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Williams R, Ostinelli EG, Agorinya J, Minichino A, De Crescenzo F, Maughan D, Puntis S, Cliffe C, Kurtulmus A, Lennox BR, Cipriani A. Comparing interventions for early psychosis: a systematic review and component network meta-analysis. EClinicalMedicine 2024; 70:102537. [PMID: 38516103 PMCID: PMC10955207 DOI: 10.1016/j.eclinm.2024.102537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/23/2024] [Accepted: 02/23/2024] [Indexed: 03/23/2024] Open
Abstract
Background 'Early Intervention in Psychosis' (EIP) services have been associated with improved outcomes for early psychosis. However, these services are heterogeneous and many provide different components of treatment. The impact of this variation on the sustained treatment effects is unknown. Methods We performed a systematic review and component network meta-analysis (cNMA) of randomised controlled trials (RCTs) that compared specialised intervention services for early psychosis. We searched CENTRAL (published and unpublished), EMBASE, MEDLINE, CINAHL, PsycINFO and Web of Science from inception to February 2023. Primary outcomes were negative and positive psychotic symptoms at 3-month and 1-year follow-up and treatment dropouts. Secondary outcomes were depressive symptoms and social functioning at 1-year follow-up. We registered a protocol for our study in PROSPERO (CRD42017057420). Findings We identified 37 RCTs including 4599 participants. Participants' mean age was 25.8 years (SD 6.0) and 64.0% were men. We found evidence that psychological interventions (this component grouped all psychological treatment intended to treat, or ameliorate the consequences of, psychotic symptoms) are beneficial for reducing negative symptoms (iSMD -0.24, 95% CI -0.44 to -0.05, p = 0.014) at 3-month follow-up and may be associated with clinically relevant benefits in improving social functioning scores at 1-year follow-up (iSMD -0.52, 95% CI -1.05 to 0.01, p = 0.052). The addition of case management has a beneficial effect on reducing negative symptoms (iSMD -1.17, 95% CI -2.24 to -0.11, p = 0.030) and positive symptoms (iSMD -1.05, 95% CI -2.02 to -0.08, p = 0.033) at 1-year follow-up. Pharmacotherapy was present in all trial arms, meaning it was not possible to examine the specific effects of this component. Interpretation Our findings suggest psychological interventions and case management in addition to pharmacotherapy as the core components of services for early psychosis to achieve sustained clinical benefits. Our conclusions are limited by the small number of studies and sparsely connected networks. Funding National Institute for Health and Care Research.
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Affiliation(s)
- Ryan Williams
- Department of Brain Sciences, Imperial College London, London, UK
- South London & Maudsley NHS Foundation Trust, Maudsley Hospital, London, UK
| | - Edoardo G. Ostinelli
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | | | - Amedeo Minichino
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Franco De Crescenzo
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Daniel Maughan
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Stephen Puntis
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Charlotte Cliffe
- Biomedical Research Centre, Kings College London, London, UK
- Surrey and Borders Partnership NHS Foundation Trust, UK
| | - Ayse Kurtulmus
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
- Department of Psychiatry, Istanbul Medeniyet University, Istanbul, Turkey
| | - Belinda R. Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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O’Connell N, O’Connor K, McGrath D, Vagge L, Mockler D, Jennings R, Darker CD. Early Intervention in Psychosis services: A systematic review and narrative synthesis of the barriers and facilitators to implementation. Eur Psychiatry 2021; 65:e2. [PMID: 34913421 PMCID: PMC8792869 DOI: 10.1192/j.eurpsy.2021.2260] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/09/2021] [Accepted: 12/09/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Early intervention in psychosis (EIP) services target the early manifestation of psychosis and provide multidisciplinary care. They demonstrate effectiveness and cost-effectiveness. Implementation of EIP services is inconsistent and piecemeal. This systematic review and narrative synthesis aims to identify barriers and facilitators to EIP service implementation. METHODS We conducted an electronic search of databases (EMBASE, Medline, Web of Science, and PsychINFO) to detect papers reporting EIP service implementation findings and associated barriers and facilitators. The search occurred between June to August 2020, and again in January 2021. Articles meeting inclusion criteria were extracted and narratively synthesized. A quality assessment was conducted using the Mixed Methods Appraisal Tool. RESULTS Twenty-three studies were selected. The most common study design was descriptive accounts of implementation. Patient age ranged varied from 14 to 35 years. We identified three barrier and facilitator domains: (a) system; (b) services; and (c) staff, and a range of subdomains. The most frequent subdomains were "funding" and "strength of collaboration and communication between EIP and outside groups and services". Associations between domains and subdomains were evident, particularly between systems and services. CONCLUSIONS A range of barriers and facilitators to EIP implementation exist. Some of these are generic factors germane across health systems and services, while others are specific to EIP services. A thorough prior understanding of these challenges and enablers are necessary before implementation is attempted. Accounting for these issues within local and national contexts may help predict and increase the likelihood of services' success, stability, and longevity.
