The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis
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《英国医生杂志》
1 Institute of Psychiatry, De Crespigny Park, London SE5 8AF, 2 Lambeth Early Onset Service, South London and Maudsley NHS Trust, London SW9 9NT, 3 Biostatistics Group, School of Epidemiology and Health Science, University of Manchester, Manchester M13 9PT
Correspondence to: T K J Craig t.craig@iop.kcl.ac.uk
Abstract
Worldwide there is interest in developing early intervention services for people with a first psychotic disorder. Fifty such services are to be established in England.1 2 The rationale behind these services is that a long duration of untreated psychosis may have a detrimental effect on outcome and that sustained treatment in the two or three years after an acute episode should maintain recovery and rebuild careers, relationships, and leisure pursuits.3-10 Although the rationale may be compelling, only one randomised controlled trial has studied early intervention in patients with a first episode of psychosis.11 Other evidence comes from studies using historical controls or specific interventions such as atypical antipsychotics, cognitive behavioural therapy, and family therapy.4 9 12-21
We investigated whether a specialist team could achieve better outcomes for people with early non-affective psychotic disorders than existing services. We hypothesised that, over an 18 month period, people receiving specialised care would have more frequent contact with mental health services, fewer relapses, and fewer readmissions to hospital than patients receiving standard care.
Methods
Overall, 319 people presented to psychiatric services between January 2000 and October 2001 with symptoms suggestive of a psychotic disorder. Of these, 144 met the inclusion criteria and were randomised to receive either specialised care or standard care (figure). Data on number of relapses and readmissions to hospital were obtained for 136 (94%) patients over the 18 months of follow up. We had complete information on clinical status (recovered, unwell or relapsed) for 131 (91%) patients at 18 months.
Flow of patients through trial
Both groups were similar for most characteristics at baseline, although the specialised care group had fewer men, a higher proportion of first psychotic episodes, and a higher proportion of white people (table 1). Patients in the specialised care group also had a longer duration of untreated psychosis, although the difference between the groups was not statistically significant (mean (SD) duration (months) of untreated psychosis: 10.5 (17.2) for specialised care v 7.6 (10.7) for controls).
Table 1 Baseline characteristics of groups receiving specialised care or standard care for psychosis. Values are numbers (percentages) unless stated otherwise
For most patients, admission to hospital was their first experience of mental health care (43 of 71 patients (61%) in specialised care group, 44 of 73 patients (60%) in control group) two thirds of which were involuntary admissions (specialised care 67%, controls 72%).
At 18 months, one patient in the control group had died (unknown cause); 53 (86%) patients in the specialised care group and 44 (68%) patients in the control group were in regular contact with the clinical team (lost to care: odds ratio 0.35, 95% confidence interval 0.15 to 0.81). Patients in the specialised care group were offered more appointments during follow up than controls (mean (SD) number of appointments: 17.4 (9.1) for specialised care v 13.2 (8.7) for controls) and failed to attend a smaller proportion of the appointments (mean (SD) proportion of appointments missed: 0.12 (0.2) for specialised care v 0.33 (0.3) for controls). Seven patients in the specialised care group and 10 control patients were in hospital at the 18 months' follow up. One control patient was in prison.
Patients in the specialised care group were more likely than those in the control group to have been offered psychosocial interventions (table 2).
Table 2 Contact with mental health services and uptake of treatment over 18 months for patients receiving care for early psychosis. Values are numbers (percentages) of patients unless stated otherwise
Patients in the specialised care group were significantly more likely to be in recovery at follow up than patients in the control group; this included patients who had relapsed (table 3). When only those patients who had not relapsed after initial recovery were classified as "well" (specialised care 64%, controls 48%), the difference between groups was attenuated and fell below statistical significance (odds ratio 0.52, 95% confidence interval 0.26 to 1.03).
