text: Acknowledgements Introduction 2 Early Psychosis Clinical Programs Calgary, Alberta 4-5 Halifax, Nova Scotia 6-7 Hamilton, Ontario 8-9 Lévis, Quebec 10 London, Ontario 11-12 Montreal, Quebec 13-14 Ottawa, Ontario 15 Quebec City, Quebec 16 Saskatoon, Saskatchewan 17 Toronto, Ontario 18 Victoria, British Columbia 19 Other Early Psychosis Initiatives British Columbia Early Psychosis Initiative 21-22 BC Regional Demonstration Projects: Central Vancouver Island 23 North West 23 Okanagan Similkameen 23-24 South Fraser 24 Vancouver/Richmond 25 Canadian Mental Health Association 26 National Project Ontario Working Group 27 Glossary 28 1 Over the past decade, recognition of the provide descriptions of their activities as importance of the early phases of psychosis appropriate. In compiling this Guide, to the subsequent course of illness and of balancing breadth with depth proved a the need to develop effective interventions challenge: in many instances, much more has grown at an ever-increasing rate in could be written. Canada and around the world. Now, many Basic elements of early psychosis interven- centres are gaining the knowledge and tion are either implicit or explicit in virtual- experience that will lead to an improved ly all of the initiatives. Elements include: capacity for the detection, treatment and ACCESS support of those encountering psychosis • Providing timely access to appropriate for the first time. The fact that psychosis clinical services most often emerges during adolescence and young adulthood, severely disrupting ASSESSMENT the course of these young lives, has been • Offering comprehensive assessment further impetus to the development of by trained clinicians effective intervention strategies. APPROPRIATE TREATMENT • Establishing a therapeutic relationship This Guide is an attempt to create a single, • Providing a multidisciplinary team comprehensive source of information approach to care regarding the many and varied early • Providing care in the least restrictive psychosis initiatives being pursued in environment Canada at this time*. The Guide is intended • Providing phase-specific, individualized to serve primarily as a reference tool for treatment that includes medication, mental health planners, practitioners, and psychoeducation and psychosocial decision-makers interested in developing or interventions expanding early psychosis strategies and • Providing services over time in order to services in their communities. consolidate and sustain gains The initiatives included in the Guide FAMILY ENGAGEMENT represent both clinical programs and • Engaging, educating and supporting broader-based projects which may or may families through the treatment and not include clinical components. An effort recovery process was made to become aware of and include NORMALIZED RECOVERY CONTEXT all Canadian programs and projects that • Supporting reintegration into school demonstrate a concerted focus on early and work activities psychosis intervention, though it is possible AWARENESS AND EDUCATION that some were inadvertently missed. As • Reducing the duration of untreated well, given that new initiatives continue psychosis and supporting recovery to emerge and existing initiatives continue through community outreach and to evolve, this Guide should be viewed as education a snapshot in time. Data presented herein • Providing opportunities for ongoing were collected during the latter part of professional development for health 2000 and some of the specific information care providers presented may already be outdated. For example, data pertaining to case numbers Programs and projects are listed alphabeti- will tend to be in constant flux. cally by location. Contact information is provided for all initiatives. Taken together, The information provided by clinical sites, the quantity and scope of the initiatives generated by means of a questionnaire, is profiled in this Guide attest to the high presented in a relatively standard format level of interest and activity in Canada with the exceptions of Ottawa and today and also serve to illustrate the range Saskatoon where services are at an earlier of initiatives that are possible given a com- stage of development. The program descrip- munity's resources and state of readiness. tions include a listing of basic program *For an international review of early psychosis programs, see data and clinical components, and some Edwards, J., McGorry, P.D., & Pennell, K. (2000). Models of elaboration of adjunct program initiatives. early intervention in psychosis: An analysis of service approaches. In M. Birchwood, D. Fowler and C. Jackson (Eds.), The broader-based projects were invited to Early Intervention in Psychosis: A Guide to Concepts, Evidence and Interventions. Chichester: Wiley & Sons Ltd. INTRODUCTION 2 Early Psychosis Clinical Programs 3 Early Psychosis Treatment Contact: Phone: & Prevention Program Dr. J. Addington (403) 670-4836 Foothills Hospital and Early Psychosis Treatment Fax: University of Calgary and Prevention Program (403) 670-4008 Dr. Jean Addington, Department of Psychiatr y Email: Program Manager Foothills Medical Centre firstname.lastname@example.com Dr. Donald Addington, 1403, 29th Street, NW Web site: Medical Director www.ucalgary.ca/cdss/epp Calgary, Alberta T2N 2T9 FIRST YEAR OF OPERATION STAFFING (FTEs) 1997 Nurse Case Managers 2.6 TYPE OF SERVICE Family Workers (MSW, MN) 1.5 Outpatient Group Therapist (MSW) 0.5 TYPE OF PROGRAM Psychologist (PhD) 0.6 Comprehensive population-based program Secretarial 0.7 Psychiatrists 0.7 CATCHMENT 930,000 KEY CLINICAL COMPONENTS PROGRAM ELIGIBILITY • Case Management 16 to 50 years of age; non-affective, first • Psychiatric Management episode of psychosis; hospitalized for a first • Medication Management episode; no more than three months of • Individual Family Work prior anti-psychotic drug therapy • Family Group • Individual cognitive-behavioural therapy PERIOD OF TIME BETWEEN REFERRAL AND ASSESSMENT Brief cognitive therapy is aimed at three Approximately one to two weeks areas: adaptation to the onset of psychosis REFERRAL SOURCES and its impact; treatment of secondary In-patient units (33%); family physicians; morbidity; and treatment of persistent community and outpatient psychiatry positive symptoms. services; community agencies; emergency • Group Programs rooms; families; schools Psychosis Education Group AGE OF CLIENTS AT ADMISSION Teaching patients about the illness 67.8% under 25 years of age Recovery Group OTHER CLIENT DATA 12 sessions addressing issues in the Gender - 66% male, 34% female early stages of recovery MAXIMUM STAY IN PROGRAM Moving On Group 3 years 12 session evening group addressing issues of later recovery for those who DIAGNOSIS AT ONE YEAR have returned to school or work 100% schizophrenia spectrum disorders: 40% schizophrenia; 39% schizophreniform; Substance Group 21% other psychotic disorders 10 session group to address issues related to substance use AVERAGE NUMBER OF NEW CASES REFERRED FOR ADDITIONAL INITIATIVES ASSESSMENT ANNUALLY Professional Outreach 120 When the program started, staff visited AVERAGE NUMBER OF NEW CASES ADMITTED TO the majority of mental health agencies, PROGRAM ANNUALLY hospitals, universities and colleges in 80 Calgary. Two years later, they sent letters ESTIMATED STANDING CASELOAD and an information brochure to these 170 settings, and offered to return for another visit. Family physicians who admit patients to Foothills Hospital were also sent the CALGARY, ALBERTA 4 brochure. Family physicians are a common referral source. Beginning in September 2000, in conjunction with the Canadian Mental Health Association, Alberta South Central Region, program staff have been providing educational workshops to teachers and guidance counsellors at the secondary and post-secondary level, as well as to community-based health and social service agencies. These sessions are designed to raise awareness and provide training to promote the early identification of young people who might be experiencing symptoms of psychosis. PRELIMINARY PROGRAM FINDINGS Mean duration of untreated psychosis (DUP) is 69 weeks; median of 20 weeks. Data indicate that 72% of clients are in remission at one year. SITE RESEARCH INTERESTS INCLUDE: Outcome evaluation; neurocognitive functioning; MRI studies; prodromal research; DUP and pathways to care; social functioning and social cognition. CALGARY, ALBERTA 5 Nova Scotia Early Contact: Phone: Psychosis Program Dr. David Whitehorn (902) 464-5998 The Nova Scotia Hospital Fax: The Early Psychosis Program and Dalhousie University (902) 464-6057 Nova Scotia Hospital PO Box 1004, Email: Dr. Lili Kopala, email@example.com Director 300 Pleasant St. Dartmouth NS B2Y 3Z9 FIRST YEAR OF OPERATION KEY CLINICAL COMPONENTS 1995 • Medical/psychopharmacological treatment TYPE OF SERVICE Outpatient • Patient and family psychoeducation • Access to 24 hr/day, 7 day/week TYPE OF PROGRAM on-call nursing Multi-component, case coordination • Peer Group Sessions - Clients can CATCHMENT participate in peer support group 850,000 province-wide; resource to sessions. Clients generally choose to 3 neigbouring provinces participate for a period of approximately PROGRAM ELIGIBILITY 6 months. Group size is small and 12-54 years of age; non-affective first activities are client-driven. episode psychosis; less than five years • Occupational therapy assessment and of drug therapy for a non-affective referral to community support programs psychotic disorder ADDITIONAL INITIATIVES PERIOD OF TIME BETWEEN REFERRAL AND ASSESSMENT The program carries out an extensive set One to three weeks of educational activities. The program has developed educational materials, including REFERRAL SOURCES a series of four 'fact sheets' for use in Psychiatrists, family physicians, school health facilities across the province, and a psychologists/counsellors, mental health video with discussion guide on psychosis. programs, families Educational sessions are provided on AVERAGE AGE OF CLIENTS AT FIRST ASSESSMENT request to groups or individuals. 21.6 years Family Information Sessions MAXIMUM STAY IN PROGRAM An ongoing series of education sessions Based on individual need has been designed for families and friends AVERAGE NUMBER OF NEW CASES REFERRED FOR of individuals experiencing first-episode ASSESSMENT ANNUALLY psychosis. The series consists of seven 120 two-hour sessions delivered one evening per week for seven consecutive weeks. AVERAGE NUMBER OF NEW CASES ADMITTED TO PROGRAM ANNUALLY Group size is generally from 12 to 16 50 people per series. Participants are encouraged to attend the full seven ESTIMATED STANDING CASELOAD session series. Since the sessions began 160 (includes active consultations)* in January 1999, 100 family members *Maximum caseload given current resources. have participated. Systematic evaluation STAFFING (FTEs)* of the sessions is carried out, including the use of standardized scales measuring Psychiatrist 0.5 families' experience of psychosis. Family Physician 1.0 Clinical Nurse Specialist 1.0 Family Support Group Education Coordinator 1.0 In January 2000, an Early Psychosis Family Occupational Therapist 1.0 Support Group was established. This group *Core funded positions. Additional staff funded from offers an opportunity for family members research grants/contracts. to continue with on-going education on HALIFAX, NOVA SCOTIA 6 topics of interest to them, to share PRELIMINARY PROGRAM FINDINGS concerns and information, and to In the first four years of operation, the provide mutual support to one another. program provided full assessments for 400 Early Psychosis Mentorship Program clients with schizophrenia and schizophre- This program is designed to provide nia spectrum disorders. Early outcome data mental health clinicians, representing a based on two years of program operation