Implementing Coordinated Specialty Care for Early Psychosis: The RAISE Connection Program

Improving functional outcomes in college and university students with schizophrenia in the Western world

Retrospective research from patients with schizophrenia suggests that remission becomes increasingly less likely the longer psychosis goes untreated. Yet symptoms of schizophrenia are insidious and disease evolution varies between patients, requiring an ongoing diagnostic process. One way of justifying early treatment is by focusing on functionality rather than symptomatology. Most patients are diagnosed with schizophrenia between the ages of 17 and 25-when many young adults are undergraduates or pursuing post-graduate education. The extent to which schools partner with mental health services has implications for the short-term success of students' recovery and their future employability. Translating study findings on schizophrenia to the college setting remains an important area of investigation.

Optimizing psychosocial interventions in first-episode psychosis: current perspectives and future directions

Psychotic-spectrum disorders such as schizophrenia, schizoaffective disorder, and bipolar disorder with psychotic features are devastating illnesses accompanied by high levels of morbidity and mortality. Growing evidence suggests that outcomes for individuals with psychotic-spectrum disorders can be meaningfully improved by increasing the quality of mental health care provided to these individuals and reducing the delay between the first onset of psychotic symptoms and the receipt of adequate psychiatric care. More specifically, multicomponent treatment packages that 1) simultaneously target multiple symptomatic and functional needs and 2) are provided as soon as possible following the initial onset of psychotic symptoms appear to have disproportionately positive effects on the course of psychotic-spectrum disorders. Yet, despite the benefit of multicomponent care for first-episode psychosis, clinical and functional outcomes among individuals with first-episode psychosis participating in such services are still suboptimal. Thus, the goal of this review is to highlight putative strategies to improve care for individuals with first-episode psychosis with specific attention to optimizing psychosocial interventions. To address this goal, we highlight four burgeoning areas of research with regard to optimization of psychosocial interventions for first-episode psychosis: 1) reducing the delay in receipt of evidence-based psychosocial treatments; 2) synergistic pairing of psychosocial interventions; 3) personalized delivery of psychosocial interventions; and 4) technological enhancement of psychosocial interventions. Future research on these topics has the potential to optimize the treatment response to evidence-based psychosocial interventions and to enhance the improved (but still suboptimal) treatment outcomes commonly experienced by individuals with first-episode psychosis.

OnTrackNY: The Development of a Coordinated Specialty Care Program for Individuals Experiencing Early Psychosis

OnTrackNY is a coordinated specialty care program that delivers early intervention services to youths experiencing a first episode of nonaffective psychosis. Treatment aims to help individuals improve their mental health and achieve personal goals related to work, school, and social relationships. This column describes OnTrackNY's progression from a research project to real-world implementation. The authors describe the treatment model, approach to training and dissemination, and procedures for collecting and sharing data with OnTrackNY teams and provide data on client characteristics and selected outcomes.

Characteristics associated with the pursuit of work and school among participants in a treatment program for first episode of psychosis

OBJECTIVE

In this study, we examined the pursuit of education and employment among participants in the Recovery After an Initial Schizophrenia Episode (RAISE) Connection Program (Dixon et al., 2015; Essock et al., 2015), a first-episode psychosis (FEP) treatment program emphasizing participation in school and work.

METHOD

Data were collected between 2011 and 2013 from all 65 individuals in the RAISE Connection Program. Descriptive statistics, analysis of variance, and multinomial logit random-effects models were used to examine rates and predictors of work/school participation.

RESULTS

Most participants who eventually engaged in vocational activities did so within the first year of participation. Many engaged in both school and work. Those working (alone or with school) had better premorbid functioning and cognition and less severe concurrent symptoms.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Participants in FEP programs emphasizing school and work can have high rates of vocational participation and early engagement, often simultaneously in work and school. (PsycINFO Database Record

The Epidemiology of First-Episode Psychosis in Early Intervention in Psychosis Services: Findings From the Social Epidemiology of Psychoses in East Anglia [SEPEA] Study

OBJECTIVE

Few studies have characterized the epidemiology of first-episode psychoses in rural or urban settings since the introduction of early intervention psychosis services. To address this, the authors conducted a naturalistic cohort study in England, where such services are well established.

