Marcelo Valencia

A psychosocial skills training approach in Mexican out-patients with schizophrenia

BACKGROUND The effectiveness of a psychosocial skills training (PSST) approach applied to chronic out-patients with schizophrenia was examined. We hypothesized that the PSST programme, which included treatment as usual (TAU), PSST and family therapy (FT), would reduce positive and negative symptoms, prevent relapse and rehospitalization, and improve psychosocial functioning (PSF), global functioning and treatment adherence. METHOD Eighty-two patients were randomly assigned to receive either TAU [antipsychotic medication (AP); n=39] or the PSST approach (TAU+PSST+FT; n=43). The two groups were assessed at intake and after completion of 1 year of treatment. RESULTS There were statistically significant differences between the two groups. Patients in the PSST group improved their symptomatology, psychosocial and global functioning (symptoms and psychological, social and occupational functioning), showed lower relapse, rehospitalization and drop-out rates, a higher level of compliance with AP medication, and a high level of therapeutic adherence in comparison with TAU patients, whose symptoms also improved although they showed no improvement in any of the clinical or psychosocial variables. A comparison of the standardized effect sizes showed a medium and a large effect size of PSF and global functioning for the PSST group and a non-effect size for the TAU group. CONCLUSIONS A higher level of effectiveness was demonstrated when combining TAU, PSST and FT in comparison with AP medication alone. The PSST approach should be recommended for clinical practice.

Application in Mexico of psychosocial rehabilitation with schizophrenia patients.

To determine whether evidence-based, psychosocial treatments developed in the United States and England are applicable to Mexican outpatients with schizophrenia, the present study was carried out to evaluate the relative effectiveness of family psycho-education and psychosocial skills training added to customary treatment vs. customary treatment alone. Clinically stable outpatients with schizophrenia participated in a 12-month randomized, controlled trial at the National Institute of Psychiatry in Mexico City. An experimental group (N = 47) received the combination of psychosocial skills training, family psycho-education and customary pharmacotherapy while the comparison group (N = 36) received customary treatment alone. Patients were assessed at baseline and one year after commencement of treatment. Significant differences favoring the group that received psychosocial rehabilitation were found in ratings of adherence to medication, attendance at appointments, symptoms, social functioning, relapse, and re-hospitalization. While some adaptations were made in the psychosocial treatments to resolve cultural differences, the results provide cross-national validation of evidence-based treatments for persons with schizophrenia.

Predicting functional remission in patients with schizophrenia: a cross-sectional study of symptomatic remission, psychosocial remission, functioning, and clinical outcome.

Background New approaches to assess outcome in schizophrenia include multidimensional measures such as remission, cognition, psychosocial functioning, and quality of life. Clinical and psychosocial measures have been recently introduced to assess functional outcome. Objective The study presented here was designed to examine the rates of symptomatic remission, psychosocial remission, global functioning, and clinical global impressions in a sample of schizophrenia outpatients in order to assess functional remission and to identify predictive factors for functional remission. Methods A total of 168 consecutive Mexican outpatients receiving pharmacological treatment at the National Institute of Psychiatry in Mexico City were enrolled in a cross-sectional study. Symptomatic remission was assessed according to the definition and criteria proposed by the Remission in Schizophrenia Working Group using the Positive and Negative Symptom Scale. Psychosocial remission was assessed according to Barak criteria using the Psychosocial Remission in Schizophrenia scale. Functioning was measured with the Global Assessment of Functioning, and clinical outcome with the Clinical Global Impressions (CGI) Scale. Results Findings showed that 45.2% of patients fulfilled the symptomatic remission criteria, 32.1% achieved psychosocial remission, and 53% reported adequate functioning. However, the combination of these three outcome criteria – symptomatic, psychosocial remission, and functioning – indicated that 14.9% of the patients achieved our predefined functional remission outcome. The logistic regression model included five predictive variables for functional remission: (1) being employed, (2) use of atypical antipsychotics, (3) lower number of medications, (4) lower negative symptom severity, and (5) lower excitement symptom severity. Conclusion The study demonstrated that symptomatic remission, psychosocial remission, and functioning could be achievable goals for a considerable number of patients. The outcome of functional remission was achieved by a minority of patients, less than 15%. New approaches should include multidimensional measures to assess functional outcome in schizophrenia research.

