Secondary Schizophrenia (161 page)

studies (35%)
[22,
32, 36, 37, 39, 41]
showed at least
33.1, and other studies not in Table 33.1 have found

some symptomatic effects that were superior to con-effects on initial engagement in treatment
[55].
Within
trols. These did not always include positive symptoms
the reviewed studies, incentives for participation and
of psychosis and were not necessarily seen over all
assertive follow-up may be masking the true impact
assessment periods. However, there are examples of
of motivational procedures on engagement. Further-controlled trials on similar samples (not included in
more, brief intervention trials do not reflect the impact
Table 33.1
because they did not report on substance
of ongoing motivational components that may be inte-use), which found significant impacts on hospitaliza-grated into longer-term treatments
[56],
because most
tion or forensic outcomes
[48, 49].
Both trials used a
brief intervention studies only had one to three ses-substantial integrated intervention, comparing it with
sions, with no subsequent follow-up reminders. A
either parallel treatment
[49]
or referral for case man-potential effect from brief advice is consistent with the
agement and housing assistance
[48]
. Also absent from
empirical support for this approach in alcohol treat-

Table 33.1
is a randomized controlled trial on first-ments for the general population
[17].
People who can
episode psychosis, where the sample included 27%

make sustained changes in response to brief motiva-with substance-related harm or dependence
[50, 51].

tional interventions may also be the ones who respond
In that study, an integrated assertive community treat-to even less intensive intervention, such as a passing
ment with an offer of multiple family group interven-comment from their doctor.

tion showed superior symptomatic and substance use
The foregoing observations are based on studies
outcomes to standard case management at both 1 and
that include people who have a diagnosis of an inde-2 years post-baseline.

pendent DSM-IV psychotic disorder – that is, one that
Although reviews that also included quasi-

may be exacerbated by substance use but is also present
experimental designs and program evaluations have
when substances are not used. Brief interventions for
suggested a much more positive view of the current
people with psychosis that is clearly secondary to sub-state of treatments in this area
[52, 53],
the random-stance use may well show greater impact, especially
ized controlled trials do not give cause for a high
when other indices of substance disorder severity are
degree of confidence in our ability to make substantial
mild.

differences to the two primary treatment targets in
Greater intensity of case management per se has little
people with psychotic symptoms and substance use.

added effect. Integrated treatment using more intensive
Furthermore, results may well be better for people
and assertive community treatment offers little or no
with psychotic symptoms that are clearly secondary
additional benefit over a similar intervention within
to substance use, although to our knowledge this
less intensive case management
[34, 41, 43, 57].
At
hypothesis has not been examined.

present, it seems that a standard intensity of case man-Despite many limitations to the available data, they
agement may be sufficient.

do now permit some tentative conclusions.

Better outcomes may potentially come from

Brief interventions have limited impact on substance
extended cognitive behavioral therapy (CBT). At
use as stand-alone treatments
[54].
This observation is
present, there are no randomized controlled trials
true of three of four published studies
[20,
39, 40].
It
of extended CBT versus other forms of extended,
is also consistent with an as yet unpublished study by
integrated treatment. Studies with CBT for substance
the first author, which compared a brief motivational
use and psychosis that extend over several months
intervention with a therapist-contact control incorpo-appear to have somewhat stronger outcomes than in
410

rating rapport building, articulation of life goals, and
other studies
[22,
32]
, although the only long-term
Chapter 33 – Nonpharmacological interventions in secondary schizophrenia

follow-up published to date
[58]
suggests that signif-substance use and consolidate natural reinforcers
icant substance use effects may not be maintained.

for positive change

Further refinement of CBT approaches to comorbidity
5. Whether negative attitudes of others toward the
may have significant potential.