range of disciplines, with access to the suggest that 68% of clients had achieved latest findings regarding assessment and full remission of positive symptoms at 6 treatment of early psychosis. The program months, with an additional 22% showing consists of an initial introductory half-day significant symptom reduction. Hospital workshop, followed by a series of special- readmission rates for all clients have been ized workshops on a variety of topics less than 10% per year. tailored to the needs of participants. SITE RESEARCH INTERESTS INCLUDE: Participants have access to the clinic's Population health outcomes; clinical trials; consultative services for their own brain and cognition; family experience. practice. Participants are encouraged to network amongst themselves. Currently, a network exists of more than 200 mental health workers from throughout Nova Scotia and the Atlantic provinces who have participated. "Something is not quite right": Early detection of serious mental illness, including psychosis This half-day workshop program is designed for junior and senior high school staff (teaching and non-teaching) and university student services personnel. Since initiation of the workshop in February 1999, over 200 staff have participated from several school boards and universities in Nova Scotia. Sessions are case-based, highly interactive, multi- media presentations. Interested partici- pants are encouraged to attend the Early Psychosis Mentorship Program to obtain more in-depth information on specific aspects of assessment and treatment of first-episode psychosis. Annual Psychosis Conference The Fourth Annual Atlantic Canada Psychosis Conference was held in October 2000. This annual one day event provides a unique opportunity for mental health practitioners, family physicians, clients, families and interested community members to network and hear internation- ally known key-note speakers address the topic of early psychosis. The speakers also present interactive workshops during the conference. HALIFAX, NOVA SCOTIA 7 Psychotic Disorders Clinic (PDC) Psychotic Disorders Clinic Contact: Hamilton Health Sciences Outpatient Psychiatry Heather Hobbs Corporation, McMaster Site Hamilton Health Sciences Phone: Dr. Suzanne Archie, Corporation, McMaster Site (905) 521-5018 Clinical Director 1200 Main Street W. Fax: Heather Hobbs, Hamilton, Ontario (905) 521-2628 L8N 3Z5 Email Heather Hobbs at: Team Coordinator firstname.lastname@example.com FIRST YEAR OF OPERATION AVERAGE NUMBER OF NEW CASES ADMITTED TO 1990 PROGRAM ANNUALLY 25-30 FEP; (45-70 non FEP) TYPE OF SERVICE Outpatient ESTIMATED STANDING CASELOAD 100 active (38 FEP), 100 alumni (40 FEP) TYPE OF PROGRAM Care coordination and shared care STAFFING (FTEs) CATCHMENT Care coordinators (RNs) 1.8 160,000 Psychiatrist 1.0 PROGRAM ELIGIBILITY Family Educator (RN) 0.6 16-65 years of age; persons with psychosis Occupational Therapist 0.4 at any phase are admitted; program is Psychometrist 0.2 tailored to individual needs of clients at KEY CLINICAL COMPONENTS each phase, including early psychosis • Comprehensive assessment PERIOD OF TIME BETWEEN REFERRAL AND ASSESSMENT • Individual psychoeducation and support One to two weeks • Family psychoeducation and support REFERRAL SOURCES OF FIRST-EPISODE (FEP) CLIENTS (Family Educator role - see below) Family physicians (59%); in-patient (34%); • Negotiated treatment agreements emergency unit; schools, other • Low-dose, slow increment antipsychotic medications AGE OF FIRST-EPISODE CLIENTS AT ADMISSION TO PROGRAM • Support for reintegration (rehabilitation) <18 yrs 6% • Shared care with family practitioners 18-25 47% THE THERAPEUTIC PARTNERSHIP (TP) 25-30 17% The Therapeutic Partnership (TP) is an 30-35 15% evolving model developed by the Clinic to >35 15% address the complex needs of the client, OTHER CLIENT DATA family and treatment team members. It Gender - 57% male, 43% female; 33% of has been in use since the early 90s. It is first-episode clients using drugs/alcohol at a model guided by theories of coping and time of admission adaptation, and premised on shared power MAXIMUM STAY IN PROGRAM in the decision-making process in order As needed; active phase of treatment tends to empower all partners – client, family to range from 16 to 30 months; clients and team members – equally. It is guided then graduate to alumni status by a set of beliefs and values that includes DIAGNOSIS AT ONE YEAR respect, dignity, hope, empowerment, 74.5% schizophrenia spectrum disorders; consensual decision making and the 17% bipolar; 8.5% substance-induced well-being of all. psychosis All partners share a series of rights and responsibilities. The partnership is built AVERAGE NUMBER OF NEW CASES REFERRED FOR through the pursuit of five complementary ASSESSMENT ANNUALLY tasks: Alliance, Accompaniment, 155 (includes consultations) Agreement, Action, and Accessibility (the "Five As"). HAMILTON, ONTARIO 8 Therapeutic Partnership goals are to: • Share care effectively with family doctors • Provide an environment that will • Reduce client dependency on the "system" support recovery from psychotic illness • Provide support to GPs • Empower clients and members of • Support the health of a large number their natural social network of clients. • Prevent estrangement and social The Alumni Program rests on values of marginalization. health, recovery, hope, trust and empower- The TP model includes three phases ment, and partnership. A trusting relation- of intervention: assessment, treatment/ ship among clinicians, client and family rehabilitation, and an "alumni program". is requisite. FAMILY EDUCATOR DATA TRACKING The Psychotic Disorders Clinic (PDC) has Quality of life; client satisfaction; relapse developed and evolved a staff position rate; rehospitalization; ER use; suicide (and called "Family Educator" to specifically attempts); substance use provide professional support to families SITE RESEARCH INTERESTS INCLUDE: whose relative has experienced a psychotic Program evaluation; alumni study; family episode. The Family Educator provides and client satisfaction. instrumental and emotional support, education and advocacy for family members. This family-centered model of service provision overtly recognizes the needs of all family members and offers equal access to team resources during all clinical phases of assessment, treatment, rehabilitation and alumni follow-up. ALUMNI PROGRAM The Alumni Program is viewed as a novel approach to continuing care. In operation since 1993, it has served 100 clients and their families. It is premised on a chronic illness model, similar to approaches applied to chronic conditions such as diabetes, arthritis or asthma. Clients may choose to transfer to alumnus status as their active phase of treatment is concluded. The program is a form of shared care that involves a partnership among the client, family physician, PDC and other health professionals. Clients arrange a schedule of visits with their family physician and similarly negotiate a schedule for checking in with PDC at three, six or twelve month intervals. During these check-ins, the goals and treatment plans for the next alumni interval are negotiated. PDC remains an easily accessed resource to both client and family physician, and clients may return to active client status if necessary. Alumni Program goals are to: • Provide continuity of care • Empower clients toward the goal of health maintenance HAMILTON, ONTARIO 9 Le programme spécifique Département de Psychiatrie Contact: d'intervention Premier-Épisode* Hôtel-Dieu de Lévis Dr. Luc Nicole Hôtel-Dieu de Lévis 143, rue Wolfe Phone: and Laval University Lévis, Québec G6V 3Z1 (418) 835-7155 Fax: Dr. Luc Nicole, *First-Episode Specific (418) 835-7199 Program Coordinator Intervention Program FIRST YEAR OF OPERATION • Individual cognitive-behavioural therapy 1997 • Group interventions - two 1.5 hour TYPE OF SERVICE sessions weekly for an 8 month period Outpatient with 4 to 7 patients per group. Groups focus on developing cognitive, emotional TYPE OF PROGRAM and social competence required for inte- Case management, multidisciplinary team gration into school and/or work settings. CATCHMENT Group meetings are co-facilitated by an 210,000 occupational therapist and an educator. PROGRAM ELIGIBILITY ADDITIONAL INITIATIVES Age 16 years and up • Ongoing professional development PERIOD OF TIME BETWEEN REFERRAL AND ASSESSMENT for treatment team members through 4 to 6 weeks bi-weekly seminars • Awareness raising sessions are provided REFERRAL SOURCES Referrals generally come from outpatient to mental health teams from CLSCs clinic psychiatrists at Hôtel-Dieu. Initial (community health centres) assessments are performed at the clinic, • Family physicians are educated in a resulting in 100% intake of these referrals series of training conferences about to the First Episode Program. GPs tend to the early signs of schizophrenia. be the original source of referral to the SITE RESEARCH INTERESTS INCLUDE: outpatient clinic. Study of the evolution of the illness, tracking individuals for a 36 month period. MAXIMUM STAY IN PROGRAM Based on individual need, but generally clients are in the program for one year plus followup at regular intervals. AVERAGE NUMBER OF NEW CASES ADMITTED TO PROGRAM ANNUALLY 35 ESTIMATED STANDING CASELOAD 100 STAFFING RESOURCES INCLUDE: Psychiatrists, social worker, occupational therapist, psychologist, nurses, educators and a work integration specialist. KEY CLINICAL COMPONENTS • Comprehensive Assessment • Building a therapeutic relationship • Medical and pharmacological management • Individual psychoeducation for clients and parents • Multi-family group education LÉVIS, QUEBEC 10 Prevention and Early Contact: Phone: Intervention Program Dr. Ashok Malla (519) 667-6773 for Psychoses (PEPP) Fax: London Health Sciences London Health Sciences Centre (519) 667-6537 Centre and University 392 South Street Email: of Western Ontario London, Ontario firstname.lastname@example.com N6A 4G5 Dr. Ashok Malla, Web site: Director www.pepp.ca FIRST YEAR OF OPERATION DIAGNOSIS AT ONE YEAR 1997 87% schizophrenia spectrum disorders; 6% TYPE OF SERVICE substance-induced psychosis; 4% psychosis Predominantly outpatient, plus dedicated NOS; 2% bipolar; 2% delusional disorder beds within a 16 bed inpatient Psychosis AVERAGE NUMBER OF NEW CASES REFERRED FOR Unit in a general hospital (London Health ASSESSMENT ANNUALLY Sciences Centre). 85 (80-90) TYPE OF PROGRAM AVERAGE NUMBER OF NEW CASES ADMITTED TO Assertive case management PROGRAM ANNUALLY 55 (50-60) CATCHMENT 390,000 ESTIMATED STANDING CASELOAD 105* PROGRAM ELIGIBILITY *maximum treatment caseload given current resources. 16 - 50 years of age; non-affective, first- STAFFING (FTEs)* episode psychosis; no more than 1 month of prior antipsychotic drug therapy Clinical/Education Leader 1.0 PERIOD OF TIME BETWEEN REFERRAL AND ASSESSMENT Nurse Case Managers 5.0 48 hours maximum to initial screening Social Work Case Manager 1.0 assessment; telephone contact immediate; Social Worker (MSW) 0.6 location of initial screening assessment Clinical Psychologist (PhD) 1.0 varies as necessary (clinic, home) Secretarial 1.5 Psychiatrists 2.5 (plus Director) REFERRAL SOURCES *Outpatient services only. Inpatient staffing and Inpatient (41%); community physicians research personnel additional. (38%); family/self and schools (21%) KEY CLINICAL COMPONENTS AGE OF CLIENTS AT ADMISSION • Engagement and formation of therapeutic alliance <18 yrs 19% • Case management 18-25 47% • Medical/pharmacological management 25-30 13% • Patient and family psychoeducation 30-35 10% • Individual cognitive-behavioural therapy >35 11% • Group programs OTHER CLIENT DATA Gender - 75% male, 25% female; 71% of Recovery through Activity and Participation Group (RAP) clients using some drugs (mostly cannabis) The RAP group assists young clients with or alcohol at time of admission the transition back into their regular activities by focusing on the life and MAXIMUM STAY IN PROGRAM social skills that will help them in the Core program: 2 years. However, after 2 community. The group is offered as a years in the program, if a significant two hour session, twice weekly for degree of recovery has not been achieved, three months. clients can participate in one additional year of intensive case management. After Youth, Education and Support Group (YES) 2 to 3 years, patients continue in medical A series of 8 weekly two hour sessions are management with their respective offered to young clients to provide an psychiatrists in the Program. opportunity to discuss the issues they LONDON, ONTARIO 11 confront related to psychosis (e.g., stigma, and routes to recovery. Recently, a new peer group pressures, drugs/alcohol, etc.) video series with an accompanying written Each week a different theme is discussed. guide has been developed by PEPP to augment the family education process. Cognitively Oriented Skills Training (COST) These materials are best used initially by COST is a 10 week program for clients who staff with families, and later by families are preparing to return to school or work. on their own or in the context of a The purpose is to improve skills to compen- support group. sate for cognitive deficits. Family Support Group Multiple Family Group Interventions Initiated and maintained by PEPP family Beginning in January 2001, families who members, this group provides a great source have been with PEPP for two years or more of mutual support and encouragement. It will be invited to participate in regularly continues to prove invaluable in terms of scheduled multiple family group sessions. raising community awareness and advocat- ADDITIONAL INITIATIVES ing on behalf of the needs of their loved School-Based Awareness and Case Detection Program ones. It is also serving as a model to first- In 1997, the Program Director and staff episode families in other regions of the contacted one of two local school boards, country. For additional information, requesting permission to conduct a pilot contact Brenda Wentzell case detection project in its high schools. (email@example.com). Five schools participated. School officials, PRELIMINARY PROGRAM FINDINGS guidance counsellors and teachers first DUP Data and Remission Rates attended an information session focusing Mean DUP has decreased from 20 months on early psychosis detection and the (1997-98) to 15 months; median DUP importance of reducing the duration of from 7 months (1997) to 3 months (1999). untreated psychosis (DUP). One of the Significant difference in one year remission program staff then attended each school rate related to DUP observed: of those for 2 hours weekly as part of the school's entering the program with less than six regular guidance meetings. This process months DUP, 82% were in remission at facilitated a greater understanding of early one year compared to 58% of those with psychosis and improved the detection a DUP greater than six months (p< .03). skills among participating school staff, Hospitalization and strengthened the relationship between Hospitalization rates for initial treatment: PEPP and the community. 53%; 47% are treated as outpatients. Assertive Community Case Detection Program Readmission rates at one year: 15-20%. In January 2000 the Program launched an SITE RESEARCH INTERESTS INCLUDE: assertive case detection program in the com- Prodromal indicators; development of munity with a massive poster campaign, new psychosocial treatment strategies; use of local media - including 30-second longitudinal/epidemiological outcome television spots, public forums, direct con- studies; relationship between DUP with tact with all educational institutions, health cognition, quality of life, symptom profiles care agencies, and community physicians. and premorbid adjustment; effect of Extensive case detection materials have phase-specific treatment interventions. been prepared with assistance from families and clients. Information pamphlets have been delivered to most health and social service agencies in London, and made available to the public. Family Psychoeducation Workshop and Materials A one day, 8 hour workshop is conducted once every three months in an effort to inform family members and other interested individuals about psychosis, interventions LONDON, ONTARIO 12 Early Psychosis Intervention Contact: Phone: Clinic (EPIC) Dr. Marc Laporta (514) 842-1231 x4393 McGill University Health McGill University Health Center Fax: Center, Royal Victoria Royal Victoria Hospital, (514) 843-1644 Hospital, Allan Allan Memorial Institute Email: Memorial Institute firstname.lastname@example.com 1025 Pine Avenue West Dr. Marc Laporta, Montreal, Quebec H3A 1A1 Director FIRST YEAR OF OPERATION STAFFING (FTEs)* 1997 Psychiatrist 0.2 TYPE OF SERVICE Resident 0.2 Outpatient Nurse 0.1 CATCHMENT Occupational Therapist 0.4 Approximately 250,000 Community Worker 1.0 *outpatient staffing only. PROGRAM ELIGIBILITY As required: 17 to 30 years of age; recent onset of Psychological testing pre-psychotic or psychotic disorganization Psychologist/therapy of less than one year duration Social Worker PERIOD OF TIME BETWEEN REFERRAL AND ASSESSMENT Educator/teacher Two to three weeks; phone consultations Also, there is a nurse and occupational are available to the referring source in the therapist in a local CLSC who see some interim. of the patients. REFERRAL SOURCES KEY CLINICAL COMPONENTS Crisis Unit; regular out-patient department; • Establishing a therapeutic alliance Emergency Room; in-patient units and day • Medical and pharmacological management hospitals; CLSCs (community health cen- • Family education and support tres); schools; GPs • Individual cognitive therapy AGE OF CLIENTS AT ADMISSION • Individual supportive therapy • Occupational therapy groups <18 7% • Community-based networks of support 18-25 75% >25 18% ADDITIONAL INITIATIVES Community Linkages: Supporting Detection OTHER CLIENT DATA To enhance the chances of early detection, Gender - 66% male, 33% female EPIC has forged various links with commu- MAXIMUM STAY IN PROGRAM nity-based settings. It is working closely No predetermined maximum; stays have with the Quebec chapter of the Alliance ranged from 2 months to 4 years. for the Mentally Ill (AMI Quebec) who APPROXIMATE NUMBER OF NEW CASES REFERRED FOR have an educator who goes into schools to ASSESSMENT ANNUALLY give information about mental illness. EPIC 25 staff have been directly involved in infor- APPROXIMATE NUMBER OF NEW CASES ADMITTED TO mation sessions with teachers, along who PROGRAM ANNUALLY AMI-Q as well. They have also developed 20 links with school counsellors and some pri- ESTIMATED STANDING CASELOAD mary care settings such as Association 50 Quebecoise de la Schizophrenie, family medicine practices, local community health centers (CLSCs), crisis units and emergency rooms. They organize meetings in schools with teachers and administra- tors, and have developed links with CLSCs as well as possible to facilitate referral. MONTREAL, QUEBEC 13 Community Linkages: Supporting Recovery In order to counter the avoidance of high-stigma psychiatric services, EPIC has tried to create intermediate "holding environments" with agencies with which they form an extended team extending beyond institutional bounds. These include prominently the CLSCs, where patients can be seen while warming to the idea of treatment, and community support groups, where a normalizing stance is upheld - the main alliance here is with a group called "Projet-ARC" (Agency for Reintegration in the Community). Community-based reha- bilitation work includes behavioural work, as well as preparation for employment and academic support and short-term tutoring. SITE RESEARCH INTERESTS INCLUDE: Developing early markers for relapse; understanding the fit between help-seeking behaviour and interventions offered. MONTREAL, QUEBEC 14 Ottawa First Episode Contact: Phone: Psychosis Program Ms. Claudia Hampel (613) 737-8899 (Programme de la première Ottawa Hospital ext. 73062 intervention de la crise de 501 Smyth Street Fax: psychose, Ottawa) Ottawa, Ontario (613) 737-8085 The Ottawa Hospital and K1H 8L6 University of Ottawa Dr. Paul Roy, Director The Ottawa First Episode Psychosis will be available to support hospital Program/Programme de la première admissions for the Program as required. intervention de la crise de psychose Patients will only be admitted to hospital (Ottawa) is currently in the early stages if their illness is sufficiently severe to of implementation. The Program is actively render them a risk to themselves or supported by the Dean of Medicine and others. The attending psychiatrist from the Chair of Psychiatry at the University the Program will supervise inpatient care. of Ottawa, as well as The Ottawa Hospital A mobile team will be included in the and the Ottawa and Cornwall chapters program to perform assessments in the of the Ontario Schizophrenia Society. community and to support patients in The Program is included in the present their homes when necessar y. Functional Plan of the Ottawa Hospital – General Division. A formal application Referral sources will include emergency for expansion funding has been presented room physicians, community psychiatrists to the Mental Health Implementation and general practitioners, college and Task force in the Champlain Region. high school staff and the general public. This application will also be presented Referrals will be made directly through to the Deputy Minister of Health for Program staff via a 24 hour – 7 days Ontario in January, 2001. per week "hotline" which will be advertised to referral sources throughout The Program will serve the population of Eastern Ontario. Eastern Ontario and the National Capital Region, a catchment representing approxi- Multidisciplinary staff in the community mately 1.5 million persons. All services setting will provide care for patients and will be offered in both official languages. their families on an individual and group Criteria for program eligibility include: basis. Care will be provided for up to 3 age 17 years and up; first-episode psychosis years and will be tailored to the each with a maximum of 6 months prior treat- patient's specific phase of illness, including ment with anti-psychotic medication. the acute early recovery and late recovery The Ottawa Program will represent an or stable phases of illness. The key clinical assertive case management approach to goals will be to minimize duration of care. It will consist of a multi-disciplinary untreated psychosis, optimize recovery staff, including an attending psychiatrist, and reintegration for patients, and to case managers with nursing and social avoid hospitalization as much as possible. work training, an occupational therapist, The Program will also serve as an a psychologist, a data coordinator, a full educational and consultative resource time secretary, as well as a consulting for families and physicians throughout pharmacist. the entire catchment area. The Clinic will be located and provide most of its services in a community clinic setting. A maximum of six dedicated first- episode inpatient beds on the psychiatric unit at the Ottawa Hospital – General Site, OTTAWA, ONTARIO 15 Services cliniques pour les Polyclinique Sainte Anne Contacts: personnes en début d'évolution 65, Ste. Anne, 2nd Floor Marie-France Demers, d'une psychose, les proches et Québec City, Québec Pharmacist les intervenants du réseau* G1R 3X5 Xavier DeVriendt, Polyclinique Sainte Anne Psychiatrist Centre hospitalier Robert-Giffard *Clinical Services for First- Phone: and Centre de recherché Stage Psychosis Patients, (418) 691-0777 Université Laval Robert Giffard their families and Network Fax: Professionals (418) 691-2667 Dr. Roch-Hugo Bouchard, Director Email: email@example.com FIRST YEAR OF OPERATION ADDITIONAL INITIATIVES 1997 • Presentations and clinical training with GPs TYPE OF SERVICE • Plans to extend gatekeeper training Outpatient with access to beds at with school personnel, community psychiatric hospital pharmacists, community health CATCHMENT centre staff Over 600,000 SITE RESEARCH INTERESTS INCLUDE: PROGRAM ELIGIBILITY Psychopharmacology; medication trials; Over 18 years of age; first-episode psychosocial studies; genetic research. psychosis; schizophrenia focus PERIOD OF TIME BETWEEN REFERRAL AND ASSESSMENT Generally one to two weeks REFERRAL SOURCES Mostly GPs and inpatient unit of general hospital; will take family/self referrals OTHER CLIENT CHARACTERISTICS Many using drugs or alcohol at time of admission MAXIMUM STAY IN PROGRAM Two years NUMBER OF NEW CASES ADMITTED TO PROGRAM 500 admissions over a 40 month period STAFFING RESOURCESINCLUDE: Psychiatrists, nurses, social workers, occupational therapist, clinical pharmacists, neuropsychologist. KEY CLINICAL COMPONENTS • Multidisciplinary approach including medical, pharmacological, psychosocial, psychoeducational and family interventions • Psychoeducational groups • Family education and support - including home visits and groups • Client groups address: understanding the illness, anxiety management, substance abuse, social skills, time management, self-esteem, problem-solving, managing a budget and other issues related to integration. QUEBEC CITY, QUEBEC 16 Early Intervention Program Contact: Phone: in Psychosis and Rose Oxby or Dale Ziolkowski, (306) 655-8858 (Rose) Schizophrenia Community Mental (306) 655-8859 (Dale) Saskatchewan District Health Nurses Fax: Health (SDH) and Adult Community (306) 655-8875 University of Saskatchewan Mental Health Services Dr. D. Keegan 4th floor, 715 Queen Street Dr. S. Shrikhande Saskatoon, SK S7K 4X4 The Early Intervention Program (EIP) is an outpatient service which began in May 1999, functioning within the context of SDH, Mental Health Rehabilitation and Adult Community Services, the Department of Psychiatry of the District and University of Saskatchewan. The catch- ment of Saskatoon and surrounding region represents a population of approximately 225,000. All persons within the catchment who may be experiencing a first episode of non-affective psychosis, with symptoms of up to two years duration, are to be referred to the EIP for rapid evaluation, treatment and rehabilitation. The maximum stay in the program is two years. Referrals to the program must be made through family physicians or psychiatrists. Referrals are first contacted by telephone and the attempt is made to see the person within 72 hours. The program utilizes an assertive case management approach with intensive psychoeducation for clients and families. Staff consists of two community mental health nurses and two resource psychiatrists. In its first seven months of operation, 41 clients were participating in the program. The age range of clients has been 15 to 42 years. Key clinical components include medical and pharmacological management, psychoeducation (individual and group) for both clients and family members, and skill building (coping, stress management, problem solving). SASKATOON, SASKATCHEWAN 17 First Episode Psychosis Contact: Phone: Program April Collins, Manager (416) 535-8501 Centre for Addiction x4828 Centre for Addiction and Mental Health, email: and Mental Health Clarke Division email@example.com Clarke Institute Dr. Robert Zipursky, 250 College Street Director Toronto, Ontario M5T 1R8 FIRST YEAR OF OPERATION AVERAGE NUMBER OF NEW CASES ADMITTED TO 1992 PROGRAM ANNUALLY 150 TYPE OF SERVICE Outpatient plus dedicated first-episode ESTIMATED STANDING CASELOAD 12 bed inpatient unit 155 TYPE OF PROGRAM STAFFING (FTEs)* Multidisciplinary, time-limited case Psychiatrists 2.0 management Nurse 2.0 CATCHMENT Occupational Therapist 1.3 No restrictions, Toronto area, population Social Worker 1.0 4 million *outpatient staffing only PROGRAM ELIGIBILITY KEY CLINICAL COMPONENTS 18 - 45 years of age; first episode of a • Individualized, family-inclusive, primary psychotic illness; no more than multidisciplinary assessment three months prior anti-psychotic drug • Time limited (2 years) multidisciplinary therapy; not appropriate for those with care focused on optimizing outcome a mood disorder, a general medical • Menu of services provided which condition considered to be the cause of include individual and group approaches. their psychosis, or developmental delays These are tailored to the needs of the person and his/her family. PERIOD OF TIME BETWEEN REFERRAL AND ASSESSMENT Maximum wait of 2 weeks for outpatient ADDITIONAL INITIATIVES evaluation; triage system in place to Community Activities/Outreach deal with more urgent cases within one Activities include ongoing community work day. Clients are assessed in the outreach at different hospitals; an annual clinic setting. conference on first-episode psychosis that REFERRAL SOURCES is well-attended by a broad cross-section Family physicians (30%); in-patient (25%); of providers and educators (approx 200 emergency department (25%); community attendees); and extensive promotion of psychiatrists (10-15%); schools and the program across the province. community services (10-15%) SITE RESEARCH INTERESTS INCLUDE: AGE OF FIRST EPISODE CLIENTS AT ADMISSION The First Episode Psychosis Program has a strong commitment to clinical research < 16 5% into the mechanisms underlying the devel- 17-24 51% opment of schizophrenia and its treatment. 25-29 15% Neuroimaging approaches have been an 30-34 13% important component of this research 35 + 16% program and have been utilized to under- OTHERCLIENT CHARACTERISTICS stand mechanisms of treatment response Gender – 68% male, 32% female and to characterize the brain structure and MAXIMUM STAY IN PROGRAM function in schizophrenia. Understanding Two years the role of cognitive dysfunction in schizo- phrenia and characterizing the long-term AVERAGE NUMBER OF NEW CASES REFERRED FOR ASSESSMENT ANNUALLY outcome of schizophrenia are also major 200 priorities for this program. TORONTO, ONTARIO 18 Schizophrenia Service/ Contact: Phone: Early Psychosis David Butler, (250) 952-4410 Intervention Program Coordinator Fax: Victoria Mental (250) 952-4241 Victoria Mental Health Centre Email: Health Centre Dr. Richard Williams, firstname.lastname@example.com 2328 Trent Street Director Victoria, British Columbia V8R 4Z3 FIRST YEAR OF OPERATION KEY CLINICAL COMPONENTS 1995 with increasing focus and • Assessment specialization of services for first- • Case management episode cases since 1998 • Medical and pharmacological TYPE OF SERVICE management Outpatient, inpatient and residential • Psychoeducation for client and family • Group and individualized programs TYPE OF PROGRAM • Residential treatment (specialized for Case management, including medical first-episode) and psychosocial management ADDITIONAL INITIATIVES CATCHMENT • Community liaison/education 320,000 • Family support group PROGRAM ELIGIBILITY • Sibling support group No age restrictions • Educational retreats PERIOD OF TIME BETWEEN REFERRAL AND ASSESSMENT • Member of the British Columbia 2 weeks Early Psychosis Initiative REFERRAL SOURCES SITE RESEARCH INTERESTS INCLUDE: Most common source is GPs. National Outcomes study; medication trials AGE OF CLIENTS AT ADMISSION < 18 yrs 15% 18-25 45% 25-30 30% 30-35 10% MAXIMUM STAY IN PROGRAM Not specified AVERAGE NUMBER OF NEW CASES REFERRED FOR ASSESSMENT ANNUALLY 90 ESTIMATED STANDING CASELOAD Approximately 180 first-episode cases STAFFING RESOURCESINCLUDE: A coordinator, psychiatrists, case managers and access to psychologists, recreational therapy and occupational therapy. VICTORIA, BC 19 Other Early Psychosis Initiatives 20 The British Columbia Project Director: Project Manager: Project Coordinator: Early Psychosis Initiative Tom Ehmann, Ph.D. Laura Hanson, Ph.D. Josephine Hua, B.Sc. Mheccu, University Phone: Phone: Phone: of British Columbia (604) 877-3119 (604) 263-3502 (604) 822-1642 2250 Wesbrook Mall Email: Email: Email: Vancouver, BC V6T 1W6 firstname.lastname@example.com firstname.lastname@example.com email@example.com Web site: www.mheccu.ubc.ca BACKGROUND Regional component activities were The Ministry of Health's (MOH) Mental projected to include awareness education, Health Plan, announced in January 1998, clinical training, risk prevention and established a basis for examining mental community networking to improve identi- health issues involving early identification fication, referral, treatment, follow-up and and intervention for youth and young support services for young people with adults with mental illness. Historically, early signs of severe mental illness and early identification and intervention their families. services for youth and young adults with a PHASE ONE IMPLEMENTATION (1999/2000) serious risk for a mental illness have been Mheccu was contracted to assist the identified by the Ministry for Children and Working Group in planning and Families (MCF), particularly as they apply managing the implementation of EPI. to the development of youth transition At the regional level, lead MCF and Health services. These and other joint MCF/MOH Authority representatives were identified issues were identified in 1999/00 as priori- to work with Mheccu and the Working ties to be addressed in the Child and Youth Group to advise and collaborate on the Mental Health Plan to be completed in the development of EPI. fall of 2000. Based on the above processes, two types In 1999/00, consistent with the provisions of regional initiatives were established. of the Mental Health Plan, the MOH The first type labelled, "Strategically- undertook an initiative with one-time Targeted Initiatives" (STIs) involved funding of $1.15 million to further the a total of $552,922 allocated across all goal of developing prevention and early 18 Health Regions in accordance with a intervention services for young persons formula developed by the MOH, the (ages 13 to 30) at risk for severe mental Working Group and Mheccu in consulta- illness. tion with the regional representatives. A Provincial Inter-Ministry Working Group Funding was allocated partially (50%) co-chaired by MOH and MCF was identi- on the basis of the size of the target fied to direct the Early Psychosis Initiative population in each region (the 13 to 30 (EPI). Its overall purpose was to initiate a year old regional populations); and also process for ongoing regional inter-ministry allocated (50%) to ensure that each prevention and intervention efforts for this region had a basic allocation sufficient population. Partners with MOH and MCF to implement STIs. The awards ranged include regional health authorities, from $20,500 to $71,300. Ministry of Education, regional counselling and special service representatives, BC Regions were required to include basic Schizophrenia Society and the Canadian education and training activities Mental Health Association. Coordination addressing the following priorities: and implementation leadership is provided early identification, clinical skill building by the Mental Health Evaluation and and improvements in service delivery Community Consultation Unit (Mheccu), planning that would be reflected, in part, a Division of the Department of Psychiatry, in integrated regional comprehensive University of British Columbia. service protocols involving inter-ministr y providers. BRITISH COLUMBIA EPI 21 The second type of initiative labelled that clinician specialists will not work in "Demonstration Projects" (DPs) involved isolation as regular communication will be a total of $300,000 allocated to select developed among clinicians, tertiary centres regions. Through a competitive process, and local experts. Given