New Schizophrenia Treatment Programs where Patients and Doctors make Decisions together



I am encouraged find out about new treatment programs for schizophrenia that involve the patient in decision making in the medications they must take. A new treatment program for patients with a first time psychotic episode is OnTrackNY directed by Dr. Lisa Dixon of the New York Psychiatric Institute since 2013. The philosophy behind OnTrackNY and similar programs is rooted in two principles. One is that people are most likely to benefit when supportive services are available as a complete package: namely, a lasting relationship with a therapist; family counseling; school and work assistance; group therapy; and medication management, as in a system for adjusting doses so they are tolerable.

The second principle is the one that appeals so strongly to patients: that people are more likely to agree to and continue treatment if they help determine its direction. The psychiatrist discusses with the patient what each medicine does and its side effects. The patient decides which positive symptoms of schizophrenia he wants medication for and which side effects he can tolerate. Both the patient and their family keep a journal of behavior changes they experience with the medication and also the side effects. In other words, there is on-going communication between the doctor and the family and patient.

The doctors in these programs are offering simpler and older antipsychotics like Clozapine with reduced side effects and effectiveness at lower doses. Dr. Mackliff had early on recommended to us that Marco, my son, be taken off of a high dosage of Seroquel (1000 mg/ day) and put on 200 mg of Clozapine along with a mood enhancer drug at a low dosage. The psychiatrist we were seeing at that time said if we didn’t trust him to choose the medicine and dosage for our son, it would be better for us to find another psychiatrist. We chose to trust him; our son chose to stop taking the medicine, stop seeing a psychiatrist and take his life. This is a result of a lack of trust between the doctor and his patient.

An Expanding Concept Supported by Block Grants

At least five states have such coordinated-services programs established, and the programs are expanding quickly. Early Assessment and Support Alliance (EASA) began with five centers, and in 2007 opened centers in counties throughout the state. The New York program began in 2013, with four locations around New York City, and has since added a half-dozen more statewide. The programs rely on a combination of state funds and insurance reimbursement, and 32 states have begun using block grants set aside by Congress in 2014 to fund such programs. As far as I know, no such programs exist in California.

How much difference those programs will make is not clear. For example, the government-backed study released this fall found that the new approach had not reduced hospitalizations, a big driver of expenses.

But at last count, about 80 percent of the people who enrolled in OnTrackNY 18 months ago have remained in the program. Most of them were still in school or working, according to Dr. Dixon, who is also a professor of psychiatry at Columbia. About 60 percent of those who received care through EASA, the longer-running Oregon program, are working or in school, according to Tamara Sale, the program’s director of care.

Psychiatrists take Note

I would hope that psychiatrists keep up on what works with schizophrenia treatment and what does not. I would welcome services that offer support to families and help with integrating patients back into normal lives. These support programs are a result of block grants approved by Congress since 2014. Organizations such as the National Alliance of Mental Illness could be instigators for these new treatment programs and apply for a block grant. This would be a very useful organizational goal that would serve well its members, rather than the pharmaceutical companies that currently support the organization.


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