Psychological and social

management of schizophrenia
spectrum disorders

Presenters: Dr Neha Puri Coordinator : Dr Ravi Parkash

Dr Pooja Bhatia Chairperson : Dr Yogender Malik
Flow of the Seminar

 Introduction
 Various domains affected in Schizophrenia
 Need of psychosocial interventions
 Various psychosocial interventions
 Psychosocial situation in India
 Current deficiencies
PORT Guidelines
 Conclusion
Introduction
As per Global burden of disease report, mental disorders account for 13% of total DALYs.
The lifetime prevalence of mental disorders was found to be 13.6% in NMHS, 2016. Mental
disorders were the leading cause of YLDs in India, contributing 14.5% of the total YLDs in
2017.
Nearly, 1.9% of the people surveyed were affected with a severe mental disorder in their
lifetime, of which the prevalence of schizophrenia and other psychotic disorders was 0.4%

[National mental health survey, 2016]

Domains affected

Positive symptoms Affective symptoms

- Delusions - Dysphoria
- Hallucinations - depression
- Disorganized speech
- Disorganized behaviour
- Catatonic behaviour Social and Cognitive symptoms
- Problems representing and
occupational
maintaining goals
dysfunction - Problems sustaining attention
Negative symptoms
- Problems evaluating functions
- Alogia
- Difficulty with serial learning
- Affective blunting
- Impaired verbal fluency
- asociality
- Difficulty in problem solving
- Anhedonia
- avolition aggressive symptoms
-assaultiveness
Verbally abusive behaviours
Frank violence
Psychosocial impact on the lives of people with schizophrenia spectrum
disorders

Chronic and severe form of mental disorder with debilitating course and poor outcome.
Profound disruptions to cognition and emotions
 Progressive loss of self-care and social functioning in affected individuals
 High levels of unemployment
 Management of Schizophrenia

Diagnostic evaluation Treatment

History Investigations Pharmacological Combination

Examination
MSE Non- Pharmacological
Management of schizophrenia spectrum disorders
Pharmacological management is the mainstay of the treatment in schizophrenia, which includes 1 st and
2nd generation antipsychotics.

Antipsychotic medications are effective in reducing overall symptoms and risk of relapse in patients
with schizophrenia, with primary efficacy mainly against positive and disorganization symptom
domains. These are less consistently effective in reducing negative symptoms.

Antipsychotic medications improve attention in patients with schizophrenia, their effects on other
cognitive impairments are inconsistent.

[Kirkpatrick et al; 2006;Stahl & Buckley, 2007]

 Although antipsychotic medications are the mainstay of treatment for schizophrenia,
pharmacotherapy alone produces only limited improvement in negative symptoms, cognitive
function, social functioning and quality of life.

Many patients continue to suffer from persistent positive symptoms and relapses particularly
when they fail to adhere to prescribed medications.

[Patterson and Leeuwenkamp, 2008; Kern et al, 2009]

Comprehensive treatment of schizophrenia spectrum disorders entails a multi-nodal approach,
including medication, psychosocial interventions and assistance with housing and financial
sustenance.

Broad objectives:
1. To reduce the mortality and morbidity of the disorder
2. To decrease the frequency and severity of episodes of psychotic exacerbation
3. Improving the functional capacity and quality of lives of the individuals afflicted with the
illness
Psychosocial management in schizophrenia spectrum disorders

Psychosocial treatments enable persons with schizophrenia to cope with the disabling aspects of
their illness.
The term refers to “a systematic attempt to modify a psychosocial process”.
Any measure undertaken to change a social or psychological attribute may be considered as a
psychosocial intervention.
 It encompasses any intervention at the individual, family, workplace, community and population
level that attempts to change the psychological or social situation.
 Introduction
Psychosocial interventions - specific & complementary place, considering the pre-morbid and residual
deficits in schizophrenia
Course of illness - affected by environmental events, modifications of which may improve outcome
Medications are essential and psychosocial interventions improve overall functioning, quality of life and
drug compliance
Psychosocial interventions utilize psychological and social measures delivered in a relatively non-
technical setting that act at the individual or family level to improve psychosocial functioning of the
patient.

