1 Boring Old Man

EPPIC disagreement over early intervention: poll
Psychiatric Update [Australia]
by Michael Slezak
October 6, 2011

^{Almost 60% of psychiatrists think the Federal Government’s focus on EPPIC is inappropriate, a poll conducted by Psychiatry Update reveals. Psychiatrists also mostly oppose the similar focus on headspace, but in slightly smaller numbers, with 53.7% either disagreeing or strongly disagreeing that the focus is appropriate. A significant proportion of psychiatrists were unsure about the two approaches, leaving only 30% agreeing the focus on headspace or EPPIC was appropriate…}

 

Intervening early: solid services or false promises?
Psychiatric Update [Australia]
by Michael Slezak
October 6, 2011

^{The evidence for early intervention in psychosis has split psychiatrists, but there’s no doubt in Professor Patrick McGorry’s mind that the approach works. The EPPIC centres he has pioneered are based on what is “demonstrably the most evidenced based model in the spectrum of mental health care”, he says. Speaking with Psychiatry Update, he compares the approach of EPPIC and headspace to that used in oncology where intervening aggressively early in cancer can dramatically improve the final outcomes of the disease.}

^{As evidence, he cites two studies from Denmark and Britain showing that early, assertive and intensive treatment improves psychotic and negative symptoms while the treatment is ongoing, compared with patients merely being offered contact with a community mental health centre. But crucially, these studies also show there isn’t, at this stage, much reason to believe the intervention changes the course of the illness…}

^{But others, including Professor David Castle, chair of psychiatry at St Vincent’s Health in Melbourne, say studies such as this show the money being poured into early psychosis has been committed on a false premise: that it will change the course of young people’s illnesses. Asked about this line of argument, McGorry says it seems bizarre to argue against providing psychological services to young people who want them, adding the onus of proof should be on those who want to limit the approach.}

^{But Castle says specialised youth intervention services are problematic for several reasons. “What’s very clear is that good treatments work while they’re being given,” he tells Psychiatry Update. “But boutique stand-alone services are very bad. They’re bad for patients because they have to transition between different forms of care. They’re bad for staff because people get into siloed services like EPPIC and they lose their skills with dealing with people further down the trajectory.” Echoing the concerns of many psychiatrists who commented in our survey, Castle says: “Everybody deserves the best care at whatever age they are, at whatever age of onset they are and at however far along the trajectory of illness they are”…}

• Transition rates from schizotypal disorder to psychotic disorder for first-contact patients included in the OPUS trial.
  Schizophrenia Research. 2006 83(1):29-40.
  ^{CONCLUSION: Integrated treatment postponed or inhibited onset of psychosis in significantly more cases than standard treatment.}

• Randomised controlled trial of early detection and cognitive therapy for preventing transition to psychosis in high-risk individuals. Study design and interim analysis of transition rate and psychological risk factors.
  British Journal of Psychiatry Supplement 2002 43:s78-84.
  ^{CONCLUSIONS: The findings validate the methods of identifying individuals at high risk of experiencing a psychotic episode. Compared with non-patient controls, the cases showed dysfunctional metacognitive beliefs and self-schemas.}
• Cognitive therapy for the prevention of psychosis in people at ultra-high risk: randomised controlled trial.
  British Journal of Psychiatry . 2004 185:291-7. [full text online]
  ^{CONCLUSIONS: Cognitive therapy appears to be an acceptable and efficacious intervention for people at high risk of developing psychosis.}
• Three-year follow-up of a randomized controlled trial of cognitive therapy for the prevention of psychosis in people at ultrahigh risk.
  Schizophrenia Bulletin. 2007 33(3):682-7. [full text online]
  ^{…There appear to be enduring benefits of CT over the long term, suggesting that it is an efficacious intervention for people at high risk of developing psychosis.}
• Effects of cognitive therapy on the longitudinal development of psychotic experiences in people at high risk of developing psychosis.
  British Journal of Psychiatry Supplement  2007 51:s82-7.
  ^{CONCLUSIONS: Psychotic experiences and emotional dysfunction appear to interact in people at risk of developing psychosis. There appears to be a specific benefit of cognitive therapy.}

• Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms.
  Arch Gen Psychiatry. 2002 59(10):921-8. [full text on-line]
  ^{CONCLUSIONS: More specific pharmacotherapy and psychotherapy reduces the risk of early transition to psychosis in young people at ultra-high risk, although their relative contributions could not be determined. This represents at least delay in onset (prevalence reduction), and possibly some reduction in incidence.}

• Randomized controlled trial of interventions for young people at ultra-high risk of psychosis: study design and baseline characteristics.
  Aust N Z J Psychiatry. 2009 43(9):818-29.
  ^{RESULTS AND CONCLUSION: The present study improves on the previous studies because treatment was provided for 12 months and the independent contributions of psychological and pharmacological treatments in preventing transition to psychosis in the UHR cohort and on levels of psychopathology and functioning can be directly compared. Issues associated with recruitment and randomization are discussed.}
• Randomized controlled trial of interventions for young people at ultra high risk for psychosis: 6-month analysis.
  Journal of Clinical Psychiatry. 2011 72(4):430-40.
  ^{At 6 months, 8 of the 115 participants (7.0%) and 4 of the monitoring group (5.1%) had developed psychotic disorder. There were no significant differences between the 3 randomized groups (log rank test, P = .92) or between all 4 groups (log rank test, P = .93). There was also no difference between the 4 groups in secondary measures, with all groups showing a reduction in symptoms and increased functioning.}
  ^{CONCLUSIONS: Rates of transition to psychosis were lower than expected, particularly in the control supportive therapy + placebo group. This may have accounted for the negative finding, as the sample was therefore underpowered to find any difference between groups. Alternatively, it may be that all treatments were equally effective or equally ineffective at 6 months.}

In his first study [2002], his combined psychotherapy/pharmacotherapy approach was successful in reducing the transition to psychosis, but the treatment effect disappeared by six months after treatment. So he designed a more elaborate study that separated psychotherapy and pharmacotherapy using more subjects. That study ran from 2000 to 2007 and the results were finally published in 2011. Not only were there no differences among the treatment groups, the transition to psychosis rate was quite low in all groups. Why was this study not published earlier? Why was even the prequel published two years after the study was completed? The results didn’t come out until after the EPPIC program was approved and in Australia’s 2011 budget. Neither this timing issue nor the failure of his second study are mentioned prominently in the Australian press. However, the poll at the top of this post says 60% of the psychiatrists in Australia don’t support EPPIC and over half of them think it will result in over-medication. Apparently, this issue has gained some real traction in Australia:

A public debate : Early intervention in psychosis is not justified

For those who are able to attend, a debate entitled "Early intervention in psychosis is not justified" has been organised between Professor Alison Yung [against the motion] and Professor David Castle [for the motion] on Thursday 3rd November at 12.30 to 1.30pm. The debate will be refereed by Professor Jan Scott. At this point the venue will be the Conference Room at Orygen Youth Health, 35 Poplar Rd, Parkville. RSVPs are required by Friday October 21st to Jo Fitzsimons at:

joannakf@unimelb.edu.au

If there is a large number of RSVPs, then the venue may change so watch out for updates!