Transcript Early Intervention in Schizophrenia: Challenges and

Research Update: Early Intervention:
The RAISE Early
Treatment Program
John M. Kane, M.D.
Chairman, Dept. of Psychiatry
The Zucker Hillside Hospital
Executive VP for Behavioral Health Services
The North Shore–Long Island Jewish Health
System
Professor and Chairman
Department of Psychiatry
Hofstra North Shore LIJ
School of Medicine
Disclosure 2014 – John M. Kane
Company
Consultant/
Advisory Board
Speakers bureau
Alkermes
X
Bristol-Meyers Squibb
X
X
Eli Lilly
X
X
EnVivo Pharmaceuticals
X
Forest Laboratories
X
Genentech
X
H. Lundbeck A/S
X
Intracellular Therapeutics
X
Janssen Pharmaceutica
X
Johnson and Johnson
X
Shareholder
Grants/
Research support
X
MedAvante
X
Otsuka Pharmaceutical
X
Reviva
X
Roche
X
X
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Evolution of Psychosis
Fusar-Poli P. et al. JAMA Psychiatry. 2013;70(1):107-120.
Reported mean duration of untreated
psychosis
1 year
Wiersma 2000
Amminger 2002**
Malla 2002
Linszen 2001
Verdoux 2001
Black 2001
Larsen 2000
Hoff 2000
Ho 2000
Drake 2000
Browne 2000
Barnes 2000
Robinson 1999*
McGorry 1996**
Larsen 1996
Szymanski 1996
Loebel 1992*
0
10
20
30
40
50
60
70
80
90 100 110 120 130 140 150 160 170 180
Weeks
Presented by Diana O. Perkins, MD, MPH. University of North Carolina at Chapel Hill, 26 th Sept 2003
(available at: www.medscape.org/viewarticle/460974)
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Duration of Untreated Psychosis
RAISE ETP
n=404
Median DUP=74 weeks (mean=193.5±262.2 weeks)
68% of participants had DUP >6 months
Correlates of longer DUP included:
•earlier age of first psychotic symptoms
•substance use
•positive and general symptom severity
•poorer functioning
•referral from outpatient treatment settings
Addington J et al. Submitted for publication
Table 1: Characteristics of RAISE-ETP participants and associated Duration of Untreated Psychosis (DUP; N=404)
*p<.05, **p<.01, ***p<.001
Participant Characteristics
N
%
Weeks of DUP (Mean±SD)
Gender
Female
Male
111
293
27
73
63±6.5
53±7
Racial background
White
Black or African-American
American Indian
Asian/Pacific Islander
218
151
22
13
54
37
5
3
49±6.5
63±7
52±1
55±4.5
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
73
331
18
82
44±8
58±6.5
Prior Psychiatric Hospitalization***
Yes
No
316
88
78
22
40±7
156±4
Diagnosis at study entry
Schizophrenia
Schizophreniform disorder
Schizoaffective disorder
Brief psychotic disorder
Psychotic disorder NOS
214
67
81
2
40
53
17
20
<1
10
99±4.5
5±4
138±5
2±1.5
26±7
Substance use**
Yes
No
161
237
40
60
74±6.5
48±7
Table 1 continued: Characteristics of RAISE-ETP participants and associated Duration of Untreated Psychosis (DUP;
N=404)
*p<.05, **p<.01, ***p<.001
Participant Characteristics
N
%
Weeks of DUP (Mean±SD)
Mental Health treatment status at
study entry*
Outpatient
Inpatient/partial hospital
Unknown/other
230
120
54
57
30
13
66±7
37±7
62±5.5
Geographic region where receiving
treatment***
North
South
Mid-West
West
69
89
154
92
17
22
38
23
26±6.5
79±8
63±6
40±7
Community population density
Rural
Urban
Suburban
102
198
103
25
50
25
73±7
48±7
57±6.5
Insurance coverage
Private or private & public
Public only
No insurance
Insurance status unknown
82
127
173
19
20
32
43
5
37±6
73±7
57±7
58±7.5
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Implications of delayed treatment
 Greater decrease in functioning
 Loss of educational opportunities
 Impaired psychosocial and vocational development
 Personal suffering/family burdens
 Potential poorer response once treatment is provided
 Greater costs
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Strategies to Reduce the Duration of
Untreated Psychosis
Anonymous E-surveys of high school and college students,
linkages to psycho-ed website and referral to specialty
program
Interviews of early phase patients (and families) to understand
pathways to care and internet social media utilization and how
it was effected by incipient psychosis
Asking for access to social media communications for further
