Psychotherapy for Schizophrenia

[roubs]

http://www.nytimes.com/2011/10/04/health/research/04schiz.html?src=rechp

18 months seems like a long time to wait for improvement and obviously represents a significant cost, but worth it considering this is a lifelong illness? Are most psychiatrists already likely to advise some kind of psychotherapy in this setting? Would further research like this impact how strongly you push for it?

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[billypilgrim37]

18 months seems like a long time to wait for improvement and obviously represents a significant cost, but worth it considering this is a lifelong illness? Are most psychiatrists already likely to advise some kind of psychotherapy in this setting? Would further research like this impact how strongly you push for it?

I think most of us already want pts with schizophrenia to be in with a therapist for more close assessment, emotional support, and problem solving. Some tolerate and benefit from more cognitive or skills based therapies. Our SMI clinic has a bit of a "medical home" structure that works very well where the therapist is the point person for pretty much everything.

 

[nitemagi]

Elyn Saks is a big proponent of psychotherapy for schizophrenia. She feels it helped her to deal with the ego blow of being diagnosed with the illness. She is a bit more of a high functioning individual with schizophrenia, though. And she received psychoanalysis, I do believe.

 

[splik]

Full paper is here: http://archpsyc.ama-assn.org/cgi/content/full/archgenpsychiatry.2011.129

In the past 10 years or so there has been a resurgence in interest in psychological treatments for severe mental illness such as schizophrenia and bipolar disorder after many years of patients often just receiving medication alone, and if they did receive psychotherapy, no evidence to support the use. However in the same way that psychoanalysis became a legitimate way of spending more time with patients and engaging with them in a more meaningful way the same has become true for cognitive therapy.

There are huge problems with this study and if it were a trial of a drug you can bet it would never have been published in the Archives. There are only 60 patients in this study, it is not clear whether the reported improvement of function is actually meaningful and more than numerical, the participants psychiatrists were not blinded to the intervention, the comparison was against treatment as usual rather than against non-specific counselling, and the generalizability is limited - this study was undertaken at the world epicenter for cognitive therapy - few people could match the expertise of level of therapy offered here. It is well known that there are center effects even between academic centers for psychotherapy, so the effect differences between Penn and a community center would likely be even greater.

I do think we should be engaging meaningfully with patients with psychosis to help them make sense of their experience, and address genuine practical concerns they have, but this does not require a technical framework such as cognitive therapy, which to a certain extent can remove us from interacting in a meaningful way with patients as can psychodynamic therapy when taken to its extreme.

 

[nitemagi]

There are huge problems with this study and if it were a trial of a drug you can bet it would never have been published in the Archives. There are only 60 patients in this study, it is not clear whether the reported improvement of function is actually meaningful and more than numerical, the participants psychiatrists were not blinded to the intervention, the comparison was against treatment as usual rather than against non-specific counselling, and the generalizability is limited - this study was undertaken at the world epicenter for cognitive therapy - few people could match the expertise of level of therapy offered here. It is well known that there are center effects even between academic centers for psychotherapy, so the effect differences between Penn and a community center would likely be even greater.

Agreed, not a perfect study, though not awful considering the study population. Not sure how you can blind therapists to intervention they're providing. They did blind and separate assessors from interventionists.

On the other hand, 18 mos of weekly cognitive therapy? Would insurance pay for that? Use of the GAS is basically a precursor to the GAF (obviously an imperfect instrument with questionable interrater reliability. Furthermore, it was CT versus standard therapy -- if I'm reading this correctly that's a helluva placebo problem (The TLC issue of placebo) that confounds things. The biggest issue I see, though, is lack of f/u after the intervention ended. Decrement back to baseline once support ends is a realistic possibility.

 

[roubs]

Full paper is here: http://archpsyc.ama-assn.org/cgi/content/full/archgenpsychiatry.2011.129There are huge problems with this study and if it were a trial of a drug you can bet it would never have been published in the Archives. There are only 60 patients in this study, it is not clear whether the reported improvement of function is actually meaningful and more than numerical, the participants psychiatrists were not blinded to the intervention, the comparison was against treatment as usual rather than against non-specific counselling, and the generalizability is limited - this study was undertaken at the world epicenter for cognitive therapy - few people could match the expertise of level of therapy offered here. It is well known that there are center effects even between academic centers for psychotherapy, so the effect differences between Penn and a community center would likely be even greater.

