Cognitive behavioural therapy compared with other psychosocial therapies for schizophrenia[1]
Summary
For people with schizophrenia trial-based evidence suggests no clear and convincing advantage for cognitive behavioural therapy over other - and sometime much less sophisticated - therapies.[1]
Outcome
Findings in words
Findings in numbers
Quality of evidence
Adverse effect/event
Any adverse effect - medium-term only. Follow-up: 26-52 weeks
Cognitive behavioural therapy may increase the chance of people with schizophrenia experiencing the ill-defined outcome of 'any adverse effects', but, at present it is not possible to be confident about the difference between the two treatments and data supporting this finding are very limited.
Cognitive behavioural therapy may very slightly reduce the chance of experiencing this global state outcome but there is no clear difference between people given cognitive behavioural therapy and those receiving other psychosocial therapies. These findings are based on data of low quality.
Cognitive behavioural therapy may very slightly reduce the chance of experiencing coming back into hospital but there is no clear difference between people given cognitive behavioural therapy and those receiving other psychosocial therapies. These findings are based on data of low quality.
No important or reliable change - long-term. Follow-up: 12 months
Cognitive behavioural therapy may reduce the chance of experiencing this broad mental state outcome, but, at present it is not possible to be confident about the difference between the two treatments and data supporting this finding are very limited.
Average scores (Social Functioning Scale, high = good) Follow-up: median 26 weeks
On average, people receiving cognitive behavioural therapy scored 8.8 higher than people treated with other psychosocial therapies. There was no clear difference between the groups, and, at present the meaning of this in day-to-day care is unclear.
Average score (Euro. QOL, high = good) - long-term only. Follow-up: 26 weeks
On average, people receiving cognitive behavioural therapy scored 1.86 lower than people treated with other psychosocial therapies on this measure. There was no clear difference between the groups. The meaning of this in day-to-day care is unclear.
Specialised team compared to standard care for psychosis[2]
Summary
There is emerging, but as yet inconclusive evidence, to suggest that people in the prodrome of psychosis can be helped by some interventions. There is some support for specialized early intervention services, but further trials would be desirable, and there is a question of whether gains are maintained. There is some support for phase-specific treatment focused on employment and family therapy, but again, this needs replicating with larger and longer trials.[2]
Average number of days per month in hospital. Follow-up: 5 years
There was no clear difference between groups although the average number of days per month in hospital in the intervention groups was somewhat lower. Data supporting this finding are based on moderate quality evidence.
Specialized team probably causes little or no increase to the chance of experiencing the outcomes to do with how much hospital/community care is used, but the difference between the two treatments is not clear. Data supporting this finding are based on moderate quality evidence.
Specialized team probably does not effect chance of being unemployed or being in or out of education. Data supporting this finding are based on moderate quality evidence.
Moderate to low quality evidence suggests that music therapy as an addition to standard care improves the global state, mental state (including negative and general symptoms), social functioning, and quality of life of people with schizophrenia or schizophrenia-like disorders. However, effects were inconsistent across studies and depended on the number of music therapy sessions as well as the quality of the music therapy provided. Further research should especially address the long-term effects of music therapy, dose-response relationships, as well as the relevance of outcome measures in relation to music therapy.[3]
Outcome
Findings in words
Findings in numbers
Quality of evidence
Global state
No clinically important overall improvement (as rated by individual trials). Follow-up: 3-6 months
Music therapy (in addition to standard care) may help avoid achieving 'no improvement'. Data are based on low quality evidence.
Specific - negative symptoms - average endpoint score (SANS, high score = poor). Follow-up: 3-6 months
On average, people receiving music therapy (in addition to standard care) scored lower than people treated with standard care alone. There was a clear difference between the groups. This finding is based on data of low quality.
General - average endpoint score (PANSS, high score = poor). Follow-up: 3-6 months
On average, people receiving music therapy (in addition to standard care) scored lower than people treated with standard care alone. There was a clear difference between the groups. This finding is based on data of low quality.
General - average endpoint score (BPRS, high score = poor). Follow-up: 3-6 months
On average, people receiving music therapy (in addition to standard care) scored lower than people treated with standard care alone. There was a clear difference between the groups. This finding is based on data of moderate quality.
Average endpoint score (GAF, high score = good) medium term. Follow-up: 3-6 months
On average, people receiving music therapy (in addition to standard care) scored lower than people treated with standard care alone. There was no clear difference between the groups. This finding is based on data of moderate quality.
Average endpoint score (SDSS, high score = poor). Follow-up: 3-6 months
On average, people receiving music therapy (in addition to standard care) scored lower than people treated with standard care alone. There was a clear difference between the groups. This finding is based on data of moderate quality.
General - average endpoint score (GWB, high score = good). Follow-up: less than 3 months)
On average, people receiving music therapy (in addition to standard care) scored higher than people treated with standard care alone. There was a clear difference between the groups. This finding is based on data of moderate quality.
Supported employment versus other vocational approaches for adults with severe mental illness[4]
Summary
The limited available evidence suggests that supported employment is effective in improving a number of work-related outcomes relevant to people with severe mental illness, though there appears to exist some overall risk of bias in terms of the quality of individual studies.[4]
Outcome
Findings in words
Findings in numbers
Quality of evidence
Employment
Obtained any job during the study Follow-up: mean 18 months
Supported employment may increase the chance of obtaining a job, but, at present there are only very limited data supporting this finding.
Job tenure for competitive employment (weeks). Follow-up: 24 months
On average, people receiving supported employment maintained tenure for competitive employment 10 weeks more compared with people treated with other vocational approaches.
