Wednesday, October 21, 2015

News Flash: Psychotherapy is Helpful in Schizophrenia

In yesterday's New York Times, there was an article by Benedict Carey titled New Approach Advised to Treat Schizophrenia.  Carey writes:
Now, results of a landmark government-funded study call that approach into question. The findings, from by far the most rigorous trial to date conducted in the United States, concluded that schizophrenia patients who received smaller doses of antipsychotic medication and a bigger emphasis on one-on-one talk therapy and family support made greater strides in recovery over the first two years of treatment than patients who got the usual drug-focused care.
And I thought: This is news?  Obviously, anti-psychotics have side effects, adverse effects and risks, so using using the lowest effective dose is good.  If it takes a high dose of medication to quickly control an acute episode, it's often possible to back down on the dose after the condition has been stabilized.  Talk therapy is often helpful, and of course family support makes all the difference in the world to anyone with a chronic illness or disability.

I was relieved to see that Peter Kramer's tweet:

Oct 20
Psychotherapy helps in schizophrenia = what psychiatrists in my cohort have always believed, as a guide for practice
So I wasn't imagining that this "news" was obvious.  

Later, Dr. Mark Komrad wrote in to our psychiatric society listserv:

"Everyone is talking about this big finding reported in today's NYTs. I'm not sure what's new here. Isn't this how we have been treating schizophrenia all along?  At least everyone I know who treats schizophrenia uses all of these techniques--both in private offices and clinics. What am I missing?  Maybe the lower doses of meds--but don't we all try to use the lowest doses possible?"  

If you'd like to look at the original article, the link is Here
The study by Kane, is notable for the following:
There were 404 individuals enrolled in 34 community mental health centers in 21 states.

"The experimental treatment, NAVIGATE (19), includes four core interventions: personalized medication management (assisted by COMPASS, a secure, web-based decision support system developed for RAISE-ETP); family psychoeducation; resilience-focused individual therapy; and supported employment and education (SEE)."

In case you're interested, in Maryland, the wait-time to get into the agency that does supported employment is 16 months and there are currently 2,586 people on the wait list.  That's not related to the study, but I just thought you might like to know.   Getting back to the study now:

"The control condition, “community care,” is psychosis treatment determined by clinician choice and service availability."

Assessment of the outcomes was made in the following way: "Trained interviewers using live, two-way video conferencing performed diagnostic interviews and assessments of symptoms and quality of life."

Select Results -- I've copied and pasted them, picked out only the ones I thought might be relevant to our readers, and taken out some of the statistics: 

  • Participants assigned to NAVIGATE remained in treatment longer than community care patients (a median of 23 months compared with a median of 17 months, and were more likely to have received mental health outpatient services each month than community care subjects (a mean of 4.53 services, compared with a mean of 3.67 services);
  • NAVIGATE participants experienced significantly greater improvement during the 2-year assessment period than those in community care ; . 
  • More improvement was also found on the subscales “interpersonal relations,” “intrapsychic foundations” (i.e., sense of purpose, motivation, curiosity, and emotional engagement), and engagement with “common objects and activities.” Service Use and Resource Form data showed significantly greater gains for NAVIGATE regarding the proportion of participants who were either working or going to school at any time during each month. 
  • The average rate of hospitalization was 3.2% per month for NAVIGATE participants and 3.7% per month for community care participants. Over the 2 years, 34% of the NAVIGATE group and 37% of the community care group (adjusted for length of exposure) had been hospitalized for psychiatric indications (n.s.). 
  • Finally: Median duration of untreated psychosis was a significant moderator of the treatment effect on total Quality of Life Scale and PANSS scores over time . There was a substantial difference in effect sizes comparing the change between treatments for participants with a duration of untreated psychosis of ≤74 weeks and those with a duration of untreated psychosis of >74 weeks.

No where in the article does it say how medication doses differed in the two groups.  And while the NYTimes piece has been interpreted to say that psychotherapy is helpful in schizophrenia, the study adds a number of different interventions, a specific type of one-on-one psychotherapy being only one. Perhaps the bigger issue  rests with this statement in the researchers' conclusions, that long periods of untreated psychosis are hare more difficult to treat.
The observation that patients with shorter duration of untreated psychosis derived substantially more benefit from NAVIGATE is important. Prolonged duration of untreated psychosis is an issue of national importance; reducing duration of untreated psychosis from current level of greater than 1 year to the recommended standard of  less than 3 months should be a major focus of applied research efforts.

In sum: Patients with schizophrenia do better if they get comprehensive services, and they do better if they are treated early in the course of their illness.  And now we officially know what we all knew.

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