Transcript of Talking Heads with Dr. Noosha Niv – Episode 4

Family Matters: Transforming Schizophrenia Care

Announcer: This is Talking Heads. Explore the latest in research and policy about serious mental health disorders with Dr. Niv.

Dr. Niv: I am Dr. Niv and today’s guest is Dr. Lisa Dixon. Dr. Dixon is a professor of psychiatry at the Columbia University Medical Center and the director of the division of behavioral health services and policy research within the department of psychiatry. She also directs the center for practice innovations at the New York State Psychiatric Institute. In this role, she oversees activities for the New York State Office of Mental Health in implementing evidence-based practices for persons diagnosed with serious mental illness. This includes leading OnTrack New York, a statewide initiative designed to improve outcomes and reduce disability for the population of individuals experiencing their first episode of psychosis. Dr. Dixon is an internationally recognized health services researcher whose research has focused on improving the quality of care for individuals with serious mental disorders. with a particular emphasis on families, co-occurring addictions and medical problems and improving treatment engagement and adherence. She’s published more than 350 articles in peer-reviewed journals and has received numerous awards. She also happens to be one of the three people who inspired me to defer law school admission and study clinical psychology instead. So, I’m really grateful to your work.

Dr. Dixon: I hope you’re still happy about that.

Dr. Niv: I am indeed. Well, welcome. Thank you so much for joining me.

Dr. Dixon: Thanks for having me.

Dr. Niv: Can we start off by just what led you to psychiatry and then more specifically the focus on psychosis.

Dr. Dixon: Sure. What led me to psychiatry was my family experience. I um really didn’t know very much about mental health, medicine, psychiatry. I was an economics major at college. But around that time, one of my brothers to whom I was very close, we had six kids in our family and the brother who developed schizophrenia was like my twin two partner and everything, basketball, bridge. Um, he was closest to me in age and he was at college and toward the end of college started to develop now what we know are the signs and symptoms of schizophrenia. And it was a very very painful and difficult time for my family for a whole variety of reasons, not just because of my brother’s illness. And And we were so confused and didn’t understand what was happening. And that led me to medicine and psychiatry because I think it was just this massive ignorance and fear and also curiosity and desire to help him in some way even though I I don’t even know if I was conscious of that. But that’s what got me to psychiatry and psychosis in particular

Dr. Dixon: because that That’s what my brother was was dealing with. And just to give a one detail that was particularly painful and perhaps ironic, I don’t know, but he was in medical school. My brother was in medical school and he he just got tossed out. He just got sent home because he was unable to to complete the work. This was many years ago. I think it would have been done much more humanely now, but it wasn’t really done in a way that there was very little information, very little support and you have to remember he was an adult and I guess that part of the story also indicates why family support became so important and uh to me in in my work because we had so little of it. Yeah, it is it is very personal and I have learned over the years that for many people it’s very personal because mental illness is common and I tried to model and to help people feel like they can share it. It doesn’t have to be a big secret. Obviously, you know, you have to be respectful. If if it’s if you’re speaking about a family member or not yourself, then there’s issues around making sure that you’re doing that in a way that is respectful to that person. So, it does get complicated, but I I I have really tried to speak about my personal experience as a way to inspire other for people to feel comfortable to do that because if we don’t then we’re just contributing to the stigma and the secrecy and the and the suffering alone.

Dr. Niv: That’s right. That that sense of stigma I think because of that we don’t realize I mean you and I do but the general public doesn’t realize just how prevalent these conditions are.

Dr. Dixon: Mhm. I mean I was applying to psychiatry residency and I graduated from med school in ‘ 85. And I really was very unsure of whether I would reveal anything about my experience in the context of doing my interviews. Particularly at that time, it was somewhat scary because you didn’t know. Well, you still really don’t know, but I didn’t know how that would affect my uh applications. And ultimately, I was like, screw it. I’m just going to I don’t, you know, I don’t care. If they don’t want me, then I don’t want them.

Dr. Niv: That was brave.

Dr. Dixon: Yeah, maybe. But I I think it would have felt extremely dishonest and also really negating everything that my brother was going through if I didn’t speak honestly.

