A psychosocial skills training approach in Mexican out-patients with schizophrenia

Impact of loneliness and living alone on negative symptoms in severe mental illness: An electronic health record data analysis

Important changes in symptom profiles occur early in the course of severe mental illness (SMI) after its clinical presentation. The emergence of negative symptoms is of particular concern for later function, and these may well have strong links with loneliness and poor social support which are also recognised to be common. However, the impact of loneliness and social isolation on symptoms and treatment outcomes remains unclear. To explore this, we conducted a retrospective observational analysis using data from electronic health records of a large mental health provider in London. Loneliness, living alone and symptoms of SMI were extracted using bespoke natural language processing algorithms. Symptoms were grouped into five domains: positive, negative, disorganised, manic, and catatonic, and were measured at diagnosis and 12 months following the initial SMI diagnosis. Loneliness and living alone were operationalised as binary variables, based on any recording during the follow-up period. A total of 8237 records were analysed. The prevalence of loneliness was 20.4 % and living alone 19.9 %, with only 6.8 % recorded with both. Recorded loneliness was associated with an increase in negative symptoms over the follow-up period, in models adjusted by sociodemographic variables and pharmacological treatment [OR 1.28 (1.11-1.48), p = 0.001], as was living alone to a weaker extent [OR 1.18 (1.02-1.36), p = 0.030]. No associations were found between either exposure variable and changes in symptoms from other domains. Given that negative symptoms are disabling and challenging to treat, these results highlight the importance of effective interventions to enhance social support in SMI over the early post-diagnostic period.

Therapeutic patient education for severe mental disorders: A systematic review

Objective

This systematic review aimed to review therapeutic patient education (TPE) programmes in managing psychiatric disorders, considering the diversity in delivering agents, intervention formats, targeted skills, and therapeutic outcomes.

Methods

Comprehensive database searches, including Web of Science, PubMed, and COCHRANE, were conducted from September 2019 to January 2023, yielding 514 unique records, with 33 making it through rigorous evaluation for full-text review. Eleven studies met the inclusion criteria, focusing on various psychiatric disorders such as depression, bipolar disorder, psychosis, and multiple serious mental illnesses. A total of 38 studies were included from our previous review to supplement the current database search.

Results

TPE programmes exhibited diversity in delivering agents and intervention formats, with a notable presence of multidisciplinary teams and various professionals. The interventions prioritized coping strategies and disease management techniques, though the extent varied based on the disorder. Effectiveness was heterogeneous across studies; some interventions showed significant benefits in areas such as symptom management, coping, and functional improvement, while others reported no significant outcomes.

Conclusion

The findings underscore the potential of TPE in psychiatric care, revealing its multifaceted nature and varied impact. TPE not only addresses deficits but also leverages patients' existing strengths and capabilities. Despite the reported benefits, a portion of the interventions lacked statistical significance, indicating the necessity for continuous refinement and evaluation.

Cerebral, Psychosocial, Family Functioning and Disability of Persons with Schizophrenia

The human brain is the most cognitively capable of mammalian brains, endowed as it is with an overdeveloped cerebral cortex that, in parallel, renders it vulnerable to mental disorders. Schizophrenia is the expression of the dysregulation of the neuronal activity of cortical and subcortical regions due to modifications in the levels of the various neurotransmitters, especially of dopamine, with a reciprocal, intimate relationship among genes with environmental and psychosocial factors. If the dopaminergic system increases the function prefrontal cortex will be reduced: this is the main reason of social, occupational and familiar disruption. The present article describes the function of the brain in schizophrenia and its relation with anatomical, physiological, and genetic changes, in addition to identifying, psychosocial and family factors that can be determinant in the functionality of the patient. A review of national and international bibliography was conducted bearing in mind the following variables: functioning at the cerebral level; psychosocial functioning, familial functioning, disability, and functionality in persons with schizophrenia. Due to the variety of the issues included in this review, it can be concluded that schizophrenia is the product of a complex array of symptoms, deficits and disabilities. It was identified that there is a reciprocal confluence of diverse genetic, psychosocial, familial, environmental, educative, and social factors which affect the functionality of persons with this disorder. The latter makes it necessary to study the patient taking into consideration all of these components in an integral manner.

Psychosocial Interventions for Adults With Schizophrenia: An Overview and Update of Systematic Reviews

OBJECTIVE

The authors of this systematic review (SR) sought to provide evidence for effects of commonly used psychosocial interventions on several outcomes among adults with schizophrenia.

