Sonia Ruiz

Early treatment for psychotic episodes increases quality of life, making early intervention worth the extra cost, according to a recent study led by Yale researcher Robert Rosenheck.

The study, funded by the National Institute of Mental Health, and published in “Schizophrenia Bulletin” on Jan. 31, analyzes the cost effectiveness of a treatment strategy called “Coordinated Special Care,” or CSC —  programming designed for patients experiencing psychotic episodes. CSC targets patients at the onset of symptoms, providing personalized health care as early as possible. Recovery After an Initial Schizophrenia Episode, or RAISE, a program launched in 2008 by NIMH, implements these strategies and sponsors research that analyzes their effectiveness. A paper published by study director John Kane in October confirms that such programs improve patients’ overall quality of life, especially for those given treatment early in their development of psychotic symptoms. According to Michael Schoenbaum, a senior advisor at University of Washington’s AIMS center and one of the study’s authors, the Yale paper provides “supporting evidence” for the program’s successes, which will encourage health-care providers to implement these treatments, despite higher costs.

“There has been a great deal of interest internationally in whether intensive treatment early in psychotic illness can improve its long-term course,” said Rosenheck, lead author of the Yale study and a medical school professor. “The RAISE [Early Treatment Program] study is the largest U.S. test of this approach. My part of this study was to test the cost effectiveness of the intervention over a two-year period.”

CSC, described by the study as “a comprehensive, multidisciplinary, team-based treatment approach,” was evaluated against standard community care. Unlike community care, CSC provides patients with a care coordinator, a combination of medication, psychotherapy and specialized software that allows patients to pick medications. Programs such as supported employment or educational rehab help patients looking to continue work or school after diagnosis.

Over the course of two years, just over 400 individuals at 34 different mental-health centers were randomly enrolled in the two types of treatment programs. Clinicians evaluated study participants’ quality of life through a series of interviews, rating patients’ overall health on various psychiatric scales. Researchers found that CSC patients experienced greater improvements than those receiving standard care, including an increase in days of work or school attended and a reduction of psychotic symptoms. Rosenheck said this improvement justifies the 27 percent increase in health costs.

“There was a hope originally that this intervention would save money. The holy grail of health interventions is that you get better outcomes at lower costs,” Schoenbaum said. “But the more common case in health care is that you pay more and get more. For patients overall in this study, the result, on average, was that you paid a bit more and you got some more, and that the ratio [is] well within the range of things we already pay for.”

Amy Goldstein, associate study director for RAISE, said that NIMH is actively working with federal agencies to develop funding strategies for CSC programs. In 2014, Congress directed the Substance Abuse and Mental Health Services Administration to allocate 5 percent of mental-health funding to early-intervention programs. In October, a joint bulletin put out by the Center for Medicare and Medicaid Services, NIMH, and SAMHSA offered examples of how to pay for early intervention. Rosenheck said he believes that the findings in this study will encourage implementation of CSC more widely.

The trial-comparison sites were highly motivated to succeed, Rosenheck said, making his estimate of cost effectiveness cautious. The actual cost effectiveness is likely to be much greater, he added. Schoenbaum added, though, that despite the study being conducted under realistic conditions, it is important to keep in mind that this is only one study, with a small sample size. Further research that follows patients over a longer period of time will be important for confirmation of the study’s findings, he added.

Those at RAISE are still researching ways to reduce the duration of untreated psychotic episodes and access patients before they meet the diagnostic criteria for mental illness, Goldstein said. These preventative measures, combined with further research on application and sustainability of current CSC programs, will help the health-care system succeed in implementing treatment for patients with psychosis.

“We’re not tinkering with the available treatments — what we’re trying to do is improve the delivery of those treatments,” Schoenbaum said. “Our hope was that this would have lots of positive benefits; most immediately, that it would improve the lives of the patients, and also that it would be cost-saving; we hoped that it might reduce costs, or at least that if we gave people better care sooner, it would be a high-value enterprise.”

According to NIMH, the onset of schizophrenia normally occurs from ages 16 to 30.