Psychosocial Interventions for Patients with Schizophrenia

Goorah Deenoo BHARATHI, Nan HUANG, Zheng LU,*

· Review ·

Psychosocial Interventions for Patients with Schizophrenia

Goorah Deenoo BHARATHI1, Nan HUANG2, Zheng LU1,2*

The comprehensive treatment of schizophrenia is not limited to pharmacotherapy; it also involves the provision of ongoing support and psychosocial interventions aimed at the social rehabilitation of the patient. Research about nonpharmacological treatments for people with schizophrenia is limited in China but studies from other countries have shown that psychosocial interventions can decrease the risk of relapse and re-hospitalization. Symptom reduction remains an important treatment goal in schizophrenia but patients and their family members are often more concerned about the functional impairments in work, education, independent living and socialization. Thus, patients with schizophrenia would benefit from interventions that target reduction in their level of disability. This article reviews the main psychosocial interventions that have been used effectively in patients with schizophrenia in China—cognitive-behavioral therapy, social skills training, family intervention therapy, cognitive remediation, psycho-education, vocational training, crisis intervention,and integrated psychotherapy—and discusses differences between the use of psychosocial interventions in China and abroad.

Schizophrenia; Nonpharmacological treatment; Psychosocial Interventions

1 Introduction

Antipsychotic medications, the standard treatment for schizophrenia, are generally quite effective in reducing the positive symptoms of schizophrenia but they have only a modest effect on the negative symptoms of schizophrenia. Pharmacotherapy alone tends to produce only limited improvements in social functioning and quality of life. Serious disability often persists throughout the patient’s lifetime despite‘successful’ treatment of the clinical symptoms[1]. A recent publication from the CATIE trial noted that only small improvements in psychosocial functioning were observed in patients taking atypical antipsychotics[2].Adjunctive treatment with supportive psychosocial therapies help alleviate residual symptoms and improve social functioning and quality of life. A recent randomized controlled trial involving ten clinical sites in China concluded that patients with early stage schizophrenia receiving combined treatment with medication and a psychosocial intervention have a lower rate of changing or stopping treatment, a lower risk of relapse, improved insight, a better quality of life,and better social functioning[3]. This article reviews the main psychosocial interventions that have been used effectively in patients with schizophrenia including cognitive-behavioral therapy, family intervention therapy, social skills training and cognitive remediation.We also introduce other therapeutic approaches that have become popular in mainland China: psychoeducation, vocational rehabilitation, crisis intervention and integrated psychotherapy. The differences in the application of psychosocial interventions in China and other countries will also be addressed.

2 Psychosocial interventions in China and abroad

In economically developed countries psychosocial interventions have been a fundamental part of the comprehensive treatment provided to individuals with schizophrenia since the 1980s. These interventions address a wide range of issues including adherence,symptom reduction, relapse and re-hospitalization,patient functionality and family adjustment. In China this kind of treatment is still underdeveloped. During the cultural revolution era (1966-1976) psychotherapy was totally prohibited and reading the maxims in Chairman Mao’s ‘little red book’ was recommended treatment for persons with mental disorders, which were believed to be the result of weak will or inferior morality[4]. Despite the rapid socioeconomic changes of the 1980s and 1990s the future of Chinese psychiatry remained uncertain. Things started to improve after the 2002 promulgation of the “Ten Year Project on National Mental Health” by the Ministry of Health. Howeverthese more recent improvements in psychiatry did not have much effect on the development of psychotherapy which remained relatively slow, largely because of the lack of well-trained experts in this field.

Psychosocial interventions for schizophrenia in other countries are often divided into four broad categories:cognitive-behavioral therapy (CBT), family intervention therapy (FIT), social skills training (SST), and cognitive remediation therapy (CRT). 'Compliance therapy', a type of CBT, has also been shown to be effective in some patients with schizophrenia[5]. The 2007 guidelines on the prevention and treatment of schizophrenia in China mentions adjunctive psychosocial interventions such as cognitive-behavioral therapy, social skills training, family intervention therapy, vocational rehabilitation and crisis intervention[6]. Other therapies such as psychoeducation, vocational training, crisis intervention, and integrated psychotherapy are also becoming more popular in China. However, case management, personal therapy and art therapy were not included in the Chinese guidelines for the treatment of schizophrenia or in the 2009 updated version of evidence-based recommendations of the Patient Outcomes Research Team (PORT) in the United States, so they will not be discussed in this review.

