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Early intervention services, cognitive–behavioural therapy and family intervention in early psychosis: systematic review

  • Victoria Bird (a1), Preethi Premkumar (a2), Tim Kendall (a3), Craig Whittington (a4), Jonathan Mitchell (a5) and Elizabeth Kuipers (a6)...

Abstract

Background

Early intervention services for psychosis aim to detect emergent symptoms, reduce the duration of untreated psychosis, and improve access to effective treatments.

Aims

To evaluate the effectiveness of early intervention services, cognitive–behavioural therapy (CBT) and family intervention in early psychosis.

Method

Systematic review and meta-analysis of randomised controlled trials of early intervention services, CBT and family intervention for people with early psychosis.

Results

Early intervention services reduced hospital admission, relapse rates and symptom severity, and improved access to and engagement with treatment. Used alone, family intervention reduced relapse and hospital admission rates, whereas CBT reduced the severity of symptoms with little impact on relapse or hospital admission.

Conclusions

For people with early psychosis, early intervention services appear to have clinically important benefits over standard care. Including CBT and family intervention within the service may contribute to improved outcomes in this critical period. The longer-term benefits of this approach and its component treatments for people with early and established psychosis need further research.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial licence (http://creativecommons.org/licenses/by-nc/4.0/), which permits noncommercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work.

Corresponding author

V. Bird, National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, Standon House, 21 Mansell Street, London E1 8AA, UK. Email: vbird@cru.rcpsych.ac.uk

Footnotes

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T.K. receives, as director of the National Collaborating Centre for Mental Health (NCCMH), approximately £1.44 million per year from NICE to develop clinical guidelines. T.K. and C.W. were paid by the NCCMH to undertake the development of both the original and updated edition of the schizophrenia guideline. V.B. and I.M. were paid by the NCCMH to undertake the development of the updated edition of the schizophrenia guideline. T.K. was chair of the original NICE schizophrenia guideline and E.K. was chair of the updated edition. P.P. is supported by a Wellcome Trust Senior Research Fellowship to Veena Kumari (067427/z/02/z). The Biomedical Research Centre for Mental Health at the Institute of Psychiatry, King's College London and the South London and Maudsley NHS Foundation Trust funds some clinical sessions for E.K.

Declaration of interest

None.

Footnotes

References

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Early intervention services, cognitive–behavioural therapy and family intervention in early psychosis: systematic review

  • Victoria Bird (a1), Preethi Premkumar (a2), Tim Kendall (a3), Craig Whittington (a4), Jonathan Mitchell (a5) and Elizabeth Kuipers (a6)...
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eLetters

Re: Problematic omission of evidence about five-year outcomes

Victoria J. Bird, Research worker and Ph.D. student
22 December 2010

We acknowledge Dr Raven’s point about not having considered the 5-year follow-up data fully. Although we noted in our discussion that the evidence for long-term follow-up was limited1, we would like to thank Dr Raven for bringing these recent studies to our attention. At the time of submitting the review, the Bertelsen paper2 was the only one to have examined the effects of EIS at 5-years following randomisation. The study showed no beneficial effect of EIS over standard care in terms of positive, negative and general functioning symptoms, making its unique finding tentative. Furthermore, as nearly 50% of participants were not included in the analysis,2 we felt it would be best to include the lack of evidence as a limitation in the Discussion.

As highlighted by Dr Raven, the more recent paper by Gafoor and colleagues3 was published after our review had been submitted. This paper also suggests that the beneficial effects of EIS at 5 year follow-up are not sustained in terms of number of re-admissions, giving more certainty to the view that the beneficial effects of EIS may not be sustained once the treatment is ended. 3 It is worth noting that in both studies, the intensive early intervention services were phased out after the endpoint data collection period. In our review we concluded that the available evidence “...raises the possibility that comprehensive services comparable to those described here as early intervention services, which include a full range of evidence-based psychological interventions, should be considered for people with established psychosis.” 1 (p356) The fact that the effects of EIS weren't sustained once individuals were referred back to standard care as demonstrated in the two studies, we think supports this idea. We did not feel it would be appropriate to delay the paper, as we feel our conclusion is consistent with that reported by Gafoor and colleagues who note “Aside from limited statistical power, the absence of a difference in outcome between the two groups at 5 year follow up may reflect the withdrawal of the specialised intervention after 18 months (when there was a significant group difference), further investigation of this issue will require trials involving longer duration of specialised treatment." 3 (p.375)

We would once again like to thank Dr Raven for bringing these papers into the discussion and feel on balance that the evidence from our review is still supported. Although there is now some evidence that the long-term effects of EIS in its present format may not be sustained once treatment is removed, a meta-analysis of long-term outcomes would still not be possible, as the papers do not share any common measures of outcome. Therefore, we still believe, as do Gafoor and colleagues3, that further research examining all these outcomes is warranted. Furthermore, research is needed to assess the effectiveness of services akin to EIS, namely ones that provide a high level of support and a full range of interventions, for all individuals at any stage of psychosis.

