Is recent-onset psychosis best treated by a specialist mental health team?

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.

Mental health professionals assess a person before recommending a specific treatment. Depending on the services available, they may send people for treatment to:

- a community mental health team: mental health professionals who support people with complex mental health conditions;

- a crisis resolution team: mental health professionals who treat people who would otherwise need treatment in hospital; or

- an early intervention team: mental health professionals who work with people who are currently or have recently experienced their first episode of psychosis.

Early intervention teams specialise in treating recent-onset psychosis, and aim to treat it as quickly and intensively as possible.

Why we did this Cochrane Review

We wanted to find out whether specialist early intervention teams were more successful at treating recent-onset psychosis than outpatient or community mental health teams that do not specialise in treating it.

What did we do?

We searched for studies that investigated the use of early intervention teams to treat recent-onset psychosis compared with standard community mental health care.

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;

- the state of people's general mental health and functioning (how well they coped with daily life); and

- how many people died.

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

What we found

We found four studies in 1145 people (65% men; average age 23 to 26 years) with recent-onset psychosis. The studies compared treatment by specialist early intervention teams against 'usual treatment' (treatment by community health or outpatient mental health teams).

The studies took place in community mental health services in high-income countries: Denmark, Sweden, the UK and the USA. The studies lasted from 18 to 24 months.

What are the results of our review?

Compared with usual treatment, treatment by an early intervention team:

-may help more people recover from psychosis (2 studies; 194 people);

- probably reduces how many people stop their treatment too soon (3 studies; 630 people);

- may reduce the number of people admitted to a psychiatric hospital (4 studies; 1145 people)

- may reduce the time spent in a psychiatric hospital (1 study; 547 people); and

- may moderately improve people's general functioning (2 studies; 467 people).

We were uncertain about whether treatment by an early intervention team affects general psychotic symptoms (2 studies; 304 people), or its effect on how many people died (3 studies; 741 people).

How reliable are these results?

We are moderately confident that treatment by an early intervention team probably reduces the number of people who stop treatment too soon, although this result may change when more evidence is available.

We are less confident about how many people recover from psychosis, or are admitted to a psychiatric hospital, how long they stay in hospital, and any improvements in people's general functioning. These results are likely to change when more evidence is available.

Key message

Using specialist early intervention teams to treat recent-onset psychosis is likely to have benefits, such as more people continuing with their treatment, and increasing the number of people who recover.

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.

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 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 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 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.

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