OPUS; A sustainable treatment?

1. OPUS; A sustainable treatment? Mette Bertelsen, Bispebjerg University Hospital, Denmark

2. The Danish OPUS Trial: A two-site randomised controlled trial of integrated psychiatric treatment First episode psychosis Five-year follow-up Mette Bertelsen, Bispebjerg University Hospital, Denmark

3. Treatment by OPUS team • The OPUS trial • Results from two- and five-years follow-up • Conclusion

5. Psychiatrist Psychiatric nurse Social worker Psychologist Occupational therapist Vocational guide The OPUS team

6. Treatment by OPUS team Assertive Community Treatment Psychoeducational multi family groups Social skills training

7. Assertive Community Treatment Multidisciplinary team Contact during in - and outpatient treatment Flexible frequency of contact (weekly) Home visits Coordination of the GP, somatic department and social services

8. Family Treatment Educational workshop for relatives. Single family sessions with crisis intervention. McFarlanes model for psychoeducational multi­family groups.

9. Social skills training Coping with symptoms Managing own medication Basic social skill training Problem solving

10. The OPUS trialInclusion Criteria Age 18-45 A diagnosis (ICD10 research criteria) of F2: schizophrenia, schizotypal disorder, delusional disorder, acute psychosis, schizoaffective psychosis or unspecific non-organic psychosis Patients have not had previously adequate treatment, defined as 12 weeks of anti-psychotic medication

11. SCAN (Schedule for Clinical Assessment in Neuropsychiatry) SAPS (Schedule for Assessment of Positive Symptoms) SANS (Schedule for Assessment of Negative Symptoms) Gaf (function and symptoms) Demographic data including educational, employment and housing status Lancashire Quality of life Scale Client Satisfaction Questionnaire Life Chart Schedule Cognitive test (only at 5 years follow-up) Assessments (1)

12. Assessments (2) • Complete case records from all mental health services in the catchment areas • Danish Psychiatric Central Case Register • Cause of Death Register

13. 547 patients included and randomised 275 patients allocated to OPUS team treatment and treated for two years 272 patients allocated to standard treatment All patients were offered standard treatment for another three years 301 interviewed after five years (55%)

14. 547 patients included and randomised 275 patients allocated to OPUS team Baseline 272 patients allocated to standard treatment Attrition: 44 Attrition: 26 Attrition: 46 Attrition: 62 205 interviewed after two years (75%) 2 y 164 interviewed after two years (62%) Attrition: 80 Attrition: 60 151 interviewed after five years (56%) 5 y 150 interviewed after five years (57%)

15. Characteristics of 547 Patients, Baseline Age, years (mean) 26.6 Male gender 59 % Diagnosis of schizophrenia 66 % Secondary diagnosis substance abuse 27% Duration of untreated psychosis 43 weeks median

16. Outpatient visits, family intervention and social skills training OPUS Standard Sign Out-patient contacts 1+2y, median 75 20 <0.001 Family involved in treatment 1+2y 61 % 20 % <0.001 Family psychoeducational gr. 1+2y 46 % 2 % <0.001 Social skills training 1+2y 43 % 12 % <0.001

17. Non-adherance OPUS Standard Sign. ____________________________________________________ No out-patient visits,1y 4 % 15 % <0.001 No out-patient visits 2y 7 % 31 % <0.001 OR 0.2-0.3, NNT 4-8

18. Negative dimension Mean values at follow-up P<0.001 P<0.001 P=0.7

19. Psychotic dimension Mean values at follow-up P=0.02 P= 0.31 P=0.02

20. Harm and dependence Mean values at follow-up P = 0.03 P=0.04 P=0.49

21. OPUS Standard Antipsych. med. 2 y 60 % 55 % Chi2, P=0.23 Antipsych. med. 5 y 65 % 65 % ns Dosis Atypical Haloperidol-eqv 2 y 4.0 mg 4.9 mg T-test P=0.01 Haloperidol-eqv 5 y 2.8 mg 2.3 mg T-test P=0.1 Antipsychotic medication

22. Satisfaction with treatment 2 y

23. OPUS team treatment N=151 Standard treatment N=150 Total Episodic 21 (14%) 24 (16%) 45 (15%) Continous 68 (45%) 66 (44%) 134 (44.5%) Not psychotic 62 (41%) 60 (40%) 122 (40.5%) Remission five years after debut- past two years

