Breitborde et al.

BMC Psychiatry (2015) 15:266

DOI 10.1186/s12888-015-0650-3

RESEARCH ARTICLE Open Access

The Early Psychosis Intervention Center

(EPICENTER): development and six-month
outcomes of an American first-episode
psychosis clinical service
Nicholas J. K. Breitborde1,2*, Emily K. Bell2, David Dawley2, Cindy Woolverton3, Alan Ceaser2,4, Allison C. Waters2,5,
Spencer C. Dawson3, Andrew W. Bismark6, Angelina J. Polsinelli3, Lisa Bartolomeo2, Jessica Simmons7,
Beth Bernstein2 and Patricia Harrison-Monroe2

Abstract
Background: There is growing evidence that specialized clinical services targeted toward individuals early in the
course of a psychotic illness may be effective in reducing both the clinical and economic burden associated with
these illnesses. Unfortunately, the United States has lagged behind other countries in the delivery of specialized,
multi-component care to individuals early in the course of a psychotic illness. A key factor contributing to this lag
is the limited available data demonstrating the clinical benefits and cost-effectiveness of early intervention for
psychosis among individuals served by the American mental health system. Thus, the goal of this study is to present
clinical and cost outcome data with regard to a first-episode psychosis treatment center within the American mental
health system: the Early Psychosis Intervention Center (EPICENTER).
Methods: Sixty-eight consecutively enrolled individuals with first-episode psychosis completed assessments of
symptomatology, social functioning, educational/vocational functioning, cognitive functioning, substance use,
and service utilization upon enrollment in EPICENTER and after 6 months of EPICENTER care. All participants were
provided with access to a multi-component treatment package comprised of cognitive behavioral therapy, family
psychoeducation, and metacognitive remediation.
Results: Over the first 6 months of EPICENTER care, participants experienced improvements in symptomatology,
social functioning, educational/vocational functioning, cognitive functioning, and substance abuse. The average
cost of care during the first 6 months of EPICENTER participation was lower than the average cost during the 6-months
prior to joining EPICENTER. These savings occurred despite the additional costs associated with the receipt of
EPICENTER care and were driven primarily by reductions in the utilization of inpatient psychiatric services and
contacts with the legal system.
Conclusions: The results of our study suggest that multi-component interventions for first-episode psychosis provided
in the US mental health system may be both clinically-beneficial and cost-effective. Although additional research is
needed, these findings provide preliminary support for the growing delivery of specialized multi-component
interventions for first-episode psychosis within the United States.
(Continued on next page)

* Correspondence: [email protected]
1
Department of Psychiatry and Behavioral Health, The Ohio State University,
Columbus, Ohio, USA
2
Department of Psychiatry, The University of Arizona, Tucson, Arizona, USA
Full list of author information is available at the end of the article

© 2015 Breitborde et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
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Breitborde et al. BMC Psychiatry (2015) 15:266 Page 2 of 11

(Continued from previous page)

Trial registration: ClinicalTrials.gov Identifier: NCT01570972; Date of Trial Registration: November 7, 2011
Keywords: First-episode psychosis, Treatment, Cognitive behavioral therapy, Family psychoeducation, Cognitive
remediation, Cost-effectiveness

