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A literary review on schizophrenia the pathophysiology medical treatment nursing intervention and re

Published online 2013 Sep 25. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Ltd, provided the work is properly attributed. This article has been cited by other articles in PMC. Abstract Schizophrenia is a disabling psychiatric illness associated with disruptions in cognition, emotion, and psychosocial and occupational functioning.

This critical review of the literature was conducted to identify the common approaches to psychosocial interventions for people with schizophrenia.

Aetiology of schizophrenia and implications for nursing practice: a literature review.

Treatment planning and outcomes were also explored and discussed to better understand the effects of these interventions in terms of person-focused perspectives such as their perceived quality of life and satisfaction and their acceptability and adherence to treatments or services received. Their reference lists were screened, and studies were selected if they met the criteria of using a randomized controlled trial or systematic review design, giving a clear description of the interventions used, and having a study sample of people primarily diagnosed with schizophrenia.

Five main approaches to psychosocial intervention had been used for the treatment of schizophrenia: However, the comparative effects between these five approaches have not been well studied; thus, we are not able to clearly understand the superiority of any of these interventions. To conclude, current approaches to psychosocial interventions for schizophrenia have their strengths and weaknesses, particularly indicating limited evidence on long-term effects. To improve the longer-term outcomes of people with schizophrenia, future treatment strategies should focus on risk identification, early intervention, person-focused therapy, partnership with family caregivers, and the integration of evidence-based psychosocial interventions into existing services.

Although psychopharmacological treatment is essential and considered the mainstay for achieving better physical and cognitive functioning in schizophrenia, several limitations such as unavoidable adverse effects eg, acute extrapyramidal symptoms and other neurocognitive impairments in long-term treatment with these drugs and medication refusal or noncompliance have reduced its efficacy in the treatment of schizophrenia.

A critical review of the common approaches to psychosocial intervention for people with schizophrenia was therefore performed. First, the concepts and research evidence of five main approaches to psychosocial interventions for schizophrenia ie, cognitive therapy, psychoeducation programs, family intervention, social skills training programs, and assertive community treatment [ACT] are discussed.

Second, this review provides a summary of and discussion on the relative efficacy of the most commonly used approaches to psychosocial interventions in terms of their effect sizes on their most commonly reported patient outcomes. Third, the importance of person-focused perspectives such as quality of life, patient satisfaction and acceptability, and adherence to treatment and its use in research on psychosocial interventions for schizophrenia are also discussed.

Finally, we have made several recommendations for best practice in schizophrenia treatment on the basis of this review, as well as another related review published in Neuropsychiatric Disease and Treatment.

Psychosocial interventions for people with schizophrenia Recent research and systematic reviews suggest that both pharmacological and psychosocial treatment, offered early to people presenting with schizophrenia and other psychotic disorders, can improve their prognosis and even help prevent their illness chronicity. The five categories are cognitive therapy mainly cognitive behavioral therapy [CBT] and cognitive remediation therapypsychoeducation programs, family intervention, social skills and other coping skillstraining programs, and case management or ACT.

Even though the process of these interventions is not always described clearly, each type of intervention model has an individual set of goals and objectives, as well as a treatment agenda, and all have been found to be effective in improving different aspects of the functioning of patients with schizophrenia.

However, it should be noted that there are difficulties in implementing these interventions in everyday clinical practice in community care settings. First, staff may not be adequately trained to implement the intervention. Second, as these interventions need to be implemented for 9—12 months, there may be insufficient resources to deliver and evaluate them adequately.

All reference lists of the selected articles were also searched to identify further relevant trials. Finally, there were 92 articles included in this review, including 25 for psychoeducation, 22 for CBT, 15 for family intervention, 10 for cognitive remediation therapy, and 7 for social skills training.

Among them, 15 were review articles.

Cognitive therapy CBT Developed in the 1950s, CBT has been considered an effective therapy for depressive disorder for several decades; this therapy and some of its well-established techniques have eventually come to be used as a promising treatment modality for individuals with schizophrenia whose psychotic symptoms are not controlled by medication.

