Effective Psychosocial Interventions For Schizophrenia

Effective Psychosocial Interventions For Schizophrenia • Evidence Based Dr. Mahmoud Awara MRCPsych, MSc, DPM, DPP, MS (Internal Medicine)

Schizophrenia is at once a biological disease, a neuropsychological disorder and a dysfunction of social interactions (Murray 1996). • Therefore we need a comprehensive care involving a combination of pharmacological treatments, the provision of ongoing support, valid information and rehabilitative strategies.

Nature Of The Evidence • The evidence contained in this presentation is based on systematic reviews of RCTs carried out by the Cochrane Schizophrenia Group. • These reviews have been acknowledged in the recent National Service Framework for Mental Health (NSF) as important sources of information for clinical decision making.

Supportive Educational Interventions • 1- Individual Psychoeducational Interventions • 2- Family Intervention

Individual Psychoeducational Interventions • People with schizophrenia should expect support and have the right to be informed about their illness. • Individual psychoeducational interventions address the illness from the familial, social, biological and pharmacological perspectives.

Outcome • Nearly 800 people have participated in relevant RCTs and the evidence suggests, that after a year, this programme can decrease the risk of relapse. • Although the mechanism is unclear, (NNT 9, 95% CI 6-22). (Pekkala E, 2000). • Also this intervention increases adherence with medication.

Family Intervention • This intervention mainly involves a combination of education on schizophrenia and training in problem solving in order to:- • 1- reduce the emotional stress and burden on relatives. • 2- enhance the relatives abilities to anticipate and solve problems. • 3- reduce expressions of anger & guilt by the family.

Outcome • Over 700 people participated in RCTs of family intervention. • Interaction with the family of people with schizophrenia, does decrease the risk of relapse at one year (NNT 6.5, 95% CI 4-14). (Fuller Torrey E 1995). • Also it would lower the family burden.

Skills Training • 1- Life Skills. • 2 - Social Skills. • 3 - Vocational Skills

Life Skills • This programme could include group or individual training in managing money, organizing and running a home, domestic skills and personal self care. • It is distinct from, but often paired with social skills training.(Nicol M, 2000). • It may be undertaken by health care professional such as nurses or OTs.

Social Skills • It is a strategy aimed at enhancing social performance & reducing distress and difficulty experienced by people with schizophrenia.(Pilling S, 2000). • The goal is to build up individual behavioural elements into complex behaviours and thus develop more effective social communication. Using modelling, role-play and social reinforcement.

Outcome • Only about 300 people have participated in RCTs. • There are no effects demonstrated within RCTs on the value of social skills training for prevention of relapse. • Other outcomes such as change in social skills were too poorly reported to be informative.

Vocational Skills • 1- Pre-vocational training in which the person is supported in some form of sheltered work before entering real-world employment. (Crowther R, 2000). • 2- Supported employment attempts to help people in real-world employment. • A Cochrane review is nearing completion .

Problems/ Symptoms focused therapies • 1- Cognitive Behavioural therapy (CBT). • 2- Cognitive Rehabilitation. • 3- Psychodynamic/analytic therapy. • 4- Token economy.

Cognitive behavioural therapy • In CBT, links are made between the person’s feelings and the patterns of thinking which underpin their distress. • The patient is encouraged to take an active part by examining the evidence for and against the distressing belief, challenging it, and using reasoning abilities and personal experience to develop rational & personally acceptable alternatives.(Jones C, 2000).

Outcome • Over 400 people have entered trials of CBT. • Both short and medium term data suggest that CBT may decrease relapse/readmission. • CBT significantly reduced overall psychopathology when compared to supportive counselling plus befriending. • The NSF has highlighted the growing evidence of effectiveness of CBT, but it is difficult to generalize it to our daily practice

Cognitive rehabilitation • The perceived impact of cognitive impairment on people with schizophrenia has led to the development of cognitive rehabilitation techniques. • These involve retraining of basic-level processes such as memory, attention, speed of processing and abstraction levels in the hope of improving the functioning of people with schizophrenia.(Hayes R 2000).

Outcome • Studies were small (total n=117). • The use of different scales makes interpretation difficult. • Current RCTs don’t suggest any clinically relevant effect. • No difference detected in attention and memory between cognitive rehabilitation and the controls.

Psychodynamic/analytic therapy • Dynamic and analytic therapies have not been subject to evaluation in large scale RCTs.(Malmberg I, 2000). • Despite this, the evidence suggests that, when compared to the use of medication, psycho-dynamic therapy dose not help people recover enough to leave hospital (NNH 3, 95%CI 2-6).

Token economy • Is a behavioural therapy in which the desired change is achieved by means of tokens administered for the performance of pre-defined behaviours according to a programme.(McMinagle T, 2000). • It is disappointing that it is evaluated in studies with poorly reported outcomes on a total of just over 100 people.

Token economy • However, this technique is the only non-pharmacological therapy that measures, and shows, statistically significant improvement in negative symptoms of schizophrenia. • It may be possible to generate hypotheses that can be tested in well planned RCTs of token economy programmes.

