Supportive therapy for schizophrenia

Cognitive Behavioral Therapy Compared with Non-specialized Therapy for Alleviating the Effect of Auditory Hallucinations in People with Reoccurring Schizophrenia: A Systematic Review and Meta-analysis

Cognitive behavioral therapy (CBT) is recommended as a psychological intervention for those diagnosed with schizophrenia. The prevalence of auditory hallucinations is high among this group, many of whom are cared for by community mental health teams that may not have easy access to qualified CBT practitioners. This systematic review examined the evidence for the superiority of CBT compared to non-specialized therapy in alleviating auditory hallucinations in community patients with schizophrenia. Two RCTs met the inclusion criteria totaling 105 participants. The Positive and Negative Syndrome Scale (PANSS)-Positive Scale was the outcome measure examined. A meta-analysis revealed a pooled mean difference of -0.86 [95 % CI -2.38, 0.65] in favor of CBT, although this did not reach statistical significance. This systematic review concluded there is no clinically significant difference in the reduction of positive symptoms of schizophrenia when treated by CBT compared to a non-specialized therapy for adults experiencing auditory hallucinations.

Cognitive behavioural therapy (brief versus standard duration) for schizophrenia

BACKGROUND

Cognitive behavioural therapy for people with schizophrenia is a psychotherapeutic approach that establishes links between thoughts, emotions and behaviours and challenges dysfunctional thoughts. There is some evidence to suggest that cognitive behavioural therapy for people with psychosis (CBTp) might be an effective treatment for people with schizophrenia. There are however, limitations in its provision due to available resource and training issues. One way to tackle this issue might be to offer a brief version of CBTp.

OBJECTIVES

To review the effects of brief CBTp (6 to 10 regular sessions given in less than 4 months and using a manual) for people with schizophrenia compared with standard CBTp (12 to 20 regular sessions given in 4 to 6 months and using a manual).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (August 21, 2013 and August 26, 2015) which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO and registries of Clinical Trials. There are no language, date, document type, or publication status limitations for inclusion of records in the register. We inspected all references of the selected articles for further relevant trials. We also contacted experts in the field regarding brief CBTp studies.

SELECTION CRITERIA

Randomised controlled trials involving adults with schizophrenia or related disorders, comparing brief cognitive behavioural therapy for people with psychosis versus standard CBTp.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and assessed studies for inclusion using pre-specified inclusion criteria.

MAIN RESULTS

We found only seven studies which used a brief version of CBTp, but no study compared brief CBTp with CBTp of standard duration. No studies could be included.

AUTHORS' CONCLUSIONS

Currently there is no literature available to compare brief with standard CBTp for people with schizophrenia. We cannot, therefore, conclude whether brief CBTp is as effective, less effective or even more effective than standard courses of the same therapy. This lack of evidence for brief CBTp has serious implications for research and practice. Well planned, conducted and reported randomised trials are indicated.

Friends interventions in psychosis: a narrative review and call to action

AIMS

To highlight the importance of friendships to young people with psychosis, and the need for clinical interventions to help maintain peer relationships during illness. To structure a research agenda for developing evidence-based interventions with friends.

METHOD

An argument is developed through a narrative review of (i) the proven efficacy of family interventions, and (by comparison) a relative absence of friend-based interventions; (ii) the particular primacy of friendships and dating for young people, and typical effects of exclusion; and (iii) reduced friendship networks and dating experiences in psychosis, in pre-, during and post-psychosis phases, also links between exclusion and psychosis.

RESULTS

We put forward a model of how poor friendships can potentially be a causal and/or maintenance factor for psychotic symptoms. Given this model, our thesis is that interventions aiming to maintain social networks can be hugely beneficial clinically for young people with psychosis. We give a case study to show how such an intervention can work.

CONCLUSIONS

We call for 'friends interventions' for young people with psychosis to be developed, where professionals directly work with a young person's authentic social group to support key friendships and maintain social continuity. An agenda for future research is presented that will develop and test theoretically driven interventions.

