Coordinated Specialty Care: Paving the Way for Psychosis Recovery

SPECIAL REPORT: SCHIZOPHRENIA & PSYCHOSIS

Early intervention for psychosis shows promise in altering the outlook for individuals with schizophrenia spectrum disorder (SSD). Early intervention services for first-episode psychosis (FEP), which is typically defined as within the first 2 to 5 years of psychotic symptom onset, aim to offset psychotic symptoms and associated impairment and enhance support and skills to promote functional recovery. Availability of these services also fosters service user engagement with effective treatment early in the course of illness, thereby minimizing the duration of untreated psychosis (DUP), as longer DUP is associated with poorer long-term outcomes.

Coordinated specialty care (CSC) is a recovery-oriented, team-based, early intervention model. Because of the established effectiveness, the American Psychiatric Association Practice Guidelines recently considered CSC as the standard of care for early psychosis.¹ CSC uses a phase-specific treatment model comprising evidence-based outpatient services for FEP to improve quality of life, role functioning, symptomatology, and long-term outcomes/prognoses. While CSC programs vary, standard components include psychotherapy (typically cognitive behavior therapy for psychosis or individualized resiliency training), medication management, family services (education and support), service coordination and case management, and supported employment and education. Peer support was not initially designated as a standard component; however, many programs now consider peer specialists to be critical team members.

CSC is one of the few psychosocial treatments the US Congress has supported by dedicating national funding to ensure access to programming. In 2008, federal funds were allocated to 2 states to support 12 CSC programs. The positive results of the National Institute of Mental Health’s Recovery After an Initial Schizophrenia Episode (RAISE) initiative and subsequent increases in federal mental health block grants set aside funding for FEP contributed to a drastic rise in CSC programs nationally. As of 2023, a total of 431 CSC programs were spread across the country and available in every state, per the Substance Abuse and Mental Health Services Administration’s 2023 report. While establishing and growing CSC programming required billions of dollars in funding, most studies conclude that early intervention programs are cost-effective, given reductions in costly outcomes and services (eg, acute care) with compelling cost-related benefits.

CSC Outcomes

CSC has repeatedly yielded various treatment gains when compared with treatment as usual. Service users experience significantly improved functioning (social, occupational, and global) and quality of life, significantly reducing clinical symptoms, suicidality, and rate of hospitalizations.^2-5 CSC programs also tend to have high retention rates,^5,6 a particularly relevant outcome for individuals with SSD, as treatment disengagement is common. In addition to behavioral outcomes, CSC benefits, such as improved reward anticipation-associated activation functionality and related structures associated with positive symptoms, are also apparent using neuroimaging techniques.⁷ In line with CSC’s main aim, more significant treatment gains are associated with lower DUP and high fidelity to common elements of CSC.^2,4

Psychiatrists and other prescribers work collaboratively with other team members and service users to implement CSC with fidelity. The Table includes specific tips for CSC prescribers that are generalizable to prescribers working with FEP outside of CSC. The Schizophrenia Patient Outcomes Research Team guidelines⁸ and publicly available NAVIGATE and OnTrackNY manuals are additional sources for phase-specific psychopharmacologic recommendations.

Relative Limitations of CSC

Although most CSC participants benefit from programming while actively engaged in treatment, fewer long-term postdischarge outcome studies have been conducted. An early intervention program outside the US conducted a 10-year follow-up study and found better employment outcomes than standard care.⁹ However, 32% of the early intervention sample still represented a “poor employment” cluster. Service users who received early intervention services made more employment gains than those who received standard care. However, improvements deteriorated to the same level of functioning as standard care after 5 years. Given this, other significant improvements may fizzle over time.

