Cost Utility of cognition-enhancing interventions for individuals with first-episode psychosis: a naturalistic evaluation.

BACKGROUND: Although effective treatments are available to address the cognitive deficits experienced by individuals with first-episode psychosis, provision of such treatments within Coordinated Specialty Care (CSC) programs is rare. One factor that may contribute to this is uncertainty about the cost implications of providing cognitive-enhancing treatments within the American mental healthcare system. The aim of this study is to complete a naturalistic evaluation of the cost utility of incorporating two different cognitive-enhancing interventions within an American CSC program. METHODS: Participants included 66, predominately white (75.38%), individuals with first-episode psychosis (19 women and 47 men) with a mean age of 22.71 years. Quality adjusted life years (QALYs) and cost of care were tracked among these individuals during their participation in a CSC program. These data were compared among three groups of participants during their first six months of care: (i) individuals who participated in metacognitive remediation therapy (MCR), (ii) individuals who participated in computerized cognitive remediation (CCR), and (iii) individuals who participated in no cognitive-enhancing intervention. RESULTS: Participation in MCR, but not CCR, was associated with larger gains in QALYs than participation in no cognitive-enhancing intervention within a CSC program. Moreover, data support the cost utility of MCR as compared to CCR or no-cognitive enhancing intervention within a CSC program. Conversely, CCR did not appear to be a cost-effective addition to CSC services. CONCLUSIONS: Our results highlight the potential cost utility of incorporating MCR within CSC programs for individuals with first-episode psychosis. However, given study limitations, these results should be interpreted cautiously until replicated by large, randomized controlled trials. Trial Registration ClinicalTrials.gov Identifier NCT01570972, registered April 4, 2012, Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT01570972?term=breitborde&draw=2&rank=6 .

Perceptions of smoking cessation and a novel psychosocial intervention for quitting among individuals with psychosis: A qualitative study.

Individuals diagnosed with psychosis have high rates of smoking-related morbidity and early mortality. Only a small proportion of these smokers will attempt to quit, and many existing cessation interventions have limited effectiveness. To explore the unique and potentially unmet cessation needs of individuals with psychosis, we sought first-person experiences with smoking cessation and reactions to a proposed intervention. Twenty-four smokers with psychosis participated in focus group interviews. Multiple participants reported previous quit attempts using pharmacotherapy or behavioral methods, but few indicated they had previously tried cessation counseling. Though some individuals reported modest success with cessation, most participants tended to express negative perceptions of many available cessation approaches. When informed about the development of a novel smoking cessation intervention, participants had mixed but generally positive perceptions. Smokers diagnosed with psychosis are interested in sustained, individualized delivery of cessation services as part of their broader mental health care.

Reasons for smoking and barriers to cessation among adults with serious mental illness: A qualitative study.

AIMS: Most research into reasons for smoking among adults with serious mental illness (SMI) has focused on reasons related to SMI symptoms. The current study reports reasons for smoking and barriers to cessation that are both related and unrelated to SMI symptoms among adults with SMI. METHODS: Four focus groups were conducted among current smokers receiving outpatient care for a psychotic disorder in 2017 (N = 24). Participants were asked why they currently smoke and their barriers to quitting smoking. RESULTS: Smoking as a coping mechanism and to self-medicate SMI symptoms were reasons for current smoking and barriers to cessation. Avoidance of other unhealthy behaviors, routine, and enjoyment emerged as reasons for smoking and barriers to cessation that were unrelated to mental illness. CONCLUSION: Consideration of factors that are both related and unrelated to SMI symptoms in smoking cessation interventions and brief cessation counseling may improve cessation success in this population.

An Economic Evaluation of Coordinated Specialty Care (CSC) Services for First-Episode Psychosis in the U.S. Public Sector.

