Magazine article Clinical Psychiatry News

Practical Psychopharmacology: Psychosocial Approaches Complement Medication in Schizophrenia Treatment. (Psychopharmacology)

Magazine article Clinical Psychiatry News

Practical Psychopharmacology: Psychosocial Approaches Complement Medication in Schizophrenia Treatment. (Psychopharmacology)

Article excerpt

Few would question that medication is the bedrock of schizophrenia treatment. The evolution of antipsychotics is the major theme of recent research, and the appropriate use of these agents is the primary concern of clinicians.

But drugs are not the whole story. Patients can gain maximum benefit from pharmacologic advances only in the context of an integrated, comprehensive program.

"Psychosocial aspects of treatment are critical to good-quality care," said Dr. Anthony Lehman, professor and chair of psychiatry at the University of Maryland, Baltimore. And progress in this area, although less dramatic than the development of new drugs, has been real and important.

"What we have today is really different from psychosocial treatments of the past, which focused on caring and support," said Dr. Nina Schooler, director of psychiatric research at Hillside Hospital, Glen Oaks, N.Y. "Now there is a whole series of specific interventions shown to improve outcome." These interventions may amplify and complement the value of schizophrenia pharmacotherapy by increasing compliance and reducing relapse, as well as by addressing areas that drugs cannot reach, such as community reintegration.

According to Dr. Lehman, one core approach is "illness counseling," which aims to educate patients about their disease and help them cope with day-to-day difficulties. This approach is analogous to how a chronic medical illness such as diabetes or asthma might be managed, he noted.

In schizophrenia, illness counseling may be targeted to promote patient insight into how a behavior causes problems, and it may include skills training and cognitive perspectives. "I see [it] as a psychotherapeutic process," he said.

The intervention with perhaps the most robust research support is family psychoeducation. Well-designed programs have been shown to reduce relapse and rehospitalization, compared with medication alone. "We don't completely understand why.... There may be multiple reasons," Dr. Lehman said. "Improved compliance [no doubt] plays a role," and stress modification may be involved as well.

Dr. Lisa Dixon, associate director of research for the Veterans Affairs health care network's Mental Illness Research, Education, and Clinical Center in Baltimore, identified four components of effective family interventions:

* Promoting knowledge about the disease.

* Developing problem-solving strategies.

* Doing crisis intervention.

* Providing ongoing support.

"It's not the traditional clinical model. ... The family is regarded as a member of the team," which represents a major shift from traditional conceptualizations that regarded family as the source of stress or interference, she said.

Dr. Dixon stressed that some form of family participation should be a standard offering. Family participation should not be contingent on problematic parameters such as "expressed emotion," nor should it be reserved for the maintenance phase of treatment. "Family psychoeducation isn't just for stable patients. ... In fact, it can be most effective in a crisis when the patient and family can be more engaged," she said. Dr. Schooler pointed to social skills training (SST) as another key area. "Generally, SST is more broadly defined than it had been. It has gone from a terribly molecular approach--teaching people to make eye contact and say 'aha ' at appropriate moments in conversation--to more generalizable behavioral elements like breaking problems down into smaller components, repetition, and feedback. …

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