Schizophrenia Research
Volume 100, Issue 1 , Pages 108-119, March 2008

Adjunctive psychosocial therapies for the treatment of schizophrenia

  • Thomas L. Patterson

      Affiliations

    • Department of Psychiatry, University of California, San Diego, La Jolla, CA 92093-0680, United States
    • Corresponding Author InformationCorresponding author. Tel.: +1 858 534 3354; fax: +1 858 534 7723.
    • ,
  • Oscar R. Leeuwenkamp

      Affiliations

    • NV Organon, a part of Schering-Plough, Oss, The Netherlands

Received 22 June 2007; received in revised form 4 December 2007; accepted 6 December 2007. published online 16 January 2008.

Article Outline

Abstract 

Antipsychotic pharmacotherapy is the standard of care for the treatment of schizophrenia. Although pharmacotherapy effectively improves some symptoms, others can remain. Pharmacotherapy alone also tends to produce only limited improvement in social functioning and quality of life. Supportive psychosocial therapies have been used as adjuncts to pharmacotherapy to help alleviate residual symptoms and to improve social functioning and quality of life. Additionally, therapies with psychoeducational components can focus on improving medication adherence and reducing relapse and rehospitalization. This review describes the major psychosocial therapeutic strategies that have been used effectively in patients with schizophrenia (cognitive-behavioral therapy, family intervention, social skills, and cognitive remediation), with emphasis on their utility in improving medication adherence. Therapies that integrate various psychosocial therapeutic approaches are also discussed. It is concluded that psychosocial therapy is an effective adjunct to pharmacotherapy for schizophrenia. However, these therapies vary significantly in the functional domains that they address. It is therefore important to identify the form of psychosocial intervention most likely to benefit the individual patient, and to recognize that the effectiveness of any psychosocial intervention could be influenced by such factors as the presence and severity of psychotic or affective symptoms or cognitive impairment.

Keywords: Schizophrenia, Psychosocial therapy, Psychopathology, Adherence, Social functioning

 

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1. Introduction 

Antipsychotic pharmacotherapy is the standard of care for schizophrenia because it effectively controls acute psychotic symptoms. In this regard, atypical antipsychotics represented a significant improvement over first-generation antipsychotics. Atypical antipsychotics, in particular clozapine, are at least as efficacious as typical antipsychotics and have a lower propensity for inducing some types of adverse events, such as extrapyramidal symptoms (Chakos et al., 2001, Luft and Taylor, 2006).

However, even with pharmacotherapy, residual symptoms of schizophrenia are common. In one review, it was noted that 10% to 60% of patients experience psychotic symptoms that are resistant to medication (Lindenmayer, 2000). Additionally, medication adherence with antipsychotics is relatively poor (Lieberman et al., 2005, Nasrallah and Lasser, 2006). For example, the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) reported nonadherence rates of >60% for every treatment examined (Lieberman et al., 2005). This fact may account at least in part for the high rates of relapse and rehospitalization in patients with schizophrenia, rates that are as high as 30% after 1 year and 80% after 5 years (Dossenbach et al., 2005, Gumley et al., 2006, Robinson et al., 1999). Additionally, symptoms frequently improve during antipsychotic therapy, but functional outcomes do not. A recent publication of data from the CATIE trial noted that only small improvements in psychosocial functioning were observed in patients taking atypical antipsychotics (Swartz et al., 2007). Hence treatment strategies that supplement pharmaceutical therapy are clearly desirable.

Psychosocial treatment can directly address a wide range of issues, including adherence, symptom reduction, relapse and hospitalization, patient functionality, and family adjustment. Adherence is particularly important because of its relationship to relapse. Good adherence (ie, levels of ≥80%) has been shown to decrease the risk of hospitalization by as much as 40% (Ward et al., 2006).

In reporting the effects of psychosocial treatment as an adjunct to pharmacotherapy, comparisons are often made with pharmacotherapy alone or in combination with “standard care,” which includes such modalities as medication monitoring and supportive counseling.

There is evidence to suggest that supportive psychosocial treatment is more cost-effective than standard care (Gutierrez-Recacha et al., 2006, Stant et al., 2003). One study reported that combining psychosocial treatment with pharmacotherapy decreased the average cost of treatment per disability-adjusted life year by more than 40% (Gutierrez-Recacha et al., 2006).

