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The RAISE-Early Treatment Program (ETP) Experience
Nina R. Schooler, PhD
SUNY Downstate Medical Center
Member, BBRF Scientific Council
on behalf of the RAISE-ETP team
Recovery After Initial Schizophrenia Episode
Early Treatment Program
RAISE-ETP: Executive Committee
John Kane – PI, 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
Mary Brunette, Dartmouth University
James Robinson, Nathan Kline Institute
Patricia Marcy, ZHH – Project Director
Key Consultants:
Tom Tenhave and Andy Leon assisted in designing the trial. Robert Gibbons, Don Hedeker and Hendricks Brown reviewed
the data analytic plan. Haiqun Lin led the analysis.
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PRINCIPAL NIMH COLLABORATORS
Robert Heinssen
Susan Azrin
Amy Goldstein
With Thanks to Our 34 Sites:
Clinicians and Participants
Burrell Behavioral Health – Springfield
Burrell Behavioral Health – Columbia
Catholic Social Services of Washtenaw County
(CSSW)
Cobb County
Places for People
Community Mental Health Center, Inc.
Everly Ball
Grady Health System
Greater Nashua Mental Health Center @
Community Council
Henderson Behavioral health
Howard Center
Human Development Center
Lehigh Valley Hospital
Life Management center of Northwest Florida
Mental Health Center of Denver
The Mental Health Center of Greater Manchester
Community Mental Health Center of Lancaster Cty
Clinton-Eaton-Ingham Community Mental Health
Authority
North Point Health and Wellness
Park Center
Peach Health Oregon
Pine Belt mental Health Center
The Providence Center
River Parish Mental Health Center
St. Clare’s Hospital
South Shore Mental Health Center
Terrebonne Mental Health Center
Cherry Street Health Services
UMKC School of Pharmacy
Santa Clarita Mental Health Center
San Fernando Mental Health Center
United Services
Center for Rural & Community Behavior Health New
Mexico
Staten Island University Hospital
NAVIGATE
Coordinated Specialty Care
comprehensive and integrated treatment intervention
Overall goal is recovery – not management or maintenance
Team based intervention
•
•
•
•
Program Director – family treatment provider
Psychiatrist/Nurse practitioner –prescriber
Clinician therapists - two
Supported employment/education specialist
Services paid for through current US reimbursement models
Shared decision-based model insures client and family involvement in treatment
planning and execution
Manuals developed for all Intervention components
Training and on-going consultation to insure fidelity
NAVIGATE team members
Core skills
Collaborate with
natural supports
Promote shared
decision-making
Use a
psychoeducational
approach
Focus on strengths
and resiliency
Enhance client’s
motivation
NAVIGATE Team Meetings
Initial
treatment
planning
meeting for
NAVIGATE
team, client,
& relatives
(within first
month of
enrollment)
Treatment
review &
planning
meeting for
NAVIGATE
team, client,
& relatives
(every 6
months)
Weekly
NAVIGATE
team
meeting
Weekly
supervision
meeting
between
Director &
SEE
specialist
Weekly
supervision
meeting
between
Director &
IRT
clinicians
Compass
Psychopharmacologic treatment
Provides measurement
based treatment
Basic psychoeducation
NAVIGATE
COMPONENTS
Family treatment
Module based communication and
problem solving
Individual
Resiliency
Training
Module based and
manual driven focused
on recovery and growth
Supported
employment/
education
Return to community not rehabilitation
Computerized
Decision Support
System (CDSS)
Begins soon
after initial
contact
Includes
client,
relatives,
other
significant
persons
Modified
intensive
skills training
Family
consultation
FAMILY
PROGRAM
Coordinated
with Individual
Resiliency
Training
Assessment
and
identification
of client and
family goals
Monthly
check-ins
Education
about
disorder and
treatment
Flexible
Modular
Structure
• Standard –
recommended for all
• Individualized selected based on
need and preference
Strengths
based –
influence of
positive
psychology
Goal oriented
Individual