METHODS

MEDLINE, the Cochrane Library, and PsycINFO databases were searched through July 2020. Eligible studies were SRs and trials of at least 12 weeks duration and with ≥50 participants that compared psychosocial interventions with treatment as usual among adults with schizophrenia. Study design, year, setting, country, sample size, eligibility criteria, population, clinical and intervention characteristics, results, and funding source were extracted, along with quality criteria. The evidence was evaluated on quality and strength of evidence stratified by intervention area and outcome, according to the Evidence-Based Practice Centers Methods Guide of the Agency for Healthcare Research and Quality.

RESULTS

Nine SRs and 30 trials (N=23,921 patients) in 11 intervention areas were included. Trials were mostly of fair quality and had low-to-moderate strength of evidence. Compared with treatment as usual, most psychosocial interventions were more effective in improving intervention-targeted outcomes, including core illness symptoms. Compared with treatment as usual, assertive community treatment, cognitive-behavioral therapy (CBT), family interventions, psychoeducation, social skills training, supported employment, and early interventions for first-episode psychosis (FEP) improved various functional outcomes. CBT and early interventions for FEP improved quality of life. Family interventions, psychoeducation, illness self-management, and early interventions for FEP reduced relapse.

CONCLUSIONS

Compared with treatment as usual, most psychosocial interventions improved functional outcomes, quality of life, and core illness symptoms, and several reduced relapse frequency among adults with schizophrenia.

The effectiveness of a combination of Occupational Therapy and Social Skills Training in people with schizophrenia: A rater-blinded randomized controlled trial

Introduction

This study aimed to assess the impact of a holistic combination of Occupational Therapy and Social Skills Training on occupational performance, social participation, and clinical symptoms in people with schizophrenia.

Method

60 people with schizophrenia were randomly assigned to two groups. One group received standardized Social Skills Training once a week for a total of 10 sessions, while the other group received a combination of Occupational Therapy and Social Skills Training once a week for a total of 16 sessions.

Results

A greater increase was determined in the scores of COPM total performance/satisfaction and the Community Integration Questionnaire in the Occupational Therapy and Social Skills Training group. Furthermore, these achievements were sustained in the Occupational Therapy and Social Skills Training group compared to the Social Skills Training group at the 6-month follow-up.

Conclusion

The clients received the combination of Occupational Therapy and Social Skills Training showed a better improvement compared to the Social Skills Training group in terms of occupational performance, social participation, and severity of clinical symptoms. The use of Occupational Therapy in a holistic approach in psychosocial rehabilitation of people with schizophrenia can increase their functionality and social participation. Further studies are needed to assess long-term effects of Occupational Therapy in schizophrenia.

Culturally adapted Family Intervention (CaFI) for African-Caribbean people diagnosed with schizophrenia and their families: a mixed-methods feasibility study of development, implementation and acceptability

Background

African-Caribbean people in the UK experience the highest incidence of schizophrenia and the greatest inequity in mental health care. There is an urgent need to improve their access to evidence-based care and outcomes. Family intervention (FI) is a National Institute for Health and Care Excellence-approved psychosocial intervention. Although clinically effective and cost-effective for schizophrenia, it is rarely offered. Evidence for any research into FI is lacking for ethnic minority people generally and for African-Caribbean people specifically.

Aims

(1) To assess the feasibility of delivering a novel, culturally appropriate psychosocial intervention within a ‘high-risk’ population to improve engagement and access to evidence-based care. (2) To test the feasibility and acceptability of delivering FI via ‘proxy families’.

Design

A mixed-methods, feasibility cohort study, incorporating focus groups and an expert consensus conference.

Setting

Two mental health trusts in north-west England.

Participants

We recruited a convenience sample of 31 African-Caribbean service users. Twenty-six family units [service users, relatives/family support members (FSMs) or both] commenced therapy. Half of the service users (n = 13, 50%), who did not have access to their biological families, participated by working with FSMs.

Interventions

An extant FI model was culturally adapted with key stakeholders using a literature-derived framework [Culturally adapted Family Intervention (CaFI)]. Ten CaFI sessions were offered to each service user and associated family.

Main outcome measures

Recruitment (number approached vs. number consented), attendance (number of sessions attended), attrition (number of dropouts at each time point), retention (proportion of participants who completed therapy sessions), and completeness of outcome measurement.

Results

Of 74 eligible service users, 31 (42%) consented to take part in the feasibility trial. The majority (n = 21, 67.7%) were recruited from community settings, seven (22.6%) were recruited from rehabilitation settings and three (9.7%) were recruited from acute wards. Twenty-four family units (92%) completed all 10 therapy sessions. The proportion who completed treatment was 77.42% (24/31). The mean number of sessions attended was 7.90 (standard deviation 3.96 sessions) out of 10. It proved feasible to collect a range of outcome data at baseline, post intervention and at the 3-month follow-up. The rating of sessions and the qualitative findings indicated that CaFI was acceptable to service users, families, FSMs and health-care professionals.

Limitations

The lack of a control group and the limited sample size mean that there is insufficient power to assess efficacy. The findings are not generalisable beyond this population.

Conclusions

It proved feasible to culturally adapt and test FI with a sample of African-Caribbean service users and their families. Our study yielded high rates of recruitment, attendance, retention and data completion. We delivered CaFI via FSMs in the absence of biological families. This novel aspect of the study has implications for other groups who do not have access to their biological families. We also demonstrated the feasibility of collecting a range of outcomes to inform future trials and confirmed CaFI’s acceptability to key stakeholders. These are important findings. If CaFI can be delivered to the group of service users with the most serious and persistent disparities in schizophrenia care, it has the potential to be modified for and delivered to other underserved groups.

Future work

A fully powered, multicentre trial, comparing CaFI with usual care, is planned.

Trial registration

Current Controlled Trials ISRCTN94393315.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 32. See the NIHR Journals Library website for further project information.

The nature and efficacy of culturally-adapted psychosocial interventions for schizophrenia: a systematic review and meta-analysis

BACKGROUND

Evidence-based psychosocial treatments for schizophrenia founded on Western belief systems and values may not be efficacious in different cultures without adaptation. This systematic review analyses the nature and outcomes of culturally-adapted psychosocial interventions in schizophrenia, examining how interventions have been adapted, their efficacy and what features drive heterogeneity in outcome.

METHOD

Articles identified by searching electronic databases from inception to 3 March 2016, reference lists and previous reviews were independently screened by two authors for eligible controlled trials. Data on the nature of adaptations was analysed inductively using thematic analyses. Meta-analyses were conducted using random effects models to calculate effect sizes (Hedges' g) for symptoms.

RESULTS

Forty-six studies with 7828 participants were included, seven adapted for minority populations. Cultural adaptations were grouped into nine themes: language, concepts and illness models, family, communication, content, cultural norms and practices, context and delivery, therapeutic alliance, and treatment goals. Meta-analyses showed significant post-treatment effects in favour of adapted interventions for total symptom severity (n = 2345, g: -0.23, 95% confidence interval (CI) -0.36 to -0.09), positive (n = 1152, g: -0.56, 95% CI -0.86 to -0.26), negative (n = 855, g: -0.39, 95% CI -0.63 to -0.15), and general (n = 525, g: -0.75, CI -1.21 to -0.29) symptoms.

CONCLUSIONS

The adaptation process can be described within a framework that serves as a benchmark for development or assessment of future adaptations. Culturally adapted interventions were more efficacious than usual treatment in proportion to the degree of adaptation. There is insufficient evidence to show that adapted interventions are better than non-adapted interventions. Features of context, intervention and design influenced efficacy. Investigating whether adaptation improves efficacy, most importantly amongst ethnic minorities, requires better designed trials with comparisons against unadapted interventions.

[Psychiatric readmissions: individual and organizational factors]

BACKGROUND

Psychiatric readmission often constitutes a criterion to assess the effects of various therapies, as well as the impact of organizational changes in the healthcare system. It is used to characterize relapse or decompensation. The purpose of this study was to determine readmission rates and identify individual and organizational factors associated with significant variations in these rates.

METHODS

Adult psychiatric readmissions were identified from the full-time hospital stays registered in psychiatric wards in 2011-2012 in the Nord and Pas-de-Calais departments of France, available in the medical the RimP psychiatric admission database. Readmission rates for various follow-up periods after discharge were measured by Kaplan-Meier survival analysis and multivariate analysis was conducted using the Cox proportional hazards model.

RESULTS

Approximately 30,000 adults were hospitalized full-time in psychiatric units of the region during the study period. The 24-month readmission rate was 51.6% (95%CI: 50.8-52.3%). The Cox model showed that a diagnosis of schizophrenia (F2 - HR = 1.72 - 95%CI: 1.61-1.84 - p < 0.001) and personality disorder (F6 - HR = 1.45 - 95%CI: 1.32-1.58 - p < 0.001) was associated with a higher readmission rate. Readmission rates were higher among dependent patients in non-profit private hospitals.

