Is treating patients with first-episode psychosis cost-effective?

Effectiveness of the early intervention service for first-episode psychosis in Navarra (PEPsNa): Broadening the scope of outcome measures

BACKGROUND

This study compares the effectiveness of a new early intervention service for firstepisode psychosis (FEP) in patients under conventional treatment. Six primary and 10 secondary outcome measures are used to better characterize the comparative effectiveness between two FEP groups.

METHODS

This study plans to enroll 250 patients aged 15-55 years with FEP from all inpatient and outpatient mental health services and primary health care from January 2020 until December 2022. The control group will be composed of 130 FEP patients treated in mental health centers in the 2 years prior to the start of PEPsNa (Programa de Primeros Episodios de Psicosis de Navarra). The primary outcome measures are symptomatic remission, functional recovery, personal recovery, cognitive performance, functional capacity in real-world settings, and costs. The secondary outcome measures are duration of untreated psychosis, substance abuse rate, antipsychotic monotherapy, minimal effective dose of antipsychotic drugs, therapeutic alliance, drop-out rate, number of relapses, global mortality and suicidality, resource use, and general satisfaction in the program.

DISCUSSION

This study arises from the growing need to broaden the scope of outcome measures in FEP patients and to account for unmet needs of recovery for FEPs. It aims to contribute in the dissemination of the NAVIGATE model in Europe and to provide new evidence of the effectiveness of early intervention services for stakeholders of the National Health Service.

Early intervention service systems for youth mental health: integrating pluripotentiality, clinical staging, and transdiagnostic lessons from early psychosis

Challenges associated with operationalising services for the at-risk mental state for psychosis solely in that same diagnostic silo are increasingly well recognised-namely, the differential risk for psychosis being a function of sampling enrichment strategies, declining transition rates to psychosis, questions regarding the validity of transition as an outcome, and the frequent development of non-psychotic disorders. However, recent epidemiological and clinical research suggests that not all threshold-level psychoses are likely to occur homotypically; early-stage non-psychotic syndromes might exhibit heterotypic shifts to a first episode of psychosis, without an identifiable at-risk mental state. These findings, along with the relevance of outcomes beyond traditional diagnoses or syndromes, have substantive implications for developing next-generation early intervention infrastructures. Along with the idea of general at-risk clinics for early-stage pluripotential syndromes, we examine how this reality might affect service design, such as the need for close linkage with centres of expertise for threshold-level disorders when transitions to later stages occur, the balance between generic and specific interventions amid the need for person-centred care, and the challenges this reorientation might pose for broader mental health systems.

Baby or bathwater? Referrals of "non-cases" in a targeted early identification intervention for psychosis

PURPOSE

To explore the unintended impact of a targeted case identification (TCI) campaign for first episode psychosis (FEP) on people not experiencing FEP ("non-cases") with respect to referral patterns and reasons for being a non-case.

METHODS

Sources of referral, reasons for being a non-case, and subsequent referral destinations of non-cases were examined before and after a TCI.

RESULTS

Following the TCI, a greater proportion of non-cases lived outside the study catchment area. A smaller proportion was referred by the parent hospital's emergency room or had a substance-induced psychosis.

CONCLUSIONS

TCIs for FEP may have unintended effects, with implications for early case identification and early intervention services.

Intervention précoce pour la psychose : concepts, connaissances actuelles et orientations futures

Cet article fournit un survol de la logique de l’intervention précoce pour psychose, de ses fondements théoriques et de la littérature essentielle sur le concept. L’intervention précoce repose sur l’hypothèse de la période critique, qui vient accentuer l’importance des premiers stades de la maladie, et sur les résultats d’études dans le domaine, qui suggère que la durée d’une psychose non traitée en influence le pronostic. L’intervention précoce facilite l’accès à un traitement spécialisé adapté à la phase de la maladie par un processus de recommandations médicales plus ouvert, des délais rapides et l’éducation du public et des praticiens sur la psychose. L’intervention précoce, qui dure généralement deux ans à partir du dépistage, comprend une prise en charge intensive et des médicaments antipsychotiques à faible dose. L’accent est mis sur le fonctionnement social, l’intervention familiale, l’attention précoce aux troubles connexes ainsi qu’une alliance thérapeutique entre le jeune et sa famille. Selon les données scientifiques disponibles, une telle intervention donne de meilleurs résultats que les soins typiquement offerts. Les critiques du concept visent la qualité des études en sa faveur, sa mise en oeuvre, la répartition des ressources en intervention précoce et son utilité pour les personnes présentant un risque élevé de psychose. En termes de disponibilité et d’élaboration de politiques en intervention précoce, le Royaume-Uni détient une avance certaine, alors que le Canada se situe au milieu, et les États-Unis au bas de l’échelle. Au Québec, les résultats varient et d’autres études et investissements sont nécessaires. Récemment, le concept d’intervention précoce a servi d’exemple à des mesures plus importantes visant la transformation des soins de santé mentale des jeunes, ce qui constitue une toute nouvelle percée au Canada.

Rates of first episode of psychosis in a defined catchment area in Greece

This is the first Greek study presenting epidemiologic data on first-episode psychosis (FEP) patients in a defined catchment area. Data for first episode psychotic patients during a two-year period (2008 and 2009) were obtained by all the mental health providers in the area, public or private. A total of 132 FEP patients were examined in the 2-year period in the catchment area. Most of the patients (61.4%) were diagnosed and treated by private practicing psychiatrists. Statistical analysis showed no differences between the two sectors in terms of patients’ age, gender, family and social status, profession and duration of untreated psychosis (median duration 6 months). Patients who were abusing substances and had no family psychiatric history were less likely been treated in the public sector. Immigrants comprised only a small proportion of the patients, probably because they have difficulties in accessing the mental health system.

