Caveats for psychiatric rehabilitation

Psychiatric rehabilitation has come of age, as Rössler has amply illustrated in his fine overview of the current status of the field. However, as with any new treatment approach, broad, summary statements may fail to capture the considerable individual variation in response to psychiatric rehabilitation. Rössler suggests that evidence-based practices are indicated for all persons needing psychiatric rehabilitation. This is a misconception popularized by wholesale acceptance of research findings as though they would meet the needs of all patients regardless of their individual attributes. By their very definition, evidence-based practices are validated by large-scale studies in which means, standard deviations and statistical tests of mean differences between treatment conditions obscure differences between individuals that have profound implications for choice of treatment. Decisions about the type and amount of treatment must be made for each individual, considering their uniqueness, responses to prior treatments and phase of their illness. "One suit does not fit all". Evidence-based treatments should be carefully selected and adapted for each individual.

For example, assertive community treatment - one of the most popular evidence- based practices - is helpful to individuals who are high utilizers of hospital care and who are reluctant to voluntarily attend a mental health center or clinic. However, for the thousands of patients who have successfully reached a stable phase of their disorder, assertive community treatment is likely to be viewed as unnecessary, intrusive and not desirable. If rehabilitation practices such as social skills training and behavioral family therapy are used, patients are more self-directed and do very well with much less intensive forms of continuing treatment.

Contrary to Rössler's imperative regarding rehabilitation, not "all patients suffering from severe mental illness require rehabilitation". Again, we must assess each patient as an individual to make sure that the rehabilitation prescription is congruent with the person's history, severity and phase of illness, assets, deficits and aspirations. Individuals who have had a good premorbid adjustment, do not have concurrent substance abuse, serious negative symptoms or cognitive impairments and possess effective social skills can recover from schizophrenia and bipolar disorders without comprehensive and intensive rehabilitation once their intrusive symptoms are removed by appropriate medication (1).

In these cases, treatment can be streamlined to periodic medication reviews with a psychiatrist and supportive therapy to assist patients to realize their personal goals. Other basic elements that can be readily accomplished in league with pharmacological stabilization of symptoms are three-six months of education of the patient and family about benefits and side effects of medication, self-directed use of medication, negotiation of medication issues with the psychiatrist, recognition of warning signs of relapse and development of a relapse prevention and emergency plan. The knowledge and skills for illness management can be taught in three-six months, with refresher sessions as needed, using the Medication and Symptom Management Modules, components of the UCLA Program for Social and Independent Living Skills (2,3). In short, individualization of assessment and treatment is essential for determining each patient's personal goals, need for skills training, family intervention, vocational rehabilitation and community re-integration (4).

This brings us to Rössler's statement that "rehabilitation planning focuses on the patient's strengths, irrespective of the degree of psychopathology". In line with clinical realities, rehabilitation must begin concurrently with pharmacological efforts to remove symptoms and deviant behaviors that interfere with learning skills and living in normal community settings. There should be no distinction made between "treatment" and "rehabilitation". Surveys have documented that patients report persisting symptoms as their highest priority for treatment. Separating the rehabilitation from the treatment function is both fatuous and harmful. Rehabilitative interventions, such as motivational interviewing and family communication, can be used to engage the patient with psychotic symptoms to accept medication (1,2).

Another rehabilitation intervention during the acute and stabilizing phases of a serious mental disorder is the Community Re-Entry Module. This educational and skill building program is useful for establishing continuity of care from inpatient to outpatient phases. The program teaches patients in hospitals and day treatment programs illness management skills as well as how to reengage in community life, deal with the stressors of life after discharge and make connections with long-term, outpatient treatment (5). Pharmacotherapy and psychosocial rehabilitation are inseparable. They are two sides of the same coin (6).

As pointed out by Rössler, the Individual Support and Placement (IPS) method of supported employment is the best evidence-based service for vocational rehabilitation for the seriously mentally ill. However, it has distinct limitations that practitioners and patients must understand to avoid unrealistic expectations in planning for competitive work. Less than 50% of the seriously mentally ill elect to participate in IPS. Consistent with individualization of treatment and rehabilitation, there are other options for the non-participants, including transitional employment (1,2) and psychosocial rehabilitation offered in the context of day treatment centers (7).

While cumulatively 40-55% of mentally ill persons enrolled in IPS who express a strong interest in working obtain jobs, over 50% of them are no longer working by six months after placement. In fact, research indicates that only 10- 40% who participate in IPS are working in competitive jobs at any one time during a year after beginning the program (8). Moreover, only about 25% of the patients in supported employment studies suffer from schizophrenia; the remainder have bipolar disorder, depressive disorders or personality disorders. Over an 18-month period, patients enrolled in supported employment showed no significant increase in selfesteem, mood or quality of life (9). A new skills training program, the Workplace Fundamentals Module, when combined with IPS, has yielded longer tenure for patients working in competitive jobs (10).

Rössler's overview of the current status of psychiatric rehabilitation is comprehensive and clearly and cogently written. It should be disseminated widely to mental health professionals, the vast proportion of whom have little or no understanding of rehabilitation. However, a section on illness management (11), now considered an evidence- based practice for rehabilitation, should be ideally added. Psychiatrists must realize they have an important role to play in rehabilitation. Medication can never teach patients anything, including why and how to properly use medication. Without having the benefit of a motivating, educational, skillsbased and family oriented therapeutic relationship, psychiatrists will continue to prescribe medications with attrition and non-adherence rates becoming the norm rather than the exception (12).