regional coopera- the following 5 regions or macro-regions tion, these clinicians will be able to provide were funded to conduct projects designed services (e.g., in-home assessment and treat- to implement current best practices in early ment) that are not normally conducted. psychosis intervention during the 2000/01 3. Further development of educational materials and other fiscal year: South Fraser, Central Vancouver resources including: Island, Vancouver/Richmond, North West • Advanced training materials and Okanagan/Similkameen. Funding allo- • Web site enhancement (including cations ranged from $19,000 to $81,000. discussion groups) To assist regions in implementing their • Modification and translation of materials regional initiatives and projects, Mheccu to make them more culturally appropriate developed a series of educational materials • Support to the Ministry of Education's and a web site (www.mheccu.ubc.ca). Most school counsellor training on early of the materials developed are currently psychosis available to the public free of cost on the 4. Evaluation of Year 1 Strategically Targeted Initiatives and the web site. Demonstration Projects PHASE TWO IMPLEMENTATION 5. Continuation of regional initiatives (e.g. Year 1 Strategically Targeted Initiatives) MCF and MOH announced additional In order to support the continuation of one-time grant funds totalling $350,000 to regional EPI initiatives, $130,000 will be Mheccu to further the development of EPI directly distributed to the 18 health regions. ($200,000 from MCF; $150,000 from MOH). These funds are to be utilized to further the The primary goals to be attained with goals of the Strategically Targeted Initiatives these funds are: as outlined in Year 1. These include work on: 1. The development and dissemination of a document outlining systemic issues (i.e., regional committee the goals and procedures for implementing best current practices formation, referral pathway refinement, in early psychosis child-adult system bridging, etc.), identifica- This document is a very important element, tion training and clinical skill building. along with the EPI Framework, in mapping out service directions and guiding everyday clinical practices. 2. Intensive and ongoing clinical training organized by Mheccu A number of comprehensive and sophisti- cated assessment and treatment approaches have been developed around the world. Service providers in B.C. deserve support in learning and implementing these procedures. The Mheccu training will be much more in-depth and practical than the types of sessions generally presented in Year One. The training will focus on skill development among the attendees. In order to provide a high quality educational experience, attendance will be limited. Regional EPI committees will decide which service providers from each region will attend. The underlying objective is to establish pockets of clinical expertise in early psychosis across the province – establishing an interactive "network of excellence". It is envisioned BRITISH COLUMBIA EPI 22 BC EPI Regional On-Board Contact: Phone: Demonstration Projects Margaret Derocher, (250) 709-3040 CENTRAL VANCOUVER On-Board Coordinator Email: email@example.com ISLAND CENTRAL VANCOUVER ISLAND access to treatment services provided in There are two components to the project: the least restrictive environmnent; and Assessment in Early Psychosis the development of consultative and To examine the predictive validity of education services to rural health neuropsychological measures, intake practitioners. Team members include a psychological assessments of persons seen co-ordinator, psychiatrists, an occupational at the Victoria Early Psychosis Program will therapist, case managers and psychologists. be compared with functional outcome Program components include direct access measures taken one year after discharge. to initial triage, intake assessment within Also, local assessment teams across 36 hours of referral, multi-disciplinary Vancouver Island will be trained in com- team assessment, assertive case manage- prehensive multi-disciplinary approaches ment for up to two years, group therapy to early psychosis assessment. for clients and families, and assistance with rehabilitation goals and access to Non-Urban Pilot Project service. The On-Board Program is The On-Board Program at Duncan will be especially concerned with bridging evaluated as a model of rural service deliv- the service delivery gaps that can ery. The On-Board Program is intended to occur between child and adult mental promote early psychosis awareness; optimal health systems. BC EPI Regional Contact: Phone: Demonstration Projects Marsha Lloyd (250) 638-2202 Email: NORTH WEST email@example.com NORTH WEST and treatment. This pediatrician would Early identification and intervention of then provide both direct services to first- psychosis in the North West is impeded episode clients and act as a regional by the scarcity of psychiatric services in consultant for family physicians and this region. The project consists of the mental health clinicians working with intensive training of a local pediatrician first-episode clients. in first-episode psychosis assessment BC EPI Regional Contact: Phone: (250) 860-7549 Demonstration Projects Alice Jensen, Fax: (250) 868-7791 Early Psychosis Email: OKANAGAN Coordinator firstname.lastname@example.com SIMILKAMEEN OKANAGAN SIMILKAMEEN of this project were to: promote the early This region in south central British identification and treatment of symptoms Columbia represents a catchment area of of psychosis; reduce delays and improve approximately 110,000 people. Before this access to treatment; reduce the frequency project began, the wait for appropriate and severity of relapse; reduce the burden treatment was often extensive, especially to caregivers and promote family well- for non-urgent cases. The main objectives being; and reduce the incidences of BC EPI REGIONAL 23 secondary morbidity and disruptions to • Treatment may involve home or social and vocational functioning. In order community-based treatment by a mental to build community awareness of this health clinician (daily to bi-weekly visits). initiative, educational seminars have been • An integrated treatment approach will provided to as many service providers as involve the client, family, family possible, including the dissemination of physician, psychiatrist, psychologist, educational materials. occupational therapist, and other This is a community response project that professionals as required. will be in service from June 2000 to March • Education of both the client and family 31, 2001. It involves developing the follow- members is seen as an important ing service for clients who are experiencing component in this treatment approach. their first episode of psychosis and their • Once the individual is stabilized, they family members (or other such caregivers): will be offered the support of a trained peer support worker. • A rapid response team will conduct initial assessments in the person's home Data being collected include rate of or other community setting (including inappropriate vs. appropriate referrals, the hospital) within a 24 hour period compliance with medication or for acute cases and within a one-week psychosocial interventions, psychological period for non-acute cases. Both adult testing results (every three months), and adolescent cases will be accepted. reintegration to normal routine, and • A psychiatric assessment will be satisfaction of both client and family conducted within a 48 hour period. members with the service. BC EPI Regional Contact: Phone: (604) 951-5844 Demonstration Projects Karen Tee, Fax: (604) 951-5917 Demonstration Email: SOUTH FRASER email@example.com Project Coordinator SOUTH FRASER Services are provided by a specialized The South Fraser Region has a population early psychosis clinician, mental health of 575,000 and represents a range of clinicians, and psychiatrists. Each of the urban and rural areas. Prior to this five communities in the region has an demonstration project, people would identified mental health clinician and a access services through a variety of routes. psychiatrist who undertake primary care One of the main objectives of this project of each case. In addition to psychiatric has been to establish a single point of and psychosocial interventions, psychoe- entry to assessment and treatment for ducational sessions are provided to clients youth and young adults suspected of and their families on individual and experiencing a first episode of psychosis. group bases. Education and training pro- The program offers services to persons vided to professionals and community 13 to 30 years of age. The single point of agencies through the EPI educational ini- entry intake process makes access easier tiative have helped to support early iden- and there is no waitlist for those at risk tification and case referrals to the project. for a first episode of psychosis. Referrals The project has two additional compo- are accepted from families and individu- nents: case finding - which is directed at als as well as a variety of professionals in two targeted high risk populations aged the community. The intake clinician tries 13 to 30 (genetic risk and/or substance to make contact with the referring source abuse risk); and, a treatment comparison within 48 to 72 hours. study evaluating the impact of psychoed- ucation group interventions. BC EPI REGIONAL 24 BC EPI Regional Contact: Phone: Miriam Cohen,Coordinator (604) 822-9732 Demonstration Projects Web site: Email: VANCOUVER/ HOPE – Helping to Overcome firstname.lastname@example.com RICHMOND Psychosis Early www.hope.vancouver.bc.ca/hope/ VANCOUVER/RICHMOND Interactive Web Site There are three components to this project: The web site will provide general informa- Appointment of a Regional Case-Facilitator tion and responses to specific questions This individual will act as a resource for about diagnosis and management of early front line workers, will advise about the psychosis to clients, family members and management of individual cases and broker front line professionals. needed services when a provider is unable The project provides consultation, assess- to deliver such services. ment, initial treatment, support, education and resource materials for clients, their First-Episode Rounds families and the community. Clinicians Monthly rounds for professionals to can refer directly to the case facilitator. present and discuss challenging cases. The program is accessible to clients aged 13 to 30. BC EPI REGIONAL 25 Canadian Mental Phone: Calgary Site Coordinator: Sandy Bray Health Association (416) 484-7750 Phone: (403) 297-1716 National Office Fax: Email: email@example.com 2160 Yonge St.,3rd Floor (416) 484-4617 Manitoba Site Coordinator: Sharon Mulder Toronto, ON M4S 2Z3 Email: Phone: (204) 878-9239 Contact: firstname.lastname@example.com Email: firstname.lastname@example.com Elizabeth Lines, Web site: Fredericton Site Coordinator: Jean McBrine National Project Manager www.cmha.ca/english/ Phone: (506) 458-1803 research/projects.htm Email: email@example.com CMHA's early psychosis intervention for early psychosis activities. In Calgary, project, funded by the Population Health CMHA personnel have been working Fund of Health Canada, is a 26 month directly with staff from the Early Psychosis national initiative which began in February Treatment and Prevention Program at 1999. Clinicians from clinical/research Foothills Hospital to train high school sites in Alberta (Calgary), Ontario teachers, counsellors and other gatekeepers (Hamilton, London, Toronto), and Nova in early identification skills and promote Scotia (Halifax) are among the advisors access to the Foothills program. In to the project. Fredericton, through the work of the local project working