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Comprehensive Versus Usual Community Care For First-Episode Psychosis: 2-Year Outcomes From The NIMH RAISE Early Treatment Program

Key Messages

The impact of comprehensive first-episode psychosis programs versus usual care is not well elucidated.
Compared with usual community care, 24 months of care through NAVIGATE (a comprehensive, multidisciplinary, team-based treatment program) was associated with improvements in length of time in treatment, quality of life, symptoms, and participation in work and school in patients with first-episode psychosis.

Beneficial effects of the program appeared to be greater among patients with a shorter duration of untreated psychosis.

It may be possible to implement comprehensive, team-based care …

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Background & Purpose

The following is a summary of Kane JM, Robinson DG, Schooler NR, Mueser KT, Penn DL, Rosenheck RA, Addington J, Brunette MF, Correll CU, Estroff SE, Marcy P, Robinson J, Meyer-Kalos PS, Gottlieb JD, Glynn SM, Lynde DW, Pipes R, Kurian BT, Miller AL, Azrin ST, Goldstein AB, Severe JB, Lin H, Sint KJ, John M, Heinssen RK. Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE early treatment program. Am J Psychiatry. 2015 Oct 20:appiajp201515050632. [Epub ahead of print], which was developed independently of the article authors.

  • Intervention at psychosis onset appears to improve symptoms and functioning more than traditional care in patients with schizophrenia.
  • Comprehensive first-episode psychosis programs (including the use of low-dose antipsychotics, cognitive-behavioral psychotherapy, family education and support, and vocational and educational recovery) have been widely implemented but their true impact, relative to usual first-episode care, is largely unknown.

The primary aim of the National Institute of Mental Health (NIMH) Recovery After an Initial Schizophrenia Episode (RAISE) study was to examine the impact of NAVIGATE on quality of life compared with usual care in US community treatment centers.

  • This report presented 2-year outcome data in patients participating in NAVIGATE or community care, and explored the effects of untreated psychosis duration on-treatment response.

Methodology

  • Eligible patients included those who:
    • Had a diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, or psychotic disorder not otherwise specified, as assessed by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition, at baseline. Assessments were repeated at 1 year.
    • Experienced 1 episode of psychosis only.
    • Received ≤ 6 months of antipsychotic treatment.
  • Treatment
    • Thirty-four adequately sized clinics with an interest in providing early intervention services were randomly assigned to NAVIGATE (N = 17) or community care (N = 17).
      • NAVIGATE comprised 4 core interventions (personalized medication management, family psychoeducation, individualized resilience-focused therapy, and supported employment and education) within a framework of shared decision-making.
      • Community care psychosis treatment was determined by the clinician, based upon available services.
    • NAVIGATE sites received initial training plus ongoing expert consultation and assessment in team-based, first-episode psychosis interventions, whereas community care sites received no additional training or supervision.
  • Outcomes
    • Patients were assessed by trained interviewers (blinded and centralized) via 2-way video.
    • Clinical outcomes assessed included:
      • The Heinrichs-Carpenter Quality of Life Scale (QLS) total score (primary outcome).
        • Analyzed according to a mixed-effects linear regression model.
      • The Positive and Negative Syndrome Scale (PANSS).
      • The Clinical Global Impressions (CGI) Severity Scale.
      • The Calgary Depression Scale for Schizophrenia (CDSS).
    • Assessments were performed every 6 months, and patients were followed for 2 years.

