Studies Support Use of Team-Based Care for Early Psychosis
Significant improvements seen in symptoms and in occupational and social functioning
• Science Update
Researchers continue to build on findings from NIMH’s Recovery After an Initial Schizophrenia Episode (RAISE) program, which investigated the effectiveness of early intervention services for people experiencing first episode psychosis. Two recent studies add to the evidence that team-based early intervention services are feasible in real-world health care settings and result in improved outcomes for patients.
Christoph Correll, M.D., of the Center for Psychiatric Neuroscience at the Feinstein Institute for Medical Research in Manhasset, NY, led a team of researchers from eight countries conducting a meta-analysis of studies of early intervention services for psychosis. The meta-analysis combined data from ten randomized clinical trials, including the RAISE Early Treatment Program and the Specialized Treatment for Early Psychosis (STEP) Program. The early intervention services in every study had to be aimed specifically at early psychosis and comprise different elements of treatment (psychosocial and pharmacologic) and supportive services, such as for employment and education. In each study, a control group received treatment as usual for comparison. The combined trials included 2,176 participants with studies lasting from 6 to 24 months.
On all outcomes measured in the meta-analysis, patients receiving early intervention services experienced better outcomes. This was true for the two primary outcomes: young people receiving early intervention services were less likely to leave treatment and less likely to have a psychiatric hospitalization over the course of treatment. In addition, symptoms improved to a greater extent with early intervention services. Participants were less likely to relapse, and more likely to achieve symptomatic remission (stable or minimal symptoms) alone or symptomatic remission with improved functioning (such as in self-care, social interactions, and school or work). Participants receiving early intervention services were significantly more likely to be in school or employed than those receiving treatment as usual, and quality of life was higher with early intervention services. The superior outcomes for early intervention services were statistically significant and clinically meaningful, as well as largely consistent across time points in the studies.
“This meta-analysis shows that across countries and diverse healthcare settings, multi-element team-based early intervention services produces greater improvements in a wide array of symptom, functioning, and recovery outcomes, compared to usual early psychosis care,” said Robert Heinssen, Ph.D., director of the Division of Services and Intervention Research (DSIR) at NIMH.
As the number of clinics in the U.S. offering some form of early intervention service expands, a key question is the degree to which multi-component early intervention services work in the real world of health care, not just in the context of clinical trials. A second recent paper describes a study examining the results of an early intervention services program—OnTrackNY—which delivers care for early psychosis in community settings in New York State. OnTrackNY is based on the RAISE Connection Program and offers Coordinated Specialty Care (CSC), an integrated program of treatment and services analogous to those studied in the meta-analysis. The RAISE Early Treatment Program clinical trial also offered CSC.
OnTrackNY provides CSC care in a variety of community settings, including licensed outpatient clinics at community agencies, state-operated facilities, and community hospitals. Treatment encompasses psychotherapy and the use of antipsychotics at the lowest effective doses in coordination with monitoring general health, including cardiometabolic factors and nutrition. Case management addresses housing and health insurance. OnTrackNY also provides family support and education and supports education and employment.
Ilana Nossel, M.D., at the New York State Psychiatric Institute, led an evaluation of data for 325 individuals ages 16 to 30 with recent-onset psychosis who participated in OnTrackNY for at least three months with follow-up of up to a year. Participants experienced significant improvement in symptoms and occupational and social functioning, and the magnitude of these improvements was comparable to or exceeded those generally seen in clinical trials. The greatest improvements occurred during the first three months, but improvements were sustained; social functioning improved over every follow-up period. In six months, the rate of employment doubled from 40 to 80 percent. The rate of hospitalization declined from 70 percent to 10 percent by three months.
“These impressive real-world outcomes replicate those of NIMH-funded research and of other early intervention services randomized clinical trials reported in the scientific literature,” said Susan Azrin, Ph.D., chief of DSIR’s Early Psychosis Prediction and Prevention Unit at NIMH, “and demonstrate why CSC has set a new standard of care for early psychosis in the U.S.”
RAISE emphasized recovery-oriented care, patient involvement in decisions regarding care, and minimizing the likelihood of future disability. As part of an ongoing effort to build on the findings of RAISE and the expansion of CSC programs across the U.S., NIMH has announced funding opportunities for an Early Psychosis Intervention Network (EPINET). NIMH seeks to support regional scientific hubs linking early psychosis services programs. The goal is to create an early psychosis “learning healthcare system,” in which data that is routinely collected in CSC programs as part of clinical practice drives continuous improvement in patient care and scientific discovery. Such a network can provide insight, for example, into how to best tailor early psychosis care for individuals, and information to guide improvements in diagnosis and interventions, including supports aimed at improving success in education and employment. For more information on EPINET, see funding announcements RFA-MH-19-150 and RFA-MH-19-151.
Correll, C. U., Galling, B., Pawar, A., Krivko, A., Bonetto, C., Ruggeri, M., … Kane, J. M. (2018). Comparison of early intervention services vs treatment as usual for early-phase psychosis. JAMA Psychiatry, 75(6), 555-565.
Nossel, I., Wall, M. M., Scodes, J., Marino, L. A., Zilkha, S., Bello, I., … Dixon, L. (2018). Results of a coordinated specialty care program for early psychosis and predictors of outcomes. Psychiatric Services. 69(8), 863-870.