By Melissa Raven, Flinders University.
Melissa is a psychiatric epidemiologist and policy analyst.
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 It seems that while there’s a body of evidence about the model, it’s weak and out of date.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.
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.