Background first 6 months of EPICENTER care. The purpose of this

Psychotic disorders exert a significant burden under activity is to quantify the possible clinical and economic
current systems of care worldwide. Despite advances in benefits associated with EPICENTER participation.
the treatment of these disorders, individuals with psych-
osis typically experience a course of illness characterized Methods
by repeated relapses of psychotic symptoms [1], persist- Human subject research completed as part of this pro-
ent unemployment [2], limited social relationships [3], ject was approved by the University of Arizona Institu-
and premature mortality [4]. Not surprisingly, the cost tional Review Board (Project Numbers 09-1113-02 and
of care for psychotic disorders is astronomical. For ex- 10-0440-02) and was completed in compliance with the
ample, within the United States, the cost of care in 2002 Helsinki Declaration.
for a single psychotic disorder (i.e., schizophrenia) was
nearly 63 billion dollars [5], suggesting that in 2015 the Participants
cost will exceed $81 billion dollars after adjusting for Participants in this study were the first 68 individuals
inflation [6]. with first-episode psychosis consecutively enrolled at
There is growing evidence that specialized clinical ser- EPICENTER. Eligibility criteria for EPICENTER in-
vices targeted toward individuals early in the course of a clude: diagnosis of a schizophrenia-spectrum disorder
psychotic illness may be effective in reducing both the or affective disorder with psychotic features as deter-
clinical and economic burden associated with these ill- mined using the Structured Clinical Interview for the
nesses [7–11]. The success of these early intervention ser- DSM-IV-TR [20]; onset of psychotic symptoms within
vices has sparked significant health services reform the past 5 years per the Symptom Onset in Schizophre-
worldwide, including the establishment of a national early nia Inventory [21]; ages 15–35; and no evidence of
intervention service network in the United Kingdom [12] mental retardation or organic brain impairment as evi-
and the funding of a similar national care system by the denced by a premorbid IQ greater than 70 as estimated
federal government of Australia [13]. using the Reading subtest of the Wide Range Achieve-
Unfortunately, the United States has lagged behind ment Test [22]. Among the current sample, there were
other countries in the delivery of specialized, multi- 49 men and 19 women with an average age of 22.71 years.
component care to individuals early in the course of a The median duration of time since the onset of psychotic
psychotic illness [14]. A key factor contributing to this symptoms was 16.76 months. The distribution of psych-
lag is the limited available data demonstrating the clin- otic disorder diagnoses is summarized in Fig. 1. Seventy-
ical benefits and cost-effectiveness of early interven- eight percent were prescribed antipsychotic medication
tion for psychosis among individuals served by the prior to enrollment in EPICENTER, and none had previ-
American mental health system ([14, 15], however, see ously participated in evidence-based psychosocial treat-
[11, 16, 17]). Consequently, there is a clear need for ment for psychosis.
additional systematic evaluations of multi-component During the time in which these 68 individuals were
treatment packages for individuals with first-episode consecutively enrolled in EPICENTER, a total of 264
psychosis in the United States. individuals were referred to this clinical service. Forty-
Thus, the goal of this manuscript is twofold. First, we seven of these referred individuals were excluded from
will review the process of developing a multi-component participation due to being younger than 15 years (n =
treatment program for individuals with first-episode psych- 17), not having psychosis (n = 12), having a first onset
osis within the American mental health system: the Early of psychotic symptoms > 5 years prior (n = 10), being
Psychosis Intervention Center (EPICENTER: [18, 19]). older than 35 years (n = 4), having an estimated pre-
Established in 2010 within the Department of Psychiatry at morbid IQ < 70 (n = 2), having psychosis resulting from
the University of Arizona, this program serves a catchment a general medical condition (n = 1), and having attenu-
area of approximately 1 million individuals in the south- ated psychotic symptoms that did not meet DSM-IV
west United States. Second, we will review clinical and cost criteria for a psychotic disorder (n = 1). An additional
data among EPICENTER participants during the 6 months 149 were referred to the study but declined to partici-
prior to joining EPICENTER as compared to during the pate in the eligibility assessment.
Breitborde et al. BMC Psychiatry (2015) 15:266 Page 3 of 11

Brief Psychotic Delusional Disorder Schizophreniform

Major Depressive Episode 2% Disorder
Disorder with 2% 2%
Psychotic Features
6%

Schizoaffective
Disorder Bipolar Disorder with
13% Psychotic Features
33%

Psychosis NOS
14%

Schizophrenia
28%

Fig. 1 Distribution of Psychotic Disorder Diagnoses among EPICENTER Participants

Written informed consent with regard to study partici- item questionnaire assesses six domains of social function-
pation was obtained from all adult subjects. For partici- ing: social engagement/withdrawal; interpersonal behavior/
pants under the age of 18, written informed consent was communication; participation in prosocial activities; partici-
obtained from the participant’s parent or guardian and pation in recreational activities; independence-competence;
written assent was obtained from the participant. and independence-performance. Each domain is scored
such that higher scores are indicative of better functioning.
Procedures A total social functioning score was calculated by summing
Individuals with first-episode psychosis completed the mea- all SFS subscales into a single variable.
sures described below as part of a larger research battery de- The SFS also provides data with regard to participants’
signed to investigate mediators and moderators of treatment level of educational/vocational functioning on a 0–10
response among individuals with first-episode psychosis scale ranging from no perceived capability to work and
[19, 23]. All measures were administered upon enrollment no active efforts to find a job (0) to participation in full
in EPICENTER and after 6 months of participation in time work/school (10). Consistent with past analyses of
EPICENTER services. When possible, assessments were educational/vocational functioning among individuals
administered by blinded researchers. However, in some in- with first-episode psychosis using the SFS [17], these
stances, baseline assessments (i.e., assessments completed scores were transformed into a dichotomous categorical
prior to the start of EPICENTER care) were completed by variable defined as employed/in school (i.e., part-time or
EPICENTER clinical staff due to staffing limitations. greater participation in competitive work/school) versus
unemployed/not in school.
Measures
Symptomatology Cognitive functioning
Severity of psychotic symptoms was assessed using the The MATRICS Consensus Cognitive Battery (MCCB:
Positive and Negative Syndrome Scale (PANSS: [24]). The [26]) was utilized to assess cognitive functioning among
PANSS is a 30-item clinician-rated scale that assesses three study participants. This battery assesses seven domains
domains of symptomatology: positive symptoms, negative of cognitive functioning: (i) processing speed; (ii) atten-
symptoms, and general symptoms. Items are rated such tion/vigilance; (iii) working memory; (iv) verbal learning;
that higher scores are indicative of worse symptomatology. (v) visual learning; (vi) reasoning and problem-solving;
and (vii) social cognition. An overall index of cognitive
Social and educational/vocational functioning functioning is also computed. Scores are reported as T-
The Social Functioning Scale (SFS: [25]) was used to meas- scores with higher scores indicative of greater cognitive
ure social functioning among study participants. This 79- functioning. The MATRICS offers alternate versions of
Breitborde et al. BMC Psychiatry (2015) 15:266 Page 4 of 11

