By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at cpnews@elsevier.com
Psychiatric rehabilitation is an important but often overlooked component of managing–and sometimes preventing–prodromal schizophrenia symptoms.
However, symptom control and relapse prevention should not be confused with recovery. Studies have shown that, even with optimal drug therapy and remission of symptoms, functional recovery in early psychosis is poor.
For example, in a 2004 study involving 118 patients in their first episode of schizophrenia or schizoaffective disorder who were treated based on a standard medication algorithm, about 47% achieved remission of symptoms after 5 years, but less than 14% met full recovery criteria–defined as symptom remission and adequate social/vocational functioning–for 2 years or longer (Am. J. Psychiatry 2004;161:473-9).
Similar results were observed in the McLean-Harvard First Episode Project, which recruited 257 patients with affective and nonaffective psychosis at their first lifetime psychiatric hospitalization, conducted baseline and 6-month follow-up evaluations, and assessed syndromal and functional status at follow-up.
Recovery outcomes were syndromal status, defined as the absence of DSM-IV criteria for a current episode, and functional status, as measured by vocational and residential functioning. Although syndromal recovery was achieved by nearly half of patients within 3 months of hospitalization, functional recovery was not achieved by 6 months in nearly two-thirds of patients who had attained syndromal recovery, according to the authors (Biol. Psychiatry 2000;48:467-76).
The available literature overwhelmingly suggests that a pure symptomatic remission does not predict functional recovery, and that failing to pay due attention to social and occupational considerations in early psychosis can contribute to a worse long-term prognosis.
“A remission is a necessity but not a sufficient prerequisite for recovery,” according to Dr. Georg Juckel of Ruhr University Bochum (Germany) and Dr. Pier Luigi Morosini of the Italian National Institute of Health in Rome, who stressed in a recent review article that psychosocial functioning should be the treatment outcome criterion in schizophrenia.
“The improvement of symptoms is not sufficient to reach this difficult treatment goal. The deciding factor is how well the patient is able to fulfill private and professional requirements. Ideally, the treatment has to improve the social functioning in such a way that the patient is able to achieve reintegration and a major improvement in the quality of life” (Curr. Opin. Psychiatry 2008; 21:630-9).
Toward this end, psychiatric rehabilitation, in addition to medication, should be a major player in the field of schizophrenia management. By definition, psychiatric rehabilitation in schizophrenia involves the use of psychosocial interventions to minimize symptoms and the possibility of relapse while maximizing social and vocational functioning.
Without the inclusion of psychiatric rehabilitation interventions, according to William Anthony, Ph.D., of the Center for Psychiatric Rehabilitation at Boston University, “people who are at risk of developing long-term, severe mental illnesses will not receive the critical help they need to remain in, resume, or improve their living, learning, working, and social roles.”
In a recent editorial, Dr. Anthony advocated for “the integration of contributions of psychiatric rehabilitation into current research and practice in the area of severe mental illness,” stressing that “we should not have to learn over again in the field of prevention what has taken us so long to learn in the treatment field–that medications and therapies designed to ameliorate symptoms do not routinely or singularly help people achieve their residential, educational, vocational, or social goals” (Psychiatr. Serv. 2009;60:3).
A 2008 initiative from the National Institute of Mental Health (NIMH) provides a step in this direction. Recovery After an Initial Schizophrenic Episode (RAISE) seeks to “fundamentally change the trajectory and prognosis of schizophrenia through coordinated and aggressive treatment in the earliest stages of illness,” said Dr. John K. Hsiao of the organization's division of services and interventions research. The specific aims of the initiative include these:
▸ The development of a comprehensive, integrated treatment intervention for promoting symptom recovery, minimizing disability, and maximizing social, academic, and vocational functioning.
▸ The evaluation of the intervention's feasibility and practical implementation in the community.
▸ The assessment of the intervention's overall clinical impact and cost-effectiveness relative to current treatment standards.
Since antipsychotic drugs “are not able to restore skills and abilities lost to the illness,” said Dr. Hsiao, “the important unanswered question is whether function could be preserved and disability forestalled after an initial schizophrenic episode by intense and sustained pharmacological, psychosocial, and rehabilitative intervention.”
Preliminary findings from a study by Evan J. Waldheter and colleagues at the University of North Carolina at Chapel Hill suggest the answer to that question might be yes. The investigators have developed a manualized, comprehensive cognitive-behavioral therapy program for people recovering from an initial episode of nonaffective psychosis called the Graduated Recovery Intervention Program (GRIP).