Rehabilitation Promotes Recovery in Schizophrenia

The objective of the program, which is delivered by a multidisciplinary treatment team and comprises four phases focusing on engagement and wellness management, substance use, persistent symptoms, and functional recovery, “is to improve occupational functioning and promote goal pursuit and effective illness self-management,” the authors reported (Community Mental Health J. 2008;44:443-55).

In an open feasibility trial, 10 individuals recovering from an initial psychotic episode were assigned to receive treatment as usual plus GRIP for up to 36 weeks, and completed baseline and post-treatment assessments. Social functioning was the primary clinical outcome of the study, and symptoms, personal goal attainment, attitudes toward antipsychotic medication, and substance use were secondary outcomes.

Overall, study participants attended a mean of 15 sessions. Among participants who attended at least 12 sessions, “GRIP was associated with improvements in almost all measured domains, especially social functioning, positive and general symptoms, and goal attainment,” the authors wrote. Early treatment termination, on the other hand, “was associated with deterioration in almost all domains.”

In terms of qualitative feedback, “both therapists and participants reported positive experiences,” they said.

Although the study's small sample size and uncontrolled design limit definitive conclusions, “the preliminary results suggest that GRIP may be associated with clinical benefits, can assist clients in pursuing their personal goals, and is generally well received by clients and therapists,” according to the authors.

Taken together, the available data support the inclusion of functional recovery as a goal of schizophrenia management, according to Philip D. Harvey, Ph.D., of Emory University, Atlanta, and his colleagues. Although the primary focus for the management of schizophrenia has historically been on clinical symptoms and their consequences, this does not address most of the problems faced by schizophrenia patients, they wrote (Schizophr. Bull. 2009 Jan. 6 [doi:10.1093/schbul/sbn171]). “We see functional remission as a separate domain of functioning from clinical remission and subjective response and argue that the process of recovery includes all of these domains.”

Perspective

Schizophrenia is a devastating illness, and one of its hallmarks is also one of the most stubborn obstacles to effective management: a structural deficit that limits the brain's capacity for insight.

Without insight into the illness, individuals with schizophrenia often deny they have a disease, which in turn leads to an unwillingness to buy into treatment, whether medication or behavioral therapy. This is especially true with a first episode. Without multiple psychotic breaks, these individuals cannot see the patterns that might be suggestive of the disease.

Another challenge is the difficulty of determining the exact nature of a first break: Was it a first schizophrenic episode? Was it a drug-induced episode? To some extent, this has been solved with the identification of the unique nature of prodromal schizophrenia symptoms: magical thinking, anxiety, delusions, and hallucinations–although such symptoms can occur in many different illnesses.

Fortunately, you don't need to know how a fire started before you can put it out. The first step toward putting out the schizophrenia fire–after convincing the patient that he or she has a major psychiatric disorder–is medication, because without it, there almost certainly will be a relapse. But relapse prevention should not be confused with recovery. The individual still has an active form of schizophrenia. So, while medication is a necessary component to treatment management, it might not be the most important, as behavior is multidetermined and treatment is interdependent.

Successful management requires family support to provide external compensation for the lack of insight; a structured, individual intervention that the patient can understand and practice; and assertive case management to oversee all elements of care and compliance.

Cognitive-behavioral approaches are beneficial in that they are structured and manualized with clear expectations. Another benefit is the capacity to develop the ability to identify when a symptom begins, which puts patients in a better position to respond to the symptom vs. reacting to it.

The hope is that with these self-observations and empowering techniques, patients will be more willing to continue therapy, and by so doing progress along a normal path in their lives.