8 results
Relapse prevention through health technology program reduces hospitalization in schizophrenia
- Philipp Homan, Nina R. Schooler, Mary F. Brunette, Armando Rotondi, Dror Ben-Zeev, Jennifer D. Gottlieb, Kim T. Mueser, Eric D. Achtyes, Susan Gingerich, Patricia Marcy, Piper Meyer-Kalos, Marta Hauser, Majnu John, Delbert G. Robinson, John M. Kane
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- Journal:
- Psychological Medicine / Volume 53 / Issue 9 / July 2023
- Published online by Cambridge University Press:
- 30 May 2022, pp. 4114-4120
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Background
Psychiatric hospitalization is a major driver of cost in the treatment of schizophrenia. Here, we asked whether a technology-enhanced approach to relapse prevention could reduce days spent in a hospital after discharge.
MethodsThe Improving Care and Reducing Cost (ICRC) study was a quasi-experimental clinical trial in outpatients with schizophrenia conducted between 26 February 2013 and 17 April 2015 at 10 different sites in the USA in an outpatient setting. Patients were between 18 and 60 years old with a diagnosis of schizophrenia, schizoaffective disorder, or psychotic disorder not otherwise specified. Patients received usual care or a technology-enhanced relapse prevention program during a 6-month period after discharge. The health technology program included in-person, individualized relapse prevention planning with treatments delivered via smartphones and computers, as well as a web-based prescriber decision support program. The main outcome measure was days spent in a psychiatric hospital during 6 months after discharge.
ResultsThe study included 462 patients, of which 438 had complete baseline data and were thus used for propensity matching and analysis. Control participants (N = 89; 37 females) were enrolled first and received usual care for relapse prevention followed by 349 participants (128 females) who received technology-enhanced relapse prevention. During 6-month follow-up, 43% of control and 24% of intervention participants were hospitalized (χ2 = 11.76, p<0.001). Days of hospitalization were reduced by 5 days (mean days: b = −4.58, 95% CI −9.03 to −0.13, p = 0.044) in the intervention condition compared to control.
ConclusionsThese results suggest that technology-enhanced relapse prevention is an effective and feasible way to reduce rehospitalization days among patients with schizophrenia.
5 - Training US Community Mental Health Centers in Evidence-Based Coordinated Specialty Care for First Episode Psychosis
- from Part II - The Present
- Edited by Meaghan Stacy, Yale University, Connecticut, Charlie A. Davidson, Emory University, Atlanta
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- Book:
- Recovering the US Mental Healthcare System
- Published online:
- 03 March 2022
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- 24 February 2022, pp 103-127
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Summary
Building on positive research findings in Europe, Canada, and Australia over the past 30 years, the US National Institute of Mental Health (NIMH) funded two large trials of Coordinated Specialty Care (CSC) for first episode psychosis approximately 10 years ago. These studies found that participation in CSC, which includes both pharmacological and manualized psychosocial treatments, resulted in greater treatment retention, improved quality of life and work/school rates and reduced psychopathology among participants (Dixon et al., 2015; Kane et al., 2016). The authors of this chapter were intervention co-developers and trainers in the NIMH funded Recovery After an Initial Schizophrenia Episode (RAISE) national randomized controlled trial comparing CSC to customary care in 34 non-academic “real-world” community mental health clinics. The psychosocial components of the RAISE CSC intervention, entitled NAVIGATE, are manualized and available at navigateconsultants.org. The authors have now provided intensive onsite training and consultation in NAVIGATE in over 20 US states, typically to a combination of state and local community mental health agencies. In this chapter, they will present an overview of NAVIGATE and the national training effort, and then highlight both success and challenges in working to improve evidence-based first episode psychosis mental health treatment in the USA on a national and local level.
