Talk Therapy Found to Ease Schizophrenia

NY Times  More than two million people in the United States have a diagnosis of schizophrenia, and the treatment for most of them mainly involves strong doses of antipsychotic drugs that blunt hallucinations and delusions but can come with unbearable side effects, like severe weight gain or debilitating tremors.

Now, results of a landmark government-funded study call that approach into question. The findings, from by far the most rigorous trial to date conducted in the United States, concluded that schizophrenia patients who received smaller doses of antipsychotic medication and a bigger emphasis on one-on-one talk therapy and family support made greater strides in recovery over the first two years of treatment than patients who got the usual drug-focused care.

The report, to be published on Tuesday in The American Journal of Psychiatry and funded by the National Institute of Mental Health, comes as Congress debates mental health reform and as interest in the effectiveness of treatments grows amid a debate over the possible role of mental illness in mass shootings.

Its findings have already trickled out to government agencies: On Friday, the Centers for Medicare & Medicaid Services published in its influential guidelines a strong endorsement of the combined-therapy approach. Mental health reform bills now being circulated in Congress “mention the study by name,” said Dr. Robert K. Heinssen, the director of services and intervention research at the centers, who oversaw the research.[...]

Experts said the findings could help set a new standard of care in an area of medicine that many consider woefully inadequate: the management of so-called first episode psychosis, that first break with reality in which patients (usually people in their late teens or early 20s) become afraid and deeply suspicious. The sooner people started the combined treatment after that first episode, the better they did, the study found. The average time between the first episode and receiving medical care — for those who do get it — is currently about a year and half.[...]

The more holistic approach that the study tested is based in part on programs in Australia, Scandinavia and elsewhere that have improved patients’ lives in those countries for decades. This study is the first test of the approach in this country — in the “real world” as researchers described it, meaning delivered through the existing infrastructure, by community mental health centers.[...]

In the new study, doctors used the medications as part of a package of treatments and worked to keep the doses as low as possible — in some cases 50 percent lower — minimizing their bad effects. The sprawling research team, led by Dr. John M. Kane, chairman of the psychiatry department at Hofstra North Shore-LIJ School of Medicine, randomly assigned 34 community care clinics in 21 states to provide either treatment as usual, or the combined package.

The team trained staff members at the selected clinics to deliver that package, and it included three elements in addition to the medication. First, help with work or school such as assistance in deciding which classes or opportunities are most appropriate, given a person’s symptoms. Second, education for family members to increase their understanding of the disorder. And finally, one-on-one talk therapy in which the person with the diagnosis learns tools to build social relationships, reduce substance use and help manage the symptoms, which include mood problems as well as hallucinations and delusions.

For example, some patients can learn to defuse the voices in their head — depending on the severity of the episode — by ignoring them or talking back. The team recruited 404 people with first-episode psychosis, mostly diagnosed in their late teens or 20s. About half got the combined approach and half received treatment as usual. Clinicians monitored both groups using standardized checklists that rate symptom severity and quality of life, like whether a person is working, and how well he or she is getting along with family members.

The group that started on the combined treatment scored, on average, more poorly on both measures at the beginning of the trial. Over two years, both groups showed steady improvement. But by the end, those who had been in the combined program had more symptom relief, and were functioning better as well. They had also been on drug doses that were 20 percent to 50 percent lower, Dr. Kane said.[...]