Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review

Authors:
BIRD Victoria, et al
Journal article citation:
British Journal of Psychiatry, 197(5), November 2010, pp.350-356.
Publisher:
Cambridge University Press

The effectiveness of early intervention services, cognitive-behavioural therapy (CBT) and family intervention in early psychosis were evaluated. Data was sourced from a systematic review and meta-analysis of randomised controlled trials of early intervention services, CBT and family intervention for people with early psychosis. Findings suggest that early intervention services reduced hospital admission, relapse rates and symptom severity, and improved access to and engagement with treatment. When used alone, family intervention reduced relapse and hospital admission rates, whereas CBT reduced the severity of symptoms with little impact on relapse or hospital admission. The authors concluded that, for people with psychosis, early intervention services appeared to have clinically important benefits over standard care. Including CBT and family intervention within the service may contribute to improved outcomes in this critical period.

Extended abstract:
Author

BIRD V.; et al.;

Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: a systematic review.

Journal citation/publication details

British Journal of Psychiatry, 197(5), November 2010, pp.350-356.

Summary

Meta-analysis of data from eleven randomised controlled trials revealed beneficial effects associated with early intervention services compared with standard care. The inclusion of cognitive-behavioural therapy or family interventions in the early intervention resulted in further improved outcomes. The main limitation of the review was the small number of trials identified. The long-term benefits of early intervention need to be established as only one study provided long-term data.

Context

The provision of early intervention services for individuals with early psychosis has been recommended in the National Service for Mental Health and the National Institute for Health and Clinical Excellence guideline on schizophrenia. This systematic review, carried out as part of an update of the NICE guidelines, evaluated the effectiveness of early intervention services and examined data on the separate use of cognitive-behaviour therapy (CBT) and family intervention in early schizophrenia, both evidence-based psychological interventions that are typically used in early intervention.

Methods

What sources were searched?
The databases CINAHL, CENTRAL, EMBASE, Medline, and PsycINFO were searched in September 2009 for studies published after 2002. Earlier studies were identified from the original schizophrenia guideline of 2002. The reference lists of relevant articles, recent systematic reviews and meta-analyses of interventions in schizophrenia were hand searched. Further articles were identified by examining the tables of contents of key journals and from suggestions made by members of the schizophrenia guideline development group.

What search terms/strategies were used?
Full details of the search strategy are available in the online supplement at http://bjp.rcpsych.org/cgi/content/full/197/5/365/DC1. Searches were carried out using MeSH descriptors and keywords.

What criteria were used to decide on which studies to include?
Randomised controlled trials (RCTs) of early intervention services, CBT, or family intervention for people with early psychosis were eligible for inclusion. Early psychosis was defined as ‘clinical diagnosis of psychosis within five years of the first psychotic episode or presentation to mental health services’. Interventions targeting high-risk groups or pre-psychotic populations were excluded as were those with fewer than ten participants in the intervention arm. Only studies published in English, or with an English abstract were selected.

Who decided on their relevance and quality?
The search process is illustrated in Figure 1. Methodological quality was assessed by two named authors using a modified version of the SIGN checklist; a third author double-checked the data and disagreements were resolved by discussion.

How many studies were included and where were they from?
Over 10,000 papers were initially identified. Thirty-eight of the 230 papers retrieved in full for further examination were found to be potentially eligible. The final number included in the meta-analysis was eleven; eight new RCTs and three RCTs identified in the 2002 guideline. The main characteristics of the included studies are summarised in Table 1. More information on both the included and excluded studies is available online. The country of origin of the trials is not clear, although two studies are described as coming from the UK and another from China.

How were the study findings combined?
Three named authors extracted study data into Review Manager version 5.0.18. Where appropriate, meta-analysis was used to synthesise the data. Standardised mean difference (SMD) or relative risk (RR) was calculated. Data was pooled using a random-effects model. The results are presented separately for early intervention services, CBT, and family intervention.

 

Findings of the review

Early intervention services
Meta-analysis of four early intervention trials with a total of 800 participants revealed that early intervention was associated with a reduced risk of relapse (RR 0.67, CI 0.54 to 0.83) and hospital admission (RR 0.66, CI 0.47 to 0.94) compared to standard care. There was also a reduced incidence of positive symptoms (SMD -0.21) and negative symptoms (SMD -0.39). Participants receiving early intervention were also less likely to leave the study early for any reason and more likely to access services and engage with treatment.

Cognitive-behavioural therapy
Results from four trials of CBT in 620 participants revealed that up to two years post-treatment follow-up CBT significantly reduced mean positive symptoms (SMD -0.66) and mean negative symptoms (SMD -0.45); the effects were not evident immediately post-treatment. No beneficial effects on the rate of relapse or hospital admission were demonstrated.

Family intervention
Analysis of three trials with a combined total of 288 participants receiving family intervention revealed that, compared to standard care, intervention was associated with a reduction in the risk of relapse or hospital admission (14.5% v. 28.9%). 

Authors' conclusions

The evidence ‘suggests that early intervention services are an effective way of delivering care for people with early psychosis and can reduce hospital admission, relapse rates and symptom severity, while improving access to and engagement with a range of treatments’. ‘Providing evidence-based psychological interventions as part of an early intervention service may contribute to improving outcomes for people with early psychosis.’

Implications for policy or practice

None are discussed.

Related references

National Collaborating Centre for Mental Health. Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care (Clinical Guideline CG82). National Institute for Health and Clinical Excellence, 2009.

http://guidance.nice.org.uk/CG82/Guidance
Subject terms:
hospital admission, psychoses, behaviour therapy, cognitive behavioural therapy, early intervention, family support;
Content type:
systematic review
Links:
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Journal home page
ISSN online:
1472-1465
ISSN print:
0007-1250

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