Abstract: "Evidence-Based Psychotherapy for Schizophrenia: Past, Present, and Future (Intermediate)

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1 Shaun M. Eack, PhD David E. Epperson Professor of Social Work and Professor of Psychiatry School of Social Work and Department of Psychiatry University of Pittsburgh Pittsburgh, PA Abstract: "Evidence-Based Psychotherapy for Schizophrenia: Past, Present, and Future (Intermediate) This session will provide an overview of evidence-based psychotherapeutic treatments for people with schizophrenia. A historical review of the earliest approaches to psychotherapy, with important lessons learned, will first be presented. The current state of the field with regard to the most effective psychotherapeutic practices will then be reviewed, focusing on the comparative effectiveness of different approaches to psychotherapy for schizophrenia. Finally, the session will conclude with identifying the most promising new directions in psychotherapeutic treatment in the condition, as well as a discussion of challenges and approaches to ensuring that the most effective psychotherapies are available in routine clinical care. Learning Objectives: By the completion of this session, participants should be able to: 1. Identify the current best practices for the use of psychotherapy with people with schizophrenia; 2. Evaluate the comparative effectiveness of different psychotherapies used to treat schizophrenia; and 3. Describe the limitations of psychotherapeutic treatment for schizophrenia, including the science-toservice gap and areas for future development. References 1. Dixon, L. (2017). What it will take to make coordinated specialty care available to anyone experiencing early schizophrenia: getting over the hump. JAMA Psychiatry. 74, Mueser, K. T., Deavers, F., Penn, D. L., & Cassisi, J. E. (2013). Psychosocial treatments for schizophrenia. Annual Review of Clinical Psychology. 9, Dixon, L. B., Dickerson, F., Bellack, A. S., Bennett, M., Dickinson, D., Goldberg, R. W.,... & Peer, J. (2009). The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophrenia Bulletin. 36,

2 Evidence-Based Psychotherapy for Schizophrenia: Past, Present, and Future Shaun M. Eack, Ph.D. University of Pittsburgh Disclosures Conflicts of Interest: None Research Support: NIMH Psychotherapy for Schizophrenia Therapies that are not effective Evolution of early therapies Current evidence-based therapies Essential future directions 45

Are Not Effective: Family-Blaming Therapies Cadigan & Murray, 2009 Therapies That Are

3 Psychotherapy for Schizophrenia Therapies that are not effective Evolution of early therapies Current evidence-based therapies Essential future directions Therapies That Are Not Effective: Family-Blaming Therapies Cadigan & Murray, 2009 Therapies That Are Not Effective: Psychodynamic Psychotherapy Mueser & Berenbaum, Psychol Med. 20:

Therapies That Are Not Effective: Psychodynamic Psychotherapy Mueser & Berenbaum, 1990. Psychol Med. 20:253-262.

4 Therapies That Are Not Effective: Psychodynamic Psychotherapy Mueser & Berenbaum, Psychol Med. 20: Psychotherapy for Schizophrenia Therapies that are not effective Evolution of early therapies Current evidence-based therapies Essential future directions Gerard E. Hogarty, MSW Type Major Role Therapy Social Skills Training Family Psychoeducation Personal Therapy Cognitive Enhancement Therapy 1996-Present Theoretical Process Relationship to Pathophysiology Psychosocial help for people with Unrelated schizophrenia (early case management) Secondary environmental stress modification via correction of provocative behavioral deficits or excesses Primary environmental stress modification via education and management Identification and adaptive control of psychotic prodromes Gistful social cognition related to context appraisal and perspective taking (developmental, secondary socialization) Indirect Indirect Partially direct Entirely direct 47

Major Role Therapy An early precursor to social casework Goal was to help individuals resume their major roles in life after hospitalization Includes: At least monthly contact with a social worker

