Early intervention for psychosis: updated Cochrane review remains inconclusive

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The Cochrane Scizophrenia Group have updated the systematic review that brings together all randomised controlled trials (RCTs) designed to prevent progression to psychosis in people showing prodromal symptoms, or to improve outcome for people with first-episode psychosis.

The reviewers found 18 RCTs this time around, but (as is often the case with systematic reviews) the quality of the evidence is insufficient to draw any hard and fast conclusions.

Schizophrenia typically begins in young adulthood and may lead to disability that lasts a lifetime. The onset of psychosis is usually preceded by a period of non-psychotic symptoms, known as prodromal symptoms. The symptoms of full-blown schizophrenia include hallucinations, delusions, disordered thinking and emotional withdrawal. There is some evidence that a delay in receiving adequate treatment reduces the chances or the extent of recovery.

In broad terms, early intervention has two objectives:

  1. to prevent the onset of schizophrenia in people with prodromal symptoms
  2. to provide effective treatment to people in the early stages of schizophrenia, with the goal of reducing the ultimate severity of the illness.

Early intervention services are now widespread in America, Europe and Australia.

Implications for practice:

  • For people presenting with prodromal symptoms of psychosis
    • At the moment it is not clear whether treating people presenting with prodromal symptoms of schizophrenia provides benefits. There is inconclusive evidence on the personal and social consequences of providing treatment to people who will not necessarily become unwell. Further evidence is needed before recommendations can be given.
  • For people in their first episode of psychosis
    • There is some support for specialised early intervention services but again further evidence is needed. However, since such people do require treatment in some form, the ethical issues are less intense than for people presenting with prodromal symptoms. Moreover, there is also little evidence to support the ‘standard care’, which is the alternative to the employment of specialised first-episode teams (NICE 2002). The use of first-episode teams is therefore ethical even though there is not, as yet, strong evidence to support it.
    • Phase-specific treatments for people in their first episode of psychosis may help with employment and family therapy. Whilst this evidence is limited, it should be viewed in the broader context that family therapy is known to be effective for people with schizophrenia as a whole (Pharoah 2006). On this basis, it would seem reasonable to recommend family therapy to people experiencing their first episode of psychosis, but there is insufficient data to suggest that they should be given this intervention as a priority over people with established illness.
    • There is no evidence from clinical trials to support the benefits of early detection of patients in their first episode of psychosis.
  • For clinicians
    • Family intervention may be of value for people in their first episode of psychosis, as it may for people with longer established illnesses. It is important for clinicians to continue to keep up to date with this fast-expanding field.
  • For policy makers
    • It is premature to implement wide-spread treatment programmes for people with prodromal symptoms. Such treatment programmes should only be implemented within the context of a well-designed randomised study.

The reviewers conclude:

There is emerging, but as yet inconclusive evidence, to suggest that people in the prodrome of psychosis can be helped by some interventions. There is some support for specialised early intervention services, but further trials would be desirable, and there is a question of whether gains are maintained. There is some support for phase-specific treatment focused on employment and family therapy, but again, this needs replicating with larger and longer trials.

Marshall M, Rathbone J. Early intervention for psychosisCochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD004718. DOI: 10.1002/14651858.CD004718.pub3.

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