Recent work on early intervention services in China aims to reduce the duration of untreated psychosis and improve outcome in the early course of the illness.The efficacy of primary preventive interventions during the prodromal period is a hot research topic both in China and abroad. The whole area of nonpharmacological treatments for schizophrenia is underresearched in China, but consistent data from foreign studies indicates that psychosocial interventions can decrease the risk of relapse and re-hospitalization.Adherence is particularly important because of its relationship to relapse; good adherence (i.e., levels of ≥80%) has been shown to decrease the risk of hospitalization by as much as 40%[7]. There is evidence to suggest that supportive psychosocial treatment is more cost-effective than standard care[8]. One study in Spain reported that combining psychosocial treatment with pharmacotherapy decreased the average cost of treatment per disability-adjusted life year by more than 40%[9]. Several psychosocial treatments (skills training therapy, family intervention therapy, cognitive behavioral therapy, supported employment, assertive community treatment and token economy interventions) were included in the Patient Outcomes Research Team (PORT) 2009 treatment recommendations for schizophrenia[10]and are considered evidence-based practice in foreign countries. Apart from the obvious need to select the form of psychosocial treatment that best addresses the needs of the individual patient, the usefulness of any psychosocial intervention may be influenced by the presence and severity of cognitive or affective disturbances, pharmacotherapeutic control of psychotic symptoms, and the extent of family support and participation in the patient's treatment.

3 Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT) has been accepted as a treatment for psychiatric disorders for a number of years and been fully integrated into psychiatric services in several countries since the 1980s.In China, however, CBT gained popularity much later;it is currently much more commonly employed in the treatment of depression and anxiety disorders than in the treatment of schizophrenia though it may be used as part of an integrated psychological therapy in the treatment of patients with schizophrenia. The majority of international trials of CBT for psychosis have targeted medication resistant positive symptoms[11];several review suggest that CBT is useful in the treatment of schizophrenia[12-18]. According to the PORT recommendations, people with schizophrenia who have persistent psychotic symptoms while receiving adequate pharmacotherapy should be offered adjunctive cognitive behaviorally oriented psychotherapy to reduce the severity of symptoms. There are more randomized controlled trials on the efficacy and effectiveness of CBT for medication-resistant schizophrenia than any other type of individual psychotherapy for schizophrenia[17,19].

In CBT links are made between the person's feelings and the patterns of thinking which underpin their distress. CBT attempts to achieve reduction of symptoms, reduction of relapse, and enhance functional capacity by providing rational perspectives on the patient's experience of disease symptoms and responses to them[20]. There are several forms of CBT but all of them focus on developing a strong therapeutic alliance and on psycho-education, that is, educating patients about schizophrenia and psychosis and emphasizing the critical role of medication in controlling symptoms and preventing relapse. Zeng and colleagues proposed a two-step strategy for CBT in patients with schizophrenia[21]. In the first step the therapist helps the patient consider the changes in themselves before and after their illness; this helps patients realize that they are unwell, enhances insight and improves medication adherence. In the second step the therapist asks the patient to identify the changes within themselves before and after treatment; this helps the patient recognize the bene fit of taking medications and, thus,improves medication adherence. Through these two steps, patients learn to recognize disease symptoms and early signs of relapse; they also acquire stress reduction techniques, coping strategies, and cognitive restructuring tools to help them deal appropriately with their symptoms[22].

Given the focus of developing a strong patient–physician alliance, traditional CBT does not include family members. The most consistent effect of CBT has been the improvement of positive and negative symptoms[23,24]. In a meta-analysis focusing exclusively on positive symptoms, symptom reduction was 35%greater in CBT patients than in controls, and the success rate for reducing positive symptoms increased from 41% in controls to 59% with CBT[25]. Jiang and colleagues explored the effectiveness of CBT on social functioning and found that patients who received CBT had significant improvement in scores on the Social Disability Symptoms Scale, decreased re-hospitalization and relapse rates; and these beneficial effects lasted up to one year after the CBT treatment[26]. And a study of five group sessions of CBT with stabilized schizophrenia patients reported a significant improvement in their depressive symptoms[27].

In western studies Compliance Therapy (CT), a form of CBT developed specifically to improve medication adherence, has been shown to enhance adherence for as long as 18 months after the end of the program[28].In China a two-year follow-up study by Zhang and colleagues found that CBT can improve insight in patients with paranoid schizophrenia and enhance their adherence[29]. The positive effects of CBT can also be seen in the early stages of schizophrenia; providing CBT during the prodromal phase of the illness has been reported to reduce global psychopathology, symptoms,and social dysfunction[30]. An additional positive outcome associated with CBT was improved mental state[31]. The effects of CBT have generally been found to be long-lasting, with effects ranging from 6 months to 2 years after the cessation of treatment[32].