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Affiliation(s)
- N. O’Connell
- Discipline of Public Health and Primary Care, Institute of Population
Health, School of Medicine, Trinity College Dublin,
Dublin, Ireland
| | - K. O’Connor
- National Clinical Programme for Early Intervention in Psychosis,
Health Service ExecutiveDublin, Ireland
- Rise, South Lee Mental Health Services, Cork & Department of
Psychiatry, University College Cork
| | - D. McGrath
- Discipline of Public Health and Primary Care, Institute of Population
Health, School of Medicine, Trinity College Dublin,
Dublin, Ireland
| | - L. Vagge
- Discipline of Public Health and Primary Care, Institute of Population
Health, School of Medicine, Trinity College Dublin,
Dublin, Ireland
| | - D. Mockler
- Rise, South Lee Mental Health Services, Cork & Department of
Psychiatry, University College Cork
- Trinity College Dublin Library, Trinity College
Dublin, Dublin, Ireland
| | - R. Jennings
- National Clinical Programme for Early Intervention in Psychosis,
Health Service ExecutiveDublin, Ireland
| | - C. D. Darker
- Discipline of Public Health and Primary Care, Institute of Population
Health, School of Medicine, Trinity College Dublin,
Dublin, Ireland
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Addington D, Cheng CC, French P, Killackey E, Melau M, Meneghelli A, Nordentoft M, Nossel I, Preti A, Smith J. International application of standards for health care quality, access and evaluation of services for early intervention in psychotic disorders. Early Interv Psychiatry 2021; 15:723-730. [PMID: 32449289 DOI: 10.1111/eip.12990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 04/09/2020] [Accepted: 04/28/2020] [Indexed: 11/27/2022]
Abstract
AIM Standards for health care quality, access and evaluation of early intervention in psychosis services are required to assess implementation, provide accountability to service users and funders and support quality assurance. The aim of this article is to review the application of standards in Europe and North America. METHODS Descriptive methods will be used to illustrate the organizational context in which standards are being applied and used, specific measures being applied and results so far. RESULTS Both fidelity scales and quality indicators of health care are being used. Fidelity scales are being applied in Australia, Canada, Denmark, Italy and United States. In England, quality indicators derived from the National Institute for Health and Care Excellence guidance are being used. CONCLUSION In the last 4 years, significant progress has been made in the development and application of measures that assess quality and access to evidence-based practices for early intervention in psychosis services. This represents an important step towards providing accountability, improving outcomes and service user experience. The methods used allow for comparison between the services that are assessed with the same methods, but there is a need to compare the different methods. Further research is also required to explore links between quality of care and outcomes for community mental health services that deliver early intervention in psychotic disorders.