BACKGROUND: Schizophrenia spectrum disorders exert a large and disproportionate economic impact. Early intervention services may be able to alleviate the burden of schizophrenia spectrum disorders on diagnosed individuals, caregivers, and society at large. Economic analyses of observational studies have supported investments in specialized team-based care for early psychosis; however, questions remain regarding the economic viability of first-episode services in the fragmented U.S. healthcare system. The clinic for Specialized Treatment Early in Psychosis (STEP) was established in 2006, to explicitly model a nationally-relevant U.S. public-sector early intervention service. The purpose of this study was to conduct an economic evaluation of STEP, a Coordinated Specialty Care service (CSC) based in a U.S. State-funded community mental health center, relative to usual treatment (UT). METHODS: Eligible patients were within 5 years of psychosis onset and had no more than 12 weeks of lifetime antipsychotic exposure. Participants were randomized to STEP or UT. The annual per-patient cost of the STEP intervention per se was estimated assuming a steady-state caseload of 30 patients. A cost-offset analysis was conducted to estimate the net value of STEP from a third-party payer perspective. Participant healthcare service utilization was evaluated at 6 months and over the entire 12 months post randomization. Generalized linear model multivariable regressions were used to estimate the effect of STEP on healthcare costs over time, and generate predicted mean costs, which were combined with the per-patient cost of STEP. RESULTS: The annual per-patient cost of STEP was $1,984. STEP participants were significantly less likely to have any inpatient or ED visits; among individuals who did use such services in a given period, the associated costs were significantly lower for STEP participants at month 12. We did not observe a similar effect with regard to other healthcare services. The predicted average total costs were lower for STEP than UT, indicating a net benefit for STEP of $1,029 at month 6 and $2,991 at month 12; however, the differences were not statistically significant. CONCLUSIONS: Our findings are promising with regard to the value of STEP to third-party payers.

The Early Psychosis Intervention Center (EPICENTER): development and six-month outcomes of an American first-episode psychosis clinical service.

BACKGROUND: There is growing evidence that specialized clinical services targeted toward individuals early in the course of a psychotic illness may be effective in reducing both the clinical and economic burden associated with these illnesses. Unfortunately, the United States has lagged behind other countries in the delivery of specialized, multi-component care to individuals early in the course of a psychotic illness. A key factor contributing to this lag is the limited available data demonstrating the clinical benefits and cost-effectiveness of early intervention for psychosis among individuals served by the American mental health system. Thus, the goal of this study is to present clinical and cost outcome data with regard to a first-episode psychosis treatment center within the American mental health system: the Early Psychosis Intervention Center (EPICENTER). METHODS: Sixty-eight consecutively enrolled individuals with first-episode psychosis completed assessments of symptomatology, social functioning, educational/vocational functioning, cognitive functioning, substance use, and service utilization upon enrollment in EPICENTER and after 6 months of EPICENTER care. All participants were provided with access to a multi-component treatment package comprised of cognitive behavioral therapy, family psychoeducation, and metacognitive remediation. RESULTS: Over the first 6 months of EPICENTER care, participants experienced improvements in symptomatology, social functioning, educational/vocational functioning, cognitive functioning, and substance abuse. The average cost of care during the first 6 months of EPICENTER participation was lower than the average cost during the 6-months prior to joining EPICENTER. These savings occurred despite the additional costs associated with the receipt of EPICENTER care and were driven primarily by reductions in the utilization of inpatient psychiatric services and contacts with the legal system. CONCLUSIONS: The results of our study suggest that multi-component interventions for first-episode psychosis provided in the US mental health system may be both clinically-beneficial and cost-effective. Although additional research is needed, these findings provide preliminary support for the growing delivery of specialized multi-component interventions for first-episode psychosis within the United States. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01570972; Date of Trial Registration: November 7, 2011.

Trajectories of suicidal risk among individuals with first-episode psychosis: Relationship to recovery and symptoms.

