The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis

Retrospective analysis of hospital episode statistics, involuntary admissions under the Mental Health Act 1983, and number of psychiatric beds in England 1996-2006

OBJECTIVE

To analyse the number of voluntary and involuntary (detentions under the Mental Health Act 1983) admissions for mental disorders between 1996 and 2006 in England.

DESIGN

Retrospective analysis.

SETTING

England.

MAIN OUTCOME MEASURES

Number of voluntary and involuntary admissions for mental disorders in England's health service, number of involuntary admissions to private beds, and number of NHS beds for patients with mental disorders or learning disabilities.

RESULTS

Admissions for mental disorders in the NHS in England peaked in 1998 and then started to fall. Reductions in admissions were confined to patients with depression, learning disabilities, or dementia. Admissions for schizophrenic and manic disorders did not change whereas those for drug and alcohol problems increased. The number of NHS psychiatric beds decreased by 29%. The total number of involuntary admissions per annum increased by 20%, with a threefold increase in the likelihood of admission to a private facility. Patients admitted involuntarily occupied 23% of NHS psychiatric beds in 1996 but 36% in 2006.

CONCLUSIONS

Psychiatric inpatient care changed considerably in the decade from 1996 to 2006, with more involuntary admissions to fewer NHS beds. The case mix has shifted further towards psychotic and substance misuse disorders, which has changed the milieu of inpatient wards. Increasing proportions of involuntary patients were admitted to private facilities.

Early intervention in psychosis: concepts, evidence and future directions

The rise of the early intervention paradigm in psychotic disorders represents a maturing of the therapeutic approach in psychiatry, as it embraces practical preventive strategies which are firmly established in mainstream health care. Early intervention means better access and systematic early delivery of existing and incremental improvements in knowledge rather than necessarily requiring dramatic and elusive breakthroughs. A clinical staging model has proven useful and may have wider utility in psychiatry. The earliest clinical stages of psychotic disorder are non-specific and multidimensional and overlap phenotypically with the initial stages of other disorders. This implies that treatment should proceed in a stepwise fashion depending upon safety, response and progression. Withholding treatment until severe and less reversible symptomatic and functional impairment have become entrenched represents a failure of care. While early intervention in psychosis has developed strongly in recent years, many countries have made no progress at all, and others have achieved only sparse coverage. The reform process has been substantially evidence-based, arguably more so than other system reforms in mental health. However, while evidence is necessary, it is insufficient. It is also a by-product as well as a catalyst of reform. In early psychosis, we have also seen the evidence-based paradigm misused to frustrate overdue reform. Mental disorders are the chronic diseases of the young, with their onset and maximum impact in late adolescence and early adult life. A broader focus for early intervention would solve many of the second order issues raised by the early psychosis reform process, such as diagnostic uncertainty despite a clear-cut need for care, stigma and engagement, and should be more effective in mobilizing community support. Early intervention represents a vital and challenging project for early adopters in global psychiatry to consider.

Early Psychosis: Treatment Issues and the Role of Occupational Therapy

Research has demonstrated that the establishment of early intervention services within mental health organisations is an effective method of reducing the impact of psychosis on a young person's life. The research literature and available clinical practice guidelines describe key intervention areas that have an impact on the effectiveness of the early intervention service. These include: comprehensive assessment, social functioning, weight control, substance misuse and vocational recovery. Early intervention services can develop effective programmes to address these areas.

The occupational therapist can have a defined role in this setting, primarily across the three domains of assessment, intervention and advocacy. Effective assessment by an occupational therapist provides information on the occupational role functioning of a young person. Intervention services provide consultative and direct treatment to assist the young person in engaging in developmentally and culturally appropriate occupational roles. Advocacy involves educating members of the multidisciplinary mental health team about the role and potential outcomes of occupational therapy. By assessing, intervening and advocating for young people with early psychosis, individual therapists can contribute to developing a central role for occupational therapy in the field of early psychosis.

Cognitive--behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: randomised controlled trial

BACKGROUND

Family intervention reduces relapse rates in psychosis. Cognitive-behavioural therapy (CBT) improves positive symptoms but effects on relapse rates are not established.

AIMS

To test the effectiveness of CBT and family intervention in reducing relapse, and in improving symptoms and functioning in patients who had recently relapsed with non-affective psychosis.

METHOD

A multicentre randomised controlled trial (ISRCTN83557988) with two pathways: those without carers were allocated to treatment as usual or CBT plus treatment as usual, those with carers to treatment as usual, CBT plus treatment as usual or family intervention plus treatment as usual. The CBT and family intervention were focused on relapse prevention for 20 sessions over 9 months.

RESULTS

A total of 301 patients and 83 carers participated. Primary outcome data were available on 96% of the total sample. The CBT and family intervention had no effects on rates of remission and relapse or on days in hospital at 12 or 24 months. For secondary outcomes, CBT showed a beneficial effect on depression at 24 months and there were no effects for family intervention. In people with carers, CBT significantly improved delusional distress and social functioning. Therapy did not change key psychological processes.

CONCLUSIONS

Generic CBT for psychosis is not indicated for routine relapse prevention in people recovering from a recent relapse of psychosis and should currently be reserved for those with distressing medication-unresponsive positive symptoms. Any CBT targeted at this acute population requires development. The lack of effect of family intervention on relapse may be attributable to the low overall relapse rate in those with carers.

Economic evaluation of early intervention services

Early intervention services have been introduced in a number of countries, but the evidence base to support them is limited. In particular there are very few economic evaluations, which are crucial if decision-makers are to have a better understanding of how scarce resources can be used appropriately. This paper discusses the different approaches used in economic evaluations and shows how these differ in the way in which outcomes are measured. The most useful forms of evaluation are cost-effectiveness and cost-utility analysis. We describe how the results of evaluations can be interpreted using incremental cost-effectiveness ratios and acceptability curves. Finally, the paper summarises some key evidence to date on early intervention services and economic evaluations currently being undertaken.

