SUMMARY

In this article the efficacy of different group approaches that have been proposed for the management of psychiatric patients is reviewed.
There are few studies regarding group therapy with patients with anxiety disorders,but cognitive-behavioural techniques show positive results
Campaign to inform the public of the early signs of schizophrenia, aimed at increasing early intervention and reduced the duration of untreated . Some integrated model of early treatment of schizophrenia (primarily psychotherapeutic and dynamic-systemic approaches), working intensely with families showed successful results.
The relatively few controlled trials of group psychotherapy in the rehabilitation of schizophrenic patients present major methodological problems. The results seem to be better than those obtained with individual psychotherapy. A dynamic understanding of the patient's psychopathology and relationships with family and social networks could be very helpful. An reviewed of 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. Psychoeducational techniques enhance medication compliance including attitudes to treatment . Family therapy has been useful for treating the patient in his own environment, and reducing relapse
Good results have been in outpatients suffering from major depression assigned to cognitive-behavioural and psychoeducational group therapy. Dynamic group therapy improved compliance with medication in bipolar patients.
Groups are largely used throughout the world for patients who abuse substances, or in outpatient, halfway programmes, or in hospitals for short or medium stays.
Significant, positive results have been found with Linehan's cognitive-behavioural groups approach in borderline patients. Favourable results have been found with treatment based on group dynamic psychotherapy in a day hospital.
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RESUMEN

Los tratamientos grupales cognitivos-conductuales reducen la utilización de la hospitalización y favorecen la estabildad y la vida independinte en la comunidad de determinados pacientes esquizofrénicos seleccionados. Los tratamientos psicoeducativos, especialmente si incluyen a la familia, se han mostrado también eficaces.
Los pacientes depresivos han sido tratados con éxito en grupos de orientación cognitiva, interpersonal y psicodinámica. Los grupos en pacientes bipolares mejoran el cumplimiento y la evolución de estos pacientes.
En el futuro es probable que se generalicen programas en hospitales de día para los trastornos de personalidad, con orientación mixta dinámica y cogntivo-comportamental.
Los tratamientos grupales son útiles para pacientes con problemas de abuso de substancias, en especial cuando se realizan en programas de comunidad terapéutica.

PALABRAS CLAVE

Basado en la evidencia, terapia grupal

KEY WORDS

Evidence-based, group therapy

In this article we will first review the efficacy of different group approaches that have been proposed for the management of psychiatric patients.

GENERAL RESULTS

Hager et al (Hager et al., 2000) say that two types of evaluation can be distinguished: "comparative" and "non-comparative" evaluation studies. A question concerning the non-comparative or "isolated" efficacy studies of a therapy is that they cannot simultaneously serve to answer the question concerning the relative efficacy of two or more therapies aiming at the same goals or objectives. The 22 studies which have already been used by Grawe et al. (1994) in their comparisons of behaviour therapies and short-term psychodynamic therapies, are reanalyzed and the Heger contends that it is not possible to draw conclusions about the comparative efficacy of behaviour therapies and short-term psychodynamic therapies due to the fact that the studies have not consequently been planned and executed as comparative evaluations. Only amelioration of the 22 studies can be regarded--with certain restrictions--as comparative outcome studies with respect to amelioration of certain symptoms. A further analysis of these studies shows that there is no evidence of a "highly significant"
superiority of behaviour therapies over short-term psychodynamic therapies.
There are few studies regarding group therpy with patients with anxiety disorders. Lubin (Lubin et al., 1998) study the role of group therapy in treatment of posttraumatic stress
disorder (PTSD). They examine the effectiveness of a 16-week trauma-focused, cognitive-behavioral group therapy, named Interactive Psychoeducational Group Therapy, in reducing primary symptoms of PTSD in five groups (N=29) of multiply traumatized women diagnosed with chronic PTSD. At termination, subjects showed significant reductions in all three clusters of PTSD symptoms (i.e., reexperiencing, avoidance, and hyperarousal) and in depressive symptoms; they showed near-significant reductions in general psychiatric and dissociative symptoms, at termination. The use of structured, cognitive-behavioral elements within the group format may allow for more targeted treatment of core symptoms of the disorder.
Another sutdy by van Dam-Baggen (van Dam-Baggen et al., 2000) discuss whether group social skills training (SST) or cognitive-behavioral group therapy (CBT) works best to treat social anxiety in psychiatric patients. It was shown that both SST and CBT were effective in reducing social and general anxiety, decreasing the severity of psychopathology and increasing social skills and self-control. Keeping in mind that this was a quasiexperimental study, the authors concluded that in a clinical setting, group SST may be the best way to treat psychiatric patients with GSP
On the other hand, the use of online support groups is increasing around the world. .Finfgeld (Finfgeld, 2000) underline the advantages and disadvantages these groups made of individuals seeking assistance with problems such as depression, suicidal tendencies, substance abuse, cancer,and eating disorders. Seminal findings suggest that these groups offer some over their traditional face-to-face counterparts; however, they have also been identified many disadvantages
Groups are utlized with people of all ages but there are few contriolled studies on their results.
Asarnow et al (Asarnow et al., 2001) review the literature on psychosocial interventions for depression in youth .
Wood et al.(Wood et al., 2001) compare group therapy with routine care in adolescents who had deliberately harmed themselves. Adolescents who had group therapy wereless likely to be "repeaters" at the end of the study, were less likely to use routine care, had better school attendance, and had a lower rate of behavioral disorder than adolescents given routine care alone. The interventions did not differ, however, in their effects on depression or global outcome.
Brent (Brent et al., 1998) assess the predictors of treatment outcome across treatments, as well as those associated with differential treatment response of adolescent outpatients assigned to one of three manual-based, brief (12 to 16 sessions) psychosocial treatments: cognitive-behavioral therapy (CBT), systemic-behavioral family therapy, or nondirective supportive therapy. Predictors of poor outcome may give clues as to how to boost treatment response. Subjects who come to treatment for clinical trials via advertisement (versus clinical referral) may show more favorable treatment responses. CBT is likely to be a robust intervention even in more complex and difficult-to-treat patients.