4 Family intervention therapy

Patients with schizophrenia who experience criticism and hostility from their family have been reported to experience relapse more frequently than people with similar problems from families which tend to be less expressive of emotions[33]. There are several reasons for providing services to families of persons with a severe mental illness. Firstly, many people with severe mental illness either live with family members(parents, spouses, siblings or children) or maintain regular contact with their relatives. Secondly, having a close relationship with someone with a severe mental illness and providing care to that person can be extremely demanding for relatives[34]. Thirdly,high levels of stress in the family, often related to the burden of care-giving, can have a negative effect on the mental illness, increasing the risk of relapse and re-hospitalization[35]. Key elements of effective family interventions include education about the illness, crisis intervention, emotional support and training in how to cope with the patient’s symptoms and with related problems. Family members and patients learn to better understand both schizophrenia and the critical role antipsychotic medication adherence plays in reducing the risk of relapse[36].

Family interventions are not as popular in China as they are abroad mainly because it is not convenient for family members who work full time to accompany patients for frequent therapy sessions. However■researcher in China confirms the effectiveness of various family interventions in reducing relapse and rehospitalization, improving adherence and decreasing family burden[37], particularly for first-episode patients[38]. In a recent three-year follow-up study Chen and colleagues concluded that an individual family intervention for patients with schizophrenia who had been discharged from hospital following remission of symptoms reduced their level of disability, relapse rates and re-hospitalization rates and also increased their reemployment rates[39]. Patients with schizophrenia in China are much more likely to live with family members than in most economically developed countries so their relatives are more likely to be effective emotionally and economically, so they are more prone to anxiety depression. Recent studies conclude that psychoeducation for relatives of patients with a first episode of schizophrenia can reduce disease burden of both family members and patients; furthermore, psycho-education can also help patients adapt to family life and social life[40,41]. In Chinese society, the family not only plays an important role in the patient's social support system,but it is also an active participant in the treatment and rehabilitation process. Hou and colleagues concluded that psycho-education for patients and caregivers helped improve their understanding of patients’symptoms and resulted in better functional outcome for the patients[42]. A three-year follow-up study reported that patients who received family intervention therapy had lower scores on the Brief Psychiatric Rating Scale(BPRS) and on the Social Disability Screening Scale(SDSS), lower medical expenses, higher adherence and remission rates, and improved insight[43].

A meta-analyses found that the participation of family members in therapy was associated with fewer relapses and re-hospitalizations for patients with schizophrenia[44]. In a comparison with all other treatments, family intervention therapy has a greater positive effect on adherence[45,46]. Other positive family outcomes include reduced patient as well as family burden and increased satisfaction with family relationships[47]. However, the duration of the beneficial effects of family intervention therapy is variable.Improvements in functional outcomes and decreases in disease burden have been reported at 6- to 9-month follow-ups[48]and the positive effects on relapse and rehospitalization have been reported to last for as long as 18 months, but such effects begin to dissipate after two years and are generally non-observable after five years. Therapies that include both patients and family members may extend the time to re-hospitalization and differentially influence long-term outcome[28].

5 Social skills training

Social skills training (SST) is a long-established psychosocial adjuvant in the treatment of schizophrenia.The PORT project recommends that individuals with schizophrenia who have deficits in skills that are needed for everyday activities should be offered skills training in order to improve social interactions, independent living,and other skills that have clear relevance to community functioning[10]. It is a strategy aimed at enhancing social performance and reducing distress and difficulty experienced by people with schizophrenia. Social skills training utilizes behavior therapy principles and techniques for teaching individuals to communicate their emotions and requests so that they are more likely to achieve their goals and meet their needs for relationships and roles required for independent living.

SST learning modules cover such areas as selfcare, medication and symptom management, basic conversation, vocational skills, and recreation. Each skill set is addressed separately in order to facilitate learning. Role play and application in the natural environment are used to increase the probability that acquired skills will generalize into aspects of everyday life after treatment has ended. SST strategies are diverse in addressing such varied domains as occupational and vocational skills training, social milieu training,conversational skills training, assertiveness training,and training in the importance of medication use and disease management[49]. A meta-analysis of randomized controlled trials of social skills training conducted by Kurtz and colleagues confirmed the efficacy of social skills training for improving psychosocial functioning in schizophrenia[50].

In China SST is primarily carried out in hospitals and is based on relatively simple methods. The small number of studies about SST in China conclude that SST is effective in reducing the negative symptoms of patients with schizophrenia[51-53]. Community-based studies with SST in China report enhanced adherence and reduced rates of relapse and re-hospitalization[54,55].Pan and colleagues provided six weeks of SST to 50 patients in remission and found less social phobia,decreased levels of distress, improved social adaptation,and enhanced self-con fidence and self-esteem[56]. There are currently few community health centers in China so patients with schizophrenia often need to attend day care centers or outpatient clinics in hospitals; as community health services are expanded around the country it is expected that they will also assume an important role in the provision of community mental health services.

