10 Mar 2015
March 11, 2015. Comprehensive early treatment and support can improve some outcomes in people with schizophrenia, according to early data from the Recovery After an Initial Schizophrenia Episode (RAISE) study. Self-reported quality of life improved more for those who received the comprehensive care, as did participation in work and school.
The unpublished results were presented February 6, 2015, at the open session of the U.S. National Advisory Mental Health Council, which advises the National Institute of Mental Health on priorities and funding. The meeting took place at the NIMH headquarters in Rockville, Maryland.
Of particular importance, according to study leader John Kane of the Zucker Hillside Hospital in Glen Oaks, New York, was the setting: "We showed that it was feasible to do a study like this in real-world, nonacademic settings," Kane told SRF. "We were able to go into community clinics, train the staff, and introduce comprehensive care."
The RAISE study was rolled out with funding from the American Recovery and Reinvestment Act of 2009. Along with the study that Kane leads—the RAISE Early Treatment Program (ETP)—there is an arm called RAISE Connection led by Lisa Dixon at Columbia University in New York City. RAISE Connection has focused on working with state mental health systems in New York and Maryland to develop guidelines for establishing early psychosis treatment capacity.
Not just the usual care
Care and support for people in a first episode of psychosis in the United States is haphazard and rarely comprehensive. People who are able to access care may see just a community psychiatrist for medications, or they may be fortunate enough to be seen in a clinic with some suite of services that includes psychotherapy and other support. However, there are no standards in place to establish the parameters of adequate care.
The goal of RAISE was to create an optimal program that could reasonably be implemented, and paid for, with resources already available to most communities, and to compare that with prevailing treatment practices across the U.S.
In his presentation, Kane described the services offered through clinics that adopted the RAISE ETP package—called NAVIGATE—as recovery rather than maintenance focused, team supported, and based on shared decision making with clients and families. The teams had expertise in pharmacotherapy, psychotherapy, family therapy, and employment/education counseling, backed up with ongoing training and consultation.
In his interview with SRF, Kane particularly emphasized the fact that psychiatrists or nurse practitioners had access to a computerized decision support system to help guide prescribing and adjustments of medications. One of the studies already published from RAISE ETP found that more than one-third of people in the early stages of schizophrenia were on less than optimal medication regimens (Robinson et al. 2014).
Of the total sample of 404 subjects, those who were treated within the NAVIGATE framework were significantly more likely to have stayed in treatment and reported a higher quality of life compared to patients at clinics that continued with their regular treatment and supportive care regimens. They also made greater strides in work or school involvement.
Not all patients benefited equally, however, and the length of time between the onset of psychosis and the start of treatment emerged as a factor in the extent to which quality of life improved with the NAVIGATE program. "Those individuals with shorter duration of untreated psychosis had better results," said Kane.
On the other hand, there was no noticeable benefit in terms of symptoms as measured by the PANSS (Positive and Negative Syndrome Scale) or time to hospitalization at the end of the two-year study.
However, one factor that makes the results more hopeful is that patients from clinics receiving the RAISE intervention appeared to be more dysfunctional at the outset of the study than the patients who received the usual community treatment. Thus, these subjects apparently made greater gains just to draw even, suggesting that the NAVIGATE program may prove superior to standard care.
One reason that it was difficult to get groups that were better matched at baseline is that the study was designed to compare study sites, not patients: that is, some sites used just NAVIGATE for all their patients and the rest did not.
These are the first outcome data to be reported from the project, and the research team is still analyzing factors such as cost effectiveness.
What's next for early psychosis care research?
The RAISE ETP study was not structured to probe which aspects of a comprehensive care program were the most effective, but another presentation at the NIMH meeting provided a preview of research that could answer such questions. Robert Heinssen, director of the Division of Services and Intervention Research at NIMH, gave a short introduction to the Early Psychosis Intervention Network (EPINET), a project that is still on the drawing board. (For more information and to submit suggestions about this program, please visit the NIMH EPINET Concept Clearance page.)
EPINET will link as many as 20 first-episode psychosis clinics together to create a national "learning healthcare network" that can employ standardized measures of clinical characteristics, interventions, and outcomes to feed data into a common informatics platform. The insights gained by studying these data would then be fed back out to the clinics to improve their services.
The effects on treatment could become substantial: the number of clinics specializing in treating a first episode of psychosis is burgeoning, thanks to a 2014 mandate from Congress that a portion of the Community Mental Health Block Grant program be spent on first-episode clinics in each state.
As of 2013, there were only about a dozen clinics that specialized in treating early psychosis. Heinssen said that 29 states will have first-episode clinics in place by October of this year, and that the total number of clinics should be over 100 by the fall of 2016.—Hakon Heimer.
Disclosure: Reporter and SRF Editor Hakon Heimer is a member of the National Advisory Mental Health Council, which advises NIMH on research policy.