Supportive therapy for schizophrenia

BACKGROUND

Supportive therapy is often used in everyday clinical care and in evaluative studies of other treatments.

OBJECTIVES

To review the effects of supportive therapy compared with standard care, or other treatments in addition to standard care for people with schizophrenia.

SEARCH METHODS

For this update, we searched the Cochrane Schizophrenia Group's register of trials (November 2012).

SELECTION CRITERIA

All randomised trials involving people with schizophrenia and comparing supportive therapy with any other treatment or standard care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the risk ratio (RR) using a fixed-effect model with 95% confidence intervals (CIs). Where possible, we undertook intention-to-treat analyses. For continuous data, we estimated the mean difference (MD) fixed-effect with 95% CIs. We estimated heterogeneity (I(2) technique) and publication bias. We used GRADE to rate quality of evidence.

MAIN RESULTS

Four new trials were added after the 2012 search. The review now includes 24 relevant studies, with 2126 participants. Overall, the evidence was very low quality.We found no significant differences in the primary outcomes of relapse, hospitalisation and general functioning between supportive therapy and standard care.There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (4 RCTs, n = 306, RR 1.82 CI 1.11 to 2.99, very low quality of evidence), clinical improvement in mental state (3 RCTs, n = 194, RR 1.27 CI 1.04 to 1.54, very low quality of evidence) and satisfaction of treatment for the recipient of care (1 RCT, n = 45, RR 3.19 CI 1.01 to 10.7, very low quality of evidence). For this comparison, we found no evidence of significant differences for rate of relapse, leaving the study early and quality of life.When we compared supportive therapy to cognitive behavioural therapy CBT), we again found no significant differences in primary outcomes. There were very limited data to compare supportive therapy with family therapy and psychoeducation, and no studies provided data regarding clinically important change in general functioning, one of our primary outcomes of interest.

AUTHORS' CONCLUSIONS

There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies where we graded the evidence as very low quality. Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.

Cognitive behavioural therapy (brief versus standard duration) for schizophrenia

BACKGROUND

Cognitive behavioural therapy for people with schizophrenia is a psychotherapeutic approach that establishes links between thoughts, emotions and behaviours and challenges dysfunctional thoughts. There is some evidence to suggest that cognitive behavioural therapy for people with psychosis (CBTp) might be an effective treatment for people with schizophrenia. There are however, limitations in its provision due to available resource and training issues. One way to tackle this issue might be to offer a brief version of CBTp.

OBJECTIVES

To review the effects of brief CBTp (6 to 10 regular sessions given in less than 4 months and using a manual) for people with schizophrenia compared with standard CBTp (12 to 20 regular sessions given in 4 to 6 months and using a manual).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (August 21, 2013) which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO and registries of Clinical Trials. There are no language, date, document type, or publication status limitations for inclusion of records in the register. We inspected all references of the selected articles for further relevant trials. We also contacted experts in the field regarding brief CBTp studies.

SELECTION CRITERIA

Randomised controlled trials involving adults with schizophrenia or related disorders, comparing brief cognitive behavioural therapy for people with psychosis versus standard CBTp.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and assessed studies for inclusion using pre-specified inclusion criteria.

MAIN RESULTS

We found only seven studies which used a brief version of CBTp, but no study compared brief CBTp with CBTp of standard duration. No studies could be included.

AUTHORS' CONCLUSIONS

Currently there is no literature available to compare brief with standard CBTp for people with schizophrenia. We cannot, therefore, conclude whether brief CBTp is as effective, less effective or even more effective than standard courses of the same therapy. This lack of evidence for brief CBTp has serious implications for research and practice. Well planned, conducted and reported randomised trials are indicated.

