December 18, 2006

Is Psychological Therapy Effective for Schizophrenia?

An overview of the following journal article: (2006) Efficacy of psychological therapy in schizophrenia: conclusions from meta-analyses. Schizophrenia Bulletin.

What is Meta-Analysis
Meta-analysis is a statistical procedure that combines findings from independent studies. Because meta-analysis assigns different weights to studies depending on their size, it can provide accurate estimates of overall treatment effect. It is often difficult to draw practical conclusions from small-or medium-scale clinical trials. By integrating results in a systematic and impartial way, more coherent results are often evident.

Why is this review of interest?
Because of challenges associated with clinical research of psychological interventions (i.e., funding, subject recruitment, etc.), small- or medium-scale studies of psychological therapy for schizophrenia are common. These are attractive candidates for meta-analyses. Since 1990, twenty-one meta-analyses have synopsized the effectiveness of psychological therapies for schizophrenia. The current authors summarize the findings from these meta-analyses and identify uniform conclusions about the effects of psychological therapy for schizophrenia.

Furthermore, most of the published meta-analyses fail to distinguish between different types of psychological interventions. One meta-analysis by Pilling et al.1 compared different types, however it included a limited number of randomized controlled trials. The authors of this paper supplement their meta-analytic review with results from their own meta-analysis of randomized controlled trials on the efficacy of psychological therapies in schizophrenia. Although the authors include these results, their meta-analysis has not yet been published.

Who are the authors?
The authors are researchers in Switzerland and Chile interested in the efficacy of psychological therapy for schizophrenia.

How did the authors design the study?
First, the authors identified relevant meta-analyses and randomized clinical trails by searching databases of published literature (e.g., PsycINFO, MEDLINE, the Cochrane Schizophrenia Group’s Register of Trails, PSYNDEX).

For their review of published meta-analyses, they identified twenty-one which assessed the efficacy of psychological therapy for schizophrenia. For their own meta-analysis, they included 108 randomized controlled trials, published in peer-reviewed journals, which measured the utility of a specific psychological treatment compared with treatment-as-usual or another psychosocial treatment.
After considering published meta-analyses as well as the published trials which they chose for their own meta-analysis, the authors determined four discrete categories of psychological treatment for schizophrenia. They are training of social skills, cognitive remediation, psychoeducational interventions with families, and cognitive behavioral therapy of positive symptoms (i.e., delusions and hallucinations).

What did they find?
The authors presented results by type of psychological treatment:

1. Social Skills Training
Three previous meta-analyses have evaluated the efficacy of social skills training in schizophrenia. In general, these demonstrate that patients effectively procure skills and assertiveness, but patients’ psychopathology and hospitalization rates remain unchanged. The authors report that their own meta-analysis shows diffuse procurement of social skills, short-term improvement in assertiveness, stable improvement in social functioning, and robust decreases in hospitalization rates.

2. Cognitive Remediation
Cognitive remediation involves task-building in areas such as processing speed, attention, working memory, verbal learning, and social cognition. Six published meta-analyses have studied the efficacy of cognitive remediation in schizophrenia. Included in these meta-analyses are reports of cognitive subprograms of various structured treatments for schizophrenia, including Integrated Psychological Therapy (IPT), Cognitive Remediation Therapy (CRT), Neuropsychological Educational Approach to Rehabilitation (NEAR), Cognitive Enhancement Therapy (CET), and Cognitive Adaptation Training (CAT).

Results from these meta-analyses are inconsistent. Some show improvements in attention tasks, while others show small effects on general cognitive and social functioning. The authors’ meta-analysis shows small effects on attention, executive functioning, memory, and social cognition.

3. Psychoeducational Family Interventions
During the past three decades, family interventions for schizophrenia have been studied more than any other type of psychological intervention. Three existing meta-analyses show that schizophrenic patients with relatives participating in psychoeducational family interventions are hospitalized and relapse less frequently.
The authors, in their own meta-analysis, conclude that psychoeducational family interventions effectively educate families about schizophrenia. Furthermore, patients are often better socially adjusted, are outpatients, and have less psychopathology.

4. Cognitive Behavioral Therapy of Positive Symptoms

Delusions and hallucinations are positive symptoms in schizophrenia. Cognitive behavioral therapy for psychosis addresses the frequency, intensity, and duration of symptoms in addition to triggering events. The existing meta-analyses show that cognitive behavioral therapy is very effective for severe positive symptoms.
The authors’ own meta-analysis showed similar results for persistent positive symptoms.

The take-home message
Generally, psychological interventions for schizophrenia are effective. Sound evidence suggests that they should be an integral part of routine care for schizophrenia. The present study attempted to look at differences in efficacy among four modes of psychological intervention—social skills training, cognitive remediation, psychoeducational family interventions, and cognitive behavioral therapy of positive symptoms. The authors found that all interventions were moderately effective; however, they failed to make clear distinctions among the four with regard to specific therapeutic components. They were unable to answer important questions such as what treatment works for whom, in what setting, with what pharmacotherapy regimen, etc.?

These questions remain unanswered. Frequently healthcare settings for schizophrenic patients point to these gaps in knowledge as justifiable reasons why psychological intervention is not systematically part of routine care despite robust evidence supporting their positive role for treatment of schizophrenia. The scientific community must fill this substantial gap with lines of research focusing on specificity of psychological interventions.

Posted by szadmin at December 18, 2006 08:10 PM

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