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An RCT published in The Lancet Psychiatry looks at a trial of Open Dialogue vs standard NHS treatments for adults experiencing a mental health crisis.
Dr Sameer Jauhar, Clinical Associate Professor in Affective Disorders and Psychosis, Imperial College London and Consultant Psychiatrist, Brent Early Intervention Service, Central North West London NHS Foundation Trust, said:
“Open Dialogue is a model of mental health crisis and continuing care developed in Western Lapland, Finland, built around network meetings involving the patient, family or other members of their social network, and continuity with the same clinical team over time. This trial has attracted a lot of media interest, even before its results were published, which is unconventional.
“In this trial, Open Dialogue did not reduce relapse – the primary outcome the study was designed to test, though it was associated with fewer hospital admissions and re-referrals, and participants reported a more positive experience of care. That combination is of interest, but it does not establish that Open Dialogue changes the underlying course of illness in the way some of its advocates have suggested, and may have hoped for.
“One important finding is what did not change. There was no significant improvement in either the size or quality of participants’ social networks, despite engagement of the social network being proposed as a fundamental component, and potential mechanism of Open Dialogue. If the putative mechanism is not detectably altered, it becomes important to ask what is driving the more favourable secondary outcomes.
“Those outcomes are also difficult to interpret cleanly because neither clinicians nor participants were masked to treatment allocation. Clinicians knew which service patients were receiving when making decisions about admission, and participants knew which model of care they had received when rating outcomes such as satisfaction and recovery; exactly the kind of outcome that expectation, preference, and differences in clinical decision-making tend to alter, without implying deliberate bias by those involved.
“A related quirk is that the decrease in hospital admissions was pronounced in the first 14 days, suggesting that the triage process (gatekeeping), as opposed to any effects of therapy, may drive this finding.
“The authors also report secondary-outcome results without adjustment for multiple comparisons; this added to the above means the secondary outcomes can only be described as “exploratory” at best. It would be difficult for any scientist to suggest otherwise.
“The re-referral finding is difficult to separate from the design of the service itself. Open Dialogue provides continuity with the same team and an ‘open door’ route back into care. If the intervention changes the pathway by which patients subsequently seek help, then counting fewer referrals elsewhere partly measures the altered organisation of care rather than necessarily a reduction in illness or need -a little like changing the route back into a service and then observing that fewer people use the old one.
“Fewer than 30% of participants had a diagnosis of psychosis or bipolar disorder, a less severely unwell group, by the authors’ own comparison. Whether the same findings would hold in patients presenting with more severe or enduring illness remains untested-and these are people who should be in such a trial.
“This does not mean Open Dialogue has no value. The values-continuity of care, rapid access to a familiar clinical team, and avoiding unnecessary hospital admission are all desirable features of mental health services , but they are not unique to Open Dialogue. They were once a routine part of what community mental health teams delivered, before years of underfunding eroded the capacity to provide them. The important question is whether the distinctive, resource-intensive elements of Open Dialogue itself add benefit beyond good, adequately staffed community care. On the evidence of this trial, that question remains unresolved: the primary outcome was negative, the proposed social-network mechanism did not demonstrably change, and the more favourable story rests on secondary outcomes vulnerable to multiplicity, lack of masking, and, in the case of re-referral,the organisation of the intervention itself.
“Before the NHS commits substantial resources to a branded model of care, those claims need to be tested directly, with rigor.”
Prof Richard Morriss, Professor of Psychiatry, University of Nottingham, said:
“This trial comparing Open Dialogue versus usual care is difficult to interpret. Participants were recruited into the trial once they had recovered from their first crisis and then followed up until they relapsed. However, the definitions of recovery from crisis and therefore the timing of baseline assessment, relapse and recovery are not described clearly enough for those outside the research team to interpret or replicate. It might have been useful for one of the outcome measures to cover the period from initial presentation to the whole follow up whether they recovered or not from the first crisis. Since randomisation to Open Dialogue or treatment as usual occurred before crisis, then the decision to discharge to the community – discharged from a ward or the crisis team to follow up with a community mental health team – might have been related to the allocation. In NHS usual care, allocation to a named health care practitioner can be problematic and take some time whereas in Open Dialogue, there are two named practitioners. This means that it is possible that participants allocated to Open Dialogue might have been discharged earlier than usual care, which might be either better or worse for their mental state in an unpredictable way. The same NHS Trusts operated both treatment arms and staff circulate a lot across services, so contamination is likely. The study also operated much of the time during post-COVID restrictions which restricted face to face and home contact, so generalisation is problematic. All of these issues make finding a clear outcome difficult to achieve and difficult to interpret in the light of current clinical practice, especially with over half of in-patient provision in the private sector now.”
‘Open Dialogue versus treatment as usual for adults presenting in crisis to mental health services in England (the ODDESSI Trial): a multisite cluster-randomised trial’ by Stephen Pilling et al. was published in The Lancet Psychiatry at 23:30 UK time on Wednesday 26th August.
Declared interests
Dr Sameer Jauhar: S.J. reported personal fees from Recordati, LB Pharmaceuticals, Boehringer Ingelheim, Accord Pharmaceuticals, Wellcome Trust, Lundbeck, Janssen and Sunovion and non-financial support from National Institute for Health and Care Excellence, British Association of Psychopharmacology and the Royal College of Psychiatrists
Prof Richard Morriss: “None”