A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.38565.415000.E01 (Published 15 September 2005) Cite this as: BMJ 2005;331:602
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May I inject a note of caution into the intrepretation of this
otherwise most helpful study?
In the description of their population, the authors do not make comment on
what steps they took to identify subjects with confounding organic
conditions.
I have recently shown that many such patients are not being fully
investigated;
http://www.escriber.com/Progress/Features.asp?Action=View&Archive=True&I....
Failure to detect this group who comprise up to 8% of first epiosde
psychosis must distort the results.
Competing interests:
None declared
Competing interests: No competing interests
The authors are to be congratulated for this exciting work describing
a new initiative for a not-so-new concept. Many providers advocate
integrating treatment within one setting, rather than linking services in
separate settings by two systems. Those who propose integrated treatment
as a model, especially for dual diagnosis, will argue that it should
achieve consolidation of alcohol, drug, and mental health treatment at the
local level under one roof and preferably by one provider. The challenge
is how to modify existing clinical services to achieve the results shown
by Petersen et al (1)and not to place the heavy burden of integration on
the patient.
The authors' finding that fewer patients with first onset psychosis
abused drugs if they received integrated treatment also gives some hope to
planners and providers of services to this sub group and especially young
males. Cantwell et al (2) found high rates of substance misuse at the
onset of psychosis, younger age of onset, male gender and non-African-
Caribbean ethnicity.
This paper throws up a number of challenges:
How do you keep the whole picture in mind while at the same time
implementing the new delivery model? A redoubling of efforts will not bear
fruit if we have lost sight of the strategic considerations which underpin
the change effort.
When should you focus on the detail and when on the national picture?
How do you manage to do both at once?
We are all under pressure to change and improve the way we work.
Change is all around us - and it is accelerating daily. The NHS has
witnessed the most massive change process of any public sector
organisation ever. More and more organisations - be they private, public
sector, government or voluntary organisations - are having to introduce or
respond to, and then manage change.
Well done!
References:
1. Petersen L, Jeppesen P, Thorup A, Abel M, et al. A randomised
multicentre trial of integrated versus standard treatment for patients wih
a first episode of psychotic ilness. BMJ 2005;331:602-616
2. Cantwell R, Brewin J, Glazebrook C, Dalkin T et al. Prevalence of
substance misuse in first-episode psychosis. British Journal of Psychiatry
1999; 174: 150-153
Competing interests:
None declared
Competing interests: No competing interests
the above mentioned study is a good example of how a comprehensive
management approach fairs better than individual interventions in the
management of psychiatric disorders.but can this concept of dedicated
integrated approach can be applied in the setting of the developing
countries? because of the lack of the resources and the trained
professional in the field in such nations it might be more prudent to
develop models of intervention that are more cost effective. however the
situation is not that grim as well as if the appropriate knowledge can be
imparted to the care takers of such patients in the developing world
through some cost effective model, the good family support that these
patients enjoy may yield even better outcomes.
Competing interests:
None declared
Competing interests: No competing interests
Integrated vs. Standard Treatment for Psychotic Illness
I read with great interest the article by Petersen et al (1) “A
Randomized Multicentre Trial of Integrated versus Standard Treatment for
Patients with a First Episode of Psychotic Illness”. Psychosocial
treatment of schizophrenia and other psychiatric conditions is a crucial
part of management and often is suboptimal. Therefore, assessment of
alternative treatment models is needed.
The reported improvement in psychotic symptoms and global assessments
of functioning (GAF) with integrated treatment are seemingly modest,
although described as significant based on p values. Reported mean GAF
score differences of 2.3 – 4.0 between integrated and standard treatment
at follow-up are unlikely to be relevant clinically, despite the
associated statistical significance.
Also in the article, when determining median duration of baseline
untreated psychosis, values from a sizeable proportion of patients were
not used. Longer duration of untreated psychotic episodes often correlates
with non-adherence to treatment, a major outcome measure showing strong
group differences in the article. At baseline, patients randomized to
integrated treatment had a median duration of untreated psychosis 7 weeks
shorter than those in standard treatment, which may imply a better
prognosis.
Lastly, it was reported that patients spent fewer days in hospital
following integrated treatment. However, the authors did not clarify
baseline differences in prior hospital bed utilization. It was stated that
a slightly higher proportion of those in the standard treatment group were
randomized as inpatients, which may reflect a population using more
inpatient services. This may suggest another possible selection bias in
favor of integrated treatment.
Daniel Mamah, M.D.
References:
1.Petersen L, Jeppesen P, Thorup A, Abel M, Ohlenschlaeger J,
Ostergaard Chrstensen T, Krarup G, Jorgensen P, Nordentoft M. A randomized
multicentre trial of integrated versus standard treatment for patients
with a first episode of psychotic illness. BMJ 2005 Sep 17; 331(7517):602.
Competing interests:
None declared
Competing interests: No competing interests