METHOD

All new first-episode psychosis cases, 16-35 years old, presenting to early intervention psychosis services in the East of England were identified during 2 million person-years follow-up. Presence of ICD-10 F10-33 psychotic disorder was confirmed using OPCRIT [operational criteria for psychotic illness]. Incidence rate ratios were estimated following multivariable Poisson regression, adjusting for age, sex, ethnicity, socioeconomic status, neighborhood-level deprivation, and population density.

RESULTS

Of 1,005 referrals, 687 participants (68.4%) fulfilled epidemiological and diagnostic criteria for first-episode psychosis (34.0 new cases per 100,000 person-years; 95% CI=31.5-36.6). Median age at referral was similar for men (22.5 years; interquartile range: 19.5-26.7) and women (23.4 years; interquartile range: 19.5-29.1); incidence rates were highest for men and women before 20 years of age. Rates increased for ethnic minority groups (incidence rate ratio: 1.4; 95% CI=1.1-1.6), as well as with lower socioeconomic status (incidence rate ratio: 1.3; 95% CI=1.2-1.4) and in more urban (incidence rate ratio: 1.4;95%CI=1.0-1.8) and deprived (incidence rate ratio: 2.1; 95% CI=1.3-3.3) neighborhoods, after adjustment for confounders.

CONCLUSIONS

Pronounced variation in psychosis incidence, peaking before 20 years old, exists in populations served by early intervention psychosis services. Excess rates were restricted to urban and deprived communities, suggesting that a threshold of socioenvironmental adversity may be necessary to increase incidence. This robust epidemiology can inform service development in various settings about likely population-level need.

Early Psychosis and Trauma-Related Disorders: Clinical Practice Guidelines and Future Directions

Despite high rates of trauma-related disorders among individuals with early psychosis, no clinical practice guidelines for the treatment of comorbid early psychosis and trauma-related disorders exist to date. Indeed, the routine exclusion of individuals with past and current psychosis from participation in trauma research and practice has limited the accumulation of research that could support such clinical practice guidelines. While preliminary research evidence suggests that traditional, evidence-based treatments for trauma-related disorders can be safely and effectively employed to reduce symptoms of posttraumatic stress and chronic psychosis, it remains unclear whether such treatments are appropriate for individuals in the early stages of psychotic illness. Clinical experts (N = 118) representing 121 early psychosis programs across 28 states were surveyed using the expert consensus method. Forty-nine clinical experts responded and reached consensus on 46 of 49 expert consensus items related to the treatment of comorbid early psychosis and trauma-related disorders. Conjoint or family therapy and individual therapy were rated as treatment approaches of choice. Anxiety or stress management and psychoeducation were rated as treatment interventions of choice for addressing both trauma symptoms and psychotic symptoms. In addition, case management was rated as a treatment intervention of choice for addressing psychotic symptoms. No consensus was reached on expert consensus items regarding the appropriateness of a parallel treatment approach exposure interventions for addressing psychotic symptoms, or sensorimotor or movement interventions for addressing trauma symptoms. In areas where expert consensus exists and is supported by current research, preliminary clinical practice guidelines for the treatment of comorbid early psychosis and trauma-related disorders are offered. In areas where expert consensus does not exist, recommendations for future research are offered. The results of this study are intended to serve as a launching point for scientists and practitioners interested in advancing appropriate treatment for high-risk and underserved individuals with comorbid early psychosis and trauma-related disorders.

Methodology and Reporting of Mobile Heath and Smartphone Application Studies for Schizophrenia

The increasing prevalence of mobile devices among patients of all demographic groups has the potential to transform the ways we diagnose, monitor, treat, and study mental illness. As new tools and technologies emerge, clinicians and researchers are confronted with an increasing array of options both for clinical assessment, through digital capture of the essential behavioral elements of a condition, and for intervention, through formalized treatments, coaching, and other technology-assisted means of patient communication. And yet, as with any new set of tools for the assessment or treatment of a medical condition, establishing and adhering to reporting guidelines-that is, what works and under what conditions-is an essential component of the translational research process. Here, using the recently published World Health Organization mHealth Evaluation, Reporting and Assessment guidelines for evaluating mobile health applications, we review the methodological strengths and weaknesses of existing studies on smartphones and wearables for schizophrenia. While growing evidence supports the feasibility of using mobile tools in severe mental illness, most studies to date failed to adequately report accessibility, interoperability, costs, scalability, replicability, data security, usability testing, or compliance with national guidelines or regulatory statutes. Future research efforts addressing these specific gaps in the literature will help to advance our understanding and to realize the clinical potential of these new tools of psychiatry.

