Psychosocial Treatments Found Effective for Early Psychosis

First-episode psychosis patients who participated in a comprehensive, team-based treatment program at community clinics that included a combination of medication and psychosocial support experienced significant improvements in symptoms and quality of life compared with those receiving usual care.

That’s the finding from a landmark study—the NIMH-funded Recovery After an Initial Schizophrenia Episode (RAISE) initiative—that was published on October 18 in AJP in Advance. Importantly, the study also found that the best results were for patients who had shorter durations of psychosis, underscoring the importance of early intervention. 

“The most important implications are that patients with early-stage psychotic illness will benefit most from a comprehensive specialty care model,” said lead study author John Kane, M.D., chair of the psychiatry department at Hofstra North Shore-LIJ School of Medicine, in an interview with Psychiatric News. “That implies that the presence of a multidisciplinary team can help patients achieve their goals by providing a consistent array of treatments, including pharmacotherapy, individual psychotherapy, family psychoeducation, and supported education and employment.”

Kane and colleagues at multiple institutions used a model called NAVIGATE that includes four core interventions: personalized medication management, family psychoeducation, resilience-focused individual therapy, and supported employment and education. Thirty-four community mental health treatment centers in 21 states were randomly assigned to the experimental intervention (n=17) or to standard care (n=17). A total of 223 patients received the experimental NAVIGATE intervention, and 181 participants received usual care. 

The study found that NAVIGATE patients remained in treatment longer, experienced greater improvement in quality of life and psychopathology, and experienced greater involvement in work and school compared with patients in community care. When the researchers compared NAVIGATE participants with duration of untreated psychosis of less than 74 weeks with those with more, they found that those with less had greater improvement in quality of life and psychopathology.

“These results demonstrate the importance of early detection, early engagement, and integrated care following the onset of psychosis,” then-NIMH Director Thomas Insel, M.D., wrote in an accompanying editorial.

The findings also suggest the implementation of such a model is feasible, Kane said. “We were able to implement this model in a series of community clinics across the country—these were not teaching hospitals or research facilities, but real-world clinics. … it shows we can work with clinicians in a diverse range of settings to help them develop the skills necessary to deliver this kind of specialty care.”

Will insurance pay for this kind of comprehensive specialty care? Last month, the Centers for Medicare and Medicaid Services released an informational bulletin that described ways that states can use the federal Medicaid program to pay for evidence-based, first-episode psychosis services, such as those tested in RAISE.

“Initially this kind of model may be associated with some increase in cost, but we believe over time the improvements in functional recovery and quality of life will lead to further cost offsets and in the long run will be cost-effective,” Kane said.

The National Alliance on Mental Illness (NAMI) plans to use this program and study findings in support of a major campaign to promote broader adoption of coordinated specialty care services throughout the United States for people experiencing first-episode psychosis. As part of this effort, NAMI arranged a Congressional briefing that took place on the day the study was released in which Kane and Lisa Dixon, M.D., presented the RAISE comparative effectiveness and implementation results.

Kenneth Duckworth, M.D., medical director of NAMI, told Psychiatric News in an interview that the findings could be “a game changer for the field.” 

“This is one of the biggest and most important studies coming out of NIMH,” he said. “This is a study of approaching psychosis with a public health intervention—that’s a strategy we have not traditionally done well in this country.

“So this is a profound finding—that if you get people early in their illness and give them services we know work, they get better,” Duckworth said. ■

 “Comprehensive Versus Usual Community Care for First-Episode Psychosis: 2-Year Outcomes From the NIMH RAISE Early Treatment Program” can be accessed here. An accompanying editorial, “RAISE-ing Our Expectations for First-Episode Psychosis,” is available here.