This study examined trajectories of suicide-risk and their relationship to symptoms, recovery, and quality of life over time. Data was obtained from the Recovery after an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) study. 404 individuals with first-episode psychosis (FEP) completed measures of suicide-risk, depression, positive symptoms, recovery, and quality of life at baseline, 6mo, 12mo, 18mo, and 24mo. Latent class analysis was used to identify temporal trajectories of suicide-risk. General linear mixed models for repeated measures were used to examine the relationship between the latent trajectories of suicide-risk and clinical variables. Results identified three latent trajectories of suicide-risk (low-risk, worsening, and improving). The low-risk and improving classes experienced improvements in depression, positive symptoms, quality of life, and recovery over time. The worsening class experienced improvements in positive symptoms and quality of life, but no change in depression or recovery. These results suggest that some individuals with FEP are at risk for persistent depression and worsening suicide-risk during treatment despite experiencing improvements in positive symptoms and quality of life. These findings have important clinical implications, as persistent depression and worsening suicide-risk might be masked by the primary focus on positive symptoms and quality of life in most FEP clinics.

Policy Complexities in Financing First Episode Psychosis Services: Implementation Realities from a Home Rule State.

Over the past decade, significant investments have been made in coordinated specialty care (CSC) models for first episode psychosis (FEP), with the goal of promoting recovery and preventing disability. CSC programs have proliferated as a result, but financing challenges imperil their growth and sustainability. In this commentary, the authors discuss (1) entrenched and emergent challenges in behavioral health policy of consequence for CSC financing; (2) implementation realities in the home rule context of Ohio, where significant variability exists across counties; and (3) recommendations to improve both care quality and access for individuals with FEP. The authors aim to provoke careful thought about policy interventions to bridge science-to-service gaps, and in this way, advance behavioral health equity.

Identification of Psychosis Risk and Diagnosis of First-Episode Psychosis: Advice for Clinicians.

Early detection of psychotic-spectrum disorders among adolescents and young adults is crucial, as the initial years after psychotic symptom onset encompass a critical period in which psychosocial and pharmacological interventions are most effective. Moreover, clinicians and researchers in recent decades have thoroughly characterized psychosis-risk syndromes, in which youth are experiencing early warning signs indicative of heightened risk for developing a psychotic disorder. These insights have created opportunities for intervention even earlier in the illness course, ideally culminating in the prevention or mitigation of psychosis onset. However, identification and diagnosis of early signs of psychosis can be complex, as clinical presentations are heterogeneous, and psychotic symptoms exist on a continuum. When a young person presents to a clinic, it may be unclear whether they are experiencing common, mild psychotic-like symptoms, early warning signs of psychosis, overt psychotic symptoms, or symptoms better accounted for by a non-psychotic disorder. Therefore, the purpose of this review is to provide a framework for clinicians, including those who treat non-psychotic disorders and those in primary care settings, for guiding identification and diagnosis of early psychosis within the presenting clinic or via referral to a specialty clinic. We first provide descriptions and examples of first-episode psychosis (FEP) and psychosis-risk syndromes, as well as assessment tools used to diagnose these conditions. Next, we provide guidance as to the differential diagnosis of conditions which have phenotypic overlap with psychotic disorders, while considering the possibility of co-occurring symptoms in which case transdiagnostic treatments are encouraged. Finally, we conclude with an overview of early detection screening and outreach campaigns, which should be further optimized to reduce the duration of untreated psychosis among youth.

Costs of Coordinated Specialty Care for First-Episode Psychosis: A Microcosting Analysis.

In this study, the authors measured and described the costs of coordinated specialty care (CSC) for first-episode psychosis in Ohio. A microcosting tool was used to estimate personnel and nonpersonnel costs of service delivery at seven CSC programs. Average annual cost per participant (N=511 participants) was estimated as $17,810 (95% CI=$9,141-$26,479). On average, 61% (95% CI=53%-69%) of annual program costs were nonbillable. Key cost drivers included facility costs, administrative tasks, and social services. Novel financing models may redress reimbursement gaps incurred by CSC programs.

Perceptions of efficacy, expressed emotion, and the course of schizophrenia: the case of emotional overinvolvement.

