Post by Former NIMH Director Thomas Insel: New hope for treating psychosis
As with other chronic health conditions, there is no magic bullet for schizophrenia. At least as important as the search for magic bullets, however, is an increasing focus on early intervention and integrating existing treatments. This year, we've had encouraging news about integrated, comprehensive approaches for treating people with first episode psychosis, most recently from a major NIMH initiative, the Recovery After an Initial Schizophrenia Episode, or RAISE project. RAISE looked at coordinated specialty care for first episode psychosis. With coordinated specialty care, the young person experiencing first episode psychosis works with a team of specialists to create a personal treatment plan, combining recovery-oriented psychotherapy, low-dose medication management, family education and support, case management, and work or education support. Coordinated specialty care emphasizes shared decision making, including family members, when possible.
RAISE began as two separate studies back in 2008. Each study looked at a different aspect of coordinated specialty care. One study, the RAISE Implementation and Evaluation Study, focused on the best way for clinics to start using the treatment program. The other project, the RAISE Early Treatment Program (RAISE-ETP), studied whether or not the treatment worked better than care typically available in community settings. John M. Kane, M.D., of the North Shore - Long Island Jewish Health System and the Zucker Hillside Hospital, led RAISE-ETP and, today, his team released the primary outcomes from this large clinical trial.1
The RAISE-ETP research team spent five years testing their coordinated specialty care model, called NAVIGATE, at 34 real-world clinics across the country. They compared their treatment program to typical treatment and found that 223 clients who received the NAVIGATE coordinated specialty care program stayed in treatment longer; experienced greater improvement in their symptoms, interpersonal relationships, and quality of life; and were more involved in work or school compared with 181 clients at the typical-care sites. NAVIGATE clients who had a shorter duration of untreated psychosis (the time between the beginning of psychotic symptoms and the beginning of treatment) when they started the study showed greater improvements than those with longer duration of untreated psychosis.
Two other research teams have reported findings in recent months from trials of coordinated care for first episode psychosis. A team at Yale University collaborated with a center run by Connecticut’s mental health agency to test whether a comprehensive first episode psychosis service in the context of a public sector clinic could improve outcomes. After a year, those who received comprehensive care had fewer hospitalizations than those in standard care, were more likely to remain employed, and did better on overall measures of functioning.2 A Danish team also reported that, in a trial of specialized, intensive treatment, patients receiving the intervention for two years had reduced psychotic and negative symptoms, were more satisfied and adherent with treatment, and were hospitalized less than patients receiving standard care.3 As a result of this study, the treatment has been implemented throughout Denmark.
The information coming from these trials shows that coordinated specialty care is an incremental but positive step in treating first episode psychosis. Coordinated specialty care—and ongoing testing of these approaches, with continuous incorporation of findings into practice—brings us closer to being able to intervene in a way that will enable young people with psychosis to avoid the long-term disability and vulnerability that too many experience. It is encouraging to note that more and more states—32 to date—are adopting coordinated specialty care programs to treat first episode psychosis. Their efforts have been supported by additional funding coming from the Community Mental Health Services Block Grant program administered by the Substance Abuse and Mental Health Services Administration. Based on the RAISE results, NIMH is launching the Early Psychosis Intervention Network (EPINET), aimed at creating a network of clinical sites offering evidence-based specialty care to persons experiencing signs of first episode psychosis. Using data sharing agreements, EPINET centers will gather participant-level data which can then drive improvements in clinical practice, a “learning health-care system.”
It should perhaps be no surprise that, given the complexity and variability of schizophrenia, outcomes will be better with treatment that is individualized, multi-faceted, and attuned to the preferences of each patient. While we have a long way to go, these recent reports suggest we’re headed in the right direction
1 Kane, et al. Comprehensive Versus Usual Community Care for First Episode Psychosis: Two-Year Outcomes From the NIMH RAISE Early Treatment Program. American Journal of Psychiatry (in press). doi: 10.1176/appi.ajp.2015.15050632. Epub 2015 Oct 20.
2 Srihari VH et al. First-Episode Services for Psychotic Disorders in the U.S. Public Sector: A Pragmatic Randomized Controlled Trial. Psychiatr Serv. 2015 Jul;66(7):705-12. doi: 10.1176/appi.ps.201400236. Epub 2015 Feb 2.
3 Nordentoft M et al. From research to practice: how OPUS treatment was accepted and implemented throughout Denmark. Early Interv Psychiatry. 2015 Apr;9(2):156-62. doi: 10.1111/eip.12108. Epub 2013 Dec 5.