group and with the sup- The project is intended to raise awareness port of the provincial government, clinical among professionals, families and other services are being reorganized to accommo- community members regarding the impor- date early psychosis services and the tance of early psychosis intervention, and education of mental health professionals, promote access to appropriate first-episode gatekeepers, and the community at large services, with a focus on youth. Toward is underway. this end, project activities are centred on the development and dissemination of The province of Manitoba does not yet educational resource materials, the facilita- provide a coherent set of services for tion of local early intervention activities young people with early psychosis. There, through three CMHA sites, and the a project steering committee, representing development of a national network of a wide range of stakeholders, has been interest and information-sharing. working to raise awareness regarding the importance of early identification and the In terms of resource materials, the project need for appropriate services for youth. has produced a series of three pamphlets Key objectives include community and an introductory document on early education, gatekeeper training, and psychosis. The pamphlets are available in service improvement. A family support English, French and Chinese. The project group, modelled on the PEPP group (see has also provided support for the produc- London, Ontario program description) has tion of a national, first-episode family been initiated by family members in the newsletter. A video resource for parents Winnipeg region. These families are new to the experience of psychosis in the linking with families in London (Ontario), family is now available. Finally, this Guide Halifax (Nova Scotia) and elsewhere in the is also a product of the project. Most of country to establish a national first-episode these materials are available on the CMHA family network. The family newsletter web site (www.cmha.ca) in both official (see above) is a component of this national languages. networking initiative. The three CMHA sites participating in the Through its broad dissemination of project are: Alberta South Central Region resource materials, facilitation of national in Calgary, Alberta; the provincial-level and local level alliances, and site-based Manitoba Division; and Fredericton/ activities, CMHA's national project has Oromocto Region in Fredericton, New been helping to build awareness of the Brunswick. Sites were chosen for their importance of early psychosis intervention regional representation and in order to across Canada. reflect a range of readiness and capacity CMHA NATIONAL 26 The Ontario Contact: Centre for Addiction Phone: Working Group John Trainor and Mental Health (416) 535-8501 x2071 on Early Intervention Director, 1001 Queen Street W. Email: in Psychosis Community Support Room 2075 email@example.com and Research Unit Toronto, Ontario M6J 1H4 The Ontario Working Group on Early The Working Group has proposed a two- Intervention in Psychosis is made up of phase plan to develop a comprehensive individuals and organizations with the early intervention capacity in Ontario. goal of developing an effective treatment The first phase will feature the develop- and support system for the early stages of ment of four Early Intervention Treatment psychosis. The group is committed to and Resource Centres. These centres will be bringing the benefits of early treatment partnerships between family organizations to all citizens of Ontario who experience and clinical treatment programs and will the onset of psychosis and to providing deliver assessment and treatment, public support to their families. The Working education, community development and Group is also committed to a partnership consultation services to the broader mental approach with government and the private health system. Phase one will also include sector to reach its goals. a province-wide planning process to lay the groundwork for early intervention The members of the Ontario Working across Ontario. Phase two will see the Group on Early Intervention in Psychosis implementation of this expanded program. reflect a variety of mental health disciplines, families, and consumers. Departments of Psychiatry at the University of Toronto, the University of Western Ontario, McMaster University, and the University of Ottawa are involved as well as clinical sites in London, Hamilton, and Toronto. The Schizophrenia Society of Ontario and the families involved in the early intervention program in London are also part of the Working Group The Canadian Mental Health Association at both the national and Ontario levels is also involved. The Working Group is coordinated and supported by the Community Support and Research Unit and the Schizophrenia and Continuing Care Program at the Centre for Addiction and Mental Health. ONTARIO WORKING GROUP 27 Following are the diagnostic catagories referred to in this Guide. For comprehensive diagnostic definitions, readers are directed to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (see reference below). BIPOLAR DISORDER Essentially reflects a disturbance of affect or mood that can be accompanied by symptoms of psychosis. DELUSIONAL DISORDER A type of psychosis consisting of very strong and fixed beliefs in things that are not true. DRUG OR SUBSTANCE-INDUCED PSYCHOSIS Drugs such as marijuana, LSD, ampheta- mines and alcohol can sometimes cause the appearance of psychotic symptoms. Symptoms usually abate once the effects of the drugs wear off. However, the symptoms may still require medical treatment. PRODROME OR PRODROMAL SYMPTOMS Pre-psychotic symptoms, or warning signs, that occur prior to the onset of psychosis. The full complement of prodromal symp- toms is extensive, and can include such signs as suspiciousness, depression, sleep disturbances, social withdrawal, lack of attention to personal care, and reduced levels of functioning in school or at work, among others. The concept is relevant to the onset of the first episode and to relapse. PSYCHOSIS NOS (PSYCHOTIC DISORDER NOT OTHERWISE SPECIFIED) Psychotic symptoms are present, but there is insufficient or contradictory information that preclude a more specific diagnosis. SCHIZOAFFECTIVE DISORDER A disorder characterized by episodes of mania and/or depression in addition to symptoms consistent with schizophrenia. Adapted from: SCHIZOPHRENIFORM DISORDER Czuchta, D., & Ryan, K. (1999). First episode psychosis: A form of schizophrenia that is character- An information guide. Toronto, Canada: Centre for ized by a duration of less than six months. Addiction and Mental Health, Clarke Institute. This disorder may resolve or may persist http://mentalhelp.net/disorders – diagnostic criteria and progress to other psychiatric diagnoses, summarized from American Psychiatric Association. including schizophrenia. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American SCHIZOPHRENIA SPECTRUM DISORDERS Psychiatric Association. An umbrella term that typically includes McGorry, P.D., & Edwards, J. (1997). Early Psychosis schizophrenia, schizophreniform and Training Pack. Macclesfield, Cheshire: Gardiner- schizoaffective disorders. Caldwell Communications Ltd. GLOSSARY 28


text: Halloween Desserts Beyond Candy: 10 Spooky Desserts For Halloween by Lizzie Fuhr 10/19/11 9 Reactions 66 Shares Print 41 14 10 1 0 In October, there's nothing more delicious than a heaping bowl of candy and your favorite scary movies, but sometimes it's nice to go beyond the wrapped treats and create a special Halloween dessert. After you've been adequately inundated by an overload of snack-sized candy and all that delicious goodness, take it to the next level when you celebrate Halloween this year. Here are 10 fun dessert ideas to get you inspired! Pumpkin Whoopie Pies What's Your Reaction? 0 0 0 0 0 0 Bring some ghoulish pumpkin cheer to the table with these delicious pumpkin whoopie pies. They're sure to be a crowd-pleasing treat! 1 / 10 Spiderweb Cheesecake What's Your Reaction? 0 0 0 0 0 0 A simple no-bake spiderweb cheesecake would be a welcome addition to any spooky celebration. Just make sure you make it the night before so the cake can set. 2 / 10 Halloween Blondies What's Your Reaction? 0 0 0 0 0 0 I'm salivating just looking at this picture of all the peanut butter and chocolate goodness of these Halloween blondies. While peanut butter cups were used in this version, this recipe is another way to use any Halloween candy you like! Using Reeses Pieces candies would bring some Halloween colors into the mix. 3 / 10 Crispy Rice Treats What's Your Reaction? 0 0 0 0 0 0 For some reason, everything tastes better on a stick. These cute crispy rice treats are no exception. 4 / 10 Black and Orange Bark What's Your Reaction? 0 0 0 0 0 0 If you'd like to try to test your candy-making skills, black and orange bark is a perfect first recipe to start with. 6 / 10 Snake Cake What's Your Reaction? 0 0 0 0 0 0 Don't be intimidated by the sparkly design on this crazy-looking snake cake with venom glaze. Despite the intricate looking design, the cake comes together pretty quickly. 6 / 10 Blood Orange Sorbet What's Your Reaction? 0 0 0 0 0 0 A Halloween treat on the lighter side doesn't go unnoticed or unappreciated! Don't you love the rich orange hue of a blood orange sorbet? 7 / 10 Caramel "Apple" Cookies What's Your Reaction? 0 0 0 0 0 0 Don't worry about bobbing for apples this year. Instead enjoy some caramel "apple" cookies. 8 / 10 Pumpkin Brownies What's Your Reaction? 0 0 0 0 0 0 Layered pumpkin brownies are the perfect marriage between brownies and pumpkin pie! 9 / 10 Shortbread Candy Bars What's Your Reaction? 0 0 0 0 0 0 Sweet, candy-covered shortbread bars are an ideal way to use, or get rid, of all your leftover Halloween candy. 11 / 10 41 14 10 1 0 Read More RecipesDessertHalloween Halloween Bug-Tastic Halloween Soaps For Spooky-Clean Fun 7 hours ago 18 Halloween Pinterest Fails That Will Give You a Good Scare 1 day ago WTF: Twerking Halloween Costumes? 1 day ago Get Ready For Halloween With DIY Candy Corn Wine Bottles 3 days ago 43 "Punny" Halloween Costumes That Won't Break the Bank 4 days ago 44 Practically Free Halloween Costumes to DIY 1 week ago Dessert A Terrific Tart Cherry Pie You Can Enjoy Year-Round 6 hours ago 50 States of Ice Cream 21 hours ago Pretty Little Liars — the Secret Is in the Cake 21 hours ago Curtis Stone's "Up in Flames" Bananas Flambé 1 day ago The Easiest Ice Cream Cake You'll Ever Make 2 days ago Churros and Ice Cream, Together at Last! 3 days ago recipes Comfort Foods Almost as Good as Mom Made Them 3 hours ago A Terrific Tart Cherry Pie You Can Enjoy Year-Round 6 hours ago A Mediterranean Feast Fit For Greek Gods 9 hours ago The Foolproof Method For Grilling a Juicy, Flavor-Packed Steak 22 hours ago 28 Ways to Get Your Berry Fix Before Summer Is Over 1 day ago End Summer on a High Note With Peach-Salsa-Topped Salmon Tacos 1 day ago Get a Personalized Living Newsletter! Help us customize your newsletter by selecting your interests (optional): Love & Sex Vegetarian Tech Home Link Love Chocolate Legos are basically an excuse to play with your food — HuffPost Taste Here's the full list of chefs competing on Top Chef season 12 — Grub Street Jimmy Fallon pokes fun at how Giada De Laurentiis pronunces spaghetti — Eater Sweet tea fried chicken would make any Southerner proud — Rachael Ray Show McDonald's goes deep fried with its latest menu item — Foodbeast Banh mi meets breakfast sandwich in this must-try recipe — Food52 Source: Akihiro Mizuuchi/Behance

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Josh Wilson: Favorite Christmas Movie - Today's Christian Videos
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DAY 10 GIFT from Josh Wilson. Merry Christmas!!