tests used to assess verbal learning and reasoning and Antipsychotic medication use was assessed using the
problem-solving to reduce the effect of practice on results current medication form—a measure used in past stud-
from trials in which these measures are administered mul- ies of first-episode psychosis [32, 33]. Antipsychotic
tiple times. We utilized these alternate forms in the current medications were converted to chlorpromazine equiva-
study and the order in which original and alternate forms lents using the conversion values developed by Leucht
were administered was counterbalanced across participants. and colleagues [34] and Woods [35]. Costs for anti-
psychotic medication used by EPICENTER participants
Substance use were calculated using 2015 prices for non-generic anti-
The severity of participants’ substance use was assessed psychotic medication.
using the Alcohol Use Scale/Drug Use Scale (AUS/DUS: Costs for EPICENTER services were calculated using
[27]). The AUS/DUS is a clinician-rated scale that assesses salary and benefits cost data for EPICENTER clinical
use of 12 substances: tobacco, alcohol, marijuana/THC, staff and indirect cost estimates from the hospital
cocaine, opiates, phencyclidine (PCP), amphetamines, 3,4- where the program is located. Similar to a previous
methylenedioxy-N-methylamphetamine (MDMA), gama- cost-effectiveness evaluation of clinical services for
hydroxy butarate (GHB) or flunitrazepam (Rohypnol), first-episode psychosis [9], costs for non-EPICENTER
huffing of glue or other volatiles, hallucinogens, and other outpatient mental health services were calculated by
substances of abuse not otherwise specified. Severity of multiplying the number of such services by the hourly
participants’ use is rated on a 5-point scale based on rate for a mental health counselor as reported in the
DSM-IV-TR criteria for severity of use: (1) abstinent; (2) 2013 National Occupational Employment and Wage
use without impairment; (3) abuse; (4) dependence; and Estimates for the United States [36]. Indirect costs for
(5) dependence with institutionalization. Based on these non-EPICENTER outpatient mental health services
ratings, participants’ were assigned an overall substance were calculated using the same indirect rates used for
use score using the same 5-point scale. This overall score EPICENTER outpatient mental health services. All cost
was calculated as the highest severity ranking earned by a estimates were adjusted to 2015 values to correct for
participant across all 12 substance categories. inflation.

