Summary

There is a growing interest in evidence based studies on the efficacy of psychotherapy that has led to the formation of task forces to define, identify, and disseminate information about empirically supported psychological interventions.
Current data do not support the use of psychodynamic psychotherapy techniques for hospitalised people with schizophrenia. However the several structured studies that have been carried out showed that dynamic community meetings had the effect of reducing unfavorable ward incidents, in particular incidents with an aggressive character
A modification of CBT "Assertive Community Treatment (ACT)"has been shown to facilitate that patients remain in contact with services. In terms of clinical and social outcome, significant and robust differences between ACT and standard community care were found on some socials variables but not on mental state or social functioning or quality of life.
Psychoeducation significantly reduces relapse in schizophrenic patients and improve compliance to treatment . The so called Personal therapy improves social adjustment but can increase the rate of psychotic relapse for some patients living independently of their families.
Family intervention may decrease hospitalisation and encourage compliance with medication but does not obviously effect the tendency of individuals/families to drop out of care. It may improve general social impairment and the levels of expressed emotion within the family.

As for prevention measures it seems that even if the early detection and treatment of early signs appears to confer protection from relapse, the active ingredients of the pharmacological and psychological based treatment studies are as yet unclear
On the other hand, many psychiatrists have reservations about the evidence-based medicine' approach because of perceived limitations in methodology gaps in interpreting the available evidence and neglect of individual patient uniqueness in quantitative research thru manualized treatment procedures.

Key Words:

Evidence-based interventions. Schizophrenia

Resumen

En conjunto, Las estrategias de prevención precoz de la esquizofrenia parecen proteger de recaídas aunque no está claro todavía la influencia respectiva de los ingredientes psicoterápicos y medicamentosos.
No está claro que los tratamientos de entrenamiento de la atención sean útiles y otros tratamientos cognitivos todavía no ofrecen tampoco datos concluyentes según dos informes Cochrane.
La terapia psicológica integrada (IPT) realitada por Volker y basada en los trabajos de Brenner y la "Terapia de mejoría cognitive" (CRT) parecen útiles pero los resultados son variables.
El Assertive Community Treatment (ACT) parece útil para mantener en la Comunidad a pacientes graves , reduciendo los costes, según un informe Cochrane. Por el contrario, en otro informe de lmismo autor el case management aumenta el número de hospitalizaciones, no mejora el estado clínico y es más costoso que un tratamento habitual.
La terapia familiar y mejor aún la multifamiliar parecen eficaces en disminuir las recaídas.
Los tratamientos de intervención en crisis alternativos a la hospitalización son dificiles de evaluar según un informe Cochrane.
El tratamiento con equipos comunitarios (community mental health team (CMHT))parace asociarse con menos muertes por suicidio y con mayor satisfacción de los pacientes, aunque no hay pruebas de que se logre disminuir los ingresos, ni la duración de la hospitalización, según un informe Cochrane.
La nomenclatura sobre centros y hospitales de día para enfermos graves es imprecisa y no hay estudios randomizados respecto a su eficacia, excepto un estudio que parece sugerir mayor eficacia que el tratamiento ambulatorio y la impresión de que son más caros que el tratamiento habitual.
No hay estudios controlados sobre la eficacia de la psicopterapia psicoanalítica en enfermedades psiquiátricas graves y, en concreto, en pacientes esquizofrénicos hospitalizados.
Las intervenciones familiares destinadas a disminuir la emoción expresada tal vez disminuyan las recaídas y mejoren la cumplimentación, pero los datos no son concluyentes según un estudio Cochrane. Los resultados de los programas educacionales para adquirir habilidades de la vida independiente no tienen eficacia probada y pueden crear problemas éticos.
Hay pruebas, según un estudio Cochrane de que los abordajes psicoeducativos son útiles y eficaces en cuanto al costo en esquizofrénicos
Las hospitalizaciones planificadas como cortas no provocan más fenómenos de puerta batiente y no empeoran el seguimiento de los pacientes esquizofrénnicos,según un informe Cochrane
No está claro que la economía de fichas tenga efectos clínicos significativos en esquizofrénicos según un informe Cochrane. El trabajo protegido es más útil que la rehabilitación vocacional en esquizofrénicos según un informe Cochrane.

In spite of all the efforts made to avoid it, schizophrenic deterioration is frequent; it is not only a difficulty on an intellectual level, but also a lack of interest and energy that lead the patient to avoid the efforts of everyday life. Under the name of "absence of social competence", a series of characteristics has been described which make the chronic schizophrenic less able to live in the community, at least in Western society.
Among the most important factors aggravating social ineptitude, the role played by hospitalisation has been widely discussed (Guimón & Ozamiz, 1982; Guimón, Villasana, Totorika, & Ozamiz, 1981). Therefore, some authors tend to differentiate between the concepts of clinical remission and social remission (Brouwn, Monck, Carstairs, & Wing, 1958; Seva Diaz, 1979).
In this paper we will first review the efficacy of different psychosocial approaches have been proposed for the management of "social incompetence" and relapses in these patients. Then we will discuss the scope and limits of the concept of "evidence based studies" when applied to these interventions.

