Psychotherapy in schizophrenia and affective disorder

Head: Annette Schaub, Clinical Psychologist, Private Lecturer in Clinical Psychology and Psychotherapy

This working group focuses on research and treatment in psychiatric disorders, the development and evaluation of group interventions in schizophrenia, major depression and bipolar disorders as well as the integration of relatives in the treatment setting. Treatment strategies that view individuals as capable of taking an active role in managing their illness have gained importance in Europe and the United States over the last 25 years. Psychoeducational and cognitive behavioral group treatment programs are of great importance in this hospital.

Studies that compare neuropsychological functioning in inpatients with mood disorder or schizophrenia come to heterogeneous results (Schaub, Neubauer, Mueser et al. 2013a). Although the total scores of psychopathological symptoms in the Brief Psychiatric Rating Scale - Expanded (BPRS-E) and the Global Assessment Functioning Scale (GAF) were comparable in our study there were significant differences in most of the subscales. Patients with depressive disorder showed significantly better results in verbal and visual short-term memory, verbal fluency, visual-motor coordination, information processing in visual-verbal functioning and attention compared to patients with schizophrenia, however, there were no significant differences in abstract verbal reasoning, general verbal abstraction, spatial-figural functioning and visual perceptual speed of cognitive processing. These results show that despite comparable total scores in BPRS-E and GAF there are significant differences in most BPRS-R subscales in patients with affective disorders or schizophrenia as well as different neuropsychological test profiles in the post-acute stage of their illness. Patients with schizophrenia showed lower cognitive functioning compared to patients with mood disorder, however, they could also benefit from illness management programmes if these were to compensate the patients’ cognitive deficits.

Implementing psychoeducational programs was the first step to establish cognitive behavioral psychotherapy and to dispel the myth of schizophrenia for patients (Schaub, Hippius, Möller, Falkai, 2016). Group programs are provided for patients with mood disorder (Schaub, Roth, Goldmann, 2013b, Schaub, Benhard, Gauck, 2004) or schizophrenia (Schaub 2008) and their relatives. These groups include topics such as psychoeducation about the illness, establishing rewarding activities, stress management, cognitive therapy, and relapse prevention. Five wards offer different group treatment programs: B2 = patients with schizophrenia, C1 = affective disorders, C3 = acute psychiatry, D1 = adolescents, D2= older (>65 years) patients. There are psychoeducational groups for relatives (Schaub, Roth and Goldman, 2013b) as well as for patients’ children (Schaub und Frank 2010).

More than 1000 patients with schizophrenia or mood disorders (380 schizophrenia, 563 major depression, and 110 bipolar) have participated in illness management groups to learn about their illness and its treatment, and to learn skills to manage their illness (Schaub, Hippius, Möller, Falkai 2016a). Patients have expressed satisfaction with the programs, and research has supported their effectiveness. Individuals with severe disorders can benefit from psychoeducational and cognitive treatment programs if the programs are adapted to the level of neuropsychological functioning and compensate for cognitive deficits and emotional overload. These findings suggest that providing information about the illness and coping skills for patients and relatives are important.

Over the past 30 years, illness management programs and cognitive-behavioral therapy for psychosis have gained prominence in the treatment of schizophrenia. We investigated the long-term benefits of these programs when delivered during inpatient treatment following a symptom exacerbation. To evaluate this question, we conducted a randomized controlled trial comparing the long-term effects of a group-based coping-oriented program (COP) that combined the elements of illness management with cognitive behavioral-therapy for psychosis, with an equally intensive supportive therapy (SUP) program (Schaub, Mueser, von Werder 2016b). 196 inpatients with DSM-IV schizophrenia were randomized to COP or SUP, each lasting 12 sessions provided over 6–8 weeks. Outcome measures were collected in the hospital at baseline and post-assessment, and following discharge into the community 1 and 2 years later. We compared the groups on rehospitalizations, symptoms, psychosocial functioning, and knowledge about psychosis. Intent-to-treat analyses indicated that patients in COP learned significantly more information about psychosis, and had greater reductions in overall symptoms and depression/anxiety over the treatment and follow-up period than patients in SUP. Patients in both groups improved significantly in other symptoms and psychosocial functioning. There were no differences between the groups in hospitalization rates, which were low. People with schizophrenia can benefit from short-term COPs delivered during the inpatient phase, with improvements sustaining for 2 years following discharge from the hospital. More research is needed to evaluate the long-term impact of coping-oriented and similar programs provided during

Neuropsychological functioning turns out to be a rate-limiting factor in psychiatry. However, little is known when comparing neuropsychological and psychosocial functioning in inpatients with schizophrenia or severe depression in their treatment pathways including add-on psychoeducation or the latter combined with cognitive behavioral therapy up to 2-year follow-up. To evaluate this question, we investigated these variables in two randomized controlled trials including 196 patients with DSM-IV schizophrenia and 177 patients with major depression (Schaub, Goerigk, Mueser et al. 2020). Outcome measures were assessed in the hospital at pre- and posttreatment and following discharge until 2-year follow-up. We focused on neuropsychological and psyc hosocial functioning regarding its differences and changes over time in data of two pooled trials. There were significant time effects indicating gains in knowledge about the illness, short and medium-term memory (VLMT) and psychosocial functioning (GAF), however, the latter was the only variable showing a time x study/diagnosis interaction effect at 2-year follow-up, showing significant better outcome in depression compared to schizophrenia. Moderator analysis showed no changes in psychosocial and neuropsychological functioning in schizophrenia and in affective disorders due to age, duration of illness or sex. Looking at the rehospitalisation rates there were no significant differences between both disorders. Both groups treat ed with psychoeducation or a combination of psychoeducation and CBT improved in neuropsychological and psychosocial functioning as well as knowledge about the illness at 2-year follow-up, however, patients with major depression showed greater gains in psychosocial functioning compared to patients with schizophrenia. Possible implications of these findings were discussed.

Quintessence: Individuals with severe disorders can benefit from psychoeducational and cognitive treatment programs if the programs are adapted to the level of neuropsychological functioning and compensate for cognitive deficits and emotional overload. These findings suggest that providing information about the illness and coping skills for patients and relatives are important for treatment outcome.