Contemporary Perspectives in Schizophrenia Care
Patient-centric care

Treating First-Episode Psychosis (FEP)

The Value of Early Intervention Using Coordinated Specialty Care (CSC)

An estimated 100,000 adolescents and young adults in the US experience FEP annually.1 Delayed, suboptimal, or inconsistently applied treatment can have significant long-term consequences for these patients, both clinically and economically.2,3 A recent longitudinal and modeling analysis found that clinical deterioration resulting from delayed treatment in FEP patients is most rapid in the first weeks after psychosis onset.4

8 min
100K FEP ADOLESCENTS AND YOUNG ADULTS IN THE US EXPERIENCE ANNUALLY1

$155 BILLION

In 2013, the use of healthcare resources, unemployment,
and lost productivity for caregivers contributed to the estimated $155 billion cost of
delayed or suboptimal schizophrenia treatment in the US.5,6

What is CSC?

CSC is a multifaceted approach to treating psychosis.1,7 Its interventions include a variety of interdependent pharmacologic and psychosocial elements: comprehensive case management, support for employment and education, psychotherapy, family education and support, and selective administration of appropriate medications.1 The essence of CSC is to foster collaboration between patients, physicians, caregivers, and family members—all of whom are part of a shared decision-making environment.1

This interdisciplinary, inclusive approach to treatment helps FEP patients achieve a range of goals related to school, work, and social relationships.8 It can also help identify signs of impending relapse and reduce the risk of subsequent episodes.1

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Pharmacotherapy and primary care coordination1

Employs evidence-based approaches in selecting medications and dosing for patients with FEP, balancing efficacy, side effects, and attitudes toward medication.

Recent research has suggested that ORAL OR LONG-ACTING INJECTABLE ANTIPSYCHOTIC MEDICATION may be an appropriate choice for patients with FEP9,10

American Psychiatric Association (APA) Practice Guidelines Support Using CSC in FEP

An array of evidence indicates that early intervention with CSC in FEP patients can improve their chances of achieving remission and recovery.1 Furthermore, APA practice guidelines recommend early intervention, based on a CSC model, in patients with FEP.7 This recommendation is based in part on results from the Recovery After an Initial Schizophrenia Episode (RAISE) initiative, which was launched in 2008 and supported by the National Institute of Mental Health.7

The primary outcome from NAVIGATE showed that patients receiving CSC had significantly higher total quality of life (QoL) scores at 2 years compared to patients receiving community care (CC) (P<0.02).11

THE THE INTERVENTION, THE HIGHER THE CHANCES OF HAVING A EARLIER POSITIVE EFFECT ON THE TRAJECTORYOF THE ILLNESS. 12 —Dr. Fabio Ferrarelli

Model-based estimates of Heinrichs-Carpenter Quality of Life Scale (QLS) and PANSS* total scores11

As shown in NAVIGATE
QLS total score Month in square root QLS total score 0 50 60 55 65 70 6 12 18 24 CSC WAS SIGNIFICANTLY BETTER AT IMPROVING QoL AND PANSS SCORES VS COMMUNITY CARE OVER 2 YEARS Month in square root PANSS total score PANSS total score 0 60 70 65 75 80 6 12 18 24
NAVIGATE
Community Care

*PANSS=Positive and Negative Syndrome Scale
Treatment by square root of time interaction, P=0.015
Treatment by square root of time interaction, P=0.016

NAVIGATE is an experimental, multimodal treatment paradigm directly inspired by the National Institute of Mental Health’s RAISE initiative. The primary objective of studies utilizing NAVIGATE was to compare CSC with CC on QoL as measured by the Heinrichs-Carpenter Quality of Life Scale. 404 FEP patients between 15 and 40 years of age were enrolled and received either CSC (n=223) or CC (n=181). Patients were followed for a minimum of 2 years, and major assessments were conducted by blinded, centralized raters using live 2-way video. Baseline characteristics were similar between the 2 groups, including living situation, duration of untreated psychosis, and baseline medication status.11