1. THE EFFICACY OF INDIVIDUAL PSYCHOTHERAPY

1.1.Psychoanalytically oriented psychotherapy

Psychoanalytically oriented psychotherapy has, until recently, been shown to be of only slight utility in schizophrenia, except in a subgroup of patients with sufficient ego strength, and who remain as inpatients for long periods in special therapeutic settings. However, there is a general consensus that a dynamic understanding of the patient's psychopathology and relationships with family and social networks could be very helpful (Fenton & Schooler, 2000). On the other hand, a recent, randomised study showed that analytical psychotherapy could produce improvement in the social and professional functioning of some schizophrenics that was unattainable any other way (Hogarty, Kornblith, & Greenwald, 1997).

Gabbard (Gabbard, 1995) proposes some general guidelines for psychotherapy with schizophrenia: the main goal should be to establish a relationship; flexibility is necessary regarding therapeutic approach and content; an optimal distance between the therapist and the patient should be established; the therapist must create a setting (holding) that serves as a 'container'; he should set himself up as an 'auxiliary ego', showing himself to be open, respectful, and candid; and he should postpone making any kind of interpretation until a good relationship has been established.

However, Malmberg et al (Malmberg & Fenton, 2002) reviewing the effects of individual psychodynamic psychotherapy for people with schizophrenia conclude that, although the psychodynamic approach may be more acceptable to people than a more cognitive reality-adaptive therapy, current data do not support the use of psychodynamic psychotherapy techniques for hospitalised people with schizophrenia.

1.2.Cognitive behavioural interventions

As Roder et al (Roder, Zorn, Muller, & Brenner, 2001) propose, we have seen three eras in the development and refinement of social skills training for individuals with schizophrenia. In the 1960s, skills training relied on the use of operant conditioning, as exemplified by the token economy, which is still used to motivate anergic individuals to participate actively in community-based programs.

In the 1970s, social learning was introduced to improve nonverbal skills, as well as conversational skills, assertiveness, and emotional expressiveness. Tsang (2001) proposes that a social skills training module together with appropriate professional support afterward is effective in enhancing the social competence and vocational outcomes of persons with schizophrenia.

In the third and current era, cognitive methods for training social and independent living skills (Liberman, 1986) and techniques to improve attention, memory, and verbal learning have been introduced. Thanks to better knowledge of deficit symptoms, it has been observed that even simple learning activities are often difficult, due to certain patients' cognitive deficits. Therefore, it has been decided to improve this deficit with cognitive rehabilitation modules. Thus Hans Brenner (Brenner & Pfammatter, 2000), Roder, and other authors have developed an integrated psychological therapy (IPT) addressing deficits in the residential, vocational, and recreational domains of community functioning and they propose that is more effective than other psychosocial treatments, such as supportive group therapy and pure behavioural methods. However, Suslow et al (Suslow, Schonauer, & Arolt, 2001) reviewing the literature on training on attentional functioning contend that there is inconclusive evidence that attention training is effective in schizophrenia.

In a Cochrane review, Nicol et al (Nicol, Robertson, & Connaughton, 2002) evaluate all relevant randomised or quasi-randomised controlled trials on life skills programmes and consider that data are sparse and that no clear effects were demonstrated, concluding that " if life skills training is to continue as part of rehabilitation programmes a large, well designed, conducted and reported pragmatic randomised trial is an urgent necessity. There may even be an argument for stating that maintenance of current practice, outside of a randomised trial, is unethical". In another Cochrane study, Cormac et al (Cormac, Jones, & Campbell, 2002) review the effectiveness of cognitive behavioural therapy for people with schizophrenia, and conclude that it did not significantly reduce the rate of relapse and readmission to hospital when compared with standard care alone. A significant difference was observed, however, favouring cognitive behavioural therapy over standard care alone, in terms of being able to be discharged from hospital but after one year the difference was no longer significant. A cognitive behavioural therapy approach focusing on compliance may have some effects on insight and attitudes to medication, but the clinical meaning of these data is unclear. When compared with supportive psychotherapy, cognitive behavioural therapy had no effects on relapse rate and clinically meaningful improvements in mental state.

A modification of CBT "Assertive Community Treatment (ACT)"has been shown in a Cochrane review (Marshall & Lockwood, 2002)to facilitate that patients remain in contact with services. People allocated to ACT were less likely to be admitted to hospital than those receiving standard community care and spent less time in hospital. In terms of clinical and social outcome, significant and robust differences between ACT and standard community care were found on some socials variables but not on mental state or social functioning or quality of life.

Present evidence suggests that case management increases health care costs, perhaps substantially, although this is not certain. In summary, thy say, " case management is an intervention of questionable value, to the extent that it is doubtful whether it should be offered by community psychiatric services. It is hard to see how policy makers who subscribe to an evidence-based approach can justify retaining case management as 'the cornerstone' of community mental health care.

1.3. Psycoeducational techniques.

Psycoeducational techniques enhance medication compliance including attitudes to treatment, substance misuse and insight (Thornicroft , 2001). Thus, Amenson and Liberman (Amenson & Liberman, 2001) underline the need of overcoming the barriers to the incorporation of family psychoeducation into the routine care provided at community mental health.

However, in a Cochane review, Henderson et al (Henderson & Laugharne, 2002) warn about the need of a tactful information of the patients because it cannot be assumed that patient-held information is beneficial or cost-effective without evidence from well planned, conducted and reported randomised trials, still lacking.

In any case, it seems that psychoeducation (Pekkala et al., 2002) significantly reduces relapse in schizophrenic patients and improve compliance to treatment.