DAY 10 GIFT from Josh Wilson. Merry Christmas!!
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text: My husband and I stayed in the Roadrunner Studio for two nights. We were celebrating our anniversary and loved everything about it! Athena was so helpful with checking in, recommendations for hiking and restaurants as well as things to do and see while in the area. She asked for our breakfast requests when making reservations and had everything ready when... More


text: @include ('licence.php') ?> Jacksonville College, Jacksonville, Texas Facebook Facebook Twitter Twitter Youtube Youtube Username: Password: Create New Account Lost Password? Gateways: Future Students Current Students Alumni & Friends Faculty & Staff Directory Athletics Library Bookstore Information Technology Financial Aid Ways to Give Employment Academia: Admissions Academic Programs Continuing Education Course Catalog Curricular Offerings Press Releases Registration Information Current Students Campus Life Student Handbook Chapel Residence Halls Student Organizations Student Offices Athletics Publications Discipline Annual Campus Crime Report Financial Aid Scholarships & Financial Aid Grants & Awards Student Services Advising/Counseling Services Transcript Request Form Health Care Information Technology Services Library Services Bookstore Food Service Student Union Building Graduation Application for Graduation General Requirements for Graduation Associate in Arts Degree Associate in Science Degree Junior College Diploma Graduation Honors Technology Information Technology 105 B.J. Albritton Drive • Jacksonville, TX 75766 • (903) 586-2518 © Jacksonville College • Group M7 design


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Me and you in a midnight blue, '82 Camaro
Crossin' over the Hartwell bridge movin' fast as she would go
Windows down, radio up, we were singin' "Freebird" 173 more words
Tags » Joe's Bar
Corey Smith - Joe's Bar
Me and you in a midnight blue, '82 Camaro
Trending Today: Country Stars In New CMT Summer Series, Little Big Town Joins Team Blake, Randy Houser Adds 2nd Chicago Show
** Dierks Bentley, Kip Moore, David Nail and Chris Young are all trending today as they are the featured performers in the new… 134 more words
Randy Houser Surprises Drew On The Diner
What a great surprise to get an email at 11:45 this morning, that Randy was calling me in less than an hour!
He dialed up to reveal that he's just added a 2nd show (!) at Joe's Bar this September, after his first sold out in two hours! 64 more words
Trending Today: David Nail Plays All-Star Baseball, Brantley Career Milestone, Shania On A Postage Stamp
** David Nail is trending today as he'll make another appearance for MLB's All-Star Legends & Celebrity Softball Game this Sunday in Minneapolis as part of their All-Star Weekend. 100 more words
Missouri River Restaurant Menu Report
It's starting to feel like the summer season in Craig,MT and nothing tops off a warm day on The MO like a meal at one of our local restaurants. 607 more words
The Start to A Wonderful #RVhoneymoon
Well, the guys over at Avalon RV Center pulled through and got our RV all fixed up! I told them I would write something nice about them since they helped us out, so here it is guys. 838 more words


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Pelpro Pellet Stove - Home/Shop Heater
Model: HHPP2BD | Store SKU: 1000401441
Pelpro INVENTED shop heaters! Our designs for wood pellet stoves took a strong turn when we created the ORIGINAL pellet heater several years ago. These stoves come equipped with 120 lb capacities (300 lb stove available) and boast a BTU value of up to 50000 over 2000 square feet. The larger hopper capacity gives you the flexibility to fill up with pellets less often. The large glass window makes these models viable, aesthetic heating options for your home as well as your garage or shop.
- Up to 50000 BTUs
- 120 lb hopper capacity
- Automatic igniter
- Large view glass
- Double-row heat exchanger for enhanced heating
- Bonus radiant heat from rear sides of the unit
Warranty Information
1 year electrical, 5 years on body (metal). 1-877-303-3134.
|Assembled Depth (In Inches)
|26 In.
|Assembled Height (In Inches)
|Assembled Weight (In LBS)
|232 Lbs.
|Assembled Width (In Inches)
|Country of Origin
|CSA Certified
|Drop Ship
|Item Depth
|31 In.
|Item Height
|40 In.
|Item Weight
|238 Lbs.
|Item Width
|30 In.
Price and availability may vary by store.
*Valid only on date printed
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Amazon buys video game streaming company Twitch
In its second-largest acquisition, Amazon buys the company for $970 million.
Amazon buys video game streaming company Twitch
In its second-largest acquisition, Amazon buys the company for $970 million.
Newegg takes same-day delivery into its own hands
The computer and electronics e-retailer is unleashing its own fleet of delivery vehicles in Los Angeles.
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Sponsored by 2013 Social Media 300
Dell launches an app for Microsoft's new Windows 8 operating system.
Dell is one of the first big-name retailers to capitalize on a feature in Microsoft Corp.'s Windows 8 operating system that enables developers to create one app that works on tablets, laptops and desktop PCs.
The Dell Shop app allows customers using PCs, laptops or tablets that use Windows 8, such as the Microsoft Surface tablet, to shop for Dell PCs or accessories.
The app uses the trademark Windows 8 live tiles—dynamic icons which display on a tablet or computer's start screen—to show shoppers notifications about new products and offers from Dell, says Brandon McGee, director of global mobile for Dell. App users can also buy within the app and get product and accessories recommendations for their Dell computers by entering their Dell system ID, which identifies the type of product they own. And the app offers online access to the Dell product catalog.
The app was built in-house over the course of a few months, McGee says.
Along with the app, Dell also launched its own line of Windows 8 tablets and PCs, McGee says, including the XPS 12 Convertible Touch Ultrabook, a 12-inch convertible laptop that doubles as a Windows 8 touch tablet. It is selling on Dell.com for $1,199.
Research firm Forrester Research Inc. predicts that 27% of all global tablets will use the Microsoft Windows 8 operating system by 2016. What's more, several reports find that consumers are buying more, and more often, on tablets. For example, Forrester finds that the average conversion rate for tablet shoppers is about 4% to 5% compared to a lower 3% rate for PC shoppers. And a May study from Shop.org and Forrester reports that 77% of retailers say the average order value from tablets meets or exceeds the average order value from desktop computers.
Dell is No. 52 in the Internet Retailer Mobile 400.
The online marketplace introduced new rules for sellers last month. It's crucial that sellers understand ...
Posted 08/29/14
Consumers in many countries are buying more online each year. Understanding the nuances of each ...
Posted 08/29/14
If there's something you've bought offline that you weren't able to buy online, we're probably thinking about that."


text: girl, good luck, hipster, life Added: March 27, 2012 | Image size: 489 x 315 px | More from: www.facebook.com | Source: linkNo comments Please log in or sign up to post a comment. add to set Views: 1102 Likes (**Who?): 3 Comments: 0Tagged with :girl 395711good luck 62hipster 50069life 62318Log in or Sign upLog In" or Sign Up


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Found 18 additional ads in areas surrounding Dennistoun
Experienced Window Cleaner RequiredSouthside, GlasgowDue to expansion CSM Facilities Management are looking to employ an experienced window cleaner with a Full UK Driving Licence, preferably with no convictions or...1SaveRemove
Experienced Cleaner RequiredKnightswood, GlasgowExperienced cleaner required, to clean for 2 hours per day, everyday, at lunchtime for a long established company. Please email me your CV including: 2 references...SaveRemove
Cleaner Needed AsapGlasgow City CentreI need the service of a cleaner to take care of a warehouse. You must be above 20 years old to apply.SaveRemove
Industrial Cleaners & JettersPaisley, RenfrewshireStafffinders are currently recruiting for Industrial Cleaners & Jetters for an ongoing temporary contract based in Glasgow to start immediately but could be...1SaveRemove
Part Time Experienced Cleaner RequiredCumbernauldRed Rock are currently recruiting for a cleaner for their client based in Cumbernauld. We are looking for a candidate who has a passion for cleaning, Ideally you...1SaveRemove
looking for experienced cleaner/housekeeper with eye for detail 3hrs per weekGlasgowLooking for an experienced domestic cleaner/housekeeper for immediate start to clean family home (3 bed) with a toddler and a baby. 3hrs per week. Weds afternoon...SaveRemove
Event Cleaners - High Profile Outdoor Sporting EventEast End, GlasgowPrimestaff are recruiting for temporary staff to assist at a prestigious outdoor sporting event to take place in September. The event is expected to draw large...SaveRemove
Reliable window cleanerHamiltonIf you need a reliable window cleaner call john on 07547826721 Any size of house £5.00SaveRemove
Window Cleaners Required for small window cleaning company Part timeLenzie, KirkintillochWindow Cleaner Required for run in and around Glasgow. Experience very necessary. Traditional and some pole work Hold a UK driving licence an advantage £50 a...1SaveRemove
Window Cleaning- Part-Time Window Cleaner Wanted!!Jordanhill, GlasgowPart-time traditional window cleaner required must have at least two years experience. Work will be between 1-2 days a week and also as and when required. Please...SaveRemove
Experienced House CleanerSouthside, GlasgowLooking for a house cleaner??? Look no further anytime, any area I'm available contact me for more information thank you ;)1SaveRemove
part time cleaner required for hamilton areaHamilton, Glasgowlooking for a part time cleaner to join our team at a call centre in Hamilton area must have experience and personal reverence. please note this contract is...SaveRemove
general house cleaners reqiredBishopbriggs, Glasgowhouse cleaners required in north Glasgow area mon-fri.call Eileen for more info.thanks.1SaveRemove
general house cleaners neededBishopbriggs, Glasgowgeneral house cleaning staff required in north Glasgow.mon-fri.8.15am-5pm call Eileen for more info.thanks.1SaveRemove
Part time window cleaner requiredBroomhill, GlasgowExperienced window cleaner to work a Monday&Tuesday in the Balloch area.Must have a clean driving license.SaveRemove
VERY EXPERIENCE CLEANER REQUIRED URGENT. WITH FULL UK DRIVING LICENCE FOR MORE THAN 1 YEARKnightswood, GlasgowJOB DUTIES.. END OF TENANCY CLEANING, DEEP CLEAN , OFFICE CLEAN, END OF BUILDERS CLEAN, SHOP CLEANING, INDUSTRIAL CLEANING, CARPET CLEANING.SaveRemove
** EXPERIENCED PROFESSIONAL CLEANER WANTED ** FIRST COME, FIRST SERVE **HamiltonWe have 2 properties in fair condition needing cleaned in the central Hamilton area. These are being advertised as one Job. A payment of £70.00 will be paid for...SaveRemove
Window Cleaner Required FTNorth LanarkshireFull time window cleaner required in North Lanarkshire Area, preferably from Coatbridge or surrounding areas. Requirements: Must hold full driving license Must...SaveRemove
Cleaner in Dennistoun, General Jobs (18 ads posted)


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Move On or Hang On?