CONCLUSION

Psychiatric readmission is a very frequent event and is linked to organizational as well as individual factors.

Clinical factors related to schizophrenia relapse

OBJECTIVE

Relapses represent one of the main problems of schizophrenia management. This article reviews the clinical factors associated with schizophrenia relapse.

METHODS

A research of the last 22 years of literature data was performed. Two-hundred nineteen studies have been included.

RESULTS

Three main groups of factors are related to relapse: factors associated with pharmacological treatment, add-on psychotherapeutic treatments and general risk factors. Overall, the absence of a maintenance therapy and treatment with first generation antipsychotics has been associated with higher risk of relapse. Further, psychotherapy add-on, particularly with cognitive behaviour therapy and psycho-education for both patients and relatives, has shown a good efficacy for reducing the relapse rate. Among general risk factors, some could be modified, such as the duration of untreated psychosis or the substance misuse, while others could not be modified as male gender or low pre-morbid level of functioning.

CONCLUSION

Several classes of risk factors have been proved to be relevant in the risk of relapse. Thus, a careful assessment of the risk factors here identified should be performed in daily clinical practice in order to individualise the relapse risk for each patient and to provide a targeted treatment in high-risk subjects.

[Psychosocial Interventions in Acute and Maintenance Treatment of Adult Patients Diagnosed With Schizophrenia]

OBJECTIVES

To determine the effectiveness of the psychosocial strategies designed to improve the outcomes in adults with schizophrenia in both, acute and stable phase of the disorder. This evidence is used to propose recommendation in the guidelines of integral attention for the diagnosis, treatment and psychosocial rehabilitation of adults with schizophrenia.

METHODS

A guideline for clinical practice was developed using the methodological framework of the Ministerio de la Protección Social to collect evidence and grading recommendations. A search, evaluation and synthesis of evidence were carried out. The evidence was presented to the Guideline Developing Group and recommendations, employing the GRADE system, were produced.

RESULTS

The psychoeducation and family intervention showed higher efficacy, compared with the usual treatment, to prevent relapses and hospital readmissions, to reduce family burden and to improve adherence to treatment. The social skill training was effective to improve symptoms, social functioning and quality of life. However, the quality of evidence was low. There was not enough evidence about the efficacy of occupational therapy, but considering patients preferences and its wide clinical utilization, the GDG suggested its inclusion.

CONCLUSION

Psychoeducation, family intervention and social skill training are recommended to be offered for the treatment of schizophrenia. Furthermore, occupational therapy is suggested for inpatients and outpatients with the disorder.

Systematic review of feasibility and acceptability of psychosocial interventions for schizophrenia in low and middle income countries

BACKGROUND

In low and middle income countries there is evidence to suggest effectiveness of community-based psychosocial interventions for schizophrenia. Many psychosocial interventions have however been conceptualized in high income countries and assessing their feasibility and acceptability in low and middle income countries is pertinent and the objective of this review.

METHODS

Six databases were searched using search terms (i) "Schizophrenia"; (ii) "Low and middle income or developing countries" and (iii) "Psychosocial interventions". Abstracts identified were extracted to an EndNote Database. Two authors independently reviewed abstracts according to defined inclusion and exclusion criteria. Full papers were accessed of studies meeting these criteria, or for which more information was needed to include or exclude them. Data were extracted from included studies using a predesigned data extraction form. Qualitative synthesis of qualitative and quantitative data was conducted.

RESULTS

14 037 abstracts were identified through searches. 196 full articles were reviewed with 17 articles meeting the inclusion criteria. Little data emerged on feasibility. Barriers to feasibility were noted including low education levels of participants, unavailability of caregivers, and logistical issues such as difficulty in follow up of participants. Evidence of acceptability was noted in high participation rates and levels of satisfaction with interventions.

CONCLUSIONS

While there is preliminary evidence to suggest acceptability of community-based psychosocial interventions for schizophrenia in low and middle income countries, evidence for overall feasibility is currently lacking. Well-designed intervention studies incorporating specific measures of acceptability and feasibility are needed.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

The beneficial effects of combining pharmacological and psychosocial treatment on remission and functional outcome in outpatients with schizophrenia

OBJECTIVE

The effects of pharmacological and psychosocial treatment on remission and the functional outcome in outpatients with schizophrenia were evaluated. Remission was assessed according to the criteria proposed by the Remission in Schizophrenia Working group and psychosocial functioning according to the Global Assessment of Functioning with a score > 60. Functional outcome was the result of these two variables.

