Unlike with much of mental healthcare, the RAISE project includes the patient at the center of the decision-making. Patients are typically started at a lower dose of medication and can be tapered off of meds that aren’t working.
Heinssen said that with early psychosis intervention, patients can be trusted to help make treatment decisions because their delusions haven’t yet become fixed beliefs, leaving open an opportunity for therapy and reason.
“For example, if I’m hearing voices and I think that I heard my name, maybe the first time, I get the thought, ‘I wonder if that person was following me.’ But maybe two months later, I hear the same thing and, seeing another person on the street, I think, ‘I get a really strong feeling that this person is part of a group of people who were assigned to watch and monitor me.’” he said. “Maybe the first time, my level of conviction is not high and I could let it go. If this goes on for a long time, though, I can't be talked out of this very easily. However, if it's not yet a fixed belief they might just have therapy.”
The vast majority of the patients in the RAISE program take medication, but a small percentage use only psychotherapy and interaction with social workers.
If this doesn’t sound all that revolutionary, that’s because it isn’t, really.
“All of this stuff was around, but it wasn't being done,” Insel told me. “What RAISE does is build something that’s a little bit like what we do now for diabetes. If you've had a first episode, this is the menu that's available to help, and we're prepared to provide it."
Between a nationwide study and a set of 34 pilot sites, 223 people have been through the RAISE program. In New York, the test program is being continued in the form of “On Track New York,” with roughly 30 patients at four different sites. The pilot study will report its results in a few months, but Dixon says anecdotally that they have been positive so far.
“In terms of our findings, we are in the process of completing our data analysis and have not been subjected to peer review, but we did observe marked improvements over time in employment and school participation, significantly improved vocational and social functioning, significant reductions in symptoms, and elevated rates of remission,” she said.
As with many preventive services, Insel said hammering out a reimbursement system for the RAISE interventions has been a struggle. Most insurers don’t cover its employment support or case management functions, for example. But he hopes to “make a business case” to Medicaid and other insurers by showing that participants are less frequently hospitalized than those who go untreated.
Insel hopes that eventually, though, schizophrenia can become a preventable and manageable disease, much like heart disease has in recent decades.
“We've been treating schizophrenia as a chronic disease,” Insel said. “What we did in cardiology, for example, is we tried to understand how to predict risk. That's the same game plan here.”