Schizophrenia psychotherapy

When is medication indicated in the treatment of psychiatric illness There is no short answer to this question. At one end of the continuum, patients with schizophrenia and other psychotic disorders, bipolar disorder, and severe major depressive disorder should always be considered candidates for pharmacotherapy, and neglecting to use medication, or at least discuss the use of medication with these patients, fails to adhere to the current standard of mental health care. Less severe depressive disorders, many anxiety disorders, and binge eating disorders can respond to psychotherapy and/or pharmacotherapy, and different therapies can target distinct symptom complexes in these situations. Finally, at the opposite end of the spectrum, adjustment disorders, specific phobias, or grief reactions should generally be treated with psychotherapy alone. 

According to an often-cited review of studies provided by May (1968), antipsychotics represent considerably more effective treatment for acute forms of schizophrenia than do various types of psychotherapy ... 

Schooler and Hogartv (1987) summarized a large proportion of the works published since 1978 in which drug treatment and psychotherapy or sociotherapy were combined, and drew the following conclusions with regard to the treatment of schizophrenia ... 

Muller and Schoneich (1992) also reported on favorable experience with intensive outpatient psychotherapy combined with antipsychotic drug treatment. On the basis of a before-and-after comparison over 2x5 years in a university outpatient clinic, they were able to show that the duration of rehospitalizations required by 89 patients could be reduced from a mean of 10 weeks to 2 weeks per year when a special schizophrenia outpatient service offering individualized psychotherapy and psychosocial treatment was available to the patients instead of the routine psychiatric outpatient service. A beneficial effect of psychotherapy was demonstrated both in those patients taking antipsvchotics continuously for long-term prophylaxis and in those taking the drugs intermittently when prodromal symptoms appeared in order to prevent relapse. 

In the course of the treatment of schizophrenia, depressive and various anxiety syndromes, it has been found repeatedly that psychopharmaceuticals and psychotherapies are likely to modify different types of symptoms and... 

Consequences of Refusal of Treatment. The translation of the abstract right-to-refuse issue into real-world outcomes reveals serious consequences that are more complicated than may be assumed. For example, there is reliable research showing that psychotherapy without medication is not effective in treating such severe disorders as schizophrenia (20, 21). Therefore, when medication is refused, often no effective, alternate, less restrictive treatment is available, and the only other real option is no treatment. 

Antipsychotics have long since replaced ECT for the treatment of schizophrenia. Several studies, however, have found ECT equal in efficacy to these agents, while one large-sample, controlled trial found it less effective than drugs, but more effective than psychotherapy ( 406). Some clinicians believe that selected patients may benefit when ECT is given concurrently with an antipsychotic. One controlled study, for example, found that ECT in combination with a phenothiazine led to a more rapid remission than the phenothiazine alone ( 407). Clinical experience has clearly documented an important role for ECT in catatonic excitement or withdrawal, as well as for other severe, life-endangering psychotic states. More recently, ECT combined with novel antipsychotics has been reported to benefit previously poorly responsive psychotic patients and was well tolerated (106, 408, 409). 

In this context, the type of psychosocial interventions used in schizophrenia has changed radically in the last 15 years. In the 1950 s and 1960 s, the emphasis was on psychodynamic psychotherapy, and in particular long-term psychoanalysis was practiced in institutions such as Chestnut Lodge or the Menninger Clinic. 

TABLE 5-24. Assessment of outcome in patients with schizophrenia treated with and without antipsychotic drugs and psychotherapy... 

Grinspoon L, Ewalt JR, Shader Rl. Schizophrenia pharmacotherapy and psychotherapy. Baltimore Williams Wilkins, 1968 67-74. 

Gunderson JG, Frank AF, Katz HM, et al. Effects of psychotherapy in schizophrenia II. Comparative outcome of two forms of treatment. Schizophr BuL 1984 10 564-598. 

Arieti, S. (1959). Schizophrenia Other aspects psychotherapy. In S. Arieti (Ed.), American handbook of psychiatry (Vol. 1, pp. 455—484). New York Basic Books. 

Gottdiener, W., 8c Haslam, N. (2002). The benefits of individual psychotherapy for people diagnosed with schizophrenia A meta-analysis and review. Ethical Human Sciences and Services, 4, 163—187. 

Karon, B. (2003). The tragedy of schizophrenia without psychotherapy. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 331, 89-118. 

Karon, B., Vandenbos, G. (1981). The psychotherapy of schizophrenia The treatment of choice. New York Aronson. 

The most effective treatment for schizophrenia incorporates a multidisciplinary approach in which antipsychotic medications are a necessary but insufficient component. Medication must be complemented by specific psychotherapy modalities, including family therapy, skills training, psychoeducation, supportive intervention, vocational training, and self-help groups. 

Several issues are important in doing psychotherapy with someone with schizophrenia, where medication compliance is often an issue and where medication noncompliance is usually, eventually, associated with relapse. One goal is to recognize and take measures to minimize side effects. Several studies have shown that akinesia and akathisia are associated with medication noncompliance. Another issue is making the schizophrenic symptoms ego-dystonic to the patient. This may be a long process, involving repeatedly pointing out the ways in which the symptoms are dysfunctional in the patient s life. 

It should be noted that when a therapist takes LSD, he enters a state in which he can communicate with schizophrenic patients in a direct, close, empathic fashion. This communication opens the door to effective psychological treatment for schizophrenia. The schizophrenic is lost in time, and a therapist who will enter the paths of his disordered thinking, once he can establish trust, can lead the patient out of the disorder. It is not always sufficient to call out from the forest s edge to rescue someone lost. One must sometimes go in himself. from Toward an Individual Psychedelic Psychotherapy, by Masters, R.E.L. Houston, J. in Psychedelics The Uses and Implications of Hallucinogenic Drugs... 

Benzodiazepines are of value in the treatment of anxious depressions and anxiety-tension associated with schizophrenia, as well as in patients undergoing psychotherapy. They should be used only when the symptoms are disabling, not just to alleviate stress. 

Some groups receive very different treatment by the system , e.g. Black and Minority Ethnic (BME) groups have higher rates for diagnosing schizophrenia, MHA detentions, hospitalisation, seclusion and fewer referrals for psychotherapy (McKenzie and Bhui, 2007). 

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