The Lambeth Early Onset Crisis Assessment Team Study: general practitioner education and access to an early detection team in first-episode psychosis

BACKGROUND

There are few evaluations of strategies to improve rates of early detection and treatment of patients with first-episode psychosis.

AIMS

To evaluate the effectiveness of a general practitioner (GP) education programme and an early detection assessment team (the Lambeth Early Onset Crisis Assessment Team; LEO CAT) in reducing delays in accessing treatment for first-episode psychosis patients.

METHOD

46 clusters of GP practices randomised to GP education in early detection with direct access to LEO CAT v. care as usual. Primary outcome measures were GP referral rates, duration of untreated psychosis (DUP) and delays in receiving treatment.

RESULTS

150 patients with first-episode psychosis were recruited; 113 were registered with the study GPs, who referred 54 (47.7%) directly to mental health services. Significantly more intervention group GPs (86.1% v. 65.7%) referred their patients directly to mental health services and fewer patients experienced long delays in receiving treatment. However, their overall DUP was unaffected.

CONCLUSIONS

Educating GPs improves detection and referral rates of first-episode psychosis patients. An early detection team reduces the long delays in initial assessment and treatment. However, these only impact on the later phases of the DUP. Broader measures, such as public health education, are needed to reduce the earlier delays in DUP.

[Programs for first onset psychosis and evidence-based medicine: a case of the syndrome of the emperor's new clothes]

In this essay, the author states that the first onset psychoses clinics described in many articles of this special issue of Santé mentale au Québec are not as evidence-based than the enthusiasm of its promoters would lend to believe. Using three stories based on observations made recently in Quebec where the argument of evidence-based support was brought, it will be illustrated how groups, their interventions and programs positioned themselves to their advantage.. These promoters in the health care system aim at better care, but they are also motivated by their own professional, departmental and research agendas ; they are supported by other logics and stakeholders like pharmaceutical firms, consumers and relatives; but can be slowed down by decision-makers and planners querying the ressources required, the efficiency, the accessibility, the training and the impact on other programs in a balanced mental health care system. This essay also briefly review the definitions, the limits of an evidence-based approach, and its origins from clinical epidemiology and public health. It does not consist solely of evidence drawn from randomised clinical trials and quantitative research designs, but also from qualitative and mixed designs, that have been developed by human sciences. The practice and application of evidence is not mastered in mental health systems, but the author hopes that with increased training by all stakeholders in its use, it will introduce a continuous evaluation at the individual clinical level, at the program and system levels. A continuous questioning that signals quality in clinical practices and services.

Listen to the data when results are not significant

Unexpected non-significant results from randomised trials can be difficult to accept. Catherine Hewitt, Natasha Mitchell, and David Torgerson find that some authors continue to support interventions despite evidence that they might be harmful

Evidence for a relationship between the duration of untreated psychosis and the proportion of psychotic homicides prior to treatment

BACKGROUND

Recent studies of homicide during psychotic illness have shown that the risk of homicide is greatest during the first episode of psychosis. It is also possible that the proportion of patients who commit homicide before they receive effective treatment may be associated with the length of time they were unwell. We aimed to establish whether there was an association between the average duration of untreated psychosis and the proportion of homicides committed during the first episode of psychosis in the same countries.

METHODS

Systematic searches of published studies of homicide in psychosis and the duration of untreated psychosis were conducted. The results were combined to examine the relationship between the reported delay in receiving treatment and the proportion of homicides committed before initial treatment.

RESULTS

We found 16 studies that reported the proportion of psychotic patients who committed homicide prior to treatment. The proportion of first episode patients ranged from 13% to 76%. We were able to match 13 of those studies with DUP studies from the same country. Longer average DUP was associated with a higher proportion of patients who committed homicide prior to receiving treatment.

CONCLUSIONS

The possibility that the proportion of patients who commit homicide before receiving treatment may be related to the average treatment delay in the region that the homicide occurs needs to be examined using a case controlled design. If this finding were confirmed, then any measure that reduced the delay in treating emerging psychosis would save lives.

The prevention of schizophrenia

Preventive strategies can be divided into universal, selective and indicated prevention and early intervention. Universal interventions are directed to the general population. Selective approaches are targeted at people who have risk factors for an illness, but who do not show any current signs. Indicated approaches target high risk individuals with minimal signs or symptoms foreshadowing mental disorder, but who do not meet diagnostic levels at the current time. Early intervention involves treating those with already diagnosable disorder in a timely and optimal manner aiming to decrease the severity of the illness, and reduce secondary morbidity. Although universal and selective interventions are not yet viable strategies, indicated prevention and early intervention are now realistic possibilities in schizophrenia. Development of methods to identify those at risk of psychosis continues to evolve. Promising results in the prevention and delay of transition to psychotic disorder from high risk state have been found. Early intervention in schizophrenia, including promotion of early help-seeking, has been shown to reduce the duration of untreated psychosis, which is known to be associated with poor outcome in schizophrenia. Early intervention programmes which optimise the care of the first episode have been shown to produce better outcomes than routine management.

Predicting clinical and social outcome of patients attending 'real world' mental health services: a 6-year multi-wave follow-up study

OBJECTIVE

The aims of this study were: i) to determine changes in symptoms and social disability, and ii) to explore predictors of clinical and social outcome in patients receiving community-based mental health care.

METHOD

A total of 354 patients treated in the South-Verona Community Mental Health Service were followed up over 6 years (with assessments made at baseline, 2 and 6 years) by using a set of standardized measures exploring psychopathology (Brief Psychiatric Rating Scale) and social disability (Disability Assessment Schedule). Generalized linear latent and mixed models were used to explore longitudinal predictors of clinical and social outcome.

