Early Episode Psychosis Care Around the World, and Closer to Home: Review of the Evidence Base and 

Best PracticesIrene Hurford, M.D. 

Program Director, PEACE Program, Horizon HouseAssistant Professor, Department of Psychiatry, 

University of Pennsylvania

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John

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Consequences of prolonged DUP

Early Detection• Treatment and Intervention

in Psychosis (TIPS) ‐ 10 year outcomes

• Reduced DUP from 16 wksto 5 wks

• Currently DUP in the US averages between 1‐3 years. 

• WHO guidelines recommend DUP < 3 months

Hegelstad WT et al. Am J Psychiatry 2012;169(4):374‐380 

OR 2.5

OR 0.5

OR 3.1

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Early Intervention Around the Globe

1992 TIPS Norway

1996EPPIC Australia

1998 OPUSNetherlands/IEPA 

2001UK National Health Priority

2004 WHO Guidelines

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Patrick McGorry, Australian of the Year 2010

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Countries with Early Episode Programs

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The U.S. Joins the Party!

2001PIER/EASA

2001PIER/EASA

2004CA Prop 

63

2004CA Prop 

63

2007EDIPPP2007EDIPPP

2012NIMH RAISE

2012NIMH RAISE

2013On Track 

NY

2013On Track 

NY

20145% Set‐Aside 

20145% Set‐Aside 

2016 Federal Budget doublesset‐aside to 10%

2016 Federal Budget doublesset‐aside to 10%

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Do Early Intervention Programs Work?

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Clinical Benefits

•Symptoms improve in active intensive treatment , but effects appear to dissipate after intensive treatmentdiscontinuation

OPUS 5 Year Follow‐up Data

Bertelsen M, Arch Gen Psychiatry 20089

Functional Benefits

051015202530

Year 1‐2 Year 3‐5

# of Fewer Hospitalization Days

Hospitalization Days

OPUS Trial

At 5 years:• More intervention subjects living independently• Fewer intervention subjects using supported housing

At 10 years, all intervention gains had been lost10

RAISE Connection Study

05101520253035404550

% Improvement

GAF OccupationalGAF SocialPANSS Total

Percent Improvement on Symptom and Functional Measures after 24 Months of Intervention

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RAISE Connection Study

0%

20%

40%

60%

80%

100%

BaselineSchool/Employment Rate

24 MonthSchool/Employment Rate

Rates of engagement in school or work at baseline and 24 months of intervention 

Dixon L, et al.; Psychiatric Services 2015   12

From: Comprehensive Versus Usual Community Care for First‐Episode Psychosis: 2‐Year Outcomes From the NIMH RAISE Early Treatment Program

American Journal of Psychiatry

c Treatment by square root of time interaction, p=0.016.

Copyright © American Psychiatric Association. All rights reserved.

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Coordinated Specialty Care (CSC) Elements

• Low staff to participant ratio (10:1)• Community Outreach and Engagement• Case Management• Evidence‐based psychotherapy• Family Therapy/ Family Psychoeducation• Supported Employment/Education• Evidence‐Based Psychopharmacology• Coordination with primary care and substance abuse treatment programs

Cost‐Effectiveness Data

• EPPIC Per Annum– EIP patients cost $3588 vs. $9896 for control patients

Mihalopoulos C. et al. Schiz Bull 2009 15

Cost‐Effectiveness Data• Hong Kong EASY Trial: 

– 32% less inpatient service– $14,538 vs. $19,681

Wong K K et al. Aust N Z J Psychiatry 2011;45:673-680 16

Cost‐Effectiveness Data

Hastrup L H et al. BJP 2013;202:35-41

©2013 by The Royal College of Psychiatrists

OPUS TrialTotal cost differences = $170,683 for OPUS; $205,138 for TAU (NS)

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Cost‐effectiveness of preventing first‐episode psychosis in ultra‐high‐risk subjects

Ising et al., Psychological Medicine, 2014 18

Take Home Messages 

• Early Intervention Programs– Reduce symptoms and improve functioning and quality of life during active intervention, and for ≈ 2‐3 years post‐intervention

– Are probably cost‐effective, and certainly cost‐neutral

– Have not yet proven to be disease‐modifying

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PEACEObjectives

• Significantly shorten the duration of untreated psychosis for participants from an average of 1‐3 years (nationally) to 3 months or less (WHO guidelines)

• Promote successful recovery of participants through– Symptom reduction and functional improvement– Promotion of community integration– Reducing the use of high cost acute services

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PEACE Mission

Keep people with early signs of psychosis on their normal life paths by

• Building community awareness• Offering easily accessible, effective treatment and support with a focus of resiliency and recovery

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PEACE

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PEACE

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PEACE Team

• Program Director/Psychiatrist• Program Coordinator• Resilience and Empowerment Professionals (REPs)

• Certified Peer Specialist• Occupational Therapist• Supported Employment/Supported Education Specialists

• Nurse• Fellows, Residents, Medical Students, SW Interns

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PEACE Elements

• Community Outreach and Engagement• Screening and Assessment• CBT/Case Management• Family Therapy/Multi‐Family Group Psychoeducation• Supported Employment/Education• Occupational Therapy• Certified Peer Specialist• Evidence‐Based Psychopharmacology• Coordination with inpatient services and substance abuse treatment programs

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PEACEDiagnostic Eligibility

• Experiencing, or at risk for, early psychosis (psychosis lasting one year or less from when the threshold symptoms began)

• DSM 5 psychotic spectrum disorders AND those in the prodromal (at‐risk) stage.

• age 15 and older (there is no maximum age cap)

• who have Medicaid or are MA eligible

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Early data

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Cumulative number of Referrals to PEACE

0

20

40

60

80

100

120

140

160

180

0 10 20 30 40 50

# referrals cumulative# pts cumulative

As of 4/6/16 32

Demographic DataNumber %

N 43Mean age 20Median age 20

Male 33 74

African American 34 79

White 3 7Southeast Asian 3 7

Hispanic 3 7

As of 4/1/16 33

Diagnostic CharacteristicsDiagnosis %

Schizophrenia 43

Schizoaffective D/O 18Psychosis NOS 25

Schizophreniform D/O 5

Substance Induced  7

Co‐morbid Trauma History 79As of 4/1/16

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Family Psychosocial Stressors

0%10%20%30%40%50%60%70%80%90%

Singleparentfamily

Relativewith SMI

UncertainHousing

SubstanceAbuse inParent

DHSinvolvement

81%

58%

33%26%

19%

As of 4/1/1635

Baseline and Current Substance Abuse

0%10%20%30%40%50%60%

Baseline SubstanceAbuse

Current Substance Abuse

58%

21%

Substance Abuse Among Participants

As of 4/1/1636

Hospitalizations before and since PEACE

0

10

20

30

40

50

60

# hosps in year prior toPEACE # hosps since PEACE

52

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As of 4/1/1637

Engagement in Outpatient Treatment Prior to PEACE and at PEACE

0%

20%

40%

60%

80%

100%

Engaged Prior to PEACE Engaged at PEACE

26%

93%

As of 4/1/16 38

Growth in Functional ActivitiesAges Over 18

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Enrolled inschool

AttendingSchool

Employed Engaged inSE

Any

IntakeCurrent

As of 4/1/16 39

Growth in Functional ActivitiesAges 18 and Under

0%10%20%30%40%50%60%70%80%90%100%

Enrolled inschool

AttendingSchool

Employed Engaged inSE

Any

IntakeCurrent

As of 4/1/16 40

First Episode Psychosis Programs in PA

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John

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