Recommendation 23. Individual and group therapies employing well-specified combinations of support, education, and behavioral and cognitive skills training approaches designed to address the specific deficits of persons with schizophrenia should be offered over time to improve functioning and enhance other targeted problems, such as medication noncompliance.

Rationale. Although the scientific data for this recommendation are limited and flawed, controlled studies have found some additional benefit when a supportive form of psychotherapy is added to pharmacotherapy for persons with schizophrenia. The most effective forms and doses of these therapies and their modes of action remain unknown. (Review reference: Scott and Dixon 1995b, pp. 623-627; Level of evidence: B)

Family Treatments.

Recommendation 24. Patients who have ongoing contact with their families should be offered a family psychosocial intervention that spans at least 9 months and provides a combination of education about the illness, family support, crisis intervention, and problem-solving skills training. Such interventions should also be offered to nonfamily caregivers.

Rationale. Randomized clinical trials have repeatedly demonstrated that family interventions that provide some combination of illness education, support, problem-solving training, and crisis intervention, in combination with appropriate pharmacotherapy, reduce 1-year relapse rates from a 40 to 53 percent range to a 2 to 23 percent range. (Review reference: Dixon and Lehman 1995,p. 639; Level of evidence: A)

Recommendation 25. Family interventions should not be restricted to patients whose families are identified as having high levels of "expressed emotion" (criticism, hostility, overinvolvement).

Rationale. Although the earlier controlled trials of family psychoeducation programs focused on the variable of family expressed emotion as a mediator of the impact of this intervention on outcomes, more recent studies have found that these interventions offer substantial benefit to patients and families regardless of the level of expressed emotion. (Review reference: Dixon and Lehman 1995, p. 639; Level of evidence: B)

Recommendation 26. Family therapies based on the premise that family dysfunction is the etiology of the patient's schizophrenic disorder should not be used.

Rationale. Research has failed to substantiate hypothesized causal links between family dysfunction and the etiology of schizophrenia. Therefore, therapies specifically designed from this premise are not empirically founded. Although there has been little or no randomized, controlled research on the impact of family therapies arising from this orientation, experts in the field have expressed strong caution against the use of these techniques. The presumption that family interaction causes schizophrenia, especially as an alternative to biological risk factors, has led to serious disruption in clinician/family trust without any evidence of therapeutic effectiveness. The repudiation of the theoretical premise of these therapies, the lack of empirical studies, and the strong clinical opinion raising concerns about the potential harm caused by these approaches lead to this recommendation. (Review reference: Dixon and Lehman 1995, p. 631; Level of evidence: C)

Vocational Rehabilitation.

Recommendation 27. Persons with schizophrenia who have any of the following characteristics should be offered vocational services. The person (a) identifies competitive employment as a personal goal, (b) has a history of prior competitive employment, (c) has a minimal history of psychiatric hospitalization, and (d) is judged on the basis of a formal vocational assessment to have good work skills.

Rationale. Controlled studies of vocational rehabilitation interventions for persons with schizophrenia have not shown consistent or significant impacts on outcomes other than those directly related to involvement in the rehabilitation program (e.g., increased involvement in sheltered work). However, these studies have been flawed by the failure to control for individual characteristics that may alter a person's vocational potential. They have identified subgroups of recipients post hoc who benefited from the interventions. The above characteristics have been found to be predictive of better vocational outcomes in persons with schizophrenia, and therefore persons with these characteristics should be offered such services. (Review reference: Lehman 1995, pp. 647-653; Level of evidence: C)

Recommendation 28. The range of vocational services available in a service system for persons with schizophrenia living in the community who meet the criteria defined in Recommendation 27 should include (a) prevocational training, (b) transitional employment, (c) supported employment, and (d) vocational counseling and education services (job clubs, rehabilitation counseling, postemployment services).