RESULTS

Psychotic patients displayed clinical and social outcome characterized by complex patterns of exacerbation and remission over time; however, a clear trend towards a deteriorating course was not found, thus challenging the notion that psychotics are fatally prone to a destiny of chronicity. Non-psychotics reported a significant reduction in the core symptom of depression and in the observable physical and motor manifestations of tension and agitation, and a parallel increase in complaints about their physical health. Clinical and social dimensions of outcome are influenced by specific and different set of predictors.

CONCLUSION

The results of this study confirm the need to implement naturalistic outcome studies conducted in the 'real world' services to inform decisions and strategies to be adopted in routine clinical practice.

Managing Psychotic Illness in Young People: A Practical Overview

  The management of early onset psychosis poses a significant challenge to professionals working in Child and Adolescent Mental Health Services. Young people with psychotic illness often present with a mixed clinical picture and a wide variety of attendant issues. Over the last decade there has been accumulating research, mainly based on work with adults, regarding the efficacy and effectiveness of medical and psychosocial interventions for patients with schizoaffective spectrum disorders. This article takes a symptoms-based approach, collating and summarising recent evidence, where it exists, regarding best practice when managing young people affected by schizophrenia, schizoaffective or bipolar affective disorder.

The promise of early intervention

The focus of this review is the research and clinical work in early psychosis and early intervention which over the past 10-15 years has had a tremendous impact on the field of schizophrenia. Unparalleled progress has been made in programme and service development with a wide range of reported research results, outcome studies, treatment approaches and new initiatives. Traditional areas are being explored in the first episode that can add to our knowledge of schizophrenia. New areas that have a specific relevance for early intervention such as the duration of untreated psychosis and pathways to care are being widely studied. Despite the criticism of the lack of randomized controlled trials, there is a wealth of positive outcome from both effectiveness studies and limited controlled trials. However, there are still many unanswered issues which are in developing stages or which require further investigation.

Early intervention in psychotic disorders: detection and treatment of the first episode and the critical early stages

The two main goals of early intervention in psychotic disorders are to reduce the period of time between the onset of psychosis and the commencement of effective treatment, and to provide consistent and comprehensive care during the critical early years of illness. Effective care during the critical early years involves proactive engagement and initiation of drug and psychosocial treatments, aiming for maximal symptomatic and functional recovery and the prevention of relapse. Over the past 15 years, an increasing number of specialised or streamed treatment delivery systems for early psychosis have been established around the world. There is now evidence that these services can reduce the duration of untreated psychosis and produce better symptomatic and functional recovery. In addition, they are more cost-effective than standard models of mental health care for these patients. Fully fledged, specialised early intervention services should be established, with full integration with local communities, as well as enhanced primary care systems focused on young people.

Early psychosis: where we've been, where we still have to go

Early intervention in psychosis, while not a new concept, has seen great development over the last 15 years. Growth in this time has occurred in a number of areas and has attracted a broad coalition of researchers, consumers, clinicians, carers and policy makers. In this time the concept of early intervention has moved from the fringes to the mainstream of clinical approaches to psychosis in many places, and is doing so in even more. After a decade and a half, this paper reviews some of the key issues that have been addressed and points to areas where further growth and reform is still required. Some issues that have created controversy are examined here including pre-onset intervention and identification, the relationship of duration of untreated psychosis (DUP) to outcome and whether or not early intervention is an effective and economically viable model. Areas that are only now developing or which require further investigation are considered, including the concept of stages of mental illness and concomitant interventions, closing the efficacy-effectiveness gap and an increased focus on functioning as part of the recovery process. Early intervention in psychosis started as a reformist movement, agitating for change from outside the mainstream. Change has occurred and now early intervention is part of the mainstream approach to psychotic illness. In order to continue to develop, while enjoying the benefits of being a mainstream intervention, early intervention must not stray too far from its reformist roots.

Service responses for youth onset mental disorders

PURPOSE OF REVIEW

Many psychiatric disorders have their highest first-onset rates in adolescence and young adulthood. We summarize recent work indicating where interventions are most needed and effective. We also review the literature that examines the scope for reorienting mental health services to meet the needs of adolescents and young adults.

RECENT FINDINGS

The continuities between youth onset and later life disorders, as well as later social adjustment, have become clearer. Emotional disorders that persist or recur during the teens have the greatest effect on future mental health. To date, service systems, even in the developed world, cater poorly for youth with mental disorders. Intervention studies demonstrate the short-term benefits of intensive multidisciplinary intervention for early psychosis. There are few data concerning the benefit of early intervention for other disorders. Long-term benefits for early intervention for any condition are unknown. Youth streams of psychiatric care have developed for early-onset psychotic disorders.

SUMMARY

An increasing understanding of the high prevalence and longer-term effects of youth onset mental disorders has not yet been adequately matched by intervention research or the evaluation of different models of mental health service delivery.

Mental health of young people: a global public-health challenge

Mental disorders account for a large proportion of the disease burden in young people in all societies. Most mental disorders begin during youth (12-24 years of age), although they are often first detected later in life. Poor mental health is strongly related to other health and development concerns in young people, notably lower educational achievements, substance abuse, violence, and poor reproductive and sexual health. The effectiveness of some interventions for some mental disorders in this age-group have been established, although more research is urgently needed to improve the range of affordable and feasible interventions, since most mental-health needs in young people are unmet, even in high-income countries. Key challenges to addressing mental-health needs include the shortage of mental-health professionals, the fairly low capacity and motivation of non-specialist health workers to provide quality mental-health services to young people, and the stigma associated with mental disorder. We propose a population-based, youth focused model, explicitly integrating mental health with other youth health and welfare expertise. Addressing young people's mental-health needs is crucial if they are to fulfil their potential and contribute fully to the development of their communities.