Table 3 Primary outcome measures for patients receiving specialised care or standard care for early psychosis. Values are numbers (percentages) of patients unless stated otherwise
Most patients in both groups recovered from the index episode (specialised care: full recovery 71%, partial recovery 19%; controls: full recovery 63%, partial recovery 28%). The average time to recovery was 5.5 (SD 4.0) months in both groups. Although there were no differences in these rates, patients in the specialised care group were less likely to relapse than those in the control group (specialised care 30% v controls 48%; P = 0.042). Patients in the specialised care group were also readmitted fewer times during follow up (see table 3).
Although the higher contact with services among patients in the specialised care group remained significant (lost to care: odds ratio 0.28; 95% confidence interval 0.12 to 0.73) when we adjusted for baseline differences in sex, previous psychotic episodes, and ethnic minority group, only the difference in total number of readmissions during follow up remained statistically significant (see table 3).
Discussion
Department of Health. The NHS plan. A plan for investment. A plan for reform. London: DoH, 2000.
Department of Health. The mental health policy implementation guide. London: DoH, 2001.
Loebel AD, Lieberman JA, Alvir JM, Mayerhoff DI, Geisler SH, Symanski SR. Duration of untreated psychosis and cognitive functioning in first episode patients. Am J Psychiatry 1992;149: 1183-8.
McGorry PD, Edwards J, Mihalopoulos C, Harrigan SM, Jackson HJ. EPPIC: an evolving system of early detection and optimal management. Schizophr Bull 1996;22: 305-26.
Wyatt RJ, Green MF, Tuma AH. Long term morbidity associated with delayed treatment of first admission schizophrenic patients. Psychol Med 1997;27: 261-8.
Drake RJ, Haley CJ, Akhtar S, Lewis S. Causes and consequences of duration of untreated psychosis in schizophrenia. Br J Psychiatry 2000;177: 511-5.
Birchwood M, Todd P, Jackson C. Early intervention in psychosis: the critical period hypothesis. Br J Psychiatry 1998;172(Suppl 33): 53-9.
Melle I, Larsen TK, Haahr U, Friis S, Johannessen JO, Opjordsmoen S, et al. Reducing the duration of untreated first-episode psychosis: effects on clinical presentation. Arch Gen Psychiatry 2004;61: 143-50.
Drury V, Birchwood M, Cochrane R, Macmillan F. Cognitive therapy and recovery from acute psychosis: a controlled trial. I. Impact on psychotic symptoms. Br J Psychiatry 1996;169: 593-601.
Birchwood M, McGorry P, Jackson H. Early intervention in schizophrenia. Br J Psychiatry 1997;170: 2-5.
Nordentoft M, Jeppesen P, Abel M, Kassow P, Petersen L, Thorup A, et al. OPUS study: suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis: one-year follow-up of a randomised controlled trial. Br J Psychiatry 2002;181(Suppl 43): 98-106.
Malla A, Norman R, McLean T, Scholten D, Townsend L. A Canadian programme for early intervention in non-affective psychotic disorders. Aust NZ J Psychiatry 2003;37: 407-13.
Addington J, Leriger E, Addington D. Symptom outcome 1 year after admission to an early psychosis program. Can J Psychiatry 2003;48: 204-7.
Cullberg J, Levander S, Holmqvist R, Mattson M, Wieselgren I. One year outcome in first episode psychosis patients in the Swedish parachute project. Acta Psychiatr Scand 2002;106: 276-85.
Malla AK, Norman RM, Scholten DJ, Zirul S, Kotteda V. A comparison of long-term outcome in first-episode schizophrenia following treatment with risperidone or a typical antipsychotic. J Clin Psychiatry 2001;62: 179-84.
Lieberman JA, Tollefson G, Tohen M, Green AI, Gur RE, Kahn R, et al. Comparative efficacy and safety of atypical and conventional antipsychotic drugs in first-episode psychosis: a randomized, double-blind trial of olanzapine versus haloperidol. Am J Psychiatry 2003;160: 1396-404.
Jolley S, Garety P, Craig T, Dunn G, White J, Aitken M. Cognitive therapy in early psychosis: a pilot randomised controlled trial. Behav Cog Psychother 2003;31: 473-8.
