John J. Miller, MD: Dr Jones, how is cognitive impairment assessed in patients with schizophrenia, and what standard neuropsychiatric inventories or other assessments are utilized?

Nev Jones, PhD: A lot of assessment for cognitive impairment maps onto more standard neurocognitive batteries. There are consensus groups that have developed recommendations specific to schizophrenia. One of the particular batteries that gets used a lot is referred to as the Penn [Computerized Neurocognitive] Battery, and there was an NIMH [National Institute of Mental Health] initiative to develop consensus guidelines around cognitive assessment. So those do exist, and I think in real time, folks are working on translating them for real-world settings because depending on local capacity and training, it can be easier or harder to do detailed neurocognitive assessment. But we’re getting there as a field.

John J. Miller, MD: A quick follow-up to that, would you recommend any good assessment that could be used in a community mental health center or a coordinated specialty care practice?

Nev Jones, PhD: One of the NIMH initiatives related to early intervention and psychosis is the EPINET initiative. Early Psychosis Intervention Network is what EPINET refers to. There are hubs and sites, these are mostly community-based sites all across the country. In the Pennsylvania/Maryland network, we are in the midst of rolling out an implementation of the Penn battery for cognitive assessment across all of those sites, most of which, again, are community mental health agencies, some smaller, some larger. I think that is beginning to establish some precedent for what it means, and also what implementation supports need to be in place. One piece of that is how clinicians are then trained to relay or explain the results of neurocognitive testing to the clients they’re working with, and also what options are available in terms of supportive interventions.

As an example, you don’t necessarily want to be emphasizing to people the nuances of cognitive challenges they may be facing if you’re not prepared or able to recommend or refer them to any programs, interventions, or strategies. I think there are different pieces of it, although we start with an assessment. We need to think about training and communication and then what the options are that we’re able to either offer people or start building into programs.

John J. Miller, MD: Dr Carney, what challenges and opportunities occur in treating people with schizophrenia?

Caroline P. Carney, MD, MSc, FAPA, FAPM, CPHQ: I think the challenges are aligning individuals to get the right evidence-based care. The field has evolved and individuals who train, we know from other research, at the beginning of a decade, at the end of the decade, most of that information has turned over, and less than 20% is the same. Imagine in the field where the workforce is dwindling, where we’re still aiming toward a nadir in the number of providers in the country, we have few providers, many of whom at this point don’t know where evidence-based care is for schizophrenia. And there are challenges then aligning individuals to get that right kind of care. So, access and availability are No. 1, complicated by the lack of the ability to practice evidence-based care. The third is the models that were just described are terrific models. You talked about the RAISE [recovery after initial schizophrenic episode] model earlier and the EPINET study and what has shown to be beneficial in terms of diagnosing and understanding an individual spectrum; those are not easily disseminated outside of the academic setting. So that evidence base is more challenging to treat.

Another area we have to consider is the heterogeneous presentation of schizophrenia. Many of us who practice only see an individual at a cross-section in time. And at that cross-section in time, an episode of psychosis could be many things. Without being able to follow individuals longitudinally, get good family histories, and get good personal histories to understand the prodromal phase that we talked about earlier, it’s challenging to make that diagnosis accurately. And because of the heterogeneity in terms of outcome, it is also [difficult] to do that right kind of treatment planning. We look at taking an evidence base, and I think using the idea of a persona to define what those different treatment paths may look like after a solid diagnosis is made can be helpful. But again, that’s not done consistently, depending on where an individual shows up in the system.

John J. Miller, MD: Good point.

Caroline P. Carney, MD, MSc, FAPA, FAPM, CPHQ: [There is] a lot of complexity there.

John J. Miller, MD: You raised the important phenomena that schizophrenia is a word we created and that we use, but it probably includes hundreds of different disorders across the spectrum that have very different outcomes. Some people get all better, and some people can function reasonably well, and others have a deteriorating course. I think one of our challenges is getting better at trying to understand the person in front of us and what their path might be and how we can help them maximize their recovery.

Caroline P. Carney, MD, MSc, FAPA, FAPM, CPHQ: And bringing in those right sets of services, the combination of the psychosocial overlay with medications, with cognitive remediation. I look over at Sandy, and we see an incredible success story of someone who had been told they would have deteriorating mental capacity, and now she’s starting a master’s degree. [There are] incredible changes in what we’re able to do if we can get that right evidence disseminated across the field.

John J. Miller, MD: Thank you.

Nev Jones, PhD: Just a quick addition; one of the things that is so novel and important about NIMH’s EPINET initiative is that it is over 100 community-based clinics. These are not academic centers or academic clinics, and it is framed as a learning health care system initiative to be thinking about how implementation in community settings can best happen. One thing I would add to that then, when it comes to schizophrenia treatment, is measurement-based care. And part of what EPINET is also accomplishing is getting some kind of standardization in terms of measurement and building out the capacity across community sites to look at outcomes and potentially integrate them into care. So just putting out measurement-based care there, and we see a lot happening right now in this space, including a growing interest in improving quality measurement in behavioral health specifically, and specifically including serious mental illness. We have made more progress in terms of depression and anxiety. [I’m] emphasizing that there’s a lot of opportunity there to move the field forward to improve services, both at a clinical level in terms of clinical aspects of measurement-based care, and systems monitoring as we develop.

Transcript edited for clarity.