WASHINGTON – Medical treatment of first-episode psychosis alone is a “cornerstone” intervention, but it’s not sufficient, according to a U.S. Navy psychiatrist who annually treats about 75 people with serious mental illness.
“We need coordinated, multimodal care for optimal treatment of psychosis,” said Michael C. Hann, MD, a Navy psychiatrist and a speaker during a panel on integrated care for schizophrenia at the American Psychiatric Association’s Institute on Psychiatric Services.
Dr. Michael Hann
By moving away from the standard model in the past 3 years, and instead implementing a coordinated, recovery-oriented system of care as outlined in the National Institute of Mental Health’s RAISE study (Recovery After Initial Schizophrenia Episode), Dr. Hann said the Navy has seen impressive results: In six patients seen recently, the estimated duration of psychosis – the time between prodromal symptoms and first signs of a psychotic break – was as little as 6 weeks and no more than about 9 weeks.
“That is very, very short,” Dr. Hann said. “We’re very excited about that.”
The shorter the duration between first signs of psychosis and treatment, the greater chance a person has to sustain his capacity to function in his community, and enjoy higher a quality of life, according to the NIMH’s webpage about the RAISE trial.
Located at the Navy Medical Center San Diego, the Psychiatric Transition Program treats active-duty military personnel with first-episode psychosis, and also those with bipolar I disorder. Patients in the program are treated for up to 9 or 12 months, before being medically retired from service. Rates of psychosis seen in the military mirror those in the general population – about 1%. “That’s about 300 first breaks a year,” Dr. Hann, the program’s chief resident, said in an interview. “We capture about 20% of those, which is the upper limit of what we’re capable of [caring for],” he said in his presentation, noting that the program is growing as its reputation has spread across the service branches. Dr. Hann said part of the program’s success comes from the swift referrals by military commanders who are alert to signs and symptoms of psychosis.
Other strengths Dr. Hann listed are that all necessary services – including the emergency department, inpatient psychiatric services, and the outpatient clinic – are colocated. Access to inpatient psychiatric services means medication monitoring and modifications, such as being switched to a long-acting injectable antipsychotic, is easier to manage, particularly in high-risk patients. Peer support also is available through a group home model.
The program is staffed by psychiatrists, psychiatry residents, psychiatric technicians, social workers, and nurses who function as case managers. In an interview, Dr. Hann said the program typically has 30 patients in treatment at a time, with an annual average of 75 patients. Most of the patients are on the schizophrenia spectrum, although the program also accepts referrals for bipolar I.
Dr. Jong Yoon
“Currently, there is very little coordination between military and VA-based care systems,” Dr. Yoon said during the presentation. “After [these service personnel] are medically retired, they kind of go off into the wind, and it’s unclear what happens. Our preliminary data show it’s pretty bad.” This lack of coordinated transition puts affected veterans at greater risk of homelessness and suicide, Dr. Yoon said.
Because at present, there is no systematized way for medical personnel in the Department of Defense and the VA to communicate, simple measures that would help keep this patient population stable are not achieved, said Dr. Yoon. With its intended launch in January 2017, OPTICARE is intended to be the bridge between the two systems during the peritransition period, covering the 6 months prior to medical retirement to 1 year post discharge. “None of what we’re doing is rocket science, but none of it is currently being done,” he said.
Dr. Yoon, whose work focuses on how to stabilize faulty striatal dopamine signaling at the D2 receptor to minimize the duration of untreated psychosis, said using aripiprazole to maintain steady levels of D2 blocking is effective. In addition, Dr. Yoon said, he believes that emerging evidence for the stabilizing effects on D2 blocking that long-acting injectable antipsychotics provide mean they should be used more. However, this kind of evidence-based approach to care is frustrated by quirks between the two systems, such as the absence of a shared pharmacy formulary. This can lead to a person’s antipsychotic agent being switched or even noncompliance, and the possible end result can be relapse.
Dr. Yoon also emphasizes ways he expects OPTICARE can help use psychosocial support to minimize stress for patients, since stress disrupts a steady dopamine release in the brain.
“Although schizophrenia is incredibly complex and there is so much more we don’t know, enough coherent and consistent evidence is starting to emerge that I think can provide a unifying framework that should inform treatment decisions at these levels, Dr. Yoon said.
The opinions are the speakers’ own and do not represent those of the U.S. Navy.