The Staged Treatment in Early Psychosis Study

Phase 3

• Conditions: Psychotic Disorders; Personality Disorders; Clinical High Risk
• Interventions: Behavioral: 3-monthly monitoring; Behavioral: Support and Problem Solving Therapy; Behavioral: Cognitive Behavioural Case Management; Drug: Placebo; Drug: Fluoxetine

• Registration Number: NCT02751632
• Lead Sponsor: Orygen

Brief Summary

A sequential multistage randomised clinical trial (SMART) to produce evidence to guide a step-wise clinical approach for the treatment of ultra high risk patients and reduction of risk for psychosis and other deleterious clinical and/or functional outcomes.

Detailed Description

The study treatment sequence involves three stages, which are referred to as steps:

Step 1- Support and Problem Solving (SPS)

All trial participants receive SPS treatment in Step 1. Step 1 involves attending weekly-fortnightly SPS sessions over a six week period and the Week 4 and 6 visits will also include an interview with research staff who will assess the symptoms and mental state of participants. These assessments will enable research staff to determine whether the therapy has been effective in improving the participant's symptoms.

Depending on how they respond to the six-week period of treatment in Step 1, participants are randomly assigned to a new treatment arm at the end of Step 1 as detailed below:

Participants who improve with the SPS treatment they receive during Step 1, will be randomised to either monthly SPS treatment for up to one year OR to three-monthly appointments (Month 3, 6, 9 and 12) to monitor their mental state.

Participants who do not improve with the SPS treatment they receive during Step 1 will be randomised to continue treatment in one of two groups in Step 2 as outlined below.

Step 2- Support and Problem Solving (SPS) OR Cognitive Behavioural Case Management (CBCM)

In Step 2, participants will receive either SPS OR Cognitive Behavioural Case Management for a period of 18 weeks. Participants will be interviewed at two time points across this step so that research staff can assess whether the therapy has helped improve their symptoms.

Participants who improve with the treatment they receive in Step 2 will be randomised to receive either monthly SPS for a further six months OR to three-monthly appointments (Month 9, 12) to monitor their mental state.

Participants who do not improve with the treatment they receive in Step 2 will be randomised to one of two treatment groups in Step 3 as outlined below.

Step 3 Cognitive Behavioural Case Management plus antidepressant medication OR Cognitive Behavioural Case Management plus placebo medication.

Participants assigned to one of the two treatment groups in Step 3 will receive the corresponding treatment over a six-month period. Both treatment groups will involve: regular CBCM sessions; regular review by a clinician, as well as the assigned medication.

Depending on which group participants are randomised to, they may either receive antidepressant medication OR placebo medication.

If a participant does not improve, or deteriorates by 12 weeks into Step 3, they will be given a choice to: continue with the treatment regime already assigned to them; increase the dosage of their medication, or start a new medication. Upon their choosing, the medication at this stage may either be an antipsychotic medication OR omega-3 fatty acids ('fish oil'), taken in addition to the other treatment components of this step.

The intervention aspect of this study covers a 12 month period. After completion of this intervention period, participants will also be invited to take part in two separate follow-up interviews with research staff, at both 18 months and 24 months.

US Pilot Study:

The University of California, Davis will oversee a pilot study for the implementation of the STEP model in the Early Diagnosis and Preventative Treatment (EDAPT) clinic at UC Davis in Sacramento, California. After giving informed consent, CHR patients and their families entering treatment in the EDAPT program will be offered participation in the staged intervention trial. CHR participants will be characterized with the Structured Interview for Prodromal Syndromes (SIPS) following standard procedures in the U.S. Similarly, defining risk based on 3 core syndromes that span analogous dimensions of symptom severity from attenuated to psychotic, a recent meta-analysis demonstrates that the SIPS reliably identifies youth at clinical high risk for psychosis at a rate comparable to the CAARMS, which is used in the main trial being conducted in the Orygen parent study. Thirty patients will be enrolled and followed through the protocol until 24 month follow up.The team will also harmonize CBT practice with the CBCM model used at Orygen. All outcome measures will parallel those used in the parent study at Orygen. UC Davis research staff will complete clinical and outcome assessments with CHR participants at study entry, 6, 12 and 24 months. Data analysis will also parallel those conducted in the parent study. However, the key measures will be acceptance and retention in the staged treatment.

