Historically, there have been low expectations for recovery in schizophrenia, which is associated with high rates of morbidity, mortality, and disability, as well as estimated annual economic costs of $155.7 billion and a 10% to 15% employment rate.1 In recent years, the focus of mental health policy and treatment for individuals with schizophrenia in the United States has shifted from stabilization of those with chronic disease to intervention in the early stages of the illness.
Starting with the publication of its first set of recommendations in 1998, with periodic updates since then, the Schizophrenia Patient Outcomes Research Team identified evidence-based practices for treating the disease.2 Subsequently, the Recovery After an Initial Schizophrenia Episode (RAISE) project was funded by the National Institutes of Mental Health to develop and test a coordinated specialty care (CSC) intervention for patients with early psychosis.3 CSC was implemented in community-based mental health centers with the aim of improving outcomes and reducing disability and costs associated with schizophrenia. The RAISE studies reaffirmed the benefits of early intervention that were previously demonstrated in international research.
The RAISE early treatment program (RAISE-ETP) investigated the effectiveness of NAVIGATE, a CAC approach that consisted of 4 manual-based interventions: psychopharmacology using a computerized decision support system (COMPASS), individual resilience therapy, family therapy and psychoeducation, and supportive employment and education.4 The sample consisted of 404 patients with first-episode psychosis (mean age, 23.6 years) receiving treatment at 1 of 34 centers across 21 states. The sites were evenly randomized to provide either NAVIGATE or usual care.
Compared with patients receiving standard treatment, patients engaging in NAVIGATE showed greater improvements on the Heinrichs-Carpenter Quality of Life Scale (main outcome), the Calgary Depression Scale for Schizophrenia, the Positive and Negative Syndrome Scale, treatment duration, and engagement in work and school. These improvements were more substantial among patients with a shorter duration of untreated psychosis (DUP).
“Overall, the RAISE-ETP project demonstrated that CSC could be delivered at a range of community mental health centers, and that such care was associated with significantly better outcomes in a number of different domains,” wrote the authors of an article published in May in the Annual Review of Clinical Psychology.1 CSC was also found to be cost-effective.5 “These results provided further encouragement to national efforts to make CSC more broadly accessible to patients (and their families) experiencing a first episode of schizophrenia.”1
The RAISE Implementation and Evaluation Study (RAISE-IES) reported improved symptoms and occupational and social functioning among 65 patients treated with a CSC approach.6 In addition, the RAISE-IES project “developed resources and tools to help administrators and individuals start their own CSC programs, including treatment manuals and program guides,” wrote the authors of the 2018 article.1
After the RAISE study reports were made available, Congress allocated additional funding to the community mental health block program, leading to growth in the number of CSC programs across the United States; they were expected to reach 48 states in 2018.
To discuss the implications of these findings and future directions in this area, Psychiatry Advisor interviewed the following experts: Fabio Ferrarelli, MD, PhD, assistant professor of psychiatry and director of the Sleep and Schizophrenia Program at the University of Pennsylvania Medical Center; and Lisa B. Dixon, MD, MPH, the Edna L. Edison Professor of Psychiatry at Columbia University Medical Center and director of the Division of Behavioral Health Services and Policy Research and the Center for Practice Innovations at the New York State Psychiatric Institute. Dr Dixon coauthored the recent paper and was the principal investigator for the RAISE-IES program.
Psychiatry Advisor: What is known about the effects of early intervention in schizophrenia?
Dr Ferrarelli: Although the effects of early intervention can vary from patient to patient, it is well established that the earlier the intervention, the higher the chances are of having a positive effect on the trajectory of the illness. For example, there is strong evidence that the DUP is very important, in that a shorter DUP leads to better outcomes and higher quality of life for patients.
Dr Dixon: What is known is consistent with the notion of providing the right treatment at the right time. By the right time, we mean as early as possible after the onset of psychosis. Research has consistently shown that the shorter the DUP, the better the long-term and short-term outcomes.
Psychiatry Advisor: What are the benefits of the coordinated specialty care approach and other elements of the RAISE initiative?
Dr Ferrarelli: The RAISE trial used 4 evidence-based interventions: personalized medication management, family psychoeducation, resilience-focused individual therapy, and supported employment. These interventions were offered as a package, coordinated by a team leader, and provided according to patient preference. As such, compared with more traditional, standard interventions, the patients — and whenever possible their families — were constantly engaged, were provided “personalized” treatment, and were heavily involved in the decision-making process.
Dr Dixon: Regarding the right treatment, there has been consistent evidence that multielement, multidisciplinary care that is person-centered, recovery-oriented, and provides cognitive-behaviorally oriented psychotherapy, appropriate pharmacotherapy, supported employment/education, family support/education, and case management, if needed, improves short-term outcomes.
Psychiatry Advisor: What are the current treatment implications for clinicians?
Dr Ferrarelli: The main implication is that an early, comprehensive intervention in individuals experiencing their first psychotic episode can significantly mitigate the severity of their clinical symptoms and ameliorate their quality of life.
Dr Dixon: If you practice in a community in which CSC is offered, it would be important to be aware of this resource and refer appropriate clients, if possible. If you practice in a community in which there is no CSC or if access is very limited, I think it would be useful to try to build programs and treatment options that come as close to CSC as possible.
Psychiatry Advisor: What should be next steps to encourage wider implementation of these programs, and what should be the focus of future research on this topic?
Dr Ferrarelli: First, we need to study the long-term effects of these interventions. The RAISE trial was based on a 2-year outcome, whereas schizophrenia and other major psychotic disorders are chronic illnesses that last several decades and have massive societal costs. If these early interventions have lasting, positive effects on clinical symptoms and quality of life, this would support their broad adoption, including from a financial standpoint.
Furthermore, it would be critical to find out which individual factors and interventions can provide the best outcomes. Finally, as shown by the RAISE trial, reducing the DUP (<74 weeks) is the most important predictor of positive outcome. As such, future research should focus on the early detection of individuals experiencing psychotic symptoms, even before they develop full-blown psychosis. This is the focus of a National Institutes of Mental Health-funded study I am currently conducting in individuals at clinical high risk for psychosis.
Dr Dixon: Much work is needed. Next steps to encourage wider implementation need to focus on sustainable financing for the model as well as access to training and implementation support. Regarding research, the model still needs improvement, as not all benefit. Also, we need to work on what is needed to help patients sustain the benefits and improvements they have experienced.
- Dixon LB, Goldman HH, Srihari VH, Kane JM. Transforming the treatment of schizophrenia in the United States: the RAISE initiative. Annu Rev Clin Psychol. 2018;14:237-258.
- Lehman AF, Steinwachs DM. Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophr. Bull. 1998; 24(1):1-10
- National Institute of Mental Health. What is RAISE? https://www.nimh.nih.gov/health/topics/schizophrenia/raise/what-is-raise.shtml. Accessed August 2, 2018.
- 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. 2016;173(4):362-372.
- Rosenheck RA, Leslie D, Sint K, et al. Cost-effectiveness of comprehensive, integrated care for first episode psychosis in the NIMH RAISE early treatment program. Schizophr Bull. 2016;42(4):896-906.
- Dixon LB, Goldman HH, Bennett ME, et al. Implementing coordinated specialty care for early psychosis: the RAISE Connection Program.Psychiatr Serv. 2015;66(7):691-698.