Systematic review of interventions delivered by UK mental health nurses

The effectiveness of mental health nurse interventions has not been generally established in the literature. In this systematic review, randomised controlled trials (RCTs) were identified, undertaken in the United Kingdom, where mental health interventions delivered by mental health nurses had been evaluated. The main online literature databases were searched, key journals were hand searched and contact was made with key authors, resulting in a total of 52 studies, involving at least 7172 service users. Data were extracted and then all identified trials were assessed for inclusion by two reviewers. The results showed that in the UK, mental health nurses are involved in the delivery of a wide range of interventions in a variety of clinical health settings, with broadly positive results.

Effectiveness of early intervention in psychosis

PURPOSE OF REVIEW

Over 15 years, early intervention in psychosis has grown to become a mainstream funded approach to clinical care. This review examines recent developments in evaluating the effectiveness of early intervention. It considers identification and treatment of those at risk of psychosis, as well as interventions in the post-onset phase of illness.

RECENT FINDINGS

Development of methods identifying those at risk of psychosis continues to evolve. Promising results in the prevention and delay of transition to psychotic disorder from a high-risk state have been found. Psychological and psychosocial interventions are important components of these preventive programmes. Two recent meta-analyses indicate that there is a consistent relationship between duration of untreated psychosis and outcome independent of other factors. Further evidence shows that early intervention reduces the duration of untreated psychosis, produces better outcomes in terms of symptomatic and functional domains, and is cheaper than standard models of care.

SUMMARY

There is evidence that early intervention is effective for early psychosis. Some challenges remain. These include developing a greater focus on functional recovery and prevention of relapse.

Early Psychosis Prevention and Intervention Centre long-term follow-up study of first-episode psychosis: methodology and baseline characteristics

AIM

This paper reports the rationale, methodology and baseline characteristics of a large long-term follow-up study of first-episode psychosis from a geographically defined catchment area.

METHOD

A total of 723 first-episode psychosis patients were recruited from a specialized early psychosis service between 1989 and 2001 and prospectively followed up at a median of 7.4 years after initial presentation. Participants' baseline demographic, clinical and functional characteristics are described. Sampling bias at study recruitment was assessed by comparison with a more complete sample of Early Psychosis Prevention and Intervention Centre (EPPIC) cases rated directly from the medical records.

RESULTS

  At baseline, 57% of the sample were diagnosed with schizophrenia or schizophreniform disorder, whereas the full range of psychotic disorders was represented. Statistical analysis confirmed that the sample recruited was representative of total EPPIC-treated incident cases.

CONCLUSIONS

The EPPIC long-term follow-up study is a large and epidemiologically representative first-episode psychosis cohort that has been subsequently prospectively followed up over a long period. Such a sample provides a rare opportunity to study the course and outcome of psychotic disorders.

First-episode psychosis patients recruited into treatment via early detection teams versus ordinary pathways: course, outcome and health service use during first 2 years

AIM

Within an early detection sector, to compare the 1- and 2-year course and outcome of first-episode psychosis patients coming into the treatment system via active outreach detection teams (DTs) versus those achieving help via ordinary referral channels (not-DT).

METHODS

Longitudinal, comparative study of two parallel consecutive samples using structured clinical interview for the DSM-IV, Positive and Negative Syndrome Scale Score, Global Assessment of Functioning Scale and Premorbid Assessment of Functioning Scale.

RESULTS

The DT group had significantly better functioning at baseline, but this was reversed after 3 months. At 2 years the groups had similar outcome. The DT group developed a more serious diagnostic pattern, had more cases of schizophrenia, and was more frequently treated on an outpatient basis only.

CONCLUSIONS

The DTs recruited more chronic patients with poorer prognostic features, but fewer symptoms and better functioning at baseline. At 2 years the DT-patients did as well as the not-DT patients. They recovered more slowly, but given sufficient time, responded as well to therapy as the not-DT group.

Relapse rates in an early psychosis treatment service

To examine the relapse rate achievable in a real-life early psychosis treatment service.

METHOD

A 2-year longitudinal cohort study of consecutive admissions to an early psychosis programme which served the entire population in a catchment area. The primary outcome measure was relapse.

RESULTS

One hundred and forty-eight consecutive consenting admissions were recruited, 124 (83.8%) of whom were followed for 1 year and 116 (78.4%) for 2 years. Relapse was assessed by clinicians using structured criteria. The 2-year relapse rate among subjects with complete data collection was 34/95 (35.7%, 95% CI 26.2-46.3). A Kaplan-Meier life table censoring subjects lost to follow-up yielded a comparable estimate of the proportion not relapsing: 68% (95% CI 58-76%).

CONCLUSION

These estimates compare favourably with a published range of 2-year relapse from 55% to 70% in the older literature and are comparable with the results in recent clinical trials.

Lambeth Early Onset (LEO) and Outreach & Support in South London (OASIS) service

AIM

To establish a comprehensive phase-oriented early intervention service for young people with early psychosis in south London and to evaluate its effectiveness in delivering user friendly interventions and better outcomes.

METHODS

The Lambeth Early Onset (LEO) and Outreach & Support in South London (OASIS) service has been developed incrementally over the last 6 years into 4 teams each addressing one of the phases of early psychosis: (i) prodrome/ultra-high risk (ii) untreated psychosis (c) acute inpatient treatment and (d) recovery/ relapse prevention phases. Research and evaluation have been integral to each team's development with three of the teams configured as Randomised Controlled Trials.

