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Evaluating evidence for Early Psychosis Prevention and Intervention Centres (EPPIC)

The Federal Government’s 2011-12 Budget includes $222.4 million for a national rollout of Early Psychosis Prevention and Intervention Centres (EPPICs), but a recent survey has found that almost 60% of…

The evidence for the effectiveness of the early intervention for psychosis model is weak and out of date. Joe Houghton

The Federal Government’s 2011-12 Budget includes $222.4 million for a national rollout of Early Psychosis Prevention and Intervention Centres (EPPICs), but a recent survey has found that almost 60% of psychiatrists think the investment is inappropriate.

What’s more, the Senate Community Affairs and References Committee Inquiry into Commonwealth Funding and Administration of Mental Health Services report released yesterday notes concerns that advocates of the early intervention model may be “overstating the evidence” and that it may lead to young people being “overmedicated”.

So let’s consider what evidence there is for the EPPIC treatment model. It seems that while there’s a body of evidence about the model, it’s weak and out of date.

Comparing two early intervention programs

The key long-term study about EPPIC treatment started in 1989. Conducted at Royal Park Hospital (Melbourne), it tracked 51 EPPIC patients (diagnosed in 1993) and 51 pre-EPPIC patients (diagnosed between 1989 and 1992).

The EPPIC patients received EPPIC treatment for up to two years while the pre-EPPIC patients received specialised early psychosis treatment for several months. Both groups then received mainstream treatment.

The study was small and methodologically weak. It was excluded from the Cochrane review of early psychosis intervention because patients were not randomly allocated to treatment and because the patients began treatment a few years apart.

And although they were matched on many important characteristics, they weren’t matched on duration of untreated psychosis, which is an important predictor of recovery.

Outcomes

Evaluation of the two groups found that, after one year, there was no significant difference in severity of psychotic symptoms.

Antipsychotic drug doses were significantly lower in the EPPIC group, but this was partly because EPPIC had a low-dose prescribing policy.

A long-term follow-up, approximately seven years after diagnosis, found there was no significant difference in overall severity of psychotic symptoms between the groups.

However, “positive” psychotic symptoms, such as hearing voices, were significantly lower (better) for EPPIC patients and the total annual cost for treatment was half as much.

There were no significant differences in quality of life, employment, social/vocational recovery, or welfare reliance.

Some of the worse outcomes in the pre-EPPIC patients were partly due to the longer durations of untreated psychosis.

Comparing early intervention with mainstream treatment

Another, even more methodologically weak, study, compared patients in the mainstream Victorian mental health system with EPPIC and pre-EPPIC patients.

EPPIC/pre-EPPIC patients had more inpatient treatment days, more community treatment days, and more total treatment days than mainstream patients, contrary to subsequent claims that EPPIC reduces demands on the mental health system.

The study found EPPIC/pre-EPPIC patients had a higher suicide rate after four-and-a-half years although there was no significant difference in suicide rate overall.

Weak studies, bad conclusions

The first study was of poor quality, and it simply compared two models of early psychosis intervention. Its relevance to 2011 and beyond is limited by its vintage (initial treatment occurred 18 to 22 years ago).

It provides moderately strong evidence that EPPIC was better than pre-EPPIC for some outcomes, but not others, but no evidence of EPPIC’s superiority to initial mainstream treatment (because all patients initially received specialist treatment).

Although it’s plausible that early intervention may lead to better outcomes, EPPIC has never been systematically compared with mainstream treatment, late or early.

The second study shows that EPPIC/pre-EPPIC patients actually fared worse than mainstream patients for some outcomes.

Nonetheless, it’s frequently claimed in the media, in government submissions and even in government publications that the studies provide strong evidence for EPPIC being more effective and more cost-effective than standard late intervention.

Given the substantial Federal Government funding for EPPIC, the gap between these claims and the evidence warrants serious consideration.

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8 Comments sorted by

  1. Leanne Hall

    Clinical Psychologist/Epidemiologist at University of Sydney

    A 2005 review by Marshall et al, concluded that there was convincing evidence of a modest relationship between duration of untreated psychosis and outcome (not explained by premorbid functioning).

