AIM: Attenuated psychotic symptoms (APSs) have been the primary emphasis in youth at clinical high risk (CHR) for psychosis for assessing symptomology and determining subsequent transition to a psychotic disorder. Previous reviews primarily focused on the efficacy of cognitive behavioural therapy (CBT) on APS; however, a comprehensive assessment of other interventions to date is lacking. Therefore, we conducted a systematic review and meta-analysis of all intervention studies examining APS in CHR youth.
METHOD: The authors searched Embase, CINAHL, PsycINFO, Medline and EBM from inception to May 2017. Studies were selected if they included any intervention that reported follow-up APS in youth at CHR. Interventions were evaluated and stratified by time using both pairwise and network meta-analyses (NMAs). Due to the differences in APS scales, effect sizes were calculated as Hedges g and reported as the standardized mean difference (SMD).
RESULTS: Forty-one studies met our inclusion criteria. In pairwise meta-analyses, CBT was associated with a significant reduction in APS compared to controls at 18- to 24-month follow-up (SMD, -0.22; 95% CI, -0.43 to -0.01; I2 =0%; P = .04, 3 studies, N = 356). In the NMA, integrated psychological therapy, CBT, supportive therapy, family therapy, needs-based interventions, omega-3, risperidone plus CBT and olanzapine were not significantly more effective at reducing APS at 6 and 12 months relative to any other intervention.
CONCLUSIONS: CBT was more effective at reducing APS at long-term follow-up compared to controls. No interventions were significantly more effective at reducing APS compared to all other interventions in the NMA.
INTRODUCTION: There are now many existing studies which assess the treatments available for 'at risk mental states', as patients who are believed to be in the prodromal phase of psychotic illness are referred to. However, concerns regarding side effects of possible treatments remain. We here conduct a meta-analysis of the studies available up to July 2016. The aim of this study is to decide what would be the best treatment for 'at high risk patients'.
RESULTS: 18 studies were selected for inclusion; 12 showed significance, 5 did not and one tended towards significance. Both antipsychotic medication and psychological intervention show mixed results with cognitive behavioral therapy and olanzapine/amisulpride coming out on top. Omega 3 poly-unsaturated acid also shows promising and consistent results.
DISCUSSION: Treatments appear promising but a balance needs to be kept between adverse events and effectiveness of preventing psychosis.
CONCLUSION: It is necessary to search further for treatments in order to identify effective treatments with fewer adverse side-effects in this phase of psychotic illness.
Over the last decade many studies were conducted to assess the feasibility of early detection of people at risk of developing psychosis and intervention to prevent or delay a first psychotic episode. Most of these studies were small and underpowered. A meta-analysis can demonstrate the effectiveness of the efforts to prevent or postpone a first episode of psychosis. A search conducted according the PRISMA guideline identified 10 studies reporting 12-month follow-up data on transition to psychosis, and 5 studies with follow-ups varying from 24 to 48 months. Both random and fixed effects meta-analyses were conducted. The quality of the studies varied from poor to excellent. Overall the risk reduction at 12 months was 54% (RR = 0.463; 95% CI = 0.33–0.64) with a Number Needed to Treat (NNT) of 9 (95% CI = 6–15). Although the interventions differed, there was only mild heterogeneity and publication bias was small. All subanalyses demonstrated effectiveness. Also 24 to 48-month follow-ups were associated with a risk reduction of 37% (RR = .635; 95% CI = 0.44–0.92) and a NNT of 12 (95% CI = 7–59). Sensitivity analysis excluding the methodologically weakest study showed that the findings were robust. Early detection and intervention in people at ultra-high risk of developing psychosis can be successful to prevent or delay a first psychosis. Antipsychotic medication showed efficacy, but more trials are needed. Omega-3 fatty acid needs replication. Integrated psychological interventions need replication with more methodologically sound studies. The findings regarding CBT appear robust, but the 95% confidence interval is still wide. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
