Care for First-Episode Psychosis: New Insights From RAISE

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First-episode psychosis represents a critical juncture in the treatment of schizophrenia. Studies suggest that intervention close to the time of psychosis onset is associated with improved symptoms and functioning compared with traditional care.¹ However, few randomized controlled trials have compared multimodal, multidisciplinary team approaches with usual care in first-episode psychosis, and no trials have been conducted in nonacademic, community clinics in the US.

Kane and colleagues² have just presented 2-year outcome data for patients with first-episode psychosis who participated in a multisite, randomized controlled trial in which comprehensive, team-based treatment was compared with usual care in US community treatment centers. The Early Treatment Program study is part of the Recovery After an Initial Schizophrenia Episode (RAISE) initiative by the National Institute of Mental Health (NIMH). The RAISE initiative aims to develop, test, and implement patient-centered, integrated treatment for first-episode psychosis that promotes symptomatic and functional recovery.

A total of 404 patients aged 15 to 40 years with a DSM-IV diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, or psychotic disorder not otherwise specified were included. Patients with affective psychosis, substance-induced psychosis, psychosis due to general medical conditions, clinically significant head trauma, or other serious medical conditions were excluded. All participants had experienced only one episode of psychosis (ie, subjects with full symptom remission after a psychotic episode and relapse to another psychotic episode were excluded) and had less than 6 months of lifetime exposure to antipsychotic medications.

Thirty-four clinics in 21 states were randomly assigned to experimental treatment or community care. The experimental treatment, NAVIGATE, included 4 core interventions:

• Personalized medication management (assisted by a secure, Web-based decision support system developed for RAISE)

• Family psychoeducation

• Resilience-focused individual therapy

• Supported employment and education

Diagnosis, duration of untreated psychosis, and clinical outcomes were assessed via live, 2-way video by remote, centralized raters masked to study design and treatment. The patients (mean age, 23) were followed for longer than 2 years. The primary outcome was the total score of the Heinrichs-Carpenter Quality of Life Scale.

The 223 participants in the NAVIGATE group remained in treatment longer (median duration, 23 months versus 17 months), had greater improvement in quality of life (with a small to medium clinically meaningful effect size of 0.3) and psychopathology (as measured by the Positive and Negative Syndrome Scale), and experienced greater involvement in work and school compared with 181 participants in community care. The median duration of untreated psychosis was 74 weeks for the entire study sample. About one-third of subjects (34% to 37%) in each group were hospitalized for psychiatric indications over the 2-year period, and these rates did not differ between groups. Note that the findings were moderated by the duration of untreated psychosis. The participants in the NAVIGATE group with a duration of untreated psychosis of less than 74 weeks had greater improvement in quality of life and psychopathology than those with a longer duration of untreated psychosis and those in community care.

The authors concluded that the primary goals of the NIMH RAISE initiative were accomplished: they developed a comprehensive recovery-oriented, evidence-based intervention for first-episode psychosis; trained community providers in early intervention principles and the implementation of manual-based coordinated specialty care; and successfully implemented NAVIGATE in real-world community clinic settings.

This trial demonstrated that diverse US community clinics can implement team-based care of first-episode psychosis that was associated with greater improvement in clinical and functional outcomes compared with usual care. The benefits of a multimodal, multidisciplinary team approach were more pronounced for patients with a shorter duration of untreated psychosis, which suggests that appropriate treatment at the critical juncture of first-episode psychosis can have substantial benefits on outcomes.

This article was originally posted on 11/3/2015 and has since been updated.

Disclosures:

Dr Miller is Associate Professor in the department of psychiatry and health behavior at Georgia Regents University in Augusta. He is the Schizophrenia Section Editor for Psychiatric Times. [Full bio]

References:

1. Alvarez-Jiménez M, Parker AG, Hetrick SE, et al. Preventing the second episode: a systematic review and meta-analysis of psychosocial and pharmacological trials in first-episode psychosis. Schizophr Bull. 2011;37:619-630.

2. 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. 2015 doi: 10.1176/appi.ajp.2015.15050632.