Psychosocial interventions in management

While antipsychotic drugs may be considered the cornerstone of the treatment of schizophrenia, the most competent prescribing of these does not provide a comprehensive programme of management. Even if no formal programme is followed, all patients and their relatives will require appropriate information about the nature of the illness and the therapeutic possibilities. They will need support in coming to terms with the limitations that the illness may impose upon the expectations they have had, and guidance about alternative plans. The requirements of individual patients for rehabilitation and resocialization vary greatly, but general rules can be provided in terms of the classification of psychosocial approaches overviewed above.

Antipsychotic drugs can (and indeed overwhelming evidence indicates that they should) be given to all patients in whom the diagnosis of schizophrenia is appropriately made. This is not the case with psychosocial interventions. In general, these require co-operation from patients and/or relatives, and some of them can only be applied to certain types of patient.

There is no evidence for the value of psychodynamic psychotherapy in schizophrenia, but some will nonetheless wish to have it—and may well find it helpful. However, it should only be recommended in combination with treatments of proven effectiveness.

Family interventions have been shown to be of value, although the essential elements of any package remain far from clear. Education and support from trained staff should be offered, although not all families will be willing to accept this in a group format. While social skills training programmes of various kinds have been demonstrated to be efficacious in achieving specific goals in controlled circumstances with selected groups of patients, it is difficult to draw general guidelines about this kind of management. Nonetheless, while the goals may be restricted, enhanced skills in conversation and self-presentation may make a great deal of difference to the success of resocialization. The place of cognitive remediation is less clear and the requirement for it in routine practice cannot yet be said to be established.

Cognitive-behavioural techniques also require the co-operation of the patient and probably a degree of cognitive flexibility in respect of delusions. This again restricts the applicability of such programmes, but the benefits demonstrated by available trials indicate that they should be available for appropriate individuals.

As far as alternatives to hospital care are concerned, assertive case treatment provides benefits in terms of inpatient service utilization costs, and sometimes burden of care, but case management has not been shown to be helpful.

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