TUCSON – The latest National Institute of Mental Health–supported Schizophrenia Patient Outcomes Research Team report on the state of psychosocial interventions for schizophrenia has come under fire for what some experts see as short shrift given to several novel nonpharmacologic treatments that they view as firmly evidence based and ready for use in clinical practice.
The most recent Patient Outcomes Research Team (PORT) report, the third in a series that began in the late 1990s, recommended eight psychosocial interventions as being solidly evidence based. Most – including assertive community treatment, skills training, supported employment, family-based services, cognitive-behavioral therapy, and substance abuse treatment – have been around for decades.
Nicholas J.K. Breitborde, Ph.D.
More controversially, the PORT panel also issued summary statements regarding four newer psychosocial treatments that they deemed promising but not yet sufficiently mature: cognitive remediation exercises, interventions for recent-onset psychosis, medication adherence programs, and peer support and peer-delivered services.
None of these treatment areas yet has enough evidence to merit a treatment recommendation, although "each is an emerging area of interest," according to the PORT group (Schizophr. Bull. 2010;36:48-70).
Nicholas J. K. Breitborde, Ph.D., director of the early psychosis intervention center at the University of Arizona, Tucson, begs to differ. "The PORT recommendations provide valuable guidelines with regard to psychosocial interventions. However, my personal opinion is that the report group took an overly conservative stance on two of those treatments. I would argue that cognitive remediation and interventions for recent-onset psychosis are clearly beneficial, evidence-based treatments for schizophrenia," he asserted at the annual psychopharmacology review sponsored by the University of Arizona.
Cognitive Remediation
Cognitive remediation consists of a series of exercises that are designed to improve the cognitive defects associated with schizophrenia, including functional deficits in memory, attention, and problem solving. A meta-analysis of 26 randomized, controlled trials involving 1,151 patients has demonstrated that these exercises not only resulted in significant improvements in those areas, but in social functioning as well. Moreover, participants in cognitive remediation experienced fewer positive symptoms of schizophrenia than they did with antipsychotic medications alone (Am. J. Psychiatry 2007;164:1791-802).
"Cognitive remediation has a dramatic effect on cognitive ability. These interventions produce better results across the board on every single one of the cognitive deficits associated with schizophrenia," according to Dr. Breitborde.
Findings from brain-imaging studies that were performed before and after cognitive remediation are particularly exciting, he continued. The first studies showed that cognitive remediation exercises led to reactivation of brain structures that are concerned with executive function and that are generally dormant in individuals with schizophrenia.
More recently, MRI studies by investigators at the University of Pittsburgh demonstrated protection of gray matter in areas of the brain affected by schizophrenia among participants in a program that combined cognitive remediation exercises with group therapy designed to improve the ability to interact in social activities (Arch. Gen. Psychiatry 2010;67:674-82).
"We’re actually saving gray matter in the brain by participating in these cognitive interventions," Dr. Breitborde said.
Recent-Onset Psychosis Interventions
It’s well established that the vast majority of functional deterioration and symptomatic worsening in schizophrenia occurs within the first several years after onset of psychosis. But this is also the period when patients are most responsive to treatment, both pharmacologic and psychosocial, Dr. Breitborde observed.
In the OPUS study – the largest-ever randomized, controlled trial of intensive psychosocial interventions for recent-onset psychosis – Danish investigators assigned schizophrenia patients to either usual care (defined as medication and case management) or 2 years of intensive psychosocial therapy (including assertive community treatment, social skills training, and family psychoeducation). At the 2-year mark, when everyone returned to usual care, the intensive psychosocial intervention group had significantly lower levels of both positive and negative symptoms than did the controls. At 5 years, or 3 years after the psychosocial therapy ended, participants in that study arm remained 2.3-fold more likely to be living independently (Arch. Gen. Psychiatry 2008;65:762-71).
"A lot of the skills we can teach folks with schizophrenia in these psychosocial interventions, they don’t forget them. They continue to apply them in their lives, and while they may still struggle with symptoms, they’re nonetheless better able to navigate outcomes that are important to their recovery, like independent living," he continued.
Three separate meta-analyses have demonstrated that the longer the interval between onset of a first episode of frank psychosis and initiation of adequately dosed antipsychotic medication, the worse the initial course of illness. The same has been shown to be true for intensive psychosocial treatment in a Dutch study: The longer the delay to the start of intensive psychosocial therapy, the more negative symptoms were present at 6 years of follow-up – and the more time patients had spent in psychiatric hospitalization. The investigators concluded that delay in intensive psychosocial treatment may be a more important long-term predictor of negative symptoms than is delay in starting antipsychotic medication alone (Schizophr. Bull. 2003;29:341-8).