Rehab Rounds : Optimal Treatment for Psychosis in an International Multisite Demonstration Project

Introduction by the column editors: In the past three decades several clinical strategies for the treatment and rehabilitation of schizophrenia have been empirically validated. It is generally agreed that all persons with a schizophrenic disorder should be provided with a combination of three essential interventions—optimal dosages of antipsychotic medication, education for themselves and their caregivers to cope more effectively with environmental stresses, and assertive case management to help prevent and resolve major social needs and crises, including exacerbations of symptoms (1). Despite strong scientific support for the routine clinical implementation of these strategies, few treatment programs provide more than pharmacotherapy, and even this intervention is seldom applied in the manner associated with the best results achieved in controlled clinical trials (2,3).Only one clinical trial has attempted to determine the efficacy of providing all of the recommended treatment components to individuals with schizophrenia. In that study, a group of 40 individuals with schizophrenia received carefully titrated antipsychotic medication, family psychoeducation, social skills training, and case management; none of the study participants who received the treatments had a relapse in the first year of the program (4). The relapse rate was 40 percent in the first year for a comparison group receiving only medications and case management; 21 percent for a group who received medications, case management, and social skills training; and 19 percent for a group who received medications, case management, and family psychoeducation.By the second year, however, relapse rates for the groups receiving family psychoeducation and social skills training began to approach the level for the group receiving only medication and case management. The presumptive reason given for this outcome was that the benefits of the interventions dissipated with their termination (5), highlighting the importance of offering efficacious psychosocial interventions on a flexible, as needed, or maintenance basis just as medication is provided.Building on this finding, Dr. Ian Falloon (6) demonstrated that publicly funded services could deliver evidence-based interventions for schizophrenic, affective, and anxiety disorders in routine practice, with outcomes comparable to those found in randomized controlled trials and without the need for additional resources. Soon thereafter, Dr. Falloon recruited a large number of investigators and clinicians with ties to routine mental health services for persons with schizophrenia and established an international collaboration with the goal of implementing and evaluating optimal treatment in ordinary clinical facilities. The planning and early results of this international collaboration, known as the Optimal Treatment Project, are described in this month's Rehab Rounds.