Schizophrenia – asking the right questions

What do patients want?

In a nut-shell, patients want independence - to work, to have life skills and to have meaningful and fulfilling relationships. Perhaps surprisingly they don’t want to return to a normal healthy lifestyle but to build new goals and meanings in their lives. However, using cost to assess whether patients were achieving independence suggests, at 122,000 euros per person per year, there is still a way to go. Ironically, dissatisfaction with their current independence state contributes majorly to the high cost of treatment.

How should patients be treated?

The ‘how’ question is currently an ongoing discussion.

Guidelines

Guidelines may be the answer but up to date guidelines are lacking worldwide. Among the five sets consulted, discrepancies and paradoxes were in evidence. For example, NICE found that the evidence supporting psychoeducation for carers was poor and non-existent for individuals, and therefore, did not recommend it. And yet psychoeducation is something all psychiatrists and psychologists do as a matter of routine – it’s part of the job.

CBT

The evidence supporting the value of cognitive behavioural therapy (CBT) continues to be questioned. In 2008 it was definitively stated that CBT was effective. In 2014, a second study concluded the exact opposite. Since then, 5 other studies have supported its being beneficial – but why this discrepancy in study outcomes?

Prof Wykes concluded it was due to each meta-analysis including different studies – and that the outlier included studies it shouldn’t have. A public debate on the motion that ‘CBT has been oversold’ was lost, supporting the belief that CBT is effective. Additionally, a survey of experts showed that 43% of them valued CBT in addition to medication for their patients. For the moment, CBT appears effective therapy despite the evidence supporting its merits being questioned.

CRT

It’s well know that patients with schizophrenia have cognitive difficulties early in life. The worse their cognitive defect, the greater the costs associated with their management. One study investigated the effects of cognitive remediation training (CRT) in patients with schizophrenia and, using costs as a measure of treatment success, showed CRT to be highly (cost) effective.

But which remediation therapy is the one to choose?

Mindfulness

As exemplified by the blank screen shown to delegates during the presentation to make the point, there is no evidence to support use of this technique in schizophrenia!

Brain training

The manufacturer of a brain training programme sold worldwide was fined $2 million dollars for deceptive advertising. Furthermore two clinical studies investigating CRT in schizophrenia both failed. However, it may be that the therapies they were using to promote cognitive remediation were flawed. It seems that age, in particular, may adversely affect the outcome.

Where now for CBT and CRT?

Clearly, there is a need for further research into CRT and CBT. What certain studies seem to be signalling are benefits of both techniques under certain circumstances and in certain groups of patients. For example, CBT showed important benefits among people with non-affective psychosis who have social recovery problems, and CRT helped prevent failure in supported employment of patients with schizophrenia.

Maybe what is needed is tailored use of these treatments in certain subgroups of patients. Or maybe the CBT should be targeted differently. Persecutory delusions are a key experience in psychosis However, worry is an important factor in the occurrence of persecutory delusions. It was shown that targeting CBT to reduce worry produced reductions in persecutory delusions. However, targeting insomnia, another factor associated with persecutory delusions, had little effect. Choice of appropriate target is crucial for success it seems.

When should patients be treated?

As early as possible is the straightforward answer, including those who have first-degree relatives with the condition. With the need for such a large scale roll out, is it the time to move to mobile?

A major concern is that those with the severest illness with be excluded from this technologically-driven approach. And as it turns out, when asked, patients want apps and a person to interact with. So, some further thinking about the use of gadgets is needed.

Where should patients be treated?

The move to mobile does, however, have some unexpected consequences. It can prompt patients to take their meds – aiding adherence to therapy - and daily surveys that monitor patient symptoms are now possible remotely. Intervention when potential relapse is looming can now occur by phone. Thus, patients can effectively be treated anywhere.

‘Homework’ to reinforce what has been learned at the clinic between sessions is possible and therapy has even entered the realms of virtual reality. The advent of avatar trialogues – the patient, the physician and an avatar intermediary - has produced benefits. With an app and Google cardboard, even virtual reality therapies can be homebased.

Who should be treated?

As Dame Wykes stated, there are no data at present that would exclude anyone from psychological therapy. A comprehensive care package is best and two therapies – pharmacological and psychological – are likely to be better than one, provided they both start as early as possible.