Appraising evidence for intervention effectiveness in early psychosis: conceptual framework and review of evaluation approaches

Patterns of recovery course in early intervention for FIRST episode non-affective psychosis patients: The role of timing

BACKGROUND

Prevention of symptom relapse and promotion of functional recovery are the two main goals of early intervention following a first episode of non-affective psychosis (FEP). The identification of patterns of recovery is important in developing and implementing recovery focused interventions at set time interval.

METHOD

Patterns of recovery course, in terms of symptomatic and functional remission, were explored at 1 and 3-year follow-up in a sample of 373 consecutive FEP patients. Relapses during this period were considered.

RESULTS

Four patterns of recovery course were defined: good stable (26%), good unstable (21%), poor unstable (10%), poor stable (43%). Those who met criteria for good stable recovery were more likely have less severe baseline negative symptoms (OR = 2.092; 95% CI = 0.99-4.419) and to not be diagnosed with schizophrenia (OR = 2.242; 95% CI = 1.015-4.954). Short DUP (OR = 2.152; 95% CI = 0.879-5.27) and low premorbid IQ (OR = 2.281; 95% CI = 0.954-5.457) increased the likelihood of good unstable recovery. Less severe baseline negative symptoms (OR = 3.851; 95% CI = 1.422-10.435) and single status (OR = 4.307; 95% CI = 1.014-18.293) increased the likelihood of a poor unstable recovery. Poor unstable pattern was significantly associated with a high relapse rate (73%).

CONCLUSIONS

Our results shed light on identifying different recovery patterns in FEP. Despite evidence for early intervention effectiveness, we should explore ways to prevent relapse and improve long-term recovery, particularly in reference to the role of timing in the design of interventions.

Improving access to specialized care for first-episode psychosis: an ecological model

Psychotic spectrum disorders are serious illnesses with symptoms that significantly impact functioning and quality of life. An accumulating body of literature has demonstrated that specialized treatments that are offered early after symptom onset are disproportionately more effective in managing symptoms and improving outcomes than when these same treatments are provided later in the course of illness. Specialized, multicomponent treatment packages are of particular importance, which are comprised of services offered as soon as possible after the onset of psychosis with the goal of addressing multiple care needs within a single care setting. As specialized programs continue to develop worldwide, it is crucial to consider how to increase access to such specialized services. In the current review, we utilize an ecological model of understanding barriers to care, with emphasis on understanding how individuals with first-episode psychosis interact with and are influenced by a variety of systemic factors that impact help-seeking behaviors and engagement with treatment. Future work in this area will be important in understanding how to most effectively design and implement specialized care for individuals early in the course of a psychotic disorder.

Early intervention in psychosis: strengths and limitations of services

Early intervention services were established on the basis of a number of fundamental principles, including the notions that intervening in the early stages of psychosis alters illness trajectory and prognosis, that multicomponent interventions promote psychosocial recovery and reduce iatrogenic damage, and that early targeting of non-responders reduces treatment resistance. There is growing evidence of the benefits of specialised early intervention services. These include improved clinical, social and vocational outcomes, reduced in-patient stays and better engagement. Early intervention services can also significantly reduce the risk of a second episode and are highly valued by service users and carers. Duration of treatment appears to determine long-term outcome and there remains uncertainty about how long such intensive intervention should last and whether all patients need the same length of care. Budgetary constraints are pervasive and are particularly likely to affect prodrome clinics and community awareness programmes.

The treatment of schizophrenia: Can we raise the standard of care?

OBJECTIVE

There is evidence that over time health outcomes of people with schizophrenia are deteriorating rather than improving both in terms of mortality rate and levels of morbidity, even in Australia where service resourcing is substantial. Our objective was to examine the evidence of whether poor outcomes reflect decreases in treatment effectiveness and, if so, what are the barriers to improving standards of care. This review will argue that the confidence of clinicians to diagnose schizophrenia early, and provide assertive and long-term care, may be being undermined by a series of controversies in the published literature and discrepancies in clinical practice guidelines.

