Most acute phase antipsychotic drug trials in schizophrenia last only a few weeks, but patients must usually take these drugs much longer. We examined the long‐term efficacy of antipsychotic drugs in acutely ill patients using network meta‐analysis. We searched the Cochrane Schizophrenia Group register up to March 6, 2022 for randomized, blinded trials of at least 6‐month duration on all second‐generation and 18 first‐generation antipsychotics. The primary outcome was change in overall symptoms of schizophrenia; secondary outcomes were all‐cause discontinuation; change in positive, negative and depressive symptoms; quality of life, social functioning, weight gain, antiparkinson medication use, akathisia, serum prolactin level, QTc prolongation, and sedation. Confidence in the results was assessed by the CINeMA (Confidence in Network Meta‐Analysis) framework. We included 45 studies with 11,238 participants. In terms of overall symptoms, olanzapine was on average more efficacious than ziprasidone (standardized mean difference, SMD = 0.37, 95% CI: 0.26‐0.49), asenapine (SMD = 0.33, 95% CI: 0.21‐0.45), iloperidone (SMD = 0.32, 95% CI: 0.15‐0.49), paliperidone (SMD = 0.28, 95% CI: 0.11‐0.44), haloperidol (SMD = 0.27, 95% CI: 0.14‐0.39), quetiapine (SMD = 0.25, 95% CI: 0.12‐0.38), aripiprazole (SMD = 0.16, 95% CI: 0.04‐0.28) and risperidone (SMD = 0.12, 95% CI: 0.03‐0.21). The 95% CIs for olanzapine versus aripiprazole and risperidone included the possibility of trivial effects. The differences between olanzapine and lurasidone, amisulpride, perphenazine, clozapine and zotepine were either small or uncertain. These results were robust in sensitivity analyses and in line with other efficacy outcomes and all‐cause discontinuation. Concerning weight gain, the impact of olanzapine was higher than all other antipsychotics, with a mean difference ranging from –4.58 kg (95% CI: –5.33 to –3.83) compared to ziprasidone to –2.30 kg (95% CI: –3.35 to –1.25) compared to amisulpride. Our data suggest that olanzapine is more efficacious than a number of other antipsychotic drugs in the longer term, but its efficacy must be weighed against its side effect profile. (PsycInfo Database Record (c) 2023 APA, all rights reserved)
The population of persons of color (POC) are increasing in the United States. Unfortunately, POC are significantly impacted by serious mental illness; psychosis represents a mental health disparity among POC. Fortunately, first episode coordinated specialty care (CSC) is an effective treatment for individuals who are in the early phases of a psychotic disorder. This systematic review of the literature examined POC inclusion rates in randomized controlled trials (RCT) examining First Episode Psychosis (FEP) programs. Our review yielded seven articles that met inclusion criteria. Our findings were mixed-researchers conducting RCTs on FEP programs did an excellent job including African American participants suggesting that findings from RCTs on FEP programs may generalize to African American participants. Regarding Latines, they were broadly underrepresented in RCTs on FEP CSC. Based on the data, we cannot definitively conclude to what extent findings from RCTs on FEP CSC generalize to Latines although results from studies that included a reasonable number of Latines offer promising results. Asians were overrepresented in three of the seven studies included in this review; thus it seems that the findings from RCTs on FEP CSC generalize to the Asian population in the United States.
BACKGROUND: Psychosis is an illness characterised by the presence of hallucinations and delusions that can cause distress or a marked change in an individual's behaviour (e.g. social withdrawal, flat or blunted effect). A first episode of psychosis (FEP) is the first time someone experiences these symptoms that can occur at any age, but the condition is most common in late adolescence and early adulthood. This review is concerned with first episode psychosis (FEP) and the early stages of a psychosis, referred to throughout this review as 'recent-onset psychosis.' Specialised early intervention (SEI) teams are community mental health teams that specifically treat people who are experiencing, or have experienced a recent-onset psychosis. The purpose of SEI teams is to intensively treat people with psychosis early in the course of the illness with the goal of increasing the likelihood of recovery and reducing the need for longer-term mental health treatment. SEI teams provide a range of treatments including medication, psychotherapy, psychoeducation, and occupational, educational and employment support, augmented by assertive contact with the service user and small caseloads. Treatment is time limited, usually offered for two to three years, after which service users are either discharged to primary care or transferred to a standard adult community mental health team. A previous Cochrane Review of SEI found preliminary evidence that SEI may be superior to standard community mental health care (described as 'treatment as usual (TAU)' in this review) but these recommendations were based on data from only one trial. This review updates the evidence for the use of SEI services.
