Novel Approach Dramatically Drops Psychosis Hospitalization

Liam Davenport

November 04, 2014

An aggressive, community-wide intervention program to identify individuals at risk for schizophrenia appears to dramatically reduce first hospital psychosis admissions by more than one third compared with expected levels, results of a US study indicate.

The Portland Identification and Early Referral (PIER) program achieved a striking 26% reduction in first hospital admissions for psychosis vs a nonsignificant increase of 8% in admissions in three control urban areas in the same city.

"The approach shows promise in reducing the tremendous personal, social, and economic burdens imposed by psychotic disorders," the researchers, led by William McFarlane, MD, former director of the Center for Psychiatric Research at Maine Medical Center in Portland, write. "We hope that our findings will promote wider testing and implementation of the indicated prevention approach," they add.

The study was published in the October issue of Psychiatric Services.

Rapid Referral

The PIER program began in 2001 and was aimed at individuals aged 12 to 35 years in Greater Portland, Maine, to reduce the incidence of psychotic disorders. Staff from the PIER team educated more than 7200 physicians, school and college counselors, community mental health practitioners, community agency staff, and others who had ongoing contact with young people who were potentially at risk and their parents. They were educated on the prodromal signs of psychosis and the benefits of early treatment, and were encouraged to rapidly refer appropriate cases.

After an initial assessment, individuals meeting the criteria for the prodromal syndrome were assigned to a specifically adapted or attenuated version of the Family-aided Assertive Community Treatment (FACT). This is an evidence-based combination of psychoeducational multifamily group treatment, assertive community treatment, and supported employment and education.

The PIER program was initiated in Greater Portland, which is a relatively stable area comprising 25 towns. In 2000, the population of individuals aged 12 to 35 years was 92,565. The impact of the PIER program on first hospital admissions for psychosis was compared with that seen in three control urban areas in Maine, which in 2000 had a combined population of 223,585 individuals aged 12 to 35 years.

Specifically, the rates of hospital admissions for psychosis in both areas were examined during a control period before the introduction of the PIER program (the second quarter of 1999 to the first quarter of 2001) and the experimental period (the second of 2001 to the third quarter of 2007).

During the control period, there were 779 first admissions for psychosis. The number of first admissions during the experimental period was 2283.

First hospitalizations for psychosis decreased significantly during the experimental period in the Greater Portland area, reducing by 2.82 per 28-day month (P < .001), which represents a 26% reduction. This translated into 189 fewer hospitalizations during the 332 weeks of the intervention, or 29.7 fewer admissions per year.

In the urban control areas, the number of first hospitalizations increased by a nonsignificant 1.41 per 28-day month, representing an 8% increase. Taken together, the findings imply that the PIER program reduced the number of first admissions for psychosis by 34% over expected levels during the study period.

The concept of a community prevention program for psychosis and schizophrenia itself is, however, not a new one. A study by Ian Falloon, MD, in the early 1990s suggested that the number of schizophrenia cases could be reduced with an intensive early intervention for adults who display signs and symptoms of schizophrenic disorders.

"We in Portland put together something like what Falloon had done but on much more systematic basis," Dr McFarlane told Medscape Medical News.

He added that although the program was rigorously applied in well-defined areas, he believes that rate of hospitalizations was an imprecise measure of outcomes.

"Hospitalization rates can go up and down for lots of political or financial or social reasons, depending on which way the wind is blowing," he said. "But we had the ability to correct for much of that, because there aren't that many hospitals in this part of Maine."

Early Detection, Intervention

Commenting on the study, Swaran P Singh, MD, head of mental health and wellbeing at Warwick Medical School, which is part of the University of Warwick in the United Kingdom, told Medscape Medical News that the study is novel for two reasons.

"First, it combines early detection of at-risk cases with targeted intervention; and second, the outcome is hospitalization rather than transition to psychosis. I am not aware of any similar study," he said.

However, Dr Singh believes that hospitalization is a useful outcome, particularly because it is so expensive.

"In the UK, every patient treated by early intervention services on average saves the NHS [National Health Service] £4500 per year, largely from reductions in hospital use," he commented. "The findings of the present study would be of great interest to providers, funders, and policy makers."

The findings of the current study could also help in the fight to retain early intervention services.

"Europe and the UK are going through an unprecedented period of austerity, with healthcare facing large cuts," Dr Singh said. "Despite the overwhelming evidence that early intervention in psychosis has demonstrable clinical and cost effectiveness and has been widely welcomed by users and carers, there is real risk that such services will be trimmed or disbanded."

"The key message of the present study is that if early intervention services were further funded to take on early detection and preventive functions, then their clinical and cost benefits may be even larger," he added.

Alongside hospitalizations rates, the most important effect of the intervention is on the lives of the at-risk individuals and their families. "Psychotic disorders such as schizophrenia afflict the young and rob them of their most productive and vital years, producing huge burden not just financially but also in terms of distress and carer burden," said Dr Singh.

Gratifying Work

Reflecting on his experience with the PIER program, Dr McFarlane noted: "It is incredibly gratifying to work with these people because, in stark contrast to working with, particularly, folks with schizophrenia or bipolar disorder with psychotic features, young people prior to the onset of full psychosis are generally frightened, anxious, aware that something is going wrong, open to help, and their families are definitely open to help."

"The whole thing just works in a way that is almost qualitatively different than working with that same population in what could be just a few months later in the course of illness, when people get paranoid and they start to, essentially, see the treatment system as the enemy rather than the source of help. Families are all so fragmented by this onset of psychosis that it takes them a long time to become helpful," he added.

Crucially, the efficacy of the PIER program has been tested beyond the Greater Portland area. In a study published in Schizophrenia Bulletin, Dr McFarlane and colleagues examined the impact of the Early Detection and Intervention for the Prevention of Psychosis Program, a version of the PIER initiative, in six sites across the United States that were representative of the continental American population.

The rate of conversion to psychosis was low, at 6.3%, and was remarkably consistent across the six sites. "Based on prior international studies, we would have expected [a conversion rate of] about 29%," Dr McFarlane said, adding: "It seems to work everywhere."

This research was supported by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; the National Institute of Mental Health; the Robert Wood Johnson Foundation; the Bingham Foundation; the Unum Foundation; and the Betterment Fund. Dr McFarlane provides training and consultation on request to public and not-for-profit organizations implementing programs similar to that described in this article.

Psychiatr Serv. 2014;65:1194–1200. Abstract

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