Although it is clear that expressed emotion (EE) is associated with the course of schizophrenia, proposed models for this association have struggled to account for the relationship between the EE index of emotional overinvolvement (EOI) and relapse. To expand our understanding of the EOI-relapse association, we first attempted to replicate the finding that the EOI-relapse association is curvilinear among 55 Mexican-Americans with schizophrenia and their caregiving relatives. Second, we evaluated whether the caregivers' perception of their ill relative's efficacy may account for the EOI-relapse association. Our results comport with past findings with regard to the curvilinear nature of the EOI-relapse association among Mexican-Americans and suggest that EOI may only seem to be a risk factor of relapse because of its strong association with a true risk factor for relapse (i.e., caregivers' perception of their ill relative's efficacy).

Discrepancies between self and caregiver perceptions of agency in first-episode psychosis.

Personal agency-a key element of recovery from psychotic disorders-is formed and maintained in large part through interactions with others. Interactions with caregivers are particularly important in first-episode psychosis (FEP), as these interactions form the foundations for lifelong caregiving relationships. The present study examined shared understandings of agency (operationalized as efficacy to manage symptoms and social behaviors) within families affected by FEP. Individuals with FEP (n = 46) completed the Self-Efficacy Scale for Schizophrenia (SESS) and measures of symptom severity, social functioning, social quality of life, stigma, and discrimination. Caregivers (n = 42) completed a caregiver version of the SESS assessing perceptions of their affected relative's self-efficacy. Self-rated efficacy was higher than caregiver-rated efficacy in all domains (positive symptoms, negative symptoms, and social behavior). Self- and caregiver-rated efficacy correlated only in the social behavior domain. Self-rated efficacy was most associated with lower depression and stigmatization, whereas caregiver-rated efficacy was most associated with better social functioning. Psychotic symptoms did not relate to self- or caregiver-rated efficacy. Individuals with FEP and caregivers have discrepant perceptions of personal agency, perhaps because they base perceptions of agency on different sources of information. These findings highlight specific targets for psychoeducation, social skills training, and assertiveness training to develop shared understandings of agency and facilitate functional recovery.

Metacognitive Skills Training and Computerized Cognitive Remediation among Individuals with First-Episode Psychosis: Influence on Social Cognition.

Background: Metacognitive skills training (MST) is often integrated into cognitive remediation programs for psychosis. Social cognition - the mental processes underlying social perception and behavior - is robustly related to outcomes in psychosis and is increasingly addressed with targeted treatments. Though metacognition and social cognition are related constructs, little is known about how MST may influence social cognition among individuals with psychosis participating in broad-based, non-social cognitive remediation. Methods: Individuals with first-episode psychosis who completed six months of metacognitive remediation (MCR; n=12) were compared to a historical control group who received six months of computerized cognition remediation (CCR; n=10) alone (ClinicalTrials.gov Identifier NCT01570972). Results: Though individuals receiving MCR experienced gains in emotion processing and theory of mind, these changes were not significantly different when compared to individuals receiving CCR. MST did not contribute to social cognitive change in the context of CCR. Discussion: Though MST may be relevant to facilitating social cognitive gains within broader cognitive remediation programs for first-episode psychosis, these benefits are limited and may not exceed those conferred by standard cognitive remediation. Opportunities for investigation of other potential mechanisms of social cognitive response to interventions remain.

Variability in suicidal ideation during treatment for individuals at clinical high risk for psychosis: The importance of repeated assessment.

AIM: Suicide risk is elevated among individuals at clinical high risk for psychosis (CHR-P). The current study examined variability in suicidal ideation during treatment for individuals at CHR-P. METHODS: A retrospective chart review was used to examine the course of suicidal ideation during 16 sessions of individual psychotherapy for 25 individuals at CHR-P. RESULTS: Suicidal ideation was reported by 24% of participants at session 1 and 16% at session 16, with minimal within-subject change in the presence of suicidal ideation across the two time points. However, a more fine-grained investigation at each session indicated that 60% of individuals at CHR-P experienced suicidal ideation at least once during treatment. Additionally, there was great variability in suicidal ideation both within and between participants over the course of the 16 sessions. CONCLUSIONS: These findings highlight the importance of repeated assessment when examining suicidal ideation as a treatment outcome for individuals at CHR-P.

Within-Person Relationship between Attenuated Positive Symptoms and Suicidal Ideation among Individuals at Clinical High Risk for Psychosis.

