2. How do different moderators (in particular, modality and orientation) affect the results of psychosocial treatment?

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1 Role of psychosocial treatments in management of schizophrenia: a meta-analytic review of controlled outcome studies Mojtabai R, Nicholson R A, Carpenter B N Authors' objectives To investigate the role of psychosocial treatments in management of patients with schizophrenia. Specifically, the following questions were addressed: 1. Does the addition of a psychosocial treatment to a standard medical regimen enhance treatment outcome? And if so, what is the magnitude of this added effect? 2. How do different moderators (in particular, modality and orientation) affect the results of psychosocial treatment? 3. How durable are the results of psychosocial treatments? Searching PsycLIT ( ) and MEDLINE ( ) were searched. In addition, recent issues of the journals that had published most of the identified studies were manually searched (these were listed). The reference sections of previous reviews were also searched. Study selection Study designs of evaluations included in the review Studies had to report results from a comparison of two or more groups of patients, at least one of which received a form of psychosocial treatment. Studies in which two forms of psychosocial treatment were compared were included, as were studies in which psychosocial treatment was compared with a form of somatic treatment for schizophrenia, including antipsychotic medications and electroconvulsive therapy. Studies in which one form of psychosocial treatment was used in conjunction with a form of somatic treatment was compared with another form of treatment or another combination of treatments were also included. Specific interventions included in the review Psychosocial treatment. The definition of psychosocial treatment used was broad. It included traditional psychotherapy as well as newer forms of psychological treatment (e.g. family psychoeducation, cognitive training) and social intervention such as community treatment. Forms of psychological treatment that are of little direct clinical interest (e.g. training patients on the Wisconsin Card Sorting test and then testing their performance on the same test) were not included. The only exception to this criterion were studies with a clinically relevant psychological treatment used in conjunction with such experimental interventions or a clinically relevant outcome measure used in the study of a clinically non-relevant intervention. Psychosocial treatment was compared to either: another form of psychosocial treatment, or somatic treatment for schizophrenia (including antipsychotic medications and electroconvulsive therapy). Studies in which one form of psychosocial treatment used in conjunction with a form of somatic treatment was compared with another form or another combination of treatments were also included. Participants included in the review Patients with a diagnosis of schizophrenia. A variety of criteria were used to diagnose schizophrenia. Most studies were from inpatient settings (n = 65, 61.3%); 20 (18.9%) were from outpatient settings, and 4 (3.8%) from partial hospitalisation settings. In 2 (1.9%) studies, treatment began in an inpatient setting, and continued on an outpatient basis; for 15 (14.1%) studies the setting was not specified. Outcomes assessed in the review Outcomes were: symptomatology (positive symptoms, negative symptoms, thought disorder, anxiety/depression, Page: 1 / 6

2 disorganised behaviour, general symptomatology), cognitive functioning, objective measures of adjustment (e.g. days working), relapse (including rehospitalisation, symptomatic relapse, total days spent in hospital after index episode, time to rehospitalisation), employment, and compliance with medication. How were decisions on the relevance of primary studies made? The authors do not state how the papers were selected for the review, or how many of the reviewers performed the selection. Assessment of study quality Studies were coded for characteristics such as: random assignment, use of treatment manual, and blindedness of outcome measures.the number of authors who assessed the papers for validity was not stated. Two independent coders recoded 14 randomly selected studies (13%) according to the instructions from a coding manual. Interrater reliabilities for these codings were calculated with kappa for categorical variables and intraclass correlation coefficient for continuous variables. Data extraction The number of authors who performed the data extraction was not stated. Two independent coders recoded 14 randomly selected studies (13%) according to the instructions from a coding manual. Interrater reliabilities for these codings were calculated with kappa for categorical variables and intraclass correlation coefficient for continuous variables. Outcomes reported in the studies reviewed were translated into Cohen's (1977; See Other Publications of Related Interest no.1) d, a standardised estimate of effect size. In the estimation of d, the small sample size bias was corrected for according to Hedges' correction formula (Hedges and Olkin, 1985; See Other Publications of Related Interest no.2). In general, mean effect sizes were calculated for each study by averaging the effect sizes of all outcome measures from that study. Mean effect sizes were also calculated separately for different sources of outcome measures (e.g. self-rated measure, other-rated measure, etc), and for different contents of outcome measures (e.g. positive symptoms, cognitive functioning, etc). Methods of synthesis How were the studies combined? Mean effect sizes for classes of studies and confidence intervals (CIs) for these estimates were calculated by the method described by Hedges (1994; See Other Publications of Related Interest no.3). This method weights each effect size by the inverse of its conditional variance, a function of the sample size. How were differences between studies investigated? Between group heterogeneity statistics (QB) were used in comparisons across classes of studies. Within-group heterogeneity statistics (QW) were used to determine which classes were the major sources of within-group heterogeneity and which groups had relatively homogeneous effect sizes (Hedges 1994; see Other Publications of Related Interest no.3). Comparisons were classified into seven distinct types: 1. Psychosocial treatment plus somatic (or standard) treatment compared with somatic or standard treatment alone (103 comparisons from 71 studies). 2. Combined treatment compared with no treatment (10 comparisons from 5 studies). 3. Combined treatment compared with psychosocial treatment alone (6 comparisons from 5 studies). 4. Psychosocial treatment only, compared with no treatment (9 comparisons from 6 studies). Page: 2 / 6