BACKGROUND: In Chile, the clinical guidelines "for the treatment of people from first episode of schizophrenia" aim to support individuals with schizophrenia to live independently, establishment occupational goals, and gain an adequate quality of life and social interaction. This requires the implementation of a treatment model that integrates psychosocial and pharmacological dimensions. Community intervention strategies ensure the achievement of these goals. OBJECTIVES: This study compiles and synthesizes available scientific evidence from the last 14 years on the effectiveness of community intervention strategies for schizophrenia and related psychotic disorders. Methodology: An electronic search was carried out using PUBMED, LILACS, and Science Direct as databases. Criteria of inclusion: (i) randomized clinical trials, (ii) Community-based interventions, (iii) diagnosis of schizophrenia or related psychotic disorder (section F2 of ICD-10). Exclusion Criteria: (i) treatments exclusively pharmacological, (ii) interventions carried out in inpatient settings, (iii) bipolar affective disorder or substance-induced psychosis (greater than 50% of sample). RESULTS: Sixty-six articles were reviewed. Community strategies for integrated treatment from the first outbreak of schizophrenia significantly reduced negative and psychotic symptoms, days of hospitalization, and comorbidity with substance abuse and improved global functioning and adherence to treatment. In other stages, there were improved outcomes in negative and positive symptoms and general psychopathology. Psychoeducation for patients and families reduced the levels of self-stigma and domestic abuse, as well as improved knowledge of the disease and treatment adherence. Training focused on cognitive, social, and labor skills has been shown to improve yields in social functioning and employment status. CONCLUSION: Community-based intervention strategies are widely supported in the treatment of patients with schizophrenia. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
BACKGROUND: Proponents of early intervention have argued that outcomes might be improved if more therapeutic efforts were focused on the early stages of schizophrenia or on people with prodromal symptoms. Early intervention in schizophrenia has two elements that are distinct from standard care: early detection, and phase-specific treatment (phase-specific treatment is a psychological, social or physical treatment developed, or modified, specifically for use with people at an early stage of the illness).
Early detection and phase-specific treatment may both be offered as supplements to standard care, or may be provided through a specialised early intervention team. Early intervention is now well established as a therapeutic approach in America, Europe and Australasia.
OBJECTIVES: To evaluate the effects of: (a) early detection; (b) phase-specific treatments; and (c) specialised early intervention teams in the treatment of people with prodromal symptoms or first-episode psychosis.
SEARCH METHODS: We searched the Cochrane Schizophrenia Group Trials Register (March 2009), inspected reference lists of all identified trials and reviews and contacted experts in the field.
SELECTION CRITERIA: We included 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. Eligible interventions, alone and in combination, included: early detection, phase-specific treatments, and care from specialised early intervention teams. We accepted cluster-randomised trials but excluded non-randomised trials.
DATA COLLECTION AND ANALYSIS: We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention-to-treat analysis (ITT).
MAIN RESULTS: Studies were diverse, mostly small, undertaken by pioneering researchers and with many methodological limitations (18 RCTs, total n=1808). Mostly, meta-analyses were inappropriate. For the six studies addressing prevention of psychosis for people with prodromal symptoms, olanzapine seemed of little benefit (n=60, 1 RCT, RR conversion to psychosis 0.58 CI 0.3 to 1.2), and cognitive behavioural therapy (CBT) equally so (n=60, 1 RCT, RR conversion to psychosis 0.50 CI 0.2 to 1.7). A risperidone plus CBT plus specialised team did have benefit over specialist team alone at six months (n=59, 1 RCT, RR conversion to psychosis 0.27 CI 0.1 to 0.9, NNT 4 CI 2 to 20), but this was not seen by 12 months (n=59, 1 RCT, RR 0.54 CI 0.2 to 1.3). Omega 3 fatty acids (EPA) had advantage over placebo (n=76, 1 RCT, RR transition to psychosis 0.13 CI 0.02 to 1.0, NNT 6 CI 5 to 96). We know of no replications of this finding.
The remaining trials aimed to improve outcome in first-episode psychosis. Phase-specific CBT for suicidality seemed to have little effect, but the single study was small (n=56, 1 RCT, RR suicide 0.81 CI 0.05 to 12.26). Family therapy plus a specialised team in the Netherlands did not clearly affect relapse (n=76, RR 1.05 CI 0.4 to 3.0), but without the specialised team in China it may (n=83, 1 RCT, RR admitted to hospital 0.28 CI 0.1 to 0.6, NNT 3 CI 2 to 6). The largest and highest quality study compared specialised team with standard care. Leaving the study early was reduced (n=547, 1 RCT, RR 0.59 CI 0.4 to 0.8, NNT 9 CI 6 to 18) and compliance with treatment improved (n=507, RR stopped treatment 0.20 CI 0.1 to 0.4, NNT 9 CI 8 to 12). The mean number of days spent in hospital at one year were not significantly different (n=507, WMD, -1.39 CI -2.8 to 0.1), neither were data for 'Not hospitalised' by five years (n=547, RR 1.05 CI 0.90 to 1.2). There were no significant differences in numbers 'not living independently' by one year (n=507, RR 0.55 CI 0.3 to 1.2). At five years significantly fewer participants in the treatment group were 'not living independently' (n=547, RR 0.42 CI 0.21 to 0.8, NNT 19 CI 14 to 62). When phase-specific treatment (CBT) was compared with befriending no significant differences emerged in the number of participants being hospitalised over the 12 months (n=62, 1 RCT, RR 1.08 CI 0.59 to 1.99).
