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Meta-Analysis
. 2020 Nov 2;11(11):CD013288.
doi: 10.1002/14651858.CD013288.pub2.

Specialised early intervention teams for recent-onset psychosis

Stephen Puntis  1 , Amedeo Minichino  1 , Franco De Crescenzo  1 , Andrea Cipriani  1 , Belinda Lennox  1 , Rachael Harrison  2
Affiliations
Meta-Analysis

Specialised early intervention teams for recent-onset psychosis

Stephen Puntis et al. Cochrane Database Syst Rev. .

Abstract

Background: Psychosis is an illness characterised by the presence of hallucinations and delusions that can cause distress or a marked change in an individual's behaviour (e.g. social withdrawal, flat or blunted effect). A first episode of psychosis (FEP) is the first time someone experiences these symptoms that can occur at any age, but the condition is most common in late adolescence and early adulthood. This review is concerned with first episode psychosis (FEP) and the early stages of a psychosis, referred to throughout this review as 'recent-onset psychosis.' Specialised early intervention (SEI) teams are community mental health teams that specifically treat people who are experiencing, or have experienced a recent-onset psychosis. The purpose of SEI teams is to intensively treat people with psychosis early in the course of the illness with the goal of increasing the likelihood of recovery and reducing the need for longer-term mental health treatment. SEI teams provide a range of treatments including medication, psychotherapy, psychoeducation, and occupational, educational and employment support, augmented by assertive contact with the service user and small caseloads. Treatment is time limited, usually offered for two to three years, after which service users are either discharged to primary care or transferred to a standard adult community mental health team. A previous Cochrane Review of SEI found preliminary evidence that SEI may be superior to standard community mental health care (described as 'treatment as usual (TAU)' in this review) but these recommendations were based on data from only one trial. This review updates the evidence for the use of SEI services.

Objectives: To compare specialised early intervention (SEI) teams to treatment as usual (TAU) for people with recent-onset psychosis.

Search methods: On 3 October 2018 and 22 October 2019, we searched Cochrane Schizophrenia's study-based register of trials, including registries of clinical trials.

Selection criteria: We selected all randomised controlled trials (RCTs) comparing SEI with TAU for people with recent-onset psychosis. We entered trials meeting these criteria and reporting useable data as included studies.

Data collection and analysis: We independently inspected citations, selected studies, extracted data and appraised study quality. For binary outcomes we calculated the risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and their 95% CIs, or if assessment measures differed for the same construct, we calculated the standardised mean difference (SMD) with 95% CIs. We assessed risk of bias for included studies and created a 'Summary of findings' table using the GRADE approach.

Main results: We included three RCTs and one cluster-RCT with a total of 1145 participants. The mean age in the trials was between 23.1 years (RAISE) and 26.6 years (OPUS). The included participants were 405 females (35.4%) and 740 males (64.6%). All trials took place in community mental healthcare settings. Two trials reported on recovery from psychosis at the end of treatment, with evidence that SEI team care may result in more participants in recovery than TAU at the end of treatment (73% versus 52%; RR 1.41, 95% CI 1.01 to 1.97; 2 studies, 194 participants; low-certainty evidence). Three trials provided data on disengagement from services at the end of treatment, with fewer participants probably being disengaged from mental health services in SEI (8%) in comparison to TAU (15%) (RR 0.50, 95% CI 0.31 to 0.79; 3 studies, 630 participants; moderate-certainty evidence). There was low-certainty evidence that SEI may result in fewer admissions to psychiatric hospital than TAU at the end of treatment (52% versus 57%; RR 0.91, 95% CI 0.82 to 1.00; 4 studies, 1145 participants) and low-certainty evidence that SEI may result in fewer psychiatric hospital days (MD -27.00 days, 95% CI -53.68 to -0.32; 1 study, 547 participants). Two trials reported on general psychotic symptoms at the end of treatment, with no evidence of a difference between SEI and TAU, although this evidence is very uncertain (SMD -0.41, 95% CI -4.58 to 3.75; 2 studies, 304 participants; very low-certainty evidence). A different pattern was observed in assessment of general functioning with an end of trial difference that may favour SEI (SMD 0.37, 95% CI 0.07 to 0.66; 2 studies, 467 participants; low-certainty evidence). It was uncertain whether the use of SEI resulted in fewer deaths due to all-cause mortality at end of treatment (RR 0.21, 95% CI 0.04 to 1.20; 3 studies, 741 participants; low-certainty evidence). There was low risk of bias for random sequence generation and allocation concealment in three of the four included trials; the remaining trial had unclear risk of bias. Due to the nature of the intervention, we considered all trials at high risk of bias for blinding of participants and personnel. Two trials had low risk of bias and two trials had high risk of bias for blinding of outcomes assessments. Three trials had low risk of bias for incomplete outcome data, while one trial had high risk of bias. Two trials had low risk of bias, one trial had high risk of bias, and one had unclear risk of bias for selective reporting.