5 Major Role Therapy An early precursor to social casework Goal was to help individuals resume their major roles in life after hospitalization Includes: At least monthly contact with a social worker Brokering of services and supports Crisis management Vocational supports and rehabilitation Hogarty et al., Arch Gen Psychiatry. 31: Major Role Therapy (N = 374) Hogarty et al., Arch Gen Psychiatry. 31: Family Psychoeducation Goal is to reduce familial distress through demystifying schizophrenia Reducing familial distress would help families cope and reduce stress in the lives of patients The management of stress began to be viewed as essential to the management of schizophrenia 48

Social Skills Training Much of the stress patients experience is due to social difficulties Social skills training aims to improve social performance to reduce distress Uses behavioral strategies to

6 Social Skills Training Much of the stress patients experience is due to social difficulties Social skills training aims to improve social performance to reduce distress Uses behavioral strategies to teach individuals basic skills for interacting with others How to start a conversation How to obtain needed medicine How to behave at a job interview Family Psychoeducation and Social Skills Training Effects (N = 103) 0% Hogarty et al., Arch Gen Psychiatry. 43: Hogarty et al., Arch Gen Psychiatry. 48: Personal Therapy Delay post-hospital relapse and improve adjustment Identifying prodromes/early cues of distress Learn stress management/affect regulation Staged according clinical state (basic, intermediate, advanced) Hogarty, G. E. (2002). Personal Therapy for Schizophrenia and Related Disorders: A guide to individualized treatment. New York: Guilford. 49

Personal Therapy (N = 151) Hogarty et al., 1997. Am J Psychiatry. 154:1504-1513. Personal Therapy (N = 151) Hogarty et al., 1997. Am J Psychiatry. 154:1514-1524.

7 Personal Therapy (N = 151) Hogarty et al., Am J Psychiatry. 154: Personal Therapy (N = 151) Hogarty et al., Am J Psychiatry. 154: Personal Therapy Finally, we conclude with the caveat that although relative gains in adjustment were clearly achieved, in absolute terms most recipients of personal therapy were still recovering from a severe mental disorder.these clinically meaningful but relative improvements would not qualify as optimal recovery from schizophrenia. (p. 1523) Hogarty et al., Am J Psychiatry. 154:

8 Cognitive Enhancement Therapy A recovery-phase intervention for remediating neurocognitive and social-cognitive deficits originally developed for schizophrenia by Hogarty and colleagues (2004, 2006). Neurocognitive Training Computer-based training in attention, memory, and problemsolving. 1 hour/week 60 hours total Social-Cognitive Group Therapy Training in perspective-taking, gistfulness, non-verbal communication, emotion perception, and much, much more. 1.5 hours/week 45 sessions More information and CET Training Manual (Hogarty & Greenwald, 2006) at CET in Long-Term Schizophrenia (N = 121) CET EST 1yr. 2yr. Cohen s d Neurocognition Processing Speed Cognitive Style Social Social Cognition Adjustment Symptoms Hogarty et al., Arch Gen Psychiatry. 61: CET in Early Course Schizophrenia (N = 58) % Improvement CET EST 1yr. 2yr. Neurocognition Processing Speed Cognitive Style Social Cognition Social Adjustment Symptoms Eack et al., Psychiatry Serv. 60: ; Eack et al., RSWP. 21:

CET in Early Course Schizophrenia Eack et al., 2010. Arch Gen Psychiatry 67:674-682.

9 CET in Early Course Schizophrenia Eack et al., Arch Gen Psychiatry 67: (N = 53) 10-Year Durability of CET in Early Schizophrenia (N = 58) Psychotherapy for Schizophrenia Therapies that are not effective Evolution of early therapies Current evidence-based therapies Essential future directions 52

10 Current Evidence-Based Therapies Service coordination Major Role Therapy Case management Assertive community treatment Family psychoeducaton Social skills training Individual psychotherapy Personal Therapy Cognitive Behavior Therapy for psychosis Supported employment Cognitive remediation Case Management (k = 20) Ziguras & Stuart, Psychiatr Serv. 51: Assertive Community Treatment (k = 14) Herdelin & Scott, Journal of Disability Policy Studies. 10:

Family Psychoeducation (k = 18) Lincoln et al., 2007.