Individuals at clinical high-risk for psychosis (CHR-P) are at increased risk for suicide. However, the relationship between attenuated positive symptoms and suicidal ideation are not well understood, particularly as they interact over time. The current study addressed this gap in the literature. We hypothesized that greater attenuated symptoms would be concurrently and prospectively associated with suicidal ideation. Further, we hypothesized that suspiciousness and perceptual abnormalities would have the strongest relationship with suicidal ideation. Within-person variation in symptoms and suicidal ideation were examined across 24 treatment sessions for individuals at CHR-P. Attenuated positive symptoms (unusual thought content, suspiciousness, grandiose ideas, perceptual abnormalities, and disorganized communication) and suicidal ideation were assessed at each session. Logistic mixed effect models examined concurrent and time-lagged relationships between symptoms and suicidal ideation among 36 individuals at CHR-P. Results indicated that suicidal ideation was more likely during weeks when participants reported more severe total attenuated positive symptoms. Further, suspiciousness was uniquely associated with suicidal ideation, both concurrently and at the following session. Post hoc models examined the reverse direction of this relationship, demonstrating that suicidal ideation also prospectively predicted suspiciousness at the following session. These results suggest that within-person attenuated symptoms, particularly suspiciousness, are associated with suicidal ideation among individuals at CHR-P. However, the bidirectional relationship between suspiciousness and suicidal ideation raises questions about causal nature of this relationship. Further research is needed to examine the dynamic interplay of suspiciousness and suicidal ideation.

Symptomatic and Functional Outcomes Among Individuals at High Risk for Psychosis Participating in Step-Based Care.

Validated, multicomponent treatments designed to address symptoms and functioning of individuals at clinical high risk for psychosis are currently lacking. The authors report findings of a study with such individuals participating in step-based care-a program designed to provide low-intensity, non-psychosis-specific interventions and advancement to higher-intensity, psychosis-specific interventions only if an individual is not meeting criteria for a clinical response. Among individuals with symptomatic or functional concerns at enrollment, 67% met criteria for a symptomatic response (median time to response=11.1 weeks), and 64% met criteria for a functional response (median time to response=8.9 weeks).

Promoting the Success and Sustainability of Coordinated Specialty Care Teams in Ohio.

Recent COVID-19-related federal legislation has resulted in time-limited increases in Mental Health Block Grant (MHBG) set-aside dollars for coordinated specialty care (CSC) throughout the United States. The state of Ohio has opted to apply these funds to establish a learning health network of Ohio CSC teams, promote efforts to expand access to CSC, and quantify the operating costs and rates of reimbursement from private and public payers for these CSC teams. These efforts may provide other states with a model through which they can apply increased MHBG funds to support the success of their own CSC programs.

Cognition and suicide risk among individuals with first-episode psychosis: A 6-month follow-up.

Objective: There is emerging evidence that greater cognition is associated with increased risk for suicide among individuals with psychosis. Given this association, concerns have been raised that cognitive interventions might actually increase risk for suicide in this population. Therefore, the present study investigated the cross-sectional and longitudinal relationship between cognition and suicide risk among individuals with first-episode psychosis. Method: Sixty-five participants completed measures of suicide risk, depression, and cognition at baseline and 6 months. Within-subject mediation analysis was used to examine the indirect effect of cognition on suicide risk. Within-subject moderation analysis was used to examine whether participation in cognitive enhancing intervention (e.g., computerized drill-and-practice cognitive remediation and metacognitive remediation therapy) moderated changes in suicide risk. Results: Consistent with prior studies, our cross-sectional results suggest that greater cognition is associated with increased risk for suicide. However, this effect was limited in scope, as we found that verbal learning was the only cognitive domain associated with suicide risk in our sample. Results from our longitudinal analyses show that changes in depressive symptoms, but not changes verbal learning, mediate changes in suicide risk during the first 6 months of treatment. In addition, participation in cognitive enhancing interventions did not moderate changes in suicide risk. Conclusions and Implications for Practice: Our results suggest that cognition is a correlate, or a proxy risk factor, rather than a causal risk factor for suicide. Although these findings contradict previously raised concerns that cognitive interventions might unintentionally increase risk for suicide, ongoing assessment is warranted and additional research is needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Improvements in metacognition mediate the effect of metacognitive remediation therapy: A non-randomized controlled study among individuals with first-episode psychosis.