Early Intervention in Psychosis in the United States

Available data have demonstrated the clinical benefits and cost-effectiveness of multi-component treatment packages for individuals early in the course of psychotic-spectrum disorders. In response, an unprecedented effort aims to disseminate such multi-component treatment programs—referred to as Coordinated Specialty Care (CSC)—throughout the United States. We review the evidence in support of CSC care for first-episode psychosis and highlight specific policy reforms that may facilitate the successful dissemination and eventual improvement of CSC programs for first-episode psychosis. Among proposed reforms are novel financing strategies for CSC services and incentivizing of continued collaboration between academic and community agencies to facilitate sustained dissemination and refinement of CSC.

The RAISE Connection Program: Psychopharmacological Treatment of People With a First Episode of Schizophrenia

OBJECTIVE

This study examined the adherence of psychiatrists to the Schedule of Recommended First and Second Line Antipsychotic Medications ("Antipsychotic Schedule"), which was implemented in two Recovery After an Initial Schizophrenia Episode (RAISE) Connection Program Implementation and Evaluation Study clinics.

METHODS

Sixty-five individuals with a first episode of psychosis were enrolled in the RAISE Connection Program clinics. Two psychiatrists received training and ongoing consultation on use of a shared decision-making approach to prescribing antipsychotic medications according to the Antipsychotic Schedule. Information about participants, prescribed antipsychotic medications, and completion of side-effect assessments were obtained from standardized research assessments and chart extractions. Descriptive statistics were used to characterize the extent to which patterns of antipsychotic prescribing and side-effect monitoring were consistent with the Antipsychotic Schedule.

RESULTS

Ninety-two percent of participants were prescribed an antipsychotic medication and received the medication on 76%±35% of the days they were in treatment. Seventy-seven percent of participants were prescribed at least one Antipsychotic Schedule first-line antipsychotic, 20% were prescribed olanzapine, and 10% received a trial of clozapine. Regarding monitoring for metabolic side effects, 92% of participants had at least one weight recorded, 72% had at least one blood glucose measure recorded, and 62% had at least one lipid profile recorded.

CONCLUSIONS

In the context of a study in which training and ongoing clinical supervision by experts was provided to psychiatrists and shared decision making was encouraged, antipsychotic prescribing patterns closely adhered to recommendations established by the RAISE Connection Program.

Cost-Effectiveness of Comprehensive, Integrated Care for First Episode Psychosis in the NIMH RAISE Early Treatment Program

This study compares the cost-effectiveness of Navigate (NAV), a comprehensive, multidisciplinary, team-based treatment approach for first episode psychosis (FEP) and usual Community Care (CC) in a cluster randomization trial. Patients at 34 community treatment clinics were randomly assigned to either NAV (N = 223) or CC (N = 181) for 2 years. Effectiveness was measured as a one standard deviation change on the Quality of Life Scale (QLS-SD). Incremental cost effectiveness ratios were evaluated with bootstrap distributions. The Net Health Benefits Approach was used to evaluate the probability that the value of NAV benefits exceeded its costs relative to CC from the perspective of the health care system. The NAV group improved significantly more on the QLS and had higher outpatient mental health and antipsychotic medication costs. The incremental cost-effectiveness ratio was $12 081/QLS-SD, with a .94 probability that NAV was more cost-effective than CC at $40 000/QLS-SD. When converted to monetized Quality Adjusted Life Years, NAV benefits exceeded costs, especially at future generic drug prices.

Recent advances in supported employment for people with serious mental illness

PURPOSE OF REVIEW

Supported employment is a vocational rehabilitation approach that eschews prevocational training in favor of rapid job search for competitive work and follow-along supports to sustain employment, with the individual placement and support (IPS) model being the most standardized and researched model. This review covers recent research on the IPS model of supported employment.

