Novel Program Improves Outcomes in Young Psychosis Patients

Pauline Anderson

February 09, 2015

A comprehensive intervention for first-episode psychosis (FEP) helps young people stay out of hospital and return to school or the workforce, new research shows.

Dr Vinod Srihari

Investigators at Yale University School of Medicine, New Haven, Connecticut, found that more than 75% of FEP patients who had access to services such as cognitive-behavioral therapy (CBT), vocational supports, and family education avoided hospitalization during a 1-year period compared with just over 50% of those allocated to usual care.

The study is the first randomized trial of a first-episode service (FES) program in the United States. Such programs adapt treatments to the needs of younger patients and their families.

"We showed that comprehensive, first-episode service care is feasible and effective in a real-world public sector community setting in the US," lead study author Vinod Srihari, MD, associate professor of psychiatry, told Medscape Medical News.

The study was published online February 2 in Psychiatric Services.

Menu of Options

Chronic psychotic disorders are the leading contributor to mental illness expenditures in the United States, with a cost of $62.7 billion in 2002. Much of the direct healthcare costs are due to psychiatric hospitalizations.

The analysis included 117 predominantly young (mean age, 22 years) male patients with an average duration of untreated psychosis of about 10 months. They had significant comorbid substance abuse, functional loss, and clinical distress (almost 1 in 10 had attempted suicide), and many were unemployed.

Researchers allocated these patients to usual care ― either continued treatment with existing outpatient providers or referral on the basis of health insurance coverage ― or to the Specialized Treatment Early in Psychosis (STEP) intervention.

Patients in the STEP group could choose from a menu of options that included psychotropic medications, family education, and CBT. These patients could also access employment services and educational supports.

Education of families included learning about the signs and symptoms of psychosis and how to manage behaviors at home. Families could meet in individual sessions or in multifamily group sessions.

The STEP care team consisted of staff and trainees from psychiatry, psychology, social work, and nursing. Team members took a collaborative approach to coordinating care and targeted services to the needs of individual patients and families.

The two groups were roughly comparable in terms of the number of healthcare visits they had during the study period, but there was a "huge difference" in terms of the variety and kinds of treatments that STEP patients received, said Dr Srihari.

Improved Outcomes

Researchers used standard instruments, including the Structured Clinical Interview for DSM-IV disorders and the Positive and Negative Symptom Scale), to assess psychiatric diagnoses, symptoms, suicidality, and substance use.

They used the Social Functioning Scale to assess employment and school and housing status, and they determined hospitalization outcomes through structured in-person and telephone interviews or administrative record reviews.

The study showed that at 1 year, patients who were allocated to STEP care had better outcomes on all measures of hospital utilization ― 77% were not hospitalized during the 12 months compared with 56% of the treatment-as-usual group (estimated relative risk, 1.38; 95% confidence interval [CI], 1.08 - 1.58).

This translates into a number needed to treat (NNT) of 5 (95% CI, 2.7 - 26.5; P = .014). So for every five patients allocated to STEP instead of to usual care, one additional patient avoided psychiatric hospitalization.

And when STEP participants were hospitalized, they averaged more than 6 fewer hospital days than those in usual treatment (5.34 vs 11.51).

STEP group hospitalization outcomes might have been even better than reported, because it is likely that for some patients in the control group, hospitalizations were missed. Collecting hospitalization data in the United States is difficult because no single registry collects these data for all hospitals, said Dr Srihari.

"Our sense is that we may have had a better luck counting hospitalizations for those getting STEP care than for those getting usual care, because many of the folks who got usual care were hospitalized outside our immediate region, and we didn't have access to their records."

Reduced Hospitalization

Reductions in hospitalizations were accompanied by improved vocational outcomes. About 92% of those allocated to STEP care were classified as vocationally engaged at follow-up compared with 67% of patients allocated to usual treatment.

STEP patients were less likely to drop out of the labor force than usual-care patients (8% vs 33%) and were more likely to be in contact with mental health services (87% vs 79%).

It is not clear from this study what elements of the STEP model ― whether family education, CBT, or something else ― accounted for its success. Dr Srihari believes that improved outcomes were due to an intervention that involves "a lot of moving parts that are calibrated" to the individual patient.

"The nature of these complex interventions makes it hard to identify a single active ingredient," he said. "It's the fact that patients could tailor and combine and vary what they got based on their preferences."

The length of untreated psychosis of study patients (mean of 10 months) was "a very long time" but not unusual, noted Dr Srihari.

"The sobering fact is that in systems of care around the world, even ones that have nationalized healthcare, a year is about average for how long people are psychotic before they enter ongoing outpatient care."

Research shows that interventions early after the first signs of psychosis can have a positive impact on morbidity in schizophrenia spectrum disorders. Experts now talk about the "window of opportunity" for ameliorating long-term disability.

To shorten the wait for accessing care requires not only first-episode services such as STEP but also early detection. The researchers are now launching an early detection campaign using mass media and social media as well as professional outreach "to essentially empower individuals in the community to get people to us more quickly," said Dr Srihari.

The researchers now plan to carry out a health economic evaluation. Such an evaluation would look at things such as the cost of running the STEP program and how much is saved by filling fewer beds.

Importance of Early Intervention

Commenting on the study for Medscape Medical News, Anthony Lehman, MD, professor of psychiatry, University of Maryland School of Medicine, Baltimore, who was not involved in the research, said there are efforts to intervene at an even earlier stage ― when patients have prodromal symptoms, often as teenagers.

Studies such as this one ― and others coming down the pipeline ― are "really important" to show the benefits of intervening early to try to prevent unnecessary outcomes for people with psychosis, said Dr Lehman.

He pointed out that all treatment options offered in the STEP program have already been proven effective in more chronically ill patients.

Having a menu that individual patients can pick from "makes a lot of sense," added Dr Lehman. "Everybody doesn't need all of those things; some people need certain ones, and some people need other ones."

All too often, he said, patients do not have much in the way of options for treatment other than medications.

Experimental trials of FES programs that have been carried out in the United Kingdom, Norway, and Denmark included outreach to homes or structured residences, whereas the STEP program is office based. The US program also operates in a relatively fractured healthcare system with varying types of insurance coverage.

Dr Lehman emphasized how challenging it is to put this program together under such a "fragmented" healthcare system. "What's important is that the authors showed that they were able to do it, but it should be made easier; there's no reason for it to be so complicated in my opinion."

The STEP clinic is located within the Connecticut Mental Health Center (CMHC), which is part of a network of state agencies established under the federal Community Mental Health Centers Act, enacted in 1963. Although initially molded by efforts to deinstitutionalize patients with chronic illness, these agencies now provide a national platform for early intervention.

"CMHC is a de facto national mental health care system," said Dr Srihari. "This could be an infrastructure to actually roll out innovative early intervention programs."

The authors report no relevant financial relationships.

Psychiatr Serv. Published online February 2, 2015. Abstract

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