Original Title: Revisión de los tratamientos psicológicos en primeros episodios psicóticos

Authors' objectives: Evaluate the existing scientific evidence on the effectiveness of psychological treatments, during initial psychotic episodes, on the symptomatology, likelihood of relapse and functionality and, in accordance with the results, draw up guidelines of psychoeducational recommendations.

Authors' results and conclusions: A total of 30 articles were included, of which 18 were the result of the systematic review and 12 of the manual search. Of these articles, 5 are systematic reviews and 25 described the results of 13 clinical trial which included a total of 1846 participants. Two of the tests included a broad sample of more than 500 patients. However, a smaller number of people were recruited for the remaining tests. The participants included in the studies were persons with at ultra-high risk (UHR) for progression to psychotic disorder.and patients who had suffered a first psychotic episode. A variety of psychological treatments were evaluated in this review: integrated treatment, specific treatment for cannabis, programme of reinsertion into the community, preventive treatments, cognitive-behavioural treatment, cognitive therapy together with psychoeducation, cognitive modules and behavioural treatment together with family therapy. The control treatments with which this kind of intervention was compared were mainly the habitual types of treatment used in these cases. However, some studies compared experimental treatment with individual therapy, psychoeducation, needs-based therapy, befriending and monitoring. Integrated treatment is a preventive factor for the development of psychoses in high risk individuals (RR=0.36 IC=0.16 to 0.85). Transition rates fell from 8.1% in experimental treatment to 25% in customary treatment. During the 2nd year, rates were 25% compared to 48.3%. Likewise, an improvement in negative symptomatology was observed in the first year follow up (-0.71 (-1.21 to - 0.21) p less-than 0.01), and no effectiveness was found in the reduction of positive or disorganised symptomatology. Cognitive therapy was also effective in reducing the psychosis transition rates during the first year follow up (6%GE and 26%GC; OR 0.04, (0.01 to 0.57); p=0.019), although the positive effect was not maintained over the three years. Preventive treatment does not provide benefits compared to a needs-based intervention to reduce the positive or negative symptomatology. However, as in the case of other studies, a lower transition rates is observed in integrated treatment during the first year follow up compared to the customary treatment (19% vs. 36%). Three tests benefit from the integrated treatment in the reduction of negative symptomatology in persons who suffer their first psychotic episode. These benefits are found both after a year and after two years follow up (OR0.45 (-0.67 to –0.22); p= or less-than0.001). Likewise, psychotic symptomatology is lower in patients from the experimental group (OR -0.32 (-0.58 to –0.06); p=0.02) after two years of monitoring, and there are no significant differences after five years (OPUS). However, the NORWAY and LifeSPAN tests do not find these differences in psychotic symptomatology between the two groups. Overall symptomatology is lower in patients who receive the experimental treatment during the first year follow up (MD 3.00 (0.37 to 5.63); p=0.03), and no differences can be found as of the second year of monitoring. Relapses and hospitalisations are lower in the group that receives the integrated treatment, and the relapse rate stands at 20% in the EG compared to 50% in the CG (p= 0.03) during the following two years of monitoring. With regard to hospitalisations, the number of days that patients remain in hospital is lower in the experimental group (96 vs 123, CI 0.57 to 54.32; p=0.05). Integrated treatment is effective in reducing the consumption of cannabis after two years follow up (OR 0.5 (0.3 to 1.0); p=0.04). Overall and social functionality also improve with the experimental treatment during the following two years (DM 3.12 (0.37 to 5.88) p=0.03). With regard to pharmacological adherence, the OPUS test seems to improve adherence and reduce the need for the prescription of second generation antipsychotic drugs. Nevertheless, the NORWAY test does not find either of the treatments to be more effective than the other. However, integrated treatment is not effective in reducing positive symptomatology, in reducing suicide rates or improving patients' knowledge about their illness. The reduction in the consumption of cannabis does not offer significant results when compared to the specific treatment of cannabis and psychoeducation (F=0.40; p=0.53). In spite of this, both treatments reduce consumption from the basal moment to the sixth month follow up. Behavioural cognitive treatment improves positive, negative and functional symptomatology. However, this improvement is not maintained in the medium term. With regard to hospitalisations, no differences can be observed between the two treatments. In comparison to individual treatment, behavioural treatment in conjunction with family therapy does not involve improvements with regard to positive symptomatology and relapses.

Authors' recommendations: The studies selected confirm a significant improvement in the development and/or symptomatology of the disorder in the short and medium term, when compared with the customary treatment. The detection and early treatment of the psychosis reduces the transition rate in two-year follow up. Negative symptomatology and functionality also seem to benefit from the psychological treatment in these patients. In the first episodes, integrated treatment seems to stand out due to the fact that it has beneficial effects on the negative symptomatology, psychotic symptoms, relapse rates, hospitalisation times and the overall and social functionality of patients. These benefits can be observed during the two-year monitoring, although these are not maintained over five years. The differences found between tests may be due to the different techniques used in the control group. The standard or customary treatment is understood to be one for which no details are available. Nevertheless, a larger number of tests of sufficient methodological quality are required to increase the evidence on which of the techniques is the more efficient. Otherwise, it would be necessary to put into motion a research network in which the investigative efforts of groups with related projects work together in order to obtain competitive samples and comparable results.

Authors' methods: A systematic search was carried out in the OVID metasearch engine, which included the following databases CCTR, CDSR, CINAHL (1982-2008), EMBASE (1980-2008), MEDLINE (1950-2008), and PsycINFO (1987-2008). The Crochrane Library Plus was also searched. Moreover, searches were made of clinical practice guidelines in the National Guidelines Clearing House and in Health Guideline. Subsequently, a manual search was made as well as a backward search of articles that demonstrated high methodological quality and complied with the inclusion criteria. Selection criteria This work included systematic reviews, meta-analysis, clinical practice guidelines and randomised, controlled clinical trials in compliance with inclusion and non-exclusion criteria. The participants included in this review were persons who had suffered an initial psychotic episode, in which the disease had not developed for more than five years and persons with a high risk of suffering psychosis or who had begun to show prodromal symptoms. The type of intervention evaluated was psychological treatment based on an adequate, proven methodology, in combination in each case with a pharmacological treatment applied during the first episodes. The exclusion criteria were as follows: non-randomised clinical trial, retrospective studies of cases and controls, cohort studies and summaries of papers and presentations at congresses. Participants in whom the illness had developed for more than five years, who had undergone craniocerebral traumatisms, acquired cerebral damage, psychoses induced by drugs, or with Axis II comorbidity, were excluded. Psychodynamic treatments were also excluded as these are not systematised, repeatable techniques. Data gathering and analysis Of the studies selected for systematic review, those that did not comply with inclusion criteria but did indeed comply with exclusion criteria, were eliminated. Through a reading of the title and abstract, a selection was made of those studies appropriate for evaluation. These were analysed and evaluated by Osteba Critical Appraisal Tools by two evaluators and the most relevant data was extracted.

Project Status: Completed

Year Published: 2010

URL for published report: https://www.euskadi.eus/contenidos/informacion/2010_osteba_publicacion/es_def/adjuntos/e_10_08_trat_psicolo.pdf

English language abstract: An English language summary is available

Publication Type: Rapid Review

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: <p>Basque Office for Health Technology Assessment (OSTEBA)</p>