Social Skills Training (k = 10) Kurtz & Mueser, 2008.

11 Family Psychoeducation (k = 18) Lincoln et al., Schizophr Res. 96: Social Skills Training (k = 10) Kurtz & Mueser, J Consult Clin Psychol. 76: Cognitive Behavior Therapy (k = 50) Jauhar et al., Br J Psychiatry. 204:

12 Supported Employment Bond et al., Psychiatric Rehabilitation Journal. 31: Supported Employment (k = 7) Bond et al., Psychiatric Rehabilitation Journal. 31: Cognitive Remediation (k = 9 to 38) 55

Cognitive Remediation Effects on Functioning McGurk et al., 2007. Am J Psychiatry. 164:1791-1802. Wykes et al., 2011. Am J Psychiatry. 168:472-485.

13 Cognitive Remediation Effects on Functioning McGurk et al., Am J Psychiatry. 164: Wykes et al., Am J Psychiatry. 168: Comparative Efficacy on Symptoms (k = 48) Turner et al., Am J Psychiatry. 171: Summary of Evidence Symptoms Functioning Relapse Service Coordination Case management Assertive Community Treatment Family Psychoeducation Social Skills Training Personal Therapy/ Cognitive Behavioral Therapy Supported Employment Cognitive Remediation

therapies Current evidence-based therapies Essential

14 Summary of Evidence Psychotherapy for Schizophrenia Therapies that are not effective Evolution of early therapies Current evidence-based therapies Essential future directions Research to Practice Gap D. Butler, Nature,

Patterns of Care Lehman et al., 1998. Schizophr Bull. 24:11-20. West et al., 2005. Psychiatr Serv. 56:283-291. Work to be Done New Treatments? Use Treatments?

15 Patterns of Care Lehman et al., Schizophr Bull. 24: West et al., Psychiatr Serv. 56: Work to be Done New Treatments? Use Treatments? School of Social Work SSW Health Science Investigators SSW Community Partners Child Welfare Education & Research Programs Center on Race and Social Problems Center for Interventions to Enhance Community Health Mission: Enhance the quality and length of life of individuals living with behavioral health conditions through innovative community-based interventions Intervention Development Core Community Implementation Core Department of Psychiatry Western Psychiatric Institute & Clinic School of Medicine School of Pharmacy School of Public Health School of Nursing Develop novel communitybased interventions to improve behavioral health Conduct clinical trials to establish efficacy Ensure interventions are ready for the real world and diverse communities Develop partnerships with communities to guide research Disseminate treatment advances through community partner network Integrate interventions into everyday community settings to facilitate dissemination Center Aims 1. Develop and test effective community-based interventions to improve health, with an emphasis on behavioral health 2. Partner with community agencies to ensure real world readiness 3. Integrate behavioral health interventions into everyday community settings to serve people where they are and prevent disability 58

16 New Treatment Directions Early intervention Substance use comorbidity Peer support and mentorship Approaches to increase medication adherence Integration with brain stimulation Conclusions Psychotherapy and psychosocial interventions have an important place in schizophrenia treatment Optimal treatment = pharmacological + psychosocial Many psychosocial treatment options exist, now time to start using them Acknowledgments Gerard E. Hogarty, M.S.W. Susan S. Hogarty, M.S.N. Deborah P. Greenwald, Ph.D. Michael F. Pogue-Geile, Ph.D. Matcheri S. Keshavan, M.D. 59

17 My Mask RJ The irony of life Is that those who wear masks Often tell us more truths Than those with Open faces. Marie Lu, The Rose Society 60

Cognitive enhancement therapy in schizophrenia. Matcheri S Keshavan MD

Cognitive enhancement therapy in schizophrenia Matcheri S Keshavan MD Harvard Medical School, Massachusetts Mental Health Center and Beth Israel Deaconess Medical Center NIMH MH 60902, 92440 and 105596;