Team-based Care Optimizes Medication Treatment for First Episode Psychosis
Coordinated specialty care supports optimal prescribing of antipsychotics with fewer side effects
• Science Update
Team-based coordinated specialty care (CSC) for first episode psychosis (FEP) resulted in more optimal prescribing of antipsychotics and fewer side effects when compared with typical community care, according to findings from NIMH’s Recovery After an Initial Schizophrenia Episode (RAISE) project. These findings add detail about this component of treatment to findings from the original RAISE Early Treatment Program (RAISE-ETP) study, which found improved treatment outcomes with CSC versus typical care.
Psychosis is used to describe conditions that affect the mind, where there has been some loss of contact with reality. Symptoms of psychosis include delusions (false beliefs) and hallucinations (seeing or hearing things that others do not see or hear). Untreated, psychotic symptoms can lead to disruptions in school and work, strained family relations, and separation from friends. In a series of reports, the RAISE project has provided information on the feasibility and benefits of individualized, timely care for young people with early psychosis.
In the RAISE-ETP study, the research team trained clinical staff, located at clinics around the country, to use a CSC program called NAVIGATE. This program incorporated features aimed specifically at optimizing the prescribing of medication to treat FEP. These features included medication guidelines developed for NAVIGATE; a computer-based support system (COMPASS) to facilitate patient-prescriber communication and shared decision-making; and training and support for prescribers.
Using COMPASS, participants entered information about their symptoms, medication side effects, substance use, treatment preferences, and attitudes towards medication. Providers also entered assessments into COMPASS. Based on patient and provider information, the system suggests treatment strategies, and providers and participants made decisions in the context of this information.
The RAISE-ETP study enrolled 404 individuals—223 at clinics providing the NAVIGATE program and 181 in clinics providing typical care. Individuals between the ages of 15 and 40 who were experiencing FEP and who presented for treatment at 34 community-based clinics across 21 states were included in the study. Study participants had been treated with antipsychotic drugs for six months or less at study entry.
Over the two years of the study, participants in NAVIGATE had nearly twice as many medication visits as participants in typical care and were more than three times as likely to receive an antipsychotic prescription. At the same time, they reported fewer side effects. There was a greater likelihood that participants in NAVIGATE would receive antipsychotics that conformed with NAVIGATE FEP prescribing guidelines. Study investigators had reported previously that many patients with FEP receive medications that do not comply with recommended guidelines for FEP treatment, which emphasize low doses of antipsychotic drugs and strategies for minimizing the side effects that might contribute to patients stopping their medication.
Participants in NAVIGATE had fewer symptoms of depression while also being significantly less likely to receive antidepressant medication. The authors suggest this may be because depressive symptoms often improve as a consequence of antipsychotic treatment alone. The psychosocial interventions used in NAVIGATE may have also have played a role in the lower rate of depressive symptoms.
Finally, participants in NAVIGATE gained less weight than those in typical care (which also includes a medication component). One of the long-term challenges of antipsychotic medications is that they can cause weight gain and changes in metabolic measures associated with risk of diabetes and heart disease. Despite the increased use of antipsychotics in NAVIGATE, participants gained less weight and there was no significant difference in metabolic measures.
NAVIGATE participants who received antipsychotic prescriptions also completed a questionnaire to assess attitudes that might reduce the likelihood that they would continue taking an antipsychotic as prescribed. Measured attitudes were the same in both groups at the beginning of the study, but by the end of the study, NAVIGATE participants had scores that were significantly lower; they endorsed fewer beliefs associated with discontinuing medication.
The findings detailed above were reported in a 2018 article written by Delbert Robinson, M.D., John M. Kane, M.D. (both from the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York), and colleagues.
These findings are consistent with an earlier report from a companion RAISE project, the RAISE Implementation and Evaluation Study (RAISE-IES), which explored how to implement a CSC model called the Connection Program in community clinics.
According to Susan Azrin, Ph.D., Chief of the Early Psychosis Prediction and Prevention Unit in NIMH’s Division of Services and Intervention Research, “This work shows how a systematic approach to prescribing medication for FEP—one that incorporates medication guidelines and computerized decision support within a patient-provider shared decision-making framework—can improve the quality of medication prescribing, including minimizing side effects, for people experiencing FEP.” This report adds to insights from RAISE that are already informing care for early psychosis throughout the U.S.
For more information about RAISE-ETP, visit:
Robinson, D. G., Schooler, N. R., Correll, C. U., John, M., Kurian, B. T., Marcy, P … Kane, J. M. (2018). Psychopharmacological treatment in the RAISE-ETP study: outcomes of a manual and computer decision support system based intervention. American Journal of Psychiatry, 175, 169–179.