Medication-Psychotherapy Combination Most Effective for Schizophrenia

"Can we talk?" asks a recovering patient who chastises psychiatry for too readily dismissing patients with her diagnosis as unable to benefit from talking therapy (A Recovering Patient, 1986). With managed care administrators quick to seize upon a lack of outcome data as a pretext for limiting treatment and a public mental health system pressed to handle caseloads as high as 200 to 300 patients per clinician, psychiatry's regrettable answer has often been: "No, we're too busy." Recent research findings, however, convincingly demonstrate that a flexible form of individual psychotherapy, when combined with appropriate neuroleptic medication, can yield improvements in social and vocational functioning unobtainable with "treatments as usual."

Gerard Hogarty, M.S.W., and colleagues at the University of Pittsburgh School of Medicine report in the November 1997 American Journal of Psychiatry the first rigorous scientific data to support the efficacy of a disorder-specific individual psychotherapy (Hogarty et al., 1997a, 1997b).

Personal Therapy (PT), a flexible form of individual psychotherapy, was evaluated among 151 recently discharged outpatients with schizophrenia or schizoaffective disorder receiving maintenance neuroleptics. Results of the randomized clinical trial indicated that the social adjustment and role performance of patients treated with supportive case management and/or family therapy plateaued after 12 months. Conversely, patients receiving PT continued to improve over the entire three-year trial with no evidence of a plateau. Furthermore, over three years, remarkably few (six in 74 or 8%) patients receiving PT were dropped from the treatment program because of noncompliance or other reasons.

Contentious History

The value of psychotherapy for schizophrenia has long been the subject of contentious debate within psychiatry. Early in the century most clinicians considered the disorder untreatable. Kraepelinian "organic" psychiatrists viewed schizophrenia as a progressive brain deterioration; Freudian psychoanalysts viewed it as a "narcissistic neurosis" where transference, and hence cure, was not possible. Despite widespread therapeutic nihilism, a few early renegades were drawn to talk and spend time with the incurable.

Based on his intuition that "like can help like" and, perhaps, his own experience with a psychotic episode, Harry Stack Sullivan ran a unit for young men with schizophrenia at the Sheppard and Enoch Pratt Hospital in Towson, Md., during the 1920s. He staffed the unit with shy, introverted male attendants and observed that providing an experience of reciprocal trust--which he felt many patients had missed during critical periods of development--could be beneficial by allowing a "validation of personal worth." Sullivan described schizophrenic psychopathology as the lasting residue of unsatisfactory interpersonal experiences, and saw a basic mistrust of others as central to the condition.

Later, under the leadership of Dexter Bullard Sr., a group of psychoanalysts and social scientists, including the German refugee Frieda Fromm-Reichmann, at Chestnut Lodge Hospital, Rockville, Md., explored the therapeutic potential of Sullivan's ideas by attempting to talk with patients.

Fromm-Reichmann summarized these efforts in her Principles of Intensive Psychotherapy (1950), the first description of what later became known as intensive psychodynamic psychotherapy. In the decades before the introduction of neuroleptic medications, heroic efforts to establish contact with acutely ill and unmedicated patients were described in the works of Searles (1965), Burnham et al. (1969), and others. The patient's expectation of harm from others, marked ambivalence in relationships, difficulty separating personal thoughts and impulses from those of others, and pervasive passivity were thought to be correctable.

The introduction of chlorpromazine (Thorazine) in 1954 dramatically transformed the treatment of schizophrenia and placed a therapeutic tool of unparalleled efficacy in the hands of biologically oriented psychiatrists. Proponents of individual psychotherapy, however, largely rejected medications as covering up the problems of schizophrenia. Professional views became polarized and debate between competing factions acrimonious.

While randomized clinical trials unambiguously showed the value of medications, trials that compared various forms of individual psychotherapy with other treatments provided no scientific evidence for the efficacy of individual psychotherapy as the sole treatment for schizophrenia. In addition, long-term follow-up studies conducted at Chestnut Lodge and elsewhere showed that most patients treated with psychotherapy alone remained seriously and chronically disabled (McGlashan, 1984, 1988). The biological paradigm gained decisive ascendancy in American psychiatry.

The Boston Psychotherapy Study was later conducted by Gunderson et al. (1984) to compare the efficacy of supportive psychotherapy (as practiced by biologically oriented psychiatrists) and psychodynamic psychotherapy against a backdrop of adequate medications for all patients (Gunderson et al., 1984; Stanton et. al., 1984). Contrary to the investigators' expectations, neither treatment emerged as clearly superior, and both were limited by very high (60% to 70%) dropout rates.

Independent of level of psychopathology, however, the investigators found that patients able to achieve a good therapeutic alliance in the first six months were more likely to remain in treatment, comply with medication and achieve better outcomes. Despite differing ideologies, supportive and psychodynamically oriented therapists tended to actually use similar techniques--for both therapies, a sound dynamic understanding of the patient's concerns was associated with better results.

Changing Paradigms

Today, debates about drugs versus psychotherapy or supportive versus psychodynamic care are no longer salient. No single approach can claim to ameliorate all symptoms and disabilities of schizophrenia (Lehman, 1995). As reflected in the American Psychiatric Association's 1997 Practice Guideline for the Treatment of Patients with Schizophrenia (APA, 1997), treatment most often requires the sophisticated integration of several pharmacologic, psychosocial and rehabilitative strategies.

When many treatment modalities are required, someone is needed to orchestrate and coordinate them. This can often be best accomplished by a psychiatrist providing continuity of care within a flexible long-term psychotherapeutic relationship. While medications improve symptoms and cognition, and rehabilitation can remediate social and vocational skills, a psychotherapeutic relationship can address the human aspects of suffering from a serious and long-term disorder.

