The MAPNET Mission

MAPNET's mission is to offer technical assistance on best practices in First Episode Psychosis treatment to service providers throughout the state. Read on to understand the history and importance of this project. 



    Psychotic disorders typically emerge in youth, have a lifetime prevalence of 3%, often lead to frequent hospitalization, and derail functioning in school, career and family. Schizophrenia (prevalence of ~1%) is among the most disabling of all medical diseases (Tandon et al., 2008; PMID 18514488). Psychotic disorders have large personal and societal costs; mental health, comorbid medical and substance abuse services cost 11.5% of overall Medicaid expenditure. Annually about 3 in 10,000 persons experience a first psychotic episode yearly. Thus, with a population of ~6,500,000 people, and roughly 20% between the ages of 16-30, .03% or 390 in this age group in Massachusetts will develop a new psychotic disorder in a given year, or roughly 1/day.  There is accumulating evidence that early identification and intervention (EI) can greatly minimize the disability caused by these illnesses and improve lives.

    Scope of the problem


    EI can substantially reduce relapse, disability and chronicity. Delays of up to 2 years are seen between the onset of psychosis and initiation of treatment (Perkins et al., 2005; PMID 16199825); such delays are associated with poor outcome (Keshavan et al 2003; PMID14989413) and disengagement from the social world and other socially and biologically maladaptive processes (e.g., weight gain, loss of work or interrupted schooling). Stigma, limited mental health training, and negative attitudes about psychiatric treatment interfere with help seeking and delay appropriate diagnoses. The “duration of untreated psychosis” (DUP) can be reduced by early referral and treatment of youth in the early stages of psychotic illness, and such reductions improve long term outcome (Hegelstad et al., 2012; PMID 22407080).

    EI may protect brain development. The brain is more “plastic” (better able to adapt) during adolescence and early adulthood. This period of development is also critical to maturation of cognitive, emotional, and social functioning. The emergence of a psychotic disorder is often associated with decline in brain structure and function, as well as deterioration (or failure of normal growth) of social, academic, and vocational functioning, as well as overall quality of life. The timing of therapeutic intervention may be critical to altering brain, cognitive, and functional outcomes and preventing long-term disability.

    EI can save lives. Suicide risk is high in early psychosis. In schizophrenia, nearly 50% of all suicides occur in the first 5 years of illness. Many attempt suicide prior to treatment. Specialized EP treatment programs decrease suicide risk (Addington et al., 2004; PMID 14725592). Substance abuse, psychosis, and mood disorders underlie such risk. The risk of violence, including homicide, in mental illnesses such as schizophrenia is highest for those with no, delayed, or inadequate treatment and comorbid substance use disorders during the initial episode, and might be mitigated with early treatment. 

    Why early intervention in psychosis?


    Approaches to EI in psychotic disorders

     

    We (Keshavan & Amirsadri, 2007; PMID 17880865) have proposed that an early psychosis integrated care (EPIC) model can substantially alter the course of illness and will become the standard of care in the coming years for adolescents and young adults age 16-30. Figure 1 shows the phases of early psychoses and these key principles: Early and evidence based; Phase-specific; Integrated longitudinally (across developmental phases) and cross-sectionally (medical, psycho-therapeutic, social aspects of care); and providing Continuity of care (EPIC). To this we add the principles of: Family focused, Individualized, Recovery-based, Shared decision making, Trauma informed and Team-based, and Developmentally oriented care.  

    Elements of EI include engaging with patient and the family, optimum psychopharmacologic treatment, and psychotherapeutic interventions tailored to the individual’s illness phase, stage and unique deficits. Treatment adherence needs to be enhanced with appropriate psychoeducation and judicious use of long-acting medications. Concomitant substance misuse, cognitive deficits and emotional difficulties need to be addressed in a timely manner using evidence-based approaches.  Integrated medical and psychiatric care and avoidance of unnecessary polypharmacy will greatly diminish the likelihood of medical comorbidity.

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    Specialized multi-element EI programs such as the Recovery After the Initial Schizophrenia Episode (RAISE, NAVIGATE New York) and STEP (New Haven , CT) programs have shownsuperiority over standard care on a broad range of outcomes, including fewer symptoms, re-hospitalizations and improved quality of life (Kane et al., 2015 [PMID 26481174]; Srihari et al 2015 [PMID 25639994]). Treatment elements in RAISE included family education, individual resiliency training, supported employment and education, and individualized medication treatment. Interventions such as cognitive-behavioral therapy (CBT) and CET also show promise in early intervention studies; effective care models may additionally include peer support, participatory decision-making and integrated medical and substance abuse services. We propose a comprehensive approach to EI in what we term a “RAISE-Plus” approach (Kline & Keshavan, 2017; see Fig. 2).   


    Our role is to support top-quality FEP care in Massachusetts

    Early intervention in psychosis prevents disability, relapse hospitalization, suicide, violence, and medical and substance use co-morbidity, but implementation remains uneven. There are no formal programs in Massachusetts (and few, if any, in the U.S.) to train providers in EI in psychoses. A cadre of well-trained professionals in Massachusetts is clearly needed to develop such services widely and implement them at all levels of care. Our technical assistance center has the knowledge and skills to train providers across the state in the RAISE-Plus model. Through our learning collaborative and workforce development program, we reach dozens of providers looking to develop skills in EI and thus have wide clinical impact across the state. Our goal is to engage each FEP program individually, while simultaneously encouraging cross-site collaboration, in a “hub-and-spokes” model (Fig. 3).