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Reduction In Incidence Of Hospitalizations For Psychotic Episodes Through Early Identification & Intervention

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Early intervention has been recognized as a promising approach for preventing initial episodes and reducing associated disability, with a recent meta-analysis estimating a 66% risk reduction associated with early intervention. Despite these findings, no large study has examined whether a community-wide effort to enhance early identification and treatment can impact incidence of psychotic disorders at the community level.
A study evaluating the effect of the Portland Identification and Early Referral (PIER) program on the rate of first hospitalizations for psychosis …

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The following is a summary of McFarlane WR, Susser E, McCleary R, Verdi M, Lynch S, Williams D, McKeague IW. Reduction in incidence of hospitalizations for psychotic episodes through early identification and intervention. Psychiatr Serv. 2014;65(10):1194-1200, which was developed independently of the article authors.

  • Schizophrenia and psychotic mood disorders are often associated with long-term disability and they rank high among all causes of disability-adjusted life years.
  • Recent studies suggest that early intervention may be an effective strategy for preventing the onset of first-episode psychosis and for reducing disability associated with psychotic illness.
    • Interventions evaluated during the prodromal period, in which it is thought that patients at CHR of psychosis may be best identified, include psychoeducational multifamily group therapy, assertive community treatment, cognitive therapy, antipsychotic medications, and administration of omega-3 fatty acids.
  • However, no large studies evaluating a community-wide program for both early identification of individuals at CHR and implementation of early intervention are available.
  • The PIER program was implemented in Portland, Maine, in 2001 with the aim of reducing the incidence of psychotic illness.
    • The PIER program enrolls young people (aged 12–35 years) at high risk of psychosis, as assessed by the Structured Interview for Prodromal Syndromes (SIPS), in the Greater Portland area. Only those meeting the scale’s criteria for prodromal syndrome were admitted.
    • The PIER staff provide education for physicians and psychiatric, nursing, counseling, and guidance staff in educational health and community mental health practices on the identification and referral of young people at risk of psychosis.


  • This study examined the effect of the PIER program on the rate of first hospitalizations for psychosis by comparing data from the Greater Portland area before and after the initiation of the program with data from three urban catchment areas in Maine where the PIER program had not been implemented.


  • The number of first hospitalizations for psychosis per month during the control period (second quarter of 1999 through first quarter of 2001) and experimental period (second quarter of 2001 through third quarter of 2007) were determined using data from the Maine Health Data Organization (MHDO) database.
    • The MHDO records information (discharge diagnosis, age, residence) for all patients hospitalized in Maine.
    • Individuals at CHR identified from inpatient discharge records of the MHDO database were those who resided in the catchment areas of the study at the time of admission, were aged 12–35 years, and had a diagnosis of schizophrenic disorder, mood disorder with psychotic features, or nonaffective nonschizophrenic psychosis.
  • Eligible and consenting youths were identified and recommended for enrollment in the intervention by professionals in educational, health, and mental health settings.
    • Eligibility criteria for the intervention program included being at CHR for psychosis, residing in the Greater Portland area at the time of referral and being aged 12–35 years, with eligibility determined according to the SIPS.
    • PIER program staff assessed and confirmed psychosis risk, and provided treatment for 24 months.
      • As part of the PIER intervention, eligible patients were offered either an adapted or attenuated version of Family-aided Assertive Community Treatment (FACT) with the goal of preventing the onset of psychosis.
        • The adapted FACT approach comprised psychoeducational multifamily group treatment, assertive community treatment and educational and occupational support.
        • The attenuated version of FACT provided family education and crisis intervention, psychotropic medications, and quarterly outreach to prevent dropout, if required.
      • The primary endpoint of the study was the change in the rate of first hospitalization for psychosis per 28-day month in the intervention versus control period and control urban areas (the three other most urban areas of Maine [Bangor, Augusta, and Lewiston-Auburn] where PIER was not implemented).


