The support, treatment, and resilience (STAR) program for youth at clinical high-risk of psychosis

With recently increased federal attention to early intervention for psychosis in the United States, clinics for youth in the initial stages of a psychotic disorder have emerged nation-wide. The goal of these programs is typically to reduce the duration of untreated psychosis, improve functional course and quality of life and, for youth at clinical high-risk (CHR), reduce the risk of progression to formal psychosis (Csillag et al., 2018). In 2012, the Psychotic Disorders Division at McLean Hospital in Massachusetts established McLean OnTrack, a coordinated specialty care program for individuals with first episode psychosis (Shinn et al., 2017). Unlike many first episode programs, McLean OnTrack is open to individuals whose presentations fall outside the schizophrenia spectrum, including individuals with affective psychosis (i.e., bipolar or major depressive disorders with psychosis) or unspecified psychosis. This transdiagnostic clinic has served >300 clients to date and is integrated with a robust biopsychosocial research program, including the Laboratory for Early Psychosis Center, which coordinates early psychosis research state-wide (Johnson et al., 2021).

In response to the success of McLean OnTrack and the need for more CHR services nationally, in 2019 we launched a new insurance-based clinic for youth at CHR, the Support, Treatment, and Resilience (STAR) clinic. The goal of STAR is to provide high quality, evidence-based outpatient services for youth ages 14–25 at increased risk for psychosis. Staffing has included psychologists, psychiatrists, and social workers representing a variety of expertise. Following the modular treatment approach recommended by Thompson et al. (2015), treatment includes a set of core components (e.g., specialized assessment using the Structured Interview for Psychosis-risk Syndromes [SIPS; Miller et al., 2003], psychoeducation, individual therapy, family support) plus additional modules (e.g., social skills support) as determined by the clinical formulation and clients’ unique strengths and goals. Pharmacotherapy is offered following a “minimum necessary” staging model (McGorry et al., 2013), with the goal of treating co-occurring symptoms and considering low dose antipsychotics in select cases. As STAR expands, we plan to offer group therapy, peer support, and training opportunities across mental health disciplines.

Outreach has focused on providing educational presentations to community clinics plus consultations for youth potentially at CHR. To date this has generated 121 referrals; of these, 83 (68.6 %) were not assessed with the SIPS, 38 (31.4 %) were evaluated with the SIPS, and 34 (28.1 %) presented with psychosis-risk symptoms following assessment and received intervention. Of the 83 referrals not assessed, reasons for non-assessment were missing for 4. The most common reasons for non-assessment among the remaining 79 were that the individual was more appropriate for a first episode program (48.1 %), declined services (13.9 %) or presented only with nonpsychotic symptoms (12.7 %). Referrals have come from McLean OnTrack, other McLean programs, and community providers, with occasional self-referrals. Each year since clinic inception we have observed a 50 % increase in the annual number of intakes, with 18 clients treated in 2021. Sixteen clients have been discharged following treatment; of these, 5 (31.3 %) developed psychosis, and another 3 required hospitalizations for nonpsychotic disorder, for a total of 50 % of discharged clients transitioning to later-stage psychopathology.

Several factors suggest the STAR program may contribute uniquely to the field. First, the clinic is situated in a tertiary psychiatric hospital which provides services for the full spectrum of psychopathology at all levels of care. Risk enrichment among clients will therefore likely be high (Fusar-Poli et al., 2019), consistent with the relatively large proportion who have developed psychosis or other serious symptoms to date. Furthermore, we anticipate referrals will continue to come from programs specializing in a range of diagnoses including affective, obsessive-compulsive, personality, and trauma syndromes. As clinical pathways to psychosis are heterogeneous, we may be uniquely positioned to identify subgroups and trajectories associated with these different histories through clinical work and research. Second, like McLean OnTrack, services are open to individuals presenting with syndromes outside the traditional CHR framework if determined to reflect the clinical complexity of a high-risk population. Evidence suggests that many individuals who develop psychosis may not pass through a conventionally defined CHR stage (Shah et al., 2022), and prevention of serious mental illness more broadly among youth with risk factors represents a critical area for clinical and research innovation. Third, although STAR offers consultation and assessment, services are treatment focused and are generating revenue through insurance reimbursement. This allows for flexibility in entry criteria, longer-term care and observation, and retention in ongoing and planned research studies.

Our goal is for STAR to be a thriving center for CHR intervention, training, and research. Each of these activities is already under way, and we are also collecting data to track clinical progress and shed light on referral patterns, diagnostic challenges, and individualized interventions. We hope that in conjunction with our clinical services, these activities will foster a meaningful contribution to the field of early intervention.