EXECUTIVE SUMMARY

Case managers can help youth with mental illnesses transition into adult mental health services.

  • A case management-style program in New York works with youth, ages 14-25, helping them return to school or work after a psychotic episode.
  • Called OnTrackNY, the program is evidence-based and includes psychoeducation, therapy services, family services, medication management, and a focus on helping youth meet their goals.
  • The program aims to reverse the trend of a mental health diagnosis leading to multiple hospitalizations and a downward spiral.

Children and youths with mental health needs often have additional challenges, including an increased risk of hospitalization or ending up in the juvenile justice system. They also have difficulty transitioning and aging into adult mental health services.

About two out of three children and adolescents arrested each year have a mental health disorder, according to the National Conference of State Legislatures. Also, short-term inpatient psychiatric stays began to increase for youth in the mid-1990s, while older adult inpatient psychiatric stays declined in the same time period (1996-2007).1

A case management-type of behavioral health intervention can keep youth with mental health issues from being lost to the prison system or otherwise unable to live independent lives.

One such model is the work done under the OnTrackNY program in New York. The program specifically targets youth who are at that point of transitioning into adulthood, when they could flounder and be lost without professional guidance.

“We work with young adults, from 14 to 25, who are struggling with their first episode of psychosis,” says Stephen Smith, PhD, a licensed clinical psychologist with MHA of Westchester in Tarrytown, NY.

“We have a targeted early intervention program to get them in after their first hospitalization.”

One of the program’s chief goals is to help youth enroll in school or find a job, and it has an 80% success rate in doing so, Smith says.

The case management-style program includes psychoeducation, therapy services, family services, medication management with a psychiatrist, and a focus on helping youth achieve their goals, including finding jobs, returning to school, and improving their grades, Smith says.

The program is called OnTrackNY and it is an evidence-based team approach to providing recovery-oriented treatment to youths with emerging schizophrenia and/or symptoms including hallucinations, disorganized thinking, and unusual thoughts and beliefs.

“Seventy-five percent of our patients come from the hospital,” Smith says. “We see those from the hospital while they’re there, and we help them transition [as adults] to us rather than to an outpatient facility.”

Once these patients are discharged, MHA contacts them and provides them with a place to stay for at least two years as part of the transitional housing Apartment Treatment Program. The organization’s services are paid by Medicaid, and there are multiple locations, he explains.

The program also includes walk-in clinics, bilingual and mobile behavioral health services, support services led by peers, and home-based therapy options.

“Psychosis is one of those disorders that’s not well understood,” Smith says. “The go-to intervention has always been medication and hospitalization; years ago, a lot of these kids would have been on a direct pipeline to the hospital and more coercive, chemical-based interventions.”

Research shows that if youth with mental health challenges are provided with interventions early on, their entire life trajectory can change, Smith explains.

Previously, a psychosis diagnosis would usually result in multiple hospitalizations and a downward spiral.

“If you do it in the right way and present a more collaborative and warm environment, then you can get them to tap into their strengths at a time when they need it the most,” he says. “A lot of times these kids are considering college and are developing their identity when they have a psychotic break that causes a collapse as their whole world is turned upside down.”

Smith provides this case study example: One student came to the program after her parents’ separation led to her first psychotic break. “She had strong convictions about the government tracking her phone and her social media, and it was mixed in with depression and suicidal thoughts,” Smith says.

With psychosis, the patient went to the hospital as her life spiraled out of control.

“We set her up with a psychiatrist and different services,” Smith says. “We worked with her, starting small and focusing on her goals and how she could feel better about herself.”

One of the program’s strengths is that employees are trained to treat mental health in a non-stigmatizing way. For instance, staff addressed the young woman’s psychosis, but did so in a way that did not suggest she was sick. This lead to a lessening of the psychosis symptoms, leaving other issues that could be dealt with through a case management-type of approach.

“After a few months, she was able to hold a job for a while, and then she began to travel,” Smith says. “She can process what’s going on now and has her desires and dreams.”

The patient even began to look at online dating sites and has successfully started to live her life again, he adds.

Some of the program’s biggest effects occur within the first few days post-discharge from the hospital, Smith says.

The youth meet with a psychologist within that first week and also meet with a psychiatrist to establish their medications. Then they meet with a nurse and social support services to help the youth return to work or school.

“Our program is an evidence-based practice,” he says. “We look for individuals with a first onset of symptoms; by the time they start hearing voices, we want to make sure they have been seen and have received treatment within two years.”

An initial assessment is about understanding the cause of the psychosis. It could be substance-related, mood-related, or schizophrenia. Then the program’s staff educate the patients about how the program works and how its approach is recovery-oriented, Smith says.

“We engage in shared decision-making, where they are the ones at the head of the table,” he explains. “The decisions go through them; we have a hand in guiding them, but never do anything without their approval.”

After the initial assessment and meetings with professionals, patients attend weekly or bi-weekly individual therapy sessions. There’s also a social skills group available, and they’re encouraged to attend that. Dialectical behavioral therapy (DBT) is available for people with personality challenges, including intense emotional responses and interpersonal difficulties, Smith says.

“We help them with psychosis, social skills, interpersonal relationship issues, primarily with someone who is trained in cognitive behavioral therapy [CBT],” Smith says. “We use that approach to help them deal with their symptoms and also to provide case management; it’s 80% clinical and 20% case management.”

The case management part helps patients find housing and transportation and provides social services, including help with school and jobs.

“We have someone who helps the person with interviewing and advocates on their behalf,” Smith says. “If they can’t help them with homework, we also have a tutor who can help the person.”

REFERENCE

  1. Blader JC. Acute inpatient care for psychiatric disorders in the United States, 1996 through 2007. Arch Gen Psychiatry. 2011;68(12):1276-83.