Dr. Niv: So, he gets sent home from medical school and does your family understand what’s happening? How did you or were there supports for your family?

Dr. Dixon: No. No, we didn’t know anything. We have a lot of graduate degrees, but we didn’t know anything. I mean, that’s it’s as simple as that. We did over the course of those early years explore different types of investing in different types of treatments and seeing what might be possible. But even then honestly it was clear that I mean my father died during this time so there was a lot of a lot of stuff going on but my mom and I didn’t really see that there was going to be a way forward that would make a big difference like we didn’t see that in terms of what was available and what options there were and and you know my brother’s been in the public system for most of his life. You know, he’s been supported by Social Security, SSI, SSDI, Medicare, Medicaid, etc., etc.

Dr. Niv: Since that time, what we know about families and care has significantly increased. And I don’t know if involvement of families in care has increased as much as we’d like. But what what do we know about involving families in care now?

Dr. Dixon: Well, there’s there’s a whole evidence base, as Noosha, you you well know, that I became familiar with when and I was involved with the schizophrenia patient outcomes research team which was a project uh led by uh Don Steinwalks and Tony Layman in in Baltimore and we you know it was sort of the the ports ushered in the era of evidence-based practices and you know it sound that sounds funny like now when was there not evidence-based practices but it was a way of thinking

Dr. Niv: it was novel at the time

Dr. Dixon: yeah I I mean the research was always there but it wasn’t conceptualized or packaged the way that it is now in terms of really okay what do we know about what works and trying to get what works implemented. So we had um a project funded by what was at that time called HCPR agency for healthcare policy and research and we were reviewing all of the studies of interventions for people with schizophrenia and their their families. And one of my pieces of that was to review uh the literature on what was called family psychoeducation. And so there was a fair amount of research done in many, you know, different places that tested these models of of essentially providing families with support, education, and problem solving skills. And those were three of the main components of these models that lasted anywhere from 9 months to two years. And they were offered to people with schizophrenia who then had to, you know, pro had consent and then which then engaged or brought in the family members to be a part of uh the treatment and to be you know to be partners really. There were many studies and it showed how powerful over and above medication these approaches were in reducing relapse and improving functioning and symptoms. So it’s important to note that those programs actually the the main target wasn’t the family well-being or family improvement. It was actually improving outcomes of the individual experiencing schizophrenia or psychosis or whatever.

Dr. Dixon: And so so there’s a a really robust evidence base I used to give this lecture when evidence-based practices failed. So there was this great model but nobody did it. Nobody. And and there were numerous efforts to implement family psycho education in different care systems. This was really quite remarkable. But it it just for a whole variety of reasons. You you could barely find a place where the clinicians would reliably even just contact the family, no less provide a, you know, a multi-element treatment approach.

Dr. Niv: So, it’s not because these individuals didn’t want their families involved, it’s the health care system didn’t support that.

Dr. Dixon: Yeah. Well, I mean, some so they may it may be said, well, the the patients didn’t give permission. Okay. But as I I always say to that and we we actually built this into an intervention later on. But if someone asked me whether I wanted my family to be involved in my psychiatric treatment, what I would say is it depends. Okay, I would, you know, I would be yes. Yes. But I would want to be able to be involved in setting the terms. And so the issue of our patients saying no because of the way that the question was asked or not asked or here’s the forms sign it. Well, what does the form say? Okay, so I’m just raising the issue that if people or you know, clinicians, and you know, I’m a clinician, too, says, well, you know, the patient didn’t want the family involved. I would like to know a little more about that.

Dr. Niv: Um, you know, how did

Dr. Dixon: how would you ask?

Dr. Niv: Yeah. And and how was that arrived at?

Dr. Niv: But then even if they said they do want their family involved,

Dr. Niv: where would they get those services, right? Like that’s that’s a bigger

Dr. Dixon: Exactly that they care systems weren’t structured to provide those services. People weren’t trained and I’m enough a part of systems now to understand it isn’t easy to make sure that all the practices that one is providing are cutting edge or people are well trained. I mean it’s it’s there’s a reality here but given the primacy of family particularly for young people who are experiencing psychosis that was just not okay to not put a lot, you know, put a substantial amount of effort into engaging and bringing families to the table

Dr. Dixon: because we know families want to be there.

