Meeting Teens Beyond the Clinic to Prevent Cannabis-Induced Psychosis

A patient enters an emergency room. He could sense he was in trouble. Things that weren’t there seemed vividly real, and voices that only he could hear were all around him. This temporary break from reality and his inability to determine what was real and what was not prompted his concerned parents to bring him to the ER, where the doctors were concerned about cannabis-induced psychosis. The came as a shock to his family, as there had been no prior indication that he was using any kind of substances. However, once his episode subsided, he admitted to frequent vape use. He reported he initially only used nicotine but began regularly vaping cannabis over the past year.   

It’s an issue that Boston Medical Center (BMC)’s Pediatrics and Psychiatrics team has seen all too often. 

That is why the director of BMC’s Wellness and Recovery After Psychosis (WRAP) program Hannah Brown, MD partnered with Amy Yule, MD, a child psychiatrist and Vice Chair of Addiction Psychiatry, with support from the Jack Satter foundation to design WRAP Without Walls (WWW).   

The WWW program aims to catch warning signs of substance use and psychosis earlier and make it easier for youth, teens, and their families to get the support they need before a life-changing episode. 

“What we’ve seen is that most of the kids that have engaged in WWW already have schizophrenia, and so we’re not catching them early enough,” says Yule. “And so, we have been working to increase awareness about some of the risks associated with today’s more potent cannabis, increase awareness in the community about cannabis-induced psychosis, and help strengthen this referral pathway to identify people earlier on.” 

Vape potency raises concerns for families, healthcare 

Vapes are particularly troubling for families because their discreet packaging and features make them harder to detect, which is one of the reasons they are popular among young people. They also have complicated potency regulations, which presents its own health risk. Think about alcohol, which does have standard public health regulations around how potent a drink is: Imagine a glass of wine had no limit to the amount of alcohol it could contain. A drink you may expect to have 3 to 8% alcohol could be anywhere up to, say, 80%— giving a whole new meaning to “just one drink.” 

“We recognize that it’s hard for kids and families to always make it to the hospital. And so, we are really excited to further develop our community-based program that has shown promise in increasing early intervention.”

Amy Yule, MD, Director of Adolescent Addiction Psychiatry at BMC

The world of cannabis limits in vape cartridges is a complicated one. Some states have specific limits on the amount of THC, the main psychoactive compound, allowed in various cannabis products, including vapes, but they vary and not all states have them. When use can be linked to several mental health issues, including psychosis, when started young, it means providers and families need to adopt a new approach to meeting this new reality. Because a psychosis diagnosis during this young age can be life-altering. 

“We’ve embedded in WRAP a first-episode program, which takes care of individuals within the first five years of onset of psychotic illness. Because after a first episode of psychosis happens, it can be really devastating. And it usually happens in a key time in their life, between 18 and 30 years old, during a very important developmental stage,” Brown explains. “It can be debilitating, but people also recover. And that’s the important thing. With treatment, people can recover.”

How WWW breaks down barriers to accessing treatment

What makes the WWW program unique is that it flips the traditional model of care on its head. Instead of asking participants to come into a clinic or hospital, WWW brings care directly to them — at home, in the community, or wherever they feel comfortable.  

It’s an adaptation of a community-based service model known as an assertive community treatment model (ACT). This model is an evidence-based approach used for people with serious mental illness. It has been proven to reduce hospitalizations, improve social and clinical outcomes, and yield high patient satisfaction.  

“We recognize that it’s hard for kids and families to always make it to the hospital. And so, we are really excited to further develop our community-based program that has shown promise in increasing early intervention,” Yule says. 

The goals of WWW are to identify youth and teens in need, build trusting relationships, and help them take the first steps towards recovery. The model is particularly vital for BMC’s patient population — 70% of whom are Black and/or Hispanic — because they are more likely to experience delays in diagnosis and less likely to receive a diagnosis at all.   

The care team’s peer support specialist meets with individuals wherever they are. Initial conversations are intended to build relationships and trust, so they’re often focused around hobbies, friendships, and family life, ideally so they can build a bridge to more difficult subject matter. This approach has been key in keeping this population engaged with clinicians and care.  

Another obstacle to treatment is that mental health and addiction services are not typically packaged together in health systems, which may lead to a host of access issues when seeking care for a dual diagnosis of psychosis and substance use disorder (SUD). With this in mind, the WWW program combines both mental health and SUD professionals into one multidisciplinary team of peer support specialists, psychiatrists, psychologists, nurses, social workers, and doctors. Together, they use a model of care known as coordinated specialty care to provide medication management, individual therapy, family therapy and education, peer support, support education, and employment services. 

Looking ahead thanks to philanthropy: clinical care, research, training, education, community outreach

The strength of BMC’s psychiatry department and its psychosis care have garnered generous philanthropic support from the Jack Satter Foundation. A recent $5 million gift will allow the department to strengthen all aspects of the WRAP program, including WWW. In the near term, the WRAP program will hire a new research director and research assistant to pursue investigative priorities that will drive targeted intervention strategies. 

“On a systems level, we are trying to accomplish two things: One, train care providers at various touchpoints to be able to identify at-risk patients and, two, train care providers on how to engage with at risk populations when they do present in the system,” Yule says. “In the community, we hope to conduct similar trainings with teachers and community leaders to accomplish the same goals.”  

“We’ll be able to serve a larger patient population and reach more people in the community. And not just patients, but we’ll also be able to engage family members and community leaders who come into contact with patients and potential patients. We’re moving forward with initiatives we’ve been planning but have been limited in our ability to do before now.” 

Hannah Brown, MD

They’re also designing a program that will involve community health workers (CHWs) on the WRAP team engaging young people with psychosis in the community, and a working with a community advisory board on tailored approaches to meet the needs in specific areas and among specific communities. 

Brown directly points to the new Jack Satter Foundation funding as a way the team can increase and better tailor their outreach efforts, making sure families, young adults with psychosis, and young adults who vape, and healthcare practitioners are equipped with the understanding and the resources they need to seek help. 

“We’ll be able to serve a larger patient population and reach more people in the community,” Brown says. “And not just patients, but we’ll also be able to engage family members and community leaders who come into contact with patients and potential patients. We’re moving forward with initiatives we’ve been planning but have been limited in our ability to do before now.” 

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BMC’s Department of Psychiatry has received a five-year $5 million gift from the Jack Satter Foundation, a long-term supporter of BMC, in support of its psychosis program, including Wellness and Recovery After Psychosis (WRAP). With help from a previous Jack Satter Foundation gift, in 2021 WRAP launched its community-based care model. The latest gift also will improve the lives of people far beyond Boston by strengthening our psychosis research, training, education and outreach. With their support of BMC’s psychosis care program, the trustees of the Jack Satter Foundation honor his interest in embracing complex and challenging issues.