorsing hearing voices, or having sensory experiences that are not consistent with reality. You might also see signs of paranoia, or signs of ideas of reference. So, that would be noticing special messages or signs in their environment, like hearing special messages meant just for them from the TV or radio. So, that would be one of the positive symptoms of psychosis.

Another thing that you can see is people really have trouble expressing themselves in a coherent way. There might be significant thought blocking, a lot of latency before responding. And people can appear very distressed or very apathetic.

Melanie Cole, MS: Thank you for defining that for us. Now, tell us a little bit about the Early Psychosis Treatment Program at Northwestern Memorial Hospital, how its unique approach, and you mentioned a little bit about that before, to managing psychosis is really something that other providers should look to.

Dr Yu(Jenny) Zhang: To understand what REP does, I should first explain why early intervention is important for psychosis. A lot of the times you will hear a neurologist say time is brain when it comes to stroke intervention. You know, the sooner you intervene, the better the prognosis. Well, the same can be said for psychotic disorders. The data is pretty clear. The sooner we can get a patient treated, the better their functional outcomes across multiple domains.

REP specifically is actually an occupational therapy-based program centered around a patient's personal values, strengths, and goals. So, every patient who enters REP is evaluated by an occupational therapist. Of course, every patient is also evaluated and treated by a psychiatrist and therapist, but that treatment is with the larger goals of the patient in mind. So from a psychiatrist point of view, I prescribe medications not just to control symptoms, but because well controlled symptoms might help a young person live the life they want to live.

There is also a significant peer support component of our program. In fact, most of our group therapies are led by or co-led by individuals with lived experience of psychosis. We have even had former rep patients decide to stick around and be peers. So, think about how powerful this might be for a young person struggling with psychotic illness to see others who have had the same struggles not only recover in terms of symptoms, but thrive by living full and meaningful lives. And actually, in some cases, people thrive functionally even without full symptom control, which really puts on its head how we conceptualize the management of psychotic disorders in the U.S. So, you also asked about how REP is a unique approach to managing psychosis. And I want to make clear the good reasons why I previously thought prognosis was hopelessly bleak for people with psychotic disorders. So, the overwhelming majority of patients who develop psychotic disorders in the United States do not get treated through an early intervention program such as REP. This is simply not the standard of care in the U.S. If you were to Google psychotic disorder treatment and click the first U.S.-based results such as WebMD, Cleveland Clinic, and even the NIH, which are all well-respected resources and institutions, the first bullet point that you're going to see under treatment is medications.

In the U.S., the cornerstone of psychotic disorder treatment is medications. Some people might also have access to therapy for psychosis if they're lucky enough to get in with someone, but that's pretty tough. Actually, if you were to look for a therapist through psychologytoday.com in Chicago, there would be well over 600 providers listed, but only 27 of these treat psychosis. I know because I actually just checked the other day. This limited access to care persists despite over 20 years of research clearly showing that multidisciplinary wraparound care through early psychosis intervention programs can make a really big difference in the course of a person's life.

If you were to go to the UK or Australia, early intervention programs are much more the standard of care. In the U.S., such programs are not funded through our current healthcare system. REP is one of the few early intervention programs in the city of Chicago and the only one, to my knowledge, that is affiliated with an academic center. The others are all non-profits and, similarly, REP services are primarily donor-funded. I would love to see programs like REP continue to improve and become the standard of care, and I hope to contribute to this goal in some way at Northwestern through our quality improvement research.

Melanie Cole, MS: Such a comprehensive approach. And Dr. Zhang, as you're talking about all of the people involved and you mentioned peer support, I'd like you to speak about the multidisciplinary collaborative program that includes so many specialists all working together and even some, as you said, with personal experience with psychosis and how patients are really benefiting from this collaborative approach of wraparound care. Speak about everybody involved.

Dr Yu(Jenny) Zhang: So to answer this question, I want to start by saying experiencing psychosis is often a very scary and derailing experience for a person and their family. Beyond the symptoms, treatment itself can feel very uncomfortable and dehumanizing. Medications often come with side effects and involuntary hospitalization is often part of the clinical course. This is why I think the multidisciplinary whole person approach is really key when it comes to early psychosis intervention. Care for each patient in REP is highly individualized. Each patient is expected to participate in their own treatment planning based on what they want for themselves, meaning we help them examine and harness their own values, goals, and personal strengths, and also identify areas for improvement.