Jackson H, McGorry P, Edwards J, Hulbert C, Henry L, Francey S, et al. Cognitively orientated psychotherapy for early psychosis (COPE). Br J Psychiatry 1998;172(Suppl 33): 93-100.
Lewis S, Tarrier N, Haddock G, Bentall R, Kinderman P, Kingdon D, et al. Randomised controlled trial of cognitive-behavioural therapy in early schizophrenia: acute-phase outcomes. Br J Psychiatry 2002;181(Suppl 43): 91-7.
Linszen D, Dingemans P, Van der Does JW, Nugter A, Scholte P, Lenior R, et al. Treatment, expressed emotion and relapse in recent onset schizophrenic disorders. Psychol Med 1996;26: 333-42.
Zhang M, Wang M, Lee J, Phillips MR. Randomised control trial of family intervention for 78 first-episode male schizophrenic patients: an 18 month study in Suzhou, Jiangsu. Br J Psychiatry 1994;165(Suppl 24): 96-102.
Department of Health. Compendium of clinical and social indicators. London: DoH, 2001.
Early Psychosis Prevention and Intervention Centre. EPPIC early psychosis training pack. Melbourne: EPPIC, 1997.
Edwards J, McGorry PD. Implementing early intervention in psychosis: a guide to establishing early psychosis services. London: Martin Dunitz, 2002.
Aitchison K, Meehan K, Murray RM. First episode psychosis. London: Martin Dunitz, 1999.
Jablensky A, Sartorius N, Ernberg G, Anker M, Korten A, Cooper JE, et al. Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten country study. Cambridge: Cambridge University Press, 1992.
McGuffin P, Farmer A, Harvey I. A polydiagnostic application of operational criteria in studies in psychotic illness: development and reliability of the OPCRIT system. Arch Gen Psychiatry 1991;48: 764-70.
Pelosi A, Birchwood M. Debate: is early intervention for psychosis a waste of valuable resources? Br J Psychiatry 2003;182: 196-8.
Garety PA, Rigg A. Early psychosis in the inner city: a survey to inform service planning. Soc Psychiatry Psychiatr Epidemiol 2001;36: 1-8.(Tom K J Craig, professor )
Correspondence to: T K J Craig t.craig@iop.kcl.ac.uk
Abstract
Worldwide there is interest in developing early intervention services for people with a first psychotic disorder. Fifty such services are to be established in England.1 2 The rationale behind these services is that a long duration of untreated psychosis may have a detrimental effect on outcome and that sustained treatment in the two or three years after an acute episode should maintain recovery and rebuild careers, relationships, and leisure pursuits.3-10 Although the rationale may be compelling, only one randomised controlled trial has studied early intervention in patients with a first episode of psychosis.11 Other evidence comes from studies using historical controls or specific interventions such as atypical antipsychotics, cognitive behavioural therapy, and family therapy.4 9 12-21
We investigated whether a specialist team could achieve better outcomes for people with early non-affective psychotic disorders than existing services. We hypothesised that, over an 18 month period, people receiving specialised care would have more frequent contact with mental health services, fewer relapses, and fewer readmissions to hospital than patients receiving standard care.
Methods
Overall, 319 people presented to psychiatric services between January 2000 and October 2001 with symptoms suggestive of a psychotic disorder. Of these, 144 met the inclusion criteria and were randomised to receive either specialised care or standard care (figure). Data on number of relapses and readmissions to hospital were obtained for 136 (94%) patients over the 18 months of follow up. We had complete information on clinical status (recovered, unwell or relapsed) for 131 (91%) patients at 18 months.
Flow of patients through trial
Both groups were similar for most characteristics at baseline, although the specialised care group had fewer men, a higher proportion of first psychotic episodes, and a higher proportion of white people (table 1). Patients in the specialised care group also had a longer duration of untreated psychosis, although the difference between the groups was not statistically significant (mean (SD) duration (months) of untreated psychosis: 10.5 (17.2) for specialised care v 7.6 (10.7) for controls).
