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In spite of the persistent divisive rhetoric, there seems to be a developing consensus about the treatment of psychotic mental illness [schizophrenia]. The notion that the only treatment is antipsychotic medication "for life" has been laid to rest [largely through the efforts of Robert Whitaker and his colleagues at Mad in America<\/font><\/em>]. Most agree that the medication is indicated for acute psychosis, but controversy persists about maintenance [in general, independent of the advice given, the patients themselves don’t continue to take it long term]. There’s a developing consensus that ongoing care for these patients from a mental health system or provider is essential, over and beyond the issue of medication. The form of that ongoing care is unclear, and the subject of heated debate. Most hope for some way to identify these patients before a psychotic break [but worry that it will lead to overmedication]. There is a concern, mainly in the lay population, that these patients are dangerous. Likewise, there is a concern almost everywhere that chronic psychotic patients are inappropriately housed in jails and prisons. With that as an introduction, yesterday we read this in the New York Times: <\/p>\n More than two million people in the United States have a diagnosis of schizophrenia, and the treatment for most of them mainly involves strong doses of antipsychotic drugs that blunt hallucinations and delusions but can come with unbearable side effects, like severe weight gain or debilitating tremors.<\/p>\n Now, results of a landmark government-funded study call that approach into question. The findings, from by far the most rigorous trial to date conducted in the United States, concluded that schizophrenia patients who received smaller doses of antipsychotic medication and a bigger emphasis on one-on-one talk therapy and family support made greater strides in recovery over the first two years of treatment than patients who got the usual drug-focused care.<\/p>\n <\/p>\n <\/p>\n <\/span><\/ul>\n <\/span><\/ul>\n So why the long introduction? It’s because when I looked at Dr. Kane et al’s paper, I could find little relationship to the AJP paper and Benedict Carey’s New York Times article [or for that matter, any of the other media reports]. Carey had reported lower antipsychotic doses, but the paper says nothing about medications. Cary’s article mentioned one-to-one talk therapy<\/em> but I found not much about that in this report.<\/font><\/strong> What I did find first off were graphs of the answers to quality assurance questionnaires:<\/p>\n And then there was this showing some modest improvements in the NAVIGATE group [though the metrics seem odd and fairly distant from the data – statistical testing of only the treatment×time interaction???]: <\/p>\n This issue of the The study compared the efficacy of an experimental intervention, called NAVIGATE, with standard community care for people with first-episode psychosis. NAVIGATE consisted of four evidence-based interventions: personalized medication management, family psychoeducation, resilience-focused individual therapy, and supported employment and education. The component interventions were offered as a package, with the addition of a team leader who coordinated services and served as a primary point of contact for individuals and their families. The NAVIGATE programs also involved a proactive focus on engagement. In contrast to standard community care, these multiple components were offered within a shared decision-making framework and implemented according to patient preference. <\/p>\n Just as the dramatic improvements for treatment of acute lymphoblastic leukemia reflected incremental gains over time, the results for NAVIGATE take a palpable step toward markedly better outcomes for young people following first-episode psychosis. A measure of quality of life improved modestly more in the NAVIGATE group than in the standard community care group over 24 months [effect size = 0.31], and the NAVIGATE group had lower levels of symptoms as measured by the Positive and Negative Syndrome Scale [effect size = 0.29]. Participants in the NAVIGATE group stayed in treatment longer than the standard community care group [a median of 23 months compared with a median of 17 months]. In contrast to some earlier studies of first- episode psychosis , the intervention did not decrease hospitalization probably because the rates of hospitalization were relatively low in both groups [over the 2 years of treatment, 34% of the NAVIGATE group and 37% of the standard community care group were hospitalized for psychiatric indications]. <\/p>\n A landmark study into the treatment of newly diagnosed schizophrenics has found that talk therapy combined with medication can be more effective in treating symptoms than just strong doses of drugs. The findings, which emphasize the success of therapy and how unusual it is for schizophrenics to be treated with it, could help shift the way health insurers in the United States cover mental health treatment costs.<\/p>\n Researchers spent four years studying more than 200 newly diagnosed schizophrenics. Half of the subjects were treated solely with medication, while the other half received a lower-dose medication combined with individual therapy, coaching sessions in the workplace or school, and family counseling.<\/p>\n The study involved patients at 34 treatment centers in 21 states. The results, released Tuesday in the American Journal of Psychiatry<\/em>, found that individuals in the early stages of schizophrenia were better off receiving lower-doses of antipsychotics in conjunction with therapy. The National Alliance of Mental Illness (NAMI) praised the study and said it would be used as part of the organization’s push to broaden access to services for the mentally ill…<\/p>\n Quickly identifying people who have suffered a first schizophrenic episode and treating them with coordinated, sustained services sharply boosts their chances of leading productive lives, according to a major study being published Tuesday. And the treatment can be provided in a typical community mental health setting, the researchers concluded…<\/p>\n The study, called Recovery After an Initial Schizophrenia Episode (RAISE), found that people who are provided years of “coordinated specialty care” in community clinics had a greater quality of life, more involvement in work and school, and less ongoing pathology than others who received typical care.<\/p>\n Although this approach is more expensive and labor-intensive, the researchers suggest that it may be cost-effective in the long run. The approach includes psychotherapy, medication, supported employment and education, help for families of the mentally ill person, and case management. Much of the effort can be funded under insurance and government reimbursement policies, the researchers note.<\/p>\n The study confirms previous research results that the most critical element of treatment may be starting it as quickly as possible after a first psychotic episode. It found “a substantial difference” in effect for patients who began treatment less than 74 weeks after their first symptoms — the median length of time that people in the study went untreated after the onset of psychosis.<\/p>\n “Doing the right thing — and doing the right thing at the right time — that’s the key finding,” said Robert Heinssen, director of the division of services and intervention research at the National Institute of Mental Health, which funded the $25 million, six-year study. “That is guiding our efforts going forward. That has become the north star of where we’re going”…<\/p>\n But after reading and reading, I’m afraid my reaction is a bit more critical than that. I suspect that the published paper casts the study is the best possible light [or better], and that the untouched data is less glowing. The NIMH track record with naturalistic<\/font> studies isn’t so hot [as in STAR*D<\/font>]. And from what I’ve highlighted above, it’s obvious that this paper in linked to a campaign for more mental health funding [which is more than fine by me]. So to the dilemma. I support the conclusions and their implications, but am suspicious that a closer look at RAISE would raise<\/font> lots of questions. Like I said at the outset…<\/p>\n <\/p>\n\n
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