William T. Carpenter, a professor of psychiatry at the University of Maryland School of Medicine, who was not involved in the study. Mary E. Olson, an assistant professor of psychiatry at the University of Massachusetts Medical School, who has worked to promote approaches to psychosis that are less reliant on drugs, said the combined treatment had a lot in common with Open Dialogue, a Finnish program developed in the s. Olson said. In the new study, doctors used the medications as part of a package of treatments and worked to keep the doses as low as possible minimizing their bad effects.
The sprawling research team, led by Dr. John M. Kane, chairman of the psychiatry department at Hofstra North Shore-LIJ School of Medicine, randomly assigned 34 community care clinics in 21 states to provide either treatment as usual, or the combined package. The team trained staff members at the selected clinics to deliver that package, and it included three elements in addition to the medication. Second, education for family members to increase their understanding of the disorder.
And finally, one-on-one talk therapy in which the person with the diagnosis learns tools to build social relationships, reduce substance use and help manage the symptoms, which include mood problems as well as hallucinations and delusions. For example, some patients can learn to defuse the voices in their head — depending on the severity of the episode — by ignoring them or talking back. The team recruited people with first-episode psychosis, mostly diagnosed in their late teens or 20s.
About half got the combined approach and half received treatment as usual. Clinicians monitored both groups using standardized checklists that rate symptom severity and quality of life, like whether a person is working, and how well he or she is getting along with family members.
The group that started on the combined treatment scored, on average, more poorly on both measures at the beginning of the trial. Over two years, both groups showed steady improvement. But by the end, those who had been in the combined program had more symptom relief, and were functioning better as well. The researchers expect to have lowered average doses in the combined program but had not yet finished analyzing that data.
The treatment of schizophrenia: a patient's perspective.
Kane said. The gains for those in typical treatment were apparent to doctors, but much less obvious. There was overall agreement that psychosocial interventions are necessary to achieve functional recovery Among all interventions proposed, family interventions and those aimed at developing social skills and improving employability were considered the most useful for functional recovery Additional file 1 : Table S5. Although the inclusion of cognitive rehabilitation in psychosocial interventions was considered useful, cognitive disorders were not agreed to be the primary target of these interventions.
The majority of experts in the panel It was also agreed that the various antipsychotic agents have different impacts on functional recovery. The experts agreed that the perspective of clinicians on functional recovery differed significantly from that of patients and their relatives Additional file 1 : Table S7. According to this observation, psychiatrists are more concerned with the clinical aspects of the disease, whereas patients and their relatives are more concerned with subjective aspects of the lifetime project and factors influencing activities of daily living. Following a two-round Delphi dynamics approach, we found high homogeneity in the opinion of clinicians regarding functional recovery in patients with schizophrenia.
Functional recovery is a complex, multidimensional concept to be considered not only by clinicians but also researchers, patients and caregivers, as well mental health policy makers. Although the perspective of the various stakeholders involved in the definition of functional recovery may converge on many aspects, the lack of a common terminology and the pursuit of different goals has led to a wide repertoire of definitions, none of which stands out clearly over the rest [ 2 , 6 , 7 , 16 , 26 ].
The result of our consensus regarding the concept of functional recovery mirrored this scenario, resulting in a lack of consensus regarding a well-established concept of functional recovery. Nevertheless, the general agreement on specific factors influencing the concept of functional recovery suggests that despite the lack of a standardized definition of recovery, most clinicians share a common archetype of what functional recovery actually is.
The feasibility of achieving functional recovery in patients with schizophrenia has been under discussion since the emergence of interest in this concept [ 2 , 6 , 22 , 27 ].
Patient Story: Schizophrenia
This is in line with the results of recent research on schizophrenia, which showed that psychological well-being and mental health recovery can improve in individuals with first-episode psychosis [ 28 ]. The lack of a clear definition and assessment tools prevents from drawing strong conclusions regarding the feasibility of a therapeutic model based on the concept of recovery. However, empirical evidence on various therapeutic interventions suggests that many patients with schizophrenia can achieve goals related to functional recovery such as independent living and competitive employment and education in routine community settings [ 18 — 21 , 29 ].
In line with the common perception regarding the definition of functional recovery, M.
European Brain Council
The lack of a standardized definition is probably a bottleneck for the development of validated tools for the assessment of functional recovery. Other difficulties that may compromise an appropriate assessment of functional recovery include the limitations of some informants to make accurate judgments [ 31 ], the limited capacity of some patients for self-assessment [ 32 ], and the heterogeneity in their clinical course, which may lead to inconsistencies between the outcome of functioning scales and milestone achievement in some patients e.
Indeed, some authors have warned of the risk of bias associated with motivation-related negative symptoms e. Furthermore, patient-reported assessments of quality of life and everyday abilities have shown poor correlation with information about lifetime achievements in many patients with schizophrenia [ 35 ]. All these limitations are consistent with the lack of consensus on the concept that the patient is the most reliable source of information for functional assessment.
Due to the absence of a single tool for the assessment of functional recovery, clinicians and researchers use different strategies to evaluate it. In an attempt to broaden functional assessment towards a comprehensive model of functional recovery, researchers have combined commonly used scales such as the Global Assessment Functioning GAF scale and Global Assessment Scale GAS with the Social Functioning Rating Score — which includes both social skills and social roles — and other objective indicators of lifetime achievements [ 36 — 38 ].
In this regard, treatments based on a recovery model should be consistent with evidence-based treatments [ 2 ]. Functional recovery, may be influenced by multiple factors. According to the experts, these factors are a combination of environmental factors, stressful life events, substance abuse, socioeconomic conditions, and family dynamics. Some authors have observed that patients living in rural areas tend to show better functional outcomes, probably due to greater family and social support as well as simpler vocational roles [ 39 ]. Thus, while some centers provide mental health care to patients from both rural and urban areas, most of them serve one or the other type, whereby the influence of this factor may be unnoticed.
