Post by Former NIMH Director Thomas Insel: Network Solutions
In a commentary just published on innovation in health care, Narayan and colleagues describe the need for integrated solutions to mental health care.1 Moving beyond “magic bullets” and the magical thinking of a single intervention for a complex problem, they recommend a comprehensive model that includes early detection, better access to care, monitoring, and patient-reported outcomes. None of this would be particularly innovative, except that Narayan and his colleagues all work for a pharmaceutical company. They aren’t just suggesting new health care policy, they are recommending that pharmaceutical R&D redefine innovation around a holistic approach to patient needs rather than a singular focus on molecular targets.
This is vaguely reminiscent of the IBM story. A company formerly focused on innovation through new hardware and new software realized the potential for innovation (and profit) from “network solutions.” In this case, “solutions” meant an understanding of the unique needs of individual clients and tailoring a suite of products and services along with an ongoing relationship to meet these needs. Does that sound like an innovative approach to healthcare?
Which brings me to RAISE. The Recovery After an Initial Schizophrenia Episode initiative consists of two NIMH-funded studies that are all about integrated “network solutions.” The first episode of psychosis has been a neglected opportunity for helping people with schizophrenia avoid chronic disability. We know that there is a long delay in getting treatment, with an average latency of 110 weeks in the United States—and that the longer the duration of untreated psychosis, the poorer the long-term outcome.2,3 We also know that once initiated, treatment for most people is acute, transient, and inadequate.
For many first episode patients, treatment is hospitalization and medication. Every medical student learns that approximately 90 percent of young people in a first episode of psychosis will respond to anti-psychotic medication, but that over 80 percent will experience a second psychotic episode within 5 years.4,5 Psychosocial treatments (e.g., assertive case management, family psychoeducation, social skills training, supported employment, cognitive therapies, psychiatric rehabilitation) have long been known to be essential for the treatment of schizophrenia, but in spite of their recommendation via evidence-based guidelines, these are rarely available to the people who need them most.6,7
RAISE takes the IBM approach to this problem. Rather than testing a new medicine or a new cognitive intervention, RAISE creates a network solution, delivering that which we already know to be effective, but personalizing recovery-oriented treatments based on the unique needs of the client. The entire suite of interventions, medications and psychosocial treatments is available as a toolkit. Based on the specific preferences and needs of the person with psychosis, and in the context of an ongoing relationship with a treatment team, patients and providers work together to select the most useful approaches from this toolkit. RAISE is testing the impact of this team-delivered, multi-component intervention for first episode psychosis in 35 community mental health centers across 23 states.
Of course this makes clinical sense. This is how we manage hypertension, diabetes, and other chronic diseases for which there is no “magic bullet.” But this also makes business sense. The healthcare costs of schizophrenia in the first year post-psychosis are largely driven by re-hospitalization. 8, 9 That cost can be preempted by improving the quality of phase-specific outpatient treatments as done through RAISE. And the cost of schizophrenia as a chronic disability with high risks of unemployment, homelessness, incarceration, and complex medical problems exceeds $62B/year.10 RAISE intervenes early to reduce chronic disability. The ongoing projects will estimate the impact of the RAISE toolkit on participants’ symptoms and functioning, as well as the larger societal benefits that accrue from early intervention.
What Narayan and colleagues are suggesting is that pharmaceutical companies can follow the IBM lead and the RAISE model to develop similar toolkits that bundle medical and psychosocial care. The jury is still out on whether this will work for mental health care as well as it has worked for information technology. But there is little question that we need better “solutions” for patients with serious mental illness. It’s time to think beyond magic bullets.
1 Narayan VA, Mohwinckel M, Pisano G, Yang M, Manji HK. Beyond magic bullets: true innovation in health care. Nature Reviews. Drug Discovery. 2013;12:85-86. Doi:10.1038/nrd3944
2 Marshall M; Lewis S; Lockwood A; Drake R; Jones P; Croudace T. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Arch Gen Psychiatry. 2005;62:975-983.
3 Perkins D, Gu H, Boteva K, Lieberman J. Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. Am J Psychiatry. 2005;162:1785–1804.
4 Robinson DG, Woerner MG, Alvir JM, Geisler S, Koreen A, Sheitman B, Chakos M, Mayerhoff D, Bilder R, Goldman R, Lieberman JA. Predictors of treatment response from a first episode of schizophrenia or schizoaffective disorder. Am J Psychiatry. 1999;156:544-549.
5 Robinson D, Woerner MG, Alvir JM, Bilder R, Goldman R, Geisler S, Koreen A, Sheitman B, Chakos M, Mayerhoff D, Lieberman JA. Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder . Arch Gen Psychiatry. 1999;56(3):241-247.
6 Aron L, Honberg R, Duckworth K et al. (2009). Grading the States 2009: A Report on America’s Health Care System for Adults with Serious Mental Illness. Arlington, VA: National Alliance on Mental Illness.
7 Lehman A, Steinwachs D. Patterns of usual care for schizophrenia: initial results from the schizophrenia patient outcomes research team (PORT) client survey. Schizophrenia Bulletin. 1998;24:11–20.
8 Cullberg J, Mattsson M, Levander S, Holmqvist R, Tomsmark L, Elingfors C, Wieselgren I. Treatment costs and clinical outcome for first episode schizophrenia patients: a 3-year follow-up of the Swedish ‘Parachute Project’ and two comparison groups. Acta Psychiatr Scand. 2006;114:274-281.
9 Mihalopoulos C, Harris M, Henry L, Harrigan S, McGorry P. Is early intervention in psychosis cost-effective over the long term? Schizophrenia Bulletin. 2009;35:909-18.
10 Wu E, Birnbaum H, Shi L, Ball D, Kessler R, Moulis M, Aggarwal J. The economic burden of schizophrenia in the United States in 2002. J Clin Psychiatry. 2005;66(9):1122-1129.