Integrated Treatment to Achieve Functional Recovery for First-Episode Psychosis

This study describes an integrated treatment approach that was implemented to enhance functional recovery in first-episode psychotic patients. Patients were randomized to two treatment conditions: either to an integrated treatment approach: pharmacotherapy, psychosocial treatment, and psychoeducation (experimental group: N = 39) or to medication alone (control group: N = 34). Patients were evaluated at baseline and after one year of treatment. Functional recovery was assessed according to symptomatic and functional remission. At the end of treatment, experimental patients showed a 94.9% of symptomatic remission compared to 58.8% of the control group. Functional remission was 56.4% for the experimental group and 3.6% for the control group, while 56.4% of the experimental group met both symptomatic and functional remission criteria and were considered recovered compared to 2.9% of the control group.

Comparison of Early Intervention Services vs Treatment as Usual for Early-Phase Psychosis: A Systematic Review, Meta-analysis, and Meta-regression

Importance The value of early intervention in psychosis and allocation of public resources has long been debated because outcomes in people with schizophrenia spectrum disorders have remained suboptimal. Objective To compare early intervention services (EIS) with treatment as usual (TAU) for early-phase psychosis. Data Sources Systematic literature search of PubMed, PsycINFO, EMBASE, and ClinicalTrials.gov without language restrictions through June 6, 2017. Study Selection Randomized trials comparing EIS vs TAU in first-episode psychosis or early-phase schizophrenia spectrum disorders. Data Extraction and Synthesis This systematic review was conducted according to PRISMA guidelines. Three independent investigators extracted data for a random-effects meta-analysis and prespecified subgroup and meta-regression analyses. Main Outcomes and Measures The coprimary outcomes were all-cause treatment discontinuation and at least 1 psychiatric hospitalization during the treatment period. Results Across 10 randomized clinical trials (mean [SD] trial duration, 16.2 [7.4] months; range, 9-24 months) among 2176 patients (mean [SD] age, 27.5 [4.6] years; 1355 [62.3%] male), EIS was associated with better outcomes than TAU at the end of treatment for all 13 meta-analyzable outcomes. These outcomes included the following: all-cause treatment discontinuation (risk ratio [RR], 0.70; 95% CI, 0.61-0.80; P < .001), at least 1 psychiatric hospitalization (RR, 0.74; 95% CI, 0.61-0.90; P = .003), involvement in school or work (RR, 1.13; 95% CI, 1.03-1.24; P = .01), total symptom severity (standardized mean difference [SMD], −0.32; 95% CI, −0.47 to −0.17; P < .001), positive symptom severity (SMD, −0.22; 95% CI, −0.32 to −0.11; P < .001), and negative symptom severity (SMD, −0.28; 95% CI, −0.42 to −0.14; P < .001). Superiority of EIS regarding all outcomes was evident at 6, 9 to 12, and 18 to 24 months of treatment (except for general symptom severity and depressive symptom severity at 18-24 months). Conclusions and Relevance In early-phase psychosis, EIS are superior to TAU across all meta-analyzable outcomes. These results support the need for funding and use of EIS in patients with early-phase psychosis.

Remisión sintomática y recuperación funcional en pacientes que padecen esquizofrenia

SUMMARY A recently proposed definition for remission and recovery in schizophrenia is receiving increased attention by clinicians and researchers. The interest on these issues is based on the recent proposed definition for symptomatic remission, and the development of operational criteria for its assessment, by the Remission in Schizophrenia Working Group (RSWG), in the United States, in 2005. Remission is assessed using eight items of the Positive and Negative Syndrome Scale (PANSS), all of which have to be scored with a symptom severity of ≤3 points (mild or better), sustained for a minimum duration of six months. In Europe, since 2006, proposed definition criteria about response and remission were introduced. Response can be assessed, with the PANSS, using a cut-off of at least 50% reduction of the baseline score for the acutely ill, and a cut-off of at least of 25% reduction for refractory patients. Remission could be assessed using a formula for calculating percentage PANSS reduction from baseline. Definition criteria have also been introduced to assess functional recovery that includes the combination of clinical and social outcomes for two consecutive years, including dimensions such as psychosocial functioning, cognition, and quality of life. The purpose of this review is to examine existing research on symptomatic remission and functional recovery in schizophrenia. We included clinical and epidemiological studies, reviews and meta-analyses published between January 1970 and July 2013. Sixty two studies on remission and recovery were included, with a total of 94 940 patients, comprising six months to 37 years follow-up. Thirty two studies on functional recovery were included, with a total of 6 483 patients with a range of six months to 42 years follow-up. Research indicates that symptomatic remission can be achieved in 20-97%, and functional recovery in 10-68% of people with schizophrenia. The use of remission and recovery criteria has been recommended for clinical practice and scientific research.

