PSYCHOSOCIAL INTERVENTIONS FOR PSYCHOSIS

Transcription

1 PSYCHOSOCIAL INTERVENTIONS FOR PSYCHOSIS What Works? Hour Mobile Crisis Intervention and Support needs greater differentiation 2. Acute Care Foster Homes needs further replications 3. Assertive Community Treatment Case Management System 4. Family Interventions single and/or multiple family setting 5. Real Work for Real Pay - supported employment program - individual placement and support - social firms 6. Cognitive Behaviour Therapy - for specific symptoms - for associated problems of living?

2 PSYCHOSOCIAL INTERVENTIONS IN SCHIZOPHRENIA Psycho-educational strategies Individual Decreases relapse by 33% (Possibly) increases medication adherence Family (Support, Education, Problem-solving and Communication Skills Training) Decreases relapse (by 50-75%) (Possibly) decreases family burden? Single Family vs Multiple Family Intervention (Kuipers vs McFarlane) Family and Assertive Community Treatment (FACT) Also increases sustained employment

3 PSYCHOSOCIAL INTERVENTIONS IN SCHIZOPHRENIA Cognitive Behavioural Therapy for Schizophrenia (Vs Standard Care, Supportive Counseling and befriending) Faster effect initially Reduces time in hospital (at 6 months) Reduces combination of positive and negative symptoms longer (at 9 months, though no difference at end of treatment) Durable symptom reduction over 18 months but not in time to relapse (Birchwood et al). Token Economy (Vs Standard Care ) Improves negative symptoms, though often considered intractable

4 PSYCHOSOCIAL INTERVENTION IN SCHIZOPHRENIA From Vocational Programmes to Real Pay for Real Work Individual Placement and Support (IPS) Assertive Community Treatment and IPS - Evidence Level I III Supported Employment (SEP) Clubhouse etc. - Evidence Level III Social Firms and Cooperatives - Evidence Level IV V

5 PSYCHOSOCIAL INTERVENTIONS IN SCHIZOPHRENIA Service Systems Assertive Community Treatment (small case loads, home-based care, 24 hour cover, physical and psychiatric and functional care) - large number (2700) subjected to RCT s - more likely to remain in contact - less likely to be admitted - 50% less time in hospital Home-based Crisis Intervention -? risk of repeat admissions - more likely to remain in contact - less perceived family burden

6 Diluted Intervention Models Comprehensive 24 hour community mental health care doesn t work only where it has never really been tried - eg - UK 700 trials - Stein, L (pers. comm.) - PRiSM study, Maudsley Conclusion: We need consistency of INGREDIENTS, but the RECIPE might vary according to local demography, geography, culture and resources

7 PSYCHOSOCIAL INTERVENTIONS: What Works? Operative Variables? The challenge for the next wave of research on complex packages of human interventions is to discern the most crucial variables eliciting desirable outcomes. - Rosen (l993) International Trends in Systems of Mental Health Care. Package Assertive Community Treatment Family Intervention Vocational Interventions Operative variables: best bets - Intensity of contact plus - systematic intervention content - Information - Practical Skills - Multiple family contact interfamily learning - Individual Placement and Support (IPS) - Supported Employment Program (SEP)

8 PSYCHOSOCIAL INTERVENTIONS FOR PSYCHOSIS What May Work? 1. Consumer empowerment and involvement - eg consumer run centres and clubs 2. Carer empowerment and involvement 3. Consumers and Carers as providers - eg ancillary case managers enablers - eg home care - eg respite providers - family education programmes 4. Recovery re-orientation of services

9 PSYCHOSOCIAL INTERVENTIONS FOR PSYCHOSIS Recovery Oriented Services focus on quality of life more than symptoms more enabling, less pejorative language focus on strengths, not just impairments focus on hope, optimism, potential for growth goal: restore full citizenship

10 PSYCHOSOCIAL INTERVENTIONS IN SCHIZOPHRENIA Factors Promoting Diffusion of Innovation (McFarlane, 2002) 1. Offers a significant relative advantage 2. No more complex than standard intervention 3. Operationable - can train many practitioners 4. Trialable - must be applied for 2+ years 5. Readily observable outcomes

11 PSYCHOSOCIAL INTERVENTIONS IN PSYCHOSIS Are They Essential? Registrars might worry about being failed for getting the type or dose of medication for psychosis wrong. At the same time, they may conclude from the behaviour of their consultants that psycho-social interventions are optional, and have little to do with them, despite strong evidence to the contrary. Conclusion: In evidence, psychosocial interventions in psychosis are as essential as medication for good outcome and are mutually synergistic