Table 1 Baseline characteristics of groups receiving specialised care or standard care for psychosis. Values are numbers (percentages) unless stated otherwise
For most patients, admission to hospital was their first experience of mental health care (43 of 71 patients (61%) in specialised care group, 44 of 73 patients (60%) in control group) two thirds of which were involuntary admissions (specialised care 67%, controls 72%).
At 18 months, one patient in the control group had died (unknown cause); 53 (86%) patients in the specialised care group and 44 (68%) patients in the control group were in regular contact with the clinical team (lost to care: odds ratio 0.35, 95% confidence interval 0.15 to 0.81). Patients in the specialised care group were offered more appointments during follow up than controls (mean (SD) number of appointments: 17.4 (9.1) for specialised care v 13.2 (8.7) for controls) and failed to attend a smaller proportion of the appointments (mean (SD) proportion of appointments missed: 0.12 (0.2) for specialised care v 0.33 (0.3) for controls). Seven patients in the specialised care group and 10 control patients were in hospital at the 18 months' follow up. One control patient was in prison.
Patients in the specialised care group were more likely than those in the control group to have been offered psychosocial interventions (table 2).
Table 2 Contact with mental health services and uptake of treatment over 18 months for patients receiving care for early psychosis. Values are numbers (percentages) of patients unless stated otherwise
Patients in the specialised care group were significantly more likely to be in recovery at follow up than patients in the control group; this included patients who had relapsed (table 3). When only those patients who had not relapsed after initial recovery were classified as "well" (specialised care 64%, controls 48%), the difference between groups was attenuated and fell below statistical significance (odds ratio 0.52, 95% confidence interval 0.26 to 1.03).
Table 3 Primary outcome measures for patients receiving specialised care or standard care for early psychosis. Values are numbers (percentages) of patients unless stated otherwise
Most patients in both groups recovered from the index episode (specialised care: full recovery 71%, partial recovery 19%; controls: full recovery 63%, partial recovery 28%). The average time to recovery was 5.5 (SD 4.0) months in both groups. Although there were no differences in these rates, patients in the specialised care group were less likely to relapse than those in the control group (specialised care 30% v controls 48%; P = 0.042). Patients in the specialised care group were also readmitted fewer times during follow up (see table 3).
Although the higher contact with services among patients in the specialised care group remained significant (lost to care: odds ratio 0.28; 95% confidence interval 0.12 to 0.73) when we adjusted for baseline differences in sex, previous psychotic episodes, and ethnic minority group, only the difference in total number of readmissions during follow up remained statistically significant (see table 3).
Discussion
Department of Health. The NHS plan. A plan for investment. A plan for reform. London: DoH, 2000.
Department of Health. The mental health policy implementation guide. London: DoH, 2001.
Loebel AD, Lieberman JA, Alvir JM, Mayerhoff DI, Geisler SH, Symanski SR. Duration of untreated psychosis and cognitive functioning in first episode patients. Am J Psychiatry 1992;149: 1183-8.
McGorry PD, Edwards J, Mihalopoulos C, Harrigan SM, Jackson HJ. EPPIC: an evolving system of early detection and optimal management. Schizophr Bull 1996;22: 305-26.
Wyatt RJ, Green MF, Tuma AH. Long term morbidity associated with delayed treatment of first admission schizophrenic patients. Psychol Med 1997;27: 261-8.
Drake RJ, Haley CJ, Akhtar S, Lewis S. Causes and consequences of duration of untreated psychosis in schizophrenia. Br J Psychiatry 2000;177: 511-5.
Birchwood M, Todd P, Jackson C. Early intervention in psychosis: the critical period hypothesis. Br J Psychiatry 1998;172(Suppl 33): 53-9.
Melle I, Larsen TK, Haahr U, Friis S, Johannessen JO, Opjordsmoen S, et al. Reducing the duration of untreated first-episode psychosis: effects on clinical presentation. Arch Gen Psychiatry 2004;61: 143-50.