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Affiliation(s)
- Donald Addington
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | | | - Paul French
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, UK
| | - Eoin Killackey
- Division Medicine, Dentistry And Health Sciences, Orygen, National Centre of Excellence in Youth Mental Health, Melbourne, Australia
| | - Marianne Melau
- Psychiatric Centre Copenhagen, University of Copenhagen, Denmark
| | - Anna Meneghelli
- Azienda Ospedaliera, Ospedale Niguarda Ca' Granda, Programma 2000, Milan, Italy
| | - Merete Nordentoft
- University of Copenhagen · Psychiatric Center Copenhagen, Psychiatric Center Copenhagen, Denmark
| | - Ilana Nossel
- Columbia University, Department of Psychiatry, New York State Psychiatric Institute, New York, USA
| | - Antonio Preti
- Genneruxi Medical Center, Programma 2000, Milan, Italy
| | - Jo Smith
- School of Allied Health and Community, University of Worcester, Worcester, UK
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Csillag C, Nordentoft M, Mizuno M, McDaid D, Arango C, Smith J, Lora A, Verma S, Di Fiandra T, Jones PB. Early intervention in psychosis: From clinical intervention to health system implementation. Early Interv Psychiatry 2018; 12:757-764. [PMID: 29143456 DOI: 10.1111/eip.12514] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 09/06/2017] [Accepted: 09/13/2017] [Indexed: 12/20/2022]
Abstract
AIM Early intervention in psychosis (EIP) is a well-established approach with the intention of early detection and treatment of psychotic disorders. Its clinical and economic benefits are well documented. This paper presents basic aspects of EIP services, discusses challenges to their implementation and presents ideas and strategies to overcome some of these obstacles. METHODS This paper is a narrative review about the evidence supporting EIP, with examples of successful implementation of EIP and of cases where major obstacles still need to be overcome. RESULTS Experience from successfully implemented EIP services into the mental healthcare system have generated evidence, concepts and specific strategies that might serve as guidance or inspiration in other countries or systems where EIP is less well developed or not developed at all. Previous experience has made clear that evidence of clinical benefits alone is not enough to promote implementation, as economic arguments and political and social pressure have shown to be important elements in efforts to achieve implementation. CONCLUSIONS Users' narratives, close collaboration with community organizations and support from policy-makers and known people within the community championing early intervention (EI) services are just a few of the approaches that should be considered in campaigns for implementation of EI services. Fast progress in implementation is possible.
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Affiliation(s)
- Claudio Csillag
- Mental Health Centre North Zealand, University of Copenhagen, Hilleroed, Denmark
| | | | - Masafumi Mizuno
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
| | - David McDaid
- Personal Social Services Research Unit, Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Celso Arango
- Hospital General Universitario Gregorio Marañón, Universidad Complutense, School of Medicine, CIBERSAM, IiSGM, Madrid, Spain
| | - Jo Smith
- Institute of Health and Society, University of Worcester, Worcester, UK
| | | | - Swapna Verma
- Department of Early Psychosis Intervention, Institute of Mental Health, Singapore, Singapore
| | | | - Peter B Jones
- Department of Psychiatry, University of Cambridge, Cambridge, UK
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Durbin J, Selick A, Hierlihy D, Moss S, Cheng C. A first step in system improvement: a survey of Early Psychosis Intervention Programmes in Ontario. Early Interv Psychiatry 2016; 10:485-493. [PMID: 25366518 DOI: 10.1111/eip.12201] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 09/24/2014] [Indexed: 11/30/2022]
Abstract
AIM Ontario, Canada is a large province with a geographically dispersed population. Early psychosis intervention (EPI) programmes are available province-wide, with delivery approaches adapted to context. This study examined EPI programme delivery in relation to recently released provincial EPI Program Standards, and variations based on geographic context. METHODS The data source was a province-wide key informant survey of early psychosis programmes conducted after release of the Standards. Chi-squared tests compared large- and small-area programmes on selected programme structural features and perceived adherence to 19 service components. RESULTS Responses were obtained from 52 programme sites, including 21 small-area programmes with 1 to 2 staff. In general, frequency of EPI delivery was highest for individual assessment and treatment components, and moderate for social supports and family support. Implementation was lowest for public education, early detection and recovery planning. Small-area programmes reported lower implementation for over half of the components, with differences statistically significant for psychiatric assessment and physical health monitoring. CONCLUSION Since the release of the Standards, the Ontario Ministry of Health has partnered with a provincial network of EPI stakeholders to support practice improvement. This survey identified components where more implementation support is needed, overall and for rural area delivery. Ultimately, systematic monitoring of programme fidelity and measuring client outcomes are key to advancing the quality of EPI programme delivery.