Programs such as the UCLA Social and Independent Living Skills Program are aimed at a wide range of skills. Some reports indicate benefits in functionality,reduction in co-morbid substance abuse and improvements in symptoms, benefits that may persist for one to two years[57]. When individuals have been equipped with skills to deal with stressful life events and daily hassles they are more proficient in solving problems and challenges that arise in their lives;and, consequently, stressors are less likely to trigger exacerbations or social decompensation[58]. The protective effects of social skills training also help individuals stabilize their illnesses, improve adherence to medication and psychosocial treatment, and promote progress toward recovery[59].

6 Cognitive remediation therapy

Cognitive deficits (impaired memory, attention and executive functioning) are common among patients with schizophrenia and can significantly impair psychosocial functioning and the patient’s response to psychosocial treatment. Specific cognitive impairments associated with negative symptoms directly affect working memory and, thus, functioning in interpersonal relationships. This reflects a synergistic association between symptoms and cognition: negative symptoms arise from cognitive impairment but also impact detrimentally on the functioning of working memory.To maximize the improvement on social functioning,cognitive remediation needs to focus on both cognitive processes and negative symptoms[60,61]. Unfortunately,cognitive dysfunction is not reliably improved by antipsychotic medications[57]so psychosocial approaches are the main methods for addressing these problems.The class of behavioral treatments known as “cognitive remediation” specifically target the memory, attention,reasoning and similar capacities with the ultimate aim of enhancing everyday functioning. Its hypothesized that when addressing cognitive dysfunction directly by using Cognitive Remediation Therapy (CRT) patients' insight into their illness will increase and, thus, their adherence with pharmacotherapy will improve. The ideal outcome is restoration of cognitive functioning, but this is often not feasible so CRT also employs strategies aimed at compensating for cognitive impairment[61]. Tactics used in CRT include repetitive supervised exercises, positive reinforcement, and “errorless learning” (in which a task is broken into ordered components and training proceeds from the simplest components to the most complex). CRT consistently improves performance on neuropsychological tests of cognitive function in patients with schizophrenia[62]. It also improves patients’ insight into their illness, problem solving skills,social autonomy and everyday functioning. Cognitive remediation therapy is not frequently practiced by therapists in China.

7 Psychoeducation, Vocational rehabilitation and Crisis intervention

Psychosocial interventions for schizophrenia in China includes the four evidence-based practices:psycho-education, family intervention, skills training and cognitive behavior therapy. Crisis intervention,group therapy and vocational rehabilitation are other psychosocial interventions that have been employed in China. Psycho-education in China involves teaching patients and caregivers about symptoms,treatment and the course of schizophrenia; the goal of these approaches is usually to improve medication adherence and, thus, to reduce relapse. Educational programs for caregivers of patients with schizophrenia in China often focus on a wider range of targets including empathic engagement, ongoing support,better access to clinical resources, social network enhancement, and increased problem-solving, coping and communication skills. Educational interventions that affect these attitudes may be an important part of psychosocial intervention[63]. Vocational rehabilitation programs focus on vocational issues, such as obtaining employment or enhancing interview skills, and have been shown to improve employment outcomes. Crisis intervention involves preparing family members and caregivers to deal with the crises that can occur in individuals with serious mental illnesses. This training improves their attitudes about patients’ aggressiveness and violence, increases their support of local treatment programs, enhances their knowledge about the illness,and decreases the social distance between patient and caregiver.

8 Integrated Psychosocial Therapy

A number of integrated strategies combine aspects of cognitive behavior therapy, family intervention therapy, social skills training, and cognitive remediation therapy in an attempt to enhance the strengths and minimize the weaknesses of each approach[64].Examples of integrated therapies include Functional Adaption Skills Training (FAST), Cognitive Adaptation Training (CAT), and Integrated Psychological Therapy(IPT)[65]. International studies of integrated psychosocial approaches to schizophrenia usually combine social skills training with CBT or family intervention therapy for patients who are in remission. Therapists in China prefer Integrated Psychosocial Therapy (IPT)as it aims at a broader range of domains and, thus,maximizes the bene fits of treatment. Results of a metaanalysis showed that IPT could significantly improve cognitive function, positive and negative symptoms,and social function for up to eight months after the intervention[65]. Research on recent-onset schizophrenia in China finds that IPT reduces illness burden, decreases relapse, and improves social functioning[66-68]. Thorup and colleagues in the Danish OPUS study concluded that integrated approaches are crucial because different components of the integrated treatment contributed to the reduction of both negative and positive symptoms of schizophrenia in their sample[69]. A recent study carried out in China had similar results[70].