examination using word count/linguistic analysis
Working with teenagers to develop social media strategies to
educate and respond
Key concepts for optimal first-episode
medication treatment
 Response rates for positive symptoms are very high
 No antipsychotic has demonstrated superior efficacy for the treatment of
the initial psychotic episode. Tolerability is key
 Effective antipsychotic doses are usually lower than those needed
for multi-episode patients
 Despite low antipsychotic doses, rates of side effects are high
 Relapse is frequent and the most important factor driving relapse is
medication non-adherence
 There is often an overwhelming drive by patients and their families
to stop treatment
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The risk for psychotic relapse is high
95% CI
Relapse rate
(%)
Lower limit
Upper limit
Patients still
at risk at end
of year, n
1
16.2
8.9
23.4
80
2
53.7
43.4
64.0
39
3
63.1
52.7
73.4
22
4
74.7
64.2
85.2
9
5
81.9
70.6
93.2
4
Year*
n=104 first-episode schizophrenia patients; *year(s) after recovery from the previous episode;
CI=confidence interval
Robinson et al. Arch Gen Psychiatry 1999;56:241–247
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Stopping medication is the most
powerful predictor of relapse
 Survival analysis: risk of a first or second relapse when not taking
medication is ~5 times greater than when taking it
Hazard ratio for the first and second relapse
n=104
Robinson et al. Arch Gen Psychiatry 1999;56(3):241–247
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Relapse fuels the progression of illness
 With each relapse:
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Recovery can be slower and less complete
More frequent admissions to hospital
Illness can become more resistant to treatment
Increased risk of self-harm and homelessness
Regaining previous level of functioning is harder
Patient has a loss of self-esteem and social and vocational
disruption
 Greater use of healthcare resources
 Increased burden on families and caregivers
Kane. J Clin Psychiatry 2007;68(Suppl 14):27–30
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Consequences of a first and second
relapse in early phase illness
 After a first episode a young person might go back to
school or work
 What happens if they relapse, will they be able to return
a second time, or a third time?
 How do close friends or lovers react to a psychotic
episode, and then a relapse?
 Many of life’s opportunities, and a person’s potential, can
be eroded by a small number of relapses early in the
illness
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UCLA recovery criteria
 Recovery criteria must be met in each of 4 domains
 Improvement in each domain must be sustained
concurrently for 2 years
 Level of recovery in these 4 domains is measured by
symptom remission, appropriate role function, ability to
perform day-to-day living tasks without supervision, and
social interactions
Liberman et al. Int Rev Psychiatry 2002;14:256–272
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Cumulative recovery rates by year in study
95% CI
Cumulative
recovery rate (%)
Lower
limit
Upper
limit
3
9.7
3.7
15.8
4
12.3
5.4
19.1
5
13.7
6.4
20.9
Year
CI=confidence interval
Robinson et al. Am J Psychiatry 2004;161(3):473–479
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A systematic review and meta-analysis of
recovery in schizophrenia
Conclusions:
Based on the best available data, approximately, 1 in 7
individuals with schizophrenia met our criteria for recovery.
Despite major changes in treatment options in recent
decades, the proportion of recovered cases has not
increased
Jääskeläinen et al. Schizophr Bull 2013;39(6):1296–1306
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A nationwide cohort study of oral and depot
antipsychotics after first hospitalisation for
schizophrenia
Tiihonen et al. Am J Psychiatry 2011;168:603–609
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Is there a case for earlier use of LAI
antipsychotics?