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Affiliation(s)
- Janet Durbin
- Performance Measurement and Implementation Research Unit, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
| | - Avra Selick
- Performance Measurement and Implementation Research Unit, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | | | - Sarah Moss
- Performance Measurement and Implementation Research Unit, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Chiachen Cheng
- First Place, Canadian Mental Health Association - Thunder Bay Branch, Thunder Bay, Ontario, Canada
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Abstract
AbstractThis paper examines the concept of early intervention in psychosis at primary and secondary prevention levels. Examples of early intervention service models from different countries are presented and we discuss current evidence for efficacy. We highlight the Irish experience of early intervention to date, and discuss future implementation of early intervention services in Ireland.
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Phillipson A, Akroyd M, Carley J. Audit of discharges from a regional service in the United Kingdom. Early Interv Psychiatry 2014; 8:91-7. [PMID: 23773423 DOI: 10.1111/eip.12061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 05/04/2013] [Indexed: 11/29/2022]
Abstract
AIM As early intervention in psychosis (EI) continues to develop, clinical governance maintains an important role in the 'real world' analysis of services. This paper details an audit of all discharges from a regional early intervention service in the United Kingdom, providing benchmarking information on service structure, interventions and outcomes. The background places the service in the context of national and international guidelines. METHODS All discharges between service inception in 2004 and February 2011 were retrospectively examined and audited according to identified standards, based upon international and national guidelines. A total of 110 patients were discharged from the EI service after a period of involvement of at least 6 months. RESULTS A high proportion of service users (55%) had their care transferred back to primary care after discharge. Physical health and social needs were well addressed, and almost half of individuals were in education, training or employment upon discharge. Most service users (69%) did not require inpatient admission during their involvement with the service. Although the majority had psychological, pharmacological and physical health needs addressed, there remained room for improvement when measured against identified standards. CONCLUSIONS This paper details outcomes of every patient seen by an EI service since inception, providing valuable benchmarking information for those involved in management of similar services, service redevelopment, commissioning, and implementation of evidence-based practice. The proportion of service users in education, training or employment after discharge exceeded expectations considerably.
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Affiliation(s)
- Adrian Phillipson
- North Derbyshire Early Intervention in Psychosis Service, Wye House, Newholme Hospital, Bakewell, Derbyshire, UK
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McCrone P, Singh SP, Knapp M, Smith J, Clark M, Shiers D, Tiffin PA. The economic impact of early intervention in psychosis services for children and adolescents. Early Interv Psychiatry 2013; 7:368-73. [PMID: 23343433 DOI: 10.1111/eip.12024] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 07/31/2012] [Indexed: 11/29/2022]
Abstract
AIMS To develop and populate a plausible model of the impact of early intervention (EI) for children and adolescents with psychosis to estimate potential short-term health-related cost savings compared to generic Child and Adolescent Mental Health Services (CAMHS). METHOD A decision-tree-based model for EI in CAMHS was developed. The model was populated using data relating to the use of inpatient care and EI service activity for people aged under 18 from an area of North East England. Data were abstracted from the National Health Service clinical reporting systems for 2001-2008. Sensitivity analyses were performed to examine costs associated with the model under differing assumptions. RESULTS EI delivered cost savings of £4814 per patient compared to care provided by generic CAMHS. Cost savings were predominantly a consequence of reduced length of hospital admissions for patients served by the EI team. The findings were robust to sensitivity analyses. CONCLUSIONS These findings suggest that EI services for children and adolescents with psychosis provide potential direct health cost savings comparable to those observed for working-age adults.
