RESEARCH WEEKLY: Innovative approaches to improving schizophrenia outcomes

(Apr. 4, 2016) One of the standing criticisms about the treatment of schizophrenia and other psychotic disorders is the heavy reliance on medications, which do not address the full range of symptoms and have side effects, many of them significant.

This is not for lack of interest in the alternatives, based on projects and studies described during “Improving identification and treatment of early phase psychosis” on the opening day of the 5th Schizophrenia International Research Society Conference, underway from April 3-6, 2016, in Florence, Italy.

“Improving identification and treatment” focused on 21st-century tools and strategies that illustrate both the opportunities and obstacles to improving outcomes.

Social Media
The Internet and social media are “powerful potential tools” to enhance mental health literacy, facilitate early identification of symptoms and engage adolescents and young adults as they begin to experience psychotic symptoms, according to John Kane, MD, of Hofstra University.

Few online resources encourage potentially psychotic youth to seek professional evaluation, he said. Instead, most lead to unmonitored chat forums that lack a unified message, promote stigma and/or normalize potentially psychotic experiences. Kane described a current campaign of Facebook, Twitter and Instagram ads that have reached 10,000 college students with a screening for psychotic disorders and an opportunity to consult at no cost with a professional for those who scored positively.

“Mental health literacy is one of the biggest challenges we face in our field,” he said. “The average person knows very, very little about mental illness, particularly psychotic disorders.” Because young people experiencing early signs of psychosis typically reach out first to family or friends, he said, “clearly, we have to reach out to families and friends about how to respond.”

Social media offers a means to do so, but its translation into action remains in doubt. Of the 10,000 students reached by the campaign, he said, fewer than 1,000 have taken the screening quiz, and only one respondent has sought a consultation.

Social Marketing
Connecticut has operated a comprehensive early intervention program for psychosis for nearly a decade. Now STEP, as the program is called, is conducting a five-year study to determine whether the period between the onset of psychosis and initial treatment (the “duration of untreated psychosis” or DUP) can be reduced in a 10-town regional around New Haven by changing the route that patients follow to find their way into treatment.

Vinod Srihari, MD, of Yale University, described the project as a multi-media social marketing campaign to educate the public about mental illness and to “make a pitch” for individuals with emerging symptoms to seek help sooner through “pathways to care” advertised by the campaign.

Srihari said reaching the target audiences required using words and phrases that are “not the ones we would have chosen as clinicians.” Googling “schizophrenia” may produce accurate and detailed information about psychosis, he said, but people experiencing early signs of psychosis are more likely to search “Am I going crazy?” Or “Am I losing my mind?” Reflecting that reality, the posters designed by the project for its website and on public buses pose questions like, “Feeling paranoid?” “Seeing or hearing things?”

The effort – based in New Haven and localized to surrounding towns – can be viewed on Mindmapct.org. The project launched in February 2015 and is funded for five years.

Mobile Behavioral Modeling
Social media and social marketing are active tools that require participants to engage with them, said Dror Ben-Zeev, MD, of Dartmouth University. Dartmouth is actively at work on the potential role of mobile applications for studying, assessing, treating or preventing psychotic illness. These include person-to-person mobile applications, automated applications that are visible (e.g., appointment reminders) and automated applications that are invisible (e.g., tracking sleep).

Ben-Zeev described the capabilities of CrossCheck, a mobile application he called “a new paradigm for illness monitoring and relapse prevention in schizophrenia.” The app uses a combination of observational and self-report data to determine the participant’s “relapse signature” – the changes in patterns of movement, speech or sleep unique to a patient that may indicate the onset of psychotic symptoms. The goal is to increase the amount of time between relapses and decrease the number of relapses.

Ben-Zeev described a study in which small groups of inpatients and outpatients given smartphones responded positively to the app. He also acknowledged that privacy concerns remain to be resolved before widespread use of applications that run in the background to monitor behavior is likely.

Dartmouth describes and reports on its work on mh4mh.org.

First-Episode Intervention
Coordinated, specialized response to a first episode of psychosis has been practiced in Europe for decades and is currently being implemented across the US as “RAISE,” “NAVIGATE, “STEP” (in Connecticut) and under a variety of other names.

Christopher Correll, MD, of Hofstra University, described a review of nine randomized, controlled trials of early intervention for psychosis: five from Europe, two from the US and two from Mexico. Correll said the goal of the review was to answer “Why use coordinated, specialized care?” Compared with “care as usual,” is coordinated care more effective? Combined, the studies reported on 2,000 patients with an average age of 27 years, most of them male.

Correll said all the studies reported statistically significant “small to medium” reductions in relapse, re-hospitalization and hospital days with greater remission of symptoms and improved likelihood of being employed or in school at the end of the early-intervention treatment. But the good news came with a large caveat.

“Once you stop the intervention, the effects dwindle,” he told the audience. “The advantages seem to disappear after coordinated specialized response stopped.”

In a closing overview of the session, Robert Zipursky, MD, of McMaster University, noted that only 1% to 5% of overall functional and symptomatic outcomes likely result directly from duration of untreated psychosis. “So we have to be skeptical about whether investing in (first-episode psychosis intervention) will significantly change outcomes.”