Integration of Pharmacological and Psychosocial Treatment for Schizophrenia in Mexico: The Case of a Developing Country Proposal

For decades, schizophrenia was considered exclusively as a biological disorder. As a result, pharmacotherapy has been considered as the predominant mode of treatment. Antipsychotic medication is indicated for first episode, acute, chronic as well as for refractory patients. So much research has been conducted to evaluate the efficacy of antipsychotics through clinical studies, randomized controlled trials and meta-analyses. Scientific journals are full of research on pharmacotherapy. According to the American Psychiatric Association [APA] (2004), a treatment plan for patients with schizophrenia should include: 1.The reduction or elimination of symptoms, 2.Improving quality of life and adaptive functioning, and 3.Promote and maintain recovery. In the last decades, research in the social sciences and psychiatric rehabilitation has produced a considerable body of knowledge with respect to psychosocial factors that influence the curse of this illness. As a result psychosocial treatments have also been designed and implemented. With the beginning of the new century and after more than 60 years of research, there is a consensus that biological, psychological and social factors play a very important role in understanding and treating schizophrenia. Hence, the biopsychosocial model has been considered as the most comprehensive treatment approach for this illness. The treatment of schizophrenia has been the focus of changes since the introduction of neuroleptics in the 1950 s which initiated the transition from mental hospitals to the community, with long-stay patients confined in mental institutions going through the deinstitutionalization process, to the new millennium where the majority of them are actually living in the community. A considerable effort has been carried out in recent years to articulate the scientific basis of the treatment for people with schizophrenia. As a result evidence based treatment for schizophrenia has recommended that all persons with schizophrenia should receive the combination of: 1) optimal dose of antipsychotic medication, 2) psychosocial interventions, 3) psychoeducation for patients and carers as well as family therapy, and, 4) assertive homebased management to help prevent and resolve various issues such as: crises, relapse, medication adherence, etc, (Drake et al., 2009; Falloon et al., 2004; Fenton & Schooler, 2000; Lehman & Steinwachs, 2003; Shean, 2009; Thornicroft & Susser, 2001). In summary, scientific

Social-Skills Training for Spanish-Speaking Persons with Schizophrenia: Experiences From Latin America, Spain, and the United States

A review was conducted on the cross-cultural adaptation, effectiveness, and validation of social-skills training (SST), an evidence-based practice that originated in the English language, carried out in the Spanish language for persons with schizophrenia in Latin America, Spain, and the United States. This review of research delineates the methodology of the published literature that contained a wide variety of studies from empirically based evaluation of case reports to randomized, controlled trials. The weight of the evidence from all three regions revealed greater benefits to Spanish-speaking patients who received SST in symptoms, skill acquisition and community functioning than for patients who received customary treatment. To ensure the cross-cultural effectiveness of rehabilitation practices originating in English-speaking countries, it is essential that adaptations beyond language translations be made to meet the unique expectations, norms, values, and customs of Spanish-speaking patients and families in the three regions that are the focus of this report.

Necesidades de los familiares de pacientes con esquizofrenia en situaciones de crisis

Objetivo. Identificar y analizar las principales situaciones de crisis que enfrentan los familiares de pacientes con esquizofrenia, asi como sus necesidades en la atencion psiquiatrica en momentos de crisis. Metodo. Con metodologia cualitativa de recoleccion y analisis, la tecnica utilizada fue la creacion de un grupo de discusion con ocho familiares de pacientes con esquizofrenia. Las sesiones grupales se grabaron y transcribieron para analizar posteriormente la informacion. Ademas, se realizaron entrevistas individuales a cada familiar. Resultados. Los familiares destacaron tres principales situaciones de crisis: 1. La crisis psicotica; 2. La crisis familiar ante el diagnostico y en el proceso de aceptacion de la enfermedad; 3. La crisis ante las recaidas subsecuentes. Tambien se detallan: 4. Las deficiencias en la atencion en situaciones de crisis y 5. Las necesidades de los familiares en estas situaciones. Conclusiones. Desde la narrativa de los familiares se puede destacar la experiencia de una falta de informacion tanto a familiares y a pacientes como a la poblacion en general, para que se conozcan los principales rasgos y sintomas que caracterizan a la esquizofrenia, para lograr con ello una deteccion temprana que facilite el tratamiento y la prevencion de crisis posteriores. Es conveniente desarrollar intervenciones en los momentos de crisis y establecer una red social de apoyo en la comunidad.