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Kristen Gardner, PharmD, BCPP, Clinical Pharmacy Specialist – Behavioral Health, Kaiser Permanente Colorado
CPNP Programming Committee Vice-Chair

 
In her CPNP 2019 keynote session, Early Psychosis Treatment: How Did We Get here & Where Are We Going?, Dr. Lisa Dixon, Director of OnTrackNY, a New York statewide early intervention program for persons with first-episode psychosis (FEP), walked us through the moving story of how the US moved towards an early intervention model for FEP treatment and the benefits offered by integrated coordinated specialty care (CSC) programs in this population. Dr. Dixon described the push for FEP early intervention program study and implementation as the culmination of a “perfect storm” with known gaps in the current mental health care landscape (e.g., community mental health center movement failed to prevent disability), the National Institutes of Health thinking big with their RA1SE initiative and calling for study proposals, increased public concern about mental health care, and federal funding opportunities.

The goal of the RA1SE initiative was to develop, refine, deploy, and test an FEP early intervention model (i.e., integrated coordinated specialty care or CSC) relevant for the US mental health system using community treatment programs and not academic research clinics. CSC have the following key service elements: case management, supported employment/education, psychotherapy, family education and support, pharmacotherapy and primary care coordination. CSC uses core service processes such as a team-based approach, specialized training, community outreach, client and family engagement, mobile outreach and crisis intervention services, and shared decision-making. The RA1SE study found that CSC improved functional and clinical outcomes in those with FEP relative to standard community care and that these benefits were further heightened when the duration of untreated psychosis (DUP) was shorter (< 74 weeks, ~1.5 years).

Dr. Dixon emphasized that encouraging people to seek help is necessary to achieving shorter DUP in FEP. This may be accomplished by using mainstream media, targeting public AND professionals, and emphasis on changing attitudes and not just knowledge of symptoms. In fact, a study found that an intensive informational campaign was associated with an increased number of referrals to care, and, hence shorter DUP; however, when the campaign stopped, the number of referrals began to decline highlighting that continued campaigns, and not just a one-time only campaign, is likely necessary.

Dr. Dixon also emphasized the importance of shared-decision making in treatment of FEP. She reviewed a three-talk model of shared-decision making (see figure).

Dr Dixon also described specific tools used by OnTrackNY including (1) an option grid for patients, caregivers, and doctors, to help decide how best to manage medications for psychosis (see figure) and (2) a worksheet called “My Designated Observer” (see figure).

The talk briefly reviewed evidence based antipsychotic treatment options for FEP highlighting clozapine as an option after 2 failed adequate antipsychotic trials and the option to use long-acting injectables in this patient population.

Lastly, Dr. Dixon reviewed whether the benefits of CSC persist beyond end of treatment or whether continued treatment in a CSC setting is necessary for continued benefit. Presently, there is modest evidence that the benefits of CSC extend beyond the end of the CSC program, response is heterogenous and may depend on nature of available post-discharge services, and that there may be some overall longer-term protection in the likelihood of suicide. Strategies to support the ongoing benefits are being tested and continuation of programs appears to be helpful.

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