AIM: Metacognitive remediation therapy (MCR) has been shown to help individuals with first-episode psychosis experience improvements in cognition, social functioning, vocational/educational functioning and quality of life. The theoretical model underlying MCR has yet to be empirically validated. METHODS: Seventy-three individuals with first-episode psychosis completed measures of metacognition and cognition at enrollment and after 6-months of care at a specialized clinical program for individuals with first-episode psychosis. Among this group, we compared changes in these variables between the 21 individuals who opted to participate in MCR and the 52 individuals who did not participate in MCR. RESULTS: Improvements in metacognition were moderated by MCR treatment participation. Consistent with the MCR theoretical model of change, increases in metacognition mediated the relationship between treatment and longitudinal changes in cognition. CONCLUSIONS: Our findings suggest that the benefits of MCR on cognitive functioning may stem, in part, from the ability of MCR to produce improvements in metacognitive functioning.

Uncontrolled trial of specialized, multi-component care for individuals with first-episode psychosis: Effects on motivation orientations.

AIM: Deficits in motivation are present early in the course of psychotic disorders. However, growing data have highlighted important heterogeneity in motivation among individuals with psychosis, suggesting that this variable may not be a unitary concept. Outside of the psychosis literature, research on self-determination theory has identified three motivational orientations that guide the initiation and regulation of behaviour: autonomous, controlled and impersonal. Thus, our study goal is to investigate the longitudinal course of motivational orientations among individuals participating in a specialized clinical service for individuals with first-episode psychosis (ie, coordinated specialty care: CSC). METHODS: Forty-one individuals with first-episode psychosis participating in CSC completed assessments of motivation orientations at enrolment and after 6 months of care. RESULTS: Whereas there were no changes in controlled or impersonal orientations over the first 6-months of care, individuals with first-episode psychosis reported an increase in autonomous orientations. Moreover, while individuals with first-episode psychosis reported lower autonomous orientations at enrolment as compared to individuals without psychosis, after 6 months of care, ratings of autonomous orientations among individuals with first-episode psychosis were equivalent to those of individuals without psychosis. CONCLUSIONS: Although the results should be interpreted cautiously given the uncontrolled study design, the results suggest that the benefits of participation in early intervention services for psychosis may extend to improvements in motivation.

Suicidality and social problem-solving skills among individuals with first-episode psychosis participating in Coordinated Specialty Care.

AIM: Although suicidal ideation may decrease over the course of participation in specialized clinical programmes for first-episode psychosis (FEP), it is unclear whether such improvements exceed those that occur during treatment as usual. Clarifying the mechanisms underlying reductions in suicidal ideation and behaviour among individuals with first-episode psychosis may highlight important strategies through which specialized clinical programmes can increase the potency of their services to reduce suicidality among this high-risk population. Thus, the goal of this study is to evaluate the longitudinal relationships between suicidality and social problem-solving skills among individuals with FEP participating in Coordinated Specialty Care. METHODS: Within-subject mediational and moderational models were applied to explore the interrelationships and longitudinal course of suicidality, social problem-solving and duration of untreated psychosis (DUP). RESULTS: Over the first 6 months of care, individuals with FEP experienced improvements in social problem-solving skills that were found to mediate concurrent reductions in suicidality. Although longitudinal changes in social problem-solving skills were moderated by DUP, these results should be interpreted cautiously as they may stem in part from a relatively limited number of participants with longer durations of illness. CONCLUSIONS: Improvements in social problem-solving skills during participation in CSC may facilitate reductions in suicidality. Treatments targeting suicidality among individuals with FEP may thus benefit from working to enhance social problem-solving skills among these individuals. Further research is needed to clarify if and how DUP may influence the magnitude of change in social problem-solving skills during participation in CSC.