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Fuelled by the desire to resolve difficulties encountered by young people experiencing psychosis for the first time, the early intervention movement has grown. Historically, first-episode psychosis patients experienced long delays of 1 year or more before receiving effective treatment (1,2). Many families experienced barriers to collaboration with treatment teams (3), and many first-episode patients were lost to follow-up beyond the initial hospitalization (4). Early skilled interventions for individuals experiencing their first episode of psychosis can make a difference by improving symptoms, reducing substance abuse (5), increasing quality of life (6), and reducing hospitalization rates (7). Patients with longer durations of untreated psychosis have poorer outcomes with respect to relapse rates, control of symptoms, and remission rates (8–10). Without specialized early intervention follow-up, as many as 60% of patients with first-episode schizophrenia relapse within 2 years of illness onset (11). Persons suffering one relapse have a higher risk of subsequent relapses (12). Suicide rates are high within the first 10 years of diagnosis (13), so early intervention has the potential to save lives. A 1-year randomized controlled trial (RCT) of integrated early intervention vs regular treatment found that the former reduced hopelessness (14) and improved adherence to treatment (15,16). Unfortunately, there are few published RCTs in the field of early intervention. Most trials are small, use historical controls, or have short follow-up periods (16,17). This study offers important 1-year program evaluation data on first-episode patients treated in a small early intervention program embedded within an outpatient program for chronic patients. It is unique because most early intervention studies involve larger early intervention centres. Our main objective was to assess whether the Psychotic Disorders Clinic (PDC) achieved clinic goals set forth for first-episode patients. When we compared outcomes up to 6 months before and after 12 months of involvement with the PDC, would patients experiencing a first episode of psychosis achieve significant improvements in symptom control, functioning, and hospitalization rates? Program DescriptionThe PDC is an outpatient service at McMaster Hospital, Hamilton Health Sciences, and the Department of Psychiatry and Neurobehavioural Sciences at McMaster University, Hamilton, Ontario. It serves a catchment area of about 160 000 people in Hamilton’s west end. The PDC program provides comprehensive mental health care to people with psychosis and, in particular, early intervention strategies to persons in the early stages of psychotic illness. It aims to improve symptom control and functioning and reduce hospitalizations. The key service components are those found in most early intervention programs (18) and include the following evidence-based treatments: rapid service to avoid long delays in treatment (19), low-dosage antipsychotic medication, psychoeducation to increase the patient’s understanding of the illness, family education and intervention (20), and support for return to work or school settings (21). The PDC is a small, interdisciplinary team of health professionals (3.2 full-time equivalents in all) comprising a full-time psychiatrist, a full-time nurse, a part-time registered nurse, a part-time nurse family educator, a part-time occupational therapist, and a part-time psychometrist. Between 1997 and 2000, the clinic received about 200 new patient referrals yearly. There were about 100 active patients and 100 nonactive patients (alumni) (22) seen in shared care with their family physician each year. About one-third of all clients were first-episode patients; the rest were chronic patients. Some unique features set the PDC apart from other early intervention programs. It is an early intervention program embedded inside an outpatient service for chronic patients. The clinicians treat both chronic and first-episode patients. The PDC has fewer staff and higher caseloads than other early intervention programs that use a case-management model. Instead, an occupational therapist, family educator, and nurse care coordinator work together to provide the care offered by a case manager. This allows each health professional to specialize within his or her expertise while supporting other professionals in their work with the patient. The family educator offers family education and support. Partnership meetings or family sessions involve any members of the team, patient, or family to review progress, provide psychoeducation, manage crises, and negotiate treatment plans. Once the patient’s treatment goals are met, clinicians offer shared care in partnership with the discharged patient’s family physician, thereby preserving continuity of care yet reducing the clinic’s client caseloads (4). MethodsWe used a prospective, naturalistic, longitudinal design