Rationale. Recent controlled studies have reported significantly improved vocational outcomes for the supported employment model, which emphasizes rapid placement in a real job setting and strong support from a job coach or other employment specialist to adapt to and sustain the job. Therefore, unless ongoing research fails to substantiate these early findings, supported employment should definitely be available to persons meeting the aforementioned criteria. Scientific data supporting the effectiveness of the other forms of vocational services mentioned above are lacking, but some persons who are good candidates for supported employment may benefit from the addition of these services as well, so they are mentioned in the recommendation. (Review reference: Lehman 1995, pp. 647-653; Level of evidence: B)

Service Systems.

Recommendation 29. Systems of care serving persons with schizophrenia who are high service users should include assertive case management (ACM) and assertive community treatment (ACT) programs.

Rationale. Persons with disabling schizophrenia who are at high risk for discontinuation of treatment or for repeated crises require an array of clinical, rehabilitation, and social services to address their needs. Coordination, integration, and continuity of services among providers over time can be substantially enhanced through ACM and ACT. Randomized trials have demonstrated consistently the effectiveness of these programs in reducing inpatient use among such high-risk patients. Several studies also support improvements in clinical and social outcomes. These studies suggest that both ACT and ACM are superior to conventional case management for high-risk cases. (Review reference: Scott and Dixon 1995a, pp. 659-664; Level of evidence: A)

Recommendation 30. Assertive community treatment programs should be targeted to individuals at high risk for repeated rehospitalizations or who have been difficult to retain in active treatment with more traditional types of services.

Rationale. The original ACT studies reporting efficacy for these approaches targeted these high-risk persons. The efficacy of either model with lower risk patient groups has not been established. The high cost of ACT therefore warrants careful targeting for cost-effectiveness. (Review reference: Scott and Dixon 1995a, pp. 659-664; Level of evidence: B)

Discussion

The PORT Treatment Recommendations represent a concerted and systematic effort to develop guidelines about the treatment of persons with schizophrenia distilled narrowly from available scientific evidence. As such, they reflect both the strengths and limitations of this knowledge base. Such recommendations are useful from at least two major perspectives.

First, they form a basis for disseminating current knowledge into practice. The Treatment Recommendations provide focal points or benchmarks for asking whether current practices measure up to what is known to be helpful based on the best scientific evidence available. Such questions about the quality of care should be asked by treatment practitioners, patients, families, service system planners, and health care payers. Are we providing care based on the best knowledge available? These recommendations can challenge practitioners and service systems to do better and can challenge patients and families to expect better services. The recommendations are recommendations, not mandates, because individual patient needs vary considerably from the average. However, the Treatment Recommendations should stimulate close examination of practices at both the aggregate and the individual patient levels to ensure that treatments are offered in the most effective manner.

Second, they serve to highlight what we do not know. Not all of the gaps in our knowledge about treatment can be filled by evidence developed in clinical trials. Clinical wisdom can and should be accumulated and shared directly from practical experience. But there are many aspects of treatment for schizophrenia that need careful, ongoing scientific scrutiny to ensure that, whenever possible, objective evidence of effectiveness is the basis for practice. It should be good news that treatment recommendations such as those presented here will be outdated in the not too distant future and that new knowledge will require their modification, as well as the addition of new recommendations. In short, we should practice what we know today while we are continually learning to change practices for tomorrow.

References for:
At Issue: Translating Research Into Practice The Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations

[Schizophrenia Bulletin 24(1):1-10, 1998. National Institute of Mental Health.]

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Lehman, A.F. Vocational rehabilitation in schizophrenia. Schizophrenia Bulletin, 21(4):645-656, 1995.

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Scott, J.E., and Dixon, L.B. Assertive community treatment and case management for schizophrenia. Schizophrenia Bulletin, 21(4):657-668, 1995a.

Scott, J.E., and Dixon, L.B. Psychological interventions for schizophrenia. Schizophrenia Bulletin, 21(4):621-630, 1995b.

Umbricht, D., and Kane, J.M. Risperidone: Efficacy and safety. Schizophrenia Bulletin, 21(4):593-606, 1995.

Zito, J.M. Psychotherapeutic Drug Manual. 3rd ed. New York, NY: John Wiley & Sons, 1994.

 

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