Dr. Niv: Yeah.

Dr. Niv: Right. They they’re looking for support.

Dr. Dixon: Yeah.

Dr. Niv: So, so where does that leave families if the system isn’t supporting that? What what do you say to families who are seeking who are like your family who need it who need help?

Dr. Dixon: Well, I mean I can just say that I mean this then becomes a narrative of how my own sort of work evolved. So it was Howard Goldman and I and we were we sent out a survey to different states to find out whether they were supporting family psycho education and there wasn’t a whole I don’t remember all the data but there wasn’t a lot of it but what we did learn about was something called family-to-family which was the national alliance on mental illnesses family education support program and this is very different and I so I learned about this and I thought this was very cool because so this is not a clinical service delivered out of a a hospital or an outpatient clinic. This is a program of essentially peer support in the family space. So families supporting and teaching other family members. And this was developed. I mean there’s a whole history to it with Journey of Hope and and Joyce Berlin. I mean she’s a giant. Okay. So this whole evolution of this program that you know there were some issues and some politics and whatever but at the end of the day what we had was families helping families.

Dr. Dixon: And the beauty of what became the NAMI family-to-family education program, this is a pretty structured and replicatable program since it was organized around families and not from the clinic. The patients or the individuals with the illness didn’t have to give permission. Okay?

Dr. Dixon: And with all of what that entailed, it was really up the families could go get help and support if they wanted it. So, So that became a focus and was able to um work with Joyce and NAMI to say okay well here’s this intervention that people are getting and there’s no data there’s no we don’t have any information about its effectiveness so over really several years we did a series of studies first an open pre-post and then a study with a follow-up and then finally an NIH funded randomized trial of the NAMI family-to-family education program and that was very challenging for a whole bunch of reasons, but um I I’ll never forget this for the rest of my life talking to Joyce about whether she would agree to partner on a study of the family-to-family program. And she’s like, “This is not a program. This is a consciousness. This is a movement. This is a way of living. Like, don’t reduce it to a program with 12 sessions or 10 sessions.”

Dr. Niv: Oh, interesting.

Dr. Dixon: This is a way of of living in the world. And I said, “You’re absolutely right. Let’s work together. If together you don’t like the assessments and the outcomes or the the scales that that I would suggest, but we’ll measure whatever you want to measure.” And it it worked and it was very clear with this whole series of studies that family-to-family was empowering for families. Family to family,

Dr. Dixon: you know, increased the knowledge, the well-being, the skills of family members in and living with, you know, the situations that they were living with. And it wasn’t focused on one particular illness. That’s one of the nice things about family-to-family. And so the shift went from okay, we’re we’re in the system, family psycho education, this clinical model, and then okay, that’s that’s not happening. So what options do families have? And families clearly, at least where where NAMI was and wherever these, you know, where Nami could offer the programs. Families did have this potential option of a family support program which helped them and could also potentially help their loved ones. Although we tried, but we were never able to really do an adequately powered study where we could see the effect of the family-to-family program on the individual with the for whom the family member was attending the class.

Dr. Niv: So, we know there’s benefits for the family but not necessarily the relative.

Dr. Dixon: Yes. It’s not an unfair question to ask. I mean research imposes an artificialness in the delivery of what are these more organic types of programs and processes. And so it was very difficult to start with the family member as we were recruiting family members who were taking family-to-family class and get to the individual with illness. Uh we we just we had a hard time making that happen.

Dr. Niv: I would argue it’s not that important, right? Because the family outcomes are important.

Dr. Dixon: Mhm. Yeah. Yeah. I’m not saying the family outcomes are unimportant, but I do think that as a family member, the outcome of my brother is important to me. I want what I do to help him. Okay? And I think that’s true of, you know, most of us, if not all of us, right? And it would be nice to demonstrate that. And and honestly, you know, people take the family-to-family class who may or may not have any contact with their loved one who has I mean, the doors were open to anybody who felt they needed it. I I just I’m so proud of the work that this program does, the family-to-family program, and I’m proud that, you know, I was able to be a part of a team with NAMI to demonstrate that the model works and and helps people, but it still left this unresolved question of how to improve the clinical services, but that comes next. So,

Dr. Niv: you alluded to what I I think is reorder earlier. Um you developed this intervention. Can you talk about reorder and what it’s named to do?

