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Early patient engagement tied to psychosis outcomes.


Integrated, patient-centered treatment delivered earlier in people with first-episode psychosis lead to better outcomes than standard community care, primary results from the RAISE study have shown.

"These results demonstrate the importance of early detection, early engagement, and integrated care following the onset of psychosis," Dr. Thomas R. Insel, outgoing director of the National Institute of Mental Health (NIMH), wrote in an editorial accompanying the RAISE study's NAVIGATE results published online (Am J Psychiatry. 2015. doi: 10.1176/ appi.ajp.2015.15050632).

Although the median duration of untreated psychosis across the study was 74 weeks, the overall effects of the study intervention were larger when there was less time between onset of psychosis and treatment. With an effect size of 0.31, quality of life was significantly improved in the 223 study participants, mostly men in their early 20s still living at home, given the study intervention. Study participants also showed greater improvement in how they functioned on a daily basis and interacted with others, with an effect size of 0.42 for overall symptoms, wrote Dr. John M. Kane of the division of psychiatry research, Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, N.Y., and his associates.

These 2-year outcome data are part of the NIMH's RAISE Early Treatment Program (Recovery After an Initial Schizophrenia Episode), intended to discover the most effective evidence-based prevention and intervention strategies for patients with psychosis, including the role of early intervention in outcomes.

At 34 sites across 21 states, patients with DSM-IV diagnoses including schizophrenia, schizoaffective disorder, and brief psychotic disorder were randomly assigned to receive either comprehensive, team-based study care or standard community care.

Patients ranged in age from 14 to 40 years, and the median age across the study was 23 years. Their respective psychiatric profiles varied, but all had experienced only one episode of psychosis and had been adhering to 6 months or fewer of antipsychotic treatment since their initial episode. In the study group, 89% met schizophrenia spectrum criteria, as did 90% of controls.

The four-part NAVIGATE intervention begins with medication management agreed upon with the patient, family psychoeducation, resilience training for the individual patient, and education and employment support.

All aspects of the program are conducted within a shared decision-making framework, implemented according to patient preference.

Members of the 223-person study group given more say in their care were more likely than the 181 controls to stay in treatment, with a median of 23 months, compared with 17 months (P less than .004). Study participants also were more likely to receive a mean of 4.53 (standard deviation, 5.07) outpatient mental health services, compared with 3.67 (SD, 5.93) such services given their community care counterparts (P = .013).

The average rate of psychiatric hospitalization for the study group was 3.2% per month vs. 3.7% in community care patients, which by the study's end totaled 34% of the NAVIGATE group, compared with 37% of controls.

At baseline, the study group also tended to have lower rates of hospitalization (76.6% vs. 81.6%, P = .05), however their baseline Positive and Negative Syndrome Scale for Schizophrenia (PANSS) scores tended to be worse (P = .02) and their levels of school attendance also were lower (15.7% vs. 26%, P = .03).

The results excited many advocates in the mental health community, including Dr. Ken Duckworth, medical director of NAMI, the National Alliance on Mental Illness.

"This study demonstrates that getting people into care earlier makes a difference," Dr. Duckworth said in an interview. "Delay [works] against a person's recovery. The duration of untreated psychosis is a risk factor." Dr. Duckworth added that clinicians should be on the look out for programs in the community that use the NAVIGATE model, or something like it so that when a patient experiencing first-episode psychosis presents, getting them the care they need can be done immediately. "The kind of care they receive when they arrive matters--comprehensive and coordinated care makes a difference."

In his editorial (Am J Psychiatry. 2015. doi: 10.1176/appi.ajp.2015.15091204), Dr. Insel emphasized practicality over purity, and urged clinicians and policymakers to take immediate action based on the study results. "The egregious delay for first-episode psychosis treatment revealed in this study demonstrates that we cannot wait a decade to provide more comprehensive care earlier in the trajectory of schizophrenia," Dr. Insel wrote.

The NIMH has created the Early Psychosis Intervention Network to help move the findings into practice, and vice versa by collecting clinical data on NAVIGATE interventions in practice.

"The NAVIGATE program was designed for real-world conditions, so it can be implemented in many U.S. community clinics," Dr. Kane said in a statement. "The finding that NAVIGATE was especially important for patients who received treatment early in their illness underscores the need for interventions that are tailored to new patients, to keep them from developing chronic illness." On Twitter @whitneymcknight


Key clinical point: Early, integrated treatment for first-episode psychosis delivered in a community setting can help patients stay functional and productive.

Major finding: Quality of life, Positive and Negative Syndrome Scale for Schizophrenia, and treatment duration were more improved in an early intervention group of patients with first-episode psychosis than in controls given standard community-setting treatment.

Data source: Multisite, 2-year, clinical, blinded, randomly assigned trial of 223 study participants with first-episode psychosis, compared with 181 controls.

Disclosures: The study was supported with funding from the American Recovery and Reinvestment Act and the National Institute of Mental Health.
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Author:McKnight, Whitney
Publication:Clinical Psychiatry News
Date:Nov 1, 2015
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