Although some studies have found CBT to have positive benefits in terms of reduction of positive symptoms and recovery time over the course of 9—12 months in comparison with standard care and a few psychological approaches, it has not yet shown promising evidence of reduction of negative and persistent severe psychotic symptoms for people with schizophrenia, particularly over a longer-term ie, 2-year follow-up. Although the effect sizes for improving the positive symptoms in more recent randomized controlled trials 2000—2006 were mainly very low to medium ie, 0.

Gumley et al 28 showed the significant effect of CBT in identifying prodromal signs of relapse from schizophrenia during a 12-month follow-up, whereas Durham et al 29 found a modest effect in relapse prevention and reduction of positive symptoms with newly trained and minimally supervised therapists for psychosis.

Overall, the research evidence on CBT favors its use among people with schizophrenia, and it is recommended in the United Kingdom and United States that it be included as the main approach to interventions for schizophrenia.

A specific technique used in CBT for patients with schizophrenia is the normalizing rationale, in which the patient with poor coping ability and social withdrawal from mental health services is empowered and facilitated to collaboratively develop effective coping strategies, leading to symptomatic improvement.

However, there were no significant differences on relapse, rehospitalization, or level of functioning between groups. Similar to the findings of the recent systematic reviews, 21 — 2326 the evidence identified for the effectiveness of CBT in terms of controlling positive, negative, and mood-related symptoms and relapse prevention, particularly in terms of the specificity and durability of these intended benefits, is not conclusive or consistent.

As Tarrier et al 31 and Turkington et al 32 point out, these requirements exclude a high proportion of more disabled patients and limit its widespread dissemination into routine practice. These contradictory findings and limitations of CBT for schizophrenia reveal a need for more randomized controlled trials focusing on the durability of the effect, with an expansion of the targeted symptoms, including negative symptoms, depression, and anxiety.

For instance, although cognitive remediation focuses on neurocognition and social cognition, there is a possibility of synergy with CBT for improving the cognitive and social functioning of patients with schizophrenia. Cognitive remediation therapy In response to the impaired cognition that occurs in many patients with schizophrenia, recent research has also raised concerns about the aspects of psychomotor function, attention, working memory, executive function, and other cognitive functions.

These impairments could persist in the course of schizophrenia, limiting the psychosocial and work functioning of the patients, and thus reducing the efficacy of CBT, which requires high levels of self-monitoring, attention, rational thought, and insight into the illness and its symptoms.

As a result, several approaches to cognitive remediation have been developed since the 1990s to enhance executive function and social cognition through information restructuring or reorganization, effective use of environmental aids and probes, and a wide range of techniques concerning cognitive functioning mainly neurocognition and social cognition. Neurocognition refers to the basic cognitive processes involved in thinking and reasoning and supporting attention, memory, and executive function abilities.

Although effect sizes did not differ in terms of types of remediation training used, a larger effect size in verbal memory was associated with more time of remediation training. Two recent clinical trials of 12-week individual-based and 20-week group-based ie, Social Cognition and Interaction Training social cognition training programs, both with 31 outpatients with schizophrenia, found significant improvements in emotional perception.

Although there were no significant effects found on some domains of social recognition and emotional functioning in this and most previous studies of social cognitive training, more broad-based approaches with a combination of training in social cognitive, neurocognitive, and behavioral skills are recommended to enhance its effect on more functional outcomes in schizophrenia.

A few cognitive enhancement programs such as Cognitive Enhancement Therapy 45 and Social Cognition and Interaction Training 43 have been designed to provide enriched cognitive training and experiences through integrated neurocognition and social cognitive training strategies.

More research with longer follow-up and larger, diverse samples is recommended to conclusively show the substantive positive effects of these integrated cognitive remediation training programs and its active components among people with schizophrenia spectrum disorders. Psychoeducation programs The psychoeducational model of patient care, as conceptualized by its pioneers, focused on the plight of people with mental illness, particularly on their higher risk for relapse and rehospitalization and its considerable cost to the patient and to society as a whole.