Dr. Dixon: Yes. As a clinician and as a family member whose brother was, you know, in and out of services, it still just was really troubling that we had all of this potential to help family members within the system, you know, when people are suffering really and we weren’t doing it. So a number of us in your group and Shirley Glenn out in at UCLA and number of us who had been working in this space sort of got together and we were trying to figure out what to do and this was this was at the time of the role of peers as providers. You know it’s becoming more accepted and more understood how powerful this was and um we were all in the in the VA actually and so we developed an approach that was initially called family member provider outreach FMPO and the idea was that we had a clinician who was also a family member but who is the key provider or the key center of this strategy. Okay. So we had a particular someone with a particular experience, someone with the experience of being a professional but also being a family member. And then what we we built a program that was really centered on this notion of shared decision making. which was something that was starting to get play internally. Well, you know, you it’s like when you’re working with individuals, your job as a professional is to provide them with information, support, maybe some recommendations, but ultimately you you want to help them make a decision that aligns with their values and their goals. And it’s particularly useful when you have a choice of interventions that where there’s not one that’s clearly superior to the other in terms of outcomes.

Dr. Niv: Mhm.

Dr. Dixon: So the gist of it, the heart of it is helping the individual be a part of the decision-m process. That’s the key. So it’s not sticking a form in front of somebody and telling them to sign it. That’s that’s like the opposite of what it is.

Dr. Niv: I’m the expert. You do what I say. That’s not what we’re called for.

Dr. Dixon: Right. Right. Right. So we ended up and then the name FMPO didn’t really take so well. So we created a new name as you alluded to. It’s called reorder which is stands for recovery-oriented decision making for relative support. Recovery oriented decision making for relative support. So reorder and the idea was that this family member provider would connect with the patient, the service recipient and engage in sort of a shared decision-m process around including their family members in their care. And it was a structured very brief two to three session intervention very brief. Who who’s in your family, what are your goals, how can your family be helpful or not helpful, and you’re meeting your goals. So, it starts with the individual and and brings the family into the room, but tries to help the individual think about how their the involvement of their family and their care can be helpful to them or not. Like, as I say, it depends. Right.

Dr. Niv: Right.

Dr. Dixon: And so, you know, what we found was that that was a very powerful way to get uh service recipients to say, “Yeah, include my family and let’s do it this way.” And then we would do sort of the same kind of shared decision-making approach with the families, assuming that the participant said yes.

Dr. Dixon: And the idea here is that it there wasn’t just one way to do family services. It wasn’t just here’s your family group or here’s your cognitive behavioral session. It’s like there are different ways to have involvement and we wanted the participant and the family members to make some choices what worked for them. For some families, they just want to be able to talk to the doctor.

Dr. Niv: Yep.

Dr. Dixon: Others, you know, they really wanted to learn some skills. And so, we got a grant to study it and and we did find that it was was very helpful in maintaining care continuity and in improving involvement of families in care in the VA. And that reorder that approach has become the foundation of the approach that we use in our early psychosis program in OnTrack New York. And and just this idea that, you know, the notion that But we start with the individual and we try to help that person again think of the advantages and the disadvantages and and sort of what are the parameters and how can this work for me.

Dr. Niv: So systematically think through

Dr. Dixon: yeah and and in an empowering way so that they both hopefully can enjoy the benefits of their family support but also exercise control. Who who are we to say you know it’s justified or not, right? So, you know, it’s done in a respectful manner. It’s actually interesting now that I think about it ultimately, you know, we we felt like anybody could deliver this. It didn’t have to be a family member provider. In other words, you know, it’s it’s basically a a structured a fairly structured easy to follow intervention that was manualized. So,

Dr. Niv: so you don’t have to put those constraints on who’s delivering it.