Main approaches to psychosocial intervention which are used for the treatment of schizophrenia:
Cognitive therapy (cognitive behavioral and cognitive remediation therapy)
 Psychoeducation
 Family intervention
 Social skills training
Assertive community treatment
 Family therapy and
psychoeducation Supported
employment

Psychoanalysis
Cognitive Cognitive
Behaviour remediation
Therapy

Early 20th cent. 1950s 1960s 1970s 1980s 1990s 2000’s and beyond
Psychoeducation and coping-oriented interventions

Psychoeducation refers to a set of measures aimed to increase patients’ and the family members’
knowledge of the illness and its treatment and to develop some degree of insight in the process.

It can be presented in the form of

individual sessions with the patient or the family member or caregiver
 a session involving the entire family together
 conducted in groups

[Xia et al. 2011]

 It can be delivered in

Structured sessions Unstructured sessions

each session having a particular agenda the queries are answered sequentially
Psychoeducational interventions provide information about the disorder and its treatment to patients and
their family members, and additionally inform the patients and family members about strategies to cope
with schizophrenic illness.

These interventions reduce high expressed emotion among relatives, and decrease relapse and
rehospitalization rates.

[Giron et al., 2010]

Study Methodology Results
Pitschel waltz et al  N = 25 , intervention studies regarding the effect • Relapse rate found to be reduced by 20
2001 of including relatives in schizophrenia treatment. percent if relatives of schizophrenia
 The patient's relapse rate in the first years after patients are included in the treatment.
hospitalization was the main study criterion. • The bifocal approach was found to be
superior to the medication-only standard
treatment.

Pharaoh et al 2006  Randomized studies  Family intervention improved general

 Comparison of community-orientated family- social impairment and the levels of
based psychosocial intervention with standard expressed emotion within the family
care
 Cochrane Schizophrenia Group Trials Register

Lincoln et al 2007  Meta analysis study  Interventions that included families were
 18 RCTs comparing psychoeducation to standard more effective in reducing symptoms by the
care end of treatment
 Relapse prevention at 7-12 month follow-
up.
Study Methodology Results

Grion et al 2010  N= 50, RCT  Family intervention was associated

 Psychosocial intervention in Schizophrenia family
intervention,
 Individual counselling versus standard treatment
with fewer clinical relapses,
hospitalizations and major incidents,
 Improvement in positive and negative
symptoms, social role performance,
social relations, employment and
family burden.

Chien et al 2017  Single-blind, multi-site, RCTs across three countries  Compared with TAU and CPEG,
 38 patients per country (n = 342) were assigned to MBPEG improves remission and
each treatment group hospitalization rates of people with
schizophrenia spectrum disorders
over 24 months
Social Skills Training

Schizophrenia patients manifest deficits in social competence and these contribute to poor
outcome.
The goal is to improve day-to-day living skills by focusing on components of social competence
such as self-care, basic conversation, vocational skills, and recreation.
These skills are practiced mostly in group settings using techniques based on operant and social
learning theory.
During the 1980s and 90s, specific training approaches were developed to address each of the skill
deficits and their application was found to be effective in improving social skills and reducing rates
of relapse

[Benton and Schroeder, 1990]

Learning activities used to teach social skills
Introduction to skills

Video tape demonstration

Role play

Resource problem solving

Outcome problem solving

In vivo assignment

Home work assignment

Study Methodology Results

Koujalgi et al,  Cross-sectional interventional study , total of
2014  N= 65 patients with chronic schizophrenia as per ICD-
10 (34 in experimental, 31 in control group).
 SST is effective in improving social
skills of patients with schizophrenia.
 SST is effective in alogia, apathy and
anhedonia, but not other domains of
negative symptoms

Turner et al, 2018  27 RCTs  SST demonstrated superiority over

 N = 1437 TAU and active controls for negative
 Trials assessing SST against active controls and symptoms.
treatment-as-usual (TAU) were included.
Cognitive Behaviour Therapy

About a third of patients with schizophrenia continue to suffer from persistent psychotic
symptoms despite adequate pharmacotherapy.
CBT has emerged to address this need, and is based on the hypothesis that psychotic symptoms
such as delusions and hallucinations stem from misinterpretations and irrational attributions
caused by self-monitoring deficits.
CBT seeks to help patients rationally appraise their experience of disease symptoms and how
they respond to them, thereby reducing symptoms and preventing relapse.

Effective CBT techniques to target psychotic symptoms include:

 belief modification
 focusing/ reattribution
 normalizing psychotic experiences
Study Methodology Results

Turkington et al, 2008  5 year follow up study  In comparison to usual treatment,

 N=90 subjects, RCT study CBT showed evidence of a
significantly greater and more
durable effect on overall symptom
severity and level of negative
symptoms.
Gould et al, 2001  Meta-analysis for psychotic symptoms  Cognitive therapy was found to be
in schizophrenia. an effective treatment for patients
 Effect sizes were calculated for 7 studies with schizophrenia who have
involving 340 subjects. persistent psychotic symptoms.

