Anthony Lehman, M.D., picked a tough audience for reiterating the findings of a major evaluation of treatment options for schizophrenia. Speaking at the annual meeting of the U.S. chapter of the International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses last month in Washington, D.C., Lehman said that treatment should combine the use of antipsychotic medications, treatment for comorbid depression, and—yes—psychotherapy. Lehman is chair of the department of psychiatry at the University of Maryland School of Medicine.

However, said Lehman, these findings, contained in the 1998 Patient Outcomes Research Team (PORT) report on schizophrenia, also explicitly recommended that "individual and group psychotherapies adhering to a psychodynamic model—defined as therapies that use interpretation of unconscious materials and focus on transference and regression—should not be used in treatment of persons with schizophrenia."

There was no evidence from good clinical trials of psychodynamic psychotherapy that showed improved outcomes, said Lehman, who chaired the PORT group, and the expert panel believed it could be harmful to patients with schizophrenia. In addition, he said, since families were not part of the etiology of the illness, they should not be burdened with "needless guilt."

Another speaker, Wilfried ver Eecke, Ph.D., of the department of philosophy at Georgetown University in Washington, D.C., countered that PORT, while correct in trying to avoid guilt, was wrong to exclude a parental role in the etiology of the disease. He agreed with the psychoanalyst Jacques Lacan, M.D., that people with schizophrenia have a defective relation with language and cited Finnish adoption studies pointing to communication deviance from parents to children and vice versa. Ver Eecke also said that techniques used in classical psychoanalysis for neurotic patients had to be adapted for treating schizophrenic patients.

Schizophrenia, said Lehman, probably originates as a polygenic genetic vulnerability, followed by contributing factors like a viral infection in the second trimester, maternal malnourishment during gestation, or low levels of oxygen at birth. The disease then appears in adolescence and derails the life plans and dreams of young people. It produces such a sense of hopelessness and despair that 10 percent of all patients commit suicide within 10 years of onset.

"What can we do from a psychological standpoint to help these people?," asked Lehman. The PORT committee examined the role of antipsychotic medications, psychological treatments, rehabilitation, somatic therapies (including anticonvulsives and lobotomy), and family therapy. Their conclusions, reported in the January-March, 1998, Schizophrenia Bulletin, recommended the combined use of antipsychotic medications, treatment for comorbid depression, and psychotherapy to help patients understand their illness and find ways of coping with it.

The PORT study looked at a wide range of previous research covering the origins, diagnosis, and treatments for schizophrenia and then sought how to bring actual practice in line with evidence-based practices. It was funded by the federal Agency for Health Care Policy and Research and the National Institute of Mental Health. Other conditions that were studied in similar PORT projects were ischemic heart disease, back pain, diabetes, pneumonia, childbirth, stroke, breast cancer, and depression.

Lehman made special note of the work of Gerald Hogarty, M.S.W., a professor of psychiatry at the University of Pittsburgh School of Medicine, who has recommended a long-term, three-phase intervention along with medications. He randomized 300 patients, all of whom were on antipsychotic medications, to drugs alone or drugs with what he termed "personal therapy." At one year there was no difference, but after three years, relapse rates had been cut in half for patients using the combination therapy.

Hogarty’s treatment plan begins by trying to demystify schizophrenia to patients, explaining that it is a brain disorder that can be helped by medication. Hogarty then suggests an educational regimen in which the patient learns about day-to-day coping and how to recognize the early warning signs of relapse. He explains how important taking medications is. The third phase is long-term psychotherapy to help deal with the despair and hopelessness that patients experience. It is important for patients to talk about and deal with their views of the self, he noted.

Other kinds of therapy have proved useful too. In Hogarty’s study, family intervention helped reduce the risk of rehospitalization, said Lehman. Multifamily group therapy decreased relapse rates from 70 percent to 55 percent compared with single-family groups, possibly because families benefited from a reduced sense of isolation. (Multifamily groups were also less expensive to conduct, said Lehman.)

Another approach uses self-contained, assertive community treatment teams to substitute outpatient treatment for inpatient care. Members of the team—a combination of psychiatrists, psychologists, and social workers—collaborate to provide clinical treatment and rehabilitation, and help the patient build relationships with family and community. The result cuts time in the hospital, in jail, and on the street. Cost are reduced by 25 percent as well.

Unfortunately, he said, under 10 percent of patients get such family intervention, and other barriers to treatment still must be overcome. There are wide regional variations in psychosocial interventions, for instance. One state might promote family rehabilitation, while another concentrates on vocational services. More significantly, there are low rates of treatment for almost every sort of psychosocial intervention. Less than 50 percent of patients get any psychological help; only 10 percent get family therapy; 25 percent get vocational assistance; and only 25 percent to 33 percent even get case management, said Lehman.

"In addition," he said, "providers often don’t know about many current techniques or community support programs, and many providers don’t believe they’ll work anyway. Treatment models are complex and can’t be learned in an evening or weekend. Bad prior experiences may reduce credibility with patients and family." By "bad experiences," he was referring to previous therapists who may believe that parents are responsible for the development of schizophrenia or caregivers who provide little more than adult day care.

Costs are another issue. They are perceived as high, but some interventions, like multifamily group therapy, costs only $200 a year for each patient, and overall cost-effectiveness is quite good, said Lehman. Unlike drug therapies, there is little profit motive: "There’s not a lot of money to be made in psychosocial interventions," said Lehman, "and managed care will pay for drugs but not long-term treatment."

Finally, said Lehman, the impact of any therapy is still modest. Most people with schizophrenia, he said, still aren’t doing very well. The best hope in the future lies in early detection and treatment, identifying at-risk adolescents, and educating and supporting them to prepare them for what they may face. The ultimate goal should be recovery, rather than mere maintenance, he said.