Study sample

  • From a total of 404 young people who were referred to the PIER program and screened between May 6, 2001 and September 30, 2007, 148 met CHR criteria.
    • The mean age was 16.6 ± 3.2 years and 53% were male; 8% experienced conversion to psychosis during the first 12 months.

Regarding first hospital admissions for psychosis

  • Of a total of 13,936 hospital admissions meeting the criteria for age, diagnosis, and residence in the experimental or control areas in the MHDO database, 3062 were first admissions for psychosis: 779 during the historical control period and 2283 during the intervention period.

Regarding effect of intervention on first hospital admissions

  • A significant reduction in first hospital admissions for psychosis in the Greater Portland (PIER) area during the intervention period compared with the historical control period was observed (7.95 vs. 10.77 per 28-day month; 26% reduction, p<0.001).
    • This was reported to be equivalent to 29.7 fewer first hospitalizations per year.
    • The reduction in first hospitalizations for psychosis was similar to the annual number of young people identified as CHR or experiencing first-episode psychosis (36 per year).
  • In the urban control area, the rate of first hospitalizations per month increased during the intervention versus the historical control period, although the difference was not statistically significant (19.46 vs. 18.05; 8% increase, p-value not reported).
  • The largest reductions in first hospitalizations for psychosis with intervention were observed in patients with a diagnosis of nonaffective nonschizophrenic psychosis
    (–30%), followed by those with schizophrenic disorder (–26%) and mood disorders with psychotic features (–19%).
  • A significant inverse correlation was observed between rates of PIER intake and first hospitalization for psychosis between 2003 and 2007 (r=–0.75, p<0.001).

Regarding incidence rates of first hospitalization

  • Mean annual admission rates per 100,000 individuals aged 12–35 years in the Greater Portland area were 148.1 during the historical control period, compared with 107.9 during the intervention period; corresponding values in the urban control areas were 106.3 and 110.5, respectively (p values not reported).
    • The annual difference between the control and intervention periods in the Greater Portland area was –40.2/100,000 (27% reduction; p values not reported).


  • Utilizing hospital admission data from the MHDO database, this study determined that the rate of first hospitalizations for psychosis was significantly reduced following the introduction of the PIER early identification and intervention program for young people at CHR for psychosis in the Greater Portland area, whereas a non-significant increase in hospitalizations was observed in the urban control areas during the same period.
  • The authors noted that this is the first study in which the incidence of first hospitalizations for psychosis was reduced with an indicated prevention strategy on a community-wide scale.
  • Comparison of annual first hospitalization rates in two previous studies showed that the annual incidence rate was higher in this study, which was suggested by the authors to have been partly due to selection of urban vs semi-urban areas.
  • The authors noted that admission data do not capture first episodes of psychosis in patients who are not hospitalized, and suggest that the reduction in first hospitalizations may be primarily due to amelioration of the symptoms that lead to acute psychotic episodes and low rates of hospitalization for individuals experiencing first episode psychosis.
  • The findings of this study suggest that early identification and treatment of young people at CHR may be an effective public health approach to reducing hospital admissions for first episode psychosis.


  • This study determined that implementation of the community-wide PIER program for early identification and intervention in young people at CHR of psychotic illness was associated with reduced rates of first hospital admissions for psychosis. The authors noted that the reduction in first hospitalization rates may be due primarily to mitigation of symptoms leading to acute psychotic episodes. This study demonstrated that implementation of a population-wide early identification and intervention program for psychotic disorders can be feasible in a mid-sized city. Further evaluation in other areas is therefore warranted.


This summation has been developed independently of the authors. The following disclosures were reported in the original article: “This research was supported by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; the National Institute of Mental Health (grant R01MH065367); the Robert Wood Johnson Foundation; the Bingham Foundation; the Unum Foundation; and the Betterment Fund. Dr. McFarlane and Ms. Lynch provide training and consultation on request to public and not-for-profit organizations implementing programs similar to that described in this article. The other authors report no competing interests.”