The use of psychological therapies by mental health nurses in Australia

This paper reports on a research project which examines the feasibility of mental health nurses employing psychological therapies in the nursing care of people with severe mental illness. Attitudes towards current usage and factors influencing the adoption of psychological therapies are investigated. The paper addresses the gap in the Australian nursing literature regarding the therapeutic role of mental health nurses (MHN)s in relation to the use of evidence-based psychological therapies. This paper presents the findings from an online questionnaire survey of 528 practising MHNs in Australia. The findings demonstrate enthusiastic support among nurses towards employing psychological therapies, with 93% of respondents indicating they would like to use psychological therapies in their current practice. Correspondingly, there is strong demand for education and training in applying psychological therapies. A number of barriers to implementing psychological therapies are identified. It is noted that place of employment is a significant factor, with mental health nurses working in the public sector more likely to state institutional barriers are restricting their therapeutic potential and preventing them from implementing psychological therapies.

Definitions and drivers of relapse in patients with schizophrenia: a systematic literature review

Relapse in patients with schizophrenia has devastating repercussions, including worsening symptoms, impaired functioning, cognitive deterioration and reduced quality of life. This progressive decline exacerbates the burden of illness on patients and their families. Relapse prevention is identified as a key therapeutic aim; however, the absence of widely accepted relapse definition criteria considerably hampers achieving this goal. We conducted a literature review in order to investigate the reporting of relapses and the validity of hospitalization as a proxy for relapse in patients with schizophrenia. The primary aim was to assess the range and validity of methods used to define relapse in observational or naturalistic settings. The secondary aim was to capture information on factors that predicted or influenced the risk of relapse. A structured search of the PubMed database identified articles that discussed relapse, and hospitalization as a proxy of relapse, in patients with schizophrenia. National and international guidelines were also reviewed. Of the 150 publications and guidelines identified, 87 defined relapse and 62% of these discussed hospitalization. Where hospitalization was discussed, this was as a proxy for, or a component of, relapse in the majority of cases. However, hospitalization duration and type varied and were not always well defined. Scales were used to define relapse in 53 instances; 10 different scales were used and multiple scales often appeared within the same definition. There were 95 references to factors that may drive relapse, including non-adherence to antipsychotic medication (21/95), stress/depression (11/95) and substance abuse (9/95). Twenty-five publications discussed the potential of antipsychotic therapy to reduce relapse rates-continuous antipsychotic therapy was associated with reduced frequency and duration of hospitalization. Non-pharmacological interventions, such as psychoeducation and cognitive behavioural therapy, were also commonly reported as factors that may reduce relapse. In conclusion, this review identified numerous factors used to define relapse. Hospitalization was the factor most frequently used and represents a useful proxy for relapse when reporting in a naturalistic setting. Several factors were reported to increase the risk of relapse, and observation of these may aid the identification of at-risk patients.

Cognitive behavioural therapy and the psychopathology of schizophrenia: systematic review and meta-analysis

PURPOSE

To examine whether cognitive behaviour therapy (CBT) reduces psychopathology in patients with schizophrenia more effectively than the use of non-cognitive psychotherapies.

METHOD

Systematic review and meta-analysis of the literature was performed. All Randomized Controlled Trials meeting the inclusion criteria were analysed using RevMan software. This design was used to maximize power and study efficacy. Medline, PsycINFO, and Embase were searched using free-text keywords to identify potential papers. Nine were included in the final meta-analysis. Change in psychopathology at the end of therapy was the end point investigated. A random effects model was used to assess the standard mean difference between the CBT and supportive control groups.

RESULTS

Meta-analysis of CBT versus supportive therapy did not find significant differences between the therapy groups at the end of treatment in respect of psychopathology. There was no evidence of publication bias. Post hoc power analysis using the Z test ruled out type one error.

CONCLUSIONS

Theoretically based CBT therapies, although proving effective, may not out perform more accessible and simpler forms of therapy for patients with schizophrenia in reducing psychopathology. Consideration of supportive therapy should be made for patients with psychotic mental disorder.