METHOD

A critical review was conducted of the evidence regarding six issues of high clinical relevance to the treatment of schizophrenia formulated as questions: (1) Is schizophrenia a progressive disease? (2) Does relapse contribute to disease progression and treatment resistance? (3) When should the diagnosis of schizophrenia be made? (4) Should maintenance antipsychotic medication be discontinued in fully remitted first-episode patients? (5) Do antipsychotic medications cause deleterious reductions in cortical grey matter volumes? and (6) Are long-acting injectable antipsychotics more effective in reducing relapse rate compared to oral formulations?

RESULTS

There is reliable evidence for schizophrenia being a progressive disease with emergent treatment resistance in most cases, that relapse contributes to this treatment resistance, that maintenance antipsychotic medication should not be discontinued in remitted first-episode patients, that antipsychotic medication does not appear to cause deleterious grey matter volume changes, that maintenance antipsychotic medication reduces the mortality rate in schizophrenia and that long-acting injectable antipsychotics are more effective in preventing relapse than oral formulations.

CONCLUSION

There is an urgent need to re-engineer the early management of schizophrenia and to routinely evaluate this type of innovation within practice-based research networks. A proposal for an assertive treatment algorithm is included.

A first step in system improvement: a survey of Early Psychosis Intervention Programmes in Ontario

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.

Assessing the performance of mental health service facilities for meeting patient priorities and health service responsiveness

The World Health Organisation has defined health service responsiveness as one of the key-objectives of health systems. Health service responsiveness relates to the ability to respond to service users' legitimate expectations on non-medical issues when coming into contact with the services of a healthcare system. It is defined by the areas showing respect for persons and patient orientation. Health service responsiveness is particularly relevant to mental health services, due to the specific vulnerability of mental health patients but also because it matches what mental health patients consider as good quality of care as well as their priorities when seeking healthcare. As (mental) health service responsiveness applies equally to all concerned services it would be suitable as a universal indicator for the quality of services' performance. However, performance monitoring programs in mental healthcare rarely assess health service performance with respect to meeting patient priorities. This is in part due of patient priorities as an outcome being underrepresented in studies that evaluate service provision. The lack of studies using patient priorities as outcomes transmits into evidence based guidelines and subsequently, into underrepresentation of patient priorities in performance monitoring. Possible ways out of this situation include more intervention studies using patient priorities as outcome, considering evidence from qualitative studies in guideline development and developing performance monitoring programs along the patient pathway and on key-points of relevance for service quality from a patient perspective.

Essential components of early intervention programs for psychosis: Available intervention services in the United States

Programs providing interventions for early psychosis are becoming commonplace in the United States (U.S.); however, the characteristics of existing services remain undocumented. We examined program characteristics, clinical services, and program eligibility criteria for outpatient early intervention programs across the U.S. using a semi-structured telephone interview. Content analysis was used to identify the presence or absence of program components, based in part on a recent list of essential evidence-based components recommended for early intervention programs (Addington, MacKenzie, Norman, Wang and Bond, 2013) as well as program characteristics, including eligibility criteria. A total of 34 eligible programs were identified; 31 (91.2%) program representatives agreed to be interviewed. Of the examined components, the most prevalent were individual psychoeducation and outcomes tracking; the least prevalent were outreach services and communication with inpatient units. The populations served by US programs were most frequently defined by restrictions on the duration of psychosis and age. This study provides critical feedback on services for the early psychosis population and identifies research to practice gaps and areas for future improvement.

Molecular detection of knockdown resistance (kdr) in Blattella germanica (Blattodea: Blattellidae) from northwestern Iran

Pyrethroid insecticides are highly insecticidal compounds that are widely used against the German cockroach, a significant household insect pest. In several insect species, there is a point mutation in the para-type sodium channel gene associated with knockdown resistance (kdr). In the current study, genomic DNA was analyzed in the region where the kdr and super-kdr (an enhanced form of pyrethroid resistance) mutations reside in Blatella germanica (L., 1767) (Blattodea: Blattellidae) collected from Iran. Studies on the extracted DNA from hand-captured German cockroach specimens were conducted by polymerase chain reaction and sequencing to detect related mutations. The kdr mutation, substitution of G for C (L1014F), which results in amino acid replacement (leucine with phenylalanine), was detected in all 18 sequenced specimens from three different locations. However, the super-kdr mutation (M918T), which is detected in super-kdr house flies, was not found in the sequences of the current study. The high ratio of the kdr mutation in a field population of B. germanica in Urmia confirms that the individuals are homozygous. These data should be helpful in designing and implementing a control program and resistance management.

