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©2002 CRC Press LLC
time of writing, the published data do not exclude
the possibility that many of the beneficial effects
may arise from non-specific factors, such as
befriending and increased contact time with the
therapist.
Neurocognitive remediation
Neurocognitive remediation attempts to improve
cognitive function, and thereby influence symp-
toms and functional outcome for the better
through task practise and repetition. Cognitive
function is a key determinant of long-term out-
come in schizophrenia
6
, but to date, the clinical
results of interventions focusing on specific cogni-
tive deficits have been disappointing. At a more
practical level, vocational rehabilitation and social
skills training remain important elements of many
treatment programmes with a focus on rehabili-
tation and functional outcome.
Compliance with drug treatment
This is another important determinant of outcome
in schizophrenia, since the majority of patients
admit to stopping their medication at some stage
(
Figure 5.3
). The latter is hardly surprising, since
they are asked to take drugs with unpleasant side-
effects, including extrapyramidal symptoms,
weight gain and sexual dysfunction (
Figure 5.4
)
for long periods of time. Few psychiatrists stop to
think whether they themselves would be 100%
compliant in taking regular medication in the face
of such side-effects. Compliance therapy
7
uses
simple psychological interventions focusing on the
psychological aspects of long-term drug treatment
in schizophrenia, emphasising insight and the
formation of a therapeutic alliance between
prescriber and patient, and appears to be effective
and relatively straightforward to incorporate into
routine practice.
80
60
40
20
0
Responders (%)
Psychiatrists Nurses
THE MAIN REASONS FOR NON-COMPLIANCE
Extrapyramidal side-effects Weight gain
Side-effects in general Sexual dysfunction
Lack of patient insight
Figure 5.4
The views of
psychiatrists and nurses on the
main reasons for patients’ non-
compliance with medication. Both
groups underestimate the import-
ance of sexual side-effects, the
psychiatrists more so than the
nurses. Figure reproduced with
kind permission from Hellewell,
JSE. Antipsychotic tolerability: the
attitudes and perceptions of medical
professionals, patients and caregivers
towards the side effects of
antipsychotic therapy.
Euro
N e u r o p s y c h o p h a r m a c o l
1998;8:S248
©2002 CRC Press LLC
Family treatments
It has long been recognised that high levels of
‘expressed emotion’ (EE) in the family increase
the risk of relapse in unmedicated patients (
Figure
5.5
). The question then arose whether psycho-
logical interventions with the families of schizo-
phrenic patients might have any effect on this.
Family therapy in schizophrenia is based on a
‘psycho-educational’ approach which includes
information about the nature of the disorder, its
treatment, and factors (including EE) which might
modify its course. It appears to have a modest
effect in reducing the risk of relapse in
schizophrenia
8
, although this may not in fact be
directly mediated through a specific effect on EE.
Another important source of family input exists in
the voluntary sector, where groups such as (in the
UK) the National Schizophrenia Fellowship can
be extremely helpful in providing support and
information for the relatives and carers of people
with schizophrenia.
Early intervention
Much interest has recently focused on the
treatment of schizophrenia early in the first
episode of illness. The impetus behind this is
preventative: many studies have shown a mean
duration of untreated psychosis of the order of
one year. Underlying this is a bimodal distribution:
people with florid psychosis often present fairly
rapidly, particularly if their symptoms bring them
into conflict with families or wider society, but
others with more insiduously-developing illnesses
can take many years to come to psychiatric atten-
tion. It is argued that the early stages of illness
represent an opportunity for intervention which
may modify its long-term course and minimize
the degree of residual disability
9
. For early inter-
vention to succeed, the repertoire of psychosocial
interventions in schizophrenia must include
public education, improving referral pathways
from primary care, and challenging stigmatizing
and discriminatory attitudes to people with
Total (n = 128)
30%
High (n = 57)
51%
More than
35 hours
69%
Less than
35 hours
28%
Low (n = 71)
13%
Nil
15%
Full
12%
Nil
92%
Full
53%
Nil
42%
Full
15%
Emotional
expression
Weekly
contact
Drug
maintenance
EXPRESSED EMOTION IN SCHIZOPHRENIA
Figure 5.5
This figure shows the
results of a trial of maintenance
antipsychotics in patients
divided according to whether
their families showed high
expressed emotion (EE) or not.
The degree of EE in families
predicts relapse in patients with
schizophrenia who are not
taking antipsychotic drugs, and
who are in contact with their
familites for more than 35 hours
each week
©2002 CRC Press LLC
schizophrenia which act as disincentives to early
referral and treatment.
