2016 Runner Up: Psychosis Identification and Early Referral (PIER) Program

One of the most pressing issues facing care providers and government officials today is how to provide effective care and support for people suffering from severely debilitating mental illness—in particular, psychotic disorders like schizophrenia and schizotypal personality disorder. Psychosis, which describes the condition of having a disabling impaired sense of reality, currently affects an estimated two and a half percent of the U.S. population. Nearly three quarters of all people suffering from psychosis are under the age of 25 when they have their first episode. Those who suffer from psychotic disorders usually struggle in finishing school and finding steady employment, are dependent on family and public assistance, and are more likely to commit suicide or homicide.


Recent studies about psychosis indicate that the best way to treat someone who is at risk is through early intervention treatment. The Psychosis Identification and Early Referral (PIER) model is one of the leading methods in treating people with pre-psychotic symptoms. Adopted by 14 counties nationwide and currently pending implementation in the State of Delaware and the City of Philadelphia, the PIER model involves three key aspects: community outreach, assessment, and treatment. The community outreach component necessitates the creation of a community-wide detection and referral network by providing education and training focused on pre-psychotic and psychotic symptoms to teachers and healthcare professionals, in addition to other community members like students and families. The assessment component of the PIER model utilizes the Structured Interview for Prodromal Syndromes (SIPS) to assess if someone is in the pre-psychotic phase of a psychotic disorder’s development. The SIPS test evaluates 19 psychosis-related symptoms within four domains by grading them on a scale from one to six. Someone who receives a score of three to five in these areas is said to be in the attenuated range. Anyone whose scores indicate an “Attenuated Positive Symptom Prodromal Syndrome” would be entered into the PIER program, along with anyone who has suffered a recent onset of psychosis. The final aspect of the PIER model involves the treatment phase, which includes family psycho-education, support for educational and employment opportunities, occupational therapy, health and wellness guidance, and the prescription of low-dose medication.

The results of the PIER model demonstrate its success. In a 2007 national effectiveness trial done with support from the Robert Wood Johnson Foundation, PIER programs were established in Albuquerque, Ann Arbor, Sacramento, Salem (OR), and Queens (NY), with a continuation of the already established program in Portland (ME). 34,368 professionals were trained over the course of 993 presentations at these locations. Together, these professionals made 1,652 referrals, leading to the inclusion of 337 young adults, ranging in ages from 12 to 25, into a sample group that would be treated for their symptoms. This group was compared to a subsample low-risk pool that was receiving little to no treatment for their symptoms. Over the course of the study, six percent of the treated group experienced a psychotic episode. This is significantly below the consensus international average of similar studies, which averages 29 percent. Participation rates in school and at work were 83 percent for the treated group at both the baseline and two year mark, whereas the low-risk group had an 84 percent participation rate in the baseline year, and a 79 percent rate after two years. In terms of social functioning after two years, there was no difference between the treated group and the low-risk group.

As these outcomes illustrate, the PIER model offers an effective community-based approach to supporting those with pre-psychotic and psychotic symptoms and helping these patients overcome the challenges presented by psychosis.

Better Government Compendium of Winning Entries 2016: Improving Care for Those with Mental Illness by Pioneer Institute

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