Rehab Rounds: A Service Response to Prolonged Recovery in Early Psychosis

The Treatment Resistance Early Assessment Team (TREAT) is a consultation team that provides technical assistance to clinicians at the Early Psychosis Prevention and Intervention Centre (EPPIC)—an integrated clinical research setting that adheres to a scientist-practitioner model with a strong emphasis on professional development via supervision and training (1,2). TREAT comprises senior EPPIC clinicians with expertise and interest in biological, psychological, and social aspects of positive and negative symptoms that persist after an initial psychotic episode.

There is an attempt to maintain a pool of six clinician consultants, and departing staff are rapidly replaced. Consultation has been provided to other mental health services, including child and adolescent programs. A manual detailing the TREAT approach is available (3).

Detection of prolonged recovery

After EPPIC clients with a first psychotic episode have been registered for nine weeks, their case manager and psychiatrist receive a written query by the TREAT coordinator to determine whether positive or negative symptoms have persisted. This method appears to reliably detect those with persisting positive symptoms, as indicated by the high concordance (97 percent) between case managers using a prompt sheet and an independent rater (N=30) using a score of 4 or above on the suspiciousness, unusual thought content, conceptual disorganization, or hallucinations subscales of the expanded version of the Brief Psychiatric Rating Scale (BPRS) (4). If symptoms have not resolved by 12 weeks, the case manager and the psychiatrist discuss the individual's treatment and progress at the next weekly TREAT team meeting. TREAT also receives referrals of patients whose illness is ongoing at any time during their 18-month episode of care at EPPIC.

TREAT screened 1,388 persons with first-episode psychosis between July 1996 and December 2001—that is, most of the new patients referred to EPPIC during this period. Nine weeks after entry into treatment, 561 (40 percent) had positive symptoms; by 12 weeks 283 (20 percent) did. The mean±SD age of those with positive symptoms at 12 weeks was 21.3±3.7 years, and 67 percent were male. Demographic characteristics were similar to those of the total EPPIC cohort. Analysis of the data on a yearly basis indicates a relatively stable pattern.

Consultation and interventions

At the TREAT meeting, the case manager and the psychiatrist inform the team about the patient's situation; the focus is on the assessment, including physical investigations, and the nature and effectiveness of interventions to date. The team then reviews pharmacological, psychological, and social interventions. Pharmacological considerations include a detailed review of medication type and dosages and features of the response. The patient's perception of medications and compliance are discussed, along with complications such as side effects and facilitating factors such as family support of treatment.

Treatment principles include four components: active pursuit of effective treatment using relatively low dosages but with the readiness to increase the dosage modestly or change the drug if response is delayed beyond six weeks; an expectation of at least two adequate drug trials—equivalent to 10 mg of haloperidol, with a lower ceiling if side effects occur—within a three-month period; use of atypical agents such as risperidone and olanzapine as first-line treatment; and the early introduction of clozapine.

Psychosocial interventions include case management tasks appropriate to the phase of illness, psychoeducation, and psychological interventions aimed at promoting recovery and reducing secondary morbidity. The psychological considerations include the nature of the therapeutic relationship, the individual's explanatory model, and identification of underlying vulnerabilities and strengths (5).

Recommendations may involve areas for further assessment and use of specialized individual therapy. For example, we have developed a cognitively oriented approach to enduring positive symptoms in early psychosis called Systematic Treatment of Persisting Psychosis (STOPP) (6). It draws on the range of approaches described in the cognitive-behavioral literature and also addresses psychological issues prominent in a young person recently diagnosed with a mental illness. Key features include youth-sensitive engagement strategies; attention to developmental tasks involving the consolidation of identity, the process of separation from parents, educational and vocational goals and the construction of a peer group; and treating comorbid substance use.

Social considerations include the impact on the family and their view of the illness, the response of the person's broader social network, and social and occupational role functioning. Interventions may include increasing access to group programs, further assessment of family stress and burden, the introduction of individual family treatment or a multifamily support group, and assistance with finding suitable accommodation if the parental home is not available.

Components of family support include exploring the impact of the psychotic episode and the delayed recovery on the family system and on each individual member. Past and ongoing trauma, experiences of loss, and changes in key relationships are explored. The family is helped to understand their role in the treatment and recovery process and, when appropriate, to address family issues that may predate the onset of the psychosis. The TREAT family group incorporates psychoeducation and strategies aimed at establishing a low expressed emotion environment and improving communication and problem-solving skills.

Treatment recommendations are recorded and, as of January 1999, a rating of functioning as assessed by the Health of the Nation Outcome Scale (HoNOS) (7) is entered onto the TREAT database. A follow-up TREAT review to evaluate the effectiveness of interventions is scheduled when appropriate. If symptoms persist, longer-term planning is begun.

Evaluation of TREAT

Data from the BPRS, the Scale for the Assessment of Negative Symptoms (SANS) (8), and the Quality of Life Scale (QLS) (9) were available for 98 participants. Subjects were recruited from August 1996 over a 12-month period and assessed at four time points after their entry to EPPIC; 81 of them had been assessed at stabilization (mean=12.6 weeks) and about 12 months later, and 26 of these were TREAT clients. The TREAT group performed more poorly than the non-TREAT group at both time points on each of the measures. A repeated-measures analysis of variance showed that both groups improved significantly over time on the BPRS (F=5.8, df=1, 79, p=.018), the SANS (F=5.3, df=1, 79, p=.024), and the QLS (F=11.3, df=1, 79, p=.001), but without a significant group by time interaction, indicating that there was no differential pattern of change over time between the groups (data available from the authors).