9 How psychosocial interventions in China differ from those provided in other countries

Psychosocial interventions in China differ from those employed in other countries primarily because of differences in culture, social structure, the organization of the health care system, and the relative scarcity of social welfare services for severely mentally ill individuals in China. These differences make it necessary to adapt the specific steps of Western psychosocial interventions when applying them to Chinese patients,but the underlying principles are the same.

Despite the reduced frequency of acute episodes as patients age, over 60% of elderly individuals with schizophrenia in the United States reside in assisted care settings ( e.g., board and care homes)[1]. Many of these individuals would benefit from interventions targeting disability reduction. But in China the vast majority of patients with schizophrenia live with their family members because of the limited social welfare services available for severely mentally ill individuals[3].This greatly increases the family burden particularly if the patient needs to have frequent contacts with the health care system. There are a limited number of daycare centers in large urban areas in China that patients can attend daily (without the involvement of family members) where they get supervised medication and different types of psychosocial interventions. But the majority of patients with schizophrenia in China do not have access to these services. This lack of services is the greatest current weakness in China’s community service network for persons with severe mental illnesses.

Psychosocial interventions have become more popular in recent decades in China, but the number of well-trained therapists remains limited[3]. Improving the effectiveness of psychosocial interventions for the seriously mentally ill in China will require training more high-quality therapists. In cities like Beijing, Shanghai,Qingdao, Yantai and Yangzhou, all mental health centers and day-care centers provide psychosocial interventions but that is not the case in other parts of China,particularly in the rural areas. Psychological treatments are not available in small towns or village hospitals so patients and their family members living in these locations (the majorityof the population) are limited to pharmacological treatments.

Finally, the Asians are somewhat less willing to reveal or discuss their family problems than individuals from Western countries so they are less likely to seek help for a mentally ill family member. This problem is magnified by the social stigma associated with mental illness, so low rates of care-seeking remains a significant hurdle in the improvement of psychiatric care in China.In some rural parts of the country families may seek help from religious healers some of whom recommend taking a non-medical approach to the management of those with severe mental illnesses. Overall the proportion of individuals in China with schizophrenia who obtain help from individuals trained to provide psychosocial interventions is very small, though this proportion has been gradually increasing over the last decade.

10 Conclusions

Providing adjunctive psychosocial interventions to patients with schizophrenia who are receiving antipsychotic medications enhances treatment outcomes across a broad range of domains. Different psychosocial methods are targeted on different aspects of patients’dysfunction but structured administration of these approaches can be effective unless the illness is complicated by serious cognitive impairment; in these cases integrated patient-specific approaches that include targeting the specific cognitive limitations have the best outcomes. The positive effects of psychosocial interventions usually dissipate after about two years(though some reports indicate these effects can persist for up to five years) so these interventions may need to be continued indefinitely or repeated regularly.Continued research in this field is needed to adapt approaches for different cultural settings, to identify the patient groups that bene fit most from the different approaches, and to determine the best ways to train the medical professionals needed to provide these services.

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精神分裂症患者的心理社会干预

白哈拉桑1黄楠2陆峥1,2

1上海同济大学附属同济医院心身科 200065；2上海交通大学医学院附属精神卫生中心 200030。

陆峥，电子信箱：luzheng@tongji.edu.cn

精神分裂症的治疗不仅包括药物治疗，还包括为患者提供支持、有效的信息、心理社会干预以及康复治疗。中国的研究者在精神分裂症患者非药物治疗领域进行着各项研究，而国外研究数据一致显示心理社会干预可以降低复发率和再住院率。尽管缓解症状仍然是精神分裂症治疗的一个重要目标，但工作、学习、独立生活及社会化方面的功能损伤往往也是患者及其家属关注的重点。因此，精神分裂症患者更有可能从着重于减轻残疾的干预中获益。本文对中外有效应用于精神分裂症患者的主要心理社会干预进行综述，包括认知行为治疗、社会技能训练、家庭干预、认知纠正、心理教育、职业训练、危机干预及综合心理治疗；同时就中外心理社会干预的差异进行讨论。

精神分裂症 非药物治疗 心理社会干预

10.3969/j. issn. 1002-0829. 2011. 06. 008

1Department of Psychiatry, Tongji Hospital, Tongji University, Shanghai 200065, China

2Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030,China.

*Correspondence: luzheng@tongji.edu.cn