Schizophrenia

Early Treatment of First-episode Psychosis: Takeaways From the RAISE Initiative

Authors: Patti Peeples, RPh, PhD, and Takeesha Roland Jenkins, MS (Psychology), MS (Neurology)

When the first episode of psychosis strikes, a rapid and comprehensive response from the medical community is critical. Without timely and multimodal intervention, psychotic symptoms can persist, placing individuals on a negative spiral and potentially reducing their ability to lead an independent and fruitful life. Individuals often wait approximately 18 months before receiving treatment,1 although it is well-recognized that delayed treatment of psychosis is associated with long-term cognitive decline, poor academic achievement, higher unemployment rates, and a higher risk of attempted and completed suicide in the patient.2-4

Recently, the National Institute of Mental Health (NIMH) and a team of researchers have been working to improve treatment for first-episode psychosis by adapting, testing, and optimizing evidence-based practices for use in a real-world environment.Their effort is called The Recovery After an Initial Schizophrenia Episode (RAISE), and it seeks to change the old research paradigm that focused on the later stages of schizophrenia, particularly the reduction of chronic disability. RAISE redirects that focus to earlier stages of first-episode psychosis in schizophrenia, when recovery may be more attainable.

Early coordinated treatment of psychosis—as close to possible after the onset of symptoms—leads to the best outcomes, including improved functional recovery, better quality of life, a lower risk of relapse or need for hospitalization, and the amelioration of symptoms.3-6 By drawing on treatment approaches backed by recent research, clinicians can ensure that individuals with first-episode have a better chance at a positive, productive future.

Multi-disciplinary Team Approach for First-episode Psychosis

The RAISE initiative explores the best ways to intervene with the client and family after the initial presenting symptoms of first-episode psychosis, such as hallucinations, delusions, or disorganized speech.6 RAISE studies have been fielded in more than 30 US-based community mental health centers across 21 states. The intent is to gain practical insights into how a comprehensive, early-intervention multidisciplinary program combining state-of-the-art drug and psychosocial therapy can be used by clinicians to improve symptom management of first-episode psychosis. The program also seeks to prevent negative events such as dropping out of school, job interruption, and distancing from family and friends, all of which may be associated with untreated or poorly managed psychosis.4,7,8

 

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The RAISE research program began with 2 studies, both examining different features of coordinated specialty care, a type of treatment program for first-episode psychosis that uses a team of specialists who work with the client to create a personal treatment plan. One study (called RAISE Early Treatment Program or RAISE-ETP) compared coordinated specialty care with usual care typically available in community settings,7 The other study explored ways to implement the coordinated specialty care treatment program.8 RAISE researchers placed emphasis on designing and testing interventions that would be relevant to many community treatment settings throughout the United States.

The lead researcher for RAISE-ETP, John Kane, MD, who is with the Department of Psychiatry at The Hofstra North Shore-LIJ School of Medicine in Hempstead, New York, explains that “in the past, comprehensive coordinated specialty care programs for first-episode psychosis were widely implemented in various countries, but not in the United States. However, the RAISE program and similar programs are now being implemented across the US as well.”

Outcomes for RAISE

Two-year outcomes of the RAISE-ETP were encouraging. The study focused on individuals with first-episode psychosis treated with the coordinated specialty care program called NAVIGATE,4 which was tested in 400 clients at 34 US clinics. The NAVIGATE program had 4 core components:

  • Individualized medication treatment based on a web-based decision support system developed for the RAISE-ETP study;
  • Individual resiliency training;
  • Supported employment and education; and,
  • A family education program with the primary focus being on medication management.

The study4 found that NAVIGATE-managed clients had better psychopathology, quality of life, and school or employment-related outcomes than clients managed at the typical-care sites. Moreover, they stayed in treatment longer, had improved symptom management, better relationships, improved quality of life, and better work/school involvement. One of the most remarkable findings from the RAISE-ETP study was the impact of early detection and engagement following the onset of psychosis. Clients who received the coordinated specialty care intervention sooner after initial first-episode psychosis symptom presentation fared better than those who had delayed intervention.6,4

The results from the RAISE-ETP also provided strong evidence for medication treatment approaches such as first- or second-generation antipsychotics when used in combination with resiliency training (eg, individual or group therapy).6 According to Dr. Kane, “the decision regarding the type of antipsychotic that will be administered for first-episode psychosis should be shared between the patient and the specialty care team. For the RAISE studies, however, aripiprazole and risperidone were the most commonly used treatment medications.” Dr. Kane also reinforced the benefits of employment/education support as well as family psychoeducation in attaining the best possible outcomes.