Service utilization and cost-effectiveness Multi-component intervention

The Service Utilization and Resources Form for Schizo- The components of the EPICENTER intervention pack-
phrenia (SURF: [28]) was used to assess participants’ age were selected following a series of meetings with
utilization of psychiatric and legal resources. With re- mental health stakeholders in our local community.
gard to psychiatric resources, we tracked participants’ Stakeholders included administrators and practitioners
use of EPICENTER services as well as non-EPICENTER in the public and private mental health systems, mem-
outpatient mental health services that participants may bers of local advocacy groups, and individuals with a
have chosen to utilize during study participation (e.g., mental illness. In these meetings, stakeholders identified
case management, medication management, etc.). Cost access to evidence-based psychosocial interventions as
outcomes for EPICENTER participants were calcu- the key treatment need of individuals with first-episode
lated using cost estimates associated with inpatient psychosis in our community. Stakeholders verified that
hospitalization in Arizona [29] and contact with the the need for psychiatric medication was successfully ad-
legal system [30]. Data with regard to financial sup- dressed by existing resources in our community. This
port provided by family members was assessed directly information is consistent with existing data on access to
in the SURF. Costs associated with unemployment and evidence-based psychosocial interventions [37–39] and
non-participation in competitive education among young antipsychotic medication [37, 39] published by other
adults were obtained from a recent report from the Cor- research groups in the United States.
poration for National and Community Service and the Thus, to avoid duplication of existing services, we
White House Council for Community Solutions [31] and limited the components of the EPICENTER multi-
included costs associated with lost wages, poor health, component treatment package solely to evidence-based
and contact with the legal system as well as savings associ- psychosocial interventions for psychosis that were
ated with reduced use of government subsidies designed otherwise unavailable in our community. All partici-
to support participation in higher education. Given that pants interested in receiving antipsychotic medication
we already obtained estimates of costs associated with were able to do so through community providers not
contact with the legal system elsewhere, these costs were affiliated with the study. Selection of components of
not included when calculating the total costs associated this treatment package was determined based on the a
with unemployment and non-participation in competitive priori goals to (i) balance the need to address the psy-
education. chiatric symptomatology and functional deficits (e.g.,
Breitborde et al. BMC Psychiatry (2015) 15:266 Page 5 of 11

cognitive functioning deficits) that are part of the core Family Psychoeducation (FP)
pathology of psychotic disorders with the goal of pro- Family psychoeducation is an evidence-based treatment
viding the least time-intensive intervention package for for psychotic disorders [45]. The FP intervention utilized
individuals with psychosis [40, 41]; (ii) incorporate in- at EPICENTER [67] was based on the protocol developed
terventions that could be applied with fidelity while by McFarlane and colleagues [45] and was modified to ad-
simultaneously being flexible enough to be responsive to dress the uniques strengths and challenges of individuals
the varying needs of EPICENTER participants [42, 43]; with first-episode psychosis. This intervention involves
(iii) address the unique gaps in treatment experienced two modules: (i) joining, (ii) family problem-solving ses-
by individuals with psychosis in our catchment area sions. During the joining module, caregiving relatives meet
(i.e., limited access to evidence-based psychosocial in- individually with a clinician for one to three sessions to
terventions); and (iv) be delivered effectively given the discuss the patient’s clinical history, the family’s experi-
available staffing resources which ranged from approxi- ence and understanding of their relative’s illness, and
mately 0.5 to 1.0 full-time positions during the course family members’ concerns and questions with regard to
of the study. The resulting intervention package was participating in a multifamily group. Following the
comprised of three components: cognitive behavioral completion of the joining module, families and their ill
therapy, family psychoeducation, and cognitive remedi- relatives have the option to participate in regular family
ation. Evidence from the study of each respective com- problem-solving sessions (2× per month). During the
ponent suggests that this combined treatment package problem-solving sessions, caregivers and ill relatives iden-
may address both the symptomatology [44–47] and tify challenges or problems occurring in their life and
functional deficits [48–50] common among individuals evaluate possible solutions to these problems through a
with psychotic disorders. To increase the flexibility of structured problem-solving activity. Of note, the family
this intervention package, we selected interventions problem-solving sessions, which are the primary compo-
that could be delivered individually or in group format. nent of this FP intervention, are delivered in either a mul-
Staffing limitations precluded the inclusion of certain tifamily group or single family format [68] depending on
evidence-based treatments (e.g., supported employment the preference of the family.
and education) for which a dedicated full-time staff
member is recommended [51, 52]. Metacognitive Remediation (MCR)
Upon enrollment in EPICENTER, participants were pro- Cognitive remediation, which is recognized as a “best
vided with education with regard to the different elements practice” in the treatment of psychotic disorders [69, 70],
of the multi-component intervention package. Participants is typically comprised of a series of repeated exercises de-
were then allowed to choose which interventions they livered by a clinician or via a computer that are designed
would complete during their care at EPICENTER. to improve cognitive functioning.
At EPICENTER, participants received metacognitive
Cognitive Behavioral Therapy (CBT) remediation (MCR: [71, 72])—a form of cognitive re-
CBT is an evidence-based treatment for individuals mediation shown to improve numerous domains of cog-
with psychotic disorders [53] with demonstrated effi- nitive functioning among individuals with first-episode
cacy in both individual [54] and group formats [55]. Of psychosis, including processing speed, attention/vigi-
note, though, a recent meta-analysis published after the lance, working memory, verbal learning, visual learning,
launch of EPICENTER has called into question the effi- reasoning and problem-solving, and social cognition
cacy of this intervention for individuals with psychosis [71]. MCR involves participation in both computerized
[56]. At EPICENTER we have opted to provide CBT in cognitive remediation exercises and metacognitive skills
both an individual and group format. In both formats, development exercises with a clinician. With regard to
we utilize well-established strategies for addressing the the former, participants were provided with the comput-
positive and negative symptoms that accompany psych- erized CR program PSSCogRehab [73]—a program fre-
otic disorders [57–59] as well as the other sequelae that quently used in past studies of cognitive remediation in
accompany psychotic disorders, including anxiety [46], psychotic disorders [74–80]. This program provides par-
insomnia [60], post-traumatic stress disorder [61, 62], ticipants with training in four areas of cognitive function-
substance use [63], and deficits in social and vocational ing: cognitive foundations (e.g., attention and processing
functioning [64–66]. The focus of the intervention is speed), visual-spatial abilities, memory, and problem-
tailored to the specific needs and motivation of the in- solving abilities. Participants initially complete simple
dividual with first-episode psychosis such that EPICEN- tasks in each domain and, once mastered, gradually pro-
TER participants, in collaboration with their therapist, gress to more difficult tasks. Following each attempt to
identify the specific therapeutic targets to address in complete a PSSCogRehab exercise, individuals with first-
CBT sessions. episode psychosis participate in a “metacognitive
Breitborde et al. BMC Psychiatry (2015) 15:266 Page 6 of 11

