1.antrios.wpic.pitt.edu/files/file/part 4.pdf · 1.identify the current best practices for the use...

Shaun M. Eack, PhD David E. Epperson Professor of Social Work and Professor of Psychiatry

School of Social Work and Department of Psychiatry University of Pittsburgh

Pittsburgh, PA

Abstract: "Evidence-Based Psychotherapy for Schizophrenia: Past, Present, and Future” (Intermediate)

This session will provide an overview of evidence-based psychotherapeutic treatments for people with schizophrenia. A historical review of the earliest approaches to psychotherapy, with important lessons learned, will first be presented. The current state of the field with regard to the most effective psychotherapeutic practices will then be reviewed, focusing on the comparative effectiveness of different approaches to psychotherapy for schizophrenia. Finally, the session will conclude with identifying the most promising new directions in psychotherapeutic treatment in the condition, as well as a discussion of challenges and approaches to ensuring that the most effective psychotherapies are available in routine clinical care.

Learning Objectives:

By the completion of this session, participants should be able to: 1. Identify the current best practices for the use of psychotherapy with people with schizophrenia;2. Evaluate the comparative effectiveness of different psychotherapies used to treat schizophrenia; and3. Describe the limitations of psychotherapeutic treatment for schizophrenia, including the science-to-service gap and areas for future development.

References

1. Dixon, L. (2017). What it will take to make coordinated specialty care available to anyoneexperiencing early schizophrenia: getting over the hump. JAMA Psychiatry. 74, 7-8.

2. Mueser, K. T., Deavers, F., Penn, D. L., & Cassisi, J. E. (2013). Psychosocial treatments forschizophrenia. Annual Review of Clinical Psychology. 9, 465-497.

3. Dixon, L. B., Dickerson, F., Bellack, A. S., Bennett, M., Dickinson, D., Goldberg, R. W., ... & Peer,J. (2009). The 2009 schizophrenia PORT psychosocial treatment recommendations and summarystatements. Schizophrenia Bulletin. 36, 48-70.

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Shaun M. Eack, Ph.D.University of Pittsburgh

Evidence-Based Psychotherapy for Schizophrenia: Past, Present, and Future

• Conflicts of Interest: None• Research Support: NIMH

Disclosures

• Therapies that are not effective• Evolution of early therapies• Current evidence-based therapies• Essential future directions

Psychotherapy for Schizophrenia

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Therapies That Are Not Effective:Family-Blaming Therapies

Cadigan & Murray, 2009

Therapies That Are Not Effective: Psychodynamic Psychotherapy

Mueser & Berenbaum, 1990. Psychol Med. 20:253-262.

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Therapies That Are Not Effective: Psychodynamic Psychotherapy

Mueser & Berenbaum, 1990. Psychol Med. 20:253-262.



Type ProcessTheoretical

Relationship to Pathophysiology

Major Role Therapy1968-1976

Psychosocial help for people with schizophrenia (early case management)

Unrelated

Social Skills Training1978-1986

Secondary environmental stress modification via correction of provocative behavioral deficits or excesses

Indirect

Family Psychoeducation1978-1986

Primary environmental stress modification via education and management

Indirect

Personal Therapy1987-1995

Identification and adaptive control of psychotic prodromes

Partially direct

Cognitive Enhancement Therapy1996-Present

“Gistful” social cognition related to context appraisal and perspective taking (developmental, secondary socialization)

Entirely direct

Gerard E. Hogarty, MSW

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• An early precursor to social casework• Goal was to help individuals resume their “major

roles” in life after hospitalization• Includes:

– At least monthly contact with a social worker– Brokering of services and supports– Crisis management– Vocational supports and rehabilitation

Major Role Therapy

Hogarty et al., 1974. Arch Gen Psychiatry. 31:603-608.

Major Role Therapy (N = 374)


• Goal is to reduce familial distress throughdemystifying schizophrenia

• Reducing familial distress would help families copeand reduce stress in the lives of patients

• The management of stress began to be viewed asessential to the management of schizophrenia

Family Psychoeducation

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• Much of the stress patients experience is due tosocial difficulties

• Social skills training aims to improve socialperformance to reduce distress

• Uses behavioral strategies to teach individualsbasic skills for interacting with others– How to start a conversation– How to obtain needed medicine– How to behave at a job interview

Social Skills Training

Family Psychoeducation and Social Skills Training Effects (N = 103)

Hogarty et al., 1986. Arch Gen Psychiatry. 43:633-642.Hogarty et al., 1991. Arch Gen Psychiatry. 48:340-347.

0%

• Delay post-hospital relapse and improveadjustment

• Identifying prodromes/early cues of distress• Learn stress management/affect regulation• Staged according clinical state (basic,

intermediate, advanced)

Personal Therapy

Hogarty, G. E. (2002). Personal Therapy for Schizophrenia and Related Disorders: A guide to individualized treatment. New York: Guilford.

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Personal Therapy(N = 151)

Hogarty et al., 1997. Am J Psychiatry. 154:1504-1513.

Personal Therapy(N = 151)


“Finally, we conclude with the caveat that although relative gains in adjustment were clearly achieved, in absolute terms most recipients of personal therapy were still recovering from a severe mental disorder….These clinically meaningful but relative improvements would not qualify as optimal recovery from schizophrenia.” (p. 1523)

Personal Therapy


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• A recovery-phase intervention for remediating neurocognitive and social-cognitive deficits originally developed for schizophrenia by Hogarty and colleagues(2004, 2006).