Dr. Dixon: Right. Right. I mean, most everybody has a family member anyway, so it’s just what I want to I want to switch gears. Um I had the opportunity to work with you on the RAY study which is a very important study in the field of psychosis. Can you talk about what the goals of that study were and what you found?

Dr. Dixon: Um so RAY stands for recovery after an initial schizophrenia episode and there were two RA studies. One was led by John Kaine and it was the RAIS early treatment program study and and that study was a 34 site randomized trial randomizing 17 sites to navigate what we now call a coordinated specialty care program. It’s a multi-element multi-disiplinary team-based model and people at 17 sites got usual care. That was the most important raise study. I was not involved in that study. I was involved in a second funded study that was um a partnership of uh uh New York State Psychiatric Institute, Columbia and the University of Maryland.

Dr. Niv: So those two studies weren’t affiliated at all.

Dr. Dixon: No, no, they were not.

Dr. Niv: I did not know that till today. I thought this was like a different part of that study.

Dr. Dixon: No, no, no. It was it was complex. But initially the raise uh IEES study, the study that I was involved with was going to be a patient level randomization study that tested a model that added some care management, etc. But we ended up being able to deploy a program in Maryland and a program in New York and Our mission as per the NIMH was to create tools and resources that could be used to disseminate the overall model which were the models were actually fairly similar across both of these RAIS um projects.

Dr. Niv: And who are these models developed for? Who was the target?

Dr. Dixon: Well, RAID stands for recovery after an initial schizophrenia episode. So these programs were built and the whole history of it is Australia and Europe and we were behind The United States was not really at the forefront of developing and testing these programs, but they were for the most part built for people who are right at the beginning of the illness of either, you know, schizophrenia, schizoaffective disorder,

Dr. Dixon: uh, other types of, you know, psychotic disorders. There’s some differentiation in terms of the inclusion of people with affective disorders like major depression with psychosis or bipolar disorder with psychosis. But actually the the race studies really more focused on schizophrenia, schizoaffective disorder. So the the nuances and the details of who was included and who wasn’t um were a little bit different. For our study, people individuals who were within 2 years of the onset of psychosis were eligible. The raise UTP study focused more on um duration of untreated psychosis and exposure to antipsychotic medications. But the the important thing is that they were focused on people like my brother when he was in college and early med school who were right at the beginning of this illness, not getting any treatment at all.

Dr. Dixon: And you know, one of the foundational elements is that there’s an association between the duration of untreated psychosis and short and long-term outcome. So the idea here was to get people, you know, the right treatment at the right time. I’m sure many of the listeners are aware of how early psychosis care has is one of those things that sort of unlike family psychoeducation, which nobody was terribly interested in for reasons that, you know, think are probably we could probably speculate about but but early psychosis care did have an appeal did take off there was you know a real interest in it and I think that’s one of the you know I sort of feel like wow I’m so lucky that at this point in my career after all these years that I’ve had the opportunity to be a part of building something really positive and and now much more extensive than it was really wasn’t there wasn’t anything there were just Oregon you know, it was in a few places in the United States, but to have that opportunity and to see that and and of course in these early psychosis programs again now called coordinated specialty care in the US, you know, families of course are very important and there’s family support and it’s needed, family support is needed almost always, but maybe no more so than at the early onset

Dr. Niv: because often times they’re still living with their families.

Dr. Dixon: Yeah. Oh, yeah. Well, and In in our program at on track New York, the vast majority of individuals live with families. The age, you know, can go from whatever it is 15 to 30 35. And in our our program, I think the the mean age is is 20 or 21, but again, the vast majority of people are still living with their families, which you know, not surprising, but family support is critical. So, at least in that space, families are getting help.

Dr. Niv: Do want to ask you, you know, you mentioned family services, what are other components of these uh early interventions.

