The first episode
Tailored, early treatment shows promise for restoring quality of life for people facing schizophrenia
Looking back, Chris Stevens (not his real name) realizes what a tough couple of years he endured before his first episode of psychosis.
After being hospitalized during an intense episode of anxiety and depression, he left college and returned to his central Minnesota hometown, moving in with his parents. He was unemployed.
Next, his grandfather passed away. Stevens moved into his grandfather’s home, in a caretaker capacity, and began delivering newspapers two days a week.
He wasn’t sleeping well, and he was feeling fairly isolated by the time the delusions started.
“I was listening to a lot of music, and I started taking [the lyrics] personally,” he recalls. “And I started believing that my brother was communicating with me by telepathy.”
One day, while home with his roommate and the roommate’s girlfriend, he mentioned reading someone’s thoughts. That was the first big red flag. They called Stevens’ parents, who were unnerved by his incoherence when they arrived. He started fixating on “a project” he wanted to start: painting his computer monitor different colors.
A few days later, at his parents’ house, Stevens became convinced that his older brother was communicating with him from afar, urging him to go swimming. He took off his clothes and jumped in the lake where they lived. It was October.
“At one point I looked back and saw that the police had come. I was able to swim back to shore, and they took me to the hospital.”
He underwent treatment for hypothermia for three days before being transferred to a Twin Cities hospital, while his parents and brother searched for a treatment program for people experiencing early psychosis.
Fortunately, he landed in one of Minnesota’s three NAVIGATE sites. NAVIGATE is a National Institute of Mental Health (NIMH) program that incorporates coordinated specialty care—individual therapy, family therapy, group therapy, pharmacological treatment, and help returning to school or work—for people who’ve experienced a first episode of psychosis.
It’s based on a growing stack of evidence showing that tailored, early intervention makes a big difference in restoring social functioning and quality of life for people who have schizophrenia.
“The goal is to reduce the duration of untreated psychosis,” says Sophia Vinogradov, M.D., head of the University of Minnesota Medical School’s Department of Psychiatry and holder of the Donald W. Hastings Endowed Chair in Psychiatry. “The longer the duration of untreated psychosis, the worse the outcome tends to be. It’s like a cancer.”
Supported by the Wells Family Trust, the University of Minnesota is on the front lines of studying and providing this treatment.
Besides administering two of the state’s three official NAVIGATE sites, the U is home to a similar Strengths Clinic that uses the same principles but serves a broader clientele, including individuals who are further out from their first episode than the one-year period defined by the NIMH. NAVIGATE participants engage intensively in the program for six months, then taper down to monthly check-ins.
“It’s a recovery- and strengths-based model, focused on [participants’] strengths, their goals, and what they want to accomplish,” says Vinogradov, who is a national authority on first episode treatment.
Her own research and clinical practice have shown that computer-based cognitive training offers great promise for people experiencing early psychosis. She works with Piper Meyer-Kalos, Ph.D., executive director of the Minnesota Center for Chemical and Mental Health and adjunct assistant professor in the Department of Psychiatry, who was key in developing the NAVIGATE model.
Similar work has been done in other developed countries for years, Meyer-Kalos says, but replicating it in the United States’ multipayer health care system has been uniquely challenging.
A difficult diagnosis
NAVIGATE participants are typically between 15 and 40 years old, with most in their mid-20s. Not everyone who’s referred to the programs ends up with a schizophrenia diagnosis, Meyer-Kalos says.
“All over the world [clinicians] struggle with the question of, ‘Does this person meet the diagnostic criteria?’ People who are experiencing psychosis for the first time don’t have a history with this; they don’t know how to describe what’s happening. And oftentimes, it’s all clouded by substance use,” she explains. “It can be tricky. Sometimes it’s about monitoring until you have more evidence.”
Scientists are still trying to untangle the respective roles of genetics and environmental factors like stress in triggering early psychosis, but they appear to be linked.
TRAINING THE BRAIN
“It’s analogous to going to the gym and doing reps,” Department of Psychiatry head Sophia Vinogradov, M.D., says of the cognitive training programs she and her team are developing for people who have schizophrenia.
Schizophrenia is closely correlated with cognitive dysfunction—impaired learning, memory, and information processing. Vinogradov’s team is working to capitalize on the brain’s plasticity and strengthen those capacities through targeted computer games and exercises.
The brain training approach requires active engagement by the patient, and it’s showing tremendous promise in improving cognition and function.
“It’s hard work,” Vinogradov says, “but [the exercises] get
these information pathways to start working correctly again.”
Among many first episode initiatives currently underway at the U is an effort to expand access to care outside the Twin Cities metro area via technology. Others include Vinogradov’s cognitive training studies; neuroimaging has shown improvements in brain function and structure among patients who undergo “brain training” (see sidebar).
And the U is pioneering interprofessional training opportunities focused on first episode treatment, furthering collaboration between medical residents and students in advanced-practice nursing, social work, pharmacy, and psychology.
Working through it together
Stevens says the 14 months since his first episode have been “unbelievably different.”
“I got a full-time job, I’m able to pay my bills, I go to the health club, I go out with my friends,” he says. “It’s been a very healthy year.”
He credits the NAVIGATE program—particularly the family engagement component and his own hard work—with putting him on “a path forward.”
His brother concurs: “The program was great for us as a family; it’s really helped us work through this together.”
And their family’s experience is not the only success story.
“It’s very exciting. People are going back to work and school,” says Meyer-Kalos. “It used to be that you got this diagnosis, and they said, ‘You’re going to have this forever; we’d better get you on disability.’ We don’t talk about disability anymore. When you say ‘schizophrenia,’ it used to send shudders down people’s spines—and it shouldn’t.”