Psychosocial treatments are underutilized in the treatment of
schizophrenia, despite proven efficacy when used in combination with
antipsychotic medication, said Anthony F. Lehman, M.D., M.S.P.H., in a
presentation at APA's 57th Institute on Psychiatric Services last month in San
Psychological and family interventions, assertive community treatment
(ACT), and supported employment strategies have been found to be highly
effective in the treatment of schizophrenia and are recommended in APA's
Anthony F. Lehman, M.D., M.S.P.H., receives the American Psychiatric
Foundation's Alexander Gralnick, M.D., Award for Research in Schizophrenia at
the IPS from Jacqueline Feldman, M.D.
Yet because of reimbursement and funding issues, or because of lack of
training in psychosocial interventions on the part of mental health
professionals, treatment of schizophrenia is often confined to pharmacotherapy
"All evidence-based psychosocial treatments for persons with
schizophrenia are recommended within the context of appropriate
pharmacotherapy," Lehman said at the institute. "Pharmacotherapy
plus psychosocial interventions are generally more effective than
pharmacotherapy alone, but there is a gap between what science tells us to do
and what we do in actual practice.
"Most patients are offered some form of counseling, but the nature of
the treatment is often ill defined. And typically the work-force is not
adequately trained in evidence-based approaches."
Lehman is professor and chair of the department of psychiatry at the
University of Maryland School of Medicine. And he was principal investigator
for the Schizophrenia Patient Outcome Research Team, which originally released
treatment recommendations, as well as a report on how patterns of usual care
conformed to those recommendations, in 1998.
At the institute, he drew on those findings and some more recent research
in an overview of psychosocial treatment including psychological
interventions, family interventions, ACT, and supported employment.
Lehman noted that early research on psychotherapy of schizophrenia was
grounded in psychoanalytic theories that have since been discounted as causal
explanations for schizophrenia. But today, cognitive-behavioral therapy (CBT),
social-skills training, and cognitive remediation—manualized strategies
that have sometimes been referred to as "training the
brain"—have a proven track record of efficacy.
Lehman said CBT appears to be most effective among outpatients with
residual symptoms for reducing beliefs in delusions, distress associated with
delusions, and overall level of symptoms. It may reduce depression and
negative symptoms, but does not appear to reduce the likelihood of
Predictors of success with CBT include whether the patients have some level
of "cognitive flexibility" regarding delusions—that is, the
ability to question the validity of delusional thoughts—and insight
about the condition.
Similarly, social-skills training does not appear to be substantially
effective for symptom reduction or relapse prevention, but does have a
reliable and significant effect on specific behavioral skills, with a positive
impact on defined areas of functioning, Lehman said. And it has a positive
effect on patient satisfaction and self-efficacy, he said.
A principal obstacle plaguing the use of social-skills training is the lack
of generalizability from the laboratory to the community; patients may
reliably learn the skills during training but fail to use them when they are
on their own.
Cognitive remediation (CR) is a third psychological intervention that
focuses on "thinking" skills, especially those cognitive abilities
affected by the disease. Targets of CR have included verbal memory, problem
solving and executive function, attention, social perception, and work
CR generally involves five weeks to six months of training on self-guided
computer tasks using commercially produced educational software, and intensive
individual training using paper and pencil neurocognitive test materials.
Lehman presented evidence from studies showing that combining medication
with family education substantially reduces the risk of relapse. Key elements
of family education are duration of at least nine months, illness education,
crisis intervention, emotional support, and training in how to cope with
Finally, he presented data from 25 studies over the years comparing ACT
with "usual care." On measures of time spent in hospital, housing
stability, quality of life, and patient satisfaction, the number of studies
that found ACT superior to usual care was greater by a wide margin than those
that found no difference. However, on measures of symptom severity, social
functioning, vocational functioning, and number of times people were arrested
and jailed, the number of studies (among the 25) that found no difference
between ACT and usual care was greater than the number that found any
difference—but the margin was small, and on all of those measures there
were some studies that found an advantage for ACT.
Pioneered by Leonard Stein, M.D., and Mary Ann Test, Ph.D., ACT employs a
multidisciplinary team, including a psychiatrist, to provide services in the
community. The strategy relies on a high frequency of patient contact and a
focus on the most high-risk patients.
Success is dependent on a high degree of fidelity to the principles of ACT,
funding arrangements, and the ability to step patients down to less-intensive
treatment, Lehman said. ▪