Piper Meyer-Kalos

Comprehensive Versus Usual Community Care for First-Episode Psychosis: 2-Year Outcomes From the NIMH RAISE Early Treatment Program

OBJECTIVE The primary aim of this study was to compare the impact of NAVIGATE, a comprehensive, multidisciplinary, team-based treatment approach for first-episode psychosis designed for implementation in the U.S. health care system, with community care on quality of life. METHOD Thirty-four clinics in 21 states were randomly assigned to NAVIGATE or community care. Diagnosis, duration of untreated psychosis, and clinical outcomes were assessed via live, two-way video by remote, centralized raters masked to study design and treatment. Participants (mean age, 23) with schizophrenia and related disorders and ≤6 months of antipsychotic treatment (N=404) were enrolled and followed for ≥2 years. The primary outcome was the total score of the Heinrichs-Carpenter Quality of Life Scale, a measure that includes sense of purpose, motivation, emotional and social interactions, role functioning, and engagement in regular activities. RESULTS The 223 recipients of NAVIGATE remained in treatment longer, experienced greater improvement in quality of life and psychopathology, and experienced greater involvement in work and school compared with 181 participants in community care. The median duration of untreated psychosis was 74 weeks. NAVIGATE participants with duration of untreated psychosis of <74 weeks had greater improvement in quality of life and psychopathology compared with those with longer duration of untreated psychosis and those in community care. Rates of hospitalization were relatively low compared with other first-episode psychosis clinical trials and did not differ between groups. CONCLUSIONS Comprehensive care for first-episode psychosis can be implemented in U.S. community clinics and improves functional and clinical outcomes. Effects are more pronounced for those with shorter duration of untreated psychosis.

The NAVIGATE Program for First-Episode Psychosis: Rationale, Overview, and Description of Psychosocial Components

Comprehensive coordinated specialty care programs for first-episode psychosis have been widely implemented in other countries but not in the United States. The National Institute of Mental Healths Recovery After an Initial Schizophrenia Episode (RAISE) initiative focused on the development and evaluation of first-episode treatment programs designed for the U.S. health care system. This article describes the background, rationale, and nature of the intervention developed by the RAISE Early Treatment Program project-known as the NAVIGATE program-with a particular focus on its psychosocial components. NAVIGATE is a team-based, multicomponent treatment program designed to be implemented in routine mental health treatment settings and aimed at guiding people with a first episode of psychosis (and their families) toward psychological and functional health. The core services provided in the NAVIGATE program include the family education program (FEP), individual resiliency training (IRT), supported employment and education (SEE), and individualized medication treatment. NAVIGATE embraces a shared decision-making approach with a focus on strengths and resiliency and on collaboration with clients and family members in treatment planning and reviews. The NAVIGATE program has the potential to fill an important gap in the U.S. health care system by providing a comprehensive intervention specially designed to meet the unique treatment needs of persons recovering from a first episode of psychosis. A cluster-randomized controlled trial comparing NAVIGATE with usual community care has recently been completed.

Coordinated Technology-Delivered Treatment to Prevent Rehospitalization in Schizophrenia: A Novel Model of Care

Despite advances in schizophrenia treatment, symptom relapses and rehospitalizations impede recovery for many people and are a principal driver of the high cost of care. Technology-delivered or technology-enhanced treatment may be a cost-effective way to provide flexible, personalized evidence-based treatments directly to people in their homes and communities. However, evidence for the safety, acceptability, and efficacy of such interventions is only now being established. The authors of this Open Forum describe a novel, technology-based approach to prevent relapse after a hospitalization for psychosis, the Health Technology Program (HTP), which they developed. HTP provides in-person relapse prevention planning that directs use of tailored, technology-based treatment based on cognitive-behavioral therapy for psychosis, family psychoeducation for schizophrenia, and prescriber decision support through a Web-based program that solicits information from clients at every visit. Technology-based treatments are delivered through smartphones and computers.

Demographic and clinical correlates of substance use disorders in first episode psychosis

BACKGROUND We assessed the prevalence and correlates of lifetime substance use disorders in people with first episode psychosis using the baseline data from the Recovery After an Initial Schizophrenia Episode (RAISE) Early Treatment Program study. METHODS Research staff assessed 404 first episode patients at 34 community mental health centers across the United States with the Structured Clinical Interview for DSM-IV for diagnoses of psychotic and substance use disorders. Logistic regression was used to evaluate the relationships between participant characteristics and lifetime substance use disorders, followed with generalized linear mixed-effects regression models to identify unique predictors of lifetime substance use disorders. RESULTS Approximately one-third of participants reported recent alcohol use (36.6%) and cannabis use (30.7%), and one half (51.7%) met criteria for any lifetime alcohol or drug use disorder. Lifetime substance use disorders were associated with male gender, White race, higher excited (hyperactivity, mood lability, impulsivity, hostility, and uncooperativeness), psychotic and depressive symptoms, less impaired cognition, and greater perceived stigma. Gender, race, and excited symptoms were the most consistent unique predictors of lifetime substance use disorders found in multivariate analyses. CONCLUSIONS Half of first episode psychosis patients have co-occurring substance use disorders, which are associated with both more severe symptoms and greater perceptions of stigma. Programs aiming to serve these patients must have the skills and clinical strategies to help people with these unique characteristics.