Managing schizophrenia in the
community
The move toward treating people with schizo-
phrenia in the community (
Figures 1.15
and
5.6
)
was made possible (both clinically and politically),
from the 1950s onwards, by the introduction of
effective antipsychotic drugs. The purpose of this
was to give patients with psychosis a better quality
of life, and there is no doubt that patients gener-
ally prefer to be treated in their own home rather
than in hospital (
Figure 5.7
). However, since drug
treatment was so crucial to the move towards
community care, the delivery and monitoring of
medication became a major preoccupation of the
organizational systems that developed to support
it. A second priority, intermittently reinforced by
clinical scandal and catastrophe, has been the
assessment and management of the risks, both
perceived and real, associated with the shift of
care away from the relatively secure and contained
environment of the hospital ward. Thirdly, the
new community mental health teams needed to
lubricate the interactions between their ill and
sometimes institutionalized patients and the
complex bureaucracies – housing, social security,
the judicial system, employers – of the outside
world. However, none of this should distract us
from the objective of delivering better care, and
the awareness that good care involves more than
simply drug treatment.
Figure 5.6
Despite the policy of care in the community there was a rise in total admissions between 1984 and 1996,
and a rise in the proportion of compulsory admissions. A combination of increased prevalence of comorbid drug
misuse, reductions in available bed numbers (a reduction of 43 000 in the UK between 1982 and 1992), and
changes in the thresholds for admission and discharge, has meant that patients are more severely ill before
admission, and services are under greater pressure, leading to a paradoxical increase in the use of compulsory
detention. (Bars represent the total number of compulsory psychiatric admissions to NHS facilities and the line
represents the proportion of all admissions that were compulsory in England, 1984–96. Data on compulsory
admissions not available for 1987–89). Figure reproduced with permission from Wall S, Hotopf M, Wessely S,
Churchill R. Trends in the use of the Mental Health Act, England 1984–1996.
Br Med J
1999;318:1520–1
0.14
0.12
0.02
1984
1985
1986
1987–8 1988–91989–90 1990–1 1991–2 1992–3 1993–4 1994–5 1995–6 1996–7
0.04
0.06
0.08
0.10
0
30,000
25,000
5000
10,000
15,000
20,000
0
COMPULSORY PSYCHIATRIC ADMISSIONS
IN ENGLAND: 1984–1996
P
roportion of all admissions
that we
re compulsory
T
otal compulsory admissions
Year of admission
©2002 CRC Press LLC
0%
20% 40%
Percentage of doctors
60%
80% 100%
Switzerland
Sweden
Denmark
Netherlands
Spain
Italy
Germany
France
UK
adequate poor
ASSESSMENT OF CARE IN THE COMMUNITY
Figure 5.8
An international
study of pyschiatrists’
attitudes to community
care. Note that the
countries in which
psychiatrists have the most
positive attitudes, Switzer-
land, Denmark, The
Netherlands and Germany,
have the highest per capita
spending on mental health
services
Figure 5.7
Prior to the
1950s and the
introduction of effective
antipsychotic treatment,
most patients with schizo-
phrenia would have been
institutionalized in large-
scale psychiatric hospitals.
This painting from 1843
shows one such hospital in
Gartnavel, Glasgow, UK
©2002 CRC Press LLC
Various models have evolved in the face of
these demands. These are mostly based on
variations of ‘case management’, in which mental
health workers take responsibility for the plann-
ing, co-ordination, review, and to varying extents
the delivery of care ‘packages’ to individual
patients. In practise, most services organized on
these principles have developed eclectic and
pragmatic ways of working, which have proved at
least as effective as more hospital-based models of
clinical care
10
. The formal models differ in their
specifics, for example in the precise role of the
keyworker, caseload, organizational philosophy,
and specialist functions, such as assertive outreach
and crisis intervention. The benefit of one
approach over any other remains a matter of
debate (see for example reference 11). In any
event, such organizational models should not be
confused with treatments, and their clinical
impact on specific symptoms is likely to be
indirect and less pronounced than their effect on
more general social variables such as housing
stability. Comparisons between different approac-
hes to the organization of community psychiatric
care are made more difficult by wide variations
internationally in clinical practice and in resour-
ces, and there are wide international differences in
the extent to which community care is regarded as
a successful policy (
Figure 5.8
)
14
.
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Wall S, Hotopf M, Wessely S, Churchill R. Trends in
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Smith-Latten, Grimdy S. Survey of European
Psychiatrists. London: Martin Hamlyn