I'm not sure about huge problems.

They give ample justification for their planned sample size, not sure how a SS of 60 is a problem with a significant result?

The reported interventions in the non-CT, standard treatment group include "case management, supportive counseling, day treatment services, housing services, peer support, and vocational rehabilitation"

Nitemagi addressed blinding to what therapy you are doing (???); what matters is that those administering the GAS were blinded to treatment condition.

Obviously one cannot argue with Penn being an epicenter for CT, however its notable that they report the therapists involved had 2+ years of CT experience (and not 10+ or 15+ years). While some of the best training occurs there, but do we doubt that clinicians outside of Penn can conduct CT for Depression proficiently? As of today they may be the most expert and delivering this treatment to this population, but theres no reason to believe that other centers couldn't start doing this well. Especially as there are experts at delivering CT for other disorders all around. Obviously some community mental health centers eschew EBT of all kinds, which is an issue that goes much beyond this trial.

Lastly, by saying improvement may be numerical and not meaningful, are you calling into question the validity of the GAS? The whole point of using an accepted and well validated scale is that numerical improvements are meaningful.

 

[billypilgrim37]

do we doubt that clinicians outside of Penn can conduct CT for Depression proficiently?

absolutely.

 

[roubs]

absolutely.

Haha, yes many places don't know what they are doing. Sorry for not being clear. What I meant to say was, it'd be hard to claim Penn is the only place doing effective CT for depression.

 

[PsychBA]

Elyn Saks is a big proponent of psychotherapy for schizophrenia. She feels it helped her to deal with the ego blow of being diagnosed with the illness. She is a bit more of a high functioning individual with schizophrenia, though. And she received psychoanalysis, I do believe.

****ing insane!

 

[nitemagi]

****ing insane!

??? Interesting term to use in this context. Care to elaborate?

 

[PsychBA]

??? Interesting term to use in this context. Care to elaborate?

I forgot to bold the proper part. It was in relation to her receiving psychoanalysis.

Anyways, by all accounts, psychoanalysis for schizophrenia is dangerous. Supportive therapy, yes. But the sort of unstructured disconnect from reality in form of free association can quite likely lead to psychotic decompensation.

I don't know about this lady but I wonder if she actually has schizophrenia as opposed to some temporary psychotic state that resolved itself. I mean sure, there is the rare schizophrenic like the genius mathematician Nash. But she is not only a professor but also received psychoanalysis and presumably it helped her, not make things worse. Something doesn't fit.

 

[nitemagi]

Not being able to speak to her specific case, while free association is a core early technique in psychoanalysis, other more contemporary styles don't necessarily use it at all.

Furthermore, while schizophrenia is talked about as if it's one condition with subtypes (DSM), it's more likely 100's of diseases, each distinct in their way. While a psychotic individual who's disorganized is pretty unlikely to be able to participate much in almost any psychotherapy, there's a broad spectrum of illness severity at baseline, and even moreso a discrepancy in who responds to medication and in what way.

 

[splik]

I'm not sure about huge problems

They give ample justification for their planned sample size, not sure how a SS of 60 is a problem with a significant result?

a sample size of 60 may be enough for 80% for a statistically significant one, but I am not going to start recommending that patients with schizophrenia who are low functioning receive cognitive therapy from a single study with only 60 participants.

The reported interventions in the non-CT, standard treatment group include "case management, supportive counseling, day treatment services, housing services, peer support, and vocational rehabilitation"

exactly my point - they control group did not receive additional supportive counselling matched by the hour to the CT group

Nitemagi addressed blinding to what therapy you are doing (???); what matters is that those administering the GAS were blinded to treatment condition.

Obviously you cannot blind the therapist, my point was the psychiatrists were not blinded and this could have had an effect (i.e. could have built positive expectancy)

Obviously one cannot argue with Penn being an epicenter for CT, however its notable that they report the therapists involved had 2+ years of CT experience (and not 10+ or 15+ years). While some of the best training occurs there, but do we doubt that clinicians outside of Penn can conduct CT for Depression proficiently? As of today they may be the most expert and delivering this treatment to this population, but theres no reason to believe that other centers couldn't start doing this well. Especially as there are experts at delivering CT for other disorders all around. Obviously some community mental health centers eschew EBT of all kinds, which is an issue that goes much beyond this trial.

there is a huge variation in the way cognitive therapy is practiced at different centers and there are as I mentioned center effects so it is possible that you would not get the same effects elsewhere. Whilst there is some evidence that for CBT for psychosis experience does matter, in general the evidence I am aware of suggests that in general it is the quality of supervision rather than level of experience which correlates with outcomes for CT.

