Early intervention in first-episode psychosis: What works?

Specialized early intervention versus treatment as usual

In early psychosis, early intervention produced better outcomes than treatment as usual

The RAISE-ETP study (Recovery After an Initial Schizophrenia Episode – Early Treatment Study) was designed to test EI that could change the trajectory of schizophrenia from the first episode, and would be widely applicable in the clinic¹. In half of the centres, patients with schizophrenia spectrum disorders and less than 6 months’ antipsychotic treatment received treatment as usual (TAU), and at half of the centres they received an integrated care approach with four components: medication (with the choice based on a computer decision-making tool), individualized resilience training, family psychoeducation, and support to re-integrate patients into employment or education.

Those patients who received the integrated care showed somewhat better outcomes than TAU after the 2 years of the study. In addition, patients with a shorter duration of untreated psychosis showed better outcomes than those who had experienced up to 18 months untreated. These results were supported by a meta-analysis of EI versus TAU²; again, outcomes favored the EI. However, it is much less clear whether those benefits of EI are maintained during follow-up.

How to maintain the benefits of EI in the long-term?

Long-term outcomes of early intervention are best maintained by extending early interventions, rather than return to treatment as usual

In a naturalistic study, with 10-year follow up and historical controls, 2 years’ EI had significant advantages in reducing hospitalizations and improving employment tenure³. However, there were no significant differences in other outcomes, such as psychotic symptoms and functional recovery.

Extending the duration of EI to 5 years has been shown to have beneficial effects over TAU on a range of outcomes including treatment adherence, patient satisfaction and both positive and negative symptoms^4,5. Outcomes for patients receiving extended EI were also better than for those who stepped down from EI to a focused TAU (which was less intense than EI)⁶.

Should antipsychotic treatment be stopped?

Maintenance antipsychotics and relapse prevention are key to good long-term outcomes

If EI is successful, and patients show a good response to treatment, when might it be appropriate to stop medication? There are no good randomized data to answer this question, so we need to look at database information on long-term follow-up of patients. Such data gathered over 20 years in Finland indicated that for patients stopping treatment before 2 years, the benefits conferred by that treatment were lost within the next few years⁷. As Prof Correll pointed out, currently available antipsychotic drugs are not disease modifying. Therefore, the rational treatment approach would be to treat patients optimally to achieve the best outcomes, and to continue that treatment in the long-term to ensure that their condition remains as stable as possible.

Long-acting antipsychotics may present the best option for EI

Prevention of relapses is a crucial aim of long-term therapy of schizophrenia, to reduce the risk of poor disease outcomes, as well other excess mortality, such as from cardiovascular disease⁸. This may best be achieved using a long-acting antipsychotic. Prof Correll pointed out that the use of these long-acting drugs is possible, and probably desirable as an EI in many patients with schizophrenia⁹.