In line with the results of clinical studies, which suggest that both negative symptoms and cognitive deficits may be primary predictors of impaired social and vocational performance [ 34 , 40 , 41 ], the experts in the panel agreed that both negative and cognitive symptoms cause a significant impact on functional recovery.
Also, in agreement with recent recommendations to treat negative symptoms [ 42 ], the experts agreed that functional recovery should not be addressed only through symptoms but also considering the cognitive, emotional, and relationship difficulties. Stigma is another factor with potential influence on functional recovery, and it is generally accepted that it has a major impact on self-esteem and hampers recovery in people with mental illnesses [ 7 , 43 ]. The experts agreed that the negative image associated with psychiatry compared to other medical specialties increases stigma in patients with schizophrenia and that self-stigma or internalized stigma has a greater impact on functional recovery than social stigma.
Although the mechanisms of stigma are not clear, social or public stigma and self-stigma might work in different ways. In an interview-based study conducted on patients with major depression or schizophrenia, social stigma showed a trend towards underestimating the importance of informal caregivers e. Conversely, self-stigma had a negative impact on the perceived importance of seeking help provided by a general practitioner or a psychiatrist [ 44 ]. The relevance of psychosocial interventions agreed in this consensus are consistent with the positive results of these interventions reported in randomized clinical trials conducted according to the gold standards of clinical design [ 45 — 47 ].
Although the items regarding the type of therapy with highest effectivity were written in an exclusive way, the experts achieved consensus in the highest effectivity of social skills training, family therapy, cognitive rehabilitation, social cognitive training, and occupational programs.
This result indicates that, irrespective of the median score achieved in each therapy, none of them stood out from the rest. Of note, recovery-based interventions are not widespread in clinical practice and some authors have stressed the need to develop more interventions going beyond symptom reduction [ 48 ].
The apparent inconsistency regarding the role of cognitive functioning in psychosocial interventions can be explained by the recent evolution of the concept of cognition. Thus, while the construct of cognitive impairment has been traditionally built solely on basic neurocognition, it is now accepted that social cognition differs from basic neurocognition and that it could be the link between neurocognition and functional recovery in psychosocial programming [ 5 , 49 ]. The positive impact of long-acting antipsychotics on adherence and the closer relationship between patients and the healthcare team associated with the dosing of these agents have been considered helpful for achieving functional recovery [ 38 ].
Some authors have questioned the suitability of maintaining long-lasting treatment with antipsychotics [ 50 ].
Living with Schizophrenia: A Family Perspective
However, the impact of long-lasting antipsychotic treatments on functional recovery is unclear, and other authors have highlighted important limitations of studies investigating early discontinuation of antipsychotic therapy [ 51 ]. Although it is not clear whether medication alone can impact directly on functional performance, there is long-time evidence on the synergistic effect of pharmacological and psychosocial treatments, particularly pharmacological treatments with a significant impact on positive symptoms [ 7 , 52 — 54 ].
Despite the proven usefulness of some antipsychotic agents in achieving functional recovery [ 57 , 58 ], the experts identified potential drawbacks of pharmacological treatment for achieving functional recovery: extrapyramidal symptoms, sedation, the worsening of negative symptoms, and cognitive impairment. Of note, most of the adverse events limiting functional recovery are more frequently associated with first-generation than second-generation antipsychotics [ 59 — 61 ]. Combination antipsychotic therapy was also considered to result in poorer functional recovery than monotherapy.
The scope of the results presented herein must be weighed considering some limitations of our work.
First, the selection of experts was neither systematic nor randomized. Alternatively, we recruited specialists in the management of schizophrenia from various Spanish regions. Second, some items expressing mutually incompatible ideas yielded inconsistent results. Items affected by this phenomenon were discussed and eventually not considered for drawing the final conclusions. Finally, the resulting recommendations were not drawn following a consensus process, but as an interpretation of the agreements and disagreements resulting from the Delphi process. Nevertheless, due to the expected heterogeneity on the concept, we deemed it more appropriate to address the conclusions by weighing the scope of each result carefully and addressing the inconsistencies that might arise from the responses of the panel of experts.
List of recommendations when addressing functional recovery of patients with schizophrenia. Despite the lack of a unified definition of functional recovery, it is recommended to ponder quality of life, cognition and clinical remission when considering functional recovery in research and routine practice. Functional recovery should be considered a goal in the management of patients with schizophrenia. Functional recovery should be always included among endpoints of clinical trials assessing patients with schizophrenia.
When seeking for the achievement of functional recovery, the combined influence of stressful life events, substance abuse, socioeconomic conditions, and family relationships, should be considered. Although negative symptoms have a great impact on functioning, clinicians should not focus exclusively on symptom remission when considering functional recovery.
Psychosocial interventions are necessary to achieve functional recovery. A combination of various therapies including social skills training, family therapy, cognitive rehabilitation, social cognitive training, and occupational programs is likely to be most useful in achieving functional recovery. Functional recovery should be considered in decision-making on pharmacological treatments.
The perspective of patients and their relatives on functional recovery. The attitudes of all stakeholders i. Hence, when seeking for achieving functional recovery, all these perspectives should be taken into account. Global Assessment Functioning. Global Assessment Scale. Health of the Nation Outcome Scale. Personal and Social Performance. Social and Occupational Functioning Assessment Scale. Medical writing assistance was provided by Dr. This project was funded by Janssen. The funding body participated in study design and data interpretation. All co-authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work were appropriately addressed and resolved.