LAUSR

Schizophrenia is a brain disorder with a lifetime prevalence near 1% that is associated with high levels of functional impairment and low expectations for recovery.1 Only 10% to 15% of people with schizophrenia work. The annual cost of schizophrenia in the United States in 2013 was estimated to be approximately $155.7 billion, including significant direct and indirect costs.2 Delivery of a new treatment approach called coordinated specialty care (CSC) to every young person experiencing the psychosis of early schizophrenia could change this state of affairs. The critical question is, “what will it take to make this happen?” Coordinated specialty care deploys a new care model developed for patients with first-episode schizophrenia that fosters recovery and attempts to prevent disability.3 It includes evidenced-based psychopharmacological management with attention to general health, cognitive and behaviorally oriented individual or group psychotherapy, family support and education, and supported education and employment, as well as case management and, more recently, peer support. Model CSC programs employ a team of culturally competent staff members skilled in (1) working with transitional age youth, (2) active engagement and outreach efforts, and (3) using shared decision-making processes. These CSC teams promote hope and understand the importance of stigma as an impediment to care. They use community outreach methods to reduce the duration of untreated psychosis. A longer duration of untreated psychosis is robustly associated with poorer outcomes for individuals who receive a diagnosis of schizophrenia. The National Institute of Mental Health Recovery After an Initial Schizophrenia Episode studies have demonstrated the benefits of CSC programs in the United States and how to implement them.4,5 In recognition of the value of CSC programs, in 2014, House of Representatives Bill 3547 added 5% to the Community Mental Health Block Grant program. States and federal territories received an additional $25 million with the requirement that the monies be used to develop and support evidence-based programs for individuals experiencing early psychosis. The 5% set-aside for CSC programs continued in 2015; the allocation was doubled in 2016, providing an additional $50 million for states to develop CSC programs. In 2008, only 2 states had such programs. Today, 32 states have begun implementing at least 1 CSC program. Although the block grant is insufficient to provide CSC to all individuals in the United States with early psychosis suggestive of schizophrenia, national CSC implementation has gained considerable momentum. For example, the Centers for Medicare and Medicaid Services, together with the National Institute of Mental Health and the Substance Abuse and Mental Health Services Administration, has issued guidance regarding strategies for Medicaid to fund CSC programs. The National Institute of Mental Health has recently funded a Small Business Innovation Research grant to develop a standardized online CSC training protocol and a virtual community of practice to support skill maintenance and collective learning. The National Institutes of Health PhenX (consensus measures for phenotypes and exposures) program has developed a toolkit of recommended measures for CSC program evaluation and research. Promoting the rollout of CSC programs has become a priority for the National Alliance on Mental Illness, representing consumer and family stakeholders. Delivery of CSC enjoys the support of scientists, clinicians, policy makers, and advocates. To capitalize on this significant momentum and ensure universal access to CSC in the United States, the following set of barriers still must be overcome.