SCHIZOPHRENIC PATIENTS

Prevention and early intervention

As I reviewed in the previous issue of this Journal,Group techniques aimed at lessening negative attitudes towards psychopharmacological medication and those that aim to reduce 'expressed emotion' within the family can lower relapses.
Only in recent years has there been interest in early intervention, and a more optimistic attitude, encouraged by the Scandinavian countries and by the International Society for the Psychological Treatment of the Schizophrenias and other Psychoses (ISPS) (Klosterkotter et al., 2001;McGorry, 2001;G. E. Hogarty et al., 1997; Birchwood et al., 2001)

Rehabilitation

Scott and Dixon (Scott et al., 1995), in a review of the literature on the clinical outcomes obtained by support and dynamic psychotherapy (both group and individual) and psychosocial skills training, found that the reality-oriented approaches seem better than insight-oriented dynamic psychotherapy.Among the most important factors aggravating social ineptitude, the role played by hospitalisation has been widely discussed (Guimon, 1982; Guimón et al., 1982;Brouwn et al., 1958; Seva Diaz, 1979).
Gabbard (Gabbard, 1990) proposes some general guidelines for analytic 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 et al., 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.
Group psychotherapy, above all when the therapist actively tries to develop the social abilities and strategies for coping with stress, has been supposed to be useful, especially once florid symptoms are under control. The results seem to be better than those obtained with individual psychotherapy individual, which can be explained by the fact that the group offers socialisation experiences, behavioural models, and a more shared transference which is less dependent on the therapist (Guimon et al., 1983; Guimón et al., 1983; Frankel, 1993)
Durint the last decade, 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 et al., 2000) 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 et al., 2001) reviewing the literature on training on attentional functioning contend that there is inconclusive evidence that attention training is effective in schizophrenia. The so called Integrated Psychological Therapy (IPT),is a group-therapy modality intended to reestablish basic neurocognitive functions (Spaulding et al., 1999) that showed incrementally greater gains compared with controls on the primary outcome measure, the Assessment of Interpersonal Problem-Solving Skills, after a six month intensive trial .However, in two Cochrane reviews, (Nicol et al., 2002;Cormac et al., 2002) consider that data are sparse and that no clear effects were demonstrated.A modification of CBT "Assertive Community Treatment (ACT)"has been shown in a Cochrane review (Marshall et al., 2002) to facilitate that patients remain in contact with service
Psycoeducational techniques enhance medication compliance including attitudes to treatment, substance misuse and insight (G. Thornicroft et al., 2001;menson et al., 2001; Henderson et al., 2002; Pekkala et al., 2002)
Family therapy has been useful for treating the patient in his own environment, and reducing relapse (G Thornicroft et al., 2001;Dixon et al., 2000;McFarlane, 2000;Pharoah et al., 2002;Penn et al., 1999;Leff, 2000).

PATIENTS WITH DEPRESSIVE DISORDERS

Combined therapies

Combining psychotherapy and pharmacotherapy sometimes (but not always) results in better results, and clinical guidelines have been proposed for its correct indications (Segal et al., 2001). In a major clinical trial, 1356 patients with depressive symptoms were enrolled in a randomised controlled trial for depression (Unutzer et al., 2001). Clinics were randomised to usual care or to one of two different quality improvement programmes that involved training local experts, who worked with patients' regular primary care providers (physicians and nurse practitioners) to improve care for depression through patient education assessment, and referral to study-trained psychotherapists. The quality improvement programmes substantially increased the success rates of antidepressant treatment. 16 sessions of Psychodynamic Supportive Psychotherapy in addition to pharmacotherapy produced a significant reduction in personality pathology (mostly in cluster C psychopathology) in depressive patients (Kool et al., 2003).
Several studies (Gitlin, 2001; Miklowitz et al., 2000; Miklowitz et al., 2003; Rothbaum et al., 2000) have reviewed the efficacy of in individual and group (Colom et al., 2003) psycho-education , individual cognitive-behavioural therapy (Lam et al., 2003), marital and family interventions, and individual interpersonal therapy in treatment-resistant bipolar disorder. Family-focused psycho-educational treatment appears to be the most efficacious adjunct to pharmacotherapy for bipolar disorder (Miklowitz et al., 2003).
There is little evidence of the efficacy of suicide-prevention activities, although some general measures (public awareness, optimising primary care, restricting the presentation of suicides in the mass media, and restricting the access to means for suicide) may help (Althaus et al., 2001).