Dr. Dixon: They’re multi-element, multidisciplinary. So the components generally and you know they’re not cookie cutter. There’s little variations but they provide psychiatric and medical care. So medications and also there should be attention to physical health you know particularly since a lot of the medications contribute to things like metabolic abnormalities, weight gain etc. So we’ve got you know medication, physical health, supported employment and education is really key. or whether and how that’s you know the individual placement and support model is one way that one sort of approach um to providing supported employment and education but in other words the focus on work and school

Dr. Niv: okay appropriate for the developmental life development

Dr. Dixon: exactly exactly and then you have sort of psychotherapy individual and group psychotherapy and John Kane’s raise ETP program there’s a a really well um articulated specified psychotherapy therapy, the navigate model, individual resilience therapy, which I love that notion of resilience therapy,

Dr. Dixon: and some programs provide more, you know, a CBT model. Then you have again the family support

Dr. Dixon: and peer support was not really like a part of the original coordinated specialty care programs, but it clearly, you know, is now, I think, much more central or, you know, there’s many programs include the role of peer and peer support. So I think I’ve covered everything individual family support employment and education health meds peers. I don’t think I left anything out.

Dr. Niv: And part of the rationale for throwing all these services at people early on is because we we know that the longer they go untreated the worse outcomes, right?

Dr. Dixon: Yeah.

Dr. Niv: And you you mentioned that duration of untreated psychosis. We want to reduce that. And so to shorten that, we need to be able to have families or friends recognize or, you know, pe individual people recognize those signs and symptoms. So what what can people be looking for? You know, we don’t want to wait till someone’s like fully psychotic.

Dr. Dixon: Yeah. Well, that’s a very hard question. I I worked with a colleague who’s built an interactive website to help identify people and get them to care. And anyway, they ended up identifying a lot of people with mood issues. But I think that the way that we divide it the universe of of sort of the pathway to care is you have onset, help-seeking, care, and then specialty care. So these four steps. So how do you think about shortening the time from onset to help seeking? That’s tough, right?

Dr. Dixon: It involves not necessarily spending a lot of in the care system. It’s educating. It’s stigma reduction. It’s, you know, where are young people? Young people are in schools. They’re in churches. They’re in youth entities. You know, I’m not an expert on that part of the care pathway. Um, but it really involves the community outreach.

Dr. Niv: Yeah. And helping the individuals that, you know, potentially helpers who might interact with young people recognize, you know, what is it, you know, It’s not that common. I mean, depression is much more common. So, I think, you know, my my sense would be to really think about how to help people know who they can ask because people in the community aren’t going to be super super knowledgeable about all of these symptoms, but is there someplace they can go for help

Dr. Niv: or somewhere where they already are with someone who can understand that something might be going on?

Dr. Dixon: Exactly. Right. So, then then you have the step from help-seeking whether That’s with a priest again with a teacher. Then they have to know where to go or what to do. And so making the availability of services known and publicized and you want to perhaps you know some programs actually go and do presentations and talks in the community you know health care professionals you know pediatricians you know internist you know where do where do young people who are having these issues show up you know because they don’t they’re not going to wake up and say I want to go see a psychiatrist and then within the mental health system this is yet it’s also still a challenge for people to identify the constellation of symptoms that’s you know schizophrenia or schizophrenic form disorder once they’ve sought help in a mental health system it still gets missed and we also need to have specialized services so you know it’ be great to identify it but if there’s no specialized services or nowhere to give that person something that might you know really be very advantageous then if you’re going to identify something you want to have a service or a program to offer. So we at on track at least initially we we really focused on making sure that anybody who touched our system and you know the extended schools etc would at least have some knowledge about these programs and what to do if they encountered somebody who might need it. But you know we have an incredible tool with the internet and various forms of you know online communication and knowledge and education that I think you know, isn’t completely fully mined in terms of what it can do.

Dr. Niv: And thankfully, programs um like on track New York and other states have really adopted these early intervention programs unlike the family programs. And that really speaks to the importance of policy improving clinical care.

Dr. Dixon: Yeah, you’re I mean you I can’t say it any better than you just said it. The states with funds from the federal government in the form of the mental health block grant set aside, so additional dollars from the federal government to all the states to fund these programs. And you know, certainly there are there’s a lot of different ways that states have tried to do this, but I would say it’s it’s really quite impressive when you see how a handful of early psychosis programs in 2013, 2014, 2015, and now they’re all over the country. Now, I’m not saying that they’re available to everybody who needs it. They’re not, but it’s it’s night and day.