An exhaustive review of psychosocial modalities is beyond the scope of this article. Instead, we focus on 4 main categories of psychosocial therapy that have been used effectively in patients with schizophrenia, with emphasis on improvement of medication adherence. Other modalities, such as supported (or “sheltered”) employment, are not addressed in this review. The therapeutic approaches included were identified by a literature search (Medline Ovid 1966 to present) on the terms “schizophrenia AND (psychosocial intervention OR psychosocial therapy OR nonpharmacologic therapy OR psychosocial occupational therapy)”.

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2. Overview of psychosocial therapies 

Psychosocial therapies may be divided into 4 broad categories: cognitive-behavioral therapy (CBT), family intervention therapy (FIT), social skills therapy (SST), and cognitive remediation therapy (CRT) (Pfammatter et al., 2006, Roder et al., 2002). A brief list of specific treatment programs in each category can be found in Table 1. The duration of treatment across and within categories varies from as brief as 6 weeks to as long as 2 years (Bustillo et al., 2001, Pfammatter et al., 2006, Pilling et al., 2002, Zimmermann et al., 2005).

Table 1. Psychosocial programs used in patients with schizophrenia
Program nameBrief description
Abilities Assessment and Objective Setting (AAOS) (Pioli et al., 2006)SST and CBT focusing on skill and task objectives and psychoeducation aimed at relapse identification and medication adherence
Cognitive Adaptation Training (CAT) (Velligan et al., 2006)SST and CRT using environmental supports to address apathy and disinhibition in the context of impaired executive function
Compliance Therapy (CT) (Kemp et al., 1996)CBT with focus on improving medication adherence
Computer-Assisted Cognitive Strategy Training (CAST) (Vauth et al., 2005)CRT designed to target cognitive dysfunction
Diversified Placement Approach (DPA) (Koop et al., 2004)SST providing intensive vocational services in stepwise fashion
Functional Adaptation Skills Training (FAST) (Patterson et al., 2003, Patterson et al., 2006)Combines CBT and SST to improve functioning in older patients
Functional Cognitive-Behavioral Therapy (FCBT) (Cather, 2005)CBT with focus on improved social functioning
Hallucination-focused Integrated Treatment (HIT) (Wiersma et al., 2004)CBT and FIT integrated with rehabilitative efforts and mobile crisis intervention to improve coping and antipsychotic medication adherence
Indianapolis Vocational Intervention Program (IVIP) (Lysaker et al., 2005)CBT with focus on negative beliefs impacting vocational function
Integrated Psychological Therapy (IPT) (Roder et al., 2006)Combines group-based CBT with neurocognitive and social cognitive remediation with psychosocial rehabilitation
Programa de Entrenamiento para el Desarrollo de Aptitudes para Latinos (PEDAL) (Patterson et al., 2005)Combines CBT and SST to improve functioning in older Latino patients
Psychosocial Occupational Therapy (Allen, 1988)SST using expressive, artistic, and recreational activities mediated with supportive therapy
Training of Self-management Skills for Negative Symptoms (TSSN) (Vauth et al., 2005)SST designed to target negative symptoms
UCLA Social and Independent Living Skills Program (Liberman et al., 1998)SST in diverse areas of social and daily living

CBT = cognitive-behavioral therapy; CRT = cognitive remediation therapy; FIT = family intervention therapy; SST = social skills therapy.

Each category has strengths and weaknesses relating to its particular therapeutic focus. A number of integrated strategies combine aspects of CBT, FIT, SST, or CRT in an attempt to enhance the strengths and minimize the weaknesses of each approach (Cather, 2005, Lysaker et al., 2005, Patterson et al., 2005, Patterson et al., 2006, Pioli et al., 2006, Roder et al., 2006, Velligan et al., 2006, Wiersma et al., 2004). Examples of integrated therapies include Functional Adaption Skills Training (FAST), the Program for Training and Development of Skills in Latinos (Programa de Entrenamiento para el Desarrollo de Aptitudes para Latinos, PEDAL), Cognitive Adaptation Training (CAT), and Integrated Psychological Therapy (IPT) (Patterson et al., 2003, Patterson et al., 2005, Patterson et al., 2006, Roder et al., 2006, Velligan et al., 2006).

