Psychosocial treatments in schizophrenia: a review of the past 20 years

Pharmacotherapy can improve some of the symptoms of schizophrenia but has limited effect on the social impairments that characterize the disorder and limit functioning and quality of life. Through computerized literature searches and bibliographies of published reports we identified peer reviewed studies of group, family, and individual therapy with schizophrenia and schizoaffective disorder patients. We identified 70 studies: 26 on group therapy, 18 on family therapy, and 11 on individual therapy. Additionally, treatment models were compared in 4 studies and combined in 11 others. Controls were included in 61 and all studies included medication. Benefits in symptoms as well as social and vocational functioning were associated with psychosocial treatments. Family therapy demonstrated the most promising findings and traditional social skills treatment yielded the least robust results. Adjunctive psychosocial treatments augment the benefits of pharmacotherapy and enhance functioning in psychotic disorders. Although these positive results have led to increased enthusiasm about psychosocial treatments for schizophrenia, questions remain about comparative benefits of specific treatment methods and additional benefits of multiple treatments.     

The importance of psychosocial interventions and patient involvement in the treatment of schizophrenia

The multifactorial nature of schizophrenia and the wide-ranging impact of the illness on the patient, their family, carers and healthcare providers mean that clinicians must be prepared to take a holistic approach to treatment. It is widely recognized that a patient's beliefs about their treatment and their experiences of schizophrenia can be very important in determining both attitude towards treatment compliance and behaviour in response to symptoms of the illness and environmental stress. Antipsychotic therapy remains the cornerstone of treatment for schizophrenia. However, there is now growing evidence to support the benefits of non-pharmacological interventions, when used in combination with antipsychotic treatment, in relieving symptoms, improving occupational and social functioning and reducing the risk of relapse. In particular, these interventions appear to provide benefits in coping skills and social and vocational functioning, as reflected in a greater ability to function independently and an improvement in quality of life. Systematic assessment of non-pharmacological therapies in schizophrenia is still a relatively new science, but there is good evidence that psychosocial therapies, such as family intervention therapy, cognitive-behaviour therapy and compliance therapy can markedly change a patient's behaviour and improve adherence to treatment and hence interaction with families, carers and healthcare providers. Psychosocial interventions can be implemented from the first episode of psychosis onwards and can contribute to an improved overall outcome in schizophrenia, to patients being more satisfied with their treatment, and to a better quality of life for the patient and their family. Initial comprehensive assessment will involve regular contact with the patient and opens channels for an ongoing dialogue. It is important that these discussions with the patients and their families and carers not only cover the need for social, emotional and behavioural support but include regular discussion of the acceptability and side-effects of antipsychotic treatment so that problems can be identified and addressed promptly. While the importance of non-pharmacological interventions in improving the quality of patient care is becoming widely accepted, access to psychological, psycho-educational and family support is by no means universal in current clinical practice. It is important that these services, provided by appropriately trained personnel, are made available to all patients for whom they may be appropriate.     

Predictors of noncompliance in patients with schizophrenia

BACKGROUND: Around 50% of patients with schizophrenia do not fully comply with treatment, and noncompliance is linked to relapse, rehospitalization, poor outcome, and high economic costs. The health belief model views noncompliance as a decision made by the patient, arrived at after weighing the perceived risks and benefits of treatment. DATA SOURCES: A MEDLINE search for the years 1980-2002 using combinations of the keywords schizophrenia, compliance, adherence, antipsychotics, tolerability, and side effects was used to identify articles investigating the factors influencing compliance in schizophrenia. RESULTS: Many factors influence compliance, including those that affect patients' beliefs about their illness and the benefits of treatment (e.g., insight into illness, belief that medication can ameliorate symptoms), perceived costs of treatment (e.g., medication side effects), and barriers to treatment (e.g., ease of access to treatment, degree of family or social support). Medication side effects that are distressing to patients and linked to noncompliance include extrapyramidal side effects, neuroleptic dysphoria, akathisia, sexual dysfunction, and weight gain. Compliance can be improved by cognitive-behavioral therapies, such as compliance therapy, and other psychosocial interventions associated with improved social functioning and a lower risk of rehospitalization. Treatment adherence may also be improved by use of atypical antipsychotics with few perceived side effects. CONCLUSION: By considering the factors leading to noncompliance and adopting a comprehensive strategy for improving compliance, encompassing psychosocial intervention and optimum choice of medication, the management of schizophrenia could be greatly improved.     