to document the outcomes of first-episode psychosis patients offered treatment in the clinic. The research nurse recruited outpatients who were referred for treatment at the PDC from 1997 until 2000. The nurse approached all first-episode patients who met all the inclusion criteria and none of the exclusion criteria and obtained informed consent from each study participant. She collected data at baseline, 3, 6, and 12 months. Patient were aged between 16 and 45 years and experiencing their first episode of psychotic illness; they were followed for a 12-month period. The study defined “first episode” as the first illness episode involving psychotic symptoms in a patient who had not received more than 6 months of antipsychotic medication treatment prior to involvement with the clinic. Psychotic symptoms included the following, taken from McGorry’s early intervention study (4): delusions, hallucinations, marked formal thought disorder, and grossly disorganized, bizarre, or inappropriate behaviour. We included affective psychosis in the study; we did not assess negative symptoms as part of the diagnostic process. We excluded patients if they had a history of untreated thyroid disorder, epilepsy, or organic mental disorder. We asked patients meeting DSM-IV criteria for current substance abuse to abstain and (or) enrol in drug rehabilitation programs and included them in the study. Using clinical rating scales, we assessed subjects at baseline, 3 months, 6 months, and 12 months. The clinical rating scales used were the Brief Psychiatric Rating Scale (BPRS, 23), the Global Assessment of Functioning (GAF, 24), and the Hamilton Depression Rating Scale (HDRS, 25). We used a 20% reduction in baseline scores as an a priori definition of clinical improvement (26). The research nurse collected data on the frequency of psychiatric admissions, number of bed-days, and self-reported substance use rates. At 12 months, the psychiatrists made psychiatric diagnoses based on the DSM-IV (24). We analyzed data using a repeated measures design. All data were normally distributed and all post hoc comparisons were performed using the Bonferroni adjustment for multiple comparisons. We analyzed changes in scores using analysis of variance with the time of measurement (baseline, 3 months, 6 months, and 12 months) as a within-subjects factor. The sphericity assumption was not met, so the Huynh-Feldt correction was applied to all analyses. The study used an intent-to-treat basis with last observation carried forward. ResultsTable 1 compares the demographic characteristics of those who were approached but declined to participate with the characteristics of those who participated. Forty subjects entered the study; 37 subjects completed data collection up to 6 months; and 6 of these 37 subjects dropped out at 12 months. The dropout rate for the study was 10% at 6 months and 25% at 12 months.
Most patients were referred by family physicians, by the St Joseph’s Health Care Emergency Psychiatry Team (a specialized emergency psychiatry service in Hamilton, Ontario), and by inpatient units at Hamilton Health Sciences, McMaster site, and St Joseph’s Hospital Health Care. In general, the duration of untreated psychosis was less than 12 months for 70% of subjects. Up to 29% presented within 1 month of experiencing symptoms. Analyses of the primary comparisons were all statistically significant (Table 2). The mean BPRS scores were improved from a mean of 40 to a mean of 24 after 12 months of PDC treatment (P < 0.0001). The average HDRS decreased from 13 to 3 at 12 months (P < 0.0001). The GAF scores improved from a mean of 44 to a mean of 71 (P < 0.0001). The relapse rate (defined as a 20% increase in BPRS scores, compared with baseline) was 5% at both 6 and 12 months. Scores on all measures were significantly improved at the 3-, 6-, and 12-month mark, compared with baseline. However, across all the measures, we discovered no significant difference between the scores at 6 and 12 months. The average number of days in hospital decreased from 23 days in the 6 months prior to PDC; it decreased to 3 days during the 12 months of PDC treatment (t36 =5.75, P < 0.001) (Table 3).
At baseline, 29/37 (78%) participants were on antipsychotic medications (Table 4). The mean haloperidol equivalents were 6.4 mg daily, SD 3.9, and the range was 0.5 to 19.5 mg daily. At 12 months, 12/37 (33%) participants were not taking medications: 6/37 (16%) were not adhering to their prescribed medication regime; the medication status of 2/37 (5%) was unknown; and 4/37 (11%) were asked to discontinue their antipsychotic medication by the treating psychiatrist. The treating psychiatrist diagnosed the latter participants with either a drug-induced psychosis or a mood disorder not requiring further antipsychotic medications (for example, bipolar disorder or depression with psychotic features). The mean haloperidol equivalents were 6.9 mg daily, SD 4.25 mg daily, and the range was 1 to 15 mg daily.
