Jessica Pollard

First-Episode Services for Psychotic Disorders in the U.S. Public Sector: A Pragmatic Randomized Controlled Trial

OBJECTIVE This study sought to determine the effectiveness of a comprehensive first-episode service, the clinic for Specialized Treatment Early in Psychosis (STEP), in an urban U.S. community mental health center by comparing it with usual treatment. METHODS This pragmatic randomized controlled trial enrolled 120 patients with first-episode psychosis within five years of illness onset and 12 weeks of antipsychotic exposure. Referrals were mostly from inpatient psychiatric units, and enrollees were randomly allocated to STEP or usual treatment. Main outcomes included hospital utilization (primary); the ability to work or attend age-appropriate schooling-or to actively seek these opportunities (vocational engagement); and general functioning. Analysis was by modified intent to treat (excluding only three who withdrew consent) for hospitalization; for other outcomes, only data for completers were analyzed. RESULTS After one year, STEP participants had less inpatient utilization compared with those in usual treatment: no psychiatric hospitalizations, 77% versus 56% (risk ratio [RR]=1.38, 95% confidence interval [CI]=1.08-1.58); mean hospitalizations, .33±.70 versus .68±.92 (p=.02); and mean bed-days, 5.34±13.53 versus 11.51±15.04 (p=.05). For every five patients allocated to STEP versus usual treatment, one additional patient avoided hospitalization over the first year (number needed to treat=5; CI=2.7-26.5). STEP participants also demonstrated better vocational engagement (91.7% versus 66.7%; RR=1.40, CI=1.18-1.48) and showed salutary trends in global functioning measures. CONCLUSIONS This trial demonstrated the feasibility and effectiveness of a U.S. public-sector model of early intervention for psychotic illnesses. Such services can also support translational research and are a relevant model for other serious mental illnesses.

Mediators and moderators in early intervention research

Aim: The goal of this paper is to provide clarification with regard to the nature of mediator and moderator variables and the statistical methods used to test for the existence of these variables. Particular attention will be devoted to discussing the ways in which the identification of mediator and moderator variables may help to advance the field of early intervention in psychiatry.

First-Episode Psychosis and the Criminal Justice System: Using a Sequential Intercept Framework to Highlight Risks and Opportunities

In first-episode psychosis there is a heightened risk of aggression and subsequent criminal justice involvement. This column reviews the evidence pointing to these heightened risks and highlights opportunities, using a sequential intercept model, for collaboration between mental health services and existing diversionary programs, particularly for patients whose behavior has already brought them to the attention of the criminal justice system. Coordinating efforts in these areas across criminal justice and clinical spheres can decrease the caseload burden on the criminal justice system and optimize clinical and legal outcomes for this population.

The duration of untreated psychosis: a phenomenological study

ABSTRACT Mounting evidence has indicated that early intervention leads to improved clinical and functional outcomes for young persons experiencing recent onset psychosis. As part of a large early detection campaign, the present study aimed to investigate subjective experiences during the duration of untreated psychosis (DUP), or time between psychosis onset and treatment contact. Participants were 10 young adults participating in early intervention services for psychosis. After DUP was estimated during standardized baseline assessment, participants engaged in qualitative interviews focused on their life experiences prior to treatment and leading up to the present. Mixed methods data analyses compared standardized DUP estimates with participants’ subjective narratives. Findings revealed that participants experienced and conceptualized a longer trajectory of subjective difficulties (TSD) beginning before and extending beyond standardized DUP estimates. Participants emphasized striving for independence and social belonging. The majority of participants reported benefiting from their current services and believed that earlier support of some kind would have been beneficial. These findings support previous research on subjective barriers to early detection and treatment seeking in young adults experiencing psychosis. Implications and future research directions include further efforts to differentiate the struggles unique to early psychosis from psychosocial risk factors and other challenges of young adulthood.

Building Early Intervention Services for Psychotic Disorders: A Primer for Early Adopters in the U.S.

Recent developments in the U.S. healthcare policy signal a growing commitment to early intervention for psychotic disorders. A growing international and U.S. research database supports the effectiveness of specialty team-based models adapted to care for young individuals with recent onset psychosis. The RAISE (Recovery After an Initial Schizophrenia Episode) initiative, sponsored by the NIMH (National Institute of Mental Health), has defined such Coordinated Specialty Care (CSC) services as a new benchmark for care across the U.S., and published a variety of resources to support dissemination. Funding initiatives led by the center for Substance Abuse and Mental Health Services (SAMHSA), and support from other national organizations, have catalyzed interest in community agencies across the country. We offer guidance to such early adopters and supplement extant resources with a focus on the process of setting up such programs. Adopters have numerous decisions to make. These include determining admission criteria, structuring care processes to maximize impact, choosing from several empirically based interventions, and resourcing workforce development. We provide a guide to salient resources, and lessons learned from a decade old CSC, to aid in these complex decisions. We end with a discussion of limitations in the current knowledge base, and the need for responsive research. Early intervention services can engender application of demonstrably effective treatment, while also providing platforms for research to improve and develop new treatments. Collaborations between a wide variety of government, academic and commercial stakeholders will be essential to realize the transformative public health impact of early intervention for psychotic disorders.