Open Dialogue in crisis care: no effect on relapse, fewer admissions

Design

Multisite, parallel, cluster-randomised superiority trial with masked outcome assessment

Population

494 adults presenting in crisis to community mental health services in five English NHS trusts

Primary outcome

Time to first relapse after initial recovery over 2 years

Effect

Marginal hazard ratio 0.95 (95% CI 0.67 to 1.32); fewer psychiatric admissions among secondary outcomes

ODDESSI randomised 30 clusters of general practices across five English NHS trusts to Open Dialogue or usual care. Open Dialogue is a service-wide approach using network meetings with the patient, their social network and usually two practitioners. 494 adults presenting in crisis took part, mean age 38.

The primary outcome, time to first relapse after initial recovery, did not differ (marginal hazard ratio 0.95, 95% CI 0.67 to 1.32). Open Dialogue was associated with lower probabilities of psychiatric admission and of re-referral to crisis or secondary services, and with better self-rated recovery, quality of life and satisfaction. Social network quality and size did not differ.

The trial was retrospectively registered, and the secondary findings were not the powered endpoint. The authors call for more work on whether the model improves crisis and continuing care. For services, the signal is on bed use and experience rather than on relapse.

• No difference in time to relapse after recovery.
• Fewer psychiatric admissions and re-referrals were seen with Open Dialogue.
• Self-rated recovery, quality of life and satisfaction were higher.
• Serious adverse events were mostly unrelated to the intervention.
• Implementation needs service-wide change, not a single clinician's decision.

Why it matters

It separates what Open Dialogue did not do, delay relapse, from what it may do, reduce admissions and improve experience.

Don't overread it

The primary endpoint was missed and the trial was registered retrospectively; the secondary benefits need confirmation.

The statistics, in plain English

A hazard ratio of 0.95 with an interval of 0.67 to 1.32 means the trial can neither show benefit nor exclude a meaningful effect either way on relapse. Secondary outcomes were not the planned test, so their significance carries less weight than the primary result.

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