Seventy studies met the inclusion criteria for the review. Most studies utilised controlled designs (N=61) and either randomised patients to a single treatment modality versus standard care, or to differing approaches within the same general modality, e.g. supportive versus psychodynamic group therapy (N=55). Four studies compared treatment modalities, e.g. family versus individual, while 11 examined combinations of interventions, e.g. group plus individual plus family. The total number of participants was not stated.
Group therapy.
Traditional social skills training (SST) has demonstrated efficacy in a narrow range of specific communication skills. However, the failure of these skills to generalise to improved social functioning and marginal support for improvement in symptoms, suggests that such training may have limited clinical efficacy. The broad approach to SST, in combination with the teaching of specific instrumental skills offered by the UCLA Social and Independent Living Skills (SILS) modules, suggests that schizophrenic patients are capable of learning specific skills related to enhancing social functioning. Moreover, SILS training may produce better outcomes than less structured, process or discussion therapies.
Family therapy.
Family therapy clearly augments pharmacotherapies with schizophrenic patients to result in symptomatic improvement, improved social and vocational functioning, and reduced relapse. In addition, these treatments may limit re-hospitalisation and enhance medication compliance. The benefits of multiple- versus single-family therapy and differences in theoretical orientation are small. An important caveat to these conclusions is that many of the studies only examined patients from high expressed emotion families, and 78% required as a study inclusion criterion that patients live with a relative or have regular contact. Such treatments may, therefore, not generalise to patients who live separate from their family. More studies are needed to address these questions.
Individual therapy.
Studies of individual therapy found that both medication knowledge and treatment compliance improved significantly with a medication education intervention, compared with standard care, although symptoms and re-hospitalisation were not reduced. Significant symptomatic improvement was found in studies of individual psychotherapy, two of which utilised a cognitive-behavioural therapy intervention. A dynamic therapy intervention showed reduced hospitalisation and improved social and vocational functioning. Better vocational functioning was found after supportive versus insight-oriented therapy.
Comparisons between treatment modalities.
Group, family or individual therapy added to pharmacological treatments can augment the benefits of pharmacotherapy alone. These results are most compelling for family therapy, suggesting that they may be more effective than group or individual therapy with schizophrenic patients. However, to draw this conclusion, family therapy must be compared experimentally with alternative psychosocial treatments.
Combinations of treatment modalities.
Overall, it appears that combining psychosocial treatments may yield better outcomes than monotherapy when the components of treatment have independently demonstrated clinical efficacy. However, such effects may be time limited.