(Dec. 9, 2015) The goal of the NIMH-funded project called RAISE – Recovery After Initial Schizophrenic Episode – was to develop and test a “real world” early-intervention approach that would work in the fragmented US health care system to change the course and prognosis of psychotic disorders. Other countries had been using coordinated first-episode models with good results for decades. Could the US replicate their results with its far-flung, multi-payer system?
The answer, according to authors of several papers in an issue of Psychiatric Services devoted largely to first-episode treatment, is a virtually unqualified “Yes.” Authors describing both of the RAISE-funded models and an independent early intervention program in Connecticut declare that the core components can be carried out in a variety of non-academic community settings.
If successful early intervention models are to become widely available to the mostly young adults at risk for first psychotic episodes, this transferability is essential. The following is a summary of reports in Psych Services’special section on first-episode response describing how RAISE-like programs work across multiple settings and what is still to be learned about them.
The two NIMH-funded RAISE programs – NAVIGATE and RAISE Connection – and Connecticut’s Specialized Treatment Early in Psychosis (STEP) program share four core components.
- Individual therapy (sometimes called “individual resiliency training” or IRT) to help participants develop coping strategies, learn how to manage psychosis and set and achieve personal goals. Addressing the trauma of experiencing a first episode of psychosis and resulting self-stigmatization are among the specialized aspects of this therapy.
- Individualized medication management that relies on shared decision-making for the selection of medications to reduce symptoms and minimize side effects and medical impacts. Because the participant has not previously taken antipsychotic medications, lower dosages are utilized.
- Family education and engagement to educate loved ones about psychosis and treatment, reduce family stress, increase family support for the individual in treatment and to “instill hope.”
- Supported employment and education to help the individual recovering from a first episode return to work or school in a competitive environment.
The components are delivered by multidisciplinary teams that typically include a medication prescriber (physician or nurse), clinicians who provide training and case management and a specialist in re-entry to school or work. The teams tend to work with smaller caseloads.
Results from the first two years of RAISE programs and from Connecticut’s STEP program are encouraging. A randomized controlled trial involving 120 enrollees found that STEP care reduced hospitalization and improved employment within the first year of participation. RAISE Connection, operating in New York and Maryland, found that participation improved symptom control and increased the likelihood individuals stayed in treatment.
For all their early success, a number of questions remain to be answered about the early-intervention models.
At a briefing at the NIMH in September, Nina R. Schooler, one of the researchers involved in NAVIGATE, told an audience, “We have seen the results for two years,” but we have yet to see what they will be after five years. Will the positive outcomes be sustained over time?
NIMH grants and other subsidies got RAISE off the ground; funding mechanisms will need to be found to keep them there. “For RAISE to work, considerable program effort and cost must be devoted to finding people in the early stages of illness and persuading them to engage in treatment,” the authors of one Psych Services paper wrote. Yet an increasing number of states are cutting their mental health budgets or “treading water,” according to a National Alliance on Mental Illness study released December 7. How will the comprehensive early intervention be paid for?
The research to date has focused on outcomes from the combined components. As the programs roll out in varying settings with variable funding and staffing levels, ad hoc, “real world” adjustments to the model are inevitable. As they are made, understanding the role each component plays could minimize the impact on outcomes these compromises are likely to have. What is the impact of each core component?
Half the counties in the United States do not have a single mental health professional within their limits. The best models in the world will be ineffective without the clinicians and specialists to staff them. Where will the professionals come from?
CHIEF OF RESEARCH AND PUBLIC AFFAIRS
References from Psychiatric Services, 66(7), July 2015:
- Dixon, L. B., et al. Implementing coordinated specialty care for early psychosis: The RAISE connection program; pp. 691-698.
- Frank, R. G., et al. Paying for early interventions in psychoses: A three-part model; pp. 677-679.
- Lucksted, A., et al. Client views of engagement in the RAISE Connection program for early psychosis recovery, pp. 699-704.
- Mueser, K. T., et al. The NAVIGATE program for first-episode psychosis: Rationale, overview, and descriptions of psychosocial components; pp. 680-690.
- Srihari, V. H., et al. First-episode services for psychotic disorders in the US public sector: A pragmatic randomized controlled trial; pp. 705-712.
See also: The Why and Who of RAISE (Part 1).