the evidence

Heterogeneous course and a range of outcomes

Bleuler, M. (1972) Die schizophrenen Geistesstörungen: im Lichte langjähriger Kranken und Familiengeschichten. New York: Intercontinental Medical Book Corporation (U.S. distributor)
- Therapies available in Switzerland in 1940s-1960s
  - 58% experienced undulating illness course
  - 22% severe end state
  - 22% recovered
Bleuler Reconsidered by Modestin et al (2003)
- Removed schizoaffective disorder and cases that did not meet current DSM-IV criteria
  - 48-49% undulating course
  - 27-28% severe end state
  - 12-15% recovered
The Harding Longitudinal Studies
1. Harding, C., Brooks, G., Ashikaga, T., Strauss, J., & Breier, A. (1987). The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. The American Journal of Psychiatry, 144, 6, 727-735.
  - longitudinal study term look at course of illness for “schizophrenia” patients; found heterogeneity of course
    - Vermont State Hospital
      - program of psychosocial rehabilitation; social psychiatry,
        
        medicine, vocational rehabilitation; organized around self-sufficiency
      - “blurring of roles...intensified relationships, and new expectations for patients and staff” (DeSisto, Harding, et al, 1995)
      - involved many “profoundly ill, back-ward, chronic patients”
        
        62-68% showed no signs of schizophrenia 32 years later
        
        50% of these were found not to use psychotropic
        
        medication
    - Maine (Augusta State Hospital)
      - comparison group of chronic schizophrenic patients
      - followed biological, medical model of treatment
        
        48% recovery showed no signs of schizophrenia 32 years later
2. DeSisto, M., Harding, C., McCormick, R., Ashikaga, T., & Brooks, G. (1995). The Maine and Vermont Three-Decade Studies of Serious Mental Illness. I. Matched comparison of cross-sectional outcome. British Journal of Psychiatry, 167, 331-342.
  - remaining subjects matched by age, sex, dx, chronicity
  - Vermont participants were found to be more productive, experience fewer symptoms, and have better community adjustment and GAF scores
    - Authors propose that the differences in outcome were due to difference between the Vermont and Maine approaches to care, as well as a policy in Vermont of allowing people to return to community life more quickly