RESULTS

During the first 6 years, 1255 young people in Lambeth were referred for assessment (963 to LEO and 292 to OASIS). Of them 578 were diagnosed as suffering from first episode psychosis (some before or after they presented to OASIS), 450 have been followed up in Lambeth by the LEO Community Team and 40% discharged back to GPs in remission at the end of their two years of follow-up. Compared to standard service, patients' delays in accessing treatment are less, and outcomes at 18 months are better.

CONCLUSIONS

The LEO and OASIS service now provide most of the mental health service requirements for young people with early psychosis in Lambeth. It represents good value for money and improved outcomes for clients. Further interventions are planned and ultimately it will be possible to evaluate the impact of each incremental step in the service's development.

Impact of a specialized early intervention service for psychotic disorders on patient characteristics, service use, and hospital costs in a defined catchment area

OBJECTIVE

To evaluate the impact of a new early intervention service for first-episode psychosis on patient characteristics, service use, and hospital costs.

METHOD

We examined clinical records of all first admissions to hospitals of patients diagnosed with first-episode psychoses (nonaffective) over a 3-year period before and after the introduction of an early intervention service, the Prevention and Early Intervention Program for Psychosis (PEPP), in a defined catchment area. We examined demographic, clinical, and service use indices covering a 2-year period subsequent to the index admission for each patient.

RESULTS

Patients in the post-PEPP phase were significantly younger (P < 0.01), were more often male (P < 0.05), and were less likely to be admitted to hospital with an involuntary status (P < 0.05) or with injuries (P < 0.05) at the time of their first hospital admission. Over the 2 years following the initial admission, post-PEPP patients had significantly fewer admissions to a regular psychiatric service (P < 0.001) and made significantly fewer visits to the hospital emergency department (P < 0.01). There was a significant mean reduction in costs per case of regular hospital bed use ($1028.49, SD 528.02, compared with $792.28, SD 528.02; P < 0.01) and emergency visits ($519.18, SD 353.79, compared with $353.79, SD 345.0; P < 0.01). Time series analyses followed by Chow tests failed to confirm that these cost changes could be attributed specifically to the introduction of an early intervention service.

CONCLUSION

Introduction of a specialized early intervention program may be beneficial to patients and to the health care system. To evaluate the cost-benefit ratio of early intervention services, longer term and more detailed data may be required.

Two years of continued early treatment for recent-onset schizophrenia: a randomised controlled study

OBJECTIVE

This random-controlled study evaluated benefits derived from continued integrated biomedical and psychosocial treatment for recent-onset schizophrenia.

METHOD

Fifty cases of schizophrenia of less than 2 years duration were allocated randomly to integrated or standard treatment (ST) for 2 years. ST comprised optimal pharmacotherapy and case management, while IT also included cognitive-behavioural family treatment, that incorporated skills training, cognitive-behavioural strategies for residual psychotic and non-psychotic problems and home-based crisis management. Psychopathology, functioning, hospitalisation and suicidal behaviours were assessed two monthly and a composite index, reflecting overall clinical outcome was derived.

RESULTS

IC proved superior to ST in reducing negative symptoms, minor psychotic episodes and in stabilising positive symptoms, but did not reduce hospital admissions or major psychotic recurrences. The composite index showed that significantly more IC patients (53%) had excellent 2-year outcomes than ST (25%).

CONCLUSION

Evidence-based treatment achieves greater clinical benefits than pharmacotherapy and case management alone for recent-onset schizophrenia.

Early intervention for psychosis

BACKGROUND

Proponents of early intervention have argued that outcome might be improved if more therapeutic efforts were focused on the early stages of schizophrenia or on people with prodromal symptoms. Early intervention in schizophrenia has two elements that are distinct from standard care: early detection and phase-specific treatment. Both elements may be offered as supplements to standard care, or may be provided through a specialised early intervention team. Early intervention is now well established as a therapeutic approach in America, Europe and Australasia, but it is unclear how far early detection, phase-specific treatments, and the use of early intervention teams are underpinned by evidence of effectiveness.

OBJECTIVES

To evaluate the effects of: (a) early detection; (b) phase-specific treatments; and (c) specialised early intervention teams in the treatment of people with prodromal symptoms or first episode psychosis.

SEARCH STRATEGY

We searched CINAHL (1982-2002), The Cochrane Controlled Trials Register (November 2001), The Cochrane Schizophrenia Group Register (July 2003), EMBASE (1980-2002), MEDLINE (1966-2002), PsycINFO (1967-2002), reference lists and contacted the European First Episode Network (2003). For the 2006 update we searched the Cochrane Schizophrenia Group's register.

SELECTION CRITERIA

We included all randomised controlled trials designed to prevent progression to psychosis in people showing prodromal symptoms, or to improve outcome for people with first episode psychosis. Eligible interventions, alone and in combination, included early detection, phase-specific treatments, and care from specialised early intervention teams. We accepted cluster-randomised trials but excluded non-randomised trials.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention-to-treat analysis (ITT).