METHOD

One hundred fifty two patients were randomized to receive either, antipsychotic treatment as usual (TAU) or social skills training and family psychoeducation in addition to TAU. A final sample of 119 patients: n = 68 in the social skills training group, and n = 51 in the TAU group completed the study protocol. Patients were assessed at baseline and at 6-month follow-up.

RESULTS

At the end of the study, 80% of the patients fulfilled the criteria for symptomatic remission: 62 patients (91.2%) in the social skills training group in contrast to 34 patients (66.7%) in the TAU group. Functional improvement criteria were accomplished by 41 patients (34.5%) at the endpoint of the study. Forty of these patients (58.8%) belonged to social skills training and one patient to customary treatment (χ(2) = 41.7, df 1, p < 0.001) and when criteria for symptomatic remission and functional improvement were combined, 39 patients (97.5%) of the social skills training group and one patient (1.9%) of the customary treatment group achieved functional outcome.

CONCLUSION

The results emphasize the need for psychosocial interventions as conjoint to pharmacological treatment to improve functional outcome in schizophrenia patients.

Psychosocial treatments for negative symptoms in schizophrenia: current practices and future directions

Schizophrenia can be a chronic and debilitating psychiatric disorder. Though advancements have been made in the psychosocial treatment of some symptoms of schizophrenia, people with schizophrenia often continue to experience some level of symptoms, particularly negative symptoms, throughout their lives. Because negative symptoms are associated with poor functioning and quality of life, the treatment of negative symptoms is a high priority for intervention development. However, current psychosocial treatments primarily focus on the reduction of positive symptoms with comparatively few studies investigating the efficacy of psychosocial treatments for negative symptoms. In this article, we review and evaluate the existing literature on three categories of psychosocial treatments--cognitive behavioral therapy (CBT), social skills training (SST), and combined treatment interventions--and their impact on the negative symptoms of schizophrenia. Of the interventions reviewed, CBT and SST appear to have the most empirical support, with some evidence suggesting that CBT is associated with maintenance of negative symptom improvement beyond six months after treatment. It remains unclear if a combined treatment approach provides improvements above and beyond those associated with each individual treatment modality. Although psychosocial treatments show promise for the treatment of negative symptoms, there are many unanswered questions about how best to intervene. We conclude with a general discussion of these unanswered questions, future directions and methodological considerations, and suggestions for the further development of negative symptom interventions.

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.

Self-management education interventions for persons with schizophrenia: a meta-analysis

Although self-management education programs for persons with schizophrenia are being developed and advocated, uncertainty about their overall effectiveness remains. The purpose of this meta-analysis was to examine outcomes of self-management education interventions in persons with schizophrenia. Six electronic databases were searched. Manual searches were conducted of the reference lists of the identified studies and major psychiatric journals. Randomized controlled trials of self-management education interventions aimed at reducing relapse and hospital readmissions, as well as improving symptoms, psychosocial functioning, and adherence to medication treatment were identified. Data were extracted and the quality of included studies were rated by two authors independently. Finally, 13 studies with 1404 patients were included. Self-management education interventions were associated with a significant reduction of relapse events and re-hospitalizations. Patients who received self-management education were more likely to improve adherence to medication and symptoms compared to patients receiving other care. However, a benefit on psychosocial functioning was not confirmed in the current meta-analysis. The study concludes that self-management education intervention is a feasible and effective method for persons with schizophrenia and should be routinely offered to all persons with schizophrenia.

A brief cognitive-behavioural social skills training for stabilised outpatients with schizophrenia: a preliminary study

Achieving social functioning and achieving social competence are two main objectives of psychosocial interventions for people suffering from schizophrenia. The present preliminary study presents a novel approach of social skills training (SST) based on the proposals of Kopelowicz et al. (Kopelowicz, A., Liberman, R. P., and Zarate, R., 2006. Schizophr. Bull. 32 (1): S12-23) that link the treatment to seven specific target behaviours: social perception, social information processing, responding and sending skills, affiliative skills, interactional skills, and behaviour governed by social norms. Thirty-one stabilised outpatients were randomly assigned to one of two groups, SST (n=13) or treatment-as-usual (n=18) (TAU; case management, medication adherence, psychotherapy, leisure engagement, and family support) and were assessed at baseline in cognitive performance, clinical symptomatology, social cognition, and psychosocial functioning. These outcomes were evaluated across post-treatment and at the 6-month follow-up appointment. SST subjects showed improvements in psychopathology, social discomfort, social cognition (self-regulation statements during interactions), social withdrawal, interpersonal communication, and quality of life compared with the TAU group. At the 6-month follow-up, results were maintained for negative symptoms, social discomfort, and some functioning outcomes. Neuropsychological variables were also examined, as mediators of benefit from skills training. Results support the efficacy of the brief SST for outpatients with schizophrenia and show the need to implement empirically supported interventions in mental health services to enhance patients' social functioning and quality of life.