OBJECTIVES: To compare specialised early intervention (SEI) teams to treatment as usual (TAU) for people with recent-onset psychosis.
SEARCH METHODS: On 3 October 2018 and 22 October 2019, we searched Cochrane Schizophrenia's study-based register of trials, including registries of clinical trials.
SELECTION CRITERIA: We selected all randomised controlled trials (RCTs) comparing SEI with TAU for people with recent-onset psychosis. We entered trials meeting these criteria and reporting useable data as included studies.
DATA COLLECTION AND ANALYSIS: We independently inspected citations, selected studies, extracted data and appraised study quality. For binary outcomes we calculated the risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and their 95% CIs, or if assessment measures differed for the same construct, we calculated the standardised mean difference (SMD) with 95% CIs. We assessed risk of bias for included studies and created a 'Summary of findings' table using the GRADE approach.
MAIN RESULTS: We included three RCTs and one cluster-RCT with a total of 1145 participants. The mean age in the trials was between 23.1 years (RAISE) and 26.6 years (OPUS). The included participants were 405 females (35.4%) and 740 males (64.6%). All trials took place in community mental healthcare settings. Two trials reported on recovery from psychosis at the end of treatment, with evidence that SEI team care may result in more participants in recovery than TAU at the end of treatment (73% versus 52%; RR 1.41, 95% CI 1.01 to 1.97; 2 studies, 194 participants; low-certainty evidence). Three trials provided data on disengagement from services at the end of treatment, with fewer participants probably being disengaged from mental health services in SEI (8%) in comparison to TAU (15%) (RR 0.50, 95% CI 0.31 to 0.79; 3 studies, 630 participants; moderate-certainty evidence). There was low-certainty evidence that SEI may result in fewer admissions to psychiatric hospital than TAU at the end of treatment (52% versus 57%; RR 0.91, 95% CI 0.82 to 1.00; 4 studies, 1145 participants) and low-certainty evidence that SEI may result in fewer psychiatric hospital days (MD -27.00 days, 95% CI -53.68 to -0.32; 1 study, 547 participants). Two trials reported on general psychotic symptoms at the end of treatment, with no evidence of a difference between SEI and TAU, although this evidence is very uncertain (SMD -0.41, 95% CI -4.58 to 3.75; 2 studies, 304 participants; very low-certainty evidence). A different pattern was observed in assessment of general functioning with an end of trial difference that may favour SEI (SMD 0.37, 95% CI 0.07 to 0.66; 2 studies, 467 participants; low-certainty evidence). It was uncertain whether the use of SEI resulted in fewer deaths due to all-cause mortality at end of treatment (RR 0.21, 95% CI 0.04 to 1.20; 3 studies, 741 participants; low-certainty evidence). There was low risk of bias for random sequence generation and allocation concealment in three of the four included trials; the remaining trial had unclear risk of bias. Due to the nature of the intervention, we considered all trials at high risk of bias for blinding of participants and personnel. Two trials had low risk of bias and two trials had high risk of bias for blinding of outcomes assessments. Three trials had low risk of bias for incomplete outcome data, while one trial had high risk of bias. Two trials had low risk of bias, one trial had high risk of bias, and one had unclear risk of bias for selective reporting.
AUTHORS' CONCLUSIONS: There is evidence that SEI may provide benefits to service users during treatment compared to TAU. These benefits probably include fewer disengagements from mental health services (moderate-certainty evidence), and may include small reductions in psychiatric hospitalisation (low-certainty evidence), and a small increase in global functioning (low-certainty evidence) and increased service satisfaction (moderate-certainty evidence). The evidence regarding the effect of SEI over TAU after treatment has ended is uncertain. Further evidence investigating the longer-term outcomes of SEI is needed. Furthermore, all the eligible trials included in this review were conducted in high-income countries, and it is unclear whether these findings would translate to low- and middle-income countries, where both the intervention and the comparison conditions may be different.
The cardinal symptoms of psychosis include hallucination and delusion, which can be both distressing and disabling. International guidelines recommend cognitive behavioural therapy for psychosis (CBTp) as an adjunctive intervention to medication management. Considering the difficulty in the widespread dissemination of the individual CBTp, group CBTp is an alternative in improving patients' access to psychological intervention. Although it has been found feasible and effective in various studies, systematic review on group CBTp, particularly in Asia, was not identified. Hence, this systematic review tried to examine the recent evidence of group CBTp in Asia in order to shed light on its implementation in routine psychiatric care. A relevant literature search was conducted in three databases (Pubmed, Web of Knowledge, and PsycINFO) during the period from January 2000 to December 2018. A total of 114 journal articles were identified. After a full-text review, four studies met our inclusion and exclusion criteria. Despite methodological shortcomings, positive results were found in terms of improvements on psychotic symptoms, functioning, and quality-of-life. These encouraging results indicate the need for future research studies with more rigorous methodology, leading to a better understanding on the applicability and effectiveness of group CBTp in the Asian context.
