Psychological and social interventions for schizophrenia

Over the past two decades few disorders have been subject to such big changes in management as schizophrenia. Yet these have gone unnoticed by the general medical and popular press—possibly because these changes have not arisen from breakthroughs in research on genetics, receptors, anatomy, or neuropharmacology.

The new generation of antipsychotic drugs has not fulfilled its promise of substantially increased effectiveness or even of much better tolerability.¹ In this week's BMJ Tiihonen and colleagues show that, in practice, some older drugs such as perphenazine are as efficacious as the newer ones.² This follows the findings of the National Institute of Mental Health clinical antipsychotic trials of intervention effectiveness (CATIE) study that 74% of patients with established symptoms of schizophrenia discontinued their medication within 18 months and there was no overall difference in effect between perphenazine and the newer atypical drugs.¹,³ When patients can accept and tolerate clozapine, this does seem to have some benefit over other drugs but still has substantial side effects.¹

In contrast, psychosocial research has started to pay dividends in schizophrenia and is leading to big changes in service delivery. There is now evidence to support psychological targets for interventions, for instance experiences of childhood mental and physical trauma,⁴ oversensitivity to everyday stresses,⁵ and use of hallucinogenic drugs,⁶ along with a range of other psychological and social factors.⁷ Working with families to improve coping and reduce high expressed emotion is already well established as a means to reduce relapse rates in schizophrenia.⁸ More than 20 randomised controlled trials and five meta-analyses have shown cognitive behaviour therapy to be beneficial in schizophrenia, reducing both positive and negative symptoms during therapy and beyond.⁹ This evidence warrants an about-turn in the approach to symptoms: cognitive therapy focused on the content of psychotic symptoms should now be replacing purely supportive therapy that avoids such discussion.

But, despite the inclusion of psychosocial and cognitive therapies in clinical practice guidelines, such as those produced by the National Institute for Health and Clinical Excellence (NICE) in England, there remain considerable problems with implementing these new treatments. Even where therapies and services are available, only a minority of patients and families have access to them.¹⁰

The original research into family therapy in schizophrenia comprised pairs of workers meeting family members for 10 or more sessions,³ a commitment that few services can make. Simpler, briefer interventions with families combined with cognitive therapy with individual patients have produced positive results and may, at least in the first instance, be the way forward.¹¹

Training schemes to expand the number of therapists are undersubscribed owing to the current severe restrictions on NHS funding. Once trained, therapists need continuing supervision and support but this is often not available because caseloads are too big and therapists' managers do not give this work sufficient priority.¹⁰ NICE guidelines recommend that all patients with schizophrenia should be referred for cognitive therapy but, again, this does not happen. Reasons for failing to refer include concern that the person with schizophrenia will not engage with therapy or is too well.¹⁰ But rates of engagement with cognitive therapy and family work have been high—up to 90%—both in research studies and in clinical practice. Furthermore, patients who are stable or are not complaining about their symptoms may yield other benefits from cognitive therapy including social recovery and relapse prevention.⁹

Social change has also played a part in revolutionising services for people with schizophrenia. The programme to close mental hospitals is near completion in the United Kingdom. Treatment at home enables patients to avoid admission to acute mental health wards and allows early discharge of inpatients. Early intervention teams are now at work in many areas of the United Kingdom. In the prodromal period of schizophrenia, cognitive therapy may reduce the risk of developing psychosis.⁹ (Such risk reduction has not been shown with psychotropic treatment,¹² although it is widely used in this context.) Supported employment schemes can help many people with schizophrenia make the transition to work, improving their social life, finances, and self esteem.¹³

Overall, mental health professionals view schizophrenia much more hopefully than in the past, giving stronger emphasis to social inclusion and recovery. This is warranted, given that long term studies now show that, for more than 50% of patients, schizophrenia is not a chronic and continuous illness.¹⁴ Stigmatisation remains substantial, however, not least because of negative publicity in the media. The term schizophrenia is unpopular with patients and carers—and alternative names for the “group of schizophrenias,” as Bleuler originally described them in 1911, have been proposed, based on psychosocial concepts, such as sensitivity and drug related or traumatic psychoses.¹⁵