Drury V, Birchwood M, Cochrane R, Macmillan F. Cognitive therapy and recovery from acute psychosis: a controlled trial. I. Impact on psychotic symptoms. Br J Psychiatry 1996;169: 593-601.
Birchwood M, McGorry P, Jackson H. Early intervention in schizophrenia. Br J Psychiatry 1997;170: 2-5.
Nordentoft M, Jeppesen P, Abel M, Kassow P, Petersen L, Thorup A, et al. OPUS study: suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis: one-year follow-up of a randomised controlled trial. Br J Psychiatry 2002;181(Suppl 43): 98-106.
Malla A, Norman R, McLean T, Scholten D, Townsend L. A Canadian programme for early intervention in non-affective psychotic disorders. Aust NZ J Psychiatry 2003;37: 407-13.
Addington J, Leriger E, Addington D. Symptom outcome 1 year after admission to an early psychosis program. Can J Psychiatry 2003;48: 204-7.
Cullberg J, Levander S, Holmqvist R, Mattson M, Wieselgren I. One year outcome in first episode psychosis patients in the Swedish parachute project. Acta Psychiatr Scand 2002;106: 276-85.
Malla AK, Norman RM, Scholten DJ, Zirul S, Kotteda V. A comparison of long-term outcome in first-episode schizophrenia following treatment with risperidone or a typical antipsychotic. J Clin Psychiatry 2001;62: 179-84.
Lieberman JA, Tollefson G, Tohen M, Green AI, Gur RE, Kahn R, et al. Comparative efficacy and safety of atypical and conventional antipsychotic drugs in first-episode psychosis: a randomized, double-blind trial of olanzapine versus haloperidol. Am J Psychiatry 2003;160: 1396-404.
Jolley S, Garety P, Craig T, Dunn G, White J, Aitken M. Cognitive therapy in early psychosis: a pilot randomised controlled trial. Behav Cog Psychother 2003;31: 473-8.
Jackson H, McGorry P, Edwards J, Hulbert C, Henry L, Francey S, et al. Cognitively orientated psychotherapy for early psychosis (COPE). Br J Psychiatry 1998;172(Suppl 33): 93-100.
Lewis S, Tarrier N, Haddock G, Bentall R, Kinderman P, Kingdon D, et al. Randomised controlled trial of cognitive-behavioural therapy in early schizophrenia: acute-phase outcomes. Br J Psychiatry 2002;181(Suppl 43): 91-7.
Linszen D, Dingemans P, Van der Does JW, Nugter A, Scholte P, Lenior R, et al. Treatment, expressed emotion and relapse in recent onset schizophrenic disorders. Psychol Med 1996;26: 333-42.
Zhang M, Wang M, Lee J, Phillips MR. Randomised control trial of family intervention for 78 first-episode male schizophrenic patients: an 18 month study in Suzhou, Jiangsu. Br J Psychiatry 1994;165(Suppl 24): 96-102.
Department of Health. Compendium of clinical and social indicators. London: DoH, 2001.
Early Psychosis Prevention and Intervention Centre. EPPIC early psychosis training pack. Melbourne: EPPIC, 1997.
Edwards J, McGorry PD. Implementing early intervention in psychosis: a guide to establishing early psychosis services. London: Martin Dunitz, 2002.
Aitchison K, Meehan K, Murray RM. First episode psychosis. London: Martin Dunitz, 1999.
Jablensky A, Sartorius N, Ernberg G, Anker M, Korten A, Cooper JE, et al. Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten country study. Cambridge: Cambridge University Press, 1992.
McGuffin P, Farmer A, Harvey I. A polydiagnostic application of operational criteria in studies in psychotic illness: development and reliability of the OPCRIT system. Arch Gen Psychiatry 1991;48: 764-70.
Pelosi A, Birchwood M. Debate: is early intervention for psychosis a waste of valuable resources? Br J Psychiatry 2003;182: 196-8.
Garety PA, Rigg A. Early psychosis in the inner city: a survey to inform service planning. Soc Psychiatry Psychiatr Epidemiol 2001;36: 1-8.(Tom K J Craig, professor )