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 Mr. X

Mr. X is a 54-year-old Caucasian male combat veteran with a history of schizophrenia

diagnosed in 1973, who presented to the Hampton Veteran’s Administration Emergency
Department one dark, fateful night. The exact reason for his presentation is not known;
his speech is unintelligible, such that obtaining a recent history is impossible.
Furthermore, when asked whether he knew why he was here, he nods in the negative.
Admittance to the 2-S Inpatient Psychiatry Ward is sought, and the patient is in
agreement with this plan.

In further questioning the patient after admission, he denies any suicidal or homicidal
thoughts, and there are no signs of aggression. Given his unintelligible speech and
inability to respond to complex questions requiring more than “yes” or “no”; as such,
ascertaining the presence and nature of hallucinations, delusions, or content of thoughts
was not possible. Review of systems is negative for shortness of breath, chest pain,
dysuria, or other identifiable problems. Physical exam is negative except for
unintelligible speech, generally disheveled appearance, and abrasions on both knees and
lower legs.

Past Psychiatric History: Diagnosed with schizophrenia in 1973. Last admission was to
2-S Inpatient Psychiatry Ward only two days prior; before this, his last admission was
one year ago. His presentation two days ago was quite similar; unintelligible, unaware of
reason for coming to the ED, but willing to be admitted. He was brought in by his sister,
who states that Mr. X had become aggressive and sexually inappropriate. He was treated
with Depakote and Quetiapine while in ward, improved quickly without sustained
inappropriate behavior or psychotic symptoms, and was discharged after 11 days.

Substance Abuse History: None, per sister from last admission

Medical History: Schizophrenia, paranoid type; Carcinoma of Lung; COPD; Tobacco

Use Disorder; Positive PPD; Obesity

Social History: Never married, no children. Unemployed, resides in assisted living

facility. 100% service connected and collects Social Security Disability. Legal
guardianship is via Mr. X’s sister, who has durable POA. No history of substance abuse
aside from significant tobacco use, which has resulted in Mr. X’s diagnosis of COPD and
Stage III lung cancer. His sister has requested palliative care, and if his condition
deteriorates such that he is no longer manageable at his assisted living facility, then he
will be transferred to inpatient hospice. Per Social Services, Mr. X does have difficulty
with instrumental activities of daily living, including meal preparation, using a telephone,
performing housework, and managing medications.

Mr. X received Depakote 500mg BID, Klonopin 1mg BID, and Seroquel 300mg Q12H.
Improvements in his awareness, comprehension, and verbal abilities were quickly seen,
though significant deficits remained. Though he has been predominantly cooperative and
pleasant, his hospital stay was accentuated with sexually inappropriate gestures
(nudity/masturbation in hallway, encouraging hospital staff to lend a hand in
masturbation) and episodes of aggression toward nursing staff (verbal outbursts, striking
nursing staff in arm). His medications were adjusted, increasing Depakote to 750mg BID
and Seroquel to 350mg Q12H. This change largely alleviated issues with aggression or
sexual inappropriateness, though occasionally disruptive actions such as singing or loud
talking in the social areas persisted. Mr. X’s physical condition has declined as a result
of the Stage III lung cancer, and he has been staying in his bedroom all day. Mr. X was
not accepted into palliative care, and his disposition remains unclear.

Adjunctive Psychotherapies for Treatment of Schizophrenia

Schizophrenia is a severe and profoundly disabling psychiatric disorder which affects

approximately 1% of the population. Although atypical antipsychotics remain the

principle treatment for schizophrenia, pharmacotherapy has limits. Between 25-50% of

sufferers continue to experience persistent and distressing positive symptoms[24,10], and

current neuroleptics still do not have a substantive effect on cognitive and negative

symptoms[24,10]. Additionally, neuroleptics fail to significantly affect functional outcomes

or psychosocial abilities; social skills remain poor, and over 70% of schizophrenic

patients are unemployed at any one time[14]. Relapse rates remain substantial, as high as

80% after 5 years[11], even when medication adherence is monitored[24]. Furthermore,

medication adherence is notoriously poor, greater than 60% according to the Clinical

Antipsychotic Trials of Intervention Effectiveness[11]. As hospital treatment of

schizophrenia has increasingly been replaced by community-based care, the imperative of

adequate psychosocial functioning and proper medication compliance is increased. As

such, a need for adjunctive psychotherapies to aid patient recovery has become apparent.

Psychosocial treatment can address a wide range of issues, from symptom and

hospitalization reduction to increasing compliance and employment rates[11].