 The percentage of time spent experiencing psychotic symptoms in
the first 2 years is the strongest predictor of long-term symptoms
and disability1
 With subsequent exacerbations, patients may experience a
decrease in their treatment response2
 Neuropathological brain changes often progress with subsequent
clinical episodes3
 LAI antipsychotics allow for swift identification of overt nonadherence and elimination of covert nonadherence4
LAI=long-acting injectable
1. Harrison et al. Br J Psychiatry 2001;178(6):506–517; 2. Lieberman et al. Neuropsychopharmacology 1996;14:13S–21S;
3. Lieberman et al. Psychiatr Serv 2008;59(5):487–496; 4. Fenton et al. Schizophr Bull 1997;23(4):637–651
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Impact of initiating LAI atypical antipsychotics
early in the disease course
 Patients initiated on an atypical LAI within 5 years of onset of illness
(24.2%) were compared with those on an atypical LAI >5 years after
the onset of illness (75.8%):
Longer median time
to discontinuation (p=0.003)
Greater improvement
in PANSS scores (p<0.01)
Longer time to relapse
(p=0.018)
Higher remission rates
(p<0.001)
Greater improvements
in BPRS scores (p<0.01)
n=1,879;
BPRS=Brief Psychiatric Rating Scale; LAI=long-acting injectable; PANSS=Positive and Negative Syndrome Scale
Detke et al. Poster presented at the 52nd Annual New Clinical Drug Evaluation Unit (NCDEU) meeting;
29th May–1st June, 2012; Phoenix, AZ
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Relapse risk despite RIS-LAI adherence
Proportion relapse free

Stepwise Cox proportional predictors: Canada vs US: HR=2.8; illness duration ˃10
years vs ≤5 years: HR=2.3; previous AP >4 vs ≤4 mg/day: HR=1.8
Illness ≤5 years
Illness 6–10 years
1.00
0.98
0.96
0.94
0.92
0.90
0.88
0.86
0.84
0.82
0.80
0.78
0.76
Illness ˃10 years
% relapsed
10.4%
17.6%
21.9%
0
5
10
15
20
25
30
Weeks
35
40
45
50
55
n=323; post-hoc analysis of a 1-year relapse prevention study of R-LAI 25 mg vs 50 mg/2 weeks: 18.3% relapsed;
RIS-LAI=risperidone long-acting injectable; AP=antipsychotic; HR=hazard ratio
Nasrallah et al. Poster presented at the 52nd Annual New Clinical Drug Evaluation Unit (NCDEU) meeting;
29th May–1st June, 2012; Phoenix, AZ
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Bartzokis et al. Sch Res 2012
RAISE-ETP: Executive Committee
ETP=early treatment program
John Kane
– Principle Investigator
The Zucker Hillside
Hospital (ZHH)
Delbert Robinson
ZHH
Nina Schooler
SUNY Downstate
Jean Addington
University of Calgary
Sue Estroff
UNC
Christoph Correll
ZHH
Kim Mueser
Boston University
David Penn
UNC
Robert Rosenheck
Yale University
Patricia Marcy
ZHH – Project Director
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Principal NIMH Collaborators
 Robert Heinssen
 Susan Azrin
 Amy Goldstein
Specified aims of RAISE
 Develop a comprehensive and integrated intervention to
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Promote symptomatic recovery
Minimise disability
Maximise social, academic, and vocational functioning
Be capable of being delivered in real-world settings utilising
current funding mechanisms
 Assess the overall clinical impact and cost-effectiveness
of the intervention as compared to currently prevailing
treatment approaches
 Conduct the comparison in non-academic, real-world
community treatment settings in the United States
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RAISE – ETP Site Distribution
34 sites in 21 states
RAISE Trial: Methods
 Sites are randomly assigned to administer either the
RAISE Intervention or their current treatment
program
 A central team of raters conducts structured
diagnostic interviews and assesses subjects via live,
two-way video interviews
― Assessors are masked to treatment condition
 Compatible with the site randomization model
― Expert assessors available to all sites
― Central rater team allows ongoing maintenance of high
reliability of assessment
 Subjects are assessed for a minimum of 2 years
RAISE Trial Design: Subjects
 Sample size: 404
 Age 15-40
 The following diagnoses are included in the
differential
― schizophreniform disorder
― schizophrenia
― schizoaffective disorder
― psychotic disorder NOS
― brief psychotic disorder
 Less than six months of treatment with
antipsychotic medications
RAISE Trial: Outcomes
 Primary outcome measure: Quality of Life scale
 Primary hypothesis
 RAISE intervention compared to community care will improve
Quality of Life
 Other measured outcomes
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Service utilization
