NIHR DC Discover

NIHR Signal Additional therapy helps social recovery from first episode psychosis

Published on 20 February 2018

doi: 10.3310/signal-000558

Social recovery therapy increases structured activity, such as work, education or sport, by eight hours per week for people with severe social withdrawal following a first episode of psychosis. This cognitive behavioural type of treatment was added to other early interventions and might be particularly useful for those lacking motivation or living with other conditions that prevent them engaging with mental health services.

This NIHR-funded trial included 154 young adults with first episode of psychosis under the care of early intervention services in England. These are specialist multidisciplinary mental health services which aim to help people make a full mental, physical and social recovery. The participants had been under their care for at least a year and had extreme social withdrawal, which often limits their capacity to engage in therapy.

Social recovery therapy not only increases structured activity levels but also appears to keep people in contact with services in the critical first nine months. It could be incorporated into early intervention services for people with persistent social withdrawal.

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Why was this study needed?

In England, there are over 1,000 referrals to early intervention services each month. The services are holistic and typically include psychological therapy, medication, family therapy, and offers to tackle social support, employment or housing issues. They tend to look after people for up to three years. They aim to prevent the episode from recurring and developing into long-term schizophrenia but also help people develop skills to cope with residual symptoms.

Social recovery can be particularly challenging because of continued symptoms and the social withdrawal that is typical in people with first episode psychosis. This study aimed to see if social recovery therapy in addition to early intervention services increased the time spent in structured activity. This was defined as constructive economic activity (work, education, voluntary work, housework or chores, and child care) and structured activity (constructive economic activity plus leisure and sport).

What did this study do?

The SUPEREDEN3 phase two randomised controlled trial included 154 adults with first episode psychosis, aged 16 to 35. They had been under the care of four early intervention services in England for 12 to 30 months. All continued to have severe social withdrawal.

The participants were randomly allocated to either a control group who continued early intervention services or the intervention group who also received social recovery therapy. The intervention group had on average 16 sessions of social recovery therapy which used cognitive behaviour therapy techniques. The three stages included; developing a therapeutic relationship, referral to education, vocation or leisure/ sports providers, and practical help in overcoming obstacles to engaging. These are more fully described in the definitions section.

The high dropout of 24% in the control group may have masked the effectiveness of the intervention at the 15-month assessment.

What did it find?

  • At nine months, time spent in structured activity had increased more in the social recovery group, from 11 hours to 26.6 hours per week, compared to increasing from 12 hours to 18 hours in the control group (mean difference [MD] 8 hours, 95% confidence interval [CI] 2.5 to 13.7).
  • Constructive economic activity had also increased more in the social recovery group, from 7.5 hours to 20.1 hours compared to increasing from 7.9 hours to 14.1 hours (MD 5.9, 95% CI 0.8 to 11.0).
  • There was little difference in either activity level between the groups at 15 months. Structured activity occurred for 23 hours per week in the social recovery group compared to 22.5 hours in the control group.
  • At nine months, fewer people in the social recovery group had positive symptoms such as hallucinations or negative symptoms such as difficulty concentrating.

What does current guidance say on this issue?

NICE guidance updated in 2016 recommends that all young people with suspected first episode psychosis are urgently referred to an early intervention service. These services do not routinely include social recovery orientated therapy. 

An individualised care plan should be agreed, including activities that promote physical and mental wellbeing. In addition to medical and psychiatric care, the team should help the person to set and achieve realistic social activity targets.

The Five year Forward View policy for mental health published in 2016 supports early intervention services as a priority for the NHS.

Depending on the severity of the illness and capacity to engage, the service can try to facilitate alternative education or supported training or employment until the person can re-join mainstream services.

What are the implications?

Social recovery therapy increases the amount of structured activity per week at nine months for people who continue to have severe social withdrawal. Early intervention services could consider incorporating elements of the therapy into their package of care. 

This is a particularly challenging group of people to engage in therapy because of the extent of social withdrawal, apathy and complex symptoms. The low level of dropout in the intervention group of 9% by 15 months was impressive. Though no difference was seen at 15 months in activity level between the groups, there was a much higher dropout rate in the control group, which might partly explain the lack of a difference.

The social recovery therapy, therefore, helped more people to increase their structured activity and remain in contact with services. This is an important outcome regarding quality of life and improving social inclusion in this vulnerable group of people.