Results

  • Regarding patient characteristics
    • Baseline patient demographic and clinical characteristics were similar in the NAVIGATE (n = 223) and community care (n = 181) treatment groups except for those listed below.
      • Compared with community care, the NAVIGATE cohort had significantly more males (77.6% vs 66.2%; p = 0.05), worse PANSS total scores (mean 78.32 vs 74.54; F-value 5.56; degrees freedom 1, 369; p = 0.02), less patients previously hospitalized (76.3% vs 81.6%; p=0.05), and fewer students (15.7% vs 26.0%;      p = 0.03). The p-values were adjusted for the clustered design by using a mixed-effects model with cluster-specific random effects.
    • Mean patient age in both groups was 23 years, and the duration of untreated psychosis was similar (median 74 weeks in the entire sample).
    • 56% of patients who received community care, and 51% of those who received NAVIGATE, met diagnostic criteria for schizophrenia.
  • Regarding the effects of treatment on quality of life
    • Compared with patients in community care, patients in the NAVIGATE treatment group:
      • Remained in treatment longer (median 23 vs 17 months; p < 0.004).
      • Received significantly more mental health outpatient services each month (mean 4.53 [standard deviation 5.07] vs 3.67 [5.93]; p = 0.013).
      • Experienced significantly greater improvement in QLS total score, PANSS total scores, and CDSS score (Table 1).
    • The proportion of patients working or going to school at any time during each month was significantly greater in the NAVIGATE cohort than in the community care cohort (group by time interaction, p < 0.05).

Table 1. Estimated model-based mean changes (standard error) from baseline to 24 months.

Outcome measure NAVIGATE Community Care p-valuea
QLS total scoreb 15.793 (1.624) 9.891 (1.918) 0.0145
QLS subscalesb
Interpersonal relations 5.691 (0.635) 3.494 (0.763) 0.0199
Instrumental role 5.271 (0.692) 3.418 (0.801) ns
Intrapsychic foundations 3.692 (0.510) 2.144 (0.616) 0.0377
Common objects and activities 1.453 (0.151) 0.971 (0.184) 0.0294
PANSS total scorec –14.313 (1.140) –9.989 (1.383) 0.0161
PANSS factor scoresc
Positive –2.742 (0.322) –2.519 (0.385) ns
Negative –2.972 (0.426) –2.280 (0.530) ns
Disorganized or concrete –1.406 (0.258) –0.721 (0.294) ns
Excited –0.944 (0.265) –0.241 (0.305) ns
Depressed –1.662 (0.239) –0.893 (0.290) 0.0407
CGI Severity Scaled –7.460 (0.066) –0.606 (0.079) ns
CDSSe –1.981 (0.277) –1.196 (0.327) 0.0318

aTreatment by time interaction.

bIncluded gender, student status, and PANSS as covariates; instrumental role subscale also included main treatment effect as a covariate.

cIncluded gender, student status, and main treatment effect as covariates.

dIncluded PANSS as a covariate.

eIncluded PANSS and gender as covariates.

ns = not statistically significant.

  • Regarding the effects of duration of untreated psychosis on response to treatment
    • The duration of untreated psychosis had a significant effect on response to treatment.
      • Among patients with a median ≤ 74 weeks versus > 74 weeks duration of untreated psychosis, treatment effect sizes over time varied significantly for both QLS (0.54 vs 0.07; p = 0.003) and PANSS total scores (0.42 vs 0.13;                p = 0.043).

Conclusions & Clinical Implications

In this study, a team-based model of first-episode psychosis care produced greater improvement in clinical and functional outcomes than standard community care, with greater effects observed with a shorter duration of untreated psychosis. The authors concluded that implementation of such a team-based model may be possible in US community care settings.

  • Based on the findings of this study, the authors suggested that implementation of a team-based model of first-episode psychosis care could be possible in many community care settings in the US.
  • Given that the effects of the NAVIGATE program were more beneficial in patients with a shorter duration of untreated psychosis, the authors suggested that reducing the duration of untreated psychosis from current levels (> 1 year) to the recommended standard of < 3 months should be a major target of focus of research efforts.

Disclosures

This summation has been developed independently of the authors. There following disclosures were reported in the original article: “This work has been funded in whole or in part with funds from the American Recovery and Reinvestment Act and from NIMH under contract HHSN271200900019C. Additional support for these analyses was provided by an NIMH Advanced Centers for Intervention and/or Services Research award (P30MH090590) to Dr. Kane.”