AIMS: This systematic review examines the effectiveness of the psycho-educational interventions (PEIs) targeted at people diagnosed with schizophrenia and their primary caregivers on improving knowledge level of schizophrenia and health-related outcomes.
METHODS: A total of 28 studies were reviewed from December 1999 to May 2015. The methods described by Centre for Reviews and Dissemination were used to guide this review.
RESULTS: The PEIs showed consistent improvement in the knowledge level of schizophrenia among participants for various follow-up intervals. In addition, PEIs were found to be superior to treatment as usual in influencing health-related outcomes.
CONCLUSIONS: Implications of the findings for mental health care practice and education and recommendations are discussed.
Despite convincing evidence of short-term symptom control and functional recovery of patients with psychosis after receiving early intervention (EI) services, little is known about the long-term outcomes of EI for these patients. This review aims to evaluate the effectiveness of EI services in improving long-term outcomes of patients with psychosis. A systematic literature search was conducted on PubMed, PsycINFO, Scopus, Medline, CINAHL, BIOSIS, and EMBASE electronic databases to identify studies that evaluated long-term outcomes of patients with psychosis measured 5 years or beyond after entering the EI service. Of 13,005 articles returned from the search, 14 eligible articles reporting study cohorts from nine EI services in seven countries and regions were identified. Data on study design, patient characteristics, intervention components, and outcomes were extracted and reviewed. Only a few studies reported better longitudinal outcomes for negative symptoms, mortality, employment, and hospitalization in patients received EI services. However, results from cross-sectional measurements provided little evidence for long-term impacts of EI services on clinical and functional outcomes. A dilution effect of benefits over time was also demonstrated in several studies. This review highlights the gap in current EI service provision and suggests possible future directions for service improvement and further research.
BACKGROUND: Cognitive behavioural therapy (CBT) is a psychosocial treatment that aims to help individuals re-evaluate their appraisals of their experiences that can affect their level of distress and problematic behaviour. CBT is now recommended by the National Institute for Health and Care Excellence (NICE) as an add-on treatment for people with a diagnosis of schizophrenia. Other psychosocial therapies that are often less expensive are also available as an add-on treatment for people with schizophrenia. This review is also part of a family of Cochrane Reviews on CBT for people with schizophrenia.
OBJECTIVES: To assess the effects of CBT compared with other psychosocial therapies as add-on treatments for people with schizophrenia.
SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Study Based Register of Trials (latest 6 March, 2017). This register is compiled by systematic searches of major resources (including AMED, BIOSIS CINAHL, Embase, MEDLINE, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register.
SELECTION CRITERIA: We selected randomised controlled trials (RCTs) involving people with schizophrenia who were randomly allocated to receive, in addition to their standard care, either CBT or any other psychosocial therapy. Outcomes of interest included relapse, global state, mental state, adverse events, social functioning, quality of life and satisfaction with treatment. We included trials meeting our inclusion criteria and reporting useable data.
DATA COLLECTION AND ANALYSIS: We reliably screened references and selected trials. Review authors, working independently, assessed trials for methodological quality and extracted data from included studies. We analysed dichotomous data on an intention-to-treat basis and continuous data with 60% completion rate. Where possible, for binary data we calculated risk ratio (RR), for continuous data we calculated mean difference (MD), all with 95% confidence intervals (CIs). We used a fixed-effect model for analyses unless there was unexplained high heterogeneity. We assessed risk of bias for the included studies and used the GRADE approach to produce a 'Summary of findings' table for our main outcomes of interest.