Citation and Funding

Fowler D, Hodgekins J, French P, et al. Social recovery therapy in combination with early intervention services for enhancement of social recovery in patients with first-episode psychosis (SUPEREDEN3): a single-blind, randomised controlled trial. Lancet Psychiatry.2018;5(1):41-50.

This project was funded by the National Institute for Health Research under the Programme Grants for Applied Research programme (RP-PG-0109-10074).

Bibliography

NICE. Psychosis and schizophrenia in children and young people: recognition and management. CG155. National Institute for Health and Care Excellence; 2013 (updated 2016).

NHS England. Statistical Press Notice: Early intervention in psychosis waiting times November 2017. NHS England; 2017.

Why was this study needed?

In England, there are over 1,000 referrals to early intervention services each month. The services are holistic and typically include psychological therapy, medication, family therapy, and offers to tackle social support, employment or housing issues. They tend to look after people for up to three years. They aim to prevent the episode from recurring and developing into long-term schizophrenia but also help people develop skills to cope with residual symptoms.

Social recovery can be particularly challenging because of continued symptoms and the social withdrawal that is typical in people with first episode psychosis. This study aimed to see if social recovery therapy in addition to early intervention services increased the time spent in structured activity. This was defined as constructive economic activity (work, education, voluntary work, housework or chores, and child care) and structured activity (constructive economic activity plus leisure and sport).

What did this study do?

The SUPEREDEN3 phase two randomised controlled trial included 154 adults with first episode psychosis, aged 16 to 35. They had been under the care of four early intervention services in England for 12 to 30 months. All continued to have severe social withdrawal.

The participants were randomly allocated to either a control group who continued early intervention services or the intervention group who also received social recovery therapy. The intervention group had on average 16 sessions of social recovery therapy which used cognitive behaviour therapy techniques. The three stages included; developing a therapeutic relationship, referral to education, vocation or leisure/ sports providers, and practical help in overcoming obstacles to engaging. These are more fully described in the definitions section.

The high dropout of 24% in the control group may have masked the effectiveness of the intervention at the 15-month assessment.

What did it find?

  • At nine months, time spent in structured activity had increased more in the social recovery group, from 11 hours to 26.6 hours per week, compared to increasing from 12 hours to 18 hours in the control group (mean difference [MD] 8 hours, 95% confidence interval [CI] 2.5 to 13.7).
  • Constructive economic activity had also increased more in the social recovery group, from 7.5 hours to 20.1 hours compared to increasing from 7.9 hours to 14.1 hours (MD 5.9, 95% CI 0.8 to 11.0).
  • There was little difference in either activity level between the groups at 15 months. Structured activity occurred for 23 hours per week in the social recovery group compared to 22.5 hours in the control group.
  • At nine months, fewer people in the social recovery group had positive symptoms such as hallucinations or negative symptoms such as difficulty concentrating.

What does current guidance say on this issue?

NICE guidance updated in 2016 recommends that all young people with suspected first episode psychosis are urgently referred to an early intervention service. These services do not routinely include social recovery orientated therapy. 

An individualised care plan should be agreed, including activities that promote physical and mental wellbeing. In addition to medical and psychiatric care, the team should help the person to set and achieve realistic social activity targets.

The Five year Forward View policy for mental health published in 2016 supports early intervention services as a priority for the NHS.

Depending on the severity of the illness and capacity to engage, the service can try to facilitate alternative education or supported training or employment until the person can re-join mainstream services.

What are the implications?

Social recovery therapy increases the amount of structured activity per week at nine months for people who continue to have severe social withdrawal. Early intervention services could consider incorporating elements of the therapy into their package of care. 

This is a particularly challenging group of people to engage in therapy because of the extent of social withdrawal, apathy and complex symptoms. The low level of dropout in the intervention group of 9% by 15 months was impressive. Though no difference was seen at 15 months in activity level between the groups, there was a much higher dropout rate in the control group, which might partly explain the lack of a difference.

The social recovery therapy, therefore, helped more people to increase their structured activity and remain in contact with services. This is an important outcome regarding quality of life and improving social inclusion in this vulnerable group of people.

