Intervening Early in Psychosis
Kate Hardy, Clin.Psych.D., is a clinical associate professor in the Department of Psychiatry and Behavioral Sciences at Stanford University. Jacob Ballon, M.D., M.P.H., is co-director of the INSPIRE Clinic, co-chief of the Specialty Clinics Section, and medical director of the H2 Inpatient Psychiatry at Stanford University. Doug Noordsy, M.D., is chief of mental health at the White River Junction VAMC, a professor of psychiatry at Geisel School of Medicine at Dartmouth University, and a clinical professor of psychiatry and behavioral sciences at Stanford University. Steven Adelsheim, M.D., is associate chair for community engagement in Stanford University’s Department of Psychiatry and Behavioral Sciences and co-leads the national clinical network for early psychosis called PEPPNET. They are the authors of Intervening Early in Psychosis: A Team Approach from APA Publishing. APA members may purchase the book at a discount.
It is widely considered best practice to identify and treat conditions as early in the course of an illness as possible. Routinely adopted as the standard of care for many physical health disorders, this approach has only relatively recently gained traction as critical in the treatment of serious mental health problems, including psychotic disorders. Traditionally, psychiatrists have been reluctant to make a psychotic disorder diagnosis until an individual was chronically ill due to fear of the effects of labeling and fatalistic beliefs about prognosis.
Intervening early in the course of psychosis is largely grounded in the understanding that a longer duration of untreated psychosis (DUP) results in more severe symptoms and poorer functional outcomes. In contrast, early intervention results in less severe symptoms and better functional outcomes and has been shown to be cost-effective. Consequently, the World Health Organization recommends a DUP of no longer than 12 weeks to optimize treatment outcomes. Proactive outreach and community education can help connect people experiencing psychosis to services quickly. Once connected with these services, individuals experiencing a first episode of psychosis should receive evidence-based interventions as early as possible.
While Europe and Australia were the frontrunners in developing and adopting early intervention for psychosis models over the past two decades, the United States has only recently started to implement early psychosis service programs. In fact, the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE ETP) study highlighted just how challenging it can be for a patient experiencing a first episode of psychosis to receive care; patients reported a median DUP of 74 weeks, which far exceeds the international recommendations. However, RAISE ETP reported that a short DUP alone is not sufficient for achieving optimal results, demonstrating that individuals with a DUP of 74 weeks or less and in receipt of specialized early psychosis services exhibited improved clinical and functional outcomes compared with those who received treatment as usual.
The RAISE ETP findings have since led to the development of specialized early psychosis programs termed Coordinated Specialty Care (CSC) in the United States. CSC services are designed to provide comprehensive care to individuals experiencing a first episode of psychosis and their families. Such care includes medication management, individual therapy, case management, educational and vocational support, family intervention, and peer support. Care is recovery oriented, provided by multidisciplinary teams, and based around a shared decision-making model.
The success of RAISE ETP and other early psychosis services in the United States contributed to the allocation of 5% of the federal Mental Health Block Grant, doubled to 10% in 2016, for first-episode psychosis treatment. This dedicated funding allowed for the expansion of specialized early psychosis care across the United States, resulting in an exponential growth of CSC clinical programs. There are now approximately 280 such programs across the United States.
A national coordinating network called the Psychosis-Risk and Early Psychosis Program Network (PEPPNET) was established to support clinical program development and coordination between the CSC programs. PEPPNET disseminates training and technical assistance materials, coordinates national webinars on a number of topics pertinent to the field, and plans to support the development of an annual early psychosis meeting focusing on service development and provision of early psychosis care in community settings.
As CSC services become more established in the United States, more attention has been given to identifying individuals who may be at risk of developing psychosis, with the aim of preventing or delaying a transition to psychosis while addressing functional goals.
The NIMH North American Prodrome Longitudinal Study (NAPLS) study has led the way in clarifying risk factors for young people at risk for transition to psychosis. These individuals typically present with attenuated psychotic symptoms or brief, transient psychosis. The NAPLS study has helped clarify risk factors for young people at risk for transition to psychosis through the development of a risk calculator.
The Robert Wood Johnson–funded Early Detection and Intervention for the Prevention of Psychosis Program study also highlighted the benefits of outreach and intervention for individuals considered to be at clinical high risk (CHR). Interventions for this population typically focus on identification through broad outreach, individual therapy to address attenuated psychotic symptoms, and management of comorbidities. Antipsychotic medication is not routinely recommended for this population unless the individual makes a transition to full psychosis or displays worsening symptoms despite intervention.
In 2018, with support from the Substance Abuse and Mental Health Services Administration, 21 sites across the United States developed or expanded CHR services. With the development of specialized services for CHR, and the established CSC services for individuals with first-episode psychosis, the United States is moving toward embracing a broader continuum of care for young people along the spectrum of psychotic symptoms.
As the recognition of this innovative model of early detection and intervention gains increasing traction across the country, it is critical that young people, families, and mental health professionals from all disciplines become more aware of the importance and value of intervening early in the course of psychosis to support our young people to remain on track toward becoming resilient adults. ■
