Three out of Three NIMH Directors Agree: Coordinated Specialty Care Is Success

As this year’s Annual Meeting wound down, the past three directors of the National Institute of Mental Health (NIMH) gathered for a roundtable discussion that looked backward and forward at the institute’s accomplishments as it celebrates its 75th anniversary. One of these accomplishments involves an innovation that has markedly improved care in the area of schizophrenia and could not have been possible without the efforts of all three directors: coordinated specialty care (CSC) clinics to treat first-episode psychosis.

The seeds were planted during the tenure of Steven Hyman, M.D. (1996-2001), who wanted the institute to start conducting large, practical trials. “I came in as the pharmaceutical industry was basking in the effervescence of Prozac,” along with other second-generation antidepressants and antipsychotics, he said. “But clinicians needed to know how to use these medications.” Under Hyman’s watch, NIMH launched the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) and CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) trials; they were designed to assess how these new medications performed in community health settings.

The results of both studies were sobering in their own way; STAR*D revealed that many patients do not respond to their first or even second antidepressant, while CATIE found that second-generation antipsychotics were not more effective at improving symptoms than older antipsychotics. But both studies showed large community trials could be done and could inform clinical practice.

After Hyman departed, one of the talented people he had brought with him to NIMH — Robert Heinssen, Ph.D. — approached the new director, Thomas Insel, M.D. (2002-2015), with another large trial proposal to study whether aggressive early treatment could improve the outcomes of people experiencing their first psychosis event.

“I admit, after he was done [speaking], I said, ‘I don’t get it,’” said Insel, who as a neuroscientist came to NIMH looking to dig deeper into the biology underlying mental illness. “Fortunately, Bob was patient and explained that innovation isn’t always a new molecule; sometimes it’s just how you package patient care.”

At the time, there were multiple therapies for schizophrenia, including behavioral therapies, social services, and second-generation antipsychotics. Heinssen realized that they were never brought together in a way that might promote recovery. Thus, the Recovery After an Initial Schizophrenia Episode (RAISE) initiative was founded, which demonstrated the efficacy of early, coordinated psychosis care.

When Gordon came on (2016-2024), he set out to expand and evolve the CSC centers. “I’m happy to report that as of now we have 380 clinics across the country, in every single state, serving more than 28,000 individuals,” he said. “We also have data to show coordinated specialty care reduces symptoms, reduces hospital visits, and raises employment.”

One of Gordon’s proud accomplishments was taking CSCs to the next level with EPINET(Early Psychosis Intervention Network); this is a set of CSC regional hubs, each one bundling about 10 clinics via a coordinating center that collects data on how care is delivered along with patient outcomes, and then shares those data with the clinics to improve care in real time.

Insel agreed that the CSC program has been a great success, but noted that the work isn’t done yet. “We still need to fix the payment structure, so these clinics don’t have to rely on block grants from SAMHSA to be sustainable,” he said. “This is a program that should be an entitlement like any other type of health care.”

Some progress was made late last year — the Centers for Medicare and Medicaid Services approved billing codes for bundled CSC services, and some states have mandated that private insurance covers at least some CSC costs. ■