OPEN DIALOGUE: Naturalistic study designs for developing the system of care. Jaakko Seikkula

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1 OPEN DIALOGUE: Naturalistic study designs for developing the system of care Jaakko Seikkula

2 Problems in clinical trials Taylor M, Cavanagh J, Hodgson R, Tiihonen J. Examining the effectiveness of antipsychotic medication in first-episode psychosis. J Psychopharmacol 2012; 26: RCTs measure efficacy, but the controlled environment of a RCT affects the generalisability of the results in the real world, especially when high drop-out rates, short trial duration, and the selection bias in patient recruitment are considered (Hodgson et al., 2007; Thornley and Adams, 1998). The drop-out rates of even relatively brief RCTs in medication trials in psychiatry can be up to 70% or even 80%, confounding the applicability of the results. In addition, large multicentre RCTs are expensive to conduct, which militates against undertaking long-term or maintenance studies.

3 Naturalistic design Looking at what happens in the real world Not a laboratory design Emphasize on external validity Design according to the specific context and specific method Mixed methods both quantitative and qualitative data in the same project

4 Aspects Interactional therapies Step 1: Follow-up of outcomes Step 2: Choosing cases for comparison Step 3: Poor and Good outcome case studies Step 4: Integrating the results of cases to statistical data

5 Open dialogue studies in Western Lapland : The boundary between the hospital and the family 1) difference between first, reoccuring and long term patients in the admission 2) teamwork opens up broader social interest 3) first ideas on the importance of dialogue 4) don t force the family to accept the home treatment instead of hospitalization

6 Psychosis studies Integrated Treatment of Acute Psychosis (IAP- API) project Open Dialogue in Acute (ODAP I) ODAP II Long term follow-up of the three ODAP projects

7 : Change of the system from hospital to mobile interventions Data: 3000 patients records, 2 years followup - Incidence of schizophrenia Main principles of Open Dialogue as an outcome of the qualitative content analysis (Grounded Theory)

8 Long term follow-up of OD Three inclusion periods N= 108 Register study comparison to national statistics N= 1763 Life story about having living through psychotic crises N=20

9 MAIN PRINCIPLES FOR ORGANIZING OPEN DIALOGUES IN SOCIAL NETWORKS IMMEDIATE HELP SOCIAL NETWORK PERSPECTIVE FLEXIBILITY AND MOBILITY RESPONSIBILITY PSYCHOLOGICAL CONTINUITY TOLERANCE OF UNCERTAINTY DIALOGISM

10 Focusing on dialogues Kauko Haarakangas 1997: Voices of the treatment meeting Jaakko Seikkula 2002: Poor and Good outcome in psychotic crises 2011: Dialogical Methods in Investigation of Happenings of change : Relational Mind looking at embodiment in multiactor dialogues

11 Open dialogues with good and poor outcomes for psychotic crisis/ Jaakko Seikkula, 2002 /Journal of Marital and Family Therapy, 28(3): SUMMARY Good outcome Poor outcome Interactional dominance by clients 55-57% 10 35% Semantic dominance by clients 50-70% 40-70% Symbolic language area in sequences 67 80% 0 20% Dialogical dialogue in sequences 60 65% 10 50%

12 Dialogical Methods for Investigations in Happenins of Change Jaakko Seikkula Aarno Laitila Peter Rober Making Sense of Multi-Actor Dialogues in Family Therapy and Network Meetings. Journal of Marital and Family Therapy (2011). doi: /j x

13 STEP I: Exploring Topical Episodes in the dialogue STEPII: Exploring the series of responses found in utterances STEP III: Exploring the processes of narration and the language area STEP IV: Micro analysis of selected episodes

14 5 years follow-up of Open Dialogue in Acute psychosis (Seikkula et al. Psychotherapy Research, March 2006: 16(2), ) in Western Lapland, inhabitants Starting as a part of a Finnish National Integrated Treatment of Acute Psychosis project of Need Adapted treatment Naturalistic study not a randomized trial Aim 1: To increase treatment outside hospital in home settings Aim 2: To increase knowledge of the place of medication not to start neuroleptic medication in the beginning of treatment but to focus on an active psychosocial treatment N = 90 at the outset; n=80 at 2 year; n= 76 at 5 years Follow-up interviews as learning forums