The Empathic Ward
- Whitaker, L. & Deikman, A. (2009). The empathic ward: Reality and resistance
  in mental health reform. Ethical Human Psychology and Psychiatry, 11, 50-62.
  - see also: Deikman, A. & Whitaker, L. (1979). Humanizing a psychiatric ward: Changing from drugs to psychotherapy. Psychotherapy Theory, Research and Practice, 16, 2, 204-214.
  - Whitaker and Deikman opened an “experimental” inpatient ward consisting only of psychosocial interventions for one year
  - Rather than focusing on reduction of psychotic experiences and medication compliance as discharge criteria, the goal of this ward was to help residents of the ward gain psychological strength, and become more actively and creatively engaged with their own experiences and in helping others. With time, staff and residents developed a truly therapeutic milieu and sensibility in the ward, cultivated through empathy, camaraderie, and the sharing of power and responsibility.
  - At the end of one year, the “empathic ward” boasted fewer elopements (even with the ward being unlocked), fewer incidents of violence towards others and self-harm, and lower rates of readmission at follow-up than comparable units in the hospital with psychiatric treatment as usual
Leff et al (1992)
- Original WHO study (1979) showed better outcomes for people diagnosed with schizophrenia in low or middle income countries; at 5 year follow-up, most powerful predictor of better outcomes for sz patients in “developing v. developed” countries (best in India and Nigeria centers)
Karon’s Michigan State Psychotherapy Project
- Karon, B. & VandenBos, G. (1994). Psychotherapy of schizophrenia: The treatment of choice. New York, NY: Aronson.
  - Three experimental groups: psychotherapy without medication,
    psychotherapy with medication, only medication no therapy
  - After two years:
    - medication only group - 2:1 chance of being rehospitalized
    - psychotherapy group (particularly with experienced therapists) -
      2:1 chance of not being rehospitalized
Open Dialogue (Finland, Western Lapland)
- Seikkula, J., Alakare, B., & Aaltonen, J. (2011). The comprehensive
  open-dialogue approach (II). Long-term stability of acute psychosis outcomes in advanced community care: The Western Lapland Project. Psychosis, 3, 1–13.
  - Open Dialogue is a recovery-oriented psychosocial approach that emphasizes patient-centered care and engaging an individual’s family and social network
  - improved outcomes for acute psychosis: fewer and shorter hospitalizations, less recidivism, reduced neuroleptic medication dosage, improved likelihood of employment, and greater improvements in functioning
Recovery-Oriented Cognitive Therapy (CT-R)
- Grant PM, Huh GA, Perivoliotis D, Stolar NM, Beck AT. Randomized Trial to Evaluate the Efficacy of Cognitive Therapy for Low-Functioning Patients with Schizophrenia. Archives of General Psychiatry, 69, 2, 121-127.
- Grant PM, Bredemeier K, and Beck AT. (2017). Six-Month Follow-Up of Recovery-Oriented Cognitive Therapy for Low-Functioning Individuals with Schizophrenia. Psychiatric Services, 68, 10, 997-1002.
  - In a randomized clinical trial, CT-R improved community participation, motivation, and positive symptoms to a greater extent than treatment as usual (Grant et al., 2012); improvements were maintained 6-months after treatment ended (Grant et al., 2017). Gains were experienced regardless of the individuals’ duration of illness.
Supportive Psychodynamic Psychotherapy
- Rosenbaum, B., Harder, S., Kundsen, P., Koster, A., Lindhart, A., Lajer, M., Valbak, M., & Winter, G. (2012). Supportive psychodynamic psychotherapy versus treatment as usual for first-episode psychosis: two-year outcome. Psychiatry, 75, 4, 331-341.
  - Danish schizophrenia project (DNS) compared psychodynamic psychotherapy for psychosis with standard treatment in patients with a first-episode schizophrenia spectrum disorder; intervention group improved significantly on measures of both PANSS and GAF scores, with large effect sizes at two years follow-up after inclusion. Further, improvement on GAF(function) (p = 0.000) and GAF(symptom) (p = 0.010) significantly favored SPP in combination with TaU over TaU alone.
Harrow et al (2014)
- longitudinal study of outcomes of use of antipsychotic medication
  - those who used less antipsychotic medication over time had fewer psychotic symptoms
Volavka et al (2018)
- "very long-term" outcomes for people diagnosed with schizophrenia and related disorders
  - shows highly variable course for people with same diagnosis
  - use of low-dose antipsychotic medication associated with better outcomes than higher maintenance dose
  - early interventions associated with better long-term outcomes
Lysaker, P. & Klion, R. (2018). Recovery, meaning-making, and severe mental illness: A comprehensive guide to metacognition reflection and insight therapy (MERIT). Routledge: New York, NY.
- integrative system of psychotherapy to help people with psychosis develop more complex understandings of themselves and others,
- the approach is associated with a range of positive outcomes for people who experience psychosis and other extreme states

Informed consent: What are the benefits and risks of treating psychosis with antipsychotic medication?

Ho et al (2011)
- antipsychotic medication use associated with brain tissue reduction (gray and white matter volumes)
  - this study controlled for other variables (e.g., substance use)
- authors urge careful review of benefits and risks by prescribers with patients
Turner (2004)
- essay by consulting psychiatrist in Journal of British Medicine on the complicated literature regarding use of antipsychotic medication for psychosis

Rebuttal to criticism of bio-bio-bio models of psychosis

1. Goff et al (2017)

https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2017.16091016

2. Jobe et al (2005)
https://www.ncbi.nlm.nih.gov/m/pubmed/16494258/