Psychological well-being and mental health recovery in the NIMH RAISE early treatment program

Recovery-oriented practices that promote client-centered care, collaboration, and functional outcome have been recommended to improve treatment engagement, especially for individuals with serious mental illness (SMI). Psychological well-being (PWB) is related to recovery and refers to experiencing purpose and meaning in life through realizing ones potential. The recently completed Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE ETP) study sought to improve quality of life, functional outcome, and well-being in individuals with first episode psychosis (FEP). Therefore, the primary aims of the present analysis were: 1) to examine the impact of treatment on PWB and mental health recovery trajectories, 2) to examine the impact of duration of untreated psychosis (DUP) on these outcomes, and 3) to examine the relationships among these outcomes and quality of life. Multilevel modeling was used given the nested data structure. Results revealed that PWB and mental health recovery improved over the course of the 2-year treatment; there were no significant treatment differences. In addition, DUP was associated with the Positive Relationships and Environmental Mastery dimensions of PWB. Finally, PWB, mental health recovery, and quality of life were all significantly correlated at baseline while controlling for depressive symptoms. Overall, the findings indicate that PWB and mental health recovery can improve in FEP, are related to yet distinct from quality of life, and that DUP may play a role in certain facets of these constructs.

Factor structure of therapist fidelity to individual resiliency training in the Recovery After an Initial Schizophrenia Episode Early Treatment Program.

Evidence‐based approaches and early intervention have improved the long‐term prognosis of individuals with schizophrenia. However, little is known about the therapeutic processes involved in individual therapy in first‐episode psychosis. A comprehensive psychosocial/psychiatric programme for this population, NAVIGATE, includes an individual therapy component, individual resiliency training (IRT). Fidelity of clinicians’ adherence to the IRT protocol has been collected to ensure proper implementation of this manual‐based intervention. These data can provide insight into the elements of the therapeutic process in this intervention.

What are the key ingredients of optimal psychosocial treatment for persons recovering from a first episode of psychosis

In their comprehensive synthesis of what is known and remains to be learned about the treatment of first-episode psychosis, Fusar-Poli et al offer an intriguing staging model and highlight several important challenges to the field. However, one topic to which they give relatively little attention is identifying the key components of the psychosocial treatments that are essential to comprehensive specialty care for these persons. Just as pharmacotherapists must adapt what they have learned from treating longterm consumers to those experiencing a first episode of psychosis, so psychosocial researchers are expected to tailor interventions found effective for those who have been ill for years to meet the needs of those receiving treatment for the first time. In this commentary, we briefly outline two key issues that are yet to be resolved in defining optimal psychosocial treatment for persons experiencing an initial episode of psychosis. The first key issue is: does cognitivebehavioral therapy for psychosis (CBTp) alone meet the needs of individuals diagnosed with a first episode of psychosis, or is a broader intervention required? Most multi-component interventions referenced by Fusar-Poli et al have included CBTp, but the defining elements of that therapy are unclear across these studies. Although there are similarities in the CBTp strategies, the models that have been used with consumers who have been ill for several years incorporate a wide degree of heterogeneity, and not all firstepisode programs have employed individual interventions based on CBT. Persons who experience their first episode of psychosis are typically in their late teens or early 20s, and often have a diverse set of developmental needs to be addressed in individual therapy. Therefore, a comprehensive yet individualized approach which is more encompassing than a typical course of CBTp may be desirable. For example, the individual resiliency training component of the NAVIGATE program incorporates many elements of CBT, but also includes bolstering individuals’ personal resiliency, education about psychosis, processing the psychotic episode, teaching illness self-management strategies, social skills training, substance abuse treatment, and health and wellness promotion. A broad-based model such as this one may offer young people a wider range of options and empirically supported strategies for addressing their individual needs and helping them make progress towards their goals. At this point, we are lacking trials comparing more comprehensive individual interventions to CBTp in firstepisode psychosis, so the optimal breadth of the individual intervention with this consumer group is unclear. The second key issue is: does the prevailing evidence-based model of supported employment in psychiatric illness, i.e. individual placement and support, meet the needs of those recovering from a first episode of psychosis? There is little agreement across the specialized integrated early intervention programs cited by Fusar-Poli et al in terms of the vocational supports required to help individuals return to school or work following a first episode of psychosis. Although three of the programs cited by the authors refer to vocational help or support, and one program refers to supported employment and education, it is unclear to what extent any of these approaches are suited to address the unique needs of individuals recovering from an initial episode of psychosis. Recently, it has been suggested that early intervention programs for psychosis should include a component that places a premium on rapid job search or school enrollment for individuals with such goals, and the provision of follow-along supports to facilitate job retention or completion of educational degrees, based on the success of the individual placement and support model at improving competitive employment outcomes in persons with (typically longer term) severe mental illness. However, there are many developmental challenges commonly experienced by most adolescents and young adults. Identifying and pursuing an appropriate career or educational path can be daunting and involve many false starts, even under the best circumstances. With regard to those recovering from a first episode of psychosis, it is unclear what proportion endorse work or school as an immediate goal, and individuals frequently cite barriers to returning to work or school. Many young people who have developed a psychosis experience a profound sense of loss which further interferes with their ability to articulate work or school goals during early recovery. Most individuals entering a first episode of psychosis are enduring heightened psychiatric symptoms and are new to mental health care. They may be experiencing significant medication side effects and often require time to become socialized into treatment. These issues can all impact on the “rapid job search” approach. For example, in the trial of the NAVIGATE program, at study entry all participants were assigned a supported employment and education specialist who was a member of their treatment team, but only 68% engaged in that component of the program (defined as meeting with their specialist three or more times). Furthermore, about onehalf of the individuals who eventually engaged in that component did so after more than six months into the program. The NAVIGATE results and other findings raise questions about the emphasis on rapid job search or school enrollment in supported employment and education programs, and suggest that more attention is needed early in the course of treatment to harnessing individuals’ motivation by facilitating the exploration of work, school and career options to foster their ability to articulate specific personal goals related to role functioning. Resolution of the differing vocational perspectives and goals of the consumer and involved family members may also