Brief group treatments in depressive patients

In a controlled clinical trial, Piper et al. (Piper et al., 1994; Piper et al., 1996) studied the capacity of seven characteristics of patients to predict their success in an intensive psychodynamic group therapy programme aimed at patients with affective and personality disorders. Among them, two personality characteristics (psychological sophistication and the quality of object relations) were shown to be the strongest success predictors. Recently, specific intensive groups have been aimed at helping to elaborate mourning, obtaining good results.
McCallum et al. (McCallum et al., 1993) compared the results of two dynamically-oriented group therapy programmes, one brief, the other of long duration. Both were aimed at outpatients who presented difficulty in managing personal losses due to death or separation. The post-sessions assessments of positive and negative affect were carried out by the patients themselves, their therapists, and the other patients in their groups. The psychodynamic work was independently assessed, using the content analysis system. Patients who had suffered a separation presented more affective inhibition. Positive affect increased over time, and a direct relationship was found between positive affect and favourable results.
In earlier work along the same lines, Lieberman et al. (Lieberman et al., 1972) created a brief group format -- eight 80-minute sessions -- in which the therapists were particularly aware of the need to discuss, with those undergoing mourning, certain issues, such as the meaning of life and loneliness. Other authors have developed analytical group psychotherapy programmes for depressive patients with or without personality disorders (Rosie et al., 1995). In any case, it is noteworthy that the majority of papers reporting on the results of brief group psychotherapy programmes with depressive patients highlight that the results are more favourable with cognitive techniques or interpersonal therapy than with dynamically-oriented techniques. The interpersonal approach has been used in groups aimed at patients who have had episodes of major depression or dysthimia, but not in bipolar patients, those who suffered from a psychotic depression, or who were considered at risk for suicide.
McKenzie (McKenzie, 1990) explored, in his groups, each patient's type of depression, interpersonal relationships, and the disorder's impact on their lives. The psychotherapy was centred on current and future problems, rather than on past experiences. The 16 sessions lasted 90 minutes each, and no medication was used. No new patients were allowed to join the group after the third session. This format was adapted from Klerman and Weissman (interpersonal therapy, (Klermann et al., 1984) and has been shown to be as effective as cognitive-behavioural therapy, and with perhaps more lasting effects. Interpersonal therapy has been shown to have effects similar to those of antidepressant medication, even in severe cases with marked endogenous symptoms. Interpersonal group therapy is useful for all patients, including those who present a double diagnosis (major depression/dysthimia).
Interpersonal therapy strategies are halfway between psychodynamic therapies and cognitive-behavioural techniques, and focus on relationships and their alteration, using models similar to those of cognitive-behavioural therapy. Different categories of life stress are discussed (loss, mourning, interpersonal disputes, role transitions, loneliness and social isolation). The therapist works more with support techniques than with interpretations, trying to reinforce patients' coping and resource-mobilisation strategies. This model can also be used in a wider range of patients, such as those presenting simultaneously with anxiety disorders and depressive syndromes.
Regarding the cognitive-behavioural approach, Stravynski et al. (Stravynski et al., 1994) reported good results in a study in which outpatients suffering from major depression were assigned to 15-session programme of cognitive-behavioural group therapy.
Bright et al. (Bright et al., 1999) compared the relative efficacy of professional and paraprofessional therapists in providing group cognitive-behavioural therapy and mutual support group therapy, and found clinically significant improvement, although more patients in the professionally-led cognitive-behavioural therapy groups were classified as non-depressed than in the paraprofessionally-led groups.

Groups with bipolar patients

Contrary to the former pessimistic reports in the literature, Graves (Graves, 1993) described a study conducted with bipolar outpatients, showing that dynamic group therapy improved their compliance with medication and lowered their denial mechanisms, facilitating a higher consciousness of internal and external stress factors.
For this type of patients, simple cognitive or psycho-educational techniques have been found to be very effective. Honig et al. (Honig et al., 1997) described a controlled study using a multifamily psycho-educational intervention in bipolar disorder. The parents showed a significant change from a high to a low level of expressed emotion, compared with a control group. In addition, the patients who had parents with a low level of expressed emotion were hospitalised less frequently than those who lived with parents having a high level of expressed emotion. The multifamily groups were well received by the participants, and there were only a few dropouts.
Weiner (Weiner, 1992) showed the positive impact of group therapy on bipolar outpatients who attended at least 12 sessions over the course of a year. Kanas (Kanas, 1993), in a review of the literature, suggested that bipolar patients could be treated in homogenous group therapy programmes, in conjunction with lithium treatment. Interpersonal and psychodynamic techniques were used. The groups' objectives included educating the patients regarding the nature of their illness, helping them to learn how to manage their symptoms, and encouraging them to discuss important interpersonal and psychodynamic issues. To reach these objectives, therapists used techniques that included education and support, facilitating group discussion.