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 therapy program may be influenced by such factors as 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.

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3. Cognitive-behavioral therapy 

3.1. Therapeutic focus 

CBT attempts to achieve reduction of symptoms, reduction of relapse, and enhanced functional capacity by providing rational perspectives on the patient's experience of disease symptoms and responses to them (Dickerson and Lehman, 2006). Within the context of a dialogue, the patient describes his or her experiences with schizophrenia and, with the clinician's help, learns to better understand and cope with those experiences. Simultaneously, the clinician identifies issues that are especially problematic for the patient.

CBT exists in several forms, but all of them focus on developing a strong therapeutic alliance and on psycho-education, i.e., informing patients about schizophrenia and psychosis and emphasizing the critical role of medication in controlling symptoms and preventing relapse. Patients thus learn to recognize disease symptoms and early signs of relapse, and they acquire stress reduction techniques, coping strategies, and cognitive restructuring tools to help them deal appropriately with their symptoms (Bellack, 2004). Given the focus of developing a strong patient–physician alliance, traditional CBT does not typically include family members.

3.2. Positive outcomes 

The most consistent effect of CBT has been the improvement of positive and negative symptoms (Bechdolf et al., 2005a, Bechdolf et al., 2005b, Drury et al., 1996, Gumley et al., 2006, Kemp et al., 1996, Kemp et al., 1998, Kuipers et al., 1997, Sensky et al., 2000, Startup et al., 2005, Tarrier et al., 1999, Tarrier et al., 2004, Temple and Ho, 2005). Recent meta-analyses of CBT support the findings of individual studies (Pfammatter et al., 2006, Zimmermann et al., 2005). 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 (Zimmermann et al., 2005). In this meta-analysis, the overall fixed effect model effect size (FEM ES; in this case, Hedges' g) of CBT on positive symptoms was 0.35, with greater effect during acute psychotic episodes (ES, 0.57) than in the chronic state (ES, 0.27). A meta-analysis of meta-analyses of CBT effects concluded that CBT led to substantial declines in general psychopathology (Hedges' g ES, 0.45) and persistent reductions in positive symptoms (ES, 0.47) (Pfammatter et al., 2006).

CBT may also improve medication adherence. 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 (Kemp et al., 1996, Kemp et al., 1998). In another report, CT and behavior-modification regimes were considered effective although the need for more research was acknowledged (Dodds et al., 2000). However, other research has questioned the utility of CT in patients with schizophrenia, finding no notable benefit in terms of improved compliance or positive changes in symptoms, attitude, insight, functionality, or quality of life (O'Donnell et al., 2003), and no clear evidence of advantage over nonspecific patient counseling (McIntosh et al., 2006).

The positive effects of CBT can be seen in the early stages of schizophrenia. Applying CBT during the prodromal phase has been reported to reduce global psychopathology, symptoms, and social dysfunction (Bechdolf et al., 2005b). An additional positive outcome associated with CBT is improved mental state (Gumley et al., 2006). The effects of CBT have generally been found to be long-lasting, with effects lasting from 6 months to 2 years after the cessation of treatment (Bechdolf et al., 2005a, Drury et al., 1996, Sensky et al., 2000, Startup et al., 2005, Tarrier et al., 1999, Temple and Ho, 2005).

3.3. Limitations 

CBT effects on global and social functioning are equivocal (Bechdolf et al., 2005b, Kuipers et al., 1997, Startup et al., 2005, Temple and Ho, 2005), perhaps because of its focus on reducing symptoms and relapse. This limitation is important because poor social and occupational function has been associated with lower perceived quality of life in individuals with schizophrenia (Bengtsson-Tops and Hansson, 1999). The FAST and PEDAL programs were initiated to improve functionality in patients with psychotic disorders (Patterson et al., 2003, Patterson et al., 2005, Patterson et al., 2006).

Timing is also relevant. CBT techniques may be more effective during acute psychotic episodes (Zimmermann et al., 2005). Finally, aside from the fact that the reported effectiveness of CBT on medication adherence has been mixed, CBT has not consistently reduced rates of relapse and rehospitalization (Gumley et al., 2006, Startup et al., 2004, Tarrier et al., 2004). Additionally, CBT techniques can be difficult to implement (Siddle and Kingdon, 2000). However, the fact that supportive CBT is the standard of care in the United Kingdom shows that this limitation is not insurmountable and that there is still a widely held perception that CBT is useful in this population.