Rector and Beck, 2001  7 RCTs to test the efficacy of CBT for
schizophrenia.
 effect size estimates were computed to
determine the magnitude of clinical change in
CBT and control treatment conditions.
 CBT has been shown to produce
large clinical effects on measures of
positive and negative symptoms of
schizophrenia.
 Patients receiving routine care and
adjunctive CBT have experienced
additional benefits as compared to
routine care and adjunctive
supportive therapy.
Study Methodology
Zimmermann et al., 2005  14 studies,
 1484 patients,
 between 1990 and 2004
Pfammater et al 2006  Between 1990 and 2005
 21 meta-analyses of studies assessing the
efficacy of various psychological
therapies in schizophrenia
Jones C et al, 2018  The Cochrane Schizophrenia Group's
Trials Register (up to March 6, 2017)
was used and analysed.
 60 trials with 5,992 participants.
 CBT added to standard care was
compared with standard care alone.
Results
 CBT showed significant reduction in positive
symptoms.
 There was a higher benefit of CBT for patients
suffering an acute psychotic episode versus the
chronic condition.
 Reduction of positive symptoms.
 Social skills training, cognitive remediation,
psychoeducational coping-oriented
interventions with families and relatives, as
well as CBT of persistent positive symptoms
emerge as effective adjuncts to
pharmacotherapy.
 No clear difference between CBT and standard
care for relapse.
 Adding CBT to standard care may reduce the
risk of having an adverse event
 no significant effect on long-term social
functioning .
Cognitive remediation
 Impaired cognition in patients of schizophrenia, in the domains of psychomotor speed,
attention, working memory and executive function, verbal learning, social cognition.
These deficits persist during the illness and serve as rate limiting factors for functional recovery.
Cognitive remediation, a.k.a cognitive training and cognitive rehabilitation is a behavioural
training intervention that aims to improve cognitive processes.

[Tandon et al, 2010]

Cognitive remediation approaches
Based on some combination of three main principles:
- Training,
- Strategy Monitoring
- Generalization.

Michael W Best & Christopher R Bowie (2017)

Study Methodology Results

McGurk et al 2007  Meta- analysis  Largest effects on verbal

 26 RCTs on cognitive working memory and social
remediation in schizophrenia cognition.
 No significant improvement on
visual learning and memory
Assertive community treatment

 Comprehensive, individualized approach to delivering care for people whose functional

impairments traditionally from chronic psychosis prevents them from effectively navigating their
lives and health care systems in less intensive care models.

 The fundamental principles include:

• Multidisciplinary staffing
• Integration of services
• Team approach
• Low patient to staff ratio
•Point-of- contact care delivery in the community
•Medication management
•Focus on everyday concerns
•Assertive outreach (being persistent in offering services to clients who are not engaging in their
care
•Individualized and time-unlimited services
Study Methodology Results

Schottle et al 2018 115 patients were assessed over 48 months. Within continuous intensive 4-year ACT-
care, sustained improvements in
psychopathology, functioning, quality of
life, low service disengagement and re-
hospitalization rates, as well as low rates
of involuntary treatment were observed
Community outreach

These involve modifications of the standard service delivery by bringing therapeutic processes
closer to the patient.
It involves provision of service at the doorstep of the patient and reduces dropouts and non-
adherence.
Raipur Rani project

The Raipur Rani project was one of the first systematic structured community intervention
projects in India. The project was carried out in the Raipur Rani block of Ambala district in
Haryana, north India, and covered a population of around 60,000 in about 100 villages.

Neuro-psychiatric cases such as psychosis, epilepsy, mental retardation and depressive and
anxiety neurosis were identified, and a limited list of needed drugs was drawn up for providing to
the patients.

At the PHC, a weekly psychiatric clinic was set up, It was seen that regular follow-up at the
centre depended upon the accessibility and distance from patient’s residence.
Training of the health personnel was undertaken with the aim of building acceptability of
services, easy access of care, expanding the workforce to deliver psychiatric treatment and
maintain continuity of care.

The services, especially that of follow-up care, were decentralized to the sub-centres, where brief
assessment and provision of treatment was conducted by health workers under the overall
supervision of psychiatrists. The project proved successful and paved way for other upcoming
projects in India.