MAIN RESULTS

We included seven studies with a total of 941 participants. Six studies were small with numbers of participants ranging between 56 and 83, and one study randomised 547 people. None of the studies had similar interventions and therefore they were analysed separately. One small Australian trial (n=59) was concerned with a phase-specific intervention (low dose risperidone and cognitive behavioural therapy) for people with prodromal symptoms. This group were significantly less likely to develop psychosis at a six month follow up than people who only received care from a specialised team which did not involve phase-specific treatment (n=59, RR 0.27 CI 0.1 to 0.9, NNT 4 CI 2 to 20). This effect was not significant at 12 month follow up (n=59, 1 RCT, RR 0.54 CI 0.2 to 1.3). A UK-based study (EDIE) randomised 60 people with prodromal symptoms, to cognitive behavioural therapy (CBT) or a monitoring group. Only two outcomes were reported: leaving the study early and transition to psychosis, both sets of data were non-significant. A Chinese trial used a phase-specific intervention (family therapy) plus out patient care trial for people in their first episode of psychosis and found reduced admission rates care compared with those who received only outpatient care (n=83, RR 0.28 CI 0.1 to 0.6, NNT 3 CI 2 to 6). The applicability of this finding was, however, questionable. One Dutch study (n=76) comparing phase-specific intervention (family therapy) plus specialised team with specialised team for people in their first episode of schizophrenia found no difference between intervention and control groups at 12 months for the outcome of relapse (n=76, RR 1.05 CI 0.4 to 3.0). The large Scandinavian study (n=547) allocated people with first episode schizophrenia to integrated treatment (assertive community treatment plus family therapy, social skills training and a modified medication regime) or standard care. Global state outcome GAF significantly favoured integrated treatment (n=419, WMD -3.71 CI -6.7 to -0.7) by one year, but by two years data were non-significant. Rates of attrition were significantly lower (n=547, RR 0.59 CI 0.4 to 0.8, NNT 9 CI 6 to 18) for integrated treatment by one and two year follow-up. PRIME (USA) was the only double blind study and allocated people with prodromal symptoms to olanzapine or placebo. No significant differences were found between olanzapine and placebo in preventing conversion to psychosis by about 12 months (n=60, RR 0.58 CI 0.3 to 1.2). Clinical Global Impression change scores 'severity of illness' were equivocal by 12 months. Scale of Prodromal Symptoms (SOPS) scores were also equivocal and the PANSS, total, positive and negative outcomes were non-significant. There were no significant differences between the olanzapine and placebo group on adverse effects rating scales - SAS, BAS and AIMS scores; Weight gain was significantly higher in the olanzapine group (n=59, WMD 7.63 CI 4.0 to 11.2) by 12 months. Finally one more Australian study included people in their first episode of psychosis who were acutely suicidal and allocated people to phase-specific cognitively orientated therapy or standard care. Outcome data for leaving the study early and suicide were equivocal.

AUTHORS' CONCLUSIONS

We identified insufficient trials to draw any definitive conclusions. The substantial international interest in early intervention offers an opportunity to make major positive changes in psychiatric practice, but making the most of this opportunity requires a concerted international programme of research to address key unanswered questions.

Need for closure and anxiety in delusions: A longitudinal investigation in early psychosis

This study investigated the role of need for closure (NFC) and anxiety in delusions. The Need For Closure Scale (NFCS) and measures of trait and state anxiety were administered to an early psychosis group with current delusions, a clinical (generalised anxiety disorder--GAD) control group and a non-clinical control group. The battery of questionnaires was repeated at follow-up one year later. The NFCS did not meet criteria for a unidimensional scale and two sub-scales were removed from all further analyses. At baseline the deluded and GAD groups scored significantly higher on the reduced NFCS (NFCS-R) than the control group. Trait anxiety was related to NFCS-R in the GAD and non-clinical control groups, but not in the deluded group. At follow-up all groups scored significantly lower on the NFCS-R, perhaps suggesting a practice effect, although the two clinical groups continued to have higher scores than the non-clinical control group. The recovered and non-recovered deluded groups did not differ on the NFCS-R one year later, unlike in the GAD group where recovered participants had significantly lower scores than the non-recovered. Change scores on the NFCS-R and trait anxiety were correlated at trend level in the GAD and non-clinical control groups, but not in the deluded group. These findings suggest that whilst NFC and trait anxiety are related in non-psychotic groups, NFC may be implicated in the formation of delusions, independently of anxiety, in psychotic individuals.

Cognitive, emotional, and social processes in psychosis: refining cognitive behavioral therapy for persistent positive symptoms

Psychosis used to be thought of as essentially a biological condition unamenable to psychological interventions. However, more recent research has shown that positive symptoms such as delusions and hallucinations are on a continuum with normality and therefore might also be susceptible to adaptations of the cognitive behavioral therapies found useful for anxiety and depression. In the context of a model of cognitive, emotional, and social processes in psychosis, the latest evidence for the putative psychological mechanisms that elicit and maintain symptoms is reviewed. There is now good support for emotional processes in psychosis, for the role of cognitive processes including reasoning biases, for the central role of appraisal, and for the effects of the social environment, including stress and trauma. We have also used virtual environments to test our hypotheses. These developments have improved our understanding of symptom dimensions such as distress and conviction and also provide a rationale for interventions, which have some evidence of efficacy. Therapeutic approaches are described as follows: a collaborative therapeutic relationship, managing dysphoria, helping service users reappraise their beliefs to reduce distress, working on negative schemas, managing and reducing stressful environments if possible, compensating for reasoning biases by using disconfirmation strategies, and considering the full range of evidence in order to reduce high conviction. Theoretical ideas supported by experimental evidence can inform the development of cognitive behavior therapy for persistent positive symptoms of psychosis.

Predictors of service disengagement in first-admitted adolescents with psychosis

OBJECTIVE

To assess the risk and predictors of service disengagement in adolescents with first-episode psychosis (FEP) receiving their first treatment in a long-standing early intervention and prevention centre.

METHOD

The Early Psychosis Prevention and Intervention Centre (EPPIC) in Australia admitted 157 adolescents, ages 15 to 18, with FEP from January 1998 to December 2000. Treatment at EPPIC spans an average of 18-months. Data were collected from patients' charts using a standardized questionnaire; 134 charts were available. Time to service disengagement was the outcome of interest. Baseline and treatment predictors of service disengagement were examined via Cox proportional hazards model.