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4. Family intervention therapy 

4.1. Therapeutic focus 

The families of individuals with schizophrenia are affected both financially and emotionally. Furthermore, patients who experience criticism and hostility from their families have been reported to experience relapse more frequently (Vaughan et al., 1992). The Patient Outcomes Research Team (PORT) project has recommended that family intervention be provided to both family and nonfamily caregivers of schizophrenics (Lehman and Steinwachs, 2003).

The fundamental components of FIT are psychoeducational. Domains addressed include the illness, family support, crisis intervention, and problem solving (Lehman and Steinwachs, 2003). Family members, and where applicable, the patient as well, learn to better understand both schizophrenia and the critical role that antipsychotic medication adherence plays in reducing the risk of relapse (Pitschel-Walz et al., 2001). In addition, families learn skills that enable them to effectively deal with nonadherence and relapse, as well as techniques they can use to support the patient and to cope with the stress of having a family member with schizophrenia.

4.2. Positive outcomes 

The most consistently reported positive outcomes of FIT are reductions in relapse and in the number and duration of rehospitalizations (Buchkremer et al., 1997, Falloon et al., 1982, Falloon et al., 1985, Hogarty et al., 1986, Leff et al., 1990, Lenior et al., 2001, Linszen et al., 1996, McFarlane et al., 1995a, McFarlane et al., 1995b, Randolph et al., 1994, Ro-Trock et al., 1977, Tomaras et al., 2000, Xiong et al., 1994). These findings have been confirmed by meta-analyses (Pfammatter et al., 2006, Pilling et al., 2002, Pitschel-Walz et al., 2001). A meta-analysis that included 12 studies of FIT showed that this modality was more effective than standard care at reducing relapse rates at 1- to 2-year follow-up (overall ES, 0.20); however, no clear advantage is seen for FIT over other forms of patient-oriented therapy (Pitschel-Walz et al., 2001). The review of meta-analyses concluded that schizophrenic patients with family participating in therapy had significantly fewer relapses (Hedges' g ES, 0.42 at 6- to 12-month follow-up) and rehospitalizations (ES, 0.51 at 18- to 24-month follow-up) (Pfammatter et al., 2006). Meta-analyses have also indicated that FIT may improve treatment adherence (Pharoah et al., 2006, Pilling et al., 2002). In a comparison with all other treatments, FIT had a greater positive effect on adherence (Hedges' g ES, 0.63) (Pilling et al., 2002).

Improved social functioning is commonly reported following FIT, although these findings are less robust than the effects on relapse and hospitalization (Barrowclough and Tarrier, 1990, Chien et al., 2005, Falloon et al., 1987, Li and Arthur, 2005, Magliano et al., 2006a, Magliano et al., 2006b, Veltro et al., 2006). FIT also reduces disease burden on the family and patient (Magliano et al., 2005, Magliano et al., 2006a, Magliano et al., 2006b, Veltro et al., 2006). Reduced disease burden is likely the result of both increased knowledge about schizophrenia and increased coping ability (Li and Arthur, 2005, Magliano et al., 2005). FIT has also been reported to reduce positive symptoms (Falloon et al., 1982, Falloon et al., 1985, Li and Arthur, 2005, Magliano et al., 2005, Montero et al., 2001).

The duration of beneficial effects with FIT is variable. Reliable improvements in functional outcome and decreases in disease burden have been reported at 6- to 9-month follow-ups (Magliano et al., 2006a, Magliano et al., 2006b). Positive effects on relapse and rehospitalization have been reported to last for as long as 18 months (Xiong et al., 1994). However, such effects begin to dissipate after 2 years and are generally nonobservable after 5 years (Hogarty et al., 1991, Montero et al., 2006). Therapies that include both patients and family may slightly extend the time to rehospitalization and differentially influence long-term outcome (Montero et al., 2006).

4.3. Limitations 

FIT may have limited effectiveness early in the course of disease. A study in which the duration of illness was <1 year and 52% of patients were experiencing a first psychotic episode showed no significant effects of FIT (Lenior et al., 2001). In contrast, in studies that have demonstrated the effectiveness of FIT, the average duration of illness ranged from 3 to 10 years (Falloon et al., 1982, Falloon et al., 1985, Li and Arthur, 2005, Magliano et al., 2005, Montero et al., 2001).

