Psychosocial interventions

Controlled studies of psychosocial interventions are less extensive than those concerning drug treatments, and assessments in many of the studies have not been blind, but it is possible for the psychosocial therapy of schizophrenia to be evidence based.

The major types of intervention are as follows:

• psychodynamic psychotherapy

• social skills training and illness self-management programmes

• family interventions

• cognitive-behavioural therapy.

A further group, while strictly relating more to administrative measures, may nonetheless be conveniently considered here:

• alternatives to hospitalization.

Psychodynamic psychotherapy

Analytical psychotherapy was widely used in the first half of this century and continues occasionally to be utilized, although usually in combination with antipsychotic medication. The studies of May and colleagues, mentioned above, provide no support for the view that psychotherapy is an appropriate treatment for first-episode schizophrenia.

Gunderson et a/.(67> reported a randomized trial comparison of two forms of psychotherapy in schizophrenia: reality adaptive-supportive, which focused on practical problems, and exploratory insight-orientated psychotherapy. The latter was stated to be the more effective in terms of 'ego-functioning' but was clearly less effective than reality adaptive-supportive in terms of measures of rehospitalization and vocational and social adjustment.

Social skills training and illness self-management programmes

Social skills training refers to a structured learning-orientated approach towards the acquisition of skills relevant to the individual and the demands of his or her environment.*68) The studies of Claghorn et a/}69) in which emphasis was put upon tasks of daily living, and of Malm, (79 which stressed communication skills, both demonstrated effectiveness in terms of enhanced insight and socialization. Spencer et a/.(71) compared social skills treatment with group discussion in a sample of chronic schizophrenic patients and found that conversational skills were improved in the social skills treatment group but not in the others, with improvements maintained at 2-month follow-up. Hogarty et a/.(72> studied family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare of schizophrenic patients, considering the effects after 1 and 2 years. They found an additive beneficial effect of social skills and family therapy after 1 year but this was less after the second year. Dobson et a/.(73) randomized 33 schizophrenic patients to social skills training or milieu therapy and found that at 3 months there was a reduction in negative symptoms in the social skills as compared with the milieu therapy group.

Benton and Schroeder(74) conducted a meta-analysis of 27 studies of social skills training and found benefits in terms of assertiveness, general social skills, and speed of discharge. There was a possible reduction in relapse rates and limited evidence for generalization of skills and of their maintenance. Generalization of skills is an important issue for social skills training. Skills are generally taught in a role-play situation, and although some studies have indicated that behaviour learned in this way will generalize to unprompted situations,(75) some reviews have concluded that it is not clear that changes in treatment settings generalize to community settings.(76)

Individuals with substantial cognitive deficits and/or high levels of conceptual disorganization are poor candidates for most social skills training programmes. Illness self-management is an element of a number of these, but this particular area of patients' functioning has been more specifically addressed in separate plans of psychosocial management. Eckman et a/.{77) studied the effects of an intensive, twice-weekly group programme directed to illness management which included video modelling, role playing and problem-solving activities. Patients received focused instructions, active coaching, and homework. This package was compared to a similarly intensive, supportive psychotherapy group. The package resulted in improved self-management in medication but little change in symptom levels. Linszen et a/.(78> reported that a programme of illness self-management was alone as effective in reducing relapses as it was when combined with a family intervention.

Therefore available trials offer support for various types of social training in relevant skills. In general they have not been assessed on a blind basis. However, it has been shown(6,79) that this can be done successfully using edited video recordings.

Family interventions

Forms of management for schizophrenia focusing upon the patient's family arose from the observation that criticism and hostility on the part of close relatives was an important determinant of relapse.(89 Such criticism and hostility was referred to as high 'expressed emotion', and forms of management designed to reduce this were devised. They combined attempts to improve family interactions with education about the disorder and direct advice about dealing with crises etc. Such packages have been extensively evaluated and their efficacy demonstrated, but which of the diverse elements is necessary for that efficacy is still unclear. (8182)

Leff and colleagues have published a series of studies comparing education and relatives' groups with family therapy designed to reduce high expressed emotion. They found that relapse rates were reduced in those patients who remained on medication and whose relatives participated in family therapy. (8,84> It was concluded that reduction of expressed emotion and of time in face-to-face contact were important elements in determining the efficacy of this approach, although the authors acknowledge the difficulties of persuading relatives to participate in this type of intervention. Tarrier and colleagues have found essentially similar results. (8,86)

Family education and social skills training were also examined by Hogarty et a/.(87) in 103 patients with schizophrenia and schizoaffective psychosis from high expressed emotion households. Relapse rates over 1 year were reduced by about 20 per cent by both treatments. It was concluded that some of the benefit was attributable to high expressed emotion reduction but that on-going antipsychotic medication was essential for schizophrenic patients in high expressed emotion households and that the effect of family therapy was in terms of delaying, rather than preventing, relapse. Glick et a/.(88) reported that family education improved symptom ratings over 6 months, while McFarlane et a/.,(89> comparing psychoeducation in single family and multiple family treatment styles, showed advantages for the multiple family groups, and suggested that family support may have been the important element.

