Community Programs Improve Psychosis Outcomes

Liam Davenport

July 01, 2020

Community-based services that tap into local environments not only reduce the duration of untreated psychosis (DUP) but also provide improved long-term outcomes for patients with first-episode psychosis (FEP), results of two new studies show.

In the first study, investigators led by Vinod Srihari, MD, director of specialized treatment early in psychosis, Yale University, New Haven, Connecticut, developed a program to reduce DUP to complement their first-episode service (FES).

Through a combination of mass media and social media campaigns, outreach events with local professionals, and rapid triage, the team was able to nearly halve the time from diagnosis to initiation of antipsychotic treatment.

In the second study, a team led by Delbert G. Robinson, MD, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, East Garden City, New York, conducted a 5-year follow-up of RAISE-ETP, the first US randomized trial to compare a 2-year comprehensive early intervention service (EIS) with usual care.

These trial results showed that among more than 400 FEP patients, the EIS significantly improved both symptoms and quality of life and reduced inpatient days in comparison with standard care.

The research was scheduled to be presented at the Congress of the Schizophrenia International Research Society (SIRS) 2020, but the meeting was canceled because of the coronavirus pandemic.

Norwegian Model

Srihari and colleagues note that a specialized treatment early in psychosis (STEP), which delivers a specialty team–based FES, was established at their institution in 2006.

However, in a bid to reduce DUP, in 2015 they launched MindMap, a 4-year early detection campaign based on the Scandinavian TIPS Early Detection in Psychosis Study.

Sirhari told Medscape Medical News that they visited the team that developed the TIPS program in Norway "to try to understand what elements of their approach had resulted in a successful reduction of DUP."

He pointed out that the healthcare system in Norway has "more reliable pathways to care, with an ability to route people in more predictable ways from primary care to secondary care, and so on."

In the United States, "there's no expectation that people will go through a primary care provider," he said. He noted that patients "make their way to specialty care in many different ways."

Sirhari said, "The other change we realized we'd have to make was that, since TIPS had been completed many years back, the media environment had changed substantially.

"At the time that TIPS was done, there was no such thing as social media, whereas when we began to think about designing our campaign, we thought social media would be a very efficient and also cost-effective way to target young people."

MindMap, which covered a 10-town catchment area that has a population of 400,000, targeted both demand- and supply-side aspects of DUP. The former focused on delays in identifying illness and help seeking, and the latter concentrated on referral and treatment access delays.

The researchers used a combination of mass media and social media messaging, professional detailing, and the rapid triage of referrals.

The media campaign included Facebook, Twitter, and other social media platforms that allowed the team to "target individuals in a somewhat more fine-grained way than mass media allows," Srihari said. They focused on individuals in a particular age range and geographic location.

The professional detailing encompassed mental health agencies, emergency departments, and inpatient units, as well as colleges, college counseling centers, high schools, and police departments.

The team hosted meetings, "often at local restaurants, where we provided a meal and provided some general education about what our mission was," said Srihari. The researchers followed up these meetings with more in-person visits.

"The third arm was finding ways to basically eliminate any kind of a waiting time at our front door, such as ensuring that transportation issues were circumvented, in addition to cutting through any ambivalence they might have about finally making the leap to come to the center."

More Rapid Treatment

Over the course of the baseline year and the 4 years of the MindMap program, almost 1500 individuals were assessed. Of these, approximately 200 were eligible, and almost all were enrolled.

The researchers measured DUP at two time points from the onset of psychosis ― the initiation of antipsychotic treatment (DUP1), and the initiation of FES care.

Across the study period, they found that DUP1 fell significantly between the pre- and post-program assessments, from 329 days to 185 days (P = .03).

By contrast, there was no change over the same period for the Prevention and Recovery in Early Psychosis FES program in Boston, Massachusetts, which served as a comparator.

There was also a cumulative effect on DUP, with each year of the 4-year program associated with a 46-day reduction in DUP1.

However, the significant reduction was restricted to the third quintile of DUP1 and was not found in the other quintiles of DUP1 or for DUP2, despite all measures showing a consistent trend for reduction over time.

Srihari acknowledges that the team was "disappointed" that DUP2 did not fall significantly in their study.

He suggested, "It might take longer for agencies to change their workloads and refer patients to STEP, which is what ended up resulting in the DUP2 not dropping as quickly."