discussion” with a clinician designed to promote metacog- Table 1 Rates of participation in EPICENTER interventions
nitive skills development and facilitate transfer of Intervention Rate of Participation n(%)
knowledge/skills developed during the MCR session to Cognitive Behavioral Therapy—Individual 47(61 %)
real-world situations. Of note, not all EPICENTER par- Cognitive Behavioral Therapy—Group 30(39 %)
ticipants were able to complete MCR during the first 6
Family Psychoeducation—Individual 17(22 %)
months of EPICENTER care due to their participation
in another study in which they were randomized not to Family Psychoeducation—Group 34(44 %)
receive this intervention during the first 6 months of Metacognitive Remediation 19(25 %)
care [81]. In addition, the first 10 EPICENTER partici-
pants to receive cognitive remediation did so before the compared to group CBT (39 %: t = 3.72; p < 0.01). Con-
development of MCR, and so completed the same versely, families were more likely to participate in multifam-
PSSCogRehab tasks but did not participate in metacog- ily (i.e., group) psychoeducation (44 %) as compared to
nitive discussions as described above. individual family psychoeducation (22 %: t = 4.38; p < 0.01).

Statistical analyses Symptomatology

All data were analyzed following the intention to treat Baseline and 6-month follow-up scores for PANSS are
principle [82]. Consistent with current statistical guide- presented in Table 2. Over the first 6 month of care, par-
lines [83, 84], missing data were addressed using mul- ticipants experienced reduction in both positive (t = −3.93;
tiple imputation [85, 86]. To facilitate the completion of p < 0.01) and general symptoms (t = −4.48; p < 0.01). There
these analyses, change scores were calculated for con-
tinuous variables by subtracting baseline assessment
values from 6-month assessment values. These values Table 2 Symptomatology, social functioning, cognition, and
were then analyzed using t-tests. For the investigation of substance use at baseline and after 6 months of epicenter care
within-subject change in categorical variables, t-values Baseline Six Months
were calculated using effect sizes and standard errors PANSS
combined using Rubin’s rule [86, 87]. As degrees of free- 1) Positive Symptoms 15.53 13.03*
dom calculated using standard metrics for t-tests are 2) Negative Symptoms 15.07 13.52
overly liberal in the analysis of multiply imputed data, 3) General Symptoms 30.41 26.29*
we adjusted the degrees of freedom for our analyses
SFS
using the formula develop by Barnard and Rubin [88].
Participants who completed both the baseline and 6- 1) Social Engagement 9.77 9.78
month assessments did not differ from those who only 2) Interpersonal Communication 6.60 7.22
completed baseline assessments with regard to symp- 3) Prosocial Activities 15.44 18.77
tomatology, cognitive functioning, and most domains of 4) Recreation 18.32 20.37
substance use and social functioning. Individuals who 5) Independence-Competence 33.93 36.07*
did not complete the 6-month assessment reported
6) Independence–Performance 22.85 25.47
higher use of marijuana and lower use of tobacco at
baseline compared to individuals who completed both MCCB
the baseline and 6-month assessment. Additionally, indi- 1) Processing Speed 35.39 41.29*
viduals who did not complete the 6-month assessment 2) Attention/Vigilance 36.83 38.85
reported better interpersonal communication and com- 3) Working Memory 40.11 46.59
petence with regard to the completion of independent 4) Verbal Learning 40.02 43.98*
tasks of daily living as assessed by the SFS as compared
5) Visual Learning 38.07 44.89
to individuals who completed both the baseline and 6-
month assessment. 6) Reasoning and Problem-Solving 40.00 43.85
7) Social Cognition 42.33 49.86
Results 8) Overall Cognitive Composite 32.9 40.16*
Intervention participation AUS/DUS
Rates of participation in EPICENTER interventions are 1) Overall Substance Use 2.53 1.95*
summarized in Table 1. Among all interventions, individ-
2) Alcohol 1.98 1.64*
ual CBT was the most utilized intervention with 61 % of
individuals with first-episode psychosis participating in 3) Marijuana 1.76 1.39*
this intervention. Individuals with first-episode psychosis 4) Tobacco 1.79 1.81
were more likely to participate in individual CBT as *p < 0.05 as compared to value for baseline assessment
Breitborde et al. BMC Psychiatry (2015) 15:266 Page 7 of 11