Phase-specific treatment E-EPA oils suggested no benefit (n=80, 1 RCT, RR no response 0.90 CI 0.6 to 1.4) as did phase-specific treatment brief intervention (n=106, 1 RCT, RR admission 0.86 CI 0.4 to 1.7). Phase-specific ACE found no benefit but participants given vocational intervention were more likely to be employed (n=41, 1 RCT, RR 0.39 CI 0.21 to 0.7, NNT 2 CI 2 to 4). Phase-specific cannabis and psychosis therapy did not show benefit (n=47, RR cannabis use 1.30 CI 0.8 to 2.2) and crisis assessment did not reduce hospitalisation (n=98, RR 0.85 CI 0.6 to 1.3). Weight was unaffected by early behavioural intervention.
AUTHORS' CONCLUSIONS: 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.
As an extension of the early intervention in psychosis paradigm, different focused treatments are now offered to individuals at ultra high risk of psychosis (UHR) to prevent transition to schizophrenia, however the effectiveness of these treatments is unclear. A systematic literature search in PubMed/Medline and PsycINFO was performed to derive information on randomized control trials (RCTs) in UHR samples. Seven reports were identified detailing results from five independent RCT studies. Two studies used antipsychotic drugs (one in combination with cognitive behavior therapy); one study employed cognitive therapy; one study used a two-year program of intensive community care with family psychoeducation; one study assessed the effectiveness of 3-months omega-3 polyunsaturated fatty acids (Omega-3 PUFAs) supplementation. Intensive community care and the Omega-3 PUFAs supplementation were effective in reducing the transition to psychosis at 12 months. Overall, rates of transition to psychosis at 1 year were 11% for focused treatment groups (<i>n</i> = 180) and 31.6% for control UHR groups (<i>n</i> = 157). Receiving any of the focused treatment was associated with a lower risk of developing psychosis if compared with no treatment or treatment as usual (Relative Risk = 0.36; 95%CI: 0.22–0.59). The available evidence at 2/3 years follow-up indicates that the effects of focused treatments are not stable after intervention cessation and when treatment is delivered over a restricted time (e.g. 6 months or less), it may achieve only a delay in psychosis onset. Due to the heterogeneity in the interventions considered, the current results do not allow recommendation for any specific treatment. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Attenuated psychotic symptoms (APSs) have been the primary emphasis in youth at clinical high risk (CHR) for psychosis for assessing symptomology and determining subsequent transition to a psychotic disorder. Previous reviews primarily focused on the efficacy of cognitive behavioural therapy (CBT) on APS; however, a comprehensive assessment of other interventions to date is lacking. Therefore, we conducted a systematic review and meta-analysis of all intervention studies examining APS in CHR youth.
METHOD:
The authors searched Embase, CINAHL, PsycINFO, Medline and EBM from inception to May 2017. Studies were selected if they included any intervention that reported follow-up APS in youth at CHR. Interventions were evaluated and stratified by time using both pairwise and network meta-analyses (NMAs). Due to the differences in APS scales, effect sizes were calculated as Hedges g and reported as the standardized mean difference (SMD).
RESULTS:
Forty-one studies met our inclusion criteria. In pairwise meta-analyses, CBT was associated with a significant reduction in APS compared to controls at 18- to 24-month follow-up (SMD, -0.22; 95% CI, -0.43 to -0.01; I2 =0%; P = .04, 3 studies, N = 356). In the NMA, integrated psychological therapy, CBT, supportive therapy, family therapy, needs-based interventions, omega-3, risperidone plus CBT and olanzapine were not significantly more effective at reducing APS at 6 and 12 months relative to any other intervention.
CONCLUSIONS:
CBT was more effective at reducing APS at long-term follow-up compared to controls. No interventions were significantly more effective at reducing APS compared to all other interventions in the NMA.
