Improving Access to Psychiatric Care for Teens with Mood and Anxiety Disorders

London’s First Episode Mood & Anxiety Program

Dr. Elizabeth Osuch

“My experience with this program is that it’s incredibly needed and it’s incredibly valued by the people who use the service. It’s also incredibly rewarding for us to treat these young people and it’s rewarding for the young people who are able to get their lives back.” Dr. Elizabeth Osuch.

In brief

When psychiatrist Dr. Elizabeth Osuch first joined the London Health Sciences Centre in 2005 as the Rea Chair of Affective and Anxiety Disorders, the mandate of her position was to conduct functional brain imaging research on mood and anxiety disorders. 

As her research progressed, she realized that the youth participating in her study were unable to quickly access the psychiatric care they needed. Some of the younger participants would end up on waiting lists that were one to two years long, others would wind up cycling in and out of the emergency department or would be referred to adult psychiatric facilities. So, Dr. Osuch expanded her research program to include clinical care and health care delivery evaluation research for youth with mood and anxiety concerns.

With this change, the First Episode Mood & Anxiety Program (FEMAP) was born in 2006. At full capacity, the program sees about 250 new youth per year. Through FEMAP, youth with mood or anxiety disorders in the London-Middlesex region are able to directly and rapidly access psychiatric care without a physician’s referral.

EENet’s Andrea Flynn has produced a new edition in the Promising Practices series, focused on this program and the approach it takes to providing services for youth with first episode mood and anxiety concerns. Click below to read the full story.

Promising Practices profiles innovative practices and initiatives from around Ontario.

Read it below or download the PDF.

About the program

When psychiatrist Dr. Elizabeth Osuch first joined the London Health Sciences Centre in 2005 as the Rea Chair of Affective and Anxiety Disorders, the mandate of her position was to conduct functional brain imaging research on mood and anxiety disorders.

Dr. Osuch wanted to identify brain changes resulting directly from these disorders as opposed to other factors associated with long-term mental illness, such as medication use or social isolation. As such, she began to study individuals aged 16 to 30 who were in the early stages of depression.

As her research progressed, she realized that the youth participating in her study were unable to quickly access the psychiatric care they needed. Some of the younger participants would end up on waiting lists for psychiatrists that were one to two years long. Others would wind up cycling in and out of the emergency department or would be referred to adult psychiatric facilities, neither of which Dr. Osuch viewed as user-friendly options for youth experiencing symptoms of mood or anxiety disorders.

So, Dr. Osuch expanded her research program to include clinical care and health care delivery evaluation research for youth with mood and anxiety concerns. With this change, the First Episode Mood & Anxiety Program (FEMAP) was born in 2006. At full capacity, the program sees about 250 new youth per year. Through FEMAP, youth with mood or anxiety disorders in the London-Middlesex region are able to directly and rapidly access psychiatric care without a physician’s referral. 

Program Details

Currently, FEMAP aims to improve access to treatment for London-Middlesex youth aged 16 to 25 experiencing early-stage mood and anxiety concerns who have not been treated for these symptoms for more than 18 months. Also, through ongoing research, the program is advancing knowledge of mood and anxiety disorders and models of care.

FEMAP is part of the London Health Sciences Centre’s Adult Mental Health Services and the Schulich School of Medicine and Dentistry at Western University.

FEMAP is modeled in part after London’s Prevention and Early Intervention Program for Psychoses (PEPP), a longstanding community-focused mental health program of the London Health Sciences Centre and Western University that provides rapid assessment and comprehensive treatment for individuals experiencing their first episode of psychosis.

“One of the things that we were finding, especially for students who are not from here and who don’t have a family doctor or don’t know how to access a family doctor, was that it was a long and complicated process to get in to see a psychiatrist,” Dr. Osuch says.

At FEMAP, rapid access to care is achieved through three defining features of the program:

1. Youth Can Self Refer

First, youth with mood or anxiety concerns can self-refer to FEMAP. Dr. Osuch explains that being able to directly contact the program without requiring a physician’s referral is crucial for meeting the needs of youth with mental health issues.