Furthermore, as more pressure is put on physicians and administrators to contain costs,

the benefits of psychotherapeutic approaches may be able to improve outcomes while

lowering health care costs; indeed, combining psychosocial treatment with

pharmacotherapy can decrease the average cost of treatment per disability-adjusted life

year by more than 40%[28]. This paper discusses four of the most common adjunctive

therapies: cognitive-behavior therapy, cognitive remediation, psychoeducational therapy,

and social skills therapy. Psychodynamic therapy is not discussed; it is widely viewed as

harmful to the schizophrenic patient, and as such no recent publications on its use are

available.

Cognitive Behavioral Therapy

Originally developed for the treatment of anxiety and depression, Cognitive Behavioral

Therapy is now recommended as a treatment for schizophrenic patients by multiple

professional organizations, including the American Psychiatric Association, the

Schizophrenia Patient Outcomes Research Team, and the National Institute of Clinical

Excellence. Drop-out rates are low (12-15%), and CBT appears to be a safe treatment,

not precipitating any rise in suicidal ideation, agitation, or violence [23]. Therapy goals are

to help the patient cope with schizophrenia by providing rational perspectives on the

patient’s experience of disease symptoms. Within the context of a dialogue, the patient

describes the experience and, with the clinician’s help, learns to better understand and

cope with those experiences [11]. Through this dialogue, patients learn to recognize

disease symptoms and they acquire stress reduction techniques, coping strategies, and

cognitive restructuring tools to aid in dealing with symptoms of psychosis.

The most consistent benefit of Cognitive Behavioral Therapy is a reduction in positive

symptoms, as measured by summary scores on the PANSS or Brief Psychiatric Rating

Scale[8-11,22,24]. Overall, there appears to be a modest effect size; the most recent meta-

analysis by Tarrier and Wykes[9] found an effect size of 0.41, whereas a 2006 meta-

analysis reported an effect size of 0.47 for reduction of positive symptoms[24]. These

results are also similar to previous meta-analyses in 2004 and 2005[8]. Of note, the effect

size for reduction of positive symptoms is greater during acute psychotic episodes

(ES=0.57) than during the chronic state (ES=0.27) [11]. Initially, these reductions in

positive symptoms were seen as being better than routine care, but no better than general

supportive therapy; later, more rigorous studies which had a longer follow-up time

showed that the benefits attained through CBT were sustained for one to two years longer

than supportive therapy[22]. Whereas supportive therapy effects were negligible nine

months after treatment, effect sizes of 0.39 for reduction in positive symptoms, and 0.47

for reduction in delusions, were found on 12-month or 24-month follow-up for the groups

receiving CBT[24].

Whether the benefits seen in individual CBT are transferable to a group setting is

debatable. In their randomized controlled trial, Barrowclough et al compared group CBT

to treatment as usual (defined as whatever treatment the subject was receiving prior to

entry into study). While feelings of hopelessness and low self-esteem were reduced, a

reduction in psychotic symptoms was not seen[23], which the authors attributed to the lack

of flexibility in group therapy needed to respond to diverse individualized symptom

presentations. The later meta-analysis by Tarrier and Wykes, however, which took into
account the Barrowclough study, found an effect size of 0.39 for group CBT, suggesting

that there is no evidence of a difference in effect size between individual and group

CBT[9].

Other purported benefits of Cognitive Behavioral Therapy, including medication

compliance, relapse prevention, and social functioning, appear to have equivocal

evidence [5,11]. Kemp tested a specific form of CBT called Compliance Therapy (CT)

against supportive counseling to assess medication compliance in psychotic patients and

found that CT improved adherence and had a 25% lower relapse rate up to 18 months

after treatment completion (hazard ratio=2.1) [22]. Other studies have shown no benefit of

CT over nonspecific patient counseling in medication compliance or quality of life [5,11,29],

while still others report benefit but are essentially equivocal, owing to methodological

problems such as small sample size or no control group[29,30]. Overall, Cognitive

Behavioral Therapy is still an improvement over treatment as usual and supportive

therapy. In all tested domains, CBT has a larger effect size than TAU; compared to

supportive therapy, positive symptoms are extinguished for longer, and there appears to

be a trend favoring CBT in benefitting compliance and relapse, although clinical

significance has not been adequately demonstrated.

Cognitive Remediation

Cognitive deficits are common among patients with schizophrenia, and the degree of

cognitive dysfunction shows direct correlation with the severity of negative symptoms

and impairment in social and occupational functioning [22]. The most commonly reported
deficient domains include processing speed, sustained attention, working memory, verbal

learning, and social cognition; 85% of individuals suffering from schizophrenia score

1.3-2 SD’s below the mean in these areas compared to mentally healthy populations [24].

Cognitive impairments tend to be stable over the course of the disorder and are present

even when psychotic symptoms remit. Furthermore, these deficits are not reliably

improved by antipsychotic medications [11].