Cost
Consumer perception
Prevention of relapse
Enhanced recovery
Navigate
 Team based
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Shared decision-making
Strength & resiliency focus
Psychoeducational teaching skills
Motivational enhancement teaching skills
Collaboration with natural supports
 Four components

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

Psychopharmacology – COMPASS
Individual Resiliency Training (IRT)
Family psychoeducation
Supported employment/education
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Individual Resiliency Training
(IRT)

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
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Strength and Goal oriented
Skill based
Recovery emphasis
Motivational techniques utilized throughout
 Connecting skills and information to goals
 Reframing events in positive light
 Promoting hope and positive expectations
 Tailored for first-episode clients
 Clinicians have at least Bachelor’s level
education and prior clinical experience
 Most have Master’s level degrees
 Modular and sequenced
 But sequence can be modified to address client’s needs
IRT Modules
 Standard :
 Orientation
 Assessment
 Resiliency training
 Wellness management
 Psychoeducation/processing the illness
 Goal setting
 Relapse prevention
 Advanced
 Managing distress and grief
 Coping with depression and other symptoms
 Reducing substance abuse/dependence
 Improving social relationships
Family Psychoeducation
 Begins soon after initial contact
 Includes client, relatives, other significant persons
 Basic and Advanced modules
 Coordinated with Individual Resiliency Training
 Assessment and identification of client and family
goals
 Education about disorder and treatment
 Opportunity to process experience of psychotic
episode and reduce stigmatizing beliefs about
mental illness
 Strategies for improving quality of communication
and problem solving
Supported Education /
Employment
 Established principles of supported employment
in chronic populations modified for first episode
 Focus on return to school or work as soon as
possible after symptom stabilization
 Goals determined by client preferences
 Supports provided to
 enroll/re-enroll in school
 re-enter or obtain work
 Ongoing supports provided to maintain
school/work
 Coordination with clinical treatment and team
 Benefits counseling
The Value of Measurement
 Contribution to diagnostic process
 Establishing baseline severity
 Providing targets and treatment goals
 Evaluating the efficacy of treatment
 Evaluating tolerability and adverse effects
 Influencing level of care
 Medical record documentation
Obstacles to Measurement
 Inadequate appreciation of benefit
 Perceived value of global judgment
 Time constraints
 Lack of appropriate instruments
 Inadequate training
 Reimbursement concerns
Computerized Decision Support System
Longitudinal Symptom Assessment
Figure 1. Patient Evaluation Screen
Desired Characteristics of a Decision Support System
•Ease of use
•Web-based: available for desk tops, lap
top, I Pad
•Incorporating patient self-report
•Interactive (results are constantly modified
based on patient and prescriber input)
•Grade school level reading for self-report
•Validated assessment tools
•Incorporates psychiatric and medical data
•Substance abuse
•Nicotine use
•Adherence (including assessment of
attitudes towards medication)
•Comprehensive side effect assessment
•Senior national experts involved in
designing
•Extensive prescriber feedback
Patient Self Report Form
Little red boxes
indicate items not
yet addressed
Clinician Rated Form Includes Information From
Patient Self-Rated Form On Corresponding Items And
Adjusts The Prompt Questions Accordingly
This item includes prompt
question for a patient who did not
endorse depressed mood on the
Self-Report Form
Prompt question for patient who did
endorse anxious mood
Referral Source of Participants
 335 (79%) came from the usual referral
sources for the agency (e.g. an inpatient
unit, ER)
 88 (21%) came from community outreach
activities
Diagnoses at Enrollment
10.5%
Psychosis NOS
Brief Psychotic
Disorder
0.8%
Schizophreniform
Schizoaffective
16.2%
19.5%
53.0%
Schizophrenia
0%
20%
40%
60%
% of Subjects
80%
100%
Prior Psychiatric Hospitalizations
 316 (78%) had a prior psychiatric
hospitalization
 88 (22%) had no prior psychiatric
hospitalizations
Demographic Characteristics
 293 (73%) men and 111 (27%) women
 340 (84%) were between the ages of 18
and 30 years old
 Mean age is 23.1 years; modal age is 19.