was no change in severity of negative symptoms from participated in an average of 14.94 EPICENTER-related
baseline to 6-month assessment (t = −1.59; p = 0.13). outpatient mental health visits during the first 6 months
of EPICENTER care. The number of episodes of in-
Social and educational/vocational functioning patient psychiatric hospitalization (t = −3.29; p < 0.01),
Baseline and 6-month follow-up scores for the SFS sub- nights of inpatient hospitalization (t = −2.54; p = 0.01),
scales are presented in Table 2. Overall, there was an and contacts with the legal system (t = −2.11; p < 0.04)
increase in total social functioning over the first 6 were lower in the first 6 months of EPICENTER care as
months of EPICENTER care (total SFS M = 108.08 vs. compared to the 6 month period prior to the start of
118.92; t = 3.08; p = 0.02). With regard to SFS subscales, EPICENTER care. Conversely, there was a near signifi-
the independence-competence subscale increased over cant increase in the number of non-EPICENTER out-
the first 6 months of EPICENTER care (t = 2.73; p = 0.03), patient mental health visits during the first 6 months of
indicating that participants perceived themselves as more EPICENTER care (t = 2.18; p = 0.07). Although anti-
competent in the independent completion of tasks of daily psychotic medication dose declined from the baseline to
living. There was no statistically significant change in any 6-month assessment, this change did not meet criteria for
other SFS subscale from baseline to 6-month assessment. statistical significance (t = −0.99; p = 0.34). Daily doses of
Participation in competitive employment/education in- antipsychotic medication (chlorpromazine equivalents)
creased over the first 6 months of EPICENTER care. would be considered low (i.e., ≤400 mg) at baseline and
More specifically, the percentage of participants engaged after 6 months of EPICENTER care [90].
in part-time or greater work/school increased from 38 % Per person cost of services are presented in Fig. 2.
at baseline to 49 % after 6 months of EPICENTER care The cost of services received by individuals during the
(t = 5.98; p < 0.01). 6-month period prior to the start of EPICENTER care
(M = $43,456) was greater than the cost of services dur-
Cognitive functioning ing the first 6 months of EPICENTER care (M = $26,355;
Baseline and 6-month follow-up scores for the MCCB t = −3.00; p < 0.01). Care elements contributing to this cost
are depicted in Table 2. There was a statistically signifi- savings included reductions in costs associated with
cant increase in the overall composite cognition score inpatient hospitalizations ($27,480 vs. $10,367; t = −3.24;
for individuals participating in EPICENTER care (t = p < 0.01) and contact with the legal system ($8,604 vs.
3.14; p = 0.03). With regard to the individual MCCB $3,169; t = −2.10; p = 0.04). There was a near significant
subscales, there were statistically significant improve- increase in the costs associated with non-EPICENTER
ments in verbal learning (t = 2.54; p = 0.01) and process- outpatient mental health services during the first 6
ing speed from baseline to 6-month assessment (t = months of EPICENTER care ($477 vs. $854; t = 2.16; p =
5.05; p < 0.01). There was also a trend suggesting pos- 0.07). There was no change in costs associated with finan-
sible improvements in visual learning from baseline to cial support provided by family members, cost of anti-
6-month assessment (t = 2.03; p = 0.08). Of note, the psychotic medications, or costs associated with being
magnitude of these improvements exceed changes that unemployed and not in school.
would be expected due to repeated administration of The per person cost of providing EPICENTER care to
the MCCB alone (i.e., practice effects [89]). study participants was $6,136. Dividing the difference of
the total costs for the pre-EPICENTER and EPICENTER
Substance use treatment periods ($17,101) by this value reveals that for
Baseline and 6-month follow-up scores for the AUS/ every $1 spent on EPICENTER care, $2.79 dollars were
DUS are presented in Table 2. Participants’ overall sub- saved during the first 6 months of treatment.
stance use declined from baseline to 6-month follow-up
(t = −5.55; p = 0.01). Among our sample, the three most Discussion
frequently used substances at baseline were alcohol The results of the current report highlight the potential
(63 %), tobacco (53 %), and marijuana (48 %). Although clinical effectiveness of a multi-component psycho-
participants’ use of alcohol (t = −2.34; p = 0.03) and social intervention package for first-episode psychosis.
marijuana (t = −3.16; p < 0.01) both declined from base- On average, individuals participating in EPICENTER
line to 6-month assessment, there was no change in par- care showed improvements in symptomatology, social
ticipants’ use of tobacco during the first 6 months of functioning, educational/vocational functioning, cogni-
EPICENTER care (t = 0.18; p = 0.86). tive functioning, and substance use during the first 6
months of treatment. These improvements occurred
Service utilization and cost-effectiveness despite the fact that, on average, participants (i) were
Service utilization for EPICENTER participants is summa- already taking antipsychotic medication prior to study
rized in Table 3. Individuals with first-episode psychosis enrollment and (ii) did not experience an increase in
Breitborde et al. BMC Psychiatry (2015) 15:266 Page 8 of 11