Integrated treatment to achieve functional recovery for first-episode psychosis

This study describes an integrated treatment approach that was implemented to enhance functional recovery in first-episode psychotic patients. Patients were randomized to two treatment conditions: either to an integrated treatment approach: pharmacotherapy, psychosocial treatment, and psychoeducation (experimental group: N = 39) or to medication alone (control group: N = 34). Patients were evaluated at baseline and after one year of treatment. Functional recovery was assessed according to symptomatic and functional remission. At the end of treatment, experimental patients showed a 94.9% of symptomatic remission compared to 58.8% of the control group. Functional remission was 56.4% for the experimental group and 3.6% for the control group, while 56.4% of the experimental group met both symptomatic and functional remission criteria and were considered recovered compared to 2.9% of the control group.

Strategies for addressing adherence problems in patients with serious and persistent mental illness: recommendations from the expert consensus guidelines

Poor adherence to medication can have devastating consequences for patients with serious mental illness. The literature review and recommendations in this article are reprinted from The Expert Consensus Guideline Series: Adherence Problems in Patients with Serious and Persistent Mental Illness, published in 2009. The expert consensus survey (39 questions, 521 options) on adherence problems in schizophrenia and bipolar disorder was completed by 41 experts in 2008. This article first reviews the literature on interventions aimed at improving adherence. It then presents the experts' recommendations for targeting factors that can contribute to nonadherence and relates them to the literature. The following psychosocial/programmatic and pharmacologic interventions were rated first line for specific problems that can lead to nonadherence: ongoing symptom/ side-effect monitoring for persistent symptoms or side effects; services targeting logistic problems; medication monitoring/environmental supports (e.g., Cognitive Adaptation Training, assertive community treatment) for lack of routines or cognitive deficits; and adjusting the dose or switching to a different oral antipsychotic for persistent side effects (also high second-line for persistent symptoms). Among pharmacologic interventions, the experts gave high second-line ratings to switching to a long-acting antipsychotic when lack of insight, substance use, persistent symptoms, logistic problems, lack of routines, or lack of family/ social support interfere with adherence and to simplifying the treatment regimen when logistic problems, lack of routines, cognitive deficits, or lack of family/social support interfere with adherence. Psychosocial/programmatic interventions that received high second-line ratings in a number of situations included medication monitoring/environmental supports, patient psychoeducation, more frequent and/or longer visits if possible, cognitive behavioral therapy (CBT), family-focused therapy, and services targeting logistic problems. It is important to identify specific factors that may be contributing to a patient's adherence problems in order to customize interventions and to consider using a multifaceted approach since multiple problems may be involved.

The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements

The Schizophrenia Patient Outcomes Research Team (PORT) psychosocial treatment recommendations provide a comprehensive summary of current evidence-based psychosocial treatment interventions for persons with schizophrenia. There have been 2 previous sets of psychosocial treatment recommendations (Lehman AF, Steinwachs DM. Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophr Bull. 1998;24:1-10 and Lehman AF, Kreyenbuhl J, Buchanan RW, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophr Bull. 2004;30:193-217). This article reports the third set of PORT recommendations that includes updated reviews in 7 areas as well as adding 5 new areas of review. Members of the psychosocial Evidence Review Group conducted reviews of the literature in each intervention area and drafted the recommendation or summary statement with supporting discussion. A Psychosocial Advisory Committee was consulted in all aspects of the review, and an expert panel commented on draft recommendations and summary statements. Our review process produced 8 treatment recommendations in the following areas: assertive community treatment, supported employment, cognitive behavioral therapy, family-based services, token economy, skills training, psychosocial interventions for alcohol and substance use disorders, and psychosocial interventions for weight management. Reviews of treatments focused on medication adherence, cognitive remediation, psychosocial treatments for recent onset schizophrenia, and peer support and peer-delivered services indicated that none of these treatment areas yet have enough evidence to merit a treatment recommendation, though each is an emerging area of interest. This update of PORT psychosocial treatment recommendations underscores both the expansion of knowledge regarding psychosocial treatments for persons with schizophrenia at the same time as the limitations in their implementation in clinical practice settings.