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As described in the 2004 guideline, psychosocial treatments such as family intervention, supported employment, assertive community treatment, skills training, and cognitive-behavioral therapy (CBT) can prevent relapse and enable recovery during the stable phase of treatment. Some interventions, such as family psychoeducation, may also be initiated during the acute phase. "Recovery," a construct that overlaps with but differs from treatment goals of cure or remission of symptoms, is defined by the President's New Freedom Commission on Mental Health as the "process in which people are able to live, work, learn, and participate fully in their communities" (22). The Substance Abuse and Mental Health Services Administration (23) has identified 10 components of recovery: "self-direction; individualized and person-centered; empowerment; holistic; non-linear; strengths-based; peer support; respect; responsibility; and hope." These components refer to the nature of treatment and the individual experience of the recovery process.

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Family Psychoeducation

The 2004 guideline recommends engaging and collaborating with family members during an acute episode, whether first episode or relapse. Studies cited in the guideline and more recent studies have shown that family psychoeducation, delivered for 6–9 months following recent illness exacerbation or hospitalization, including family support, education, access to providers during crises, and some type of problem-solving skills, can reduce relapse rates among persons with schizophrenia as well as reduce family burden (24). Other studies that have focused on individuals who have not had an illness exacerbation have found that family psychoeducation contributed to improved social and vocational outcomes for individuals with schizophrenia and lower levels of distress and increased perceptions of professional and social support among family members (25,26). Family psychoeducation programs lasting less than 6 months have been shown to contribute to positive outcomes for patients, including increased treatment adherence (27), and for family members, including increased knowledge about schizophrenia and improved family relationships (28–30).

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Assertive Community Treatment

Studies have continued to demonstrate that assertive community treatment (ACT) results in reduced hospitalization rates and reduced homelessness (31–34), particularly among individuals with high rates of hospitalization (35). Interventions that show higher fidelity to the ACT model show stronger outcomes (35).

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Supported Employment

Recent studies of supported employment offer further evidence for its role in helping individuals with schizophrenia obtain competitive employment, earn more wages, and work more hours (36–38). Employment outcomes are better when there is greater fidelity to the supported employment model (39–41). Recent studies of supported employment have focused on improving long-term job retention and economic independence by augmenting supported employment with cognitive remediation (42,43), social skills training (44,45), and CBT (46,47).

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Cognitive-Behavioral Therapy

Recent studies continue to offer support for the role of CBT in reducing both positive and negative symptoms (48–51) and improving social functioning (52). However, there is not consistent evidence that CBT improves outcomes among individuals who are experiencing acute psychotic symptoms (52–54). A recent meta-analysis suggests that CBT can be delivered in both individual and group formats with similar benefits, improving overall outcome in patients with schizophrenia who have residual symptoms (55).

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Social Skills Training

Similar to supported employment, social skills training assumes that recovery requires a multifaceted approach. Recent studies suggest that skills training contributes to improvements in broader functional outcomes (24,56) and has been shown to lead to improved skills in refusing drugs of abuse (57), as well as improved communication in the workplace (44,45) and with health care professionals (58). More recently, social skills training has been combined with family interventions (59,60), case management (58), and CBT (61). There have been attempts to facilitate generalization of skills training to real world settings through application of skills training outside of the therapeutic context (58,62). Skills training has evolved into so-called illness management and recovery programs (63).

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Cognitive Remediation

The 2004 guideline characterizes cognitive remediation as a variety of experimental treatments addressing the cognitive deficits associated with schizophrenia. A large number of studies on these approaches have been conducted over the last 5 years. This emerging literature continues to be limited by the wide variation in cognitive targets, small sample sizes, and a tendency for outcomes to be performance on neuropsychological tests rather than functional status or even symptoms. Studies using cognitive remediation in combination with vocational rehabilitation to enhance work functioning (42,47,64–66) have yielded positive findings, but more research is needed.

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Peer Support and Peer-Delivered Services

A critical part of the emerging focus on recovery has been recognition of the importance of enhancing the role of individuals who have mental illness in the delivery of services and in roles in which the value of this experience is appreciated as therapeutic. Programs have been developed in which individuals with serious mental illness deliver traditional services, either as paid staff or as volunteers, as well as provide support to other individuals with serious mental illness. Peer-to-peer services include in-person self-help groups, Internet support groups, peer-delivered services, peer-run or peer-operated services, peer partnerships, and peer employees (67). Davidson et al. (68) outline three types of peer programs: mutual support, participation in peer-run programs, and the use of individuals with severe mental illness as a source of support and services for other individuals with severe mental illness.

When the evidence base for peer-delivered services is being considered, it is important to note a critical disconnect between these types of programs and traditional diagnostic-driven treatment systems. Peer-based programs and services tend to discount or deemphasize formal psychiatric diagnoses. Therefore, the formal psychiatric diagnoses of persons served in these studies may be unknown. A majority of randomized trials that compare peer-delivered with non–peer-delivered services do not show differences on most outcome measures (69–72). It is notable that despite the lack of significant group differences in these randomized, controlled trials, participants improved over the course of their participation in peer-delivered services (70,71). Studies have shown that the delivery of peer-based services is feasible despite the fact that the precise benefits of peer-delivered services are as yet uncertain because of poorly defined comparison groups, small samples sizes, and the heterogeneity of outcomes. Future work needs to focus on either documenting advantages to consumer-delivered services or identifying the positive effect on standard clinical outcomes (e.g., symptoms, hospitalization) or other dimensions, such as increased self-esteem, social support, and progress toward recovery.

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Psychosocial Interventions for Weight Management

Several clinical trials have investigated pharmacological and cognitive-behavioral treatments that may attenuate or reverse antipsychotic-related weight gain and lipid, glucose, and insulin changes (10). Several recently published randomized, controlled trials investigating psychoeducation and behavioral interventions for weight loss for individuals with schizophrenia found support for modest weight loss (mean weight loss across seven studies was 5.8 lbs) (11,73–81). Moreover, recent reviews and meta-analyses further support the use of a psychoeducation or cognitive-behavioral intervention to promote weight loss among individuals with schizophrenia who are overweight or have experienced antipsychotic-related weight gain (82–85). Two studies also found support for psychoeducation and behavioral interventions in the prevention of weight gain among individuals with schizophrenia who had recently begun taking antipsychotic medications (86,87). Despite these positive findings, it should be noted that retention of weight loss was either not measured or problematic in many of the aforementioned investigations. Moreover, there is marked variability across studies in terms of treatment modality and length and format of treatment. It appears that individuals with schizophrenia can successfully participate in weight loss interventions. Future investigations should target weight loss retention strategies and weight prevention interventions.

References

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