(Wig et al. 1981)

Study Methodology Results

Asher et al 2017  Eleven RCTs in five middle-income The results support the feasibility
countries and effectiveness of community-
 1580 participants.  based psychosocial interventions for
schizophrenia, even in the absence of
community mobilization
Camps

The camp approach has been quite successful in providing mental health and deaddiction
services to the community.
During the camp, patients are evaluated by trained physicians and psychiatrists. Counselling is
provided, and medications are supplied wherever possible. Aftercare and follow-up are provided,
and referrals are made for serious cases.
This kind of intervention helps those patients to seek help who otherwise do not approach
structured health care systems.

[Padhy et al, 2015]

 Supported employment

Supported employment involves individually tailored job placement, rapid job search, provision of
ongoing job supports, and integration of vocational and mental health services.

There is evidence that supported employment is a more effective approach to help patients find and
maintain competitive employment than traditional approaches to vocational rehabilitation.

(Campbell et al., 2009; Dixon et al., 2010)

Study Methodology
Suijkerbuijk et al 2017  In a Cochrane systematic data review, 48
RCTs
 8743 participants
 Of these, 30 studies supported
employment, 13 augmented supported
employment, 17 prevocational training,
and 6 transitional employment
Results
 On short‐term follow‐up of
maintaining employment,
supported employment was
more effective than:
psychiatric care only,
transitional employment,
prevocational training, and
augmented supported
employment.
 On long term follow up,
augmented supported
employment was found to be
most effective amongst all.
AVATAR Therapy

AVATAR therapy (invented by Julian Leff in 2008) – an approach in which people who hear
voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced
by the therapist so that the avatar responds by becoming less hostile and concedes power over the
course of therapy.

Specially designed computer software, the clients create a visual representation of the entity
(human or nonhuman) that they believe is talking to them.
Additional software is used to transform the voice of the therapist to match the pitch and tone of the voice heard
by the person; the two processes finally being combined to produce a computer simulation (avataR) through which
the therapist can have a dialogue with the person.

 Time taken to create the “AVATAR”, therapy - 6×45 minutes sessions (around 15 minutes is spent in dialogue
with the avatar).

[Leff et al. 2014]

Study Methodology Results
Craig et al, 2017  single-blind, RCT  124 (83%) showed reduction
 N= 150 in auditory verbal
18 to 65 years with schizophrenia hallucinations at 12 weeks.
spectrum or affective disorder with
psychotic symptoms as per ICD-10 and had
enduring auditory verbal hallucinations
during the previous 12 months, despite
continued treatment
 Participants were randomly assigned
(1:1) to receive AVATAR therapy or
supportive counselling.
 Assessments were done at baseline, 12
weeks, and 24 weeks.
Wellness recovery action planning

•Peer led, self management intervention programme for chronic mental health conditions.
•Fosters an environment which empowers the clients to build a life worth living, rather than
simply managing symptoms, through emphasizing holistic health, wellness, strengths, and social
support.
•Leads to psychiatric symptom reduction, improvement in physical health, quality of life
measures, and recovery- oriented perspectives like hopefulness.
Psychosocial situation in India
o Distinct psychosocial milieu as compared to the west
o Families in India are stable cohesive units
o Closeness in families; substantial support and care to the mentally ill
o Lack of health insurance to all
o Out of pocket expenditure for treatment of health conditions
o Overburdened health sector
o Non- uniform availability of quality services.
oMagico-religious beliefs regarding the genesis of illness
o low interest and adherence to psychotherapeutic measures
Padhy et al 2015
Current deficiencies

Pharmacological, psychological, and social treatments for schizophrenia have evolved over the
past two decades, generating much excitement but only modest improvements in the lives of
people with schizophrenia.

limited availability and access to the broad range of effective treatments

inconsistent application.

Existing treatments are incompletely effective and associated with a range of adverse effects.
Furthermore, by the time most patients with the illness present to the clinic for treatment, the
pathology of schizophrenia has often advanced to such a degree that its course is difficult to
reverse.

The significant variations in the way patients respond to different treatments, without the ability
to predict how a particular individual will respond, makes optimal personalized therapy difficult.
Bridging the efficacy- effectiveness gap

Key practices that can help reduce the gap are:

Knowledge about pros and cons of different treatments and the practice of evidence-based
medicine
Precise definition of treatment targets for patients based on informed personal preferences,
individual vulnerabilities and needs
Measuring the full impact (benefit to risk ratio) of individual treatments in each patient by the
practice of measurement-based care
Collaborative and informed decision-making on an ongoing basis, evaluating patient needs and
preferences, measured effects of current treatments, and available treatment options at each stage
PORT RECOMMENDATIONS
The Schizophrenia Patient Outcomes Research Team (PORT) provide recommendations on current
evidence based psychosocial treatment interventions for persons with schizophrenia.