Psychosocial interventions and medication adherence in bipolar disorder

Recent research has indicated that psychosocial interventions can have a valuable role in reducing the substantial psychosocial disability associated with bipolar disorder. Randomized controlled trials of these interventions indicate that improvements are seen in symptoms, psychosocial functioning, and treatment adherence. These interventions, systematically presented in the form of standardized treatment manuals, vary in format, duration, and theoretical basis. All are meant to augment pharmacotherapy, which represents the standard of treatment in the field. Modalities that have gathered the most empirical support include cognitive-behavioral therapy, family-focused therapy, interpersonal and social rhythms therapy, and psychoeducation. The enhancement of adherence to pharmacotherapy is a common therapeutic target, due to the association of nonadherence with higher relapse rates, hospitalization, and health care costs among people with bipolar disorder. Given the complexity of nonadherence behavior, multicomponent interventions are often required. In this review, we provide an overview of the rationale, evidence base, and major psychotherapeutic approaches in bipolar disorder, focusing on the assessment and enhancement of medication adherence.     

Training of affect recognition (TAR) in schizophrenia--impact on functional outcome

Deficits in facial affect recognition as one aspect of social cognitive deficits are treatment targets to improve functional outcome in schizophrenia. According to preliminary results antipsychotics alone show little effects on affect recognition. A few randomized intervention studies have evaluated special psychosocial treatment programs on social cognition. In this study, the effects of a computer-based training of affect recognition were investigated as well as its impact on facial affect recognition and functional outcome, particularly on patients' quality of life. Forty clinically stabilized schizophrenic patients were randomized to a six-week training on affect recognition (TAR) or treatment as usual including occupational therapy (TAU) and completed pre- and post-treatment assessments of emotion recognition, cognition, quality of life and clinical symptoms. Between pre- and post treatment, the TAR group achieved significant improvements in facial affect recognition, in particular in recognizing sad faces and, in addition, in the quality of life domain social relationship. These changes were not found in the TAU group. Furthermore, the TAR training contributes to enhancing some aspects of cognitive functioning and negative symptoms. These improvements in facial affect recognition and quality of life were independent of changes in clinical symptoms and general cognitive functions. The findings support the efficacy of an affect recognition training for patients with schizophrenia and the generalization to social relationship. Further development is needed in the impact of a psychosocial intervention in other aspects of social cognition and functional outcome.     

Multimodal Cognitive Therapy: Combining Treatments That Bypass Cognitive Deficits and Deal With Reasoning and Appraisal Biases

The process of recovery in schizophrenia involves resolving persistent symptoms, addressing cognitive impairments, and improving functional outcomes. Our research group has demonstrated the efficacy of cognitive adaptation training (CAT)—a home-based psychosocial treatment utilizing environmental supports such as medication containers, signs, checklists, and the organization of belongings to bypass deficits in cognitive functioning and cue and sequence adaptive behavior) for improving adherence to medications and functional outcomes in schizophrenia. Early CAT pilot studies utilizing some therapists with training in cognitive behavior therapy (CBT) techniques for psychosis found significant improvements in positive symptoms. More recent larger scale randomized clinical trials failed to replicate this finding with CAT therapists not trained in CBT techniques. Persistent psychotic symptoms substantially impair patients’ ability to adapt to life in the community. Cognitive behavior therapy for psychosis (CBTp) is an evidence-based practice for addressing persistent positive symptoms and the distress associated with them. CBTp decreases symptomatology and minimizes the negative effect of persisting symptoms upon individuals with this disorder. We now describe a home-delivered, multimodal cognitive treatment targeting functional outcomes and persistent positive symptoms for individuals with schizophrenia by utilizing both CAT and CBT techniques. We discuss the advantages and challenges of combining these 2 interventions, present a small retrospective data analysis to support their combination into a multimodal treatment, and describe the design of an ongoing randomized trial to investigate efficacy.     

