Cognitive-behavioral therapy and clozapine for clients with treatment-refractory schizophrenia. Cost-effectiveness evaluation of compliance therapy for people with psychosis. Parental affective style and the treatment of schizophrenia. Predicting course of illness and social functioning. Cognitive-behavioural techniques for general psychiatrists in the management of patients with psychoses. Two-year follow-up of cognitive--behavioral therapy and supportive counseling in the treatment of persistent symptoms in chronic schizophrenia. Psychiatric rehabilitation as a deterrent to recidivism. A study of client-focused case management and consumer advocacy: the Community and Consumer Service Project. Effects of cognitive treatment in psychiatric rehabilitation. Tayside-Fife clinical trial of cognitive-behavioural therapy for medication-resistant psychotic symptoms. Results to 3-month follow-up. Technique for training schizophrenic patients in illness self-management: a controlled trial. A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis. A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Immigrant families coping with schizophrenia. Behavioral family intervention v. case management with a low-income Spanish-speaking population. Three-year trials of personal therapy among schizophrenic patients living with or independent of family, II: Effects on adjustment of patients. The role of the therapeutic alliance in the treatment of schizophrenia. Relationship to course and outcome.
nan Non-compliance rates with antipsychotic medication can be high, and the personal and societal costs are considerable. A new psychological intervention, compliance therapy seeks to improve compliance and patient outcomes and reduce treatment costs.
                A randomised controlled study examined the cost-effectiveness of compliance therapy compared to non-specific counselling over 18 months for 74 people with psychosis admitted as inpatients at the Maudsley Hospital. Bivariate and multivariate analyses were conducted to test for differences and to explore inter-patient cost variations.
                Compliance therapy is more effective and is no more expensive. Consequently, compliance therapy is more cost-effective than non-specific counselling at six, 12 and 18 months.
                There are compliance, outcome and cost-effectiveness arguments in favour of compliance therapy in preference to non-specific counselling. In a randomized controlled study, the affective style (AS) of parents of schizophrenics in clinic-based individual treatment groups and home-based family treatment groups was compared prior to treatment and again three months after treatment had begun. Affective style is an index reflecting the quality of the family emotional climate, measured from face-to-face discussion. Pretherapy and posttherapy measures of negative AS were significantly predictive of relapse within the nine-month treatment period for patients in individual treatment. In addition, for both treatment groups, a negative AS pattern at the posttherapy reassessment was significantly associated with decreased patient social functioning, reduced ability of the family to absorb the family intervention, and lower capacity of the family to cope with everyday family stresses. The results suggest that AS is an important intrafamilial attribute, with implications for treatment strategy and planning. Recent research progress showing the benefits of cognitive therapy in schizophrenia leaves the general psychiatrist unsure whether to attempt to use such techniques.
                To test whether cognitive-behavioural techniques are beneficial in the management of patients with schizophrenia in general psychiatric practice.
                A randomised controlled study comparing the use of cognitive-behavioural techniques and befriending in schizophrenia.
                Significant improvement in symptoms occurred in the group treated with cognitive-behavioural techniques but not in the befriending group. During the 6-month follow-up period the cognitive-behavioural group tended to have shorter periods in hospital.
                General psychiatrists could help their patients with schizophrenia by using cognitive-behavioural techniques. Such techniques are well within the capability of general psychiatrists, but their application would involve more of the consultant's time spent in direct contact with patients with psychoses. The article reports the 2-year follow-up of patients suffering persistent symptoms of schizophrenia who entered a single blind randomized controlled trial. Patients were randomly allocated to cognitive-behavioral therapy (CBT) plus routine care (RC), supportive counseling (SC) plus RC, or RC alone. Treatment took place over 3 months, and follow-up was made 12 and 24 months after treatment finished. Sixty-one patients were available to the 2-year follow-up and assessed for positive and negative symptoms and clinical improvement; all of the 87 patients who entered the trial were assessed for relapse over the follow-up period. On all measures, patients who received RC alone did significantly worse at 2 years. There were no significant differences at 2 years between the CBT and SC groups. An experiment was conducted to evaluate the effectiveness of a comprehensive rehabilitation program in deterring the rehospitalization of severely distributed psychiatric outpatients. A total of 102 clients were randomly assigned at intake to either a fulltime, comprehensive rehabilitation program or a part-time supportive treatment program at a separate location. After nine months, only 14 per cent of the subjects in comprehensive treatment had been rehospitalized, compared with 44 per cent of the subjects in supportive treatment. Regardless of treatment method, subjects who had histories of more frequent hospitalization and subjects who encountered higher levels of life-event stress during the follow-up period were more likely to relapse. The authors conclude that the great reduction in hospital days for subjects in the comprehensive treatment more than compensated for the program's higher cost. The study investigated the provision of client-focused services to community-based clients with schizophrenia and bipolar disorder. It hypothesised that the delivery of more client-focused services would improve client outcome in terms of functioning, disability and satisfaction with services. Client-focused services were developed using an empowerment model of case management and by the addition of consumer advocates.
