Methods

Inclusion criteria

Patients are included from inpatient and outpatient mental health services in Copenhagen, patients fulfilling the following inclusion criteria can be offered treatment:

(1)                  age 18 to 35 years and legal residence in the catchment areas

(2)                  F2 diagnosis: schizophrenia, schizotypal disorder, persistent delusional disorder, acute and transient psychotic disorder, schizoaffective disorder, induced delusional disorder, or unspecified non-organic psychosis according to ICD-10 research criteria,(10) based on Schedules for Clinical Assessment in Neuropsychiatry, SCAN version 2.0 (since 1999 version 2.1) (11)

(3)                  no exposure to antipsychotic medications exceeding 26 weeks of continuous medication

(4)                  absence of mental retardation, organic mental disorder, and psychotic condition only due to acute intoxication or a withdrawal state

OPUS team provides the following treatment modalities:

Assertive community treatment

The integrated treatment is provided by the multidisciplinary teams and can be defined as a rich assertive community treatment model,(12) including protocols for medication, family involvement, and social skill training. Two multidisciplinary teams in Copenhagen are established and trained to provide the integrated treatment modelled on assertive community treatment. Each team includes the following disciplines: psychiatrist, psychologist, psychiatric nurse, occupational therapist, and social worker. Caseload is approximately 10 and never exceeded 15 for any professional team member. Each patient is offered integrated treatment for a period of two years. A primary team member is designated for each patient and is then responsible for maintaining contact and co-coordinating the treatment within the team and across different treatment and support facilities. The patients are visited in their homes or other places in their community, or they are seen at the office according to the patients' preference. When hospitalised, the patient is visited weekly at the hospital. During inpatient treatment, the treatment responsibility is transferred to the hospital. The office hours are Monday to Friday from 8 a.m. to 5 p.m. All team workers has a cell telephone with an answering function. Outside office hours patients can leave a message and be sure that the team will respond the next morning. A crisis plan is developed for each patient. The patients are encouraged to take responsibility for their own affairs as soon as possible during the process of recovery. If the patient is reluctant about treatment, the team tries to motivate the patient to continue treatment and stay in contact with the patient.

The fidelity of the programme, which was measured with IFACT (Index of Fidelity of Assertive Community Treatment) (13) was 70 percent in Copenhagen. The factors responsible for the reduced fidelity were time-limited treatment, 24-hour coverage in other settings, and for each patient, approximately two contacts weekly with the patient, patient's family and collaborating partners.

Antipsychotic medication

Patients are offered antipsychotic medication according to guidelines from the Danish Psychiatric Society, which recommends a low-dose strategy for first-episode psychotic patients and use of second-generation antipsychotic drugs as first choice.(14) Psycho-education is carried out along with antipsychotic medication, and team members pays close attention to adverse events.

Psycho-educational family treatment

Psycho-educational family treatment is offered to patients in contact with at least one significant other. The family treatment follows McFarlane's manual for Psycho-educational Multiple Family Group Treatment(15) and includes 18 months' treatment, 11/2 hours biweekly in a multiple-family group with two therapists and 4-6 families, including the patients. The multiple-family group focus on problem solving and development of skills to cope with the illness.

Social skill training

Patients' social skills is assessed using the WHO Psychiatric Disability Assessment.(16) The patients who are unable to work in a group were offered individual training. Patients with an intermediate level of impaired social skills are offered social skills training focusing on medication, coping with symptoms, conversation, problem solving, and conflict-solving skills in a group of maximum six patients and two therapists.(17) Patients who does not need social skills training receives individual psycho-education.