The second study under the RAISE initiative umbrella, the RAISE Implementation and Evaluation Study (RAISE-IES),8 explored how to implement a specialty coordinated specialty care clinic and an associated treatment program, called the Connection Program. Multiple clinician-, administrator-, and client-facing tools were developed that can be used by other service providers. These include treatment manuals; program guidelines; program quality assessment tools; strategies for monitoring treatment fidelity; staffing and cost-estimating tools; and client-facing coordinated specialty care service manuals. Methods to pay for and seek reimbursement for coordinated specialty care services and support clinic expansion were also developed. RAISE-IES program materials are publicly available.9

In addition to developing tools and resources, the RAISE-IES study compared client functioning at baseline and 2 years after coordinated specialty care initiation. Results showed that the Connection program improved client occupational and social functioning, reduced symptoms, and improved remission rates.8 Clients were favorable about the coordinated specialty care program, as demonstrated by better engagement and treatment longevity rates, and reported positive views about their treatment and the effectiveness of the Program.6,10 RAISE-IES underscored that flexible and individualized treatment that incorporates recovery- and goal-focused shared decision-making between the client and the staff can improve engagement in services for first-episode psychosis.10

Implementing Coordinated Specialty Care in Your Practice

Clinicians managing patients with first-episode psychosis should seek out a comprehensive person-centered, team-based treatment approach as soon as possible after assessment and diagnosis. The specific coordinated specialty care program should be based on the client’s life goals and preferences. In the US, various options for coordinated specialty care programs exist. Beyond NAVIGATE and the Connection Program, programs such as OnTrackNY, STEP (Specialized Treatment Early in Psychosis), and EASA (Early Assessment and Support Alliance) are available.11

The chosen coordinated specialty care treatment program should include the following components: a team-based approach to treatment, person-centered treatment planning that involves the client in all treatment decisions, family involvement (when possible) in treatment, and a treatment team. The treatment team should provide the following services:

  • Case management;
  • Psychotherapy that is recovery-oriented;
  • Medication management oriented for individuals with first-episode psychosis;
  • Supported education and employment;
  • Coordination with the client’s other medical care (primary and specialty care); and,
  • Family education and support.

Takeaways From the RAISE Initiative

The RAISE initiative research program has provided service users, family members, and clinicians with tools and evidence to improve the outcomes for first-episode psychosis,12 based on multisite trials of coordinated specialty care in the United States. As community care settings move toward implementing specialty care teams for individuals experiencing first-episode psychosis, the resources from the multi-level NAVIGATE and CONNECTION Programs can aid in this transition.

Even in community clinics with a diverse client base, this team-based model offers hope for first-episode psychosis management that can produce better clinical, functional, social, and employment/educational outcomes that can reduce or stop the deleterious consequences often associated with first-episode psychosis.

According to Dr. Kane, the lead researcher of the RAISE-ETP initiative, “the main goal for individuals who are experiencing first-episode psychosis is to link them with a coordinated specialty care team as soon as possible after the initial psychotic symptoms begin, by obtaining referrals from general practitioners, hospitals, and outpatient clinics." This treatment approach substantially increases the probability that patients will benefit from complete functional and clinical recovery, thus avoiding a lifetime of disability and increasing the chance of experiencing a fulfilling and healthy life.

Patti Peeples, RPh, PhD, is Principal Researcher at HE Institute, located in Ponte Vedra Beach, Florida.

Takeesha Roland Jenkins, MS (Psychology), MS (Neurology), is a Medical Writer at HE Institute, located in Ponte Vedra Beach, Florida.

References

1. Addington J, Heinssen RK, Robinson DG, et al. Duration of untreated psychosis in community treatment settings in the United States. Psychiatr Serv. 2015;66(7):753-756.

2. Cloutier M, Aigbogun MS, Guerin A, et al. The economic burden of schizophrenia in the United States in 2013. J Clin Psychiatry. 2016;77(6):764-771.

3. Norman RM, Lewis SW, Marshall M. Duration of untreated psychosis and its relationship to clinical outcome. Br J Psychiatry Suppl. 2005;48:s19-s23.

4. Kane JM, Robinson DG, Schooler NR, et al. Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE Early Treatment Program. Am J Psychiatry. 2016;173(4):362-372.

5. Robinson DG, Woerner M, Delman H, Kane J. Pharmacological treatments for first episode schizophrenia. Schizophr Bull. 2005;31(3):705-722.

6. National Institute of Mental Health (NIMH). RAISE Questions and Answers. RA1SE: Recovery After an Initial Schizophrenia Episode. https://www.nimh.nih.gov/health/topics/schizophrenia/raise/raise-questions-and-answers.shtml#6. Accessed January 4, 2017.

7. Kane JM, Schooler NR, Marcy P, et al. The RAISE early treatment program for first-episode psychosis: Background, rationale, and study design. J Clin Psychiatry.2015;76(3):240-246.

8. Dixon LB, Goldman HH, Bennett ME, et al. Implementing coordinated specialty care for early psychosis: the RAISE Connection Program. Psychiatr Serv. 2015;66(7):691-698.

9. Center for Practice Innovations. OnTrack USA 2017. Columbia Psychiatry, New York State Psychiatric Institute. http://practiceinnovations.org/OnTrackUSA. Accessed January 5, 2017.

10. Luckstead A, Essock SM, Stevenson J, et al. Client views of engagement in the RAISE Connection Program for early psychosis recovery. Psychiatr Serv. 2015;66(7):699-704.

11. National Institute of Mental Health. Coordinated Specialty Care Fact Sheet and Checklist. https://www.nimh.nih.gov/health/publications/raise-fact-sheet-coordinated-specialty-care/index.shtml. Accessed on January 5, 2017.

12. National Institute of Mental Health. RAISE Resources for Patients and Families. https://www.nimh.nih.gov/health/topics/schizophrenia/raise/raise-resources-for-patients-and-families.shtml. Accessed on January 5, 2017.