The show in the first episode of Pittsburgh leads to new developments in the treatment of psychosis

Current approaches to supporting people with first episode psychosis (FEP) have been made possible by the work of combined research and treatment settings over the past 30 years. A recent article published in Early Intervention in Psychiatry covers the work of a Pittsburgh-based early intervention program, Services for the Treatment of Early Psychosis (STEP), and how it has contributed to important developments in the conceptualization and treatment of early psychosis.

An interdisciplinary team of researchers from universities and medical centers on the East Coast of the United States was led by Helen Wood in STEP at the University of Pittsburgh Western Psychiatric Hospital (UPMC). The team describes how STEP integrates feedback from service users and family members into its programming:

Importantly, the researchers also valued service user dialogue and learning, including hosting innovative annual STEP conferences that incorporate client and family perspectives. Dialogue between patients, families and researchers at an initial STEP conference led to referrals for patients to receive Cognitive Enhancement Therapy (CET) for early psychosis, leading to the first study of the effectiveness of CET and the neuroplasticity benefits that mediated cognitive improvement. This also led to a multi-element approach in STEP that combines psychosocial and pharmacological interventions.

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Early intervention for psychotic symptoms has been shown to lead to better outcomes and has been receiving increasing attention over the past 3 decades in the United States and internationally. The article highlights 30 years of research and development that have taken place in a program to address early psychosis in Pittsburgh, Pennsylvania.

Research and clinical work conducted at the University of Pittsburgh and its academic medical center in the late 1990s reached similar conclusions to later research that clinics alone were not effective in reducing the duration of untreated psychosis. The combination of research and clinical work facilitated the creation of STEP and also informed other treatment programs, such as the Recovery from Initial Episode Schizophrenia (RAISE) project. The RAISE project then investigated the effectiveness of coordinated specialist care (CSC), which has now become the main approach to treating FEP in the US.

The CSC places the individual and their family at the center of recovery-oriented care, which includes professional and educational support, individual and group psychotherapy, medication management, case management, and family support.

The STEP program has adopted a CSC model and is the largest FEP clinic in the state of Pennsylvania. It provides care to people with and without insurance and serves a diverse population, including those in rural and urban areas with different socioeconomic, racial, and ethnic backgrounds. The program offers up to 5 years of treatment, while most CSC clinics offer 2 years. It also exists along a continuum of care within the UPMC health system, with services offered from support for people at high risk of developing psychosis to community treatment, crisis intervention and hospital care, among others services.

STEP has made significant contributions to how FEP is understood and treated, specifically in the domains of medication management, understanding racial and cultural differences in symptoms and recovery, clarifying diagnostic categories, integrating voices and needs of service users and their families, emphasizing interdisciplinary care and developing practice guidelines for early schizophrenia.

The authors describe the benefits one patient found from the program:

One early user of the STEP service commented that he benefited from both his own agricultural therapy (he later started a horticultural business) and family therapy through multi-family groups as he did from the pharmaceutical therapy prescribed for he

A holistic approach is taken with STEP patients, as in addition to addressing psychosis, the program also supports patients as they navigate non-psychiatric health care needs and provides assistance with things such as smoking cessation to those who are interested. In addition, while therapeutic groups are part of the program, there are opportunities for patients to participate in other thematic groups, such as those led by peer specialists, which include craft, walking and computer groups.

STEP continues to emphasize research and innovation as key aspects of its mission, and this can be seen in its recent strides during the COVID-19 pandemic to support both staff and clients, such as through implementing customer feedback to provide them with content that meets their needs. In addition, 3 decades of early psychosis studies are ongoing within the program and cover a range of topics including sleep, long-term outcomes, cultural adaptation, and neurophysiology, among other areas.

Despite positive developments, treating FEP is not without its challenges. International research has observed a decline in the quality of FEP service and has suggested that the benefits of early intervention are not usually sustained in the long term. Other concerns include high staff turnover, financial challenges, lack of clarity about what length of treatment is sufficient and the integration of service user feedback and perspectives in program implementation and design.

However, because STEP is a five-year program and part of a larger health system, clinicians and researchers have the opportunity to build a relationship with patients and continue to assess what level of support patients need throughout of time, which can provide more detailed insight into treatment scheduling and duration.

In addition, STEP has adopted a Learning Health System (LHS) philosophy, which emphasizes the need for lived experience at all levels of research and treatment. As such, people with lived experiences of psychosis are actively involved in STEP, including in roles such as leadership, research co-producers and more.

The authors conclude by discussing future directions for STEP, such as integrating early intervention with new developments in neuroscience to increase understanding and improve treatment related to how neurobiology may contribute to psychosis.

Although STEP takes a holistic approach to understanding and treating early psychosis, concerns have been raised elsewhere about the brain’s approach to conceptualizing and treating schizophrenia, as it has been shown which causes an increase in stigma, which in turn causes an increase in distress for people. people who hear voices.

Like the emphasis on lived experience in the STEP programme, the importance of integrating lived experience into mental health care continues to receive growing interest internationally and has been advocated through research, clinical practice, defense and the academic world. A recent project, Psychosis Outside the Box, co-developed by one of the authors of the current article, Nev Jones, is led by individuals with lived experiences and highlights first-person narratives of psychosis experiences.

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Wood HJ, Jones N., Eack SM, Chengappa, KNR, Prasad, KM, Kelly, C., Monstrose, D., Schooler, NR, Ganguli, R., Carter, CS, Keshavan, MS, Sarpal, DK (2024 ) ) 30+ years of STEP: The Pittsburgh experience with first-episode psychosis. Early Intervention in Psychiatry. DOI: 10.1111/eip.13536. (Link)