The Nature of Schizophrenia

Schizophrenia research provides three assumptions to inform a contemporary approach to individual psychotherapy: the stress-vulnerability model, illness heterogeneity and the phasic nature of the illness.

The stress-vulnerability model posits that biologically based vulnerability due to genetic predisposition and/or intrauterine neurodevelopmental insults interacts with environmental stressors to determine the onset and course of schizophrenia. Stressors related to illness onset are highly individualized and can include developmental (leaving home, military basic training), biochemical (substance abuse) or interpersonal (romantic disappointment, death in family) challenges. After illness onset, a balance between severity of vulnerability, ongoing stressors and protective factors such as medication and coping strategies will influence relapse rates and outcome.

Heterogeneity refers to the observation that schizophrenia is not the same in all patients and may in fact be a syndrome made up of several underlying pathophysiologic processes. Current efforts to subtype schizophrenia aim to reduce this heterogeneity.

Patients with the deficit subtype, for example, have enduring negative symptoms such as poverty of speech, anhedonia and lack of sense of purpose not explained by psychosis, medication side effects or depression. We have found that these patients often have an earlier illness onset, an unremitting course, and suffer spontaneous movement disorders and severe cognitive impairments, resulting in significant social and vocational disability.

In contrast, nondeficit patients with few negative symptoms have a later age of onset, fewer cognitive difficulties and an intermittent illness with a better prognosis (Fenton and McGlashan, 1994). Illness heterogeneity indicates that one type of treatment is not suitable for all patients and that treatment strategies and goals must be individualized.

Schizophrenia can be viewed as progressing through illness phases (Strauss, 1985). These may include: 1) a prodromal period, where signs such as isolation, withdrawal and irritability that warn of impending decompensation, may be evident; 2) an acute phase characterized by florid positive symptoms; 3) a convalescent phase that may include post-psychotic depression; 4) adaptive plateaus characterized by relatively stable functioning with residual disabilities; 5) change points or shifts in functioning associated with the possibility of improvement as well as risk of relapse; and 6) stable end states in which a predictable and enduring level of functioning is established.

Flexible Psychotherapy

Flexible psychotherapy is a broad and pragmatic approach that relies on a variety of techniques applied flexibly and based on the individual patient's type of schizophrenia and phase of illness (Fenton and McGlashan, 1995). At times, the therapist will engage in supportive, directive, educational and insight-oriented activity within an overall treatment plan informed by an understanding of the individual patient's beliefs, experiences, attitudes and aspirations.

All interventions aim to minimize the effect of vulnerabilities, strengthen coping mechanisms and reduce the impact of stress. Determining which interventions are of value for a specific patient at a particular illness phase becomes the critical question. As shown in the Table, the range of clinical tasks that may require therapeutic attention can be ordered hierarchically to roughly correspond to illness phase.

Although many of the treatment goals are salient across more than one illness phase, ordering treatment tasks hierarchically generally presupposes that more basic goals (e.g., medical evaluation, acute pharmacologic treatment) will be the major therapeutic focus during early illness phases.

Once these goals are attained, clinical attention can shift to psychosocial tasks such as inventorying and rallying available social support and ensuring that basic human service needs are adequately met. Establishing an ongoing supportive treatment relationship and therapeutic alliance will often be a prerequisite for embarking on psychoeducation and skills remediation. At the heart of the approach is the therapist's ability to flexibly shift roles based on the patient's changing needs and circumstances.

The patient's severity of illness, degree of cognitive impairment and self-defined treatment goals are considered in selecting treatment priorities. Some goals are appropriate for nearly all patients, others may be pertinent for only some. For patients with severe deficit types of schizophrenia, establishing a supportive ongoing treatment within a sheltered setting that ensures basic human service needs are met may be a reasonable long-term goal.

Patients with less severe forms of schizophrenia or those who have had exceptional responses to new antipsychotic agents may benefit from an introspective focus that targets problems such as damaged self-esteem, illness self-management and social relations. While many of the therapeutic goals shown in the table overlap with the concerns of other service providers, all should be of concern to the individual psychotherapist. Focusing on psychological issues when more basic problems such as basic human service needs remain unaddressed is a common mistake to be avoided.

Hogarty et al.'s (1997a) PT included three levels of treatment with defined criteria for progression from basic to more challenging levels. Basic phase PT is applied in the early months after discharge and aims for clinical stabilization, therapeutic joining and basic psychoeducation. The intermediate phase, which most often occured during the first 18 months after discharge, teaches awareness of internal cues associated with stress and employs psychoeducation, skills remediation, relaxation training and role playing. Advanced PT, in the last 18 months of treatment, promotes introspection and an understanding of the relationship between stressors, maladaptive responses, the reaction of others and symptoms. Treatment is individualized to patient response, and patients remain at a particular level as long as needed.

Over three years, about 50% of patients progressed to advanced PT. Although patients living with family who received PT showed a reduced relapse rate, patients living alone experienced an increased relapse rate with PT. These patients were more likely to have unstable housing and difficulty procuring food and clothing. The authors suggest that premature application of a psychologically oriented treatment before symptom reduction and human service needs were attained can be destabilizing.

The Pittsburgh study was completed prior to the widespread availability of the new antipsychotic agents clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), ziprasidone (Zeldox) and quetiapine (Seroquel). The greater efficacy of these new agents raises the ceiling on the degree of improvement possible for many patients. Exploring the therapeutic synergies possible when new psychosocial treatments are combined with new pharmacologic agents will be an exciting area for future investigation (Fenton and McGlashan, 1997).

References:

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