3 5. Somatic treatment compared with no treatment (12 comparisons from 6 studies). 6. Psychosocial treatment compared with somatic treatment (4 comparisons from 3 studies). 7. Two different forms of psychosocial treatment, each in combination with somatic treatment, compared with each other (28 comparisons from 23 studies). The relationship between moderator variables and the outcome of the studies was examined by calculating WLS correlations for continuous variables and between-group heterogeneity statistics for the categorical variables. In total, the effects of 35 different study, patient and outcome variables were examined. The impact of the validity characteristics of studies on the results were also examined. Results of the review There were 106 studies (172 comparisons) included in the review. The mean number of participants was 63.4 (range 10 to 374), suggesting that the total number of participants in the study was approximately Effect size estimates from different types of comparisons: Unless otherwise stated, studies within comparison groups were homogeneous. For studies comparing combination treatment to somatic (or standard) treatment alone (n=71) the weighted least squares (WLS) average of the effect sizes was d= 0.39 (95% CI: 0.32, 0.44). Effect sizes were heterogeneous (QW= , p<0.001). For psychosocial treatment plus somatic (or standard) treatment versus no treatment (n=5), d = 0.85 (95% CI: 0.62, 1.09). Effect sizes were heterogeneous (QW= 12.28, p= 0.015). For psychosocial treatment plus somatic (or standard) treatment versus psychosocial treatment alone (n=5), d= 0.27 (95% CI: 0.03, 0.51). For psychosocial treatment versus no treatment (n=6), d = 0.37 (95% CI: 0.19, 0.55). For psychosocial treatment alone versus somatic treatment alone (n=3), d = (95% CI: -0.32, 0.21). Effect sizes were heterogeneous (QW= 12.93, p= 0.002). Effect of psychosocial treatment on relapse (14 studies): The relapse frequencies for patients who received psychosocial treatment in addition to somatic (or standard) treatment were consistently lower than for patients who received only somatic (or standard) treatment. The relapse frequencies for the psychosocial treatment groups were, on average and after weighting for sample size, 20% lower than that for the control groups. Moderator variables: More recent studies tended to produce larger effect sizes before, but not after, adjustment for multiple testing. Studies with larger sample sizes produced smaller effect sizes (r=-0.38, df = 68, p=0.0013), an association statistically significant before and after adjustment for multiple testing. Random assignment, manualization, equal attrition rates and use of structured interview in diagnosis did not have any reliable effects on the outcome of comparisons. The effect of patient expectation could not be examined, because none of the studies reported this variable. Effect sizes from those studies in which the authors had a clear allegiance to the experimental treatment were larger than those in which the allegiance was not clear. This effect was statistically significant before adjustment for multiple testing, but not after. The impact of source (e.g. self rated vs other-rated vs objective measures) and context (e.g. negative symptoms, behavioural disorganisation) could not be assessed. Time since onset of illness was the only patient variable which had a statistically significant effect before and after adjustment for multiple testing (r=0.63, df =30, p<0.001). Other factors such as patients' gender, age, marital status, education, IQ score, alcohol/drug abuse, and even previous hospitalisation did not have any reliable effect. Studies that had used formal criteria in diagnosis of patients produced larger effect sizes (QB = 18.15, df = 1, p<0.001) before and after adjustment for multiple testing. Classifying the diagnostic criteria as reflecting either a narrow or Page: 3 / 6

