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Meta-Analysis
. 2020 Nov 2;11(11):CD013287.
doi: 10.1002/14651858.CD013287.pub2.

Specialised early intervention teams (extended time) 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 (extended time) 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 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. SEI teams provide a range of treatments including medication, psychotherapy, psychoeducation, 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. Evidence suggests that once SEI treatment ends, improvements may not be sustained, bringing uncertainty about the optimal duration of SEI to ensure the best long-term outcomes. Extending SEI has been proposed as a way of providing continued intensive treatment and continuity of care, of usually up to five years, in order to a) sustain the positive initial outcomes of SEI; and b) improve the long-term trajectory of the illness.

Objectives: To compare extended SEI teams with treatment as usual (TAU) for people with recent-onset psychosis. To compare extended SEI teams with standard SEI teams followed by TAU (standard SEI + 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 extended SEI with TAU for people with recent-onset psychosis and all RCTs comparing extended SEI with standard SEI + TAU for people with recent-onset psychosis. We entered trials meeting these criteria and reporting usable 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, with a total 780 participants, aged 16 to 35 years. All participants met the criteria for schizophrenia spectrum disorders or affective psychoses. No trials compared extended SEI with TAU. All three trials randomly allocated people approximately two years into standard SEI to either extended SEI or standard SEI + TAU. The certainty of evidence for outcomes varied from low to very low. Our primary outcomes were recovery and disengagement from mental health services. No trials reported on recovery, and we used remission as a proxy. Three trials reported on remission, with the point estimate suggesting a 13% increase in remission in favour of extended SEI, but this included wide confidence intervals (CIs) and a very uncertain estimate of no benefit (RR 1.13, 95% CI 0.97 to 1.31; 3 trials, 780 participants; very low-certainty evidence). Two trials provided data on disengagement from services with evidence that extended SEI care may result in fewer disengagements from mental health treatment (15%) in comparison to standard SEI + TAU (34%) (RR 0.45, 95% CI 0.27 to 0.75; 2 trials, 380 participants; low-certainty evidence). There may be no evidence of a difference in rates of psychiatric hospital admission (RR 1.55, 95% CI 0.68 to 3.52; 1 trial, 160 participants; low-certainty evidence), or the number of days spent in a psychiatric hospital (MD -2.70, 95% CI -8.30 to 2.90; 1 trial, 400 participants; low-certainty evidence). One trial found uncertain evidence regarding lower global psychotic symptoms in extended SEI in comparison to standard SEI + TAU (MD -1.90, 95% CI -3.28 to -0.52; 1 trial, 156 participants; very low-certainty evidence). It was uncertain whether the use of extended SEI over standard SEI + TAU resulted in fewer deaths due to all-cause mortality, as so few deaths were recorded in trials (RR 0.38, 95% CI 0.09 to 1.64; 3 trials, 780 participants; low-certainty evidence). Very uncertain evidence suggests that using extended SEI instead of standard SEI + TAU may not improve global functioning (SMD 0.23, 95% CI -0.29 to 0.76; 2 trials, 560 participants; very low-certainty evidence). There was low risk of bias in all three trials for random sequence generation, allocation concealment and other biases. All three trials had high risk of bias for blinding of participants and personnel due to the nature of the intervention. For the risk of bias for blinding of outcome assessments and incomplete outcome data there was at least one trial with high or unclear risk of bias.

Authors' conclusions: There may be preliminary evidence of benefit from extending SEI team care for treating people experiencing psychosis, with fewer people disengaging from mental health services. Evidence regarding other outcomes was uncertain. The certainty of evidence for the measured outcomes was low or very low. Further, suitably powered studies that use a consistent approach to outcome selection are needed, but with only one further ongoing trial, there is unlikely to be any definitive conclusion for the effectiveness of extended SEI for at least the next few years.

Trial registration: ClinicalTrials.gov NCT00914238.

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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: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 1: Global state: recovery
1.2
1.2. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 2: Service use: disengagement from services
1.3
1.3. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 3: Service use: admission to psychiatric hospital
1.5
1.5. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 5: Global state: relapse, as defined by the study
1.6
1.6. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 6: Mental state: specific, average endpoint score on specific symptoms mental state scale/subscale, general psychotic symptoms
1.10
1.10. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 10: Adverse effects/events: death, suicide or natural cause
1.11
1.11. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 11: Leaving the study early: for any reason
1.12
1.12. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 12: Functioning: general, average endpoint score on general functioning scale
1.13
1.13. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 13: Functioning: specific, any change in education or employment status
1.14
1.14. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 14: Satisfaction with care: recipient, average endpoint score on satisfaction scale
1.15
1.15. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 15: Sensitivity analysis (assumptions for lost binary data) ‐ global state: recovery
1.16
1.16. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 16: Sensitivity analysis (assumptions for lost binary data) ‐ service use: disengagement from services
1.17
1.17. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 17: Sensitivity analysis (fixed‐effect model) ‐ global state: recovery
1.18
1.18. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 18: Sensitivity analysis (fixed‐effect model) ‐ service use: disengagement from services
1.19
1.19. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 19: Subgroup analysis (extended SEI 60 months or more) ‐ global state: recovery
1.20
1.20. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 20: Subgroup analysis (extended SEI 60 months or more) ‐ service use: disengagement from services
1.21
1.21. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 21: Subgroup analysis (extended SEI 60 months or more) ‐ service use: number of days in psychiatric hospital
1.22
1.22. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 22: Subgroup analysis (extended SEI 60 months or more) ‐ mental state: specific, average endpoint score on specific symptoms mental state scale/subscale, positive psychotic symptoms
1.23
1.23. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 23: Subgroup analysis (extended SEI 60 months or more) ‐ mental state: specific, average endpoint score on specific symptoms mental state scale/subscale, negative psychotic symptoms
1.24
1.24. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 24: Subgroup analysis (extended SEI 60 months or more) ‐ adverse effects/events: death, suicide or natural cause
1.25
1.25. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 25: Subgroup analysis (extended SEI 60 months or more) ‐ leaving the study early: for any reason
1.26
1.26. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 26: Subgroup analysis (extended SEI 60 months or more) ‐ functioning: general, average endpoint score on general functioning scale
1.27
1.27. Analysis
Comparison 1: Extended specialised early intervention versus standard specialised early intervention + treatment as usual, Outcome 27: Subgroup analysis (extended SEI 60 months or more) ‐ functioning: specific, any change in education or employment status
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Wang 2012 {published data only}
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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