DiscussionThis program evaluation has many weaknesses that limit its usefulness as an efficacy study: lack of a control group, small sample size, lack of blinding, and lack of a randomized control design. Although this study lacks scientific rigour, it still provides information about services and outcomes under real-world conditions. Consumers want to attend programs that meet their needs and that can demonstrate improvements in level of functioning. This program evaluation meets the need to document the outcomes for patients attending a specialized early intervention program; it will interest small outpatient programs attempting to incorporate early intervention strategies. Interestingly, by 12 months, the first-episode psychosis patients yielded a spectrum of diagnoses ranging from schizophrenia spectrum disorders through mood disorders to drug-induced disorders. In addition, although most patients ultimately received atypical antipsychotic medications, some remained on traditional antipsychotics, and the treating psychiatrist no longer prescribed antipsychotic medications for others. These findings differ from most first-episode studies that focus on first-episode schizophrenia and the efficacy of specific treatments (27,28). First-episode patients followed by the PDC achieved significant improvements in both symptoms and functioning and had decreased hospitalization rates. As in other first-episode studies, most of the gains occurred within the first 6 months of treatment. Unfortunately, few improvements occurred between 6 and 12 months. This may indicate the need for more intensive psychosocial interventions than our program currently provides. However, our data on duration of untreated psychosis, symptom control, and hospitalization are comparable to the findings from other, larger Canadian centres (9,29–34) that share the goal of supporting patients and their families with specialized early intervention strategies and services. We need scientifically rigorous studies that compare the effectiveness of small outpatient programs with that of large early intervention centres. Is it better to apply evidence-based strategies or to offer specialized early intervention centres? Although early intervention offers a promise of hope, the challenge will be to offer it to a range of communities. FundingThis research was generously supported by a research grant from the Chedoke-McMaster Hospitals Foundation. References1. Johnstone EC, Crow TJ, Johnson AL, MacMillan JF. The Northwick Park Study of first episode schizophrenia: I. Presentation of the illness and problems relating to admission. Br J Psychiatry 1986;148:115–20. 2. Loebel AD, Lieberman JA, Alvir JMJ, and others. Duration of psychosis and outcome in first episode schizophrenia. Am J Psychiatry 1992;149:1183–8. 3. Bogart T, Solomon P. Procedures to share treatment information among mental health providers, consumers, and families. Psychiatr Serv 1999;50:1321–5. 4. McGorry PD, Edwards J, Mihalopoulos C, and others. EPPIC: an evolving system of early detection and optimal management. Schizophr Bull 1996;22:305–21. 5. Addington J, Addington D. Impact of an early psychosis program on substance use. Psychiatr Rehabil J 2001;25:60–7. 6. Malla AK, Norman RM, McLean TS, McIntosh E. Impact of phase-specific treatment of first episode of psychosis on Wisconsin Quality of Life Index (Client Version). Acta Psychiatr Scand 2001;103:355–61. 7. deHaan L, Linszen DH, Lenior ME, and others. Duration of untreated psychosis and outcome of schizophrenia: delay in intensive psychosocial treatment versus delay in treatment with antipsychotic medication. Schizophr Bull 2003;29:341–8. 8. Wyatt RJ. Early intervention for schizophrenia: can the course of the illness be altered? Biol Psychiatry 1995;38:1–3. 9. Black K, Peters L, Rui Q, and others. The duration of untreated psychosis predicts treatment outcome in an early psychosis program. Schizophr Res 2001;47:215–22. 10. Birchwood M, Todd P, Jackson C. Early intervention in psychosis. The critical period hypothesis. Br J Psychiatry 1998;172(Suppl):53–9. 11. MacMillan JF, Crow FT, Johnson AL, Johnstone EC. Short-term outcome in trial entrants and trial eligible patients: Northwick Park Study of First Episodes of Schizophrenia III. Br J Psychiatry 1986;148:128–33. 12. Robinson DG, Woerner MG, Alvir JM, Geisler S, Koreen A, Sheitman B, and others. Predictors of treatment response from a first episode of schizophrenia or schizoaffective disorder. Am J Psychiatry 1999;156:544–9. 