Table 3 Service utilization during 6-month period prior to epicenter care versus during first 6 months of epicenter care
6-Month Period Prior to EPICENTER Care First 6 Months of EPICENTER Care
Outpatient Mental Health Visits (Non-EPICENTER) M = 14.59 M = 26.13
Outpatient Mental Health Visits (EPICENTER) N/A M = 14.94
Antipsychotic Medication (chlorpromazine equivalent) M = 331.74 mg M = 288.72 mg
Inpatient Hospitalization (Number of Episodes) M = 0.88 M = 0.33*
Inpatient Hospitalizations (Number of Days) M = 13.18 M = 4.80*
Contact with the Legal System (Number of Episodes) M = 2.00 M = 0.73*
*p < 0.05 as compared to value for 6 month period prior to EPICENTER care

antipsychotic medication dose during the course of the Moreover, with the exception of the social cognition sub-
study. In total, these results add to the growing literature scale, performance on the remaining subscales remained
with regard the potency of psychosocial interventions– 0.5–1.0 standard deviations below the norm for individ-
and multi-component psychosocial intervention pack- uals without psychotic disorders (i.e., T = 50) following 6
ages–provided early in the course of a psychotic disorder months of EPICENTER care. In total, these data highlight
[45, 91, 92]. the need for continued investigations of intervention strat-
Yet, at the same time, care should be taken to avoid egies with which to further improve clinical and functional
overly-enthusiastic views of the clinical benefits of the outcomes among individuals with first-episode psychosis.
EPICENTER intervention package. Certain key out- With regard to service utilization and cost of care,
comes among our participants (i.e., tobacco use and the data are more encouraging. More specifically, the
severity of negative symptoms) did not improve over the average cost of care during the first 6 months of EPI-
first 6-months of EPICENTER care. Likewise, although CENTER participation was lower than the average cost
we found improvements in global measures of social and during the 6 months prior to joining EPICENTER.
cognitive functioning among individuals with first-episode These savings occurred despite the additional costs as-
psychosis, analysis of the subcomponents of these global sociated with the receipt of EPICENTER care and were
measures suggests a more conservative interpretation. For driven primarily by reductions in the utilization of in-
example, among the six subcomponents of social func- patient psychiatric services and contacts with the legal
tioning used to calculate an overall score for the Social system. These savings are especially valuable given the
Functioning Scale, only one subscale increased signifi- high cost of care of individuals with first-episode psych-
cantly over the first 6 months of EPICENTER care (i.e., osis. More specifically, the per person 12-month cost of
independence-competence). Likewise, only two of seven care among our sample of individuals with first-episode
subcomponents used to calculate the overall cognitive psychosis was $69,810—a cost value noticeably greater
functioning score for the MATRICS Consensus Cognitive than that reported in other cost of care studies that did
Battery increased during the first 6 months of EPICEN- not limit their sample to individuals early in the course
TER care (i.e., verbal learning and processing speed). of their psychotic illness [5, 93, 94].