    The EPPIC model is based on a clinical staging model, which has been used in medicine for many years. The aim of this model, is to access people at a more responsive stage of illness in which psychosocial damage is less extensive. As such, the model aims to reduce duration of untreated psychosis, and…

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  2. Richard Monfries

    logged in via Twitter

    A little more balance, and a lot less polemic would be helpful.

    What alternatives do you propose?

    There may not be 'enough evidence' to answer the skeptics and naysayers, but as a model of assistance and early intervention that has been around since at least 1991, with a worldwide movement based on the EPPIC model: http://www.iepa.org.au/ , the alternative to being available (and you can include the headspace model as well http://www.headspace.org.au/ ) for young people, their families and their friends, even with the risk of an occasional false positive, is...?

    I've been a dual Registered & Psychiatric Nurse for 30+ years: for 21 of those years I've worked in public mental health, for 14 of those years I've worked in youth mental health as a case manager, providing supervised assistance to young people and the families that love them. I'm pretty sure I know what the alternative to doing nothing, or less, might be, and it isn't nice, or ethical.

    All the best

    Richard

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    1. Melissa Raven

      Adjunct lecturer at Flinders University

      In reply to Richard Monfries

      Hi Richard

      Firstly, '[lack of] balance', '[excessive] polemic', 'skeptics and naysayers' - these are all useful disparaging comments that deflect attention from the issues I have raised.

      My article is about the evidence about EPPIC. If you think it is unbalanced, feel free to contribute some evidence about EPPIC to redress this imbalance. Or just mention one or two specific points of mine that are unbalanced. Or otherwise explain in what way(s) the article is unbalanced.

      The first two paragraphs (which cited/quoted other people's concerns) and the last two, and the last heading, are clearly polemical. The middle eighteen paragraphs are a critical review of the evidence. If this is polemical, so is much of the literature on evidence-based medicine.

      Do you include the Cochrane Centre http://bit.ly/Cochraneexcluded among the 'skeptics and naysayers'?

      Melissa

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    2. Melissa Raven

      Adjunct lecturer at Flinders University

      In reply to Richard Monfries

      Secondly, questions about alternatives to EPPIC buy into the premise that the existing public mental health system is beyond redemption. They also tend to invoke a false dichotomy between EPPIC or nothing, as your final sentence suggests. I do not accept either the premise or the dichotomy.

      There are multiple possible options apart from massively boosting EPPIC, which will further fragment the system by creating stand-alone youth mental health silos, with barriers at both the lower and upper age…

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  3. Leanne Hall

    Clinical Psychologist/Epidemiologist at University of Sydney

    Interesting......

    I would have to agree with much of what Richard says. The EPPIC and headspace models came about due to very clear gaps in the Public Health System. To borrow the words of Prof Ian Hickie; "by ignoring a gap, it does not go away" yet this was the traditional view of both the Federal and State Govt, until the Howard Govt. It was because of this gap that clinicians like Richard were faced with overwhelming work loads, with limited resources and next to no Govt support.

    Melissa I…

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    1. Melissa Raven

      Adjunct lecturer at Flinders University

      In reply to Leanne Hall

      Hi Leanne

      I agree that the research I quote is extremely outdated. That is one of the main points of my article.

      Unfortunately Patrick McGorry did not explain that to the Senate last year:
      'if you compare patients that are treated in standard psychiatric care with patients that go through these streamed early psychosis programs, the costs are three times as much over an eight-year period if patients just go through the normal late intervention system. So it is actually irresponsible of Australian…

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  4. Jill Hill

    Barrister

    Dear Richard,
    There are alternatives that work and that have been ignored. Have a look at the 2008 review of the Soteria paradigm by Carlton et al. published in the Schizophrenia Bulletin ( vol. 34 no. 1 pp. 181–192, 2008) Even more astonishing are the apparent outcomes from the Finnish Western Lapland open dialogue and family network approach (Seikkula et al, Psychotherapy Research , March 2006; 16(2): 214  /228). The last seems to have a 5 year outcome with 86% of patients returning to full time work or study, 82% with no residual symptoms, and almost without medication.

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