24. OPUS Standard Sign. Mean days in hospital 95 122 0.05 (baseline-2y) Mean days in hospital 59 71 0.34 (2y-5y) Mean days in hospital 154 193 0.08 (baseline-5y) Use of bed days from baseline – 5y

25. Cost-Benefit of OPUS Team-Treatment Mean of 39 bed days (20%) saved for patients in OPUS team treatment during five years Saved cost of in-patient treatment for one year: 7 million DKK for 100 patients ( 930000 euro) -more than enough to pay the wages of 10 staff members

26. Use of bed days amongst patients with a secondary diagnosis of substance abuse P<0.05 P<0.05

27. OPUS Standard Sign. Not living independently (%) 7% 7% ns after 2 years Not living independently (%) 4% 10% 0.02 after 5 years Days (mean) not living independently (0-2 years) 30 35 0.6 Days (mean) not living independently (2- 5 years) 57 102 0.05 Independent housingbaseline – 5 years

28. Survival in the first 5 years Civil registration system: 547 patients RR 0.6 (0.2-1.6), P= 0.3 Power calculation: 1522 patients in each treatment condition necessary to detect a difference between 2 % and 4 % mortality Figure 2. Probality of death (all causes) in the two treatment groups as a function of time (days)

29. OPUS;A sustainable treatment?Driving licence or painkiller Mette Bertelsen, Bispebjerg University Hospital, Denmark

30. Conclusion (1) Significant reduction in symptoms after 2 years Significant reduction in drug- and alcohol misuse after 2 years Significantly higher satisfaction with treatment Low dose strategy succeeded Better adherence to treatment

31. Conclusion (2) • When patients were transferred to standard treatment after 2 years - no differerence between treatment groups with regard to; - negative symptoms - psychotic symptoms - harm and dependence

32. Conclusion (3) • Number of bed days were reduced with a mean of 39 (20%) in OPUS team group compared with standard treatment after five years • More patients from OPUS team live independently after 5 years

33. Clinical Implications • Longer duration of treatment (3,4 or 5 years?) • Transition from OPUS treatment to standard treatment? • Booster sessions?

34. Funding: Danish Ministry of Health, Danish Ministry of Social Affairs, Danish Medical Research Council, University of Copenhagen, Copenhagen Hospital Corporation, Danish Medical Research Council, Aarhus County, Copenhagen Municipality, The Stanley Medical Research Institute Slagtermester Wørzners Foundation. The Danish OPUS Trial

35. Merete Nordentoft Pia Jeppesen Maj-Britt Abel Anne Thorup Lone Petersen Johan Øhlenschlæger Runa Munkner Mette Bertelsen Ralf Hemmingsen Per Jørgensen Torben Christensen Gertrud Krarup Phuong Le Quach Ole Mors Preben Bo Mortensen The Danish OPUS Trial Psychiatric Hospital, Risskov and Center for Registerbased Research University of Aarhus H:S, Bispebjerg and Sct Hans Hospital, University of Copenhagen

36. 547 patienter inkluderet og randomiseret 275 patienter allokeret til OPUS team Baseline 272 patienter allokeret til standard behandling Frafald: 62 4 selvmord 1 ukendt dødsårsag 1 død v. ulykke 33 afviste interview 9 flyttet langt væk 10 kunne ej spores 4 uvist Frafald: 44 1 selvmord 21 afviste interview 10 flyttet langt væk 6 kunne ej spores 6 uvist Frafald: 26 13 afviste int. 4 flyttet 6 ej spores 3 uvist Frafald 46 22 afviste int. 7 flyttet 12 ej spores 5 uvist 205 interview efter to år (75%) 2 y 164 interview efter to år (62%) Frafald: 80 2 selvmord 2 ukendt dødsårsag 1 død v. ulykke 48 afviste interview 1 flyttet langt væk 26 kunne ej spores Frafald: 60 1 naturlig dødsårsag 3 ukendt dødsårsag 32 afviste interview 5 flyttet langt væk 19 kunne ej spores 151 interview efter fem år (56%) 5 y 150 interview efter fem år (57%)