RESULTS

Kaplan-Meier 18-month risk of service disengagement was 0.28. A lower severity of illness at baseline (hazard ratio [HR] = 0.2; 95% confidence interval [CI] 0.1-0.4), living without family during treatment (HR = 4.8; 95% CI 2.1-11.2), and persistent substance use during treatment (HR = 2.6; 95% CI 1.1-5.9) contributed significantly to predicting service disengagement. Neither initial substance use nor insight at baseline was related to service disengagement.

CONCLUSIONS

Clinicians should focus on treating substance use and establishing a social network if family support is missing in adolescents with FEP. In addition, clinicians should apply strategies to keep in touch with those adolescents who might not see the necessity of continuous treatment because of a moderate severity of illness.

Helping to prioritise interventions for depression and schizophrenia: use of Population Impact Measures

BACKGROUND

To demonstrate the potential of Population Impact Measures in helping to prioritise alternative interventions for psychiatry, this paper estimates the number of relapses and hospital readmissions prevented for depression and schizophrenia by adopting best practice recommendations. The results are designed to relate to particular local populations.

METHODS

Literature-based estimates of disease prevalence, relapse and re-admission rates, current and best practice treatment rates, levels of adherence with interventions and relative risk reduction associated with different interventions were obtained and calculations made of the Number of Events Prevented in your Population (NEPP).

RESULTS

In a notional population of 100,000 adults, going from current to 'best' practice for different interventions, the number of relapses prevented in the next year for schizophrenia were 6 (increasing adherence to medication), 23 (family intervention), 43 (relapse prevention), and 44 (early intervention); and for depression the number of relapses prevented in the next year were 100 (increasing care management), 227 (continuing treatment with antidepressants), 279 (increasing rate of diagnosis), and 325 (Cognitive Behaviour Therapy). Hospital re-admissions prevented in the next year for schizophrenia were 6 (increasing adherence to medication), 36 (relapse prevention) and 40 (early intervention).

CONCLUSION

Population Impact measures provide the possibility for a policy-maker to see the impact of a new intervention on the population as a whole, and to compare alternative interventions to best improve psychiatric disease outcomes. The methods are much simpler than others, and have the advantage of being transparent.

Outreach and support in south London (OASIS): implementation of a clinical service for prodromal psychosis and the at risk mental state

BACKGROUND

While recent research points to the potential benefits of clinical intervention before the first episode of psychosis, the logistical feasibility of this is unclear.

AIMS

To assess the feasibility of providing a clinical service for people with prodromal symptoms in an inner city area where engagement with mental health services is generally poor.

METHOD

Following a period of liaison with local agencies to promote the service, referrals were assessed and managed in a primary care setting. Activity of the service was audited over 30 months.

RESULTS

People with prodromal symptoms were referred by a range of community agencies and seen at their local primary care physician practice. Over 30 months, 180 clients were referred; 58 (32.2%) met criteria for an at risk mental state, most of whom (67.2%) had attenuated psychotic symptoms. Almost 30% were excluded due to current or previous psychotic illness, of which two-thirds were in the first episode of psychosis. The socio-demographic composition of the 'at risk' group reflected that of the local population, with an over-representation of clients from an ethnic minority. Over 90% of suitable clients remained engaged with the service after 1 year.

CONCLUSION

It is feasible to provide a clinical service for people with prodromal symptoms in a deprived inner city area with a large ethnic minority population.

Psychiatrische Fachpflege und gemeindepsychiatrische Versorgung am Beispiel London

We examine the role of nurses in community mental health care. We describe training, careers, specialization and discuss new trends and problems. We look at what psychiatric nurses stand for, how they relate to other professions and new developments in research.

Status of first-episode psychosis patients presenting for routine care in a defined catchment area

OBJECTIVE

To examine the clinical and behavioural status of all first-episode psychosis (FEP) patients admitted to hospital within a defined catchment area.

METHOD

We used a structured format to review clinical records of all first admissions to hospitals from a catchment area (population 390 000) with diagnosis of a first episode of nonaffective psychosis over a 3-year period.

RESULTS

Patients were somewhat older than usually reported for FEP (mean age 31.3 years). They were mostly male (63.7%), single (80.8%), unemployed (87.4%), with a primary diagnosis of schizophrenia spectrum psychoses (85%), and had spent a mean of 31 days in an open inpatient unit and 2.93 days in an intensive care psychiatric unit during their first admission. Most (60.3%) were admitted involuntarily; 34.2% had a history of legal involvement; 18.8% had attempted suicide prior to admission; 31.5% had demonstrated violence toward people, property, or animals; 14.4% had suffered injuries; and 15.9% had shown aggressive behaviour during the hospital admission.

CONCLUSIONS

These results identify some of the potential needs of FEP patients, toward whom early intervention services should be directed.

Specialised care for early psychosis: symptoms, social functioning and patient satisfaction: randomised controlled trial

BACKGROUND

The provision of early intervention services for people with psychosis is UK government policy, although evidence for benefit of such services is sparse.

AIMS

To evaluate the effects of a service providing specialised care for early psychosis (the Lambeth Early Onset Team) on clinical and social outcomes, and on service user satisfaction.

METHOD

One hundred and forty-four people with psychosis, presenting to mental health services for the first or second time (if previously failed to engage in treatment), were randomly allocated to care by the early onset team or to standard care. Information was obtained on symptoms, treatment adherence, social and vocational functioning, satisfaction and quality of life. Relapse and rehospitalisation data have been reported separately.

RESULTS

Outcomes for the participants treated by the early onset team were significantly better at 18 months for aspects of social and vocational functioning, satisfaction, quality of life and medication adherence. Symptom improvement did not significantly differ between the groups.

CONCLUSIONS

The provision of specialised care for early psychosis can achieve better outcomes. The study therefore provides support for current policy.

First-episode psychosis, early intervention, and outcome: what have we learned?

