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Added Value: Combined Therapy Benefits People With Schizophrenia

27 September 2010. Combining psychosocial treatments with antipsychotic medication can lead to greater gains in early-stage schizophrenia patients compared to taking medication alone, according to a study published in the September issue of Archives of General Psychiatry.

Led by Jingping Zhao at Central South University in Changsha, China, the study addresses whether treatment with current antipsychotic medications—the mainstay for people with schizophrenia—can be improved upon. Though these medications effectively quell some symptoms, they often fail to address others and have adverse effects that compel many to stop taking them. The end result is that many patients are unable to live independent lives with regular employment, responsibilities, and relationships. With no new drugs on the horizon, the researchers asked whether adding an intensive psychosocial component to treatment could help.

While other studies have taken this combination therapy approach before (e.g., Tarrier et al., 2004 and Bertelsen et al., 2008), this study is notable for its wide scope in both treatment components and measured outcomes. Study participants assigned to the medication plus psychosocial treatment group attended group therapy sessions that discussed various aspects of schizophrenia, provided skills training, and employed cognitive behavioral therapy, which helps people adapt their emotions and cognitive habits appropriately. For outcomes, the researchers looked at rates of treatment discontinuation and relapse, as well as other real-world factors like social functioning, quality of life, and employment. Almost across the board, the combined treatment resulted in greater improvements than those observed in the group taking medication alone.

One year, 48 hours later
Conducted in China, the one year-long study enrolled 1,268 people (average age 26 years) who had been diagnosed with schizophrenia within the past five years. The study participants were randomly assigned to either the medication alone group or the combined treatment group, who received both medication and psychosocial therapy. These groups did not differ in their demographic or clinical characteristics, including the dosage and kind of antipsychotic drugs taken.

Once a month, study participants visited their clinic so that clinicians could assess their responses to medication. Those in the combined treatment group also received four hours of group psychosocial therapy there that same day. Over the year, this amounted to 48 hours of psychosocial therapy. Their accompanying family members also received psychosocial education in a group setting during these visits.

Of those in the combined treatment group, 67.2 percent made it to the end of the study—significantly more than the 53.2 percent of those in the medication alone group (HR, 0.62; 95 percent CI, 0.52-0.74; P <.001). People left the study for a number of reasons, including clinical relapse, refusal to participate, or changing medications. The researchers noted a significantly lower rate of clinical relapse in the combined treatment group (14.6 percent) compared to the medication alone group (22.5 percent) (HR, 0.57; 95 percent CI, 0.44-0.74; P <.001). Preventing relapse bodes well for long-term improvements for people with schizophrenia.

Though both groups had similar decreases in symptom severity, as measured by the Positive and Negative Symptom Scale (PANSS), the combined treatment group seemed to have greater insight into their disorder, obtaining higher scores on the Insight and Treatment Attitudes Questionnaire (ITAQ) than did the medication alone group.

The researchers also found that the combined treatment favorably influenced how the study participants live and integrate into society. Compared to the medication alone group, the combined treatment group had greater gains in measures of social functioning, daily living skills, and four areas of quality of life, including general and emotional health. A greater proportion of people in the combined group got a job or pursued education during the year than those in the medication alone group (30.1 percent vs. 22.2 percent χ2 = 10.09; P = .001).

Though it is hard to draw conclusions about which component of the psychosocial intervention influenced which outcomes, the study demonstrates the feasibility of delivering psychosocial intervention in conjunction with medication. The researchers suggest that this model—which requires a family commitment to get the patient to the clinic and to participate in family sessions themselves—may work best in countries like China, where people with schizophrenia tend to live with their families.

The study also emphasizes the importance of early-stage treatment in schizophrenia, and the importance of finding ways to manage the disease—both with and without drugs—before it becomes chronic and disabling.—Michele Solis.

Reference:
Guo X, Zhai J, Liu Z, Fang M, Wang B, Wang C, Hu B, Sun X, Lv L, Lu Z, Ma C, He X, Guo T, Xie S, Wu R, Xue Z, Chen J, Twamley EW, Jin H, Zhao J. Effect of antipsychotic medication alone vs combined with psychosocial intervention on outcomes of early-stage schizophrenia: A randomized, 1-year study. Arch Gen Psychiatry. 2010 Sep; 67: 895-904. Abstract

 
Comments on News and Primary Papers
Comment by:  Wendy Camp
Submitted 18 October 2010 Posted 18 October 2010

In Connecticut we have a wonderful Medicaid/T19/Behavioral Health program that allows home health nurses to monitor and/or administer medications for noncompliant mental health patients and home health aides to be in the home up to 14 hours a week to assist with medication reminders, ADLs, and IADLs.

I would be interested to know what impact our behavioral health nurses might have on an early-stage schizophrenia population versus our chronic noncompliant population. If we had our nurses in the home sooner, could we correct potentially problematic behavior before it became chronic?

View all comments by Wendy Camp


Comment by:  Douglas Turkington (Disclosure)
Submitted 16 November 2010 Posted 17 November 2010

This paper is important because of its power and because this most basic question has never been satisfactorily answered. My concern is the very high dropout rate in both groups. Dropout across CBT of schizophrenia trials normally averages about 15 percent. CBT also usually attempts to work from a mini-formulation or macro-formulation which extends beyond the A-B-C. The CBT given here, however, does parallel the pragmatic technique-orientated CBT given in the Insight trial (Turkington et al., 2002). The problem here would appear to be the delivery of all four interventions in group format on the same day once per month. This is a massive burden on patients with cognitive deficits, negative symptoms, and treatment-resistant hallucinations and delusions. We must therefore be guarded about the conclusions. There is a signal, however, of the need for a psychosocial component in the management of every patient with schizophrenia. We are grateful to the authors for this publication.

References:

Turkington D, Kingdon D and Turner T. (2002) Effectiveness of a brief cognitive-behavioural therapy intervention in the treatment of schizophrenia. British Journal of Psychiatry 180, 523-527. Abstract

View all comments by Douglas Turkington

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