404 subjects entered the
RAISE-ETP study
 We examined their medication prescriptions at the time
of study entry before any influence of treatment by study
guidelines or procedures
 We identified 159 (39.4%) subjects who might have
benefitted from one or more changes in their
psychotropic prescriptions
ETP=early treatment program
Robinson et al. In Press Amer J Psych
Of these 159 subjects…
 14 (8.8%) were prescribed recommended antipsychotics at higher
than recommended doses
 51 (32.1%) were prescribed olanzapine (often at high doses)
 37 (23.3%) were prescribed more than one antipsychotic
 58 (36.5%) were prescribed an antipsychotic, but, also an
antidepressant, without a clear indication
 16 (10.1%) were prescribed psychotropic medications without an
antipsychotic
 5 (1.2%) were prescribed stimulants
Robinson et al. In press Amer J Psych
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Prevalence / lack of intervention (%)
RAISE: smoking, lipid abnormalities, hypertension
diabetes + metabolic syndrome with related drug
treatment
Smoking
Dyslipidemia
Low
HDL-C
High total
cholesterol
High
LDL-C
High
triglyceride
High
BP
Prediabetes
mellitus
(HbA1C)
Diabetes Metabolic
syndrome
After 47 days average lifetime antipsychotic treatment, olanzapine and quetiapine were related to higher metabolic
values; dyslipidemia: TC ≥200 mg/dL or TG ≥150 mg/dL, or low HDL;
TC=total cholesterol; TG=triglyceride; HDL=high-density lipoprotein; LDL=low-density lipoprotein
Correll et al. In press JAMA Psych
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Smoking at study entry
 51.2% of subjects reported smoking cigarettes at the
time of study entry
 No subject was being prescribed nicotine replacement or
varenicline
 Only 11 subjects (7 currently smoking) were prescribed
bupropion (indication for bupropion not recorded)
Robinson et al. Unpublished data
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E-Health: Potential to Address Problem Areas of
In-Person Services
1. Severe mental illness: treatment is insufficient


>50% do not receive specialty mental health services (Mojtabai et al, 09),
4%-15% receive minimally adequate treatment (far short of
standards for care) (Wang et al, 02)
2. 15-25 years for EBPs to reach routine care (IOM, 01)
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3.
4.
5.
6.
7.
Lack of expertise in community treatment settings
High cost of setting up & maintaining an EBP
Too few clients for economy of scale in clinics, or geographic areas
Once reach routine care EBPs often lack fidelity (Drake et al, 01)
Travel adds burden
Families/supporters left out of treatment
Healthcare is poorly understood--regardless of education level
Chronic illness management occurs at home
The Improving Care Reducing Cost (ICRC)
Program
Translates to
The Health Technology Program (HTP)
John Kane , Delbert Robinson, Nina Schooler, Mary
Brunette, Kim Mueser, Dror Ben-Zeev, Jennifer Gottlieb,
Armondo Rotundi, Christoph Correll, Susan Gingrich,
James Robinson, Bob Rosenheck, Patricia Marcy
Program Overview
 Goal:
 To reduce ER visits and hospital days while providing
better care, better health and increased patient
satisfaction. This will be done by fostering innovation
in the use of technology and by training and deploying
a new cadre of personnel in the behavioral health
field: Mental Health/Health Technology (MH/HT) Case
Managers.
