Elsevier

Schizophrenia Research

Volume 79, Issue 1, 1 November 2005, Pages 95-105
Schizophrenia Research

Integrated treatment ameliorates negative symptoms in first episode psychosis—results from the Danish OPUS trial

https://doi.org/10.1016/j.schres.2004.12.020Get rights and content

Abstract

Purpose

To investigate the effect of integrated treatment on negative, psychotic and disorganised symptoms in patients with first episode psychosis.

Method

A RCT comparing integrated treatment (IT) with standard treatment (ST) was conducted, including 547 patients, aged 18–45, diagnosed with schizophrenia spectrum disorders. All patients were assessed with SCAN, SAPS and SANS at entry and after 1 and 2 years. The IT consisted of assertive community treatment, multifamily groups, psycho-education and social skills training, and the caseload was 1:10 compared with 1:25 in ST.

Since attrition was considerable, a mixed model analysis with repeated measurements was used to examine the possible effects of IT statistically.

Results

IT reduced both negative and positive symptoms significantly better than ST. Most marked were the results from the negative dimension, where all five global scores from SANS had a significantly better reduction in IT. Sub-analyses did not single out any one element in the integrated treatment that could explain this result.

Conclusion

Integrated treatment significantly reduced both negative and psychotic symptoms, assumably due to the different psychosocial treatment elements that were provided in the IT.

The results indicate that the integrated approach is crucial, since, most likely, many aspects of the integrated treatment have contributed to the reduction of symptoms.

Introduction

Negative symptoms are often less visible than psychotic symptoms when patients with first episode psychosis are diagnosed or admitted. However, family members or partners will often report changes in energy, empathy or engagement in the surroundings of the patient over the last weeks, months or even years. Negative symptoms influence the patients' abilities to maintain their social functioning and to create social networks (Macdonald et al., 2000), since aspects like asociality, anhedonia and apathy all contribute to isolation and introvert behaviour. And since negative symptoms are known to correlate with poorer prognosis and poorer social outcome, their influence must not be underestimated or ignored (McGlashan and Fenton, 1992, Ho et al., 1998).

Negative symptoms can be divided into primary and secondary negative symptoms as suggested by Carpenter (Carpenter et al., 1988). Primary negative symptoms are the core symptoms of the disorder; they have an insidious development and an enduring nature and appear long before patients seek treatment. Secondary negative symptoms are negative symptoms caused by extrinsic factors like side effects of medication (Carpenter et al., 1985), abuse, social deprivation caused by hospitalisation or social isolation (Wing and Brown, 1970) or they are a psychological reaction to psychotic symptoms (Buchanan and Gold, 1996). Males have been shown to have more severe negative symptoms (Leung and Chue, 2000).

In principle, secondary negative symptoms can be treated by specific pharmacological and psychosocial treatment elements directed against the causing agent. However, while psychotic symptoms are by and large relieved by antipsychotic medication, negative symptoms are more resistant to pharmacological treatment (Arango et al., 2004). As mentioned, negative symptoms may even be a side effect of high doses of antipsychotic treatment of the psychotic symptoms (Moller, 2003). Nevertheless, the second generation antipsychotics (SGAs) seem to have a better effect on negative symptoms than first generation antipsychotics (FGAs)(Moller, 2003).

Both negative and psychotic symptoms have a complex origin and a global influence on the patients' lives biologically as well as socially and psychologically. The psychosocial point of view is crucial when treatment for future patients with first episode psychosis is being planned as described by, e.g. Lauriello et al. (2003) in his review “Maximizing the synergy between pharmacotherapy and psychosocial therapies for schizophrenia”.

Section snippets

Aim

We aimed to investigate if integrated treatment (abbreviated IT, please see Section 3.5 for description. OPUS being the name of the project) is more efficient in treating negative, psychotic and disorganised symptoms in first episode psychosis (mainly patients with schizophrenia) than standard treatment (ST). Second, to analyse if there was a specific effect of IT for subgroups divided by diagnosis of schizophrenia, abuse, gender, and age. The three subgroups were chosen on the basis of the

Design

A randomised controlled study was conducted in Copenhagen and Aarhus comparing standard treatment (ST) with “integrated treatment” (intensive psychosocial assertive community treatment—IT) while investigating the effects of early detection.

Subjects

Patients aged between 18 and 45 were included if they met the criteria for ICD-10 diagnoses of schizophrenia, acute or transient psychotic disorder, schizotypal disorder, schizoaffective disorder or other delusional disorders in the F.2 spectrum. All patients

Representativeness

Analyses of representativeness revealed that the number of patients included in the project corresponded to 90% in Aarhus and 63% in Copenhagen of the patients registered in the psychiatric case register as having had their first contact with psychiatric services in the same period and diagnosed within the same diagnostic spectrum. Comparison between the patients included in the project and the official statistics revealed no differences in sex distribution, but at both centres the patient

Discussion

The IT reduced both the negative and the psychotic symptoms more efficiently than the ST for these young patients with first episode psychosis, but no single treatment element in the IT could explain these results. The most remarkable result is the impact of the IT on the negative symptom score. Negative symptoms are known to be more resistant to treatment than positive symptoms (Arango et al., 2004, Arndt et al., 1995), and the complexity of their origin contributes to that. Therefore, this is

Conclusion

Integrated treatment (IT) reduces negative symptoms in first episode psychosis in all global scores of SANS. It is assumable that this result is caused by the integrated and differentiated treatment plan and through the lower doses of SGAs and the reduced need for admission that was seen in the IT group. Subgroup analysis revealed no significant effect as between schizophrenia and other first episode psychosis, abusers and non-abusers, men and women or younger and older patients, thus

Acknowledgements

Declaration of interests: The Danish Ministry of Health, Danish Ministry of Social Affairs, Danish Medical Research Council, Copenhagen Hospital Corporation, Aarhus County and The University of Copenhagen have founded the OPUS trial.

The author of this article has received grants from: Copenhagen Hospital Corporation Research Foundation, Copenhagen, Slagtermester Wørzner Foundation, Danish Psychiatric Research Foundation of 1967, I.A. Strobels Foundation, and The Medical Scientific Research

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