“One of the things that we were finding, especially for students who are not from here and who don’t have a family doctor or don’t know how to access a family doctor, was that it was a long and complicated process to get in to see a psychiatrist,” Dr. Osuch says. “It’s a very circuitous route for youth to get psychiatric care if they have to first receive a referral from another physician. We decided that this isn’t user-friendly for young people – they should be able to just pick up the phone and get in to see somebody about their concerns, who can determine what sort of treatment they might need. This self-referral piece is a really important part of FEMAP’s model.”

In addition to self-referrals, FEMAP accepts referrals from other healthcare providers, such as family physicians, inpatient hospital services, or social workers. In these cases, the youth must have a conversation with the FEMAP intake worker before an appointment is made, to ensure that the youth is motivated and interested in receiving treatment. 

2. Youth-Friendly Setting

A second key feature of FEMAP is that the program is discreetly located in a renovated house in the community rather than in a hospital. Dr. Osuch explains that hospital settings can be intimidating to youth, especially those experiencing symptoms of anxiety or depression. FEMAP’s private, house-based setting is well-suited to the target population, offering a quiet, comfortable, and welcoming environment. 

3. First Contact Involves Clinical Staff

Third, when a young person first comes to FEMAP they receive an in-person assessment with the program’s social worker. This ensures that the first person taking personal information from the youth is knowledgeable about psychiatric conditions and is skilled at engaging youth. This approach facilitates follow-through with services and is therapeutic in itself, as the initial assessment is often the first time the youth has shared their personal story about their illness with a professional.

FEMAP’s staff includes an addictions counsellor, a psychologist, a family therapist, a social worker, and three psychiatrists (including Dr. Osuch). FEMAP offers a range of services designed to provide client-centred care to youth with mood and anxiety concerns, including individual and/or family psychotherapy, medication prescription and monitoring, and substance abuse counselling.

FEMAP also has a resource library for youth and parents to explore at their leisure, allowing them to read and learn more about mood and anxiety disorders, substance use, and coping strategies. This resource library houses a SMART board with a computer projector for meetings so that FEMAP staff can communicate effectively with one another about complex topics.  

Providing rapid access to services and meeting clients’ specific needs

At intake, FEMAP’s social worker assesses the youth to find out what kind of distress they’re having, what kind of services they might need, and whether FEMAP is the right place for them. The clinical team then collaboratively develops a preliminary care plan based on the individual youth’s needs. This client-centred approach allows FEMAP to offer tailored treatments that address the youth’s specific issues, including, for example, co-occurring mental health issues, substance use problems, and history of trauma.

“For example, we might decide that a youth needs to see our addictions therapist before they see a psychiatrist. In fact, our data show that about half of the youth we see are at moderate to high risk for an addiction issue, and that’s after we’ve screened out youth that are presenting with addiction as their primary concern, in which case we refer them to a more appropriate service,” explains Dr. Osuch.

The waitlist at FEMAP is minimal, with youth typically seeing a psychiatrist within four to six weeks.  There is no limit on the number of sessions that youth can receive. The average duration of treatment is about nine sessions, although some youth require only a few sessions while others are with the program for years.

Data collected between 2009 and 2012 as part of a research study of their program show that, on average, the client base is 19 years old, with around 60% being female. While nearly 40% of their clients are referred by physicians or other health practitioners, around 60% are self-referrals. In all, FEMAP accepts 73% of all referrals, and refers 27% to other health practitioners that would better meet the client’s needs.

“One of the things we want to propose with the cost-utility analysis is that if these young people are not treated, they could end up coming in and out of the emergency department for years down the road,” says Dr. Osuch. 

Advancing knowledge of models of mental health care delivery and functional brain changes 

Ongoing research is also a core component of Dr. Osuch’s work at FEMAP, where she is conducting two programs of research.

1. Health systems evaluation research

The first is a series of health systems evaluation projects designed to assess FEMAP’s ability to help youth with mood and anxiety disorders recover through early intervention. This involves two stages, the first of which is complete and the second of which is ongoing.

