1. Preventing the First Episode of Psychosis
William R. McFarlane, M.D., Director,
National Program Office
Early Detection, Intervention and Prevention of Psychosis Program
Robert Wood Johnson Foundation
Maine Medical Center Research Institute
Portland, Maine
Tufts University School of Medicine

2. Early detection and prevention in another illness
“If you catch cancer at Stage 1 or 2, almost everybody lives. If you catch it at Stage 3 or 4, almost everybody dies.
We know from cervical cancer that by screening you can reduce cancer up to 70 percent.”
---Lee Hartwell, MD
Nobel Laureate, Medicine
President and Director,
Hutchinson Center
New York Times Magazine
December 4, 2005, p. 56

3. 2-3%
Proportion of youth who develop schizophrenia or a severe, psychotic mood disorder

4. 75%
Proportion of people who have one psychotic episode and schizophrenia and then develop disability

5. 12-15%
Proportion of people with schizophrenia or a psychotic mood disorder who commit suicide 5

6. Annual U.S. costs for schizophrenia
$61 billion
Annual U.S. costs for schizophrenia

7. Functioning as an effect of number of psychotic episodes

8. Portland Identification and
Early Referral
(PIER)
Reducing the incidence of major psychotic disorders in a defined population, by early detection and treatment

9. Professional and public education
Reducing stigma
Increasing understanding of early stages of mental illness and prodromal symptoms
How to get consultation, specialized assessments and treatment quickly

10. EDIPPP Team Family practitioners College health services
Mental health clinicians
Pediatricians
Military bases and recruiters
EDIPPP Team
School teachers, guidance counselors, nurses, social workers
Clergy
Emergency and crisis services
Advertising
Employers
General Public 10

11. Family-aided Assertive Community Treatment (FACT)
In-depth assessment of symptoms of risk
Rapid initiation of treatment
Psychoeducational multifamily groups
Supported employment and education
Key intensive case management methods

12. A national multisite effectiveness trial
Early Detection and Intervention for the Prevention of Psychosis (EDIPPP)
A national multisite effectiveness trial
Reducing the incidence of major psychotic disorders in a defined population, by early detection and treatment

13. Early Detection and Intervention for the Prevention of Psychosis
Effectiveness Test at six sites:
Portland, Maine
Glen Oaks and Queens, New York
Ann Arbor, Michigan
Salem, Oregon
Sacramento, California
Albuquerque, New Mexico
Large, nationally representative sample
PIER community outreach and identification systems
Sponsored by RWJF: $17 million

14. Outcomes

15. Early identification across cities
SITE
Population
Age-corrected rate**, at 25/100,000*
Years of community outreach
Maine
323,105
63% 8
Michigan
344,791
37%
Oregon
631,853
29%
2.5
California
466,488
26%
New York
557,725
17%
1.5
New Mexico
662,564
12%
Total
2,986,526
27%
*Rate for Nottingham, U.K., in Kirkbride, et al., Arch Gen Psychiatry. 2006;63:
** Proportion (69.2%) of ages population represented by ages population 15

16. Rates of psychosis and negative events Over 24 months
Low-risk
High-risk
Severe Psychosis
2.3%
6.3%
Negative Events*
22%
25%
*Hospitalizations, incarcerations, suicide attempts, assaults, rape 16

17. In school or working: Baseline and 24 months

18. First hospitalizations for psychosis Maine Urban controls areas vs
First hospitalizations for psychosis Maine Urban controls areas vs. Greater Portland
*p<0.0001

19. Annual per capita savings, 2001-2007
Savings for First Hospital Admissions for Psychosis Greater Portland vs. Urban Maine vs
Difference in incidence vs
Portland population
Average
Cases prevented
Mean LOS, days
Bed Day Rate
Annual savings, Greater Portland
Annual per capita savings,
15.9 per 100,000 population
330,000 52 11
$900
$519,453
$1.57 19

20. Fusar-Poli, et al, JAMA Psychiatry, 2013
Early intervention is prevention One year rates for conversion to psychosis
Risk reduction = 66%
23.0% %
Fusar-Poli, et al, JAMA Psychiatry, 2013

21. Outcomes in First Four California PIER Programs
Baseline
12 Month
Working
15%
49%
In school
57%
56%
Onset of Psychosis:
21% 3%
Hospitalizations:
13% 7%
Suicide attempts: 8% 2%

22. Conclusions Five cities show a declining incidence.
Community-wide education is feasible.
Referral of 30% up to 60% of the at-risk population.
Global outcome in FACT was better than regular treatment.
The rate psychosis onset is less than 1/4 of expected.
Average functioning was in the normal range by 24 months.
Five cities show a declining incidence.
Programs in California are showing same results.
¾ were in school or working up to 10 years later.

23. Conclusion
As in successes for prevention in cancer and cardiovascular disease, early identification and intervention for psychosis give us enormous opportunities to reduce the total burden of disease in the United States.

24. For further information: