Mario Pfammatter

Psychological therapy in schizophrenia: What is the evidence?

Objective: The present contribution provides a critical outline of the current position of psychological therapies in schizophrenia.

Effects of a coping-orientated group therapy for schizophrenia and schizoaffective patients: a pilot study

Andres K, Pfammatter M, Garst F, Teschner C, Brenner HD. Effects of a coping‐orientated group therapy for schizophrenia and schizoaffective patients: a pilot study.

Gemeindeintegrierte Akutversorgung Möglichkeiten und Grenzen

ZusammenfassungDie Verlagerung der psychiatrischen Versorgung in das Gemeindeumfeld der Patienten ging einerseits mit einer Reduktion der Anzahl Klinikbetten und der stationären Behandlungsdauer einher, war gleichzeitig aber mit einer Zunahme stationärer Aufnahmen verbunden. Zu dieser Entwicklung scheint insbesondere die primäre Ausrichtung von gemeindepsychiatrischen Diensten auf die Nachsorge beigetragen zu haben. Für die Weiterführung der psychiatrischen Versorgungsreformen erscheint daher von zentraler Bedeutung, ob durch einen stärkeren Einbezug von gemeindenahen Ansätzen zur Behandlung akuter Krankheitsepisoden dieses “Drehtürsystem” durchbrochen werden kann. Seit Mitte der 60er-Jahre haben sich durch eine Reihe kontrollierter Studien vor allem 2 Modelle gemeindeintegrierter Akutversorgung etabliert: die Akutbehandlung im häuslichen Umfeld der Patienten und die Behandlung akuter Krankheitsepisoden in einer Tagesklinik. Diese beiden Ansätze erzielen bei einem Teil der Patienten im Allgemeinen die gleiche Wirkung wie die vollstationäre Akutbehandlung, deren Bedarf sie entsprechend senken. Sie stellen damit eine kosteneffektive Ergänzung der bestehenden psychiatrischen Regelversorgung dar.SummaryThe shift of psychiatric care from the hospital to the community has been accompanied by a reduction of hospital beds and shortened durations of inpatient treatment, but also by an increase in admissions. This evolution may be largely attributed to the prime focus of community mental health institutions on rehabilitation. The continued implementation of reforms in psychiatric care is contingent upon effectively halting the “revolving door phenomenon” by incorporating community-integrated treatment approaches into the care of acutely ill patients. Since the mid-1960s, a series of studies have established the efficacy of two community-integrated modalities for the treatment of acute psychiatric illness, i. e. home-based and day hospital treatment. In general, these approaches not only seem to be as effective as inpatient care for certain groups of patients but also reduce their need of hospitalisation, thereby contributing towards a cost effective, comprehensive psychiatric care system.

Wirksamkeit und Prozessmerkmale einer psychoedukativen und bewältigungsorientierten Gruppentherapie für schizophren und schizoaffektiv Erkrankte

Outcome and Process Characteristics of a Psychoeducational, Coping Oriented Group Therapy for Schizophrenia and Schizoaffective Patients Background: Psychoeducation is a core element in psychological therapy for schizophrenics. Its application has been intensively studied and well established in the family setting. Empirical data concerning its efficacy without involvement of relatives are scarce. Patients and Methods: In a randomized controlled trial, effects and process quality of a psychoeducational coping oriented group therapy for schizophrenia and schizoaffective patients were compared to those of a control group in which supportive discussions and training in problem solving were offered. Results: Both groups showed clear reductions in psychopathology and improved cognitive coping with the illness at completion of the therapy and at one-year follow-up. In addition, coping oriented therapy reduced relapse rates and days in hospital compared to the control group during the first year after therapy. Regarding process-outcome-relations a good therapeutic relationship, as perceived by the patients, was associated with the success of the psychoeducational, coping oriented intervention. In contrast, those patients of the supportive therapy who demonstrated the highest degree of psychopathology at the end of therapy, felt more comfortable in this treatment. Other assessments of the quality of the therapeutic process also revealed strong relations to the outcome at the end of therapy. These relations varied between the two treatment groups. Discussion: On the one hand, our results indicate that the patients’ ratings of the quality of the therapeutic relationship determine the success of the psychoeducational, coping oriented therapy. On the other hand, patients with more persistent symptoms may prefer the less structured supportive therapy approach. Therefore, in future psychotherapy research with schizophrenia patients it will be important to be more concerned with the formation of a good therapeutic relationship and to identify differential indication criteria to enhance the efficacy of psychological therapy approaches.

Integrierte psychotherapeutische Behandlung von schwer psychisch Kranken

Psychiatric care for severe and persistent mentally ill individuals has considerably changed over the last three decades. Striving for improvement in services provision for these patients has led to the emergence of various specialized community services, suited housing and supported work offers. Moreover, community-based treatment is also offered during acute episodes of mental illness. At the same time a range of evidence-based psychotherapeutic approaches targeting treatment needs of people with severe mental illness were developed in a process independent of the rise of community psychiatry. At present, however, a sufficient level of coordination of psychiatric services and integration of evidence-based psychological treatment into psychiatric care has not been achieved. Thus, these issues represent important steps in the further development.This paper discusses recent developments in psychiatric care of people with severe mental illness and reviews the evidence-based psychotherapy approaches suited to fit the needs of patient-centered integrated care.

The Importance of Cognitive Processes for the Integrative Treatment of Persons with Schizophrenia

Cognitive impairment is a hallmark of schizophrenia. Such impairment precedes the onset of the illness and typically endures over time.1 Alterations in cognitive processing, such as deficient source monitoring2,3 or lack of connectivity,4 are considered essential pathologic mechanisms involved in the development of schizophrenia. Reasoning biases such as “externalization” or “jumping to conclusions” contribute to the emergence and maintenance of delusions and hallucinations.5 Most important, however, cognitive impairment substantially interferes with everyday functioning. Deficits in everyday functioning are associated with the pervasive disability seen in schizophrenia. In recent years, research has increasingly shown that cognitive impairment is at the base of the skill deficits observed in schizophrenia patients and, thus, is a barrier to functional recovery.6–8

[Integrating psychotherapeutic treatment of severe mental illness: between desirability and clinical practice].

Psychiatric care for severe and persistent mentally ill individuals has considerably changed over the last three decades. Striving for improvement in services provision for these patients has led to the emergence of various specialized community services, suited housing and supported work offers. Moreover, community-based treatment is also offered during acute episodes of mental illness. At the same time a range of evidence-based psychotherapeutic approaches targeting treatment needs of people with severe mental illness were developed in a process independent of the rise of community psychiatry. At present, however, a sufficient level of coordination of psychiatric services and integration of evidence-based psychological treatment into psychiatric care has not been achieved. Thus, these issues represent important steps in the further development.This paper discusses recent developments in psychiatric care of people with severe mental illness and reviews the evidence-based psychotherapy approaches suited to fit the needs of patient-centered integrated care.

Neuere Entwicklungen in der kognitiv-behaviouralen Therapie der Schizophrenie

Fur kognitiv-behaviourale Behandlungsansatze bei schizophrenen Erkrankungen fehlte lange Zeit ein ausreichender Wirksamkeitsnachweis. Dies hat sich in den letzten zwei Jahrzehnten grundlegend geandert. Die Entwicklung effektiver antipsychotischer Medikamente, der Deinstitutionalisierungsprozess sowie die Konzipierung des Vulnerabilitats-Stress-Bewaltigungsmodells haben ganz allgemein psychologischen Therapieverfahren in der Behandlung schizophrener Patienten enormen Auftrieb gegeben. Gemass dem Vulnerabilitats-Stress-Modell machen neurobiologische Normabweichungen die kognitiven Funktionen einer betroffenen Person psychosozialen Stressoren gegenuber vulnerabel (Kopelowicz und Liberman 1995). Eine effektive Behandlung schizophrener Erkrankungen muss daher mindestens einen der drei pathogenetisch interagierenden Faktoren therapeutisch gunstig beeinflussen: (1) Die biologisch verankerte, neurophysiologisch und neuropsychologisch erfassbare Vulnerabilitat, (2) psychosoziale Stressoren und/oder (3) die Bewaltigungskapazitat des betroffenen Individuums. In den letzten 20 Jahren hat eine grosse Zahl empirischer Arbeiten gezeigt, dass psychologische Interventionen im Verbund mit der medikamentosen Behandlung auf alle drei Faktoren therapeutischen Einfluss nehmen konnen. Sie konnen uber eine Verbesserung der Medikamenten-Compliance indirekt und durch Kompensationsstrategien direkt den neurobiologisch verankerten, vulnerabilitatsverbundenen Dysfunktionen entgegenwirken.

Kognitiv-verhaltenstherapeutische Ansätze in der Behandlung schizophrener Menschen

Wir sind heute von einem umfassenden Verstandnis schizophrener Erkrankungen noch weit entfernt. Um so hoher erscheint der heuristische Wert des Vulnerabilitats-Stres-Bewaltigungs-Modells fur eine konzeptionelle Einbettung der verschiedenen therapeutischen Behandlungsstrategien [1]. Betrachtet man dieses Modell mit Blick auf die Folgerungen, die sich daraus fur die Therapie schizophren Erkrankter ergeben, so mussen effektive Behandlungsansatze mindestens einen der drei Faktoren therapeutisch beeinflussen, von denen angenommen wird, das sie den Krankheitsverlauf wesentlich mitbestimmen: Die neurobiologisch verankerte Vulnerabilitat kognitiver Funktionen, psychosoziale Stressoren und/oder die Bewaltigungskompetenz der Patienten [2]. Es stellt sich sodann die Frage, inwieweit dies auf psychologische Therapieansatze zutrifft.

EPA-0479 – Specific ingredients and common factors of evidence-based psychotherapy for schizophrenia - a systematic review

Introduction A series of meta-analyses points to the benefits of different psychotherapy approaches in the treatment of persons with schizophrenia such as psycho-educational family interventions or cognitive behaviour therapy for psychosis. However, the advantages of these specific psychotherapeutic interventions as compared to non-specific supportive interventions are moderate. This challenges the validity of the presumed specific therapeutic ingredients. Objectives and methods To analyse the significance of specific therapeutic ingredients of evidence-based psychotherapy approaches for schizophrenia all efficacy studies with component control designs were identified by systematic electronic searches. Subsequently, moderator analyses of the standardized weighted effect sizes differences between psychotherapy approaches with different therapeutic components were performed. The effect size differences were integrated by transforming them into weighted mean point-biserial correlations between single therapeutic components and outcome variables. Furthermore, studies relating common factors such as therapeutic alliance or self-efficacy expectations of patients with outcome were searched, and weighted mean Pearsons correlations between common factors and outcome variables were calculated. Results The findings indicate that specific therapeutic components such as psycho-education, cognitive restructuring or skills training represent key therapeutic ingredients of evidence-based psychotherapy for schizophrenia. However, also common factors such as positive therapeutic relationship, changing expectations for self-efficacy or successful mastery efforts are associated with positive outcomes. Conclusions There is an urgent need to dismantle the actual therapeutically active components in order to promote the targeted, personalized and, thereby, efficient implementation of evidence-based psychotherapy approaches for persons with schizophrenia in routine care.