Effective Psychosocial Interventions For Schizophrenia

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Effective Psychosocial Interventions For
Schizophrenia

• Evidence Based
• Dr. Mahmoud Awara
• MRCPsych, MSc, DPM, DPP, MS (Internal Medicine)

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• 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.

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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.

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Supportive Educational Interventions

• 1- Individual Psychoeducational Interventions
• 2- Family Intervention

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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.

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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.

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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.

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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.

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Skills Training

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

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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.

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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.

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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.

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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 .

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Problems/ Symptoms focused therapies

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

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Cognitive behavioural therapy

• In CBT, links are made between the persons
  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).

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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

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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.(Haye
  s R 2000).

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Outcome

• Studies were small (total n117).
• The use of different scales makes interpretation
  difficult.
• Current RCTs dont suggest any clinically
  relevant effect.
• No difference detected in attention and memory
  between cognitive rehabilitation and the
  controls.

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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, 95CI 2-6).

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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.

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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.

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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.

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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
  (gt28 days).

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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).

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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.

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Planned short admission (gt 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.

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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).

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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.

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Implications for practice and research

• 3- Evidence suggests that CBT may decrease
  relapse/readmission rates and may improve the
  patients 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.

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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.

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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.

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Thank You
Mahmoud Awara