MAIN RESULTS: The review now includes 36 trials with 3542 participants, comparing CBT with a range of other psychosocial therapies that we classified as either active (A) (n = 14) or non active (NA) (n = 14). Trials were often small and at high or unclear risk of bias. When CBT was compared with other psychosocial therapies, no difference in long-term relapse was observed (RR 1.05, 95% CI 0.85 to 1.29; participants = 375; studies = 5, low-quality evidence). Clinically important change in global state data were not available but data for rehospitalisation were reported. Results showed no clear difference in long term rehospitalisation (RR 0.96, 95% CI 0.82 to 1.14; participants = 943; studies = 8, low-quality evidence) nor in long term mental state (RR 0.82, 95% CI 0.67 to 1.01; participants = 249; studies = 4, low-quality evidence). No long-term differences were observed for death (RR 1.57, 95% CI 0.62 to 3.98; participants = 627; studies = 6, low-quality evidence). Only average endpoint scale scores were available for social functioning and quality of life. Social functioning scores were similar between groups (long term Social Functioning Scale (SFS): MD 8.80, 95% CI -4.07 to 21.67; participants = 65; studies = 1, very low-quality evidence), and quality of life scores were also similar (medium term Modular System for Quality of Life (MSQOL): MD -4.50, 95% CI -15.66 to 6.66; participants = 64; studies = 1, very low-quality evidence). There was a modest but clear difference favouring CBT for satisfaction with treatment - measured as leaving the study early (RR 0.86, 95% CI 0.75 to 0.99; participants = 2392; studies = 26, low quality evidence).
AUTHORS' CONCLUSIONS: Evidence based on data from randomised controlled trials indicates there is no clear and convincing advantage for cognitive behavioural therapy over other - and sometimes much less sophisticated and expensive - psychosocial therapies for people with schizophrenia. It should be noted that although much research has been carried out in this area, the quality of evidence available is mostly low or of very low quality. Good quality research is needed before firm conclusions can be made.
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; <i>P</i> < .001), at least 1 psychiatric hospitalization (RR, 0.74; 95%CI, 0.61-0.90; <i>P</i> = .003), involvement in school or work (RR, 1.13; 95%CI, 1.03-1.24; <i>P</i> = .01), total symptom severity (standardized mean difference [SMD], −0.32; 95%CI, −0.47 to −0.17; <i>P</i> < .001), positive symptom severity (SMD, −0.22; 95%CI, −0.32 to −0.11; <i>P</i> < .001), and negative symptom severity (SMD, −0.28; 95%CI, −0.42 to −0.14;<i> P</i> < .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. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
Most acute phase antipsychotic drug trials in schizophrenia last only a few weeks, but patients must usually take these drugs much longer. We examined the long‐term efficacy of antipsychotic drugs in acutely ill patients using network meta‐analysis. We searched the Cochrane Schizophrenia Group register up to March 6, 2022 for randomized, blinded trials of at least 6‐month duration on all second‐generation and 18 first‐generation antipsychotics. The primary outcome was change in overall symptoms of schizophrenia; secondary outcomes were all‐cause discontinuation; change in positive, negative and depressive symptoms; quality of life, social functioning, weight gain, antiparkinson medication use, akathisia, serum prolactin level, QTc prolongation, and sedation. Confidence in the results was assessed by the CINeMA (Confidence in Network Meta‐Analysis) framework. We included 45 studies with 11,238 participants. In terms of overall symptoms, olanzapine was on average more efficacious than ziprasidone (standardized mean difference, SMD = 0.37, 95% CI.: 0.26‐0.49), asenapine (SMD = 0.33, 95% CI.: 0.21‐0.45), iloperidone (SMD = 0.32, 95% CI.: 0.15‐0.49), paliperidone (SMD = 0.28, 95% CI.: 0.11‐0.44), haloperidol (SMD = 0.27, 95% CI.: 0.14‐0.39), quetiapine (SMD = 0.25, 95% CI.: 0.12‐0.38), aripiprazole (SMD = 0.16, 95% CI.: 0.04‐0.28) and risperidone (SMD = 0.12, 95% CI.: 0.03‐0.21). The 95% CIs for olanzapine versus aripiprazole and risperidone included the possibility of trivial effects. The differences between olanzapine and lurasidone, amisulpride, perphenazine, clozapine and zotepine were either small or uncertain. These results were robust in sensitivity analyses and in line with other efficacy outcomes and all‐cause discontinuation. Concerning weight gain, the impact of olanzapine was higher than all other antipsychotics, with a mean difference ranging from –4.58 kg (95% CI.: –5.33 to –3.83) compared to ziprasidone to –2.30 kg (95% CI.: –3.35 to –1.25) compared to amisulpride. Our data suggest that olanzapine is more efficacious than a number of other antipsychotic drugs in the longer term, but its efficacy must be weighed against its side effect profile. (PsycInfo Database Record (c) 2023 APA, all rights reserved)
Pregunta de la revisión sistemática»Revisión sistemática de intervenciones