CSC accelerated involvement in work and school vs CC11

CSC was more than 90% likelier to be more cost-effective relative to improvements in QoL vs CC, as shown in a separate analysis13

Estimates indicate that CSC would save $300 billion over 20 years vs CC if 75% of appropriate patients were enrolled14

A New Paradigm in Treating FEP

In schizophrenia, the doctor-patient dynamic is often focused primarily on medication adherence. However, the growing body of evidence pointing to the effectiveness of patient-centric approaches, such as CSC, promises a future in which psychiatrists will better understand their patients’ needs and be able to offer a more informed course of treatment. This will enhance patients’ ability to adhere to their treatment.15

Progress takes time, but patient-centric treatment represents the start of an

Emerging standard in schizophrenia care

that prioritizes comprehensive psychosocial care on a foundation of pharmacologic intervention.

References: 1. Heinssen RK, Goldstein AB, Azrin ST. Evidence-based treatments for first episode psychosis: components of coordinated specialty care. National Institute of Mental Health website. Published April 7, 2014. Accessed October 7, 2020. https://www.nimh.nih.gov/health/topics/schizophrenia/raise/evidence-based-treatments-for-first-episode-psychosis-components-of-coordinated-specialty-care.shtml. 2. Correll CU, Galling B, Pawar A, et al. Comparison of early intervention services vs treatment as usual for early-phase psychosis: a systematic review, meta-analysis, and meta-regression. JAMA Psychiatry. 2018;75(6):555-565. 3. Hastrup LH, Kronborg C, Bertelsen M, et al. Cost-effectiveness of early intervention in first-episode psychosis: economic evaluation of a randomised controlled trial (the OPUS study). Br J Psychiatry. 2012;202(1):35-41. 4. Drake RJ, Husain N, Marshall M, et al. Effect of delaying treatment of first-episode psychosis on symptoms and social outcomes: a longitudinal analysis and modelling study. Lancet Psychiatry. 2020;7(7):602-610. 5. First episode psychosis programs. A guide to state expansion. National Alliance on Mental Health website. Accessed October 7, 2020. https://www.nami.org/getattachment/Extranet/Advocacy/FEP-State-Advocacy-Toolkit/FEP-State-Advocacy-Guide.pdf. 6. Cloutier M, Aigbogun MS, Guerin A, et al. The economic burden of schizophrenia in the United States in 2013. J Clin Psychiatry. 2016;77(6):764-771. 7. Keepers GA, Fochtmann LJ, Anzia JM, et al. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. Third edition. American Psychiatric Association website. Accessed October 7, 2020. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841. 8. Bello I, Lee R, Malinovsky I, et al. OnTrackNY: the development of a coordinated specialty care program for individuals experiencing early psychosis. Psychiatr Serv. 2017;68(40):318-320. 9. Subotnik KL, Casaus LR, Ventura J, et al. Long-acting injectable risperidone for relapse prevention and control of breakthrough symptoms after a recent first episode of schizophrenia. A randomized clinical trial. JAMA Psychiatry. 2015;72(8):822-829. 10. Correll CU, Citrome L, Haddad PM, et al. The use of long-acting injectable antipsychotics in schizophrenia: evaluating the evidence. J Clin Psychiatry. 2016;77(suppl 3):1-24. 11. 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. 12. Rodriguez T. Early intervention in schizophrenia: the RAISE program. Schizophrenia Advisor website. Published September 6, 2018. Accessed October 7, 2020. https://www.psychiatryadvisor.com/home/schizophrenia-advisor/early-intervention-in-schizophrenia-the-raise-program. 13. Rosenheck R, 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. 14. Psychiatric illness (SPI) is a major public health issue. One Mind website. Accessed October 7, 2020. https://onemind.org/aspire. 15. Dixon L, Lieberman J. Psychiatry embraces patient centered care. Psychiatric News website. Published February 7, 2017. Accessed October 7, 2020. https://doi.org/10.1176/appi.pn.2014.2a15.

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