A major limiting factor for FIT can be a lack of available family members or an unwillingness of family members to participate. This problem may be particularly salient for older patients. Providing FIT to nonfamily caregivers, as suggested by the PORT project (Lehman and Steinwachs, 2003), can partially mitigate this problem.

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5. Social skills training 

5.1. Therapeutic focus 

With its focus on improving skills needed for everyday living, SST most directly addresses social functioning and quality of life. SST learning modules cover such areas of dysfunction as self-care, medication and symptom management, basic conversation, vocational skills, and recreation (Liberman et al., 1998). In more complex versions, impairments in information processing are addressed by providing skills for receiving, processing, and sending information. 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 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 (Evans et al., 2004, Glynn et al., 2002, Granholm et al., 2005, Liberman et al., 1998, Marder et al., 1996, Moriana et al., 2006, Shaner et al., 2003, Tsang, 2001, Tsang and Pearson, 2001, Yildiz et al., 2002).

5.2. Positive outcomes 

Programs that focus on vocational issues, such obtaining employment or enhancing interview skills, have been shown to improve employment outcomes (Evans et al., 2004, Tsang, 2001, Tsang and Pearson, 2001). The meta-analysis of Pfammatter et al. reported Hedges' g ES 0.77 for SST on skill acquisition at the completion of treatment and 0.52 at follow-up (Pfammatter et al., 2006). Programs such as the UCLA Social and Independent Living Skills Program (Liberman et al., 1998, Moriana et al., 2006) are aimed at a wide range of skills. Some reports indicate benefits in functionality (Chien et al., 2003, Liberman et al., 1998, Marder et al., 1996), reduction in comorbid substance abuse (Shaner et al., 2003), and improvement in symptoms (Chien et al., 2003, Dobson et al., 1995, Moriana et al., 2006, Roder et al., 2002, Yildiz et al., 2002); benefits may persist for 1 to 2 years (Liberman et al., 1998, Marder et al., 1996, Roder et al., 2002).

5.3. Limitations 

The primary limitation of SST is its focus on one or more specific skill sets. Because of this, the probability of generalization to domains outside the skill set(s) is limited. Of particular importance, the effectiveness of SST on medication adherence is uncertain. Some reports indicate measurable benefit (Shaner et al., 2003, Yildiz et al., 2002), but a more recent study found no advantage with SST over standard treatment (Morken et al., 2007). Correspondingly, the effectiveness of SST in reducing relapse risk is also questionable. In at least one study, SST delayed but did not prevent symptom exacerbation (Marder et al., 1996).

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6. Cognitive remediation therapy 

6.1. Therapeutic focus 

Cognitive deficits (impaired memory, attention, and executive function) are common among patients with schizophrenia and can significantly impair psychosocial outcome and response to psychosocial treatment (Evans et al., 2003, Green, 1996, Green et al., 2000). Furthermore, the degree of cognitive dysfunction shows direct correlation with the presence and severity of negative symptoms (Greenwood et al., 2005). Unfortunately, cognitive dysfunction is not reliably improved by antipsychotic medications (Daban et al., 2005, Wagner et al., 2005, White et al., 2006). It is hypothesized that addressing cognitive dysfunction through modalities such as CRT will improve patients' insight into schizophrenia and their adherence with pharmacotherapy. Although the ideal is restoration of cognitive function, CRT also employs strategies aimed at compensation for cognitive impairment (Koren et al., 2006, Kurtz et al., 2007, Vauth et al., 2005, Wexler and Bell, 2005). Tactics used in CRT include repetitive supervised exercises, positive reinforcement, and “errorless learning” (in which a task is broken into ordered components, with training proceeding from the simplest components to the more complex).

6.2. Positive outcomes 

CRT consistently improves performance on neuro-psychological tests of cognitive function (Cochet et al., 2006, McGurk et al., 2005, Nieznanski et al., 2002). Pfammatter et al. reported Hedges' g ES 0.28–0.36 on indices of attention, memory, and executive function after CRT (Pfammatter et al., 2006).

