All published studies of Family Interventions have taken place while subjects are receiving appropriate medication. There have been no studies to demonstrate if psychosocial interventions are effective without concomitant use of medication. Some interventions are effective in part because they improve compliance with medication. Psychosocial intervention should not be seen as an alternative to drug treatment and the most effective treatment will make use of a combination of complementary approaches.
|The treatment of individuals with schizophrenia requires a co-ordinated multidisciplinary approach.|
|A Care Plan should be drawn up which specifies all aspects of the care to be provided.|
Throughout all phases of the illness support and encouragement are a standard component of treatment. Individual or group psychotherapy are sometimes considered as a treatment component, but there is no good quality evidence on their effectiveness.
|Care should be taken to avoid overly stressful interventions which may result in worsening of psychotic symptoms.|
Specific interventions are considered below in relation to the phase of the illness. For more detailed discussion of the evidence and references relating to the effectiveness of recommended interventions, see section 2.
The illness can be characterised by three phases that merge into one another without absolute clear boundaries between them:13
During this florid psychotic phase, patients exhibit severe psychotic symptoms such as delusions and/or hallucinations and severely disorganised thinking and are usually unable to care for themselves appropriately. Negative symptoms often become more severe as well.
During this phase, acute psychotic symptoms decrease in severity. This phase may last for six or more months after the onset of an acute episode.
Symptoms are relatively stable and, if present at all, are almost always less severe than in the acute phase. Patients can be asymptomatic, others may manifest non-psychotic symptoms such as tension, anxiety, depression or insomnia.
3.2 Acute phase
3.2.1 SUPPORT AND EDUCATION FOR FAMILIES AND CARERS
A number of randomised studies have demonstrated benefit from involving families and carers in Family Intervention programmes, including the provision of information and education for families and carers. As discussed in section 2, the form of intervention varies between studies, but in each case information was provided by experienced health professionals. Evidence level Ib (see sections 2.1 and 2.2)
|Families and carers should be involved from the outset (with the patients' consent).|
|Once a diagnosis has been established, information should be provided to families and carers on the illness, its aetiology, course, treatment and the services available, including information regarding local and national support groups.|
|Information should be provided by an experienced health professional who is familiar with the concerns and circumstances of the carers/relatives.|
|Information may not be assimilated in one session and repetition may be required.|
3.2.2 PATIENT EDUCATION
An Education Programme for patients may be initiated at this stage but will need to be tailored to the individual's mental state. This may necessitate waiting until the 'stabilisation' phase.
3.2.3 COGNITIVE BEHAVIOUR THERAPY
The addition of Cognitive Behaviour Therapy to standard inpatient treatment has been shown to accelerate recovery and discharge from hospital in one study.32, 33 This important finding requires further clarification before this can be recommended for routine clinical use (see section 2.3).
3.3 Stabilisation phase
As discussed in section 2.1, Education Programmes have been shown to improve patients' knowledge of schizophrenia, compliance with treatment, and satisfaction with services provided. Evidence level Ib (see section 2.1)
|An Education Programme for patients should be undertaken in this phase, giving information on the illness and on the benefits and side effects of medication, which should allow optimal prescribing and hence improve compliance.|
|Information should be skilfully delivered in a way that meets individual needs.|
Education and support for family and carers, if appropriate, would be continued in this phase as part of a Family Intervention programme.
3.3.2 FAMILY INTERVENTION
Family Intervention has been shown to be effective in reducing relapse and admission to hospital when implemented after first episodes of illness or subsequent relapses. 34 Evidence level Ia (see section 2.2)
|Family Intervention Programmes should be implemented in appropriate cases following assessment.|
The programme should include:
|Family Intervention programmes should be integrated with other aspects of care.|
It is important that professional staff involved in Family Intervention programmes adopt a non-judgmental approach when dealing with issues related to 'high expressed emotion.' The aim is to help the family to cope with the illness not to allocate blame for relationship difficulties. The Family Intervention approach is likely to be applicable in settings where there are other carers.35
|Family relationships should be assessed to identify the need for family sessions to address relationship difficulties.|
|A relationship of trust and an explanation of the aims of the programme are essential.|
Families may merit priority where the patient relapses frequently or has been violent, where there is a single parent or where a substantial number of hours of face to face contact occur each week.
The aims of family sessions should include:
Family Intervention Programmes of different length and intensity have been shown to be effective. Brief interventions may not be effective and it has been suggested that programmes should be indefinite in length, but there is no clear evidence on this or on the benefits of repeating a programme.
|The Intervention programme should continue for at least nine months with family sessions at least monthly.|
3.4 Stable phase
3.4.1 FAMILY INTERVENTION
Family Intervention Programmes will continue into this phase. Depending on the extent of recovery, the focus of rehabilitation will be on self care, occupation and leisure activities.
3.4.2 COGNITIVE BEHAVIOUR THERAPY
Cognitive Behaviour Therapy techniques have been demonstrated to produce benefits for some patients at this stage, although their advocates suggest that the potential benefit is greatest when they are used before delusions and behaviour patterns have become established. These techniques are still undergoing modification. Evidence level Ib (see section 2.3)
|Cognitive Behaviour Therapy should be considered for symptoms of psychosis which are distressing and resistant to conventional treatment.|
Cognitive Behaviour Therapy requires further study and treatment should be undertaken where possible as part of a clinical trial designed to define the role of Cognitive Behaviour Therapy more clearly.
3.4.3 EARLY INTERVENTION
The identification of prodromal symptoms which would facilitate an early intervention strategy has been an area of recent interest. The early intervention used in studies completed to date has usually been an adjustment of medication, but the use of early cognitive intervention is under investigation. Reliable identification of prodromal symptoms which predictably lead to relapse has not been demonstrated. Monitoring patients for prodromal and early symptoms is good practice. Families and carers can provide the earliest indication of this.