Hospitalization and
schizophrenia
 Schizophrenia is characterized by relapses
(hospitalizations) and returns to the community
 Challenging for making progress toward recovery
 Hospital stays are a major cost driver
 Six month cost for newly discharged patients
 16,300
 Re-hospitalization
 Medication
 Other
11,900
3,000
1,400
 Six month cost for other patients
 8,200
 Risk for rehospitalization is greatest in the months
immediately following discharge
Health Technology Program
 Focuses on critical 6 months following hospital
discharge
 Engages patient with a treatment team
 Uses innovative tech tools to provide treatment
 Outcome assessment and monitoring is
integrated in treatment
 Treatment is tailored to patient needs and
preferences
 Shared decision making
The Health Technology Team
 Project director
 Identifies and enrolls patients at the critical time
 At or immediately following a hospitalization
 Leads the team
 Psychiatrist/prescriber
 Assesses symptoms, side effects and adherence
 Prescribes medication based on assessment and evidencebased treatment guidelines
 Mental Health/Health Technology Case Manager
 Provides case management services
 Guides the patient in use of new tech tools
The Health Technology Program
Components
 Relapse Prevention Plan
 In-person guidance to create “My Relapse Prevention Plan”
 Daily Support Website
 Web-based support for patients and families
 FOCUS
 smart phone app to cope with adherence, mood, sleep, social
dysfunction and voices
 Coping with Voices and Paranoia
 Web-based computer CBT programs
 Prescriber Decision Assistant
 Web-based Medication Decision Support System
Relapse Prevention Planning (RPP)
 Five in person sessions occurring in the first 2
months of treatment
 Session 1: Orientation to Program and goals
 Session 2: Medication Strategies
 Session 3: Stress
 Session 4: Substance Use
 Session 5: Putting it All Together
The Daily Support Website
(DSW)
 Web-based support for patients and families
 Provide illness & coping education material to patients and
families
 Social networks with participants and family members
 Chat rooms for patients, families, and patients and families
 Help individuals and families with the illness
 Opportunity to interact with an online therapist
 Identify early warning signs and prevent relapse
 Option to identify early warning signs and receive daily text
reminders
 Case managers alerted if early warning signs are present
FOCUS – A smart phone application
• 5 treatment targets: Med adherence,
voices, social functioning, mood and
sleep
• Up to 3 targets can be selected at
one time
• Patients can receive up to 3 push
notifications/check-ins per day
• Each check-in= 4 messages
•
•
•
Case Managers work with patient to
select appropriate targets
Case managers have access to a real
time report of patient responses
Targets can be changed throughout the
program
“Coping with Voices and Paranoia”
• Interactive, game-based program that teaches CBT
skills to persons with psychotic disorders
• Self-paced but forced exposure to all program
components in order
• Cumulative building of skills, complexity increases
somewhat over sessions
• “Multi-Modality” – animated tutorials, readings, audio
and video, interactive games, symptom reporting
and tracking, social feed component, interactive
quizzes
PDA Decision Support System
•The PDA is a web-based decision support system that
assists patient-provider communication and decision
making
•Patients complete a self assessment prior to seeing the prescriber
•The prescriber interview is tailored based on the patients
responses on the self assessment
•The HTP program uses evidence-based medication
treatment to decrease patient risk of relapse
•The appropriate use of clozapine and efforts to promote
medication adherence (e.g. long-acting injectable antipsychotics)
are crucial for this goal
Implementation
 Project Director & Case Manager identify patient
 Patient consents to participate and receives
baseline assessments
 Patient meets with case manager
 Goal to develop and implement a plan for preventing
relapse and rehospitalization that incorporates
appropriate tech tools
 Laptop computer, internet connection and Smart
Phone are provided
 Patient meets with prescriber for assessment
and medication management
 Treatment continues for SIX months
Conclusions
 Early and effective intervention is key for achieving the
best outcomes in schizophrenia
 Non-adherence remains a major challenge and is a
frequent cause of relapse and re-hospitalisation
 Recovery rates remain disappointingly low
 A combination of pharmacotherapy and psychosocial
treatments are critical to facilitate recovery
71