Is extending the treatment time by specialist mental health teams better for people with recent-onset psychosis?

What is psychosis?

Psychosis describes conditions affecting the mind, in which people have trouble distinguishing what is real from what is not real. This might involve seeing or hearing things that other people cannot see or hear (hallucinations), or believing things that are not true (delusions). The combination of hallucinations and delusional thinking can cause severe distress and a change in behaviour. A first episode psychosis is the first time a person experiences an episode of psychosis. Recent-onset psychosis is the first few years of the illness after someone experiences it for the first time.

Psychosis is treatable

Many people recover from a first episode and never experience another psychotic episode.

Early intervention teams specialise in treating recent-onset psychosis, and aim to treat psychosis as quickly and intensively as possible. Intensive, early treatment of psychosis may help more people to continue with their treatment and to recover.

Early intervention treatment usually lasts for two or three years. After early intervention treatment, a person will be cared for by their doctor or by standard community mental health professionals.

Why we did this Cochrane Review

We wanted to find out if longer treatment (for up to 5 years) by specialist early intervention teams was more successful at treating recent-onset psychosis than the usual two or three years of treatment followed by treatment by non-specialist teams.

What did we do?

We searched for studies that looked at the use of longer treatment of recent-onset psychosis by specialist early intervention teams.

We looked for randomised controlled studies, in which the treatments people received were decided at random. This type of study usually gives the most reliable evidence about the effects of a treatment.

We wanted to find out, at the end of the treatment:

- how many people recovered;

- how many people stopped their treatment too soon;

- how many people were admitted to a psychiatric hospital, and for how long;

- people's psychotic symptoms and functioning (how well they cope with daily life); and

- how many people died.

Search date: we included evidence published up to 22 October 2019.

What we found

We found three studies conducted in Denmark, Canada and Hong Kong in 780 people (55% men; average age 20 to 25 years).

The studies compared longer treatment (up to 5 years) with standard treatment (up to 3 years) by an early intervention team followed by treatment as usual (by their doctor or community mental health professionals).

What are the results of our review?

We found no difference between standard treatment and longer treatment by an early intervention team in the numbers of people who recovered (assessed by remission of symptoms; 3 studies; 780 people).

Fewer people may stop their treatment too soon during longer treatment than standard treatment (2 studies; 380 people).

There may be no difference between standard treatment and longer treatment for how many people are admitted to a psychiatric hospital (1 study; 160 people), or for how long they stay in hospital (1 study; 400 people).

Longer treatment may reduce psychotic symptoms more than standard treatment (1 study; 156 people); but may not improve people's functioning (2 studies; 560 people).

We are uncertain about whether longer treatment reduces the number of people who died, compared with standard treatment, because so few deaths were reported in the studies (3 studies; 780 people).

How reliable are these results?

Our results are likely to change when more evidence becomes available. We are not confident that longer treatment affects how many people stop treatment too soon, how many are admitted to hospital and how long they stay in hospital.

We are uncertain about the effect of longer treatment on how many people recover, people's psychotic symptoms and functioning, and on the number of people who die. These results will change when more evidence becomes available.

Key messages

Longer treatment of recent-onset psychosis by specialist mental health teams may lead to fewer people stopping their treatment early. However, we need more evidence before we can be certain about whether longer treatment is better overall than the usual two- or three-year treatment.

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.

Read the full 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 affect). 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 strategy: 

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.

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