OBJECTIVE

There has been increased interest in the potential of early intervention to positively influence outcome in first-episode psychosis (FEP) and, consequently, to influence mental health policy and practice. This study's objective was to examine the concept of early intervention and the evidence that currently exists to support such a shift in the delivery of care.

METHOD

We examined the evidence for phase-specific treatment of FEP, looking for interventions that attempt to arrest the transition from a putative prodromal state to full psychosis, as well as for interventions that attempt to reduce delay in treatment.

RESULTS

Some evidence supports specialized FEP interventions for short-term outcome in terms of symptom reduction, relapse rates, and greater adherence to and retention in treatment. As well, there is modest support for benefits to aspects of social and community functioning and satisfaction with life. Limited evidence supports a positive effect of community-wide case detection in terms of reduced delays in treatment and pharmacologic and psychological interventions in the prodromal phase.

CONCLUSIONS

The field of early intervention in psychosis is young, with encouraging preliminary results, especially for improving outcome in established FEP. It requires further study, especially of longer-term outcome. Further studies need to examine the effects of a specialized approach on longer-term outcome and to explore cost-effective methods to reduce delays in treatment and provide interventions in the prodromal phase.

Early intervention in psychotic disorders: beyond debate to solving problems

The challenges of early diagnosis are similar in psychiatry to the rest of medicine. For potentially severe and persistent disorders there is great value in early diagnosis, however, only under certain conditions. Early diagnosis would not be justified if there were no efficacious treatments or if such treatments provided earlier would do more harm than good for those exposed. There is growing evidence that earlier and sustained intervention improves at least short-term outcomes. However, early intervention may be iatrogenic where systems of care are poor in quality. One thing is clear, the general pattern of care is still "too little, too late" even in the most affluent countries. Consistent and extensive reform of health systems, with recognition of early intervention as an increasingly evidence-based "best buy", represents one of the key priorities in international mental health.

Developing services for first-episode psychosis and the critical period

BACKGROUND

Providing specialised services to individuals experiencing first-episode psychosis (FEP) is a relatively new endeavour.

AIMS

To overview developing services for newly diagnosed cases of FEP and the context in which they develop.

METHOD

This paper describes five model multi-element FEP programmes, outlines recent evaluation studies of FEP services, discusses current evidence gaps relating to the evaluation of complex interventions and specific interventions for FEP and illustrates attempts to examine aspects of clinical work practised at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia.

RESULTS

Considerable progress has been made in terms of influencing practice in the assessment and treatment of early psychosis.

CONCLUSIONS

There is need for quality clinical and research efforts to inform and accelerate progress in this burgeoning field.

A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness

OBJECTIVES

To evaluate the effects of integrated treatment for patients with a first episode of psychotic illness.

DESIGN

Randomised clinical trial.

SETTING

Copenhagen Hospital Corporation and Psychiatric Hospital Aarhus, Denmark.

PARTICIPANTS

547 patients with first episode of schizophrenia spectrum disorder.

INTERVENTIONS

Integrated treatment and standard treatment. The integrated treatment lasted for two years and consisted of assertive community treatment with programmes for family involvement and social skills training. Standard treatment offered contact with a community mental health centre.

MAIN OUTCOME MEASURES

Psychotic and negative symptoms (each scored from 0 to a maximum of 5) at one and two years' follow-up.

RESULTS

At one year's follow-up, psychotic symptoms changed favourably to a mean of 1.09 (standard deviation 1.27) with an estimated mean difference between groups of -0.31 (95% confidence interval -0.55 to -0.07, P = 0.02) in favour of integrated treatment. Negative symptoms changed favourably with an estimated difference between groups of -0.36 (-0.54 to -0.17, P < 0.001) in favour of integrated treatment. At two years' follow-up the estimated mean difference between groups in psychotic symptoms was -0.32 (-0.58 to -0.06, P = 0.02) and in negative symptoms was -0.45 (-0.67 to -0.22, P < 0.001), both in favour of integrated treatment. Patients who received integrated treatment had significantly less comorbid substance misuse, better adherence to treatment, and more satisfaction with treatment.

CONCLUSION

Integrated treatment improved clinical outcome and adherence to treatment. The improvement in clinical outcome was consistent at one year and two year follow-ups.

The national policy reforms for mental health services and the story of early intervention services in the United Kingdom

In this review, we summarize and review reforms to the mental health service in the United Kingdom from 1999 to the present. Our analysis is based on government documents describing the reforms and providing guidelines for their implementation. In addition, we summarize prospective studies of psychosis from the first episode and early treatment studies on the basis of existing systematic reviews. The UK mental health reforms have attracted major government funding and have been used to commission specialized ("functional") community teams for people with severe mental illness. The reforms include changes to services for first-episode psychosis, which have attracted considerable consumer support. The UK service reforms are continuing, with the aim of providing services fit for the 21st century.

Patients as parents and young people approaching adulthood: how should we manage the interface between mental health services for young people and adults?

PURPOSE OF REVIEW

The present review discusses critically recent research findings (published during the period 2003-2004) on the mental health needs of young people in transition (old adolescents and young adults), including those of young parents. Also, the evidence on effective interventions and service models is considered.

RECENT FINDINGS

Emerging evidence indicates that young people have high rates of mental health needs (in addition to high prevalence of psychiatric disorders) that may be related to life transitions. These needs often fall between the remit of adolescent/adult and mental health/social care services, and therefore are not adequately met. With the exception of mental health interventions for early psychosis and psychosocial programmes for teenage parents, there is very limited knowledge on how best to meet the mental health needs of young people in transition.

SUMMARY

It is widely recognized that young people in transition require services and interventions tailored to their characteristics, rather than a mere extension to either child/adolescent or adult services. Recent policies and research findings have led to the development of early psychosis interventions, with initial encouraging messages. Similar initiatives are required for young people with nonpsychotic disorders.