To see whether there was indeed a time lag in changes to practice, the team conducted an analysis in which they cut out the first year from the results and analyzed only the last 3 years. Then "we do see a decline in DUP2," he said.

The study's full results are currently being prepared for publication, and the investigators are considering relaunching the initiative.

"The question we are having now is how to resource the campaign without the research funds and which parts of it we think we can launch sustainably so we can continue the reduction of DUP," Srihari said.

Plans may include developing partnerships with local businesses to help fund the media costs and working with the state government to build a learning healthcare network, which would make it easier for mental health agencies to consult with the team on problematic cases.

"We're trying to reduce DUP referrals on the supply side by providing this kind of learning health collaborative...that we also think might be fiscally a more sustainable way to do this vs what we did in MindMap," which would be "very expensive" to implement on a statewide basis, Srihari added.

Long-term Benefit

In the second study, Robinson and colleagues highlight that EISs have been implemented worldwide for FEP patients and have been associated with improved outcomes.

However, these services typically provide care for a limited period, and cross-sectional follow-up studies have identified few advantages in comparison with standard care.

To provide a more robust longitudinal assessment of the ongoing effects of an EIS, the team conducted a 5-year follow-up of the first US-based, multicenter, randomized clinical trial comparing an EIS, NAVIGATE, with usual clinical care in FEP.

RAISE-ETP was conducted at 34 sites across the United States. Seventeen sites provided NAVIGATE to 223 individuals with FEP, and the remaining 17 sites provided usual care to 181 patients.

NAVIGATE, which continued for 2 years, consisted of treatments and services delivered by a coordinated team of providers. Those services included the following:

  • Education on schizophrenia and its treatment for patients and their families

  • Symptom and relapse prevention medication, using a computerized decision support system

  • Strategies for illness management building personal resilience

  • A supported employment/education model

Patients were assessed every 6 months for up to 60 months via a video link using the Heinrichs-Carpenter Quality of Life Scale (QLS) and the Positive and Negative Syndrome Scale (PANSS).

The average age of the participants was 23 years; 78% of those who received NAVIGATE and 66% of those who received usual care were male.

The opportunity for each participant to engage in NAVIGATE treatment lasted an average of 33.8 months. The longest was 44.4 months.

Over 5 years, NAVIGATE was associated with a significant improvement over usual care in QLS scores by an average of 13.14 units (P < .001). PANSS scores improved by an average of 7.73 units (P < .002).

QLS scores were not affected either by the length of opportunity to participate in NAVIGATE or by DUP, the team reports.

Patients who received NAVIGATE also had an average of 2.5 fewer inpatient days compared with those on usual care (P = .02).

The investigators note that the study "provides compelling evidence of a substantial long-term benefit for FEP treatment with the NAVIGATE EIS compared with standard care."

A "Great Message"

Commenting on the findings for Medscape Medical News, Ragy R. Girgis, MD, associate professor of clinical psychiatry, Columbia University and the New York State Psychiatric Institute, New York City, said the research "adds to the growing literature that treating people, especially people with psychosis, early on in their illness leads to better outcomes."

Girgis, who was not involved in either study, told Medscape Medical News that the research is "a great message." He noted that it is "really important for people to know and it's really important that we're still doing research in those areas."

However, he noted that psychosocial interventions such as these "sometimes take a lot of work." Girgis said that it "so easy to just give people a medication" but that approach has its own disadvantages, including adverse effects and sometimes a lack of efficacy.

"Psychosocial interventions, on the other hand, are very well tolerated by people. They are very effective, but they may require a lot more manpower, and in some ways they can also be more expensive.

"So this is a dialectic that we oftentimes have to deal with when we figure out the right balance between psychosocial vs medication types of treatments," he said.

STEP has received research funding from the National Institutes of Health and the Patrick and Catherine Weldon Donaghue Medical Research Foundation. RAISE-ETP was funded by the National Institute of Mental Health as part of the Recovery After an Initial Schizophrenia Episode (RAISE) Project. Gopal is an employee of Janssen Research & Development, LLC, and owns stock/equity in Johnson & Johnson. Girgis has received research support from Genentech, BioAdvantex, Allegran/Forest and Otsuka, and royalties from Wipf and Stock and Routledge/Taylor and Francis.

Congress of the Schizophrenia International Research Society (SIRS) 2020: Abstracts O1.2 and O4.5

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