A meta-analysis of family intervention studies in the Cochrane database found that these reduce relapse rates by about 50 per cent for up to 2 years, and that medication compliance is similarly improved.(90) It was calculated that about six families need to be treated to prevent one relapse. It is therefore clear that family interventions are effective. The extent to which this effectiveness relates to improved compliance with medication, encouragement of realistic expectations, increased family involvement in clinical decision-making, improved family interaction, or indeed reduction of criticism and hostility towards the patient, is unclear.

These issues are underlined by the findings of a large multicentre study in which patients were allocated to one of three antipsychotic drug regimens and either supportive or intensive family treatment strategies.(61) There were clear advantages for standard as opposed to low or intermittent antipsychotic regimens, but no differences could be demonstrated between the two family interventions.

Cognitive-behavioural therapy

In recent years, controlled trials of cognitive-behavioural therapy in schizophrenia have been published. Tarrier et a/.i9l) randomly allocated 27 patients with residual symptoms on antipsychotic medication to coping strategy enhancement or problem solving, and compared them with 22 patients allocated to a waiting list condition. Both treatments reduced positive symptoms, but not negative symptoms or social functioning. Drury et a/.(92) undertook a trial of cognitive-behavioural therapy in drug-treated patients with 'acute non-affective psychosis'. Subjects were randomized to cognitive therapy or equivalent hours of therapeutic input. Of 117 patients, 69 satisfied inclusion criteria and 62 were randomly allocated to the two treatments, but 22 were withdrawn, essentially for non-cooperation. Both groups showed a decline in symptoms, but this was more marked (p < 0.001) in the cognitive therapy group. The authors emphasize that the study was not blind and observe that blindness is not possible in studies of psychosocial interventions, though as noted above, this is not now the case. ^M9.'

The London-East Anglia randomized controlled trial of cognitive-behavioural therapy for psychosis ^M4» allocated 60 patients with at least one positive schizophrenic symptom resistant to medication to cognitive-behavioural therapy + standard care, or standard care. Fifty per cent of the cognitive-behavioural therapy group, as compared with 31 per cent of the control group, improved over 9 months. A major determinant of improvement with cognitive-behavioural therapy was 'cognitive flexibility concerning delusions'.(94)

Cognitive remediation has recently been applied to the care of schizophrenic patients, where the desired endpoint is not symptom reduction but amelioration of cognitive deficits. Benedict et a/.(95} compared 16 patients who received computerized vigilance task training with 17 who did not. The training improved task performance. Vollema et a/.(96) found that performance on the Wisconsin Card Sorting Test was improved by training but not financial reward, while Corrigan et a/.(97) comparing the effects of a 1-h session of vigilance with and without memory training on social cue recognition in 40 patients randomized to these two conditions, found that the combined training had greater benefits. (See also Chapter..6,,3.2.,4.)

Alternatives to hospitalization

Several randomized controlled trials have demonstrated that alternatives to hospitalization can be successful. Assertive (or intensive) case treatment involves multidisciplinary teams with high staff/patient ratios, working assertively with patients on an 'as-required' basis to avoid hospitalization. Case management involves a designated key worker writing out a care plan for each patient and reviewing progress in meeting their needs via a number of agencies. In randomized controlled studies of mentally ill people not specified as having schizophrenia, Rosenheck et a/A98* and Quinlivan et a/.(99) reported that, as compared with standard care, assertive case treatment reduced inpatient service use and reduced overall care costs. Aberg-Wistedt et a/.{199) studying schizophrenic patients, reported that assertive case treatment (in comparison with standard care) reduced the burden upon relatives and increased the patients' social networks. On the other hand, Telles et a/.(101) found that case management and a family management programme appeared to be associated with increased symptomatology in schizophrenic patients.

Case management has been the subject of a meta-analysis in the Cochrane database. Marshall et a/.'(1°2) in a review of nine studies, found that case management does lead to increase in contact with patients but doubles the rates of hospital admission and is not associated with any definite improvements in symptomatology or social functioning.

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