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Preventing progression to first-episode psychosis in early initial prodromal states

  • A. Bechdolf (a1), M. Wagner (a2), S. Ruhrmann (a3), S. Harrigan (a4), V. Putzfeld (a3), R. Pukrop (a5), A. Brockhaus-Dumke (a6), J. Berning (a7), B. Janssen (a8), P. Decker (a9), R. Bottlender (a9), K. Maurer (a10), H.-J. Möller (a11), W. Gaebel (a12), H. Häfner (a10), W. Maier (a13) and J. Klosterkötter (a6)...
Abstract
Background

Young people with self-experienced cognitive thought and perception deficits (basic symptoms) may present with an early initial prodromal state (EIPS) of psychosis in which most of the disability and neurobiological deficits of schizophrenia have not yet occurred.

Aims

To investigate the effects of an integrated psychological intervention (IPI), combining individual cognitive–behavioural therapy, group skills training, cognitive remediation and multifamily psychoeducation, on the prevention of psychosis in the EIPS.

Method

A randomised controlled, multicentre, parallel group trial of 12 months of IPI v. supportive counselling (trial registration number: NCT00204087). Primary outcome was progression to psychosis at 12- and 24-month follow-up.

Results

A total of 128 help-seeking out-patients in an EIPS were randomised. Integrated psychological intervention was superior to supportive counselling in preventing progression to psychosis at 12-month follow-up (3.2% v. 16.9%; P = 0.008) and at 24-month follow-up (6.3% v. 20.0%; P = 0.019).

Conclusions

Integrated psychological intervention appears effective in delaying the onset of psychosis over a 24-month time period in people in an EIPS.

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Copyright
Corresponding author
Andreas Bechdolf, MD, MSc, Associate Professor, Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Str. 62, 50924 Cologne, Germany. Email: andreas.bechdolf@uk-koeln.de
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Declaration of interest

None.

Footnotes
References
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Preventing progression to first-episode psychosis in early initial prodromal states

  • A. Bechdolf (a1), M. Wagner (a2), S. Ruhrmann (a3), S. Harrigan (a4), V. Putzfeld (a3), R. Pukrop (a5), A. Brockhaus-Dumke (a6), J. Berning (a7), B. Janssen (a8), P. Decker (a9), R. Bottlender (a9), K. Maurer (a10), H.-J. Möller (a11), W. Gaebel (a12), H. Häfner (a10), W. Maier (a13) and J. Klosterkötter (a6)...
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eLetters

Re:Integrated psychological intervention for the prevention of psychosis

Richard Keefe, Professor
01 February 2012

This is an excellent study with some of the most encouraging results to date that behavioral interventions with minimal side effects may prevent psychosis. The limitations mentioned in the accompanying comment by Dr. Kapoor are small indeed. If a slight increase in face-to-face contact with a therapist were to prevent psychosis, this would certainly offer a low-cost intervention strategy. It is important for mental healthprofessionals and researchers to communicate the results of this study to those making decisions about research funding, as this study needs to be replicated and extended. The once scoffed-at notion that the horror of psychosis may be preventable by behavioral intervention is gaining more empirical support. The authors of this paper are leading the way in this very important area of work, and deserve our praise.

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Conflict of interest: None declared

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Integrated psychological intervention for the prevention of psychosis

MOHINDER KAPOOR, ST6 Old Age Psychiatry
26 January 2012

Bechdolf et al 1 present interesting findings in their randomised controlled trial study of integrated psychological intervention (IPI) versus supportive counselling in the prevention of psychosis in the early initial prodromal state (EIPS).

However, I have few reservations in relation to the study design and analysis of outcomes in this study. We all know the strength of a double blind design in eliminating the potential for observation (information) bias.2 Authors mention the same research therapists delivered IPI and supportive counselling and no formal measures of adherence to the manual or of therapist competence were employed in the IPI or supportive counselling conditions. To make matters worse the authors also acknowledgethat face to face contact with therapists within the trial was higher for patients in the IPI group than for patients receiving supportive counselling. This knowledge of the intervention to which participant has been assigned raises the potential of intervention bias.2 It raises questions about the actual role played by a variety of psychological strategies within IPI, given that the trial design did not allow assessment of the relative contribution of the psychological strategies provided.

In addition to this patients were classified as converters or non-converters by an independent consultant psychiatrist or senior clinical psychologist. However, the masking of these independent consultant psychiatrists or clinical psychologists was not formally measured. In relation to this I would like to state that the potential for observation bias in ascertainment of outcome can exist in an intervention study. Knowledge of a participant's treatment status might, consciously or not, influence the identification or reporting of relevant events.2 Also the authors fail to mention if participants were aware or blind to their treatment allocations. Although authors have mentioned some of these shortcomings under the limitations section of the study, it is imperative that we all understand not only the importance of these shortcomings but also the impact these can have on the main findings of this study.

Declaration of interest: None

References:

1.Bechdolf A et al. Preventing progression to first-episode psychosis in early initial prodromal states. Br J Psychiatry 2012; 200: 22-29.

2.Hennekens CH, Burning JE et al. Epidemiology in Medicine. Little, Brown and Company Boston/Toronto, 1987.

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Conflict of interest: None declared

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