Resiliency
Training
(IRT)
Cognitive
behavioral
skills
Standard IRT modules
Orientation
Assessment/initial goal setting
Psychoeducation
Processing the illness
Relapse prevention
Final goal setting
Developing resiliency
Individualized IRT modules
Dealing with
negative
feelings
Coping with
symptoms
Substance
use
Having fun
and
developing
relationships
Health and
wellness
Depression
Hallucinations,
paranoia
Smoking
cessation
Suicidal
thinking
Negative
symptoms
Minimizing
weight gain:
exercise/
nutrition
PTSD
symptoms
Depression,
anxiety
Anxiety
Supported Education and Employment (SEE)
Based on
supported
employment for
severe mental
illness
Focus on
helping client
return to school
or work
Coordination
with clinical
treatment
SEE
Ongoing supports
provided to
maintain
engagement in
school or keep job
Goals
determined by
client
preferences
Supports provided to
help client enroll/
re-enroll in school
and/or obtain work
Pharmacologic treatment needs in
First Episode Psychosis
First episode patients have better response to
antipsychotics than multi-episode patients
• Effective antipsychotic doses are lower for first
episode patients
• Despite lower medication dosing, side effects are
frequent
• The suggested sequence of medication trials differ
between first episode and multi-episode patients
•
•
e.g. PORT recommendations suggest olanzapine not be used
as a first line agent with first episode patients
How to Convey This
Information to
Busy Clinicians
at
Community Care
Settings?
COMPASS
is our answer
A computer decision support system to facilitate patient-provider
communication and medication choice within a shared decision making
framework.
A Web-Based application available on Desktops, Laptops or iPAD
Patient Visit Flow Diagram
RA Visit Flow
Patient checks in
Front desk
receptionist
notifies RA
RA enters:
•
•
•
•
Once Patient SR
Form is entered
in the computer,
patient is ready
to see doctor
New patient info
Medical History Form
Lab & Vitals
Opens Patient SR Form
Prescriber
Visit Flow
.
Doctor assesses
patient and completes
the Clinician Rating
Form online
Doctor and Patient
discuss priorities for
treatment and
exercise shared
decision making
Doctor reviews
messages from
decision support and
selects treatment
Doctor finalizes visit
on the Finishing UP
screen and completes
the visit
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
Obtaining Patient Priorities
Decision Support
Selecting Medications
Patients completed
3939
self report assessments.
Preferences About Medication
Change
Significantly decreased likelihood over time of a subject wanting to consider a
medication change
Randomized Controlled Trial (RCT)
•
RCT to compare
•
•
•
•
•
NAVIGATE – experimental intervention
Community Care – treatment as offered in local clinics
in the United States
Cluster/site randomization of 34 sites in 21 states
Two-year treatment period
Assessment model includes
•
•
On-site recruitment , engagement and retention
Remote assessors of primary and secondary clinical
outcome
Conduct the comparison in non-academic,
United States community treatment settings
ETP sites are in 21 US contiguous states
RAISE-ETP Study Design with
Cluster/Site Randomization
NAVIGATE
17 sites
n = 223
COMMUNITY
CARE
17 sites
n = 181
RAISE – ETP
n = 404
SUBJECT
INCLUSION
CRITERIA
Age 15 – 40
SCID confirmed
diagnosis
Schizophrenia
Schizophreniform disorder
Schizo-affective disorder
Brief psychotic disorder
Psychosis NOS
No more than six
months of antipsychotic medication
First episode of
psychosis
Actually taken
Addressing the Problem of
Masking Assessments
•
Rigorous RCTs demand unbiased and therefore
masked or blinded assessment
•
Masked Assessors at the site
•
•
•
Requires training of many assessors and insuring reliability
over time
Needs oversight to insure masking is maintained
Masked, remote assessors
•
•
•
•
Clinical evaluators trained to determine diagnosis and evaluate
symptoms and functional status
Insures that assessments are consistent across sites and
treatment condition