6.3. Limitations 

Because CRT is focused on cognition, its effects on overall functioning and psychopathology are less clear. In different reports, CRT reduced symptoms (Cochet et al., 2006) or offered no advantage over usual treatment (Nieznanski et al., 2002). The meta-analysis of Pfammatter et al. found that CRT yielded only modest improvements in general psychopathology and negative symptoms (Hedges' g ES 0.20 and 0.24, respectively) (Pfammatter et al., 2006).

Furthermore, even if CRT enhances performance on specific cognitive tasks, it has not yet been conclusively demonstrated that improved neuropsychological test performance translates into improved overall functioning (Bellack, 2004). CRT does not directly target medication adherence, and it is uncertain how long its effects may persist. Based on available evidence, CRT might be most useful as part of a comprehensive program of integrated psychosocial interventions that address overall psychological and social function.

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7. Integrated psychosocial therapies 

The broad approaches discussed above (CBT, SST, FIT, and CRT) improve some, but not all, domains of function. These domains are summarized in Table 2. However, evidence suggests that integrating different approaches into such therapies as FAST, PEDAL, CAT, or IPT (see Table 1) promises to yield more favorable global outcomes. One of the most extensively used programs of this type is IPT, a group-based CBT program that combines neurocognitive and social cognitive remediation therapies (Roder et al., 2006). In a recent meta-analysis of 30 independently conducted studies, IPT significantly improved neurocognition (Cohen's d ES, 0.54), positive symptoms (ES, 0.46), negative symptoms (ES, 0.41), and psychosocial function (ES, 0.41). The superiority of IPT over standard care was maintained for as long as 8 months (Roder et al., 2006).

Table 2. Domains of improvement with psychosocial therapies
InterventionDomains most consistently improvedDomains less consistently improved
Cognitive-behavioral therapy (CBT)Psychopathology, residual symptomsAdherence, social function
Family intervention therapy (FIT)Adherence, relapse, hospitalization, disease burdenResidual symptoms, social function
Social skills therapy (SST)Social function, activities of daily lifeAdherence, residual symptoms
Cognitive remediation therapy (CRT)Cognitive functionResidual symptoms, social function
Integrated therapiesSocial function, residual symptomsAdherence, relapse

In another integrative approach, Patterson and colleagues combined CBT and SST for use in older populations of English-speaking (FAST) and Spanish-speaking (PEDAL) patients with schizophrenia (Patterson et al., 2003, Patterson et al., 2005, Patterson et al., 2006). The FAST program improved social function and negative symptoms, with effects lasting up to 6 months (Patterson et al., 2005). The PEDAL program has been demonstrated to improve social function at a 6-month follow-up, and medication management at an 18-month follow-up.

Other integrated programs include CAT, Hallucination-focused Integrative Therapy (HIT), and Psychosocial Assertive Community treatment (Thorup et al., 2005, Velligan et al., 2006, Wiersma et al., 2004). CAT is a complex mix of individualized cognitive-behavioral assessment, skills training, and environmental supports (Velligan et al., 2006). It has been shown to improve functioning, to reduce positive symptoms, and to reduce relapse (Velligan et al., 2000). Psychosocial Assertive Community treatment combines assertive community treatment, SST, and family intervention (Thorup et al., 2005). In 2-year follow-up assessments, this strategy reduced positive and negative symptoms (Thorup et al., 2005).Wiersma et al. reported that the HIT program, a combination of CBT and FIT, significantly improved social functioning and quality of life at 9-month and 18-month follow-up assessments (Wiersma et al., 2004).

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8. Conclusions 

Psychosocial therapy in support of pharmacotherapy in patients with schizophrenia clearly enhances treatment outcomes across a broad range of domains when compared with usual or standard care (Hedges' g ES, 0.23–0.45) (Pfammatter et al., 2006, Zimmermann et al., 2005). In this review, we have emphasized psychosocial interventions that have shown some effectiveness in improving medication adherence.