Understandably, CSC treatment is time limited, with most programs offering a 2-year model. Some programs, while a minority, provide up to 3 to 5 years of treatment, and even fewer offer longer postdischarge extensions. Service users establish strong therapeutic rapport and benefit from the comprehensive nature of CSC. Meanwhile, there is a critical dearth of specialized psychiatric and psychotherapeutic services available for individuals with SSD in the community. For example, cognitive behavior therapy for psychosis (CBTp) is an evidence-based treatment that is recommended as the standard of care for individuals with SSD in the US. However, there is an incredible gap in CBTp-trained providers in the US to individuals diagnosed with SSD (approximately 11-22 providers for every 10,000 individuals with SSD).¹⁰ Similarly, other evidence-based services, such as supported employment and family services, are scarcely available. Therefore, it is unsurprising that many service users and clinicians report unreadiness for discharge and hesitation regarding follow-up services.¹¹

After discharge, service users tend to have poor follow-up with outpatient treatment, but rates are increased with more months of CSC treatment and fewer relapses before discharge.¹² Given treatment duration limitations, most service users, even after the entire duration of CSC treatment, continue to experience residual symptoms and functional impairment and are prone to relapse,¹³ similar to individuals who were not afforded CSC treatment. CSC outcomes demonstrate meaningful gains while engaged in specialty care, and all individuals with SSD should receive similar, comprehensive treatment. Therefore, the resource-intensive nature of the CSC approach must be balanced with the basic principle that effective treatment should benefit all patients.

A second limitation is that most of the initial CSC programs targeted nonaffective psychosis, and materials were developed for those experiencing symptoms consistent with emerging SSD. However, early psychosis often co-occurs with bipolar and depressive disorders. Many CSC programs have opted to include individuals with affective psychosis; however, CSC data are strongest for nonaffective psychosis, and most manuals and implementation tools have just been tested with this population.

Discussion

The widespread implementation of CSC has made outstanding strides toward improving the lives of those with psychosis. With time, more mental health providers, including the authors, wonder, “What about the rest of our clients with SSD?” Access to specialized, effective, and comprehensive treatment for individuals who did not receive CSC-based care or who have already been discharged from CSC programs is incredibly limited. Increasing the number of trained mental health clinicians working with individuals with SSD is a well-recognized requirement in pursuing this aspiration. Stimulating interest in working with SSD (perhaps by continuing to increase future clinicians’ awareness of effective treatments, counter to widely held misconceptions) and subsequent specialized training in CBTp and other evidence-based interventions, such as skills training, family services, and well-informed psychopharmacologic practices, would benefit this population.

Psychiatric rehabilitation models typically comprise several evidence-based treatments for individuals with SSD. Although effective, there remains a sizable science-to-service gap, given the scarcity of these programs in the community. As with most mental health models of care, funding/reimbursement frequently hinders implementation. As a product of CSC’s impact on mental health care, a team-based billing code was recently established to reimburse CSC-based care for FEP. Considering the widespread need, what would it take to establish a similar billing system to fund comprehensive and specialized programs for all patients with SSD (not just FEP)? While psychiatric and psychological services are often reimbursable, some of the most impactful services are rarely available or are not adequately reimbursable (eg, supported employment, family services, peer support). Also, CSC programs have variable and often strict eligibility criteria (eg, age, time since onset, insurance status), which can lead to frustration and disappointment among service users, families, and clinicians. Furthermore, many CSC programs are well under service capacity,¹⁴ so perhaps some programs could use funds for flexibility and longer-term care for those in need.

Concluding Thoughts

CSC has transformed mental health care for psychosis and recalibrated the field’s outlook on recovery. The recovery orientation and multicomponent model often meet the needs of individuals with SSD who often experience demoted autonomy with cross-domain impairment. Implementing CSC has vastly improved important outcomes for service users and frequently lessens the costly burden of high-cost mental health care. Early intervention for SSD would benefit from more long-term outcome studies to further illuminate differences in illness trajectory. Countless individuals would benefit from taking the lessons learned from CSC to apply them to mental health care for individuals past the first episode of psychosis, the majority of the population with SSD.

Dr Warner is an associate professor of psychiatry and behavioral sciences at the University of Texas Health Science Center at Houston. Dr Glynn is a research psychologist at the University of California, Los Angeles. Dr Hong is an endowed professor of psychiatry and behavioral sciences at The University of Texas Health Science Center at Houston.

References

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