Multiplicity of data in trial reports and the reliability of meta-analyses: empirical study

OBJECTIVES

To examine the extent of multiplicity of data in trial reports and to assess the impact of multiplicity on meta-analysis results.

DESIGN

Empirical study on a cohort of Cochrane systematic reviews.

DATA SOURCES

All Cochrane systematic reviews published from issue 3 in 2006 to issue 2 in 2007 that presented a result as a standardised mean difference (SMD). We retrieved trial reports contributing to the first SMD result in each review, and downloaded review protocols. We used these SMDs to identify a specific outcome for each meta-analysis from its protocol. Review methods Reviews were eligible if SMD results were based on two to ten randomised trials and if protocols described the outcome. We excluded reviews if they only presented results of subgroup analyses. Based on review protocols and index outcomes, two observers independently extracted the data necessary to calculate SMDs from the original trial reports for any intervention group, time point, or outcome measure compatible with the protocol. From the extracted data, we used Monte Carlo simulations to calculate all possible SMDs for every meta-analysis.

RESULTS

We identified 19 eligible meta-analyses (including 83 trials). Published review protocols often lacked information about which data to choose. Twenty-four (29%) trials reported data for multiple intervention groups, 30 (36%) reported data for multiple time points, and 29 (35%) reported the index outcome measured on multiple scales. In 18 meta-analyses, we found multiplicity of data in at least one trial report; the median difference between the smallest and largest SMD results within a meta-analysis was 0.40 standard deviation units (range 0.04 to 0.91).

CONCLUSIONS

Multiplicity of data can affect the findings of systematic reviews and meta-analyses. To reduce the risk of bias, reviews and meta-analyses should comply with prespecified protocols that clearly identify time points, intervention groups, and scales of interest.

A systematic review of the international published literature relating to quality of institutional care for people with longer term mental health problems

BACKGROUND

A proportion of people with mental health problems require longer term care in a psychiatric or social care institution. However, there are no internationally agreed quality standards for institutional care and no method to assess common care standards across countries. We aimed to identify the key components of institutional care for people with longer term mental health problems and the effectiveness of these components.

METHODS

We undertook a systematic review of the literature using comprehensive search terms in 11 electronic databases and identified 12,182 titles. We viewed 550 abstracts, reviewed 223 papers and included 110 of these. A "critical interpretative synthesis" of the evidence was used to identify domains of institutional care that are key to service users' recovery.

RESULTS

We identified eight domains of institutional care that were key to service users' recovery: living conditions; interventions for schizophrenia; physical health; restraint and seclusion; staff training and support; therapeutic relationship; autonomy and service user involvement; and clinical governance. Evidence was strongest for specific interventions for the treatment of schizophrenia (family psychoeducation, cognitive behavioural therapy (CBT) and vocational rehabilitation).

CONCLUSION

Institutions should, ideally, be community based, operate a flexible regime, maintain a low density of residents and maximise residents' privacy. For service users with a diagnosis of schizophrenia, specific interventions (CBT, family interventions involving psychoeducation, and supported employment) should be provided through integrated programmes. Restraint and seclusion should be avoided wherever possible and staff should have adequate training in de-escalation techniques. Regular staff supervision should be provided and this should support service user involvement in decision making and positive therapeutic relationships between staff and service users. There should be clear lines of clinical governance that ensure adherence to evidence-based guidelines and attention should be paid to service users' physical health through regular screening.

Disagreements in meta-analyses using outcomes measured on continuous or rating scales: observer agreement study

OBJECTIVE

To study the inter-observer variation related to extraction of continuous and numerical rating scale data from trial reports for use in meta-analyses.

DESIGN

Observer agreement study.

DATA SOURCES

A random sample of 10 Cochrane reviews that presented a result as a standardised mean difference (SMD), the protocols for the reviews and the trial reports (n=45) were retrieved.