Implementation of NAVIGATE Coordinated Specialty Care for First Episode Psychosis: the Michigan Experience
- Eric D. Achtyes, Kari Kempema, Zhehui Luo, Katharine N. Thakkar, Catherine Adams, Dale D’Mello, Kellen Stilwell, Donna Tran, Patricia Marcy, Kim Mueser, Nina R. Schooler, Delbert G. Robinson, John M. Kane
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- Journal:
- CNS Spectrums / Volume 26 / Issue 2 / April 2021
- Published online by Cambridge University Press:
- 10 May 2021, pp. 177-178
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Study Objectives
Coordinated specialty care (CSC) is widely accepted as an evidence-based treatment for first episode psychosis (FEP). The NAVIGATE intervention from the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) study is a CSC intervention which offers a suite of evidence-based treatments shown to improve engagement and clinical outcomes, especially in those with shorter duration of untreated psychosis (DUP). Coincident with the publication of this study, legislation was passed by the United States Congress in 2014–15 to fund CSC for FEP via a Substance Abuse and Mental Health Services Administration (SAMHSA) block grant set-aside for each state. In Michigan (MI) the management of this grant was delegated to Network180, the community mental health authority in Kent County, with the goal of making CSC more widely available to the 10 million people in MI. Limited research describes the outcomes of implementation of CSC into community practices with no published accounts evaluating the use of the NAVIGATE intervention in a naturalistic setting. We describe the outcomes of NAVIGATE implementation in the state of MI.
MethodsIn 2014, 3 centers in MI were selected and trained to provide NAVIGATE CSC for FEP. In 2016 a 4th center was added, and 2 existing centers were expanded to provide additional access to NAVIGATE. Inclusion: age 18–31, served in 1 of 4 FEP centers in MI. Data collection began in 2015 for basic demographics, global illness (CGI q3 mo), hospital/ED use and work/school (SURF q3 mo) and was expanded in 2016 to include further demographics, diagnosis, DUP, vital signs; and in 2018 for clinical symptoms with the modified Colorado Symptom Inventory (mCSI q6 mo), reported via an online portal. This analysis used data until 12/31/19. Mixed effects models adjusted by age, sex and race were used to account for correlated data within patients.
ResultsN=283 had useable demographic information and were included in the analysis. Age at enrollment was 21.6 ± 3.0 yrs; 74.2% male; 53.4% Caucasian, 34.6% African American; 12.9 ± 1.7 yrs of education (N=195). 18 mo retention was 67% with no difference by sex or race. CGI scores decreased 20% from baseline (BL) to 18 mo (BL=3.5, N=134; 15–18 mo=2.8, N=60). Service utilization via the SURF was measured at BL (N=172) and 18 mo (N=72): psychiatric hospitalizations occurred in 37% at BL and 6% at 18 mo (p<0.01); ER visits occurred in 40% at BL and 13% at 18 mo (p<0.01). 44% were working or in school at BL and 68% at 18 mo (p<0.01). 21% were on antipsychotics (AP) at BL (N=178) and 85% at 18 mo (N=13) with 8% and 54% on long acting injectable-AP at BL and 18 mo, respectively. Limitations include missing data and lack of a control group.
ConclusionThe implementation of the NAVIGATE CSC program for FEP in MI resulted in meaningful clinical improvement for enrollees. Further support could make this evidence-based intervention available to more people with FEP.
FundingSupported by funds from the SAMHSA Medicaid State Block Grant set-aside awarded to Network180 (Achtyes, Kempema). The funders had no role in the design of the study, the analysis or the decision to publish the results.
Psychiatric Prescriber Attitudes, Experiences, and Proclivities Toward Digital Medicine and How They Influence Adoption of Digital Medicine Platforms
- Charles Ruetsch, Dawn Velligan, Delbert Robinson, Chris Jaeger, William Carpenter, Tigwa Davis, Joshua N. Liberman, Jennifer Clerie, Heidi Waters, Felicia Forma
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- Journal:
- CNS Spectrums / Volume 26 / Issue 2 / April 2021
- Published online by Cambridge University Press:
- 10 May 2021, pp. 144-145
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Background
Psychiatric prescribers typically assess adherence by patient or caregiver self-report. A new digital medicine (DM) technology provides objective data on adherence by using an ingestible event monitoring (IEM) sensor embedded within oral medication to track ingestion. Despite likely clinical benefit, adoption by prescribers will in part depend on attitudes toward and experience with digital health technology, learning style preference (LSP), and how the technology s utility and value are described.