Cognitive Remediation (CR) is a rehabilitation approach adapted from the literature on

brain injury. The ultimate goal of CR is to restore neurocognitive function, but CRT also

teaches patients strategies to compensate for deficits [22]. Tactics to achieve this aim

include repetitive supervised exercises, positive reinforcement, and “errorless learning”

(in which tasks are parsed into components; training proceeds from simplest component

to most difficult) [11]. Therapy can be administered in groups or per individual,

computerized or without, and usually involves more than 25 sessions [12]. These methods

may be employed alone or combined into various titled assemblies, such as Integrated

Psychological Therapy (IPT), Neuropsychological Educational Approach to

Rehabilitation (NEAR), Cognitive Enhancement Therapy (CET), or Cognitive Adaptive

Therapy (CAT).

As expected, CR consistently improves performance on neuropsychological tests of

cognitive function, such as the Wechsler Memory Scale, Reaction time tests, Digit span

tests, and the MMSE. A 2006 meta-analyses showed effect sizes of 0.32 and 0.36 [24] for

individual cognitive components such as attention and memory. A later meta-analysis

showed more robust findings, between 0.39 and 0.52 [15]. Overall social cognition was

also significantly improved, with effect sizes of 0.40 [24] and 0.54 [15] reported in the two

reviewed meta-analyses. These gains do appear to translate into practical gains in

society; moderate effect sizes were seen for social functioning (defined as improvements

in obtaining and working in competitive jobs), satisfaction with interpersonal

relationships, and ability to solve interpersonal problems; the 2006 meta-analysis found

an effect size of 0.49 [24], while a 2007 meta-analysis reported an average effect size of

0.35 [15]. However, a recent randomized controlled trial of CR used with psychiatric

inpatients, utilizing work activity at 12-month follow-up as a primary endpoint, found a

trend toward increased employment after CR which did not achieve clinical

significance[7]. Therefore, while it appears that there is real-world applicability to

Cognitive Remediation therapy, and the effects of therapy have been shown to last as

long as ten years[14], effect sizes are not large and more robust studies must be conducted

to determine translational utility.

Identifying factors associated with improved cognitive and real-world functioning will

help refine treatments and ensure successful implementation of Cognitive Remediation

programs. Some work in this arena is underway. Demographic factors such as gender,

age, or years of education are not significantly different among those who improve from

CR and those who do not. Additionally, illness factors such as acuity, severity and scope

of symptoms, and years spent in hospital care do not differentiate good from poor CR

outcomes. Rather, patient factors (motivation toward treatment, work ethic) and
treatment factors (intensity and number of sessions, expertise of the administrating staff)

are all strongly correlated with an individual patient’s success in CR therapy[12].

Psychoeducational Family Therapy

Families of individuals with schizophrenia are affected both financially and emotionally,

and family interactions characterized by highly expressed emotions, criticism and

hostility increases a schizophrenic patient’s chance of relapse[11,24]. In order for patients

and families to assume the most constructive role possible, from the beginning stages of

schizophrenia onward, a basic competency with regards to comprehension and handling

of schizophrenia is indespensible[21]. Psychoeducational family therapy works toward this

end, and is now an American Psychiatric Association recommended therapy for

schizophrenic patients.

Psychoeducation may be defined as educating a patient and the family in subject areas

that serve the goals of treatment, with the ultimate aim of changing behavior, skills, or

attitudes[2]. It must be stressed that education alone is not efficacious; education must be

goal-oriented. Specific goals may be preventing hospitalization, increasing medication

compliance, managing social situations, or reducing internal stress from psychotic

symptoms. Therapy structures are highly variable, but the Family Forum, sponsored by

the Department of Veterans Affairs, found that effective family psychoeducation models

last at least nine months and provide illness education, support, problem-solving training,

and crisis intervention services [17]. For reference, one particular plan, the Alliance

Psychoeducational Program, comprises 12 modules covering symptoms and causes of

schizophrenia, effects and side effects of medications, warning signs, contingency

planning, psychosocial treatment, tasks of family members, alcohol and drugs, and

partnership and sexuality [20]. Additionally, therapy that uses multi-modal methods (live

demonstrations, testimonials, role play, videos) are superior to didactic-only methods [17].

The most obvious benefit of psychoeducational family therapy is an increased working

knowledge of schizophrenia as a disorder, its clinical sequelae, and treatment modalities.

