(Dec. 2, 2015) With recent mass media coverage, the NIMH’s seven-year-old Recovery After Initial Schizophrenia Episode project – RAISE, for short – has gone mainstream, not necessarily with all its details intact. In the first of two reports, Research Weekly highlights the more precise reporting in a special section on RAISE and other early-intervention services published in the July issue of Psychiatric Services.
Why RAISE?
Recognition that comprehensive and aggressive early treatment can change the trajectory and prognosis of schizophrenia and other psychotic disorders is not new. Damage to cognitive and social functioning from psychosis is known to be most dramatic in the first five years after the onset of psychosis. Thus, shortening the duration of untreated symptoms has become seen as a key to improving long-term outcomes.
In countries with unified health systems – Canada, Australia, Great Britain, Norway – collaborative, multidimensional early intervention treatment models have been widely used for decades. (Dr. E. Fuller Torrey advocated them more than 30 years ago in his groundbreaking book, Surviving Schizophrenia.) In Great Britain, for example, there is a statutory requirement for response to initial psychotic episode within two weeks; median durations of 50 days were reported in 2013. In the US, Addington et al. write in Psych Services, median duration is 74 weeks.
The goal of RAISE was to develop and test an early-intervention model that would work in “real world” of the fragmented US health system, with its thousands of community settings and multitude of payers. The NIMH funded two contracts to this end, from which emerged:
- NAVIGATE, which was tested in 34 sites in 21 states and was the subject of the widely publicized September 2015 report in The American Journal of Psychiatry.
- RAISE Connection, which was tested at two sites, one in Baltimore and one in New York City.
Unassociated with RAISE, Connecticut has operated STEP (Specialized Treatment Early in Psychosis) since 2006, which has also reported improved outcomes that are included in the special Psych Services section.
Beyond the success of established early intervention models combining therapy, family support and other treatment modalities with medication, the Affordable Care Act created a new awareness among lawmakers that the existing approach to financing care for long-term disorders was expensive. States and the federal government were beginning to consider that, if earlier intervention produced better outcomes, it might reduce taxpayer costs. Headline violence involving young adults was heightening public awareness of the “paucity of readily available, youth-friendly mental health services” in the United States.
The convergence of all these factors led to RAISE.
The Who of RAISE
RAISE was developed for and tested in a narrow population, a key feature that has been overlooked in some general reporting on its results.
Both NAVIGATE and RAISE Connection primarily targeted individuals from 15-35 years of age, when psychotic spectrum disorders such as schizophrenia and schizoaffective disorder are most likely to develop and before treatment has begun. (Individuals up to the age of 40 were accepted only if they were experiencing a first episode of psychosis.) The duration of symptoms and whether symptoms were active or stable were not determining factors, but being untreated was. Generalizing from the RAISE findings to the entire population of people with psychotic disorders, as some mass media reports have done, is a misrepresentation of the findings.
As the authors of “The NAVIGATE program for first-episode psychosis” wrote in Psychiatric Services, “People with a first episode of psychosis often encounter challenges, barriers and contradictory information about engaging with mental health services, with long delays and multiple pathways into treatment, often through the criminal justice system. When treatment is found, it is often not well suited to address the unique needs of those persons who, along with their family members, often struggle with the dual challenges of understanding the complex and confusing nature of psychosis and entering the similarly complex and often confusing mental health system.” The authors describe this moment as “the haze of mental illness and the maze of the mental health system.”
References from Psychiatric Services, 66(7), July 2015:
- Addington, J., et al. Duration of untreated psychosis in community treatment settings in the United States; pp 753-756.
- Dixon, L. B., et al. Implementing coordinated specialty care for early psychosis: The RAISE connection program; pp. 691-698.
- Essock, S. M., et al. State partnerships for first-episode psychosis service; pp 671-673.
- Mueser, K. T., et al. The NAVIGATE program for first-episode psychosis: Rationale, overview, and descriptions of psychosocial components; pp. 680-690.
Next week: How RAISE Models Cut through the Haze and the Maze
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