The integration of all of these modalities is really key to improving the trajectory of early-phase schizophrenia and increasing the likelihood of recovery.”
DR. KANE VO: The story of schizophrenia is traditionally told as one of inevitable decline. When a young person is diagnosed, they’re prescribed an antipsychotic to stabilize symptoms, and then they often have to wait until their symptoms don’t improve or become acute again before trying another medication. And then another. For many patients, it’s a deficit-based care model predicated on the person becoming sick again before pharmacologic or psychosocial intervention strategies are adjusted. All this time, they’re getting sicker and sicker. After each relapse, it takes them longer to recover. And their response to treatment diminishes. And relapses become more frequent. This is when people living with early-phase psychosis really start to free fall. Where their risk of undesirable outcomes really accelerates. But this story is old news…because with a more comprehensive care plan that prioritizes interventions beyond medications, and recovery beyond symptom remission, this story may be a preventable one.
DR. KANE VO: The early phase of schizophrenia is particularly important in terms of getting the illness under control, and we believe that if we can do the best possible job of treating the illness early, we can increase the likelihood of recovery.
I believe that medicine is extremely important in the treatment of early-phase schizophrenia, but it’s not the only modality.
DR. HURFORD VO: So the standard of care in schizophrenia right now are very brief medication management appointments, somewhere between 15 to 30 minutes.
Usually no therapy. So therapy is not considered traditional standard of care for schizophrenia care.
Because the medication managements are so brief, it’s very hard for the psychiatrists and the patients to get to know each other.
And so symptoms are sort of taken out of the context of someone’s life.
DR. MOLLER VO: By understanding what an individual’s cardinal symptoms are, then they’re able to report those to us earlier, but that’s not going to happen unless there’s a relationship so that the person feels safe to report their symptoms to you as a provider.
And that means we have to spend time with individuals. We have to develop the relationship so that an individual will feel safe.
DR. KANE VO: I think the first two years of treatment are really important because that’s what sets the stage for what follows.
Someone with an illness like schizophrenia is going to require treatment for a long time.
The trust, the expectations that we set in the first couple of years, the education that we can provide, the motivation that we can facilitate is really important in determining what happens over the ensuing years.
DR. MOLLER VO: When a patient feels that they’re not just like a cog in a wheel and that you really care about them and that you really do want to spend time and you do spend time with them, then they’ll open up.
DR. KANE VO: Coordinated specialty care is a team-based integrated model of psychopharmacology medication, individual psychosocial treatment, family psychoeducation, supported employment, and supported education.
And the idea is that the integration of all of these approaches or modalities is really key to improving the trajectory of early-phase schizophrenia and increasing the likelihood of recovery.
DR. HURFORD VO: One of the most important tools we have to help people build resilience to their own psychotic symptoms is through talk therapy.
That can take different forms, but most people right now are using a form of cognitive therapy.
And cognitive therapy allows people to develop a toolbox of tools that they can use to help them distinguish a little bit better what’s real and what’s not real.
And that allows them to gain a sense of mastery and power over their own symptoms and allow them to move forward with their lives.
DR. MOLLER VO: Like any person, they want a house, a spouse, a car, and a job—just like you and I.
After all, a person with schizophrenia is just that: a person.
DR. HURFORD VO: Why are we doing the kind of work we do as providers if we don’t have hope that people recover?
It’s easy to give hope. It costs me nothing to be hopeful. It costs the person a lot if I’m hopeless.
DR. KANE VO: More individuals have access to coordinated specialty care than 5 or 10 years ago, but there’s more to be done. I’m very hopeful because I think the data are very encouraging.
I’m hopeful that we’re going to continue to improve on our treatments as well.
And we need to communicate that hope to our patients and their families.
The reality of schizophrenia is a challenging one. It’s episodic. Symptoms will spike and recede. Yes, sometimes relapses will occur. However, healthcare teams can do an enormous amount to reduce the risk and impact of relapse. It’s vital that every doctor, patient, and care partner know there’s a growing body of proof that offers hope. The data says that coordinated specialty care models can improve functional and humanistic outcomes for patients. And that the more they are implemented, there is nowhere to go…but up.