US Focus Groups:

The University of California, San Francisco will design, conduct and analyze output from a series of focus groups to gather input from stakeholders regarding translation of STEP trial interventions to the US healthcare system. This will include identifying barriers and solutions to implementation of STEP trial interventions in the US context for CHR patients. Groups will include CA county mental health leadership, private insurance mental health leadership, mental health leadership at DHHS and the Center for Medicare/Medicaid Services, leadership from community-based organizations currently providing services for this population, consumers, and family members.

Study Timeline

• Study Start: 2016-04
• Study First Submitted: 2016-04-12
• Study First Submitted QC: 2016-04-21
• Study First Posted: 2016-04-26
• Primary Completion: 2019-07
• Status Verified: 2020-09
• Last Update Submitted: 2020-09-15
• Last Update Posted: 2020-09-16
• Study Completion: 2021-05

Recruitment & Eligibility

• Status: UNKNOWN
• Sex: All
• Target Recruitment: 340

Inclusion Criteria

Not provided

Exclusion Criteria

Not provided

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Responders- 3-monthly monitoring	3-monthly monitoring	Participants are randomised to be monitored for risk every 3 months for up to 12 months.
Responders- Monthly SPS Therapy	Support and Problem Solving Therapy	Participants are randomised to receive monthly Support and Problem Solving Therapy for up to 12 months.
Step 2- Regular SPS Therapy	Support and Problem Solving Therapy	Participants are randomised to receive regular sessions of Support and Problem Solving Therapy, with a minimum of six sessions delivered over an 18-week period.
Step 3- Regular CBCM + Fluoxetine	Cognitive Behavioural Case Management	Participants are randomised to receive either Cognitive Behavioural Case Management plus an antidepressant medication for six months .
Step 1-Regular SPS Therapy	Support and Problem Solving Therapy	Support and Problem Solving Therapy delivered to all study participants over a six-week period with a minimum of three sessions.
Step 2- Regular CBCM	Cognitive Behavioural Case Management	Participants are randomised to receive regular sessions of Cognitive Behavioural Case Management, with a minimum of six sessions delivered over an 18-week period.
Step 3- Regular CBCM+ placebo	Placebo	Participants are randomised to receive Cognitive Behavioural Case Management plus placebo medication for six months.
Step 3- Regular CBCM+ placebo	Cognitive Behavioural Case Management	Participants are randomised to receive Cognitive Behavioural Case Management plus placebo medication for six months.
Step 3- Regular CBCM + Fluoxetine	Fluoxetine	Participants are randomised to receive either Cognitive Behavioural Case Management plus an antidepressant medication for six months .

Primary Outcome Measures

Name	Time	Method
Global Functioning Scale Score	6 months from baseline (end of Step 2)	To test the effect of a sequential treatment approach consisting of SPS/SPS and SPS/CBCM on functioning levels of UHR patients.

Secondary Outcome Measures

Name	Time	Method
Global Functioning Scale Score	12 months from baseline (end of Step 3)	To test the effect of a sequential treatment approach consisting of SPS, CBCM and antidepressant medication on functioning levels of UHR patients.
Comprehensive Assessment of At Risk Mental State score	1.5, 6, 12 and 24 months from baseline	To test the effect of a sequential treatment approach in UHR patients on level of positive psychotic symptoms.
Scale for Assessment of Negative Symptoms score	1.5, 6, 12 and 24 months from baseline	To test the effect of a sequential treatment approach in UHR patients on level of negative psychotic symptoms.
Montgomery Asberg Depression Rating Scale score	1.5, 6, 12 and 24 months from baseline	To test the effect of a sequential treatment approach in UHR patients on level and depressive symptoms.

Trial Locations

Locations (2)

Orygen Youth Health Clinical Program; 🇦🇺 Melbourne, Victoria, Australia

Headspace; 🇦🇺 Werribee, Victoria, Australia