A lot of the chatter on Sales St. this week was about year end, but not the expected banter about closing the year strong or planning for next year. It was more about which team individual sales professionals are looking to be on; and from sales leaders, who they plan to have on their team going into what most believe (hope) will be a better year.
In some ways these two sides of the coin illustrate the disconnect or difference in the way reps and leaders view the profession, their roles and resulting approach.
Many leaders realize that they have people on the bus who don't belong there, but they are reluctant to let them off at the next stop, thinking that it is worst to have a vacant territory. It is not. Coming from the "Hire slow, fire fast" camp, I have always believed there is greater risk in having someone who is either not capable or in whom I've lost confidence, in a territory than to have the territory vacant. This is why as a sales leader you should always be in interview and search mode; just like your pipeline, it easier to get rid of a dud, opportunity or rep, if you know you have other prospects, options or recruits ready.
So waiting for the new year to part company really doesn't make sense if you are a sales leader. If the rep is so bad that you want him/her off the team, how much upside can they really provide in Q4? If you wait for the first of the year, you are not only going to have to allow for ramp up time, no matter how little may be required, but you will also have turmoil when you most want to foster teams. It is likely that you are already introducing new targets, new comp plans, maybe even new territories, why take on more at that time. Seems to me the best time to initiate a departure strategy and related actions is as soon as you realize that the rep is not a fit anymore, not long after you know the situation is far beyond salvage.
Reps are indicating that they are hanging to realize any yearend closes, "having worked on the deal for ever, I want to at least close it before I move on". Others are waiting for yearend bonus, or some form of monetary reward they may (or may not) get. While this may be sound in a few instances, it is not for most. If you are basing your success on last minute deals based on budgetary cycles or other lunar driven events, you are truly "hanging on" rather than proactively driving business.
On the other hand let's say you are a good rep and feel you are limited by your current organization, or feel that you have more to offer and gain elsewhere, you should still make the move now, rather than waiting. (There is the underlying assumption here that there is somewhere for you to move to.) If there is, it must be true that you see more potential, then why wait, if you look at it from a 12 – 18 month perspective, in most cases yes, you may leave a few shekels behind, but you will also set yourself up to make a whole bunch more by better positioning yourself in your new gig.
If you make your move based on opportunity rather than "timing", you will be able to get those yearend closes at your new place, and at the same time tee things up for a great start to next year, I bet this will allow you to make up for what you may feel you leave behind and then some. So just as with the advice to the sales leaders, the time to make the move is when you know you can do better for you and your organization by moving on.
As with most thing in sales it is about the quality of the execution.
What's in Your Pipeline?
Tibor Shanto


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An open demonstration of new apps for the iPhone moderated by Steven Levy, senior writer for Wired and author of The Perfect Thing, Hackers and more. Michael Tchong, founder of Iconocast and MacWeek (now deceased), makes comments. This video demonstrates the Blue Marble app which depicts a realistic view of the earth, sun and moon on the Iphone.
Download the TV Guide app for iPhone, iPad and Android!


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About Us
Victoria Arnold
Victoria is based in the UK and currently operates two growing businesses, Desk Union and Homestayfriend. As a coworking evangelist Victoria is always looking for new opportunities to collaborate and pay it forward. Her favourite thing about her job? Taking her dog Alfie with her to work! Read more about Victoria here.
- 128 reads


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Assistant Branch Manager
The assistant branch manager's main job responsibility is collection of past due loan accounts both inside and outside the office environment. This position requires the candidate to maintain a valid driver's license, have a personal vehicle which will be used for work daily ...
Sep 2 -
Poplar Bluff
Bookkeeper Accountant
Well-established flooring company seeks a motivated individual to assume bookkeeping and accounting duties including: journal entry, inventory, cash management, close of month, and taxes. Ability to learn company computer program is essential as is a willingness to do ...
Sep 2 -
Payroll Supervisor
Orscheln Industries has an immediate opening for a dedicated and experienced payroll professional to supervise payroll processing at the corporate office. Requirements include at least three years experience with payroll systems and payroll tax laws, 3 years supervisory ...
Sep 2 -
Accounting Manager
Accounting manager will be responsible for all accounting duties including billing, accounts payable, payroll, general ledger transactions, expense analysis and financial reporting.
Major responsibilities include:
Full general ledger, journal entries and financial ...
Sep 1 -
Saint Louis
Vice President - Sales
Our client is searching for highly qualified financial sales specialists to join our team as a regional Vice President. A qualified candidate has previous success selling portfolio management services to individual stock market investors, is goal-oriented, and articulate.
Aug 29 -
Saint Louis
Staff Accountant / Audit Manager
Local Central Missouri Accounting Firm seeking a CPA to perform routine audits for non-profits, small businesses, employee benefits and credit unions.
The right candidate will have Minimum 5 years' experience in Auditing. Salary commensurate experience.
Aug 28 -
Jefferson City
Sales Account Manager - Business Broker - Permanent Revenue Share
Learn About A New And Lucrative Career As A Business Relationship Broker
Our in house analysts will close the deals and service your business relationships as
you receive a life time residual ...
Aug 27 -
Saint Louis
Bank Examiner openings in St Louis
Multiple Bank Examiner positions in St Louis, MO
The successful candidate will work in St. Louis, Missouri. Percentage of overnight travel for this position is 50%.
Job Duties & Responsibilities:
: Lead and participate on consumer protection compliance or CRA ...
Sr Auditor - Public Accounting
Senior Auditor (2530)
Oversee the completion and review of audits.
Prepare specified financial statements.
Prepare detailed audit reports.
Assess areas of risk as well as internal controls and the potential impact of any deficiencies.
Examine records to ...
Are you a mature CFO looking for a job?
Seeking Experienced CFOs – Is that you?
We need someone that has lots of CFO and Business Growth experience. Someone that has seen and done it all for a long time. In fact, you might even have some gray hairs. If you are looking to use your years of experience, rather ...
Aug 26 -
Cape Girardeau
CFOs - Experienced Consultants with M and A Experience.
We are a group of entrepreneurial CFOs who provide long-term CFO services on a 1099 basis. We do this instead of working with one employer at a time. Our firm includes some of the best and most experienced CFOs in the US, and we would like to invite you to consider joining ...
Consulting CFOs needed
Aug 26 -
We want CFOs with consulting experience
Aug 26 -
We are looking for CFOs with M and A experience
Aug 26 -
Jefferson City
CFO Position - Exit Strategy and M&A Experience needed
Aug 26 -
CFO with Exit Strategy experience wanted
Aug 26 -
Experienced CFOs Needed?
We are looking for Experienced CFOs to join our firm.
Aug 26 -
Saint Louis
CFO with Exit Strategy and M&A Experience needed
Aug 26 -


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A collection of news and information related to Lupus published by this site and its partners.
Top Lupus Articles
Displaying items 97-108
Dishing about food writing
Innocent Woman in Wheelchair Shot, Recounts Horror to FOX40
Mariah Carey and Nick Cannon renew wedding vows -- for a 4th time
Hair repair
Lupus More Common in Asians and Africans
Lucy Vodden dies at 46; inspiration for the Beatles classic 'Lucy in the Sky with Diamonds'Story | Sep 29, 2009Lucy Vodden, who provided the inspiration for the Beatles' classic song "Lucy in the Sky with Diamonds," has died after a long battle with lupus. She was 46. Her death was announced Monday by St. Thomas' Hospital in London, where she had been treated for...
Monthly Meetings in WilliamsburgStory | Aug 27, 2008CIVIC GROUPS Woman's Club of Williamsburg. 11:30 a.m. select Wednesdays, Ford's Colony Club House, 1 Ford's Colony Drive, Williamsburg. Luncheon meetings. Membership information: 229-7242. HEALTH Alliance on Mental Illness regular meeting. 7 p.m. third...
No need to whisper: Lauren Shuler Donner has lupus
I'm intelligent. I've got a good job, low debt. And I'm losing my house.Story | Dec 16, 2007When the handsome young man showed up at my door in late summer, flirting was the furthest thing from my mind. He was there as part of my new-found "popularity." I had made the highly coveted list of pre-foreclosure property owners. He was one of many...
Monday is Hollywood Bag Ladies DayStory | Oct 7, 2009 | 4:32 PMBeverly Hills Mayor Nancy Krasne is poised to proclaim Monday "Hollywood Bag Ladies Day.??? No, it has nothing to do with actual bag ladies, shuffling down the street and pushing shopping carts -- actually, quite the contrary. Hollywood Bag Ladies......
Evans holds walk-a-thon to help studentâs family pay for her funeralStory | Apr 26, 2010 | 4:32 PMEvans High school will hold a walk-a-thon from 5:30 p.m. to 7:30 p.m., Wednesday, April 28 at the 9th grade center. The address is  2751 Lake Stanley Rd., Orlando. Students and staff are hoping to raise money to help the family of Letedra "Ti...
Lady Gaga tells Larry King: I do not have lupusStory | Jun 1, 2010 | 4:34 PMLady Gaga is Larry King's guest tonight on CNN, and the entertainer weighs in on everything from politics to her health. She talks frankly about rumors that she has lupus, which runs in her family. "The truth is I don't show signs, any symptoms of...