Before They Fall
Explore the Clinical Insights Behind the Episode
Relapse Is Not Inevitable
Due to the progressive nature of schizophrenia, what happens during the early treatment phase can be critical in getting the illness under control and preventing or minimizing clinical and functional decline.1 Studies have demonstrated that comprehensive first-episode psychosis (FEP) intervention programs that emphasize low-dose antipsychotic medications, cognitive-behavioral psychotherapy, family psychoeducation, and vocational and educational support can drastically improve clinical and functional outcomes compared with standard community care.1-5
While these results are encouraging, these care models need wider application before patient success stories at scale can be realized. Currently, data indicate that more than half of patients do not receive appropriate, timely, and adequate intervention, which highlights the urgent need for a paradigm shift in current treatment standards. It is vital that the clinical community embraces a more patient-centric model that is designed to catch individuals with schizophrenia long before they fall into a cycle of repeated relapse.1
Coordinated Specialty Care Is a Demonstrated Alternative to Treatment as Usual
Within the current standard of care for schizophrenia, delays in consistent pharmacologic treatment are common, while psychosocial care is inconsistently or infrequently applied.1,6 A growing body of evidence strongly suggests that early intervention with coordinated specialty care that prioritizes multimodal psychosocial care along with pharmacological intervention may reduce the risk of relapse and improve patient outcomes.2-4,7
Dr. John Kane, Dr. Mary Moller, and Dr. Irene Hurford discuss what recovery means for them and their patients
Kane: When working toward recovery, it’s really important to consider the patient’s goals and to understand what it is that they want to achieve. We do many things in life that give us satisfaction, whether it’s work or school, friends, or hobbies, and schizophrenia can rob people of some of those opportunities. So, we want to make sure that we have conversations with the patient to understand his or her goals and work to help that person to achieve those goals.
Moller: With schizophrenia, when a person has hallmark symptoms of hallucinations, delusions, maybe some mood swings, paranoia—we don’t wait until the person’s no longer coming out of their room or maybe harming themselves or harming someone else because of the hallucinations and delusions. We want to teach people about those symptoms so that they can report them early, but that’s not going to happen unless there’s a relationship with the patient. So, you have to have the time to build trust and the person will trust you to tell you those very personal symptoms that many people find embarrassing and shameful.
Huford: My hope for schizophrenia care or a psychosis care is that people can access the type of services that we see in early psychosis care at any point along their journey with psychosis. So not just reserved for the first couple of years of somebody’s psychotic illness, but at any point that they need those services or find them valuable because early psychosis care is not particularly revolutionary care. It’s just very good care, very comprehensive care delivered in the community that someone lives in.
I think that people should be hopeful that they can have the lives that they want to have, that they can go back to school, or get the job that they want, or climb the ladder at work, or be in a relationship that’s fulfilling or have friends. In the same way you and I hope for those sorts of things in our lives, people with psychosis should be hoping for those same things in their lives.
Going Beyond the Medical Model of Psychosis
The current standard of care in schizophrenia primarily emphasizes pharmacotherapy aimed at reducing the severity and duration of positive symptoms and, to a lesser extent, negative symptoms. Yet the heterogeneity of schizophrenia often dictates that every patient will have their own unique goals and expectations that extend beyond symptom remission. Although medication remains a foundational part of treatment, patients require more holistic interventions to address the cognitive and psychosocial aspects of the disease. It’s time to embrace a more patient-centric approach that prioritizes their personal goals and gives them a role in their own care plan.7
The power of PATIENT CENTRICITY
Notably, a patient-centric approach aims to achieve more than just placing patients at the center of the treatment equation. Data from the RAISE early intervention program suggest that patients with schizophrenia who received training on shared decision-making were more engaged in their own care and more likely to adhere to the medications vs patients receiving treatment as usual.2,7,8 Empowering these patients can enhance quality of life, improve functioning, and instill hope in even the most challenging cases.7
References: 1. Mohr P, Galderisi S, Boyer P, et al. Value of schizophrenia treatment I: the patient journey. Eur Psychiatry. 2018;53:107-115. 2. 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. 3. Nossel I, Wall MM, Scodes J, et al. Results of a coordinated specialty care program for early psychosis and predictors of outcomes. Psychiatr Serv. 2018;69(8):863-870. 4. Gleeson JF, Cotton SM, Alvarez-Jimenez M, et al. A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients: outcome at 30-month follow-up. Schizophr Bull. 2013;39(2):436-448. 5. 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. 6. Kahn RS, Sommer IE, Murray RM, et al. Schizophrenia. Nat Rev Dis Primers. 2015;1(15067):1-23. 7. Dixon L, Liberman J. Psychiatry embraces patient-centered care. Psychiatric News. Published February 7, 2014. Accessed December 10, 2020. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2014.2a15. 8. Petersen L, Jeppesen P, Thorup A, et al. A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness. BMJ. 2005;331(7517):602.
A Growing Emphasis
on Social Cognition
Dr. Michael Green explores the connection between social cognition and functional outcomes.
Human Impact of
This interactive tool explores the widespread effects of relapse and ways to remediate them.
A New Standard Emerges
Recent landmark studies support the wide adoption of coordinated specialty care.
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