13. Linszen DH, Dingemans PM, Lenior ME, and others. Early detection and intervention in schizophrenia. Int Clin Psychopharmacology 1998;13(Suppl):S31–S34. 14. Nordentoft M, Jeppesen P, Abel M, and others. OPUS study: suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis. One-year follow-up of a randomized controlled trial. Br J Psychiatry 2002;43(Suppl):S98–S106. 15. Jorgensen P, Nordentoft M, Abel MB, and others. Early detection and assertive community treatment of young psychotics: The Opus Study—rationale and design of the trial. Soc Psychiatry Psychiatr Epidemiol 2000;35:283–7. 16. Larsen TK, Friis S, Haahr U, and others. Early detection and intervention in first-episode schizophrenia: a critical review. Acta Psychiatr Scand 2001;103:321–2. 17. Jenner JA, van de Willige G. HIT, hallucination-focused integrative treatment as early intervention in psychotic adolescents with auditory hallucinations: a pilot study. Acta Psychiatr Scand 2001;103:148–52. 18. Power P, Elkins K, Adlard S, and others. Analysis of the initial treatment phase in first-episode psychosis. Br J Psychiatry 1998;172(Suppl):71–6. 19. Skeate A, Jackson C, Birchwood M, Jones C. Duration of untreated psychosis and pathways to care in first-episode psychosis. Investigation of help-seeking behaviour in primary care. Br J Psychiatry 2002;43(Suppl):S73–S77. 20. Addington J, Jones B, Ko T, Addington D. Working with families of first episode patients. Acta Psychiatr Scand 2000;102(Suppl):S56. 21. Drake RE, McHugo GJ, Bebout RR, and others. A Randomized clinical trial of supported employment for inner-city patients with severe mental disorders. Arch Gen Psychiatry 1999;56:627–33. 22. Hobbs H, Hamilton-Wilson J, Archie S. The alumni program: redefining continuity of care in psychiatry. Journal of Psychosocial Nursing and Mental Health Services 1999;37:23–9. 23. Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychol Rep 1962;10:799–812. 24. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): American Psychiatric Association; 1994. 25. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1959;32:50–5. 26. Conley RR, Mahmoud R. A randomized double-blind study of risperidone and olanzapine in the treatment of schizophrenia or schizoaffective disorder. Am J Psychiatry 2001;158:765–74. 27. Malla A, Norman R, 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. 28. Sanger TM, Lieberman JA, Tohen M, Grundy S, Beasley C, Tollefson GD. Olanzapine versus haloperidol treatment in first-episode psychosis. Am J Psychiatry 1999;156:79–87. 29. Malla AK, Norman RM, Manchanda R, and others. One year outcome in first episode psychosis: influence of DUP and other predictors. Schizophr Res 2002;54:231–41. 30. Malla AK, Norman RM, Manchanda R, and others. Status of patients with first-episode psychosis after one year of phase-specific community-oriented treatment. Psychiatr Serv 2002;53:458–63. 31. Addington J, Addington D. Early intervention for psychosis: the Calgary Early Psychosis Treatment and Prevention Program. CPA Bulletin 2001;33(3):11–6. 32. Addington J, Leriger E, Addington D. Symptom outcome 1 year after admission to an early psychosis program. Can J Psychiatry 2003;48:204–7. 33. Kopala LC, Good KP, Honer WG. Extrapyramidal signs and clinical symptoms in first-episode schizophrenia: response to low dose risperidone. J Clin Psychopharmacol 1997;17:308–13. 34. Zhang-Wong J, Zipursky RB, Beiser M, Bean G. Optimal haloperidol dosage in first episode psychosis. Can J Psychiatry 1999;44:164–7. Author(s)Manuscript received January 2004, revised, and accepted April 2004. 1. Assistant Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario; Director, Psychotic Disorders Clinic, Hamilton Health Sciences, McMaster Division, Hamilton, Ontario. 2. Family Educator, Psychotic Disorders Clinic, Hamilton Health Sciences, McMaster Division; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. 3. Medical Student, McMaster University, Hamilton, Ontario. 4. Care Coordinator, Psychotic Disorders Clinic, Hamilton Health Sciences, McMaster Division; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. 5. Care Coordinator, Psychotic Disorders Clinic, Hamilton Health Sciences, McMaster Division; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. 6. Research Coordinator, Psychotic Disorders Clinic, Hamilton Health Sciences, McMaster Division; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. Address for correspondence: Dr S Archie, 3G Out Patient Psychiatry Clinic, McMaster University Medical Centre, 1200 Main Street West, Hamilton, ON L8N 3Z5 e-mail: archies@mcmaster.ca
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