Citation and Funding

Fowler D, Hodgekins J, French P, et al. Social recovery therapy in combination with early intervention services for enhancement of social recovery in patients with first-episode psychosis (SUPEREDEN3): a single-blind, randomised controlled trial. Lancet Psychiatry.2018;5(1):41-50.

This project was funded by the National Institute for Health Research under the Programme Grants for Applied Research programme (RP-PG-0109-10074).

Bibliography

NICE. Psychosis and schizophrenia in children and young people: recognition and management. CG155. National Institute for Health and Care Excellence; 2013 (updated 2016).

NHS England. Statistical Press Notice: Early intervention in psychosis waiting times November 2017. NHS England; 2017.

Social recovery therapy in combination with early intervention services for enhancement of social recovery in patients with first-episode psychosis (SUPEREDEN3): a single-blind, randomised controlled trial

Published on 11 December 2017

D Fowler, J Hodgekins, P French, M Marshall, N Freemantle, P McCrone, L Everard, A Lavis, P Jones, TiAmos, S Singh, V Sharma, M Birchwood,

The Lancet Volume 5 Issue 1 , 2017

Background Provision of early intervention services has increased the rate of social recovery in patients with first-episode psychosis; however, many individuals have continuing severe and persistent problems with social functioning. We aimed to assess the efficacy of early intervention services augmented with social recovery therapy in patients with first-episode psychosis. The primary hypothesis was that social recovery therapy plus early intervention services would lead to improvements in social recovery. Methods We did this single-blind, phase 2, randomised controlled trial (SUPEREDEN3) at four specialist early intervention services in the UK. We included participants who were aged 16–35 years, had non-affective psychosis, had been clients of early intervention services for 12–30 months, and had persistent and severe social disability, defined as engagement in less than 30 h per week of structured activity. Participants were randomly assigned (1:1), via computer-generated randomisation with permuted blocks (sizes of four to six), to receive social recovery therapy plus early intervention services or early intervention services alone. Randomisation was stratified by sex and recruitment centre (Norfolk, Birmingham, Lancashire, and Sussex). By necessity, participants were not masked to group allocation, but allocation was concealed from outcome assessors. The primary outcome was time spent in structured activity at 9 months, as measured by the Time Use Survey. Analysis was by intention to treat. This trial is registered with ISRCTN, number ISRCTN61621571. Findings Between Oct 1, 2012, and June 20, 2014, we randomly assigned 155 participants to receive social recovery therapy plus early intervention services (n=76) or early intervention services alone (n=79); the intention-to-treat population comprised 154 patients. At 9 months, 143 (93%) participants had data for the primary outcome. Social recovery therapy plus early intervention services was associated with an increase in structured activity of 8·1 h (95% CI 2·5–13·6; p=0·0050) compared with early intervention services alone. No adverse events were deemed attributable to study therapy. Interpretation Our findings show a clinically important benefit of enhanced social recovery on structured activity in patients with first-episode psychosis who received social recovery therapy plus early intervention services. Social recovery therapy might be useful in improving functional outcomes in people with first-episode psychosis, particularly in individuals not motivated to engage in existing psychosocial interventions targeting functioning, or who have comorbid difficulties preventing them from doing so. Funding National Institute for Health Research.

Social recovery therapy broadly consisted of:

  • Stage one: establishment of a working, therapeutic relationship, identifying hopes and expectations from before the illness, looking at how symptoms affect activity and outlook, drawing up a problem list, and creating goals for day-to-day tasks.
  • Stage two: preparing for new meaningful activities, referral to education, vocation or leisure/ sports providers, addressing hopelessness and how to manage symptoms during activities.
  • Stage three: behavioural experiments to start the new activities and work on overcoming any obstacles and challenges faced.

Expert commentary

Some young people experience profound social impairments following a first episode of psychosis, even after a year or more of high-quality, intensive care. Augmenting this with cognitive behavioural therapy-informed, motivational, goal-focused social recovery therapy (delivered by highly trained therapists) increases the amount of time spent on meaningful activities. 

Unfortunately, the effects are short-lived and (in this study) not accompanied by consistent evidence of symptomatic improvement.

There are important lessons here: first, schizophrenia and related illnesses continue to devastate young lives; and second, it is possible to overcome these social impairments, but it requires skill, commitment, therapeutic perseverance and, importantly, resources.

Scott Weich, Professor of Psychiatry, University of Sheffield