• Neurocognitive Training– Computer-based training in attention, memory, and problem-

solving.– 1 hour/week– 60 hours total

• Social-Cognitive Group Therapy– Training in perspective-taking, gistfulness, non-verbal

communication, emotion perception, and much, much more.– 1.5 hours/week– 45 sessions

• More information and CET Training Manual (Hogarty &Greenwald, 2006) atwww.CognitiveEnhancementTherapy.com

Cognitive Enhancement Therapy

CET in Long-Term Schizophrenia (N = 121)

Processing Speed

CETEST

1yr. 2yr.

Social Cognition

SocialAdjustment

Neurocognition SymptomsCognitiveStyle

Coh

en’s

d


CET in Early Course Schizophrenia (N = 58)

% Im

prov

emen

t

CETEST

1yr. 2yr.

Processing Speed

Social Cognition

SocialAdjustment

Neurocognition SymptomsCognitiveStyle

Eack et al., 2009. Psychiatry Serv. 60:1468-1476; Eack et al., 2011. RSWP. 21:32-42.

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Eack et al., 2010. Arch Gen Psychiatry 67:674-682.

CET in Early Course Schizophrenia

(N = 53)

10-Year Durability of CET in EarlySchizophrenia (N = 58)



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• Service coordination– Major Role Therapy– Case management– Assertive community treatment

• Family psychoeducaton• Social skills training• Individual psychotherapy

– Personal Therapy– Cognitive Behavior Therapy for psychosis

• Supported employment• Cognitive remediation

Current Evidence-Based Therapies

Case Management(k = 20)

Ziguras & Stuart, 2000. Psychiatr Serv. 51:1410-1421.

Assertive Community Treatment (k = 14)

Herdelin & Scott, 1999. Journal of Disability Policy Studies. 10:53-89.

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Family Psychoeducation(k = 18)

Lincoln et al., 2007. Schizophr Res. 96:232-245.

Social Skills Training (k = 10)

Kurtz & Mueser, 2008. J Consult Clin Psychol. 76:491-504.

Cognitive Behavior Therapy(k = 50)

Jauhar et al., 2014. Br J Psychiatry. 204:20-29.

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Supported Employment

Bond et al., 2008. Psychiatric Rehabilitation Journal. 31:280-290.

Supported Employment (k = 7)

Bond et al., 2008. Psychiatric Rehabilitation Journal. 31:280-290.

Cognitive Remediation(k = 9 to 38)

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Cognitive Remediation Effects on Functioning

McGurk et al., 2007. Am J Psychiatry. 164:1791-1802.Wykes et al., 2011. Am J Psychiatry. 168:472-485.

Comparative Efficacy on Symptoms(k = 48)

Turner et al., 2014. Am J Psychiatry. 171:523-538.

Symptoms Functioning Relapse

Service Coordination

Case management +++ +++ +++++

Assertive Community Treatment

++ ++ +++++

Family Psychoeducation +++ - +++++

Social Skills Training ++ ++++ ++

Personal Therapy/ Cognitive Behavioral Therapy

+++ +++++ +++

Supported Employment - +++++ -

Cognitive Remediation ++ +++++ -

Summary of Evidence

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Summary of Evidence



Research to Practice Gap

D. Butler, Nature, 2008

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Patterns of Care

Lehman et al., 1998. Schizophr Bull. 24:11-20.West et al., 2005. Psychiatr Serv. 56:283-291.

New Treatments?

Use Treatments?

Work to be Done

Center for Interventions toEnhance Community Health

Mission:Enhance the quality and length of life of individuals living with

behavioral health conditions through innovative community-based interventions

Intervention Development Core

Community Implementation Core

Department of PsychiatrySchool of Social Work

Center Aims1. Develop and test effective community-based interventions to improve health,

with anemphasis on behavioral health

2. Partner with community agencies to ensure “real world” readiness3. Integrate behavioral health interventions into everyday community settings

to serve people where they are and prevent disability

• SSW Health Science Investigators

• SSW Community Partners

• Child WelfareEducation & Research Programs

• Center on Race and Social Problems

• Western Psychiatric Institute & Clinic

• School of Medicine• School of Pharmacy• School of Public

Health• School of Nursing

• Develop novel community-based interventions toimprove behavioral health

• Conduct clinical trials to establish efficacy

• Ensure interventions are ready for the “real world” and diverse communities

• Develop partnerships with communities to guideresearch

• Disseminate treatmentadvances through community partner network

• Integrate interventions into everyday community settingsto facilitate dissemination

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• Early intervention• Substance use comorbidity• Peer support and mentorship• Approaches to increase medication adherence• Integration with brain stimulation

New Treatment Directions

• Psychotherapy and psychosocial interventionshave an important place in schizophrenia treatment

• Optimal treatment = pharmacological +psychosocial

• Many psychosocial treatment options exist, nowtime to start using them

Conclusions

• Gerard E. Hogarty, M.S.W.• Susan S. Hogarty, M.S.N.• Deborah P. Greenwald, Ph.D.• Michael F. Pogue-Geile, Ph.D.• Matcheri S. Keshavan, M.D.

Acknowledgments

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“My Mask” RJ

The irony of life

Is that those who wear masks

Often tell us more truths

Than those with

Open faces.

Marie Lu, The Rose Society

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