DATA EXTRACTION

Five experienced methodologists and five PhD students independently extracted data from the trial reports for calculation of the first SMD result in each review. The observers did not have access to the reviews but to the protocols, where the relevant outcome was highlighted. The agreement was analysed at both trial and meta-analysis level, pairing the observers in all possible ways (45 pairs, yielding 2025 pairs of trials and 450 pairs of meta-analyses). Agreement was defined as SMDs that differed less than 0.1 in their point estimates or confidence intervals.

RESULTS

The agreement was 53% at trial level and 31% at meta-analysis level. Including all pairs, the median disagreement was SMD=0.22 (interquartile range 0.07-0.61). The experts agreed somewhat more than the PhD students at trial level (61% v 46%), but not at meta-analysis level. Important reasons for disagreement were differences in selection of time points, scales, control groups, and type of calculations; whether to include a trial in the meta-analysis; and data extraction errors made by the observers. In 14 out of the 100 SMDs calculated at the meta-analysis level, individual observers reached different conclusions than the originally published review.

CONCLUSIONS

Disagreements were common and often larger than the effect of commonly used treatments. Meta-analyses using SMDs are prone to observer variation and should be interpreted with caution. The reliability of meta-analyses might be improved by having more detailed review protocols, more than one observer, and statistical expertise.

Tobacco quitlines and persons with mental illnesses: perspective, practice, and direction

The prevalence of tobacco use among persons with mental illnesses is 2 to 3 times that of the general population, and these individuals suffer significant related health disparities. Many people with mental illnesses contact tobacco quitlines for cessation assistance. With free telephone counseling and in some cases nicotine replacement therapy, quitlines offer a potentially effective resource for this population. However, quitlines are still trying to determine how best to meet these callers' unique needs. The authors discuss emerging practices regarding quitline services for persons with mental illnesses, as well as expert opinion for enhancing work with these individuals.

Morita therapy for schizophrenia

BACKGROUND

Morita therapy was founded in 1919 by Shoma Morita (1874-1938). The therapy involves a behavioural structured programme to encourage an outward perspective on life and hence an increased social functioning.

OBJECTIVES

To evaluate the effects of Morita therapy for schizophrenia and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Groups Trials Register, the Chongqing VIP Database, the Wanfang Database (August 2006), all relevant references and contacted the first author of each included study.

SELECTION CRITERIA

We included all randomised clinical trials comparing Morita therapy with any other treatment.

DATA COLLECTION AND ANALYSIS

We reliably selected studies and extracted data. For homogenous dichotomous data we calculated random effects, relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

We found 11 small, studies of medium-poor quality (total n=1041). The standard care versus Morita therapy comparison (total n=679 people) had very low attrition (<2%, 9 RCTs, RR 1.02 CI 0.3 to 3.1). Mental state did tend to improve with Morita therapy (n=76, 1 RCT, RR no >25-30% decline in BPRS RR 0.36 CI 0.1 to 0.9, NNT 5 CI 4 to 25). For negative symptoms data were inconsistent, with data from three trials favouring Morita therapy (n=243, RR -10.87 CI -20.5 to -1.2), but heterogeneity was considerable (I(2) =92%). Morita therapy plus standard treatment did significantly improve the ability of daily living compared with standard treatment alone (n=104, 1 RCT, WMD -4.1 CI -7.7 to -0.6). Compared with a rehabilitation programme Morita therapy did not promote attrition (n=302, 2 RCTs, RR 1.00 CI 0.5 to 2.1). In two very similar studies Morita therapy showed better effect on mental state with lower BPRS score (n=278, 2 RCTs, WMD -6.95 CI 9.3 to 4.6, I(2) =0%) insight (n=278, 2 RCTs, WMD -1.11 CI -1.3 to -0.9, I(2) = 0%) and social functioning (n=278, WMD average IPROS score -18.14 CI -21.3 to -15.0, I(2) =0%).

AUTHORS' CONCLUSIONS

Currently trial based data on Morita therapy is inconclusive. Morita therapy for schizophrenia remains an experimental intervention, new trials are justified and specific outlines for design of future studies are outlined in additional tables.