2009 PORT review produced psychosocial treatment recommendations-

 Family-based services
 Skill Trainings
 Cognitive behavioural therapy
 Assertive community treatment
 Token economy
 Supported employment
Cognitive Behavioral Therapy

Persons with schizophrenia who have persistent psychotic symptoms while receiving adequate
pharmacotherapy should be offered adjunctive cognitive behaviorally oriented psychotherapy to
reduce the severity of symptoms.
The therapy may be provided in either a group or an individual format.
It should be approximately 4–9 months in duration.

The key elements of this intervention include-

 the collaborative identification of target problems or symptoms
 the development of specific cognitive and behavioral strategies to cope with these problems or
symptoms.
Assertive Community Treatment

It should be provided to individuals who are at risk for

- repeated hospitalizations
- have recent homelessness.
Supported Employment

Any person with schizophrenia who has the goal of employment should be offered supported
employment to assist them in both obtaining and maintaining competitive employment.

The key elements include

 individually tailored job development
 rapid job search
availability of ongoing job supports
 integration of vocational and mental health services
Skills Training

• Individuals with schizophrenia who have deficits in skills that are needed for everyday activities
should be offered skills training in order to improve social interactions, independent living, and
other outcomes that have clear relevance to community functioning.
• Skills training programs typically include a focus on interpersonal skills.
key elements includes-
behaviorally based instruction
role modeling
 rehearsal
 corrective feedback
 positive reinforcement
Family-Based Services

Persons with schizophrenia who have ongoing contact with their families, including relatives
and significant others, should be offered a family intervention that lasts at least 6–9 months.

It significantly reduce rates of relapse and rehospitalization.

It also helps in
increased medication adherence
 reduced psychiatric symptoms
reduced levels of perceived stress for patients
Key elements of effective family interventions include-
 illness education
 crisis intervention
 emotional support
training in how to cope with illness symptoms and related problems.

The selection of a family intervention should be guided by collaborative decision making among
the patient, family, and clinician.
Token Economy Interventions

Emphasis is on reinforcing positive behaviour by awarding “tokens” for meeting positive

behavioural goals.

 Systems of care that deliver longterm inpatient or residential care should provide a behavioral
intervention based on social learning principle for patients in these settings in order to improve
their personal hygiene, social interactions, and other adaptive behaviors.
The key elements-
 these are contingent positive reinforcement for clearly defined target behaviors,
an individualized treatment approach
 the avoidance of punishing consequences

The intervention should be delivered in the context of a safe treatment environment that provides
patient access to basic amenities, evidence-based pharmacological treatment, and the full range
of other recommended psychosocial interventions.
 Departmental View (IMH/SIMH)
Our initiatives ( Under chairmanship of DCEO - Sr Prof Rajiv Gupta)
Half-way home – currently in pipeline
Day care centre – SIMH ( daily; skill development training of patients under a trained occupational
therapist)
Community reintegration – SIMH (70-80% of patients are reintegrated into community)
Yoga activities ( daily)
Community Camp activities
Liaison with Governmental and Non- Governmental organisations
Crisis Resolution Team of SIMH (home visits have been made)
Mental health telephone help line
Conclusions
&
Future directions
Conclusions
Still in infancy
No proper rehabilitation programs
◦ Economic constraints
◦ Attitude of health professionals
◦ Better prognosis of the disease in India?
◦ Presence of family and social support
◦ Families are: more tolerant of the deviant behaviour/ patients; more willing
to take care of the ill member, but rapid urbanisation and lack of time are
slowly bringing a detrimental change which will be difficult to manage in the
coming times
Conclusions
◦ Difficulties in Vocational Rehabilitation
◦ Lack of job opportunities
◦ Hospital as a dumping site
◦ Expressed emotions and relapse
◦ Burn out of hospital staff
 Future directions
GOs & NGOs need to establish, expand, and integrate services at all levels so that all patients with
schizophrenia, as well as other psychiatric disorders, should be offered a comprehensive long-term
aftercare program following the recovery from their acute illness.
This will mitigate some of the problems of the patients and their caregivers.