HoNOS data collected at the initial TREAT assessment and again three to four months later (mean=15.4 weeks) was available for a second sample of 48 TREAT patients. Scores on total scales (10- and 12-item versions) and on the behavioral, symptom, and social subscales significantly decreased between the two time points. We are implementing a routine outcome assessment system that will enable case managers to readily monitor clients' progress at multiple time points over 18 months.

Case vignettes

Fiona, a 26-year-old woman who had persistent, derogatory auditory hallucinations throughout most of her waking day, did not use coping strategies outside of therapy. Although listening to music on her Walkman brought some relief, she did not use this strategy, even when she was very distressed. Over time it emerged that Fiona believed that if she resisted the voices, harm would come to her parents. This belief was gently and carefully challenged. Fiona was encouraged to be brave and take a risk. With her permission, Fiona's parents were informed and were asked to provide additional support during her first evening of trying the Walkman at home. At another point in the therapy Fiona's parents were consulted about ideas for encouraging her recovery. One thing she had enjoyed was driving. Her parents believed that she would never be able to drive again because of the poor concentration she had as a result of her positive symptoms. The therapist told the family that Fiona probably would drive again and encouraged them to get her car repaired. Fiona attended the last STOPP session driving her own car, accompanied by her proud father.

Maria was a 28-year-old married woman who had a delusional belief that she smelled bad as a result of an infestation. She believed that people avoided her because of her smell, and she was reluctant to engage in a number of previously enjoyed social activities. It was suggested that she ask three trusted people to write down three adjectives to describe how she smelled. She agreed to give it a try. All three individuals gave interesting responses—"fresh" (husband), "sexy" (sister), and "like roses" (case manager)—that left Maria surprised and a little skeptical. On hot days the therapist made a point of sitting close to Maria, telling her that she couldn't smell a thing, and would certainly sit far away, as would most people, if the truth were otherwise.

Maria also had intrusive thoughts consisting of the single words "bitch" and "bastard." These words often triggered auditory hallucinations. The therapist and Maria made an audiotape with these words repeated over and over. Maria was instructed to listen to this tape in an effort to reduce the anxiety the words aroused. She was greatly amused while making the tape, and she and the therapist had fits of laughter over it.

These vignettes demonstrate the importance of involving families in the treatment process and highlight the role of behavioral techniques such as exposure in vivo and cognitive restructuring and reframing. The first vignette illustrates that eliciting the reasons for not using coping strategies can uncover complex beliefs. Fiona's story also demonstrates how planning for future events can be important in instilling hope and how the therapist can find concrete ways to demonstrate optimism. The second vignette provides an example of why opportunities to gently challenge beliefs need to be constantly sought and how requesting input from trusted others can be useful. Additionally, the therapist's adoption of an inquisitive and persistent approach, as well as humor, can be an invaluable aid.

Conclusions

It is likely that pharmacological and psychosocial treatments effect different outcomes and that the two treatments may have complex interactions. TREAT is currently overseeing a randomized controlled trial (the Recovery Plus Study) designed to establish the relative and combined effectiveness of the early introduction of STOPP and clozapine. Consecutive first-episode patients who do not achieve a certain level of remission after the initial 12 weeks of treatment are randomly assigned to one of four groups for another 12 weeks: a group given standard antipsychotic therapy, a group given standard antipsychotic therapy and STOPP, a group given clozapine, and a group given clozapine and STOPP. All groups receive case management services. Of the 283 individuals with positive symptoms at 12 weeks identified over the past four years, 88 (31 percent) were eligible for the trial, and 47 (53 percent) of these agreed to participate; the recruitment phase of the study ended in March 2002.

TREAT was developed to assist in the early identification of people experiencing persisting positive or negative psychotic symptoms after their first or a subsequent acute episode and to facilitate assertive and systematic intervention. It provides an ongoing clinical resource for case managers and clinicians within EPPIC and in the wider health care network. The monitoring of prolonged recovery in early psychosis through mandatory, regular team review could be applicable to other mental health services.

Afterword by the column editor: One of the most valuable lessons of the TREAT demonstration is the importance of periodic audits of the quality of the treatment components offered to patients. Unless fidelity to the goals and methods of the interventions is assured, it is not possible to interpret the significance or validity of outcomes. Edwards and McGorry have written a practical handbook, aimed at mental health professionals and administrators interested in establishing early psychosis services, that outlines a framework for comprehensive program evaluation (2).

Acknowledgments

The Recovery Plus Study is supported by the Victorian Health Promotion Foundation and by Novartis. The authors acknowledge the contributions of Melanie Davern, Debbie Dick, Simone Pica, Richard Bell, Chris Pantelis, Brendan Murphy, Dianne Albiston, and Lorelle Drew in the development of the Treatment Resistance Early Assessment Team and Susy Harrigan in data analysis.

Dr. Edwards is deputy clinical director of the Mental Health Services for Kids and Youth (Youth Program), North West Mental Health Program, which includes the Early Psychosis Prevention and Intervention Centre (EPPIC), Locked Bag 10, Parkville, Victoria, 3052, Australia (e-mail, [email protected]). All of the authors are affiliated with the department of psychiatry of the University of Melbourne in Australia. Ms. Maude, Ms. Herrmann-Doig, and Ms. Wong are senior research assistants for the Recovery Plus Project, Dr. Cocks, Dr. Burnett, and Dr. Bennett are EPPIC consultant psychiatrists, Mr. Wade is the EPPIC senior psychologist, and Dr. McGorry is professor and director of Mental Health Services for Kids and Youth. Alex Kopelowicz, M.D., and Robert Paul Liberman, M.D., are editors of this column.