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Strategies to reduce duration of untreated psychosis
The theme for World Mental Health Day 2018 is “Young People and Mental Health in a Changing World”. One way to transform the lives of young adults presenting with psychosis is to shorten the duration of untreated psychosis (DUP), explained John M. Kane, Professor of Psychiatry, Northwell Health, NY, in an inspiring plenary at IEPA 11. He presented evidence showing that team-based coordinated specialty care programs for young adults with first episode psychosis improve quality of life, particularly for those with a DUP less than 74 weeks. He also discussed some of the difficulties associated with adherence to oral antipsychotic treatment regimens, and how long-acting injectable antipsychotics may help to further improve outcomes and prevent relapse.
NAVIGATE is a team-based program for implementing coordinated specialty care (CSC) within the Recovery after an Initial Schizophrenia Episode – Early Treatment Program (RAISE-ETP), explained Professor Kane.
Many patients with early psychosis might benefit from changes to their psychotropic medication
RAISE-ETP enrolled 404 people aged up to 40 years who had a psychotic disorder and had been treated with antipsychotics for less than 6 months. On entry, it was considered that almost 40% might benefit from one or more changes to their psychotropic medication.
The NAVIGATE program is based on shared decision making and focuses on strength and resiliency (in contrast to pessimism and limitations). Its four components are psychopharmacology, individual resiliency training, family psychoeducation and supported employment and education.
CSC improves functional and clinical outcomes
Professor Kane and his colleagues carried out a randomized clinical trial (RCT) to compare NAVIGATE with community care in 34 local clinics in 21 US states over 2 years: 17 sites provided NAVIGATE to 223 participants and 17 sites provided community care to 181 participants. The outcomes were assessed by experts working remotely, and the primary outcome was quality of life.1
Coordinated specialty care is more effective in patients who have a shorter duration of untreated psychosis
The average age of participants in both treatment groups was 23 years and those who took part in the NAVIGATE program were:
- significantly more likely to remain in treatment
- experienced significantly greater improvement in quality of life
- were also more likely to be at school or in work
- showed significantly greater improvement on the Positive and Negative Syndrome Scale (PANSS)1
The effects were more pronounced for those with a duration of untreated psychosis (DUP) of less than 74 weeks, said Professor Kane.1
Early intervention services (EIS) benefits patients with early psychosis — but who will fund it?
The results of the RCT have been supported by a 2018 systemic review and meta-analysis. Early intervention services (EIS) were found to be superior to treatment-as-usual (TAU) for early phase psychosis across all analyzable outcomes.2
These studies highlight the need for funding EIS because team-based therapies are generally not reimbursed in the US, said Professor Kane. He added that cost-effectiveness and patient-centered outcomes need further investigation.
Long acting injectable antipsychotics can help addressing the high relapse rate
The relapse rate for psychosis is high and ranges from 16% at 1 year to 82% at 5 years.3
Stopping medication is the most powerful predictor of relapse
The risk of a first or second relapse is approximately five times greater when not taking medication,3 said Professor Kane; and antipsychotic medication has been shown to benefit patients with schizophrenia.4
He suggested that the importance of medication for preventing relapses is generally not recognized even though two to three relapses early in the course of a psychotic illness can erode life opportunities.
Destigmatizing nonadherence can improve adherence
Professor Kane advocated destigmatizing antipsychotic nonadherence. He said that it is human nature to have difficulty adhering to treatment. He added that unidentified nonadherence may lead to unnecessary changes in antipsychotic medication and dose and may result in an inaccurate diagnosis of treatment-resistant psychosis.
Long acting injectable antipsychotics are proving superior to oral antipsychotics,5,6 Professor Kane said, and because they are only administered occasionally, they address difficulties with adherence and can improve outcomes.
Further reading:
For more on the RAISE project from Professor Kane, please see this article in the Progress in Mind Resource Center: https://progress.im/en/content/right-treatment-right-time-improving-outcomes-first-episode-psychosis
Hear from experts about how early intervention services have the potential to improve the success of treatment and social functioning for individuals with schizophrenia, here: https://progress.im/en/content/early-intervention-services-have-potential-improve-success-treatment-and-social-functioning
How are you celebrating World Mental Health Day? Watch this video to hear about what others are doing! https://progress.im/en/content/what-are-you-doing-celebrate-world-mental-health-day and show your support by “liking” the World Mental Health Day Facebook page here!
References
- Kane et al. Am J Psych 2016;173(4):362–72.
- Correll et al. JAMA Psychiatry. 2018;75(6):555-65.
- Robinson et al. Arch Gen Psych 1999;56(3):241–7.
- Leucht et a. Lancet 2012;379(9831):2063–6.
- Kishimoto et al. J Clin Psych 2013;74(10):957–65.
- Kishimoto et al. Schiz Bull 2018;44(3):603–19.