Job tenure for any paid employment (weeks). Follow-up: mean 22 months
On average, people receiving supported employment maintained tenure for any paid employment 4 weeks more than people treated with other vocational approaches, but there was no clear difference between the groups.
On average, people receiving supported employment had 162 days less days before finding competitive employment than people treated with other vocational approaches.
Art therapy plus standard care compared to standard care for schizophrenia-like illnesses[5]
Summary
Randomised studies are possible in this field. Further evaluation of the use of art therapy for serious mental illnesses is needed as its benefits or harms remain unclear.[5]
Outcome
Findings in words
Findings in numbers
Quality of evidence
Global outcome
Leaving the study early
Adding art therapy to standard care does not seem to decrease the chance of leaving the study (for any reason) compared with those receiving standard care. These findings are based on data of low quality.
On average, people receiving art therapy plus standard care scored a little lower than people treated with standard care. There was a clear difference between the groups, but, at present the meaning of this finding in day-to-day care is unclear. This finding is based on data of low quality.
On average, people receiving art therapy plus standard care scored a little higher than people treated with standard care. There was no clear difference between the groups and this finding is based on data of low quality. The meaning of this finding in day-to-day care is unclear.
Compliance therapy compared to non-specific counselling for schizophrenia[6]
Summary
There is no clear evidence to suggest that compliance therapy is beneficial for people with schizophrenia and related syndromes but more randomised studies are justified for this intervention to be fully evaluated.[6]
Outcome
Findings in words
Findings in numbers
Quality of evidence
Attitudes to treatment
Non-compliance with medication Follow up: by 1 year
Compliance therapy results in no clear difference in adherence with prescribed medication. This finding is based on data of low quality.
Average score (GAF endpoint score, high = poor) Follow up: 1 year
On average, people receiving compliance therapy scored lower than people treated with non-specific counselling. There was no clear difference between the groups. The meaning of this finding in day-to-day care is unclear and is based on data of low quality.
Average PANSS endpoint score High = poor, by 1 year
On average, people receiving compliance therapy scored 6.1 higher than people treated with non-specific counselling. There was no clear difference between the groups and this finding is based on data of low quality. The meaning of this in day-to-day care is unclear.
Compliance therapy may increase the chance of experiencing the outcome, but, at present it is not possible to be confident about the difference between the two treatments. This finding is based on data of low quality.
Based on evidence of variable quality, ICM is effective in helping many outcomes relevant to people with severe mental illness. Compared to standard care, ICM may reduce hospitalization and increase retention in care. It also globally improved people's functioning socially, but ICM's effect on mental state and quality of life remains unclear.[7]
Outcome
Findings in words
Findings in numbers
Quality of evidence
Service use
Average number of days in hospital per month Follow up: by about 24 months
On average, people receiving intensive case managing spent about 1 day less in hospital per month compared with people receiving standard care. There was a clear difference between the groups. This finding is based on data of low quality.
Intensive case management may very slightly reduce the chance of suicide but there the difference between people given intensive case management and those receiving standard care for severe mental illness was not clear. These findings are based on data of low quality.
Intensive case management may reduce the chance of loss to follow up when compared with standard care for severe mental illness. Data are based on low quality evidence.
Employment status - not employed at the end of the trial Follow up: by 'long' term
Intensive case management may reduce unemployment, but, at present it is not possible to be really confident about this outcome. Data supporting this finding are very limited.
Educational game plus standard training compared to standard training for mental health professionals[8]
Summary
Current very limited evidence suggests educational games could help mental health students gain more points in their tests, especially if they have left revision to the last minute. The one salient study should be refined and repeated.[8]
Outcome
Findings in words
Findings in numbers
Quality of evidence
Knowledge
No significant improvement in test scores (> 10%)
Students had a slightly improved chance of improvement in test scores when receiving educational game plus standard training. This finding is based on data of very low quality.
On average, students receiving educational game plus standard training scored 6 higher than students with standard training. There was a clear difference between the groups. This finding is based on data of low quality.
These studies were of limited quality. Results show correct identification of people with schizophrenia in about 75-95% of the cases although it is recommended to consult an additional specialist. The sensitivity of FRS was about 60%, so it can help diagnosis and, when applied with care, mistakes can be avoided. In lower resource settings, when more sophisticated methods are not available, First Rank Symptoms can be very valuable.[9]
Summary accuracy % (95% CI)
Prevalence median (range)
Implications
Quality and comments
Diagnosis of schizophrenia from all other diagnoses
Prevalence of 48%: 48 out of every 100 people with all other mental health diagnoses will have schizophrenia. The result means that, of these, 21 will not be identified as having schizophrenia by use of FRS (43% of 48). Then, of the 52 people really without schizophrenia, 10 may be incorrectly diagnosed with schizophrenia by the FRS.
Diagnosis of schizophrenia from other types of psychosis
Prevalence of 57%: 57 out of every 100 people with other types of psychosis will have schizophrenia. The result means that, of these, 24 will not be identified as having schizophrenia by use of FRS (42% of 57). Then, of the 43 people really without schizophrenia, 13 may be incorrectly diagnosed with schizophrenia by the FRS.
For all three estimates there are important issues regarding patient selection, use of index test and reference standard. This raises doubts about the accuracy of these findings. Also most studies were not conducted in an everyday clincal setting.
Diagnosis of schizophrenia from non-psychotic disorders
With a prevalence of 55%, 55 out of every 100 people with non-psychotic disorders will have schizophrenia. Of these, 21 will not be identified as having schizophrenia by use of FRS (38% of 55). Then, of the 45 people really without schizophrenia, 3 may be incorrectly diagnosed with schizophrenia by the FRS.