A scoping review of scoping reviews: advancing the approach and enhancing the consistency

Background

The scoping review has become an increasingly popular approach for synthesizing research evidence. It is a relatively new approach for which a universal study definition or definitive procedure has not been established. The purpose of this scoping review was to provide an overview of scoping reviews in the literature.

Methods

A scoping review was conducted using the Arksey and O'Malley framework. A search was conducted in four bibliographic databases and the gray literature to identify scoping review studies. Review selection and characterization were performed by two independent reviewers using pretested forms.

Results

The search identified 344 scoping reviews published from 1999 to October 2012. The reviews varied in terms of purpose, methodology, and detail of reporting. Nearly three-quarter of reviews (74.1%) addressed a health topic. Study completion times varied from 2 weeks to 20 months, and 51% utilized a published methodological framework. Quality assessment of included studies was infrequently performed (22.38%).

Conclusions

Scoping reviews are a relatively new but increasingly common approach for mapping broad topics. Because of variability in their conduct, there is a need for their methodological standardization to ensure the utility and strength of evidence. © 2014 The Authors. Research Synthesis Methods published by John Wiley & Sons, Ltd.

A new generation of pragmatic trials of psychosocial interventions is needed

This Editorial addresses the crucial issue of which research methodology is most suited for capturing the complexity of psychosocial interventions conducted in 'real world' mental health settings. It first examines conventional randomized controlled trial (RCT) methodology and critically appraises its strengths and weaknesses. It then considers the specificity of mental health care treatments and defines the term 'complex' intervention and its implications for RCT design. The salient features of pragmatic RCTs aimed at generating evidence of psychosocial intervention effectiveness are then described. Subsequently, the conceptualization of pragmatic RCTs, and of their further developments - which we propose to call 'new generation' pragmatic trials - in the broader routine mental health service context, is explored. Helpful tools for planning pragmatic RCTs, such as the CONSORT extension for pragmatic trials, and the PRECIS tool are also examined. We then discuss some practical challenges that are involved in the design and implementation of pragmatic trials based on our own experience in conducting the GET UP PIANO Trial. Lastly, we speculate on the ways in which current ideas on the purpose, scope and ethics of mental health care research may determine further challenges for clinical research and evidence-based practice.

Evaluating interventions againstSalmonellain broiler chickens: applying synthesis research in support of quantitative exposure assessment

A scoping study and systematic review-meta-analyses (SR-MAs) were conducted to evaluate the effectiveness of various interventions forSalmonellain broiler chicken, from grow-out farm to secondary processing. The resulting information was used to inform a quantitative exposure assessment (QEA) comparing various control options within the context of broiler chicken production in Ontario, Canada. Multiple scenarios, including use of two separate on-farm interventions (CF3 competitive exclusion culture and a 2% lactose water additive), a package of processing interventions (a sodium hydroxide scald water disinfectant, a chlorinated post-evisceration spray, a trisodium phosphate pre-chill spray and chlorinated immersion chilling) a package consisting of these farm and processing interventions and a hypothetical scenario (reductions in between-flock prevalence and post-transport concentration), were simulated and compared to a baseline scenario. The package of on-farm and processing interventions was the most effective in achieving relative reductions (compared to baseline with no interventions) in the concentration and prevalence ofSalmonellaby the end of chilling ranging from 89·94% to 99·87% and 43·88% to 87·78%, respectively. Contaminated carcasses entering defeathering, reductions in concentration due to scalding and post-evisceration washing, and the potential for cross-contamination during chilling had the largest influence on the model outcomes under the current assumptions. Scoping study provided a transparent process for mapping out and selecting promising interventions, while SR-MA was useful for generating more precise and robust intervention effect estimates for QEA. Realization of the full potential of these methods was hampered by low methodological soundness and reporting of primary research in this area.

Is a national framework for implementing early psychosis services necessary? Results of a survey of Australian mental health service directors

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.