Authors' conclusions: There is evidence that SEI may provide benefits to service users during treatment compared to TAU. These benefits probably include fewer disengagements from mental health services (moderate-certainty evidence), and may include small reductions in psychiatric hospitalisation (low-certainty evidence), and a small increase in global functioning (low-certainty evidence) and increased service satisfaction (moderate-certainty evidence). The evidence regarding the effect of SEI over TAU after treatment has ended is uncertain. Further evidence investigating the longer-term outcomes of SEI is needed. Furthermore, all the eligible trials included in this review were conducted in high-income countries, and it is unclear whether these findings would translate to low- and middle-income countries, where both the intervention and the comparison conditions may be different.

Trial registration: ClinicalTrials.gov NCT00919620.

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Conflict of interest statement

Stephen Puntis: SP currently receives research grants for the purpose of investigating the effectiveness of early intervention in psychosis services

Amedeo Minichino: AM currently receives Medical Research Council funding for a DPhil studentship

Franco De Crescenzo: none

Rachael Harrison: none

Andrea Cipriani: Andrea Cipriani has received research grants and consultancy fees from INCiPiT (Italian Network for Paediatric Trials), CARIPLO Foundation and Angelini Pharma, outside the submitted work.

Belinda Lennox: I work clinically in an early intervention in psychosis service, and am clinical lead for early intervention in psychosis for NHS England. I am an investigator on a pending NIHR HTA award examining extended early intervention services. I have received travel expenses from Lundbeck and Alkermes, fees for consultancy work for Astellas, and share income from GlaxoSmithKline, all outside the submitted work. No other declarations of interest.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
3
3
Study flow diagram.
1.1
1.1. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 1: Global state: recovery
1.2
1.2. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 2: Service use: disengagement from services
1.3
1.3. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 3: Service use: admission to psychiatric hospital
1.5
1.5. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 5: Service use: number of days in psychiatric hospital
1.6
1.6. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 6: Global state: relapse
1.7
1.7. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 7: Mental state: specific, average endpoint score on specific symptoms mental state scale/subscale, general psychotic symptoms
1.8
1.8. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 8: Mental state: specific, average endpoint score on specific symptoms mental state scale/subscale, positive psychotic symptoms
1.9
1.9. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 9: Mental state: specific, average endpoint score on specific symptoms mental state scale/subscale, negative psychotic symptoms
1.10
1.10. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 10: Mental state: specific, average endpoint score on specific symptoms mental state scale/subscale, depressive symptoms
1.11
1.11. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 11: Behaviour: specific, occurrence of violent incidents (to self, others or property)
1.12
1.12. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 12: Adverse effects/events: death, suicide or natural cause
1.13
1.13. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 13: Leaving the study early: for any reason
1.14
1.14. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 14: Quality of life: recipient, overall, average endpoint score on quality of life scale
1.15
1.15. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 15: Functioning: general, average endpoint score on general functioning scale
1.16
1.16. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 16: Functioning: specific, any change in education or employment status
1.17
1.17. Analysis
Comparison 1: Specialised early intervention (SEI) versus treatment as usual (TAU, Outcome 17: Satisfaction with care: recipient, average endpoint score on satisfaction scale
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Zhang 2009 {published data only}
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References to ongoing studies

JCEP 2010 {published data only}
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References to other published versions of this review

Puntis 2019
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Publication types

Associated data