Objectiveis to identify attitudes, experiences, and proclivities toward DM platforms that may affect adoption of the IEM platform and provide direction on tailoring educational materials to maximize adoption. Methods A survey of prescribers treating seriously mentally ill patients was conducted to assess drivers/barriers to IEM adoption. Factor analysis was performed on 13 items representing prior experience with and attitudes toward DM. Factor scores were correlated with prescriber characteristics including attitude and experience with digital technologies, LSP, and level of focus on healthcare cost.
ResultsA total of 127 prescribers (56% female, 76% physicians, mean age 48.1yrs.) completed the survey. Over 90% agreed medication adherence is important, visits allow enough time to monitor adherence (84.1%), and tailoring treatment to level of adherence would be beneficial (92.9%). The majority (65.9%) preferred relying upon outcomes data as their learning style while 15.9% preferred opinion leader recommendations and 18.3% information about how the technology would affect practice efficiency. Factor analysis revealed four dimensions: Level of comfort with EHR; Concern over current ability to monitor medication adherence; Attitudes about value of DM applications; and Benefits vs cost of DM for payers. Women scored higher on attitudes about the value of digital applications (p<0.01). Providers who perceive non-adherence as costly, and those who believe DM could benefit providers and patients scored higher on the value of DM (p<.05). Those whose LSP focuses on improving efficiency and prescribers with a higher proportion of Medicaid/ uninsured patients displayed concern about their ability to monitor adherence (p<0.05). Willingness to be a Beta Test site for DM applications was positively correlated with concern about their ability to monitor adherence and attitudes about the value of DM (p <0.01).
ConclusionsPrescriber characteristics including LSP, focus on healthcare costs, and attitudes toward DM may be related to adoption of the IEM platform. Those with more Medicaid/ uninsured patients were more concerned about ability to monitor adherence while those focused-on cost and benefit to providers and patients viewed DM as part of a solution for managing outcomes and cost. Overall, LSP, patient panel size by payer type, and focus on healthcare cost containment should be considered when developing IEM provider training materials.
FundingOtsuka Pharmaceutical Development & Commercialization, Inc.
The Treatment of Acute Agitation in Schizophrenia
- Joseph Battaglia, Delbert G. Robinson, Leslie Citrome
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- Journal:
- CNS Spectrums / Volume 12 / Issue S11 / 2007
- Published online by Cambridge University Press:
- 07 November 2014, pp. 1-16
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Acute agitation is a nonspecific term applied to an array of syndromes and behaviors. It is frequently defined as an increase in psychomotor activity, aggression, disinhibition/impulsivity, and irritable or labile mood. Etiologies of acute agitation include medical disorders, delirium, substance intoxication or withdrawal, psychiatric disorders, and medication side effects. Treatment of acute agitation requires both environmental and pharmacologic intervention. Patients should be calmed with sedating agents early in the course of treatment, allowing for diagnostic tests to take place. Failure to correctly diagnose causes of agitation may lead to delayed treatment for serious conditions, and can even exacerbate agitation.The most common cause of agitation in patients with schizophrenia is psychotic relapse due to medication nonadherence. Pharmacologic treatment options for these patients include lorazepam and antipsychotic agents. Lorazepam causes nonspecific sedation and treats some substance withdrawal, but has little effect on psychosis. First-generation antipsychotics treat psychosis and, at high enough doses, cause sedation, but may induce extrapyramidal side effects (EPS). Some second-generation antipsychotics have been approved for the treatment of agitation in schizophrenia. These agents treat psychosis with a favorable EPS profile, but are comparatively expensive and cause risks such as hypotension. However, avoiding EPS may reduce patients' resistance to antipsychotic treatment.
In this expert roundtable supplement, Joseph Battaglia, MD, provides an overview of the definition of acute agitation. Next, Delbert, G. Robinson, MD, outlines evaluation methods for actue agitation. Finally, Leslie Citrome, MD, MPH, reviews interventions for acute and ongoing management of agitation.
