Robert Heinssen, PhD, ABPP North Carolina Practice Improvement Collaborative North Carolina State University, Raleigh NC November 7, 2014

Transcription

1 Robert Heinssen, PhD, ABPP North Carolina Practice Improvement Collaborative North Carolina State University, Raleigh NC November 7, 2014

2 Disclosures I have no personal financial relationships with commercial interests relevant to this presentation The views expressed are my own, and do not necessarily represent those of the NIH, NIMH, or the U.S. Government

3 Schizophrenia Facts ~2.5 million adults in U.S. are affected Onset in late adolescence, early adulthood High morbidity and mortality Multiple episodes of psychosis over the lifetime High unemployment, homelessness, incarceration Shortened lifespan (suicide, medical co-morbidities) Economic cost of $62.7 billion in 2002 Direct health care costs of $22.7 billion

4 RAISE Background The current paradigm for treating schizophrenia in the United States focuses on managing established illness and entrenched disability

5 Early Intervention Matters Rapid remission of positive symptoms Lower rates of psychiatric re-hospitalization Decreased substance use Improved social and vocational functioning Increased quality of life Bird et al. British Journal of Psychiatry, 2010 Drake et al. British Journal of Psychiatry, 2000

6 RAISE Objectives RAISE will test whether coordinated specialty care promotes symptomatic and functional recovery among persons with first episode psychosis

7 Early Intervention Principles Early detection of psychosis Rapid access to specialty care Recovery focus Youth-friendly services Respectful of clients autonomy and independence

8 Early Intervention Services Assertive outreach and engagement Team-based, phase-specific treatment Empirically-supported interventions Low-dose antipsychotic medications Cognitive and behavioral psychotherapy Family education and support Educational and vocational rehabilitation Meta-analyses of 4 RCTs (N~800 FEP Ss) support the early treatment model Bird et al. British Journal of Psychiatry, 2010

9 2008 Statement of Work Develop, deploy, and test an early intervention model that is relevant to the U.S. mental health system Incorporate features for rapid adoption and large scale implementation Assess overall clinical impact and societal benefit compared to TAU

10 2014 Endgame Generate information relevant to key stakeholders, including federal and state health care policy makers Engineer rapid adoption and broad implementation of effective treatments by engaging end users throughout the research project

11 NIMH RAISE Projects Randomized clinical trial John Kane Nina Schooler Delbert Robinson Implementation study Lisa Dixon Susan Essock Jeffery Lieberman

12 RAISE Clinical Trial WA OR ID MT WY ND SD MN WI MI NY ME VT NH MA RI CA NV AZ UT CO NM NE KS OK IA MO AR IL IN TN KY OH PA WV VA NC SC NJ DE MD MS AL GA TX LA FL Phase-specific specialty care for first episode psychosis vs. TAU Representative patients (N=404) and community clinics (N=34) Focus on clinical and functional recovery, cost of care, societal benefits

13 Lessons Learned So Far Consequences of typical communitybased care for FEP o Baseline data from 404 FEP patients Feasibility of establishing FEP specialty care programs in community settings o FEP training offered to ~125 providers from 17 community clinics across the U.S.

14 Duration of Untreated Psychosis Median DUP Percent DUP 6 months weeks RAISE-ETP (N=404) 0 RAISE-ETP (N=404) Addington et al., Psychiatric Services, in press

15 Duration of Untreated Psychosis Median DUP Percent DUP 6 months weeks RAISE-ETP Birmingham, UK 0 RAISE-ETP Birmingham, UK (N=404) (N=343) (N=404) (N=343) Addington et al., Psychiatric Services, in press Birchwood et al., BJP, 2013

16 Psychopharmacology Recommendations for FE Schizophrenia Antipsychotic medications, other than clozapine and olanzapine, are recommended as first-line treatment. Antipsychotic medications should be started with doses lower than those recommended for multi-episode patients. Bupropion SR and smoking cessation support groups should be offered to people who want to quit or reduce cigarette smoking.