The first stage of the evaluation showed FEMAP’s ability to conduct community outreach and receive appropriate referrals from youth and other sources, such as healthcare providers and family members. It also showed that the program connected these youth with needed services, either at FEMAP or from other healthcare providers. Some of the results from this phase of the research have been published in scientific journals, while others are currently in the process of being written up for publication.

For the second stage of the evaluation, Dr. Osuch and her colleagues are assessing FEMAP’s ability to help youth recover by looking at the client’s symptoms, their level of functioning, and their satisfaction with treatment before and after receiving services at FEMAP.

As part of this evaluation research, Dr. Osuch and her colleagues also hope to complete a cost-utility analysis to show the economic impact of early treatment for mood and anxiety disorders. Early results are promising, and Dr. Osuch hopes that the findings will help ensure FEMAP’s longevity in the London-Middlesex mental health care system. She also hopes that positive evaluation outcomes will help the program become a model of mental health care delivery for youth that can be used in other health care systems across the province and beyond.

“One of the things we want to propose with the cost-utility analysis is that if these young people are not treated, they could end up coming in and out of the emergency department for years down the road,” says Dr. Osuch. “We’re trying to prevent that from happening. And I think it’s quite possible to prevent that from happening. People get better when they’re younger, and people get better when they’re treated based on their clinical needs.”

“The participating youth are often excited about the suggestion that we may eventually be able to show there’s something going on with their brains and it’s not ‘all in their heads’,” says Dr. Osuch. “It validates for them that they are suffering from a medical condition, a real illness with a pathophysiological basis.”

2. Functional brain imaging research

Dr. Osuch’s other main research program involves studying functional brain changes associated with mood disorders. For instance, she and her colleagues are looking at connections between depression and self-injurious behaviour, the pathophysiology of the brain in mood disorders with and without regular marijuana use, and brain imaging of bipolar disorder compared to unipolar depression. This research has been well received by clients.

“The participating youth are often excited about the suggestion that we may eventually be able to show there’s something going on with their brains and it’s not ‘all in their heads’,” says Dr. Osuch. “It validates for them that they are suffering from a medical condition, a real illness with a pathophysiological basis.”

“I don’t think you can run a program for this age group without considering the addictions piece. I also don’t think you can do it without the family piece,” says Dr. Osuch.  

Learnings and challenges

FEMAP has evolved in some ways over time, based on their experience. For instance, the program originally accepted clients aged 16 to 30. However, Dr. Osuch began to see that people in their late 20s who were experiencing the first episode of a mood or anxiety problem were dealing with very different life issues than younger clients. Moreover, the older clients in this age range had access to other adult mental health programs in the community. To focus services on those who would benefit most from early services and for whom accessing services was particularly challenging, Dr. Osuch decided to narrow the program’s age range to 16- to 25-year-olds.

Another key lesson learned is the importance of having a multi-disciplinary team.

“I don’t think you can run a program for this age group without considering the addictions piece. I also don’t think you can do it without the family piece,” says Dr. Osuch. “A lot of young people are still highly reliant on their families, so it is important to take into consideration the family context of the problems the youth are experiencing in order to move them towards recovery. For example, a parent could be unintentionally engaging in behaviours that are enabling the youth in a way that isn’t helping them recover, so it could be that bringing the parent into the equation is critical to addressing the youth’s issues.” 

Notably, parents or other family members are only involved in clinical treatment at FEMAP if the youth provides written consent. Otherwise, services provided are entirely confidential and youth do not need to include their parents in treatment in order to access the program, as mandated by law.

The main challenge the program has faced, and continues to face, is unstable funding. The majority of staff members are available only a few days a week, and most are on “soft money,” such as private donations. Donations not only help support the staff complement, they have also funded the program’s resource library and other much-needed equipment and resources. 

Despite these challenges, Dr. Osuch remains a strong advocate of the need for early intervention programs for mood and anxiety issues.

“My experience with this program is that it’s incredibly needed and it’s incredibly valued by the people who use the service. It’s also incredibly rewarding for us to treat these young people and it’s rewarding for the young people who are able to get their lives back,” she says.

More information about the program can be found on their website – FEMAP – or by calling them at 519-646-6000, extension 65178.

Author: Andrea Flynn