1. Expansion of Early Psychosis Care in U.S. Community Settings
Susan T. Azrin, Ph.D.
Unit Chief, Early Psychosis Prediction and Prevention (EP3)
National Institute of Mental Health
National Association of Medicaid Directors Fall Conference
Arlington, VA
7 November 2017

2. Disclosures
I have no personal financial relationships with commercial interests relevant to this presentation
The views expressed are my own, and do not necessarily represent those of the NIH, NIMH, or the Federal Government

3. Schizophrenia Facts ~2.5 million U.S. citizens are affected
Typical onset between ages 16-30
Symptoms include altered perceptions, thinking, and disorganized behavior
Unemployment, homelessness, and incarceration are common
People with schizophrenia die 8-10 years earlier than other people

4. Early Intervention Matters
Rapid remission of positive symptoms
Lower rates of psychiatric re-hospitalization
Decreased substance use
Improved social and vocational functioning
Increased quality of life

5. Recommended Practices
Research-supported interventions
Low-dose antipsychotic medications
Cognitive and behavioral psychotherapy
Family education and support
Educational and vocational rehabilitation
Team-based, person-centered care
Shared decision-making
Strong community partnerships
Twin goals are to reduce DUP and provide EIS to promote long term recovery and reduce disability.
Bird et al. (2010). Early intervention services, cognitive-behavioral therapy and family intervention in early psychosis: systematic review. British Journal of Psychiatry, 197:

7. NIMH RAISE Research Teams
RAISE Early Treatment Program
RAISE Connection Program
John Kane
Nina Schooler
Delbert Robinson
Lisa Dixon
Jeffrey Lieberman
Susan Essock
Howard Goldman

8. Coordinated Specialty Care
Service User
Medication/ Primary Care
Cognitive Behavioral Psychotherapy
Family Education and Support
Case Management
Supported Employment and Education

9. RAISE Early Treatment Program Clinical Trial
Cluster RCT
Coordinated Specialty Care (CSC) versus TAU for FEP
34 Community clinics
21 States
404 participants with FEP
Mean age 23 years
Median duration of untreated psychosis 74 weeks

10. RAISE Findings
After 2 years, Coordinated Specialty Care was superior to usual community care on:
Quality of life
Symptom improvement
Involvement in work or school
Cost-effectiveness
CSC worked better for patients with shorter duration of untreated psychosis
Also learned that
Early intervention for FEP is feasible in U.S. community clinics with existing staff.
Patients in CSC were more likely to remain in treatment
DUP is the interval between the onset of psychotic symptoms and initiation of antipsychotic treatment
Kane JM, Robinson, DG, Schooler, NR, et al. (2016). Comprehensive versus usual community care for first episode psychosis: Two-year outcomes from the NIMH RAISE Early Treatment Program. American Journal of Psychiatry, 173(4):
Kane, Robinson, Schooler, et al., 2016

11. Average Annual Total Cost of Early Psychosis Treatment:
CSC vs. TAU over 2 years
Duration of Untreated Psychosis
Higher (≥74 weeks)
Lower (≤74 weeks)
Treatment as Usual (TAU)
$10,378
$16,320
Coordinated Specialty Care (CSC)
$16,514
$12,148
Overall, patients receiving CSC has healthcare costs that were about 27% higher than patients receiving typical care available in the community for FEP. The added expenses were for increased services and CSC training for the CSC team clinicians.
greater total
costs than CC with 26% of the increased costs attributable
to increased outpatient service costs, 36% to greater
medication costs, and 9% to additional training costs.
*Total costs (services and medication using generic antipsychotics costs plus training costs).
Rosenheck. Leslie, Sint, et al., 2016

12. Incremental Cost-Effectiveness Ratio:
Coordinated Specialty Care (CSC) vs. TAU over 2 years
The incremental cost-effectiveness ratio (ICER) was calculated as the difference in average annualized total costs divided by the difference in effectiveness (improvement in the QLS from baseline).
CSC had greater total costs than TAU, with 26% of the increased costs attributable to increased outpatient service costs, 36% to greater medication costs, and 9% to additional training costs.
Rosenheck. Leslie, Sint, et al., 2016

13. New Federal Funding Accelerates Implementation of Evidence-Based Care for First Episode Psychosis
Dates and Milestones
July, 2009
RAISE studies begin
December, 2013
RAISE feasibility study completed
January, 2014
H.R ($25M set-aside for FEP)
April, 2014
NIMH/SAMHSA provide guidance to states
December, 2014
H.R. 88 ($25M set-aside for FEP)
October, 2015
RAISE clinical trial completed
CMS coverage of FEP intervention services
December, 2015
H.R ($50M set-aside for FEP)
The science on the effectiveness and cost-effectiveness of CSC for FEP is having an immediate impact on clinical practice and setting a new standard of care in the U.S. We’re seeing a dramatic increase in the number of states offering evidence-based early psychosis care.
Mental Health Block Grant Plans:

14. Early Psychosis Intervention Network (EPINET)
Establish a national learning healthcare network among early psychosis clinics
Standardize measures of clinical characteristics, interventions, and early psychosis outcomes
Adopt a unified informatics approach to study variations in treatment quality, clinical impact, and value
Cultivate a culture of collaborative research participation in academic and community early psychosis clinics

15. Acknowledgements NIMH RAISE Team Robert Heinssen Amy Goldstein
Joanne Severe
Michaelle Scanlon

16. Thank You!