Masked to which sites are in which treatment condition and
what treatment participants are receiving
Participants are interviewed over live and secure two-way
video connection
Summary of RAISE -ETP
A novel Clinical Trial Model - Site or cluster randomization
• Client consent does not involve randomization
• Treatment is provided openly mirrors clinical reality
• Valid assessment by centralized masked clinical raters using live video
connection
Long term treatment – two years
• Delivered in United States community settings
Multi-dimensional treatment incorporating known effective
elements
• Team based
• Shared decision making
Demographics
Adjusted for cluster design
NAVIGATE
Community Care
Age (mean)
23.5
23.2
Males (%)
77.6
66.2
White (%)
65.9
49.9
African American (%)
25.4
44.1
8.7
6.0
In school (%)
14.9
25.5
Working (%)
12.6
16.6
76.2
81.6
p-value
Age and Gender
.05
Race
Other (%)
Role Functioning
Prior Hospitalization (%)
.03
.05
Baseline Diagnoses
Adjusted for cluster design
COMMUNITY CARE
NAVIGATE
Brief psychotic
disorder
0%
Brief psychotic
disorder
Psychotic
0%
Disporder NOS
11%
Psychotic
Disporder
NOS
10%
Schizophreniform
13%
Schizophreniform
18%
Schizophrenia
52%
Schizoaffective
depressive
14%
Schizoaffective
bipolar
5%
Schizoaffective
depressive
13%
Schizoaffective
bipolar
7%
Schizophrenia
57%
Have you had individual sessions with a mental
health provider who helps you work on your goals
and look positively towards the future? (%)
Months
Has your family met with a mental health
provider to help them understand and
address your situation? (%)
Months
Have you met with a person who is
helping you get a job in the community or
furthering your education? (%)
Months
Were you asked to record your symptoms and side effects
before you met with your psychiatrist or nurse practitioner?
(% among responders: 44% in CC, 65% in N)
Months
NAVIGATE Participants Stayed in Treatment Longer
Time to Last Mental Health Visit
(Difference between treatments, p=0.009)
Quality of Life Scale Fitted Model
Group by time interaction (p= 0.046)
Improvement/
6mo (SE)
Months
Cohen’s d = 0.257
Community Care
2.359 (0.473)
NAVIGATE
3.565 (0.379)
Difference
1.206 (0.606)
Percent with Any Work or School Days per Month
(Group by time interaction: p=0.044)
Months
PANSS Total Score
(At 6 months p<.01*)
Months
*Similarly significant results were found for positive symptoms, general psychiatric
symptoms, and depressive symptoms subscales of the PANSS at 6 months
Calgary Depression Scale Total
(Significant at p<.05 at 6 and 24 months)
Months
Time to First Psychiatric Hospitalization
(Difference between treatments, p=0.75)
Quality of Life Scale: Effects of Shorter vs Longer
Duration of Untreated Psychosis (DUP; p< 0.03)
80
QOLS total score
75
ES=.51
ES=.94
ES=.51
70
65
60
Commuity Care (High
DUP)
55
Navigate (Low DUP)
50
ES=.57
0
6
45
12
Months
18
Community Care (Low
DUP)
40
24
Navigate (High DUP)
High DUP:
DUP > 74 weeks
ES=effect size (Cohen’s d)
Recipients of NAVIGATE were significantly more likely to remain
in treatment and experienced significantly greater improvement in
the primary outcome measure (i.e., quality of life).
They were more likely to be working or going to school.
CONCLUSIONS
NAVIGATE participants showed a significantly greater degree of
symptom improvement during the first 6 months of treatment and
maintained those gains over time.
DUP appears to be an important moderator of NAVIGATE
effectiveness.
These results show that a coordinated specialty care model can
be implemented in a diverse range of community clinics and that
the quality of life of first episode individuals can be improved.
Acknowledgements
We are grateful to all of our core collaborators and consultants.
We thank and acknowledge the terrific work of many clinicians,
research assistants and administrators at the participating sites.
We are very grateful for the participation of the hundreds of clients and
families who made the study possible with their time, trust and
commitment.