Each therapeutic approach effectively targets selected domains. For CBT, those domains are psychopathology and symptoms; for FIT, adherence, relapse, and rehospitalization; for SST, social skills and employment; and for CRT, neurocognitive function. Integrated psychotherapies offer promise in addressing a wider range of outcomes. Integrated strategies may also be more cost-effective if they can be shown to consistently increase adherence and reduce relapse. For example, a cost savings of 15% was found to be associated with the use of integrated HIT therapy compared with a care-as-usual treatment program consisting of medication monitoring, psychoeducation, and supportive counseling (Stant et al., 2003). However, with the possible exception of IPT, the integrated therapies used to date have not yet demonstrated clear superiority to individual therapeutic approaches in the domains addressed by the individual approaches.

In most cases, the effectiveness of psychosocial interventions in support of pharmacotherapy is assessed in comparison with standard care, such as patient education and nonspecific counseling aimed at improved medication compliance. The benefit of education alone has been deemed doubtful (Merinder, 2000, Zygmunt et al., 2002) or inconsistent (Nose and Barbui, 2003), but educational approaches in combination with behavioral approaches may offer more positive results (Dolder et al., 2003). There is general agreement that more definitive research is necessary.

Psychosocial therapies can be impeded by common limitations, such as cognitive impairment. Cognitive impairment poses a significant barrier to overall psychosocial function and to the effective implementation of psychosocial therapies (Brekke et al., 2005, Evans et al., 2003, Evans et al., 2004, Sergi et al., 2005). Accordingly, psychosocial therapy may have limited success if neurocognitive remediation is not routinely employed. The efficacy of psychosocial therapy with overly restricted focus may also be limited; for example, therapies that focus primarily on medication management or neurocognitive function may not improve social functioning. These limitations can be overcome when an integrated therapeutic strategy is tailored to the individual. The limited duration of psychosocial therapeutic effects may be more difficult to overcome. Although positive outcomes have been reported as long as 5 years after therapy, most appear to dissipate after about 2 years, which suggests that therapy may need to be continued longer or repeated regularly, if feasible.

Improved medication adherence is a particularly important goal for psychosocial therapies because of the link between nonadherence and the risk of relapse. In this regard, FIT should be considered a critical therapeutic strategy. Only FIT has consistently been shown to reduce relapse and rehospitalization, perhaps owing to improvements in adherence. CBT programs that provide psychoeducation concerning adherence and signs of relapse also appear to have some efficacy in this domain.

For clinicians treating patients with schizophrenia, the practical issue of employing a psychosocial intervention requires identification of the individual patient's needs and the modality most likely to address them. Additional research into the actual application of the technique or consultation with a practitioner of that technique is certainly advisable.

The applicability of psychosocial therapy is limited by the clinician's training, time, and resources. To date, CBT has been administered mainly by individuals who have undergone extensive training, and there is a need for studies documenting the effectiveness of CBT delivered by front-line clinicians who lack this specialized training. Similarly, FIT, SST, and CRT each require extensive training. Training is as important in psychosocial therapy as it is in pharmacotherapy.

Although effect sizes of psychosocial therapies may be nearly as large as those observed in medication trials, we view these therapies as adjunctive to pharmacotherapy. Behavioral problems encountered by clinicians are often of long duration, and it may require several sessions of psychosocial therapy to establish substantial symptomatic improvement. Nevertheless, our experience suggests that some form of supportive psychosocial therapy is often important in helping patients achieve optimal clinical and functional outcomes. Demonstration of cost-effectiveness may facilitate implementation of supportive modalities into standard mental health care.

Finally, it is important to recognize the need for consensus in defining recovery in schizophrenia, so that the overall effectiveness of psychosocial interventions can be assessed against a uniform standard.

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Role of funding source 

Funding for the development of this manuscript and for the editorial assistance was provided by Organon, a part of Schering-Plough, Roseland, NJ.

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Contributors 

Drs. Patterson and Leeuwenkamp were involved in all stages of manuscript development and have approved the final version of the manuscript.

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Conflict of interest 

Dr. Leeuwenkamp is an employee of NV Organon, a part of Schering-Plough, Oss, The Netherlands. Dr. Patterson declares that he has no conflicts of interest.

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Acknowledgment 

Editorial support was provided by Drs. Carl Clay, Brian Kelly, and Craig Slawecki, with funding from Organon, a part of Schering-Plough Roseland, NJ.

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PII: S0920-9964(07)01038-9

doi:10.1016/j.schres.2007.12.468

Schizophrenia Research
Volume 100, Issue 1 , Pages 108-119, March 2008

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