15 OPEN DIALOGUE IN ACUTE PSYCHOSIS Charasteristics of the patients at the baseline (N=80) Male Female Total Age (mean) Employment status Studying % Working % Unemployed % Passive % Diagnosis (DSM-III-R) Brief psychotic episodes % Nonspecified psychosis % Schizophreniform psychosis % Schizophrenia %

16 OPEN DIALOGUE IN ACUTE PSYCHOSIS Means of hospital days at 2 and 5 years follow-ups API ODAP years 2-5 years

17 OPEN DIALOGUE IN ACUTE PSYCHOSIS Psychotic symptoms at 5 year follow-up compared to neuroleptic medication during the first 2 years/ % Rating of symptoms Neuroleptics Total Not used Used or cont Total Chi-square 5.93; df=3; p=.145 (NS)

18 OPEN DIALOGUE IN ACUTE PSYCHOSIS Relapses compared to use of neuroleptics during the early phase of the treatment Neuroleptics Not-used Used Total/% Chi-sq. P Relapses 0-2 years / ;3.030 At least / 18 Relapses 2-5 years / ;2 ns At least Total number of relapse cases 28%

19 OPEN DIALOGUE IN ACUTE PSYCHOSIS Employment status at 2 and 5 years follow-up/ % 2 years 5 years (N=79) (N=73) Studying Employed Unemployed and 14 7 job-seeking Disability allowance or passive Total

20 Means of treatment process variables in three schizophrenia groups at the two-year follow-up, t-test pair comparison Seikkula, J. et al. Ethical and Human Sciences and Services 2003, 5(3), API ODAP Comparison group group group N=22 N=23 N=14 Hospitalization days Mean ** SD Number of family meetings Mean *** SD

21 OPEN DIALOGUE IN ACUTE PSYCHOSIS Relapses compared to use of neuroleptics during the early phase of the treatment Neuroleptics Not-used Used Total/% Chi-sq. P Relapses 0-2 years / ;3.030 At least / 18 Relapses 2-5 years / ;2 ns At least Total number of relapse cases 28%

22 Frequencies of outcome variables in three schizophrenia groups at the two-year follow-up API group ODAP Comparison group group N=22 N=23 N=14 Number of relapsed ** patients Employment status Studying or working Unemployed Disability allowance *** Residual psychotic symptoms **

23 COMPARISON OF 5-YEARS FOLLOW-UPS IN WESTERN LAPLAND AND STOCKHOLM ODAP Western Lapland Stockholm* N = N=71 Diagnosis: Schizophrenia 59 % 54 % Other non-affective psychosis 41 % 46 % Mean age years female male Hospitalization days/mean Neuroleptic used 33 % 93 % - ongoing 17 % 75 % GAF at f-u Disability allowance or sick leave 19 % 62 % *Svedberg, B., Mesterton, A. & Cullberg, J. (2001). First-episode non-affective psychosis in a total urban population: a 5-year follow-up. Social Psychiatry, 36:

24 ODAP II Outcomes stable (Aaltonen et al.; Seikkula et al, 2011) - Duration of Untreated Psychosis (DUP) decreased to three weeks - Few new schizophrenia patients (from 33 to 3 / every year) - 84 % returned to full employment Naturalistic design really increased the external validity: The outcomes of the first study remained on the same level ten years after

25 Long term 20 years follow-up- Initial observations of significant differences (Bergström et al., in preb.) OD N=108 TAU N=1763 Mortality by illnesses Hospital days (over 30) Ongoing contact after 20y On neuroleptic Disability allowance

26 Why the dialogical practice can be effective? 1. Immediate response taking use of the emotional and affective elements of the crisis 2. Social network included throughout and thus polyphonic in two respect: both horizontal and vertical 3. Focus on dialogue in the meeting: to have all the voices heard and thus working together 4. Avoiding medication that alter central nervous system antipsychotic medication related to shrinkage of brain (Andreansen et al., 2011) and to decrease of psychological resources (Wunderink, 2013)

27 Conclusions OD developed in an intertwined process with research Naturalistic research gives valuable information about the local practice managing of the problems and dilemmas of the deisgn External validity higher compared to empiristic clinical trials: - non- medication group from the outset, not withdrawing - selective use of medication not a group mean comparison - replication ten years after not 20% decrease of the efficacy as in laboratory designs Reliability of the research may be lower no explanation, but descriptions