Lastly, by saying improvement may be numerical and not meaningful, are you calling into question the validity of the GAS? The whole point of using an accepted and well validated scale is that numerical improvements are meaningful.

Yes. Even the authors point to problems with the internal validity of the GAS, but I am more concerned about the external validity. I wish there was more qualitative research (there is some) in this area so we could learn more about whether our treatments have a meaningful effect for the patients themselves.

I studied psychology at the european epicenter for cognitive therapy (where many of the cognitive models for psychosis were proposed), so am probably brainwashed into being sympathetic towards such approaches, and I often use cognitive approaches in the management of psychotic symptoms, but the fact remains that despite the difficulties, we need to do larger and better quality randomized trials for psychotherapies. If it wouldn't past muster for a drug, it should not be acceptable for a psychotherapy.

 

[splik]

Anyways, by all accounts, psychoanalysis for schizophrenia is dangerous. Supportive therapy, yes. But the sort of unstructured disconnect from reality in form of free association can quite likely lead to psychotic decompensation.

Not by all accounts. Whilst it is true that many acutely psychotic patients would not be able to engage in psychoanalytic therapy, and whilst it is true there are reports of adverse outcomes there are all many many accounts of the use of psychoanalytically informed treatment of the schizophrenic or psychotic patient*. Have a look at Frieda Fromm-Reichmann, R.D. Laing, Aaron Esterton, Joseph Berke, Leon Redler, Murray Jackson, Harry Stack Sullivan, Bert Karon, Brian Koehler etc.

As nitemagi says schizophrenia is a syndrome, an amorphous mass of madness, it is not a unitary condition with a single etiology, but likely multiple.. we already know that about 1% of schizophrenia is caused by chromosomal microdeletions, much will be polygenic, some primarly epigenetic, some perhaps non-genetically mediated abnormal neuronal migration, and some of it is likely to be primarily environmental in origin. It cannot be chance alone that explains why so many of the schizophrenic patients I have seen have had such horrendous life experiences.

I am not the biggest fan of psychoanalytic therapy, but it is just as foolish to suggest that no one with schizophrenia receive it, as it is to suggest that everyone should. there is no good evidence either way for psychoanalytic treatment of psychosis, but we should not dismiss it outright.

*I do agree that some of these individuals probably did not have schizophrenia as we know it today, it would be wrong to say thay anyone who responds to psychoanalytic treatment did not have 'schizophrenia'.

 

[PsychBA]

Furthermore, while schizophrenia is talked about as if it's one condition with subtypes (DSM), it's more likely 100's of diseases, each distinct in their way.

Oh, this is the first time I've heard of this. Is this categorization based on the genetics of the illness? Where can I learn more about this?

 

[nitemagi]

Oh, this is the first time I've heard of this. Is this categorization based on the genetics of the illness? Where can I learn more about this?

http://www.ncbi.nlm.nih.gov/pubmed/21068826
http://www.ncbi.nlm.nih.gov/pubmed/18627674
http://www.ncbi.nlm.nih.gov/pubmed/19396704

 

[PsychBA]

Compared to other references, Insel's paper is both easy to understand and thought provoking. He notes:

"A starting point for mapping the pathophysiology of schizophrenia can begin with the increasing recognition that this is a neurodevelopmental disorder, or perhaps more accurately a collection of neurodevelopmental disorders that involve alterations in brain circuits. Although Feinberg, Weinberger and Murray proposed this approach more than two decades ago, the field is only now providing the evidence and recognizing the implications of shifting to a neurodevelopmental approach....It is unclear why the same genetic variation associated with many different neurodevelopmental syndromes is manifested in some by age 3 years (autism) and in others after age 18 years (schizophrenia). Presumably there are genomic modifiers or possibly environmental influences that determine the specific syndrome."