Implications for services and policy.

Abstract

The effectiveness of the Early Detection and Intervention for the Prevention of Psychosis Program (EDIPPP) reported by McFarlane and his colleagues is welcome news for policy makers in behavioral health services delivery circles. They will be encouraged that a multielement intervention is superior to usual care on a wide range of important outcomes, such as symptoms and functioning, and that conversion rates to psychosis are lower, as well. Policy makers will nod with appreciation that populations in 6 population areas were surveyed to identify individuals to participate in the intervention, which was implemented with fidelity in these communities. These findings are admired by policy makers, as well as scientists, because they have both internal and external validity, and they are relevant to considerations for allocating scarce resources for behavioral health services. Before continuing with our comment, we issue a warning about calling this intervention FACT, family assertive community treatment. We suggest that this is a poor choice, as the program only resembles ACT in its team structure, and the term, FACT, has been used for years to designate a “forensic” version of ACT, focused on individuals with well-established psychosis who are involved in the criminal justice system. The landscape of early intervention services is already covered with new terms with considerable overlap in their components, so this confusion will hamper understanding of the intervention and could delay adoption of a new practice. We suggest that the field refer to one term, such as Coordinated Specialty Care (CSC), and then specify the target population for the multielement intervention, first-episode of psychosis, clinical high risk, ultra-high risk, or attenuated psychosis syndrome. Whatever we decide to call these interventions, the most relevant questions for policy makers are about how to target and implement the services. The 5% supplement of the federal block grant for early intervention services will enable States to expand the implementation of CSC with a focus on first-episode care. This is the approach with the greatest evidence, and with block grant support, the greatest momentum. We believe that spread and quality monitoring should be the first priority—for services for adult mental illness, broadly, and for early intervention services, specifically. Successful implementation with fidelity, as well as adequate financing for EDIPPP-type services, will motivate policy makers and advocates to push the limits of early intervention. Paying for early intervention beyond the block grant is an urgent priority. Some components of CSC, such as psychotherapy and medications, can be covered by health insurance, whereas other elements, such as supported education and employment, cannot be covered by conventional insurance and only occasionally by Medicaid. Public behavioral health dollars, such as State and local appropriations, can fill some of the gaps, but these resources are quite limited. Funding for training and monitoring fidelity and implementation is even scarcer. Filling both of these gaps is essential to achieving access to these important services.