Cost-effectiveness of early intervention in first-episode psychosis: economic evaluation of a randomised controlled trial (the OPUS study)

BACKGROUND

Information about the cost-effectiveness of early intervention programmes for first-episode psychosis is limited.

AIMS

To evaluate the cost-effectiveness of an intensive early-intervention programme (called OPUS) (trial registration NCT00157313) consisting of enriched assertive community treatment, psychoeducational family treatment and social skills training for individuals with first-episode psychosis compared with standard treatment.

METHOD

An incremental cost-effectiveness analysis of a randomised controlled trial, adopting a public sector perspective was undertaken.

RESULTS

The mean total costs of OPUS over 5 years (€123,683, s.e. = 8970) were not significantly different from that of standard treatment (€148,751, s.e. = 13073). At 2-year follow-up the mean Global Assessment of Functioning (GAF) score in the OPUS group (55.16, s.d. = 15.15) was significantly higher than in standard treatment group (51.13, s.d. = 15.92). However, the mean GAF did not differ significantly between the groups at 5-year follow-up (55.35 (s.d. = 18.28) and 54.16 (s.d. = 18.41), respectively). Cost-effectiveness planes based on non-parametric bootstrapping showed that OPUS was less costly and more effective in 70% of the replications. For a willingness-to-pay up to €50,000 the probability that OPUS was cost-effective was more than 80%.

CONCLUSIONS

The incremental cost-effectiveness analysis showed that there was a high probability of OPUS being cost-effective compared with standard treatment.

Is early intervention for psychosis feasible and effective?

Services that provide comprehensive, early intervention (EI) have shown promise in improving long-term outcomes in schizophrenia. This article reviews the rationale and salient concepts relevant to understanding the growing EI literature. A selective review of studies evaluating the effectiveness of integrated EI is followed by a discussion of feasibility, especially in the US context. Finally, the authors present a framework that seeks to integrate activities traditionally categorized and separated as discovery and implementation. This framework is offered as a way to advance both goals.

Symptom and functional outcomes for a 5 year early intervention program for psychoses

There continues to be controversy concerning the long term benefits of specialized early intervention programs (SEI) for psychotic disorders. Recent reports of five year outcomes for SEI programs indicate that benefits of early intervention programs at two year follow-up have disappeared at five years. The Prevention and Early Intervention Program for Psychoses (PEPP) in London, Ontario offers continuity of care for five years, with a lower intensity level of specialized intervention after the initial two years. In this paper we examine whether the outcomes observed at two years were maintained at five year follow-up. In addition, it was possible to compare PEPP outcomes with those of the OPUS project at two and five years. Results indicate that improvement of symptoms between entry into PEPP and two year follow-up were maintained at five years. In addition, there was further improvement in global functioning between two and five year follow-up. Comparison of PEPP outcomes at two and five year follow-up to those of OPUS suggest that longer term continuity of care within SEI is associated with continuing benefits at least with respect to level of positive symptoms and functioning.

Detecting emotional disorder in young people in primary care

PURPOSE OF REVIEW

Screening young people for emotional disorder in primary care has seemed sensible given most attend annually and most mental disorder is undetected. Yet evidence supporting screening has been scant. This review considers recent progress around conceptual frameworks, epidemiological findings, accuracy of available instruments and evidence for effectiveness of screening in reducing the burden of emotional disorders.

RECENT FINDINGS

Despite better evidence about the accuracy of screens in identifying adolescent depression and possible benefits of early intervention with current treatments, demonstration of improved health outcomes and cost-effectiveness is still lacking. Even when screening detects mental disorder other factors such as readiness for care and availability of effective treatments may affect responses. Best results are obtained when screening is linked to collaborative models of care. Evidence around harms from screening is scant but debate exists over potential harms of false-positives such as stigma and increased strain on healthcare resources.

SUMMARY

There is growing consensus that, if screening for emotional disorder is to be effective in primary care, facilitated access of identified young people to effective treatment options is necessary. Further research is required to demonstrate that routine screening will improve mental health outcomes and be cost-effective.

Psychiatrists and neuroscientists of Indian origin in Canada: Glimpses

Psychiatrists of Indian origin are popular in Canada, being firmly rooted in the Canadian mental health system, and they have been making considerable contributions internationally. The Indian Psychiatric Society has long been collaborating with and inviting contributions from overseas Indian psychiatrists, particularly those in academics, and this collaboration has fructified well. There are several different challenges these psychiatrists have had to face in their own specialty work, with having to adjust to a new culture, new ways of living, and new ways of work. Our colleagues of Indian origin have demonstrated excellence in almost all fields of mental health and neurosciences. There are many popular teachers, outstanding researchers, and psychiatrists in community practice and community development. The Early Psychosis Program, Mood and Anxiety Program, Perinatal Psychiatry, Women's Mental Health, and Postpartum Mental Health are some of their key areas of research. Our basic scientists are involved in experimental design, neurochemistry, imaging, and genetics, where they have made their mark with acclaim. This article highlights some of the achievements of a few members and is by no means completely representative of the entire work that psychiatrists of Indian origin are doing in Canada, providing readers with a glimpse of our labors away from home.