$50,000

$45,000 Family Support

$40,000
Unemployed/Not in School
$35,000

$30,000 Contact with Legal System

$25,000
Inpatient Mental Health
$20,000

$15,000 Antipsychotic Medication

$10,000
Non-EPICENTER Outpatient
$5,000 Mental Health

$0 EPICENTER Costs
Six Months Prior to First Six Months of
EPICENTER EPICENTER Care

p < 0.05
Fig. 2 Per Person Service Costs During 6-Month Period Prior to EPICENTER Care versus First 6 Months of EPICENTER Care
Breitborde et al. BMC Psychiatry (2015) 15:266 Page 9 of 11

Despite the focus of the current investigation on psy- Abbreviations

chosocial treatments, it is important not to overlook the AUS/DUS: Alcohol Use Scale/Drug Use Scale; CBT: Cognitive Behavioral
Therapy; DSM-IV-TR: Siagnostic and Statistical Manual IV-Text Revised;
importance of pharmacological interventions in the EPICENTER: Early Psychosis Intervention Center; FP: Family Psychoeducation;
treatment of first-episode psychosis. The clinical benefits IQ: Intelligence Quotient; MCCB: MATRICS Consensus Cognitive battery;
of such interventions are well documented in the psych- MCR: Metacognitive Remediation; PANSS: Positive and Negative Syndrome
Scale; SFS: Social Functioning Scale; SURF: Service Utilization and Resources
osis literature [95]. As noted earlier, most participants form for Schizophrenia.
were already taking antipsychotic medication prior to
study enrollment, and the average per-participant dose Competing interests
NJKB received research support from the Institute for Mental Health
of antipsychotic medication did not decline over the Research—an agency currently exploring the possibility of launching a
course of the study. Given the high rates of medication multi-component treatment center for first-episode psychosis. The remaining
discontinuation/non-compliance reported in naturalistic authors declare that they have no competing interests.
studies of individuals with first-episode psychosis [96],
Authors’ contributions
the relative stability of medication dose among EPICEN- NJKB designed the study, developed study intervention protocols, completed
TER participants is particularly noteworthy and may the analyses, and wrote the first draft of the manuscript. NJKB, EB, AC, ACW, SCD,
have contributed to the positive clinical and cost out- AB, AJP, BB, and PH-M contributed to the delivery of study interventions. NJKB,
EB, DD, CW, AC, ACW, SCD, AB, LB, and JS contributed to the administration and
comes among these individuals. Although not formally scoring of study assessments as well as data management. All authors provided
assessed, it may be that an unintended benefit of partici- critical revisions to manuscript and approve the final manuscript.
pation in EPICENTER care is the facilitation of greater
Acknowledgements
medication adherence among study participants. This We would like to thank the individuals who participated in this study.
hypothesis comports with previous evidence that indi- Funding for this study was provided to NJKB by the University of Arizona
viduals participating in certain evidence-based psycho- Department of Psychiatry, the Institute for Mental Health Research, the
Arizona Center for the Biology of Complex Diseases, the University of Arizona
social interventions for psychosis may display very high Vice President for Research, and a community donor who wishes to remain
levels of medication adherence (e.g., multifamily group psy- anonymous. Funding for the open-access publishing of this manuscript was
choeducation [68]). Ultimately, future studies are needed provided by the University of Arizona Open Access Publishing Fund. None of
the funding bodies played a role in the study design or the collection,
to more clearly unpack the association between participa- analysis, and interpretation of the data, or in the writing of the manuscript.
tion in multi-component psychosocial treatment packages
and adherence to pharmacological interventions among Author details
1
Department of Psychiatry and Behavioral Health, The Ohio State University,
individuals with first-episode psychosis. Columbus, Ohio, USA. 2Department of Psychiatry, The University of Arizona,
It is important to note that this study did suffer from a Tucson, Arizona, USA. 3Department of Psychology, The University of Arizona,
number of limitations—most notably the lack of a study Tucson, Arizona, USA. 4Department of Psychiatry and Behavioral Sciences,
Stanford University, Stanford, California, USA. 5Department of Psychiatry and
design in which participants were randomly assigned to Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia,
EPICENTER care versus usual care for first-episode USA. 6VISN-22 Mental Illness, Research, Education and Clinical Center
psychosis in our community. With our current study de- (MIRECC), VA San Diego Healthcare System, San Diego, California, USA.
7
Department of Education, The University of Arizona, Tucson, Arizona, USA.
sign, it is impossible to rule out the possibility that the
improvement in clinical outcomes and cost of care for Received: 1 April 2015 Accepted: 14 October 2015
individuals with first-episode psychosis may simply re-
flect the natural course of psychotic disorders and are
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