                Clients referred for case management were randomly allocated to one of three groups: standard case management (n = 35), client-focused case management (n = 39), or client-focused case management plus consumer advocacy (n = 45). Measures of functioning, disability, quality of life, burden of care and service satisfaction were measured at baseline and 12 months. Outcome data were collected concerning number and duration of hospital readmission, crisis intervention and compliance with treatment and services.
                While there were no differences between the groups on quantitative measures of functioning, disability, quality of life, service satisfaction and burden of care, there were significant between-group differences on qualitative measures of satisfaction with services.
                Several methodological difficulties hampered interpretation of the findings. Although clients did not differ on outcome measures of functioning and disability, the group receiving client-focused case management reported greater satisfaction with service delivery. Ninety subjects with severe and disabling psychiatric conditions, predominantly schizophrenia, participated in a controlled-outcome trial of the cognitive component of Integrated Psychological Therapy (IPT), a group-therapy modality intended to reestablish basic neurocognitive functions. The cognitive therapy was delivered to subjects in the experimental condition during intensive 6-month treatment periods. Control subjects received supportive group therapy. Before, during, and after the intensive treatment period, all subjects received an enriched regimen of comprehensive psychiatric rehabilitation, including social and living skills training, optimal pharmacotherapy, occupational therapy, and milieu-based behavioral treatment. IPT subjects showed incrementally greater gains compared with controls on the primary outcome measure, the Assessment of Interpersonal Problem-Solving Skills, suggesting that procedures that target cognitive impairments of schizophrenia spectrum disorders can enhance patients' response to standard psychiatric rehabilitation, at least in the short term, in the domain of social competence. There was equivocal evidence for greater improvement in the experimental condition on the Brief Psychiatric Rating Scale disorganization factor and strong evidence for greater improvement on a laboratory measure of attentional processing. There was significant improvement in both conditions on measures of attention, memory, and executive functioning, providing support for the hypothesis that therapeutic procedures that target impaired cognition enhance response to conventional psychiatric rehabilitation modalities over a 6-month timeframe. Evidence for the efficacy of cognitive-behavioural therapy for schizophrenia is promising but evidence for clinical effectiveness is limited.
                To test the effectiveness of cognitive-behavioural therapy delivered by clinical nurse specialists in routine practice.
                Of 274 referrals, 66 were allocated randomly to 9 months of treatment as usual (TAU), cognitive-behavioural therapy plus TAU (CBT) or supportive psychotherapy plus TAU (SPT) and followed up for 3 months.
                Treatment effects were modest but the CBT condition gave significantly greater improvement in overall symptom severity than the SPT or TAU conditions combined (F (1,53)=4.14; P=0.05). Both the CBT and SPT conditions combined gave significantly greater improvement in severity of delusions than did the TAU condition (F (1,53)=4.83; P=0.03). Clinically significant improvements were achieved by 7/21 in the CBT condition (33%), 3/19 in the SPT condition (16%) and 2/17 in the TAU condition (12%).
                Cognitive-behavioural therapy delivered by clinical nurse specialists is a helpful adjunct to routine care for some people with chronic psychosis. To determine whether schizophrenic outpatients receiving low-dose neuroleptic therapy could learn and retain complex information and skills related to self-management of their illness, a novel technique of teaching, using cognitive and behavioral methods, was designed to compensate for the patients' learning disabilities.
                The subjects were 41 patients with DSM-III-R schizophrenia who were receiving constant maintenance neuroleptic drug therapy. They were randomly assigned to structured, modularized skills training or to supportive group psychotherapy.
                The patients who received skills training made significant gains in each of the areas taught, while those participating in group therapy did not. The skills learned during training were retained without significant erosion over a 1-year follow-up period.
                The effectiveness of modularized teaching of illness self-management skills to schizophrenic patients appears to be largely independent of baseline psychology and symptom improvement. Such an approach is useful for overcoming or compensating for the enduring cognitive and information processing deficits commonly found in schizophrenia. Recent research indicates that cognitive-behaviour therapy (CBT) can be effective in ameliorating persistent positive symptoms in chronic psychotic patients. The effectiveness of CBT in acute and recent-onset psychosis has been little explored, although a recent pilot study indicated that CBT could significantly improve recovery in acutely psychotic inpatients.
                Short-term individual CBT was compared to supportive counselling/psychoeducation (SC) as an adjunct to standard inpatient hospital care and medication in 21 inpatients experiencing a recent-onset acute schizophrenic episode.
                Both groups showed significant reductions in Brief Psychiatric Rating Scale (BPRS) scores following treatment, although there were no group differences. Time to discharge did not differ significantly between the groups, although there was a greater variance for the SC patients. Two-year follow-up showed no significant differences between the groups, although the number of patients who relapsed, the number of relapses and the time to recurrence of psychotic symptoms was lower in the CBT group than the SC group. Interestingly, the time to readmission was shorter in the CBT group.