4 broad definition of schizophrenia had no reliable effects. Similarly, the distinction between paranoid and nonparanoid subtypes was unrelated to treatment outcome. Studies from non-western countries (six from China and two from Israel) tended to produce higher effect sizes, while studies from Scandinavian countries and the United States and Canada tended to produce lower effect sizes compared with studies from Great Britain and Continental Europe (QB = 51.40, df = 4, p<0.001). This finding was significant before and after adjustment for multiple testing. Duration of treatment had a statistically significant impact on the results (R= 0.48, df = 41, p = ), with and without adjustment for multiple testing. This effect was not present after the removal of an outlier. Impact of modality: There was a statistically significant difference between effect sizes for six basic modalities (individual, group, family, milieu, occupational/recreational, and community care) (QB = 11.7, df =5, p<0.05). Studies reporting on the effects of group therapy produced the smallest effect sizes. When these studies were removed from the sample, there were no differences between estimates from the other five modalities. Impact of Orientation: There were no statistically significant differences between effect size estimates from three broad theoretical orientations: behavioural, "verbal" therapies, and cognitive training. Posttreatment versus followup (10 studies): Effect sizes were d = 0.38 (95% CI: 0.32, 0.44) for posttreatment and d = 0.42 (95% CI: 0.24, 0.59) for follow up. Multiple regression analysis: Two conclusions were drawn from the regression analyses. First, a large amount of the variation in the effect sizes from this heterogeneous group of studies was explainable by a small number of the variables chosen. Second, studies from Scandinavian countries and studies using measures of disorganised behaviour and possibly measures of employment tend to produce smaller effect sizes. Studies from non-western countries, studies with more chronic patients, and possibly studies using objective diagnostic criteria tend to produce larger effect sizes. Authors' conclusions Patient characteristics and the common elements of therapy are more important as determinants of outcome than a particular modality or orientation. Although the quantitative review provides a useful summary of the available evidence and addresses some important questions regarding the efficacy of combined psychosocial and somatic interventions, it should be considered an interim report. In particular, caution is urged in drawing inferences regarding the impact of moderator variables on estimates of treatment effectiveness. Additional primary studies, more complete reporting of study characteristics and findings, and increased attention to interactions in those studies may permit future quantitative reviews to examine these important interactions and draw stronger inferences regarding the role of moderator variables. CRD commentary The review focused on a well defined question. Inclusion criteria were appropriate. The search could have been extended to include other databases, such as EMBASE, and an attempt to identify unpublished literature. Although the validity of included studies was assessed, the scoring system used and the resulting scores were not reported. Details of the individual studies were not reported, but this would have been difficult, due to the large number of studies involved. Instead, the characteristics of studies and patients were reported in terms of: number of studies, mean and range. In some instances, studies were combined despite heterogeneity. Caution should be taken when interpreting the results, especially with respect to the impact of moderating variables on estimates of treatment effectiveness, due to the use of multiple testing. The conclusions follow from the results. Implications of the review for practice and research Practice: The authors state that keeping in mind the limitations of this study, the findings may have implications for the practitioners working with patients suffering from schizophrenia. First of all, the results show that psychosocial treatments can play an important role in the comprehensive management of schizophrenia not only to augment the effects of medications, but also to supplement these effects in areas where conventional medicines alone are less effective (e.g. negative symptoms). Second, there is some evidence that psychosocial interventions may be more Page: 4 / 6

5 effective in the more chronic stages of illness and, therefore, can play a more prominent role in the management of patients with chronic schizophrenia. Third, in view of the limited evidence for larger effects for other modalities over group treatments, it is advisable to choose treatments administered in an individual or family context over those administered in a group context. The authors point out that in choosing between treatment options, a host of other factors (e.g. availability and cost) need to be taken into consideration. Research: In terms of future research, the authors state that better delineation of patient characteristics and common therapeutic elements that are important determinants of outcome is required. Given the popularity of group treatments for this population, the authors suggest that the effectiveness of these treatments compared with other modalities needs to be addressed in future primary studies. It is also suggested that future studies attempting direct comparisons between therapies of different theoretical orientation should be carried out as collaborative efforts, with adherents of each treatment being equally involved in the design and conduct of the investigations. The reason for this is that this and other meta-analyses have found a significant relationship between allegiance of the researchers and effect size. Bibliographic details Mojtabai R, Nicholson R A, Carpenter B N. Role of psychosocial treatments in management of schizophrenia: a metaanalytic review of controlled outcome studies. Schizophrenia Bulletin 1998; 24(4): PubMedID Original Paper URL Other publications of related interest 1.Cohen J. Statistical power analysis for the behavioural sciences. New York (NY): Academic Press; Hedges LV, Olkin I. Statistical methods for meta-analysis. San Diego (CA): Academic Press; Hedges LV. Fixed effect models. In: Cooper H, Hedges LV, editors. Handbook of research synthesis. New York (NY): Russell Sage Foundation; p Indexing Status Subject indexing assigned by NLM MeSH Antipsychotic Agents /therapeutic use; Employment; Global Health; Humans; Psychotherapy; Schizophrenia /therapy; Social Support; Treatment Outcome AccessionNumber Date bibliographic record published 30/11/2000 Date abstract record published 30/11/2000 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract Page: 5 / 6

6 Powered by TCPDF ( contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. Page: 6 / 6

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