It is also believed that psychoeducation for the family members of these patients is useful and effective in improving patient outcomes because a positive and supportive family environment and behaviors can encourage patients and enable them to improve their functioning and self-management of the illness, thus reducing their likelihood of relapse. During the last 20 years, several models of psychoeducation for schizophrenia have been developed and empirically tested.

The theoretical foundations for these interventions are mainly derived from stress vulnerability and coping models and other psychological theories such as cognitive—behavioral, social learning, and crisis theories. In the medium term ie, 6—18 monthsit was found that when treating four participants with psychoeducation instead of standard care, one additional person would show a significant improvement in medication compliance, relapse, and knowledge about the illness.

Although most of the 44 trials reported favorable results for psychoeducation, it is noteworthy that there were no significant differences in their primary outcomes ie, compliance, relapse, and mental state between psychoeducation and standard care across countries. The review also noted that a majority of the studies reviewed were conducted in hospitals, whereas most people with schizophrenia are taken care of in the community.

A prospective randomized study by Feldmann et al 51 examined the influence of pretherapy duration of illness on the effects of psychoeducation for 191 outpatients with schizophrenia in Germany. Psychoeducation showed the most preventive effect in patients with a medium duration of illness eg, 2—4 years who had already accepted their illness but were not yet adhering to fatalistic assumptions often established to explain the manifestation of illness as nonretractable and unrecoverable.

Most successful or effective psychoeducation programs have consisted of a wide coverage of patient needs a literary review on schizophrenia the pathophysiology medical treatment nursing intervention and re concerns in relation to the illness and its treatment and self-management. Bisbee and Vickar 53 recommended that psychoeducation topics for schizophrenia include clear orientation to patienthood, adequate and up-to-date knowledge of the illness and its care, theories and practices of medication, stress and illness management, effective communication and coping skills, satisfactory family relationships and interpersonal interactions, maintenance of good nutrition and health, and prevention of relapse and substance use.

Family or family-based intervention Schizophrenia can cause disabling experiences and distress to both people with schizophrenia and their families. Because family members are the main carers for patients in the community, the effect of caring for patients is often described as burdensome and includes the different subjective and objective aspects of physical, emotional, or psychological and socioeconomic health problems.

Working with families appears to be one of the most effective ways of delivering community-based intervention to these patients. There are several other reasons for providing interventions to families of people with schizophrenia. First, studies on expressed emotion, which refers to the critical or emotionally overinvolved attitudes and behavior displayed by family members toward their relative with schizophrenia, has revealed that family dynamics and emotional climate affect the recurrence of positive symptoms, and therefore the course of the illness.

Second, having an intimate relationship with a relative with schizophrenia and providing care for such a person can place a great burden on family members. Reducing caregiver burden is an important goal of family support and care that, in turn, can help these carers take better care of their loved ones while maintaining their own health and well-being. Even though these families may have different health needs and expectations across the course of the illness, they have a few common needs for psychoeducation, including understanding about the nature of the illness, ways of coping with psychotic symptoms, methods of medication and illness management, psychological support and practical assistance during times of crisis, and means of getting links to community mental health services.

Treatment teams seek to establish a collaborative relationship with the family to share the burden of managing the illness and working toward patient recovery. Developed by McFarlane et al 55 in the United States, the program uses family education, training in communication skills, and practice in problem solving and has been delivered successfully across countries in the context of multiple-family groups via 10 sessions during a 3-month period.

Other approaches to family-based intervention for schizophrenia care include professional-led or peer-led multiple-family support and education groups aimed at providing continued education, caregiving skills training, and support for these familiesfamily-aided ACT providing family crisis intervention and case management for those with chronic or treatment-resistant schizophreniaand family consultation or supportive counseling using an individualized approach of support and adaptation training for a family member or the whole family.

However, the psychoeducation and behavioral approaches to intervention, as described by researchers in previous studies, expressed variety of content, format, and techniques.

The common elements in several of the more effective family psychoeducation programs include social support, education about the illness and its treatment, guidance and resources during a crisis, and training in problem solving. With better understanding of these crucial therapeutic elements within family intervention, it may be possible to develop a more consistent, reliable, and effective family intervention program for people with schizophrenia.