First-Episode Schizophrenia
- Delbert Robinson
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- Journal:
- CNS Spectrums / Volume 15 / Issue S6 / April 2010
- Published online by Cambridge University Press:
- 07 November 2014, pp. 4-7
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Clinicians treating patients with first-episode (FE) schizophrenia can draw upon the vast literature on the treatment of patients with multiple-episode schizophrenia. Studies with multi-episode patients, however, may not fully generalize to the treatment of FE patients. Studies with multi-episode patients typically recruit from hospitals or other acute care units, settings where patients usually have been either non-responsive or non-adherent to previous treatment, or mixtures of both. Studies of multi-episode patients therefore tend to include patients who are not fully responsive to treatment. Without the filter of prior treatment history, FE compared with multi-episode patients may show a broader range of treatment patterns, ranging from extremely good to very poor. Further, studies of FE patients may be very instructive about side effects, as the confounding effect of prior medication use is particularly important with side effects. Finally, data suggest that much of the deterioration (eg, more severe negative symptoms) associated with schizophrenia may occur during the 5 years following illness onset. Providing patients with better treatment at illness onset offers the hope of improving their long-term outcome.
FE studies do have limitations. Relatively few new cases of schizophrenia occur each year. The typically chronic course of schizophrenia results in a large number of patients with multi-episode schizophrenia for every FE patient at any one time. Recruitment for studies of FE schizophrenia compared with those of multi-episode schizophrenia is often more difficult given the smaller number of available patients. We systematically know less about the treatment of FE patients than we do about the treatment of multi-episode patients.
Neurocognitive profile analysis in obsessive-compulsive disorder
- KATHERINE E. BURDICK, DELBERT G. ROBINSON, ANIL K. MALHOTRA, PHILIP R. SZESZKO
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- Journal:
- Journal of the International Neuropsychological Society / Volume 14 / Issue 4 / July 2008
- Published online by Cambridge University Press:
- 25 June 2008, pp. 640-645
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Although neurocognitive deficits have been identified in obsessive-compulsive disorder (OCD), little research has focused on whether these deficits are generalized or specific to a given cognitive domain. We assessed the relative strengths and weaknesses of 26 adult patients with OCD compared to 38 age- and sex-matched healthy volunteers in domains of motor, verbal memory, visual memory, reasoning/problem solving, processing speed processing, and language. Profile analysis revealed an overall neurocognitive deficit of ½ standard deviation in OCD patients versus healthy volunteers, with relative weaknesses in motor and processing speed domains. In contrast, relative strengths were observed in language, verbal memory, and reasoning/problem solving. Our findings demonstrate neurocognitive impairment in OCD that may relate to functional outcome in this population. Findings of specific abnormalities on tasks of motor and processing speed are consistent with a hypothesized role of thalamocortical and basal ganglia regions in the pathogenesis of OCD. (JINS, 2008, 14, 640–645.)
Anterior cingulate grey-matter deficits and cannabis use in first-episode schizophrenia
- Philip R. Szeszko, Delbert G. Robinson, Serge Sevy, Sanjiv Kumra, Claudia I. Rupp, Julia D. Betensky, Todd Lencz, Manzar Ashtari, John M. Kane, Anil K. Malhotra, Handan Gunduz-Bruce, Barbara Napolitano, Robert M. Bilder
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- Journal:
- The British Journal of Psychiatry / Volume 190 / Issue 3 / March 2007
- Published online by Cambridge University Press:
- 02 January 2018, pp. 230-236
- Print publication:
- March 2007
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Background
Despite the high prevalence of cannabis use in schizophrenia, few studies have examined the potential relationship between cannabis exposure and brain structural abnormalities in schizophrenia.
AimsTo investigate prefrontal grey and white matter regions in patients experiencing a first episode of schizophrenia with an additional diagnosis of cannabis use or dependence (n=20) compared with similar patients with no cannabis use (n=31) and healthy volunteers (n=56).
MethodVolumes of the superior frontal gyrus, anterior cingulate gyrus and orbital frontal lobe were outlined manually from contiguous magnetic resonance images and automatically segmented into grey and white matter.
ResultsPatients who used cannabis had less anterior cingulate grey matter compared with both patients who did not use cannabis and healthy volunteers.
ConclusionsA defect in the anterior cingulate is associated with a history of cannabis use among patients experiencing a first episode of schizophrenia and could have a role in poor decision-making and in choosing more risky outcomes.