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Affiliation(s)
- Paul McCrone
- Centre for the Economics of Mental and Physical Health, King's College London, London, UK
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Welsh P, Tiffin PA. Experience of child and adolescent mental health clinicians working within an at-risk mental state for psychosis service: a qualitative study. Early Interv Psychiatry 2012; 6:207-11. [PMID: 22404782 DOI: 10.1111/j.1751-7893.2012.00352.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To qualitatively examine the common experiences of child and adolescent mental health clinicians working with adolescents suspected of having an 'at-risk mental state' (ARMS) for psychosis. METHODS A semistructured interview was conducted with six experienced child and adolescent mental health clinicians working in North East England. RESULTS A thematic analysis of clinicians' experiences indicated that the identification and management of an ARMS within this patient group is particularly complex. In terms of treatment options, approaches that promoted social inclusion were favoured, but the use of antipsychotic medication was perceived as a 'last resort', requiring serious consideration. Clear guidelines and an overall consensus were judged to be lacking in terms of coordinating care and multi-agency working practices. CONCLUSIONS Establishing a formalized care pathway that also incorporates regular training and supervision may be required by this and other clinical services working with adolescents suspected of having an ARMS. Improved identification, a firmer evidence base regarding treatment practices and clear guidelines are required for this age group. This need will become more urgent should a psychosis risk syndrome be included as a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).
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Affiliation(s)
- Patrick Welsh
- School for Health, The Wolfson Research Institute, Durham University, Queen's Campus, Stockton-on-Tees, UK.
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Catts SV, Evans RW, O'Toole BI, Carr VJ, Lewin T, Neil AL, Harris MG, Frost ADJ, Crissman BR, Eadie K. Is a national framework for implementing early psychosis services necessary? Results of a survey of Australian mental health service directors. Early Interv Psychiatry 2010; 4:25-30. [PMID: 20199477 DOI: 10.1111/j.1751-7893.2009.00157.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM Expert opinion holds that the rate of implementation of specialist services for first presentation psychosis in Australia is much too slow. We aimed to collect evidence regarding this view from the first national survey of adult public mental health services about their self-reported efforts to implement specialist early psychosis intervention (EPI). METHODS Using a purpose-designed Census form for assessing EPI implementation, adult public mental health service directors throughout Australia were asked about EPI-relevant local service activities. RESULTS Sixty Census forms were returned (response rate = 61%), representing a total catchment population of 12.5 million people. A minority of services reported high levels of EPI implementation, which varied widely between area services and across state and territory jurisdictions. Rural and remote services were overrepresented in the lowest levels of reported EPI implementation. Only one service characteristic, the value of identifiable funding committed specifically to EPI, was predictive of level of reported EPI implementation. CONCLUSIONS The disturbingly high levels of variability in EPI implementation across jurisdictions suggest a pressing need for a set of nationally agreed uniform EPI implementation standards. Additional specific strategies for rural and remote mental health services may be needed for these services to implement EPI.
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Affiliation(s)
- Stanley V Catts
- Discipline of Psychiatry, University of Queensland, Queensland, Australia.
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Tiffin P, Morrison M. AN EARLY INTERVENTION IN PSYCHOSIS (EIP) SERVICE FOR ADOLESCENTS: THE APPLICATION OF PSYCHOTHERAPEUTIC PRINCIPLES. PSYCHOANALYTIC PSYCHOTHERAPY 2007. [DOI: 10.1080/02668730701698285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Birchwood M. Commentary on Tiffin et al.'s 'From commitment to reality - early intervention in psychosis services in England'. Reasons to be cheerful. Early Interv Psychiatry 2007; 1:109. [PMID: 21352116 DOI: 10.1111/j.1751-7893.2007.00016.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Max Birchwood
- School of Psychology, University of Birmingham, Early Intervention Service, Birmingham, UK
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