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Original Investigation
June 2018

Comparison of Early Intervention Services vs Treatment as Usual for Early-Phase Psychosis: A Systematic Review, Meta-analysis, and Meta-regression

Author Affiliations
  • 1Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York
  • 2Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York
  • 3The Feinstein Institute for Medical Research, Manhasset, New York
  • 4Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
  • 5Section of Psychiatry, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
  • 6Institute of Psychiatry, King’s College London, London, England
  • 7Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
  • 8The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Copenhagen, Denmark
  • 9Department of Psychiatry, Yale University, New Haven, Connecticut
  • 10Specialized Treatment Early in Psychosis (STEP) Program, Connecticut Mental Health Center, New Haven
  • 11Department of Psychiatry and Psychology, Maastricht University Medical Center, Maastricht, the Netherlands
  • 12Department of Psychiatry, University of Hong Kong, Hong Kong, China
  • 13State Key Laboratory of Brain and Cognitive Science, The University of Hong Kong, Hong Kong, China
  • 14Division of Epidemiological and Psychosocial Research, National Institute of Psychiatry, Mexico City, Mexico
  • 15Department of Psychiatry, SUNY Downstate Medical Center, New York, New York
  • 16Department of Psychiatry, Geisel School of Medicine at Dartmouth, Dartmouth, New Hampshire
  • 17Bureau of Behavioral Health, College of Health and Human Services (CHHS), Dartmouth, New Hampshire
  • 18Department of Occupational Therapy, Center for Psychiatric Rehabilitation, Boston University, Boston, Massachusetts
  • 19Department of Psychiatry, Center for Psychiatric Rehabilitation, Boston University, Boston, Massachusetts
  • 20Department of Psychological and Brain Sciences, Center for Psychiatric Rehabilitation, Boston University, Boston, Massachusetts
  • 21Department of Psychiatry, Yale University, New Haven, Connecticut
  • 22Department of Epidemiology, Yale University, New Haven, Connecticut
  • 23Department of Public Health, Yale University, New Haven, Connecticut
  • 24The Hotchkiss Brain Institute, Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
  • 25Department of Social Medicine, The University of North Carolina at Chapel Hill
  • 26Nathan Kline Institute, Orangeburg, New York
  • 27Department of Psychology, The University of North Carolina at Chapel Hill
  • 28National Institute of Mental Health (NIMH), Bethesda, Maryland
JAMA Psychiatry. 2018;75(6):555-565. doi:10.1001/jamapsychiatry.2018.0623
Key Points

Question  Are early intervention services superior to treatment as usual regarding symptom-related and illness-related treatment outcomes in patients with early-phase psychosis?

Findings  In this meta-analysis of 10 randomized clinical trials (n = 2176 patients), early intervention services were associated with better outcomes than treatment as usual at the end of treatment regarding all meta-analyzable outcomes. These outcomes included all-cause treatment discontinuation from early intervention services or treatment as usual and at least 1 psychiatric hospitalization.

Meaning  In early-phase psychosis, early intervention services were associated with superior outcomes compared with treatment as usual, which supports the need for funding and use of early intervention services in patients with early-phase psychosis.

Abstract

Importance  The value of early intervention in psychosis and allocation of public resources has long been debated because outcomes in people with schizophrenia spectrum disorders have remained suboptimal.

Objective  To compare early intervention services (EIS) with treatment as usual (TAU) for early-phase psychosis.

Data Sources  Systematic literature search of PubMed, PsycINFO, EMBASE, and ClinicalTrials.gov without language restrictions through June 6, 2017.

Study Selection  Randomized trials comparing EIS vs TAU in first-episode psychosis or early-phase schizophrenia spectrum disorders.

Data Extraction and Synthesis  This systematic review was conducted according to PRISMA guidelines. Three independent investigators extracted data for a random-effects meta-analysis and prespecified subgroup and meta-regression analyses.

Main Outcomes and Measures  The coprimary outcomes were all-cause treatment discontinuation and at least 1 psychiatric hospitalization during the treatment period.

Results  Across 10 randomized clinical trials (mean [SD] trial duration, 16.2 [7.4] months; range, 9-24 months) among 2176 patients (mean [SD] age, 27.5 [4.6] years; 1355 [62.3%] male), EIS was associated with better outcomes than TAU at the end of treatment for all 13 meta-analyzable outcomes. These outcomes included the following: all-cause treatment discontinuation (risk ratio [RR], 0.70; 95% CI, 0.61-0.80; P < .001), at least 1 psychiatric hospitalization (RR, 0.74; 95% CI, 0.61-0.90; P = .003), involvement in school or work (RR, 1.13; 95% CI, 1.03-1.24; P = .01), total symptom severity (standardized mean difference [SMD], −0.32; 95% CI, −0.47 to −0.17; P < .001), positive symptom severity (SMD, −0.22; 95% CI, −0.32 to −0.11; P < .001), and negative symptom severity (SMD, −0.28; 95% CI, −0.42 to −0.14; P < .001). Superiority of EIS regarding all outcomes was evident at 6, 9 to 12, and 18 to 24 months of treatment (except for general symptom severity and depressive symptom severity at 18-24 months).

Conclusions and Relevance  In early-phase psychosis, EIS are superior to TAU across all meta-analyzable outcomes. These results support the need for funding and use of EIS in patients with early-phase psychosis.

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