Real-world data support early intervention for patients with first-episode psychosis

The Danish OPUS early intervention services for first-episode psychosis improved several patient outcomes, according to results of a phase 4 prospective cohort study that compared randomized trial with real-world data.

“Our aim in this study was to compare the prognosis of patients who received OPUS treatment after it was implemented nationally in Denmark as first-choice treatment for first-episode psychosis with that of patients who participated in the original randomized trial and received either the OPUS intervention or the usual-treatment control condition,” Christine Merrild Posselt, MSc, of the Copenhagen Research Center for Mental Health–CORE at Copenhagen University Hospital in Denmark, and colleagues wrote in American Journal of Psychiatry. “For all outcomes, we hypothesized a priori that the OPUS intervention in the trial would be superior to the OPUS intervention as implemented in the real world, and that the control group in the trial would have the poorest prognosis of the three groups.”

According to the researchers, a recent systematic review showed early intervention services for early-phase schizophrenia were superior to treatment as usual. Similar results occurred in the Danish OPUS trial, which was among the first trials in the world to evaluate early intervention services for first-episode psychosis in the schizophrenia spectrum. OPUS treatment features modified assertive treatment that includes family involvement and social skills training delivered via a multidisciplinary team of psychiatrists, psychologists, nurses, social workers, physiotherapists and vocational therapists.

Posselt and colleagues assessed whether the three groups included in the current study had differences on register-based outcomes, including use of secondary health care, functional outcomes and death. They adjusted analyses for relevant confounders, including number of psychiatric bed days 2 years before start of treatment, number of nonpsychiatric bed days 2 years before start of treatment, number of redeemed prescriptions for antipsychotic or other psychotropic medication 2 years before start of treatment, registered alcohol or substance use disorder 2 years before start of treatment, income 2 years before start of treatment (standardized to 1996 levels using an annual inflation rate of 2.2%), employment status 2 years before start of treatment and sex and age at start of treatment as identified via the Danish Civil Registration System.

Results showed a tendency toward lower mortality (HR = 0.6; 95% CI, 0.33-1.09), fewer and shorter psychiatric admissions and possibly fewer filled antipsychotic and other psycholeptic prescriptions after 4 or 5 years among patients who received OPUS treatment after implementation (n = 3,328) compared with trial study participants. Patients who received postimplementation OPUS treatment eventually exhibited higher likelihood of working compared with those in the OPUS trial (after 5 years, OR = 1.49; 95% CI, 1.07-2.09) despite being less likely to be working or studying at first. Those in the postimplementation group also had a higher likelihood of being in a couple relationship than those in the trial. The researchers noted less clear associations with treatment group for other outcomes. The control group in the trial generally had worse outcomes than both OPUS treatment groups.

“The implication of this study is that places that have already implemented these interventions should continue doing so, and that places that have not implemented such treatments should consider doing so,” Posselt and colleagues wrote. “However, our results merit replication in other real-world cohorts in order to establish whether they can be generalized to other settings and countries.”