精神分裂症患者的心理社会干预

精神分裂症的治疗不仅包括药物治疗,还包括为患者提供支持、有效的信息、心理社会干预以及康复治疗。中国的研究者在精神分裂症患者非药物治疗领域进行着各项研究,而国外研究数据一致显示心理社会干预可以降低复发率和再住院率。尽管缓解症状仍然是精神分裂症治疗的一个重要目标,但工作、学习,独：立生活及社会化方面的功能损伤往往也是患者及其家属关注的重点。因此,精神分裂症患者更有可能从着重于减轻残疾的干预中获益。本文对中外有效应用于精神分裂症患者的主要心理社会干预进行综述,包括认知行为治疗、社会技能训练、家庭干预、认知纠正、心理教育、职业训练、危机干预及综合心理治疗;同时就中外心理社会干预的差异进行讨论     

Social Disinterest Attitudes and Group Cognitive-Behavioral Social Skills Training for Functional Disability in Schizophrenia

The majority of clinical trials of cognitive-behavioral therapy (CBT) for schizophrenia have used individual therapy to target positive symptoms. Promising results have been found, however, for group CBT interventions and other treatment targets like psychosocial functioning. CBT for functioning in schizophrenia is based on a cognitive model of functional outcome in schizophrenia that incorporates dysfunctional attitudes (eg, social disinterest, defeatist performance beliefs) as mediators between neurocognitive impairment and functional outcome. In this report, 18 clinical trials of CBT for schizophrenia that included measures of psychosocial functioning were reviewed, and two-thirds showed improvements in functioning in CBT. The cognitive model of functional outcome was also tested by examining the relationship between social disinterest attitudes and functional outcome in 79 people with schizophrenia randomized to either group cognitive-behavioral social skills training or a goal-focused supportive contact intervention. Consistent with the cognitive model, lower social disinterest attitudes at baseline and greater reduction in social disinterest during group therapy predicted better functional outcome at end of treatment for both groups. However, the groups did not differ significantly with regard to overall change in social disinterest attitudes during treatment, suggesting that nonspecific social interactions during group therapy can lead to changes in social disinterest, regardless of whether these attitudes are directly targeted by cognitive therapy interventions.     

Update on Attention-Deficit/Hyperactivity Disorder and Tic Disorders: A Review of the Current Literature

Tic disorders impact quality of life, but when they are co-occurring with attention-deficit/hyperactivity disorder, the combined impact takes a toll on psychosocial functioning and adds another layer of complexity to treatment approaches. A review of the current literature supports evidence of a unique relationship between comorbid attention-deficit/hyperactivity disorder and tic disorders, emphasizing the intricate phenotype and impairment associated with these co-occurring conditions. The complexity of these symptoms requires careful diagnosis and appropriate treatment as determined by the level of impairment and can include pharmacotherapy, behavioral interventions, or a combination of therapies. To achieve the greatest benefits in improving quality of life and eliminating further comorbidity, an ideal treatment plan would include a comprehensive evaluation as well as a hierarchical treatment approach involving education of the child, family, and teachers; careful medication management; and cognitive and behavioral training.     

The effects of neurocognitive remediation on executive processing in patients with schizophrenia.

Approaches to cognitive remediation have differed across studies. Most of the larger studies have concentrated on group treatments designed without the benefit of recent laboratory-based studies. The current study describes a randomized trial of an intensive cognitive remediation program involving individual daily sessions of 1 hour for up to 3 months. It targets executive functioning deficits (cognitive flexibility, working memory, and planning) that are known to be problematic in people with schizophrenia. Procedural learning, as well as the principles of errorless learning, targeted reinforcement, and massed practice, was the basis of the intervention. The program was compared with an alternative therapy (intensive occupational therapy) to control for some of the effects of therapeutic contact. Some improvements in cognition followed both therapies. A differential effect in favor of cognitive remediation therapy was found for tests in the cognitive flexibility and the memory subgroups. There was a trend for those receiving atypical antipsychotic medication to benefit more from cognitive remediation for tests of cognitive flexibility. Although there were no consistent changes in symptoms or social functioning between groups, if improvement in cognitive flexibility tasks reached a threshold then there is some evidence that social functioning improved, even over the short duration of the trial. In addition, cognitive remediation differentially improved self-esteem. This study supports the view that cognitive remediation can reduce cognitive deficits and that this reduction may affect social outcome, at least in the short term.