17 FEP Pharmacotherapy 39% of FEP patients required medication changes 10% were prescribed a psychotropic medication, but not an antipsychotic 32% were prescribed olanzapine, often at high doses 09% of antipsychotic prescriptions were higher than recommended dose 23% were prescribed >1 antipsychotic medication Robinson et al., American Journal of Psychiatry, in press

18 Prevalence Cardiometabolic Risk Factors 60.0% Risk Factors 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Correll et al., JAMA Psychiatry, in press

19 Prevalence Cardiometabolic Risk Factors 60.0% Significantly greater prevalence than general population Risk Factors 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Correll et al., JAMA Psychiatry, in press

20 Prevalence Cardiometabolic Risk Factors 60.0% More Prevalence prevalent than rates in similar same age to individuals group the general years population older Risk Factors 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Correll et al., JAMA Psychiatry, in press

21 Prevalence Cardiometabolic Risk Factors 60.0% Medical treatment is lacking in most cases Risk Factors 50.0% 40.0% 30.0% 20.0% FEP cases Medical intervention 10.0% 0.0% <1% 0% 4% <1% Correll et al., JAMA Psychiatry, in press

22 Coordinated Specialty Care Model Medication/ Primary Care Case Management Psychotherapy Client Supported Employment and Education Family Education and Support 22

23 RAISE Navigate Intervention Component Provider Credentials Outreach, access, engagement Program Director Masters Pharmacotherapy Physician/Nurse Practitioner MD / MSN Patient education and support Assertive case management Integrated addictions treatment Recovery Therapist Masters Family education and support Family Therapist Masters Supported employment Employment Specialist Bachelors

24 Navigate Intervention FEP teams established in 17 community clinics 126 local providers were hired and trained 223 young adults enrolled in Navigate programs Mean age = 23 years Mean severity score = 4 (markedly ill) Implementation lessons ( ) Initial training and certification of therapists Patterns of FEP clients service utilization

25 Provider Training in Navigate Team Member Number Trained Certification Ongoing Quality Assurance 1:1 Clinical Supervision Monthly SME Consultation Turnover (<2 Years ) Recovery Therapist Family Therapist SE/E Specialist Medication Prescriber 43 72% 19% 30 67% 15% 18 55% % 1 Training in FEP pharmacotherapy also occurs via computerized decision-support at the point of care.

26 Clients 12-Month Service Utilization Navigate Component % Receiving Component 1 Mean Number of Sessions (SD) Medication Management 97% 10 (3.8) Individual Resilience Training 97% 17 (9.8) Supported Employment/Education 78% 12 (8.7) Family Education and Support 66% 12 (7.9) 1 Based on 162 participants enrolled 12-months (February 2010 December 2012)

27 Two Year Outcomes Navigate versus Standard Care Symptomatic recovery and relapse Interpersonal, school, work functioning Suicidal behaviors Quality of life Treatment costs

28 H.R 3547; January 17, 2014 Increased funds for Mental Health Block Grant Program by $24.8M New 5% set-aside for evidence-based programs for First Episode Psychosis SAMHSA/NIMH to develop guidelines for States regarding effective programs for First Episode Psychosis SAMHSA/NIMH to brief Appropriations Committees on set-aside plans within 90 days of enactment 28

29 Evidence-Based Treatments for First Episode Psychosis: Components of Coordinated Specialty Care RAISE Coordinated Specialty Care for First Episode Psychosis Manuals RAISE Early Treatment Program Manuals and Program Resources OnTrackNY Manuals & Program Resources Voices of Recovery Video Series

30 30 Ryan Fulfilling My Dream

31 Next Steps Increase the number of community clinics in the U.S. that offer coordinated specialty care for early psychosis Develop, test, and implement strategies for reducing delays in early detection, speedy referral, and rapid initiation of stage-specific FEP treatment Test clinical staging and stepped care approaches with persons at high risk for psychosis, before FEP occurs

32 For More Information