Declaration of Interest: None

References1. Bird V, Premkumar P, Kendall T, Whittington C, Mitchell J, Kuipers E. Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review. Br J Psychiatry. 2010; 197:350-6.

2. Bertelsen M, Jeppesen P, Petersen L, Thorup A, Øhlenschlaeger J, le Quach P, et al. Five-year follow-up of a randomized multicenter trial of intensive early intervention vs standard treatment for patients with a first episode of psychotic illness: the OPUS trial. Arch Gen Psychiatry. 2008; 65:762 -71.

3. Gafoor R, Nitsch D, McCrone P, Craig TK, Garety PA, Power P, et al. Effect of early intervention on 5-year outcome in non-affective psychosis. Br J Psychiatry. 2010;196:372-6.
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Conflict of interest: None Declared

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Problematic omission of evidence about five-year outcomes

Melissa Raven, Adjunct lecturer
08 December 2010

Bird et al.'s review of early psychosis intervention provides a useful meta-analysis of methodologically sound studies.1 However, there are major problems with it. The authors have stated that their review focuses on the first three to five years following onset of illness. Yet they have omitted the five-year results from the Danish OPUS study2 and the UK Lambeth Early Onset (LEO) study.3 Both of these follow-up studies found that, despite promising early results, which were included in Bird et al.'s review,4,5 positive effects were not sustained at five years.

Bertelsen et al. concluded that intensive early intervention improvedclinical outcomes in OPUS after two years, but the effects were 'not sustainable up to five years later'.2 This finding was not reported by Bird et al. In fact, Bertelsen et al. was not cited at all. According to apersonal communication from the authors, it was included in their review. However, they used primary references (in this case Petersen et al.'s analysis of one- and two-year outcomes4) to refer to all papers for all the trials included in the review. This seems idiosyncratic to say the least. More importantly, all they reported about Bertelsen et al. is that 'Only one trial of an early intervention service provided long-term data (up to 5 years post-randomisation)' (p. 354).

Gafoor et al. similarly found that specialist early intervention did not markedly improve outcomes at five years in LEO,3 in accord with the five-year findings from OPUS. Again this was not reported, and the study was not cited. Bird et al.'s review was initially submitted in January 2009, long before the publication of Gafoor et al.'s study in this journal, but the final revision occurred after it was published. Although it would not have been practical to include Gafoor et al. in the meta-analysis, publication of the review could have been delayed if necessary to allow a brief discussion of Gafoor et al.'s findings to be added (I have personally had publication of a paper in this journal delayed becauseof a late change in content). It significantly strengthened the evidence that promising early benefits are not sustainable, a very significant finding for a review of the effectiveness of early intervention in psychosis.

Bird et al. have concluded that 'it remains to be determined whether the effects of early intervention services are sustained' (p. 354), yet they have omitted the best evidence of exactly that.

References

1. Bird V, Premkumar P, Kendall T, Whittington C, Mitchell J, KuipersE. Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review. Br J Psychiatry. 2010 Nov;197(5):350-6.

2. Bertelsen M, Jeppesen P, Petersen L, Thorup A, Øhlenschlaeger J, le Quach P, Christensen TØ, Krarup G, Jørgensen P, Nordentoft M. Five-yearfollow-up of a randomized multicenter trial of intensive early intervention vs standard treatment for patients with a first episode of psychotic illness: the OPUS trial. Arch Gen Psychiatry. 2008 Jul;65(7):762-71.

3. Gafoor R, Nitsch D, McCrone P, Craig TK, Garety PA, Power P, McGuire P. Effect of early intervention on 5-year outcome in non-affectivepsychosis. Br J Psychiatry. 2010 May;196(5):372-6.

4. Petersen L, Jeppesen P, Thorup A, Abel MB, Øhlenschlaeger J, Christensen TØ, Krarup G, Jørgensen P, Nordentoft M. A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness. BMJ. 2005 Sep 17;331(7517):602.

5. Craig TK, Garety P, Power P, Rahaman N, Colbert S, Fornells-Ambrojo M, Dunn G. The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. BMJ. 2004 Nov 6;329(7474):1067.
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