According to the National Institutes of Mental Health (NIMH), three out of every 100 people will experience psychosis in their lives. Despite the number of occurrences, there is an unmet need to treat patients with psychosis, particularly patients on Medicare or Medicaid, or who are otherwise traditionally underserved. The Wellness and Recovery After Psychosis program – referred to as the WRAP program – at Boston Medical Center is working to meet those unmet needs with comprehensive care for patients with psychotic disorders.
NIMH defines psychosis is used to describe conditions that affect the mind, where there has been some loss of contact with reality. This, according to Hannah Brown, MD, Director of the WRAP program, is a really broad term.
“It can encompass anything from new, confusing, and disturbing thoughts and behaviors to hallucinations to delusional beliefs, often occurring in the context of a primary psychotic disorder. Many of our patients also have comorbid substance use, which can make it harder to distinguish a primary psychotic disorder.”
While services for psychosis have been available at BMC for many years, the official program began approximately a year and a half ago, when David Henderson, MD, a leading expert in psychotic disorders and chief of Psychiatry at the hospital, developed new services such as medication-specific clinics, with the goal of creating a structured program to care for patients with psychotic disorders. Henderson then recruited Brown, an expert in psychosis, from Massachusetts General Hospital to lead and further develop the WRAP program. As a result, WRAP has grown and now includes three subspecialty clinics– the Injection Clinic (for delivering long-acting antipsychotic medications), the Clozapine Clinic, and a First Episode Psychosis Program.
The Injection Clinic and Clozapine Clinic are both medication-focused clinics where patients can come to receive these specific treatments. In the First Episode Psychosis Program, WRAP clinicians care for patients in their first three to five years after psychotic symptoms start or after being diagnosed with a psychotic disorder. Most of these patients are 14-30 years old.
“There’s a growing body of evidence that coordinated specialty care is important for long-term outcomes, such as getting back to school or work,” says Brown. “Early identification and intervention is key to these outcomes, as well as retention in treatment, as early psychosis is a time people are particularly vulnerable.”
To this end, WRAP provides a team-based approach to first episode care where the team thinks of the patients as the hub with the providers as the spokes. Specific services include individual therapy focused on resiliency training, peer support, medication management, group therapy, and family therapy.
“Early psychosis can be a difficult time not just for patients, but for their families as well,” says Brown. “It can be frightening and confusing, but family support is essential. Our family therapy focuses on educating the family about psychosis as well as the best ways to help support the patient.”
Culturally competent care is also a major component of all types of therapy and education. WRAP provides therapy in Spanish and Haitian Creole, which provides both support in a patient’s own language and cultural insights that can impact care. This model helps fill the unmet need for psychosis care in BMC’s population.
“People conceptualize mental illness and psychosis very differently, depending on their background, including culture,” says Brown. “We work to understand patients’ individual and family framework and work within that, so that our treatment is compatible with their beliefs.”
Because the first episode program is relatively new, WRAP is still figuring out the best ways for patients to move on from these intensive services. According to Jessica Lewczyk, a nurse practitioner in the WRAP program, there are not many studies on when and how to move patients into a less intensive care model.
Because of this lack of research, the WRAP team plans to undertake research to better understand how to move patients out of the program. Brown and her team also aim to better understand barriers to care for psychotic disorders and how to best engage patients, as well as what population-level factors impact outcomes such as medication and therapy adherence.
WRAP plans to grow within the BMC and Boston community and become a resource for communities, health providers, and schools. They plan to provide community education on signs and symptoms of psychosis, as well as help other health care institutions implement their own care programs.
“There’s such as stigma around psychotic illness, and this country doesn’t do a good job of education,” says Lewczyk. “We want to provide community-embedded support, and to have people feel comfortable coming to us for care, like they feel comfortable coming to BMC for other health care.”