Dr. Niv: And the funding of these programs really followed what was attract tragic incident in this country that brought a lot of attention. Sandy Hook.

Dr. Dixon: Yeah. Well, we we in mental health, we have this very difficult relationship with violent events, right? Where there it’s horrific and just a a devastation. Some But sometimes they do focus our attention on mental health needs

Dr. Dixon: and so to that extent they can be useful in trying to accrue resources, but it shouldn’t have to be that.

Dr. Niv: It’s a mixed bag for sure. I want to switch. I only have a few minutes left with you. I have We’re not going to get to all the questions people ask, but let me ask a few of them. I don’t get it. What’s the difference between a first episode psychosis program, a coordinated specialty care for first episode program? This is all nomenclature. What is there any difference?

Dr. Dixon: There’s really no difference. I think think you just have to look at the details of, you know, sort of the inclusion criteria. I I don’t ever say first episode psychosis anymore because I don’t actually know what an episode is. So, I I think of it as early psychosis or, you know, I prefer if I have a few more words to use like again when an individual is experiencing the the firstish signs and symptoms of an illness that may turn out to be something like schizophrenia. It doesn’t have to be. We don’t know.

Dr. Dixon: But I wouldn’t spend a lot of time trying to kind of parse what’s first episode, what’s early psychosis. Coordinated specialty care, it’s maybe it’s worth saying that the notion of coordinated specialty care was kind of an invention of actually I think the National Institute of Mental Health when they were kind of describing these what these programs are and and they came up with this moniker coordinated specialty care which has these treatment elements that I previously described.

Dr. Niv: Meaning treatments coordinated between these different people, different aspects of functioning,

Dr. Dixon: different treatment components that are woven together in a team-based model. If you had said the phrase coordinated specialty care in 2010 or 2000, nobody would have known what you were talking about. So it it it just became a way to group what was different programs that had some common elements. Okay? And so they they said, “Well, let’s call these programs that have these common elements coordinated specialty care.” But if you were in Australia, they were doing first episode early psychosis care well before we were, but they don’t call it coordinated specialty care.

Dr. Niv: Okay.

Dr. Dixon: We call it that in the United States because that’s our shorthand.

Dr. Niv: Okay. I’m going to try to get in two last quickie questions if you can get quick answers. All right. Um, what are the risks of my teen taking medication so young and being on medication for his whole life? That’s kind of a complicated question to answer quickly.

Dr. Dixon: Yeah. First of all, when you take a medication today, you’re not making a decision for the rest of your life. You’re making a decision for today. And so I I think that I would be very cautious about saying to anybody you have to take medicine for the rest of your life.

Dr. Dixon: Again, I always say never say never. Never say always. So I don’t I I don’t think you need to necessarily ask yourself that question because things will unfold. Things will evolve. We’re not the same person today as we will be 5 years from now or tomorrow. And then in terms of taking a specific medication, well, you know, that becomes really an issue around again using shared decisionmaking. What are the risks? What are the benefits? What’s the data? What do we know about what works? What doesn’t work? And how what are your values? You know, you may say, and this happens all the time, I don’t want to gain weight. That’s a really important issue for me. So, I’m I’m not inclined to use this medicine, but I may be more inclined to use that medicine.

Dr. Dixon: So, I just I would get out of this mindset if you can that everybody knows what’s going to happen tomorrow. We don’t. And try to do what makes most sense today.

Dr. Niv: And So speaking of tomorrow, my last question that I ask everyone is what are you most excited about in the field of psychosis and that you think would have um it really has the potential to impact people’s lives?

Dr. Dixon: See, I don’t think that way. I don’t think in terms of singular things. I think in terms of being able to meet people’s needs. And so maybe that perhaps the thing that I’m most excited about is the possibility of offering these kind of services in ways that people, you know, regardless of their culture, their ethnicity, their sexuality, all these things that really matter, you know, that can be in some ways all things for all people, you know, that because of its flexibility and its ability to elicit and and demand that the individual is a part of the process.

Dr. Niv: Well, thank you so much for your time. I really appreciate you joining me and thank you, Dr. Dixon.

Dr. Dixon: Oh, well, thanks for having me. I really appreciate it.

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