Indeed, patients and family members using the Alliance Psychoeducational Program both

increased their general knowledge by about 8 points on a knowledge questionnaire

(p<.001) [20]. However, the most poignant benefit is the increased medication compliance,

which in turn leads to decreased hospitalization rates [24]. A Meta-analysis of family

psychoeducational therapies found an effect size of 0.63 toward greater adherence to

medications [11], with a NNT of seven[3]. While psychosocial treatments and antipsychotic

medication combined can reduce the yearly relapse percentage to 54%, the addition of

psychoeducational family therapy can further half that number to 27% [19], with a NNT of

six to prevent a relapse within 18 months [2,3,21]. A Cochrane Review study also found that

patients receiving family interventional therapy spent 8 days of a 3-month period in the

hospital, compared to 24 days for the control group [3]. According to the follow-up of the

Psychosis Information Project Study, patients who had received psychoeducation were

hospitalized for 75 days over seven years, compared to 225 days in the routine treatment

group [20]. While individual psychoeducation will yield improvements in compliance and

hospitalization, the benefit of including family members should not be overlooked;

inclusion of family members reduces hospitalization rates over a 2-year period by 20%
compared with patient-only psychoeducations [18]. These data, underscored by findings

that psychoeducational family therapy significantly increases GAF scores and quality of

life of patients [3], illustrate the importance of this valuable, though underutilized, therapy.

Social Skills

Schizophrenic patients exhibit deficits in social competence, which provoke “cliff-

hanging,” stressful interactions with the social environment, and social isolation. These

deficits are largely independent of the severity of prevailing symptoms [24]. The

development of social skills, and by extension social competence, improves integration

into the community and facilitates role functioning. As the therapeutic intervention most

directly related to real-world functioning (i.e interpersonal relationships and

employment), social skills training is best suited to improve social competence [11].

Social skills training is based on the perspective that social competence is composed of a

set of skills, which enable a patient to receive, process, and express socially relevant

clues. Social skills modules focus on problematic areas of a patient’s life, such as self-

care, medication and symptom management, conversation, vocational skills, and

recreation [11,24]. By breaking down social interactions into a series of components, and

practicing each one in group settings (social milieu training) which utilize role-play,

patients can be instructed in how to approach real-world situations without feeling

overwhelmed.

The major benefits seen with Social Skills training are in the domains of interpersonal

social functioning and vocational skills. While social skills training is not as well-studied
as other forms of psychotherapy previously mentioned, the few meta-analyses conducted

do show large and enduring effects on the acquisition of social skills, along with

moderate and stable effect sizes for overall social functioning. Skill acquisition shows an

average effect size of 0.77 immediately post-treatment, tapering to a one-year follow-up

effect size of 0.52 [24]. Social functioning, in contrast, shows a somewhat smaller, though

more enduring effect size; 0.39 at end-treatment and 0.32 at one-year follow-up [24].

Furthermore, not only are patients more adept at social interactions, but they

subsequently seek out and engage in social interactions more frequently than control

groups [25,26]. Smaller studies have shown trends toward alleviating negative symptoms

and improving medication compliance (thereby reducing relapse), but when taken

together the effects seem to be equivocal or there is too little data [1,5,8,11,25]. Nonetheless,

the effect sizes do not appear to be negative; as such, there is no worry of

decompensation which would preclude a clinician from starting skills therapy over

supportive or pharmacotherapy alone.

Conclusions

The majority of schizophrenic patients receive pharmacotherapy with generalized

supportive therapy. However, as many as 50% of patients continue to experience

persistently distressing positive symptoms, and the majority experience cognitive and

negative symptoms. Social skills remain poor; unemployment among sufferers of

schizophrenia is nearly 75%. Most schizophrenic patients are unable to adhere to

medication schedules and frequently relapse; even when compliance is monitored, 80%
of patients relapse within five years. The case study, Mr. X, is an embodiment of the

difficulties that schizophrenic patients encounter while trying to function in society.

Adjunctive psychotherapy in the forms of Cognitive-Behavioral Therapy, Cognitive

Remediation, Psychoeducational therapy, and Social Skills Training, appear to alleviate

many of the difficulties discussed. Cognitive Behavioral Therapy shows a moderate

effect size for alleviating positive and negative symptoms, medication compliance and

relapse prevention are greatest in patients undergoing Family Psychoeducational therapy,

and Cognitive Remediation and Social Skills Training both improve employment rates

and social functioning. Taken together, these four modalities address the major gaps left

by pharmacotherapy alone. Unfortunately, it currently seems impractical to implement

four psychotherapies in a single patient, as well as ‘booster sessions’ as the effect sizes

taper with time. However, ongoing research is focused on integrating modalities into a

single therapy; for example, McQuaid and Granholm utilize combined CBT-SST in older

patients who generally do poorly with social skills training alone [25,26]. Use of these

adjunctive therapies, especially when done in group sessions, is also cost-effective by

increasing population work-force and reducing costs to hospitals and medications [6].

Given the myriad benefits of adjunctive psychotherapy, alone and in conjunction with

pharmacotherapy, its under-utilization is puzzling.