Add teamwork to drugs to treat first psychosis

"With first episode psychosis, you have the opportunity to get the treatment right, from early on, before individuals and their families give up," says Kim Mueser. (Credit: iStockphoto)

For people experiencing their first psychotic episode—a symptom of schizophrenia—a comprehensive, team-based, patient-centered approach may work best.

New research shows that this approach, combined with low-doses of antipsychotic drugs, is more effective at helping people move toward recovery in the first two years of treatment than the usual, drug-focused care.

The study of 404 patients at 34 community mental health centers in 21 states, published in the American Journal of Psychiatry, is the largest, most rigorous trial of a program to date for the treatment of first episode psychosis in the US.

More than two million people in the United States have been diagnosed with schizophrenia, and most receive piecemeal care and are treated with antipsychotic medicines that decrease hallucinations and delusions, but that can also have significant side effects, like weight gain and tremors.

Quick improvement

Coauthor and clinical psychologist Kim Mueser, professor in the Boston University Sargent College of Health & Rehabilitation Sciences, helped lead the effort to create the psychosocial part of the program, called NAVIGATE. Researchers designed NAVIGATE to work in routine treatment settings serving people with serious mental illness within the US health care system and reimbursed by existing insurance plans.

Psychotic symptoms often go untreated for many months and even years before effective treatment is provided.

[Childhood trauma boosts risk of early psychosis]

Mueser says the study demonstrates that it is possible to deliver effective, comprehensive, individualized treatment for schizophrenia early on and within the US health care system, and that such care improves the lives of people with these mental health conditions.

“With first episode psychosis, you have the opportunity to get the treatment right, from early on, before individuals and their families give up,” says Mueser, executive director of the Center for Psychiatric Rehabilitation (CPR). “We see improvements across the board—in social relationships, at work, and in school, in reduction of the severity of symptoms, in all the things that are most important to people experiencing an episode of psychosis.”

Working with patients and families

One of the keys to the success of NAVIGATE, Mueser says, is that teams of mental health specialists collaborated with patients—and their families—to develop individualized treatment plans. “The overall team worked together, had regular meetings, planned how to coordinate the different treatment components,” he says. “Everything was driven by what the clients’ goals were.

“Decision-making was shared, and everyone worked together, including the client, family, and the NAVIGATE team.

“The biggest trouble in the field is that at most of the centers where people get treatment, they receive medication and some case management—a little bit of this, a little bit of that,” Mueser says. “But they do not tend to receive comprehensive treatment, including evidence-based practices shown to be effective in rigorous research studies, such as supported employment or family education.”

In addition to personalized medication management, NAVIGATE has three parts:

  • Individual cognitive behavioral therapy that includes training in resiliency, learning tools for building social relationships, and managing symptoms, and understanding and working through the psychotic episode.
  • Supported education and employment: a counselor helps the patient to return to school or find employment as quickly as possible. Support is provided at work or school to help the patient stay on track.
  • Educating the family in understanding the illness.

In addition to helping people manage their symptoms—for example, learning how to cope with voices they may hear—the therapy is aimed at helping people understand that they are much more than their illness.

[Hallucinations are surprisingly common]

“One of the awful things about having a psychotic episode is that all of a sudden, you’re pathologized—you’re a patient,” says coauthor Jennifer Gottlieb, a senior researcher at CPR and coauthor of the study.

“We’re helping people tap into positive characteristics that they have always had or that they have developed over time in the face of confronting a psychotic episode to help them recover and move forward in meaningful ways. People have this perception that if you have this psychosis or a family member receives this diagnosis, that’s it, they’re done for. That’s one of the most tragic things—they’ve lost hope.”

The National Institute of Mental Health supported the work.

Source: Boston University