We then provide them with the support they need through medication management, so working with a psychiatrist like myself, individual and group-based therapies, family therapy, education and vocational counseling, and a multitude of peer-based groups and supports. So, these include social outings and different peer-led group therapies that might play to different individual's interest. So, we have a resiliency training group, art group, games group, music and media group, a storytelling group, a peer support group, and more, all offered on a weekly basis. For many people with psychotic disorders, social isolation, loss of interpersonal connections and abolition are hallmarks of chronic illness, which lead to isolated lives on disability.

A major goal of REP is really to prevent disability. In a neuropsychiatric sense, we can think of our various approaches to care by different providers as different ways of stimulating and preserving brain circuits that get dysregulated in psychotic illness. We hope to help our patients preserve or improve social and cognitive functioning and develop the ability to pursue the life they want to live.

Melanie Cole, MS: What type of patient is a fit for this amazing program?

Dr Yu(Jenny) Zhang: This program is really meant for young people dealing with fallout from initial onset of psychosis. The basic criteria for consideration for REP are onset of psychotic disorder within 3 years of intake, and being ages 18 to 26.

Melanie Cole, MS: Now, if you were to take your vision and your hopes for the program, what would you like to see happen for this program over the next several years? How do you see it developing? What are your hopes for it?

Dr Yu(Jenny) Zhang: The program was started by and is run by Dr. Maury Goldman, a psychiatrist, and Lauren Walker, who is an occupational therapist. They're both still brilliant and have been such important mentors for me. And they have so many ideas of how REP can continue to grow in coming years, and I'm just really excited to be part of the team.

From where I sit, I see a few major goals that I'll talk about today. So, one would be just expanding services by growing our staff. So recently, two additional psychiatrists, myself and Dr. Robert Sobut, have joined the team. We have also hired an additional primary clinician, a coordinator for our peer support services, and significantly expanded our pool of peer leaders and supporters. We also formally instituted family therapy services. And overall, we hope to continue this momentum and grow the program so more patients in our geographical area can have access to this care.

Next, I'm personally interested, perhaps because of my research background, in examining various improvements we make to the program through a quality improvement lens. In this way, we can systematically look at what's working well and what needs adjustment for the sake of patient care. And perhaps because I'm an academic, I also strongly believe in sharing what's working well with the world through peer-reviewed publication. Along these lines, we are establishing several key collaborations, one with Implementation Science through Northwestern University, for the systematic quality improvement that I just alluded to.

The other is joining a larger consortium of early psychosis intervention sites around the country that is centrally organized by Dr. John Cahill at Yale. In this way, our anonymized clinical data can contribute to the larger efforts around the country to examine how early psychosis interventions are working. Who knows, it might actually lead to early intervention programs like REP finally becoming the standard of care in this country.

Melanie Cole, MS: How would you like other providers to refer a patient to the program? And I'd also like you to wrap it up for us with a summary. What you would like the key takeaways to be about this comprehensive approach for early psychosis at Northwestern Memorial Hospital.

Dr Yu(Jenny) Zhang: Really to get connected with REP is pretty simple, to call the intake for our Psychiatry Department and request to be scheduled for REP services. One key takeaway, I think, is to consider patients with psychosis beyond just their symptoms, you know, so considering them as a whole person. And the sort of other practical thing is to get patients with psychosis connected to treatment as soon as possible. And if possible, getting them connected to programs like REP that can provide more comprehensive care.

Melanie Cole, MS: Thank you so much, Dr. Zhang, for joining us today and telling us about the program at Northwestern Memorial Hospital. And to refer your patient, or for more information, please visit our website at breakthroughsforphysicians.nm.org/psychiatry to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please always remember to subscribe, rate, and review Better Edge on Apple Podcasts, Spotify, iHeart, and Pandora. I'm Melanie Cole. Thanks so much for joining us today.