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The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis
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     1 Institute of Psychiatry, De Crespigny Park, London SE5 8AF, 2 Lambeth Early Onset Service, South London and Maudsley NHS Trust, London SW9 9NT, 3 Biostatistics Group, School of Epidemiology and Health Science, University of Manchester, Manchester M13 9PT

    Correspondence to: T K J Craig t.craig@iop.kcl.ac.uk

    Abstract

    Worldwide there is interest in developing early intervention services for people with a first psychotic disorder. Fifty such services are to be established in England.1 2 The rationale behind these services is that a long duration of untreated psychosis may have a detrimental effect on outcome and that sustained treatment in the two or three years after an acute episode should maintain recovery and rebuild careers, relationships, and leisure pursuits.3-10 Although the rationale may be compelling, only one randomised controlled trial has studied early intervention in patients with a first episode of psychosis.11 Other evidence comes from studies using historical controls or specific interventions such as atypical antipsychotics, cognitive behavioural therapy, and family therapy.4 9 12-21

    We investigated whether a specialist team could achieve better outcomes for people with early non-affective psychotic disorders than existing services. We hypothesised that, over an 18 month period, people receiving specialised care would have more frequent contact with mental health services, fewer relapses, and fewer readmissions to hospital than patients receiving standard care.

    Methods

    Overall, 319 people presented to psychiatric services between January 2000 and October 2001 with symptoms suggestive of a psychotic disorder. Of these, 144 met the inclusion criteria and were randomised to receive either specialised care or standard care (figure). Data on number of relapses and readmissions to hospital were obtained for 136 (94%) patients over the 18 months of follow up. We had complete information on clinical status (recovered, unwell or relapsed) for 131 (91%) patients at 18 months.

    Flow of patients through trial

    Both groups were similar for most characteristics at baseline, although the specialised care group had fewer men, a higher proportion of first psychotic episodes, and a higher proportion of white people (table 1). Patients in the specialised care group also had a longer duration of untreated psychosis, although the difference between the groups was not statistically significant (mean (SD) duration (months) of untreated psychosis: 10.5 (17.2) for specialised care v 7.6 (10.7) for controls).

    Table 1 Baseline characteristics of groups receiving specialised care or standard care for psychosis. Values are numbers (percentages) unless stated otherwise

    For most patients, admission to hospital was their first experience of mental health care (43 of 71 patients (61%) in specialised care group, 44 of 73 patients (60%) in control group) two thirds of which were involuntary admissions (specialised care 67%, controls 72%).

    At 18 months, one patient in the control group had died (unknown cause); 53 (86%) patients in the specialised care group and 44 (68%) patients in the control group were in regular contact with the clinical team (lost to care: odds ratio 0.35, 95% confidence interval 0.15 to 0.81). Patients in the specialised care group were offered more appointments during follow up than controls (mean (SD) number of appointments: 17.4 (9.1) for specialised care v 13.2 (8.7) for controls) and failed to attend a smaller proportion of the appointments (mean (SD) proportion of appointments missed: 0.12 (0.2) for specialised care v 0.33 (0.3) for controls). Seven patients in the specialised care group and 10 control patients were in hospital at the 18 months' follow up. One control patient was in prison.

    Patients in the specialised care group were more likely than those in the control group to have been offered psychosocial interventions (table 2).

    Table 2 Contact with mental health services and uptake of treatment over 18 months for patients receiving care for early psychosis. Values are numbers (percentages) of patients unless stated otherwise

    Patients in the specialised care group were significantly more likely to be in recovery at follow up than patients in the control group; this included patients who had relapsed (table 3). When only those patients who had not relapsed after initial recovery were classified as "well" (specialised care 64%, controls 48%), the difference between groups was attenuated and fell below statistical significance (odds ratio 0.52, 95% confidence interval 0.26 to 1.03).

    Table 3 Primary outcome measures for patients receiving specialised care or standard care for early psychosis. Values are numbers (percentages) of patients unless stated otherwise

    Most patients in both groups recovered from the index episode (specialised care: full recovery 71%, partial recovery 19%; controls: full recovery 63%, partial recovery 28%). The average time to recovery was 5.5 (SD 4.0) months in both groups. Although there were no differences in these rates, patients in the specialised care group were less likely to relapse than those in the control group (specialised care 30% v controls 48%; P = 0.042). Patients in the specialised care group were also readmitted fewer times during follow up (see table 3).

    Although the higher contact with services among patients in the specialised care group remained significant (lost to care: odds ratio 0.28; 95% confidence interval 0.12 to 0.73) when we adjusted for baseline differences in sex, previous psychotic episodes, and ethnic minority group, only the difference in total number of readmissions during follow up remained statistically significant (see table 3).

    Discussion

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