                CBT and SC are acceptable treatments for recent-onset acutely psychotic inpatients. A larger randomised controlled trial over multiple hospital sites is warranted. Research evidence supports the efficacy of cognitive-behavioral therapy in the treatment of drug-refractory positive symptoms of schizophrenia. Although the cumulative evidence is strong, early controlled trials showed methodological limitations.
                A randomized controlled design was used to compare the efficacy of manualized cognitive-behavioral therapy developed particularly for schizophrenia with that of a nonspecific befriending control intervention. Both interventions were delivered by 2 experienced nurses who received regular supervision. Patients were assessed by blind raters at baseline, after treatment (lasting up to 9 months), and at a 9-month follow-up evaluation. Patients continued to receive routine care throughout the study. An assessor blind to the patients' treatment groups rated the technical quality of audiotaped sessions chosen at random. Analysis was by intention to treat.
                Ninety patients received a mean of 19 individual treatment sessions over 9 months, with no significant between-group differences in treatment duration. Both interventions resulted in significant reductions in positive and negative symptoms and depression. At the 9-month follow-up evaluation, patients who had received cognitive therapy continued to improve, while those in the befriending group did not. These results were not attributable to changes in prescribed medication.
                Cognitive-behavioral therapy is effective in treating negative as well as positive symptoms in schizophrenia resistant to standard antipsychotic drugs, with its efficacy sustained over 9 months of follow-up. This investigation compared the effectiveness and cross-cultural applicability of behavioural family management (BFM) and standard case management in preventing exacerbation of symptoms and relapse in schizophrenia.
                Forty low-income Spanish-speaking people with a diagnosis of schizophrenia were randomly assigned to receive standard case management or behavioural family management after stabilisation with neuroleptic medication.
                Survival analyses indicated that among the less acculturated patients BFM was significantly related to greater risk of exacerbation of symptoms. Among the more acculturated patients, risk of exacerbation could be predicted by medication compliance but not by type of intervention. In analyses of symptom severity and functional status at 1-year follow-up, the level of patient acculturation was found to be significantly related to various measures of treatment outcome.
                Sociocultural factors affect responses to different types of intervention. The results did not support earlier findings of a beneficial effect of BFM when applied to a socioculturally diverse population. Previous analyses of the personal and social adjustment of outpatients with schizophrenia have either relied on the assessment of unrepresentative patients who survived without relapse or used analyses that included relapse assessments, a potential confound when different rates of relapse existed among treatment conditions. The authors' goal was to conduct a study of the effects of personal therapy on outcome that was designed to take into consideration the effects of relapse.
                They evaluated the effectiveness of personal therapy over 3 years after hospital discharge among 151 patients with schizophrenia or schizoaffective disorder. The patients were randomly assigned to receive personal therapy or contrasting therapies in one of two concurrent trials. One trial included patients who were living with family (N = 97); the other included patients who were living independent of family (N = 54). Patients were assessed at 6-month intervals over 3 years of treatment on measures of personal and social adjustment; patients who relapsed and restabilized and those who did not relapse were included.
                Personal therapy had positive effects on broad components of social adjustment (role performance) but had few differential effects on symptoms, and patients receiving personal therapy remained more anxious than patients who received family or supportive therapy. For patients who were living with family, personal therapy led to better outcomes in overall performance than did the other treatments. Although family therapy had only one positive effect on patients' social adjustment, the personal adjustment (residual symptoms) of patients who received family therapy appeared to improve more than that of patients receiving personal or supportive therapy. For patients not living with family, personal therapy was more successful than supportive therapy in improving work performance and relationships out of the home. Longitudinal effects of personal therapy on symptoms were similar to those of family and supportive therapies, particularly in the first 2 years, but personal therapy effect sizes increased over time on measures of social adjustment.
                Personal therapy has pervasive effects on the social adjustment of patients with schizophrenia that are independent of relapse prevention. Supportive therapy, with or without family intervention, produces adjustment effects that peak at 12 months after discharge and plateau thereafter. However, personal therapy, a definitive psychosocial intervention, continues to improve the social adjustment of patients in the second and third years after discharge. Brief treatment would appear to be less effective than a long-term, disorder-relevant intervention for schizophrenia. This study examined the relationship of the therapeutic alliance to the treatment course and outcome of 143 patients with nonchronic schizophrenia. Results showed that patients who formed good alliances with their therapists within the first 6 months of treatment were significantly more likely to remain in psychotherapy, comply with their prescribed medication regimens, and achieve better outcomes after 2 years, with less medication, than patients who did not. These results underscored the prognostic value of assessing the alliance and the need to identify factors that contribute to its development and maintenance with schizophrenic patients.
There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies. 
Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.