Service Provision • As psychiatric services face increasing pressure on inpatient beds, they have been reconfigured into two types in order to reduce admissions. • 1st, there are packages of care designed to divert patients about to be admitted to hospital. • 2nd, interventions designed to reduce admissions for people at high risk of re-admission.

Service Provision • 1- Assertive community Treatment (ACT). • 2- Community Mental Health Team (CMHT). • 3- Home Based Care and Initial Crisis Intervention. • 4- Acute Day Hospital Care. • 5- Non health service based day care. • 6- Case Management. 7-Planned short admissions (>28 days).

Assertive Community Treatment • With ACT, patients are diverted to the care of a community-based, multidisciplinary team.(McGrew J, 1995). • The team carries small case loads and sees patients frequently in their own homes, with 24 hour cover. • Such teams care for the full range of acutely ill patients & those who are suicidal, potentially violent and difficult to engage.

Assertive Community Treatment • 2647 people have been randomized into trials of ACT, most of which were undertaken in USA where the “standard care” control may not reflect that in UK. • People receiving ACT were more likely to remain in contact with services and less likely to be admitted to hospital than those in standard care.(Marshall M, 2000). • Time spent in hospital was reduced by 50%.

Community mental health teams • CMHTs provide the core of local specialised mental health services. • Usually teams comprise several disciplines, including nurses occupational therapists, psychiatrists, psychologists and social workers.(Bennett D, 1991). • CMHTs work to provide care less focused on a hospital or institution setting.

Outcome • CMHT management causes less people to be dissatisfied with their care (NNT 4, 95% CI 3-8). • No clear difference was found in admission rates, overall clinical outcomes and duration of in-patient hospital treatment.

Home based care and initial crisis intervention • Psychiatric services in Amsterdam were at the forefront of such treatment introducing a 24-hour first-aid emergency home service. • There are two types of crisis care. One diverts people from admission to hospital, whilst the other is a home based response to a psychiatric emergency.

Outcome • Over 400 people participated in RCTs of crisis interventions.(Weisman G 1989). • Compared to the standard hospital admission for crisis, those allocated to crisis intervention were at no less risk of repeated admissions. They were, however, less likely to be lost to follow up at a year and family burden was perceived as less in crisis intervention group.

Acute day hospital care • Patients are admitted to a highly staffed, acute day hospital, from which they may return home at night. • Care is provided for the full range of acutely ill patients, but those who are suicidal or potentially violent were usually excluded.

Outcome • Three studies (one in the USA, two in the UK) examined diversion of 486 participants about to be admitted.(Sledge W, 1996). • Two of these trials reported that the proportion of people who could be diverted was 28% & 18% and two reported that the impact on the use of inpatient care was reduced by 12% & 66%.

Non health service based day care • There are a number of RCTs on crisis houses which have shown that they act as alternatives to admission, but these have not yet been evaluated.

Case Management • Is a means of coordinating services in the community.(Holloway F,1991). • Each mentally ill person is assigned to a case manager who is expected to assess needs, develop a care plan, arrange provision of suitable care, monitor quality of care and maintain contact with the person.

Case Management • Case management aims to keep people in contact with the service, reduce the frequency and duration of hospital admissions and improve outcome, especially that of social functioning and quality of life. (Rossler W, 2000).

Outcome • 1751 people entered RCTs. Case managements were moderately effective at increasing the numbers remaining in contact with services.(Marshall M, 2000). • Case management considerably increases admission rates and time spent in hospitals by more than 50%, without any evidence of benefit to mental state or quality of life.

Planned short admission (> 28 days) • When people had to be admitted to hospital they were allocated to a group who had, from the start, active plans made for discharge by about four weeks, or a group that received standard care without active planning.

Outcome • The former group were at no risk of admission within one year and were less at risk of staying beyond their predicted time of discharge. (Johnstone P, 2000).

Implications for practice and research • 1- Comprehensive care for schizophrenia involves not only drug treatments but also the provision of ongoing support, valid information, available therapies and rehabilitative strategies. • 2- There are consistent data to suggest that individual psychoeducational intervention & family intervention can decrease the risk of relapse.

Implications for practice and research • 3- Evidence suggests that CBT may decrease relapse/readmission rates and may improve the patient’s mental state, at least in the short term. • 4- ACT is an effective way of caring for people with severe mental illness in the community. ACT reduces hospital admissions and time spent in hospital by nearly 50%.

Implications for practice and research • 5- The CPA/ Case management may help health and social services keep contact with people, and may have useful administrative functions, but ACT is required to keep severely mentally ill people out of hospital.

Implications for practice and research • 6- The whole area of non-pharmacological treatments for people with schizophrenia is under researched. Well-designed, conducted & reported trials are rare. • 7- Further systematic reviews of non-pharmacological interventions and maintenance of those that exist should be a priority for funders and researchers.

Thank You Mahmoud Awara

Effective Psychosocial Interventions For Schizophrenia