Character strengths of individuals with first episode psychosis in Individual Resiliency Training

Positive psychology interventions that integrate a persons strengths into treatment result in improvements in life satisfaction and well-being. Character strengths classified within six core virtues (wisdom/knowledge, courage, humanity, justice, temperance, and transcendence) have been the subject of substantial research. Though a number of studies have been conducted in the general population, little is known about the character strengths of individuals with first episode psychosis (FEP). Moreover, positive psychology principles, in particular a focus on personal strengths, have been increasingly integrated into FEP treatment and was a core component of Individual Resiliency Training (IRT), the individual therapy component of NAVIGATE tested in the Recovery After an Initial Schizophrenia Episode Early Treatment Program. As such, the present study offers an examination of character strengths among 105 FEP clients in specialized early intervention treatment. The present study included two primary aims: 1) to conduct a descriptive analysis of character strengths of FEP individuals and 2) to examine exploratory associations between character strengths and changes in symptomatic and recovery variables over six months. Results revealed that the most commonly identified strengths were: Honesty, Authenticity, and Genuineness (40.95%), Kindness and generosity (37.14%), Fairness, equity, and justice (29.52%), Gratitude (29.52%), and Humor and playfulness (29.52%). Three virtues (Humanity, Justice, and Transcendence) were significantly associated with improvements in symptoms, psychological well-being, and interpersonal relations over six months. Overall, the present study offers a glimpse into how persons with FEP view their strengths and how certain clusters of strengths are related to important outcomes.

Opportunities for Integrating Physical Health Within Assertive Community Treatment Teams: Results from Practitioner Focus Groups

This qualitative study assessed the experiences of assertive community treatment (ACT) team members regarding the integration of physical and mental health self-management for persons with serious mental illness. Three focus groups elicited information from participants concerning barriers, strategies, and recommendations. Findings from inductive analyses revealed six overarching themes: (1) collaboration with primary care, (2) improvements in engagement, (3) team-focused roles, (4) education and training, (5) recommendations for system level barriers, and (6) systems collaboration. Participant recommendations suggest that ACT teams are well positioned to integrate mental and physical health treatment, but further research is needed to support integrated care.

Implementation and fidelity assessment of the NAVIGATE treatment program for first episode psychosis in a multi-site study

The NAVIGATE program was developed for the Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, which compared NAVIGATE to usual Community Care in a cluster randomized design involving 34 sites and 404 patients. This article describes the approach to training and implementing the NAVIGATE program at the 17 sites (including 134 practitioners) randomized to provide it, and to evaluating the fidelity of service delivery to the NAVIGATE model. Fidelity was evaluated to five different components of the program, all of which were standardized in manuals in advance of implementation. The components included four interventions (Individualized Resiliency Training, Family Education Program, Supported Employment and Education, Personalized Medication Management) and the overall organization (staffing and structure) of the NAVIGATE team. Most of the sites demonstrated acceptable or higher levels of fidelity in their implementation of the four interventions and the organization of the program, with all 17 sites demonstrating at least acceptable overall fidelity to the NAVIGATE program. The results indicate that the NAVIGATE program can be implemented with good fidelity to the treatment model in a diverse array of community mental health care settings serving persons with a first episode psychosis.