Social skills training Social skills represent the constituent behaviors that, when combined in appropriate sequences and used with others in appropriate ways and social contexts, enable a person to have the success in daily living that reflects social competence. Social skill training originated from the social skills model of Robert Liberman 75 and consists of three main components: In contrast, social competence generates social resources and improves community integration and role functioning.

Although the content of the current training programs can vary, a common set of training strategies found across them included goal setting, behaviorally based instruction, role modeling, behavioral rehearsal, corrective feedback, positive reinforcement, and homework to foster generalization of skills. When the patients learn how to properly use medication, they are more in control of their own illness, experience greater responsibility for their treatment, and achieve greater insight into their illness.

Therefore, recent studies suggest a literary review on schizophrenia the pathophysiology medical treatment nursing intervention and re incorporating generalization techniques into a skill training program, thus creating opportunities for using the skills in the living environment and receiving appropriate feedback and social reinforcements, would increase the likelihood of skill transfer to everyday life situations. However, these training programs could not demonstrate any significant effect on other patient outcomes, such as mild improvements in general psychopathology, relapse prevention and positive symptoms, and cognitive function.

For instance, in the Cognitive Enhancement Program developed by Hogarty and Flesher, 84 patients with schizophrenia were involved in practicing structured social interactions weekly, solving social dilemmas in real life, and appraising affect and social contexts, conversations with and feedback from other patients, and coaching and home assignments to implement skills in life problems or situations.

With concurrent use of computer-aided neurocognition and social cognitive remediation to improve attention, verbal learning, memory, and social adjustment and competencethe participants receiving social skills training could significantly improve their participation in employment situations and mastery of living and working skills. Similar to the results of most recent reviews, 8085 Dixon and his patient outcomes research team recommend that social skill training can be used as an adjunct to cognition and community skills training to produce synergic effects in the performance-based social and community skills and functioning of people with schizophrenia.

ACT ACT is a persistent, intensive outreach or case management model that targets difficult-to-engage or refractory schizophrenia. Bond et al 87 suggested that every community have ACT teams with a capacity to serve 0. Nevertheless, recent studies have suggested that most benefits of ACT could not be replicated outside the United States; for example, in the United Kingdom 8990 and other European countries, 91 except for maintaining contact with these patients.

The United Kingdom studies indicated that ACT did not demonstrate any consistent positive effect on social adjustment and functioning.

  • However, it should be noted that there are difficulties in implementing these interventions in everyday clinical practice in community care settings;
  • Sam was concerned about antipsychotic-related weight gain;
  • Even though the process of these interventions is not always described clearly, each type of intervention model has an individual set of goals and objectives, as well as a treatment agenda, and all have been found to be effective in improving different aspects of the functioning of patients with schizophrenia;
  • Sam agreed to weekly phone calls from his nurse to monitor his well-being and to remind him to return in two weeks for his follow-up appointment.

In addition, the dynamic and fluid nature of its service provision causes difficulty in identifying or defining the therapeutic components contributing to positive patient outcomes. Several British studies of ACT have indicated disappointing results, and thus Marshall and Creed 93 conclude that low caseload ratios do not necessarily result in better patient outcomes but, rather, specific organizational characteristics of the ACT model eg, multidisciplinary collaborations, daily team meetings, comprehensive needs assessment, and shared caseloads and responsibilities are essential and important to its effectiveness.

More evidence on the efficacy and practice standard or the program structure and content of ACT should be found before it can be widely used as an evidence-based intervention. Such tiered case management approaches can work best when the functions and roles of multidisciplinary teams are carefully organized.

CBT has indicated moderate effects on positive and negative symptoms and functioning mean effect sizes, 0. For family intervention, the effects are more prominent on improvement of patient functioning and relapse rate mean effect sizes, 0. Most consistently, these three kinds of interventions have demonstrated significant reduction of relapse during a 12-month follow-up mean effect sizes, 0.

Table 1 Mean effect sizes of three psychosocial interventions for schizophrenia on selected outcomes during a 12-month follow-up Outcome over 12 months and intervention Studies 2000—2012n.