RECENT FINDINGS

The evidence base for IPS-supported employment continues to grow, with seven new randomized controlled trials published, most conducted abroad, resulting in a total of 23 controlled studies showing that IPS is effective at improving work outcomes. Several reviews have concluded that competitive work improves quality of life in persons with serious mental illness, and some research has suggested that employment may confer clinical benefits. Encouraging research has been published on modifications of the IPS model (such as inclusion of supported education), augmentations (such as cognitive remediation) and adaptations for underserved populations (such as persons with criminal justice involvement). Recent studies have also described the effective strategies for implementing and sustaining IPS; others have reported its cost-effectiveness.

SUMMARY

Research continues to accumulate on the effectiveness of IPS-supported employment, adaptations of the model and overcoming programme and policy barriers to its widespread implementation.

Altering the course of schizophrenia: progress and perspectives

Despite a lack of recent progress in the treatment of schizophrenia, our understanding of its genetic and environmental causes has considerably improved, and their relationship to aberrant patterns of neurodevelopment has become clearer. This raises the possibility that 'disease-modifying' strategies could alter the course to - and of - this debilitating disorder, rather than simply alleviating symptoms. A promising window for course-altering intervention is around the time of the first episode of psychosis, especially in young people at risk of transition to schizophrenia. Indeed, studies performed in both individuals at risk of developing schizophrenia and rodent models for schizophrenia suggest that pre-diagnostic pharmacotherapy and psychosocial or cognitive-behavioural interventions can delay or moderate the emergence of psychosis. Of particular interest are 'hybrid' strategies that both relieve presenting symptoms and reduce the risk of transition to schizophrenia or another psychiatric disorder. This Review aims to provide a broad-based consideration of the challenges and opportunities inherent in efforts to alter the course of schizophrenia.

Treatment engagement of individuals experiencing mental illness: review and update

Individuals living with serious mental illness are often difficult to engage in ongoing treatment, with high dropout rates. Poor engagement may lead to worse clinical outcomes, with symptom relapse and rehospitalization. Numerous variables may affect level of treatment engagement, including therapeutic alliance, accessibility of care, and a client's trust that the treatment will address his/her own unique goals. As such, we have found that the concept of recovery-oriented care, which prioritizes autonomy, empowerment and respect for the person receiving services, is a helpful framework in which to view tools and techniques to enhance treatment engagement. Specifically, person-centered care, including shared decision making, is a treatment approach that focuses on an individual's unique goals and life circumstances. Use of person-centered care in mental health treatment models has promising outcomes for engagement. Particular populations of people have historically been difficult to engage, such as young adults experiencing a first episode of psychosis, individuals with coexisting psychotic and substance use disorders, and those who are homeless. We review these populations and outline how various evidence-based, recovery-oriented treatment techniques have been shown to enhance engagement. Our review then turns to emerging treatment strategies that may improve engagement. We focus on use of electronics and Internet, involvement of peer providers in mental health treatment, and incorporation of the Cultural Formulation Interview to provide culturally competent, person-centered care. Treatment engagement is complex and multifaceted, but optimizing recovery-oriented skills and attitudes is essential in delivery of services to those with serious mental illness.

The RAISE Connection Program for Early Psychosis: Secondary Outcomes and Mediators and Moderators of Improvement

The aims of this study were to explore secondary outcomes of a coordinated specialty care program for persons with early psychosis, including quality of life and recovery, as well as to explore mediators and moderators of improvement in occupational and social functioning and symptoms. Sixty-five individuals across two sites were enrolled and received services for up to 2 years. Trajectories for individuals' outcomes over time were examined using linear and quadratic mixed-effects models with repeated measures. In addition, baseline prognostic factors of participant improvement in social and occupational functioning were explored based on previous literature and expert opinion of the analytic team. Results demonstrate that the program was effective in improving quality of life and recovery over time. Furthermore, processing speed was identified as a significant moderator of improvement in occupational Global Assessment of Function, and treatment fidelity, engagement, and family involvement were identified as mediators of improvement in social and occupational functioning.