Treating Early Psychosis in the 'Real World'

Bret S. Stetka, MD; John M. Kane, MD; Kim T. Mueser, PhD; Delbert G. Robinson, MD; Robert K. Heinssen, PhD


July 20, 2016

Editor's Note:
In October 2015, results from the National Institutes of Mental Health's Recovery After an Initial Schizophrenia Episode: Early Treatment Program (RAISE-ETP) study[1] were published in the American Journal of Psychiatry. The findings suggest that a multidisciplinary, community-based treatment approach can realistically be implemented and improve functional and clinical patient outcomes. Medscape recently hosted an email discussion among four researchers involved the study: John M. Kane, MD, Chairman and Professor in the Department of Psychiatry at Hofstra Northwell School of Medicine in Uniondale, New York; Kim T. Mueser, PhD, Professor of Occupational Therapy, Psychology, and Psychiatry at Boston University; Delbert G. Robinson, MD, Professor, Departments of Psychiatry and Molecular Medicine at Hofstra Northwell School of Medicine in Hempstead, New York; and Robert K. Heinssen, PhD, Director, Division of Services and Intervention Research at National Institute of Mental Health in Bethesda, Maryland.

Medscape: What were the objectives of the RAISE study, and what was the importance of launching a trial such as this?

Dr Mueser: Over the past several decades, there has been a growing awareness worldwide of the importance of comprehensive, specialty treatment programs for people who have experienced a first episode of psychosis. To address this problem, comprehensive first episode psychosis programs were developed and implemented, and they shown to be effective at improving outcomes.

However, almost all of this research had been conducted in the metropolitan areas of other countries with single-payer health systems. This left open the question of how effective programs for this population could be designed that could be implemented in the context of the US healthcare system.

The RAISE initiative was established to develop and rigorously evaluate a comprehensive specialty program for first-episode psychosis that could be provided in routine treatment settings through the United States. To accomplish this, the RAISE-ETP study of the NAVIGATE program solicited the involvement of 34 non-academically affiliated sites through the United States, located in both urban and rural areas, to participate in the study. The NAVIGATE program is comprised of three different psychosocial treatment components, all of them tailored to help clients meet their personal goals. [Editor's note: see more on the specifics of NAVIGATE below]

One half of the sites (17) were randomly assigned to provide the NAVIGATE program, and the other half continued to provide community care (usual services).

NAVIGATE was successfully implemented across the sites assigned to provide that program. Furthermore, participants in the NAVIGATE program demonstrated significantly greater improvements over 2 years on a broad range of outcomes, including symptom severity, work and school involvement, interpersonal relationships, and quality of life.

These findings are important in that they demonstrate that it is possible to implement effective, comprehensive specialty services for persons recovering from a first episode of psychosis in routine mental health treatment settings throughout the United States. The findings are encouraging in that they provide realistic hope for improving the long-term outcome of schizophrenia through intensive, focused intervention delivered as soon as possible after the diagnosis of a psychotic episode.

Dr Robinson: The study offers an appealing model for future treatment development efforts. Designing interventions specifically for community centers and then testing these interventions in "real world" settings spread across the country ensures that a successful intervention can be implemented in diverse treatment settings.

Lessons learned while conducting the trial can inform poststudy dissemination efforts at community centers. At a minimum, it can be reassuring for community facilities contemplating adopting a new intervention that the intervention was successfully implemented at similar community facilities during a trial.

The model does impose some limitations. Community facilities are usually not equipped to provide medications that are not approved by the US Food and Drug Administration, nor can they provide nonpharmacologic interventions that require skills before study training activities that are not widely available at community facilities. Community facilities may have limited prior research experience, so the central study team often has to provide more support and guidance to sites than if the sites were academic facilities.


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