person are altered (because these attitudes are
Integrated treatment appears superior. In both the
likely to impact on ability to maintain change, and
randomized controlled trials and in research with less
on risk of symptom recurrence
[66]

rigorous methodology, integrated programs tend to
6. Whether cognitive and other performance

have superior outcomes to nonintegrated controls,
demands at each point in treatment are within the
although findings are mixed
[52, 59].
However, it is not
ability of the patients
[67]
and do not cause
yet clear what features of integrated treatments pro-distress
duce these effects. For example, is it an overall coher-7. Whether treatment strategies maximize impact by
ence and compatibility of treatment, a more flexible
affecting multiple problem areas for the individual
application or modified content of treatment com-8. Whether there is a focus on building functional
ponents, selection of strategies with multiple benefits
strengths and self-efficacy
[68]
and on recovery
(e.g., pleasurable, nondrug activities), more effective
[69]
rather than a sole or primary emphasis on
titration of concurrent demands on the patient, or sim-functional deficits
ply an assurance that assertive treatment for both psychotic symptoms and substance use is accessed? Future
Suggestions for future research

research needs to go beyond the concept of integration per se, to identify these key features, and how their
1. Given that several trials saw positive changes in
impact might be maximized.

control groups, future outcome trials need to have
Once again, it is not yet clear whether these
substantial samples (i.e., totaling 200 or more), in
comments are applicable to people whose psychotic
order to be able to detect small-to medium-effect
symptoms are clearly secondary to substance use. It
sizes with confidence.

may be that this population will respond well to an
2. Future research needs to examine more closely
intervention that has a primary focus on the sub-r
Whether people with psychosis that is clearly
stance use, without ignoring management of the psy-secondary to substance use have different
chotic symptoms or their effect on cognitive pro
responses to interventions than those with

cessing.

two or more comorbid disorders;

Although the combination of substance use and
r
Whether a program that focuses on substance
psychosis presents significant challenges for any psy-use can prevent episodes of psychosis from
chological intervention, the foregoing review suggests
emerging;

that there may be room for increasing the effect of
r
Relative impact of extended CBT and

existing treatments. Potential features, which existing
alternate interventions, in participants who

treatments include to varying extent, include:
did not fully respond to brief intervention;

r
Effective components of integrated treatment;
1. Whether other potential comorbidities that may
r
Optimal timing of interventions (e.g., at or
influence substance use are effectively addressed
between psychotic episodes, or in relation to
(e.g., antisocial personality disorder
[60],

stage of change);

depression, physical disorders)

r
Maintenance of a positive change trajectory
2. Whether all substances are addressed at some
and prevention of relapse, and more sensitive
point in the treatment (since multiple substance
assessments of change.

use is the norm
[5])

3. Whether relapse risks are addressed
[61, 62, 63,

Implications for clinical practice

64]
, and participants are effectively re-engaged
after any temporary reversions to previous

At this stage, any recommendations for practice must
substance use

necessarily be tentative. However:

4. Whether the intervention helps participants to
1. Because many people with psychotic symptoms
develop new, rewarding roles, social networks,
that are secondary to substance use are only in
411

and activities
[65]
that are inconsistent with
contact with health services for the short periods
Treatment – Section 5

when symptoms are present, and motivation for
impact in mania, although reductions in total sleep
extended treatment is often low, practicalities will
time during sleep scheduling should probably be
usually demand an initial focus on brevity,

avoided.

motivation, and immediate planning.

2. People with repeated episodes of psychotic
Suggestions for future research

symptoms after substance use may require a more
extended intervention, which may need concrete
1. Randomized trials are required for the

incentives for attendance and initial attempts at
psychological management of insomnia in people
change
[22, 23, 24],
with attention to problem
with serious mental disorder, including trials on
solving and skills training that focus on high-risk
psychosis that may be secondary to insomnia.

situations for relapse or recurrence
[62],
and
2. Research is needed into the most effective
which builds roles and activities for sustained
components of psychological interventions for
recovery.

insomnia in people with serious mental disorders,
and into changes required to maximize the impact
Psychological management of

of treatment in this population.

insomnia

Implications for clinical practice

Although sleep disturbance can be caused by psy-Given that the current, limited data suggest that the
chosis, sleep deprivation may also trigger psychotic
same psychological strategies for insomnia may be
symptoms
[70, 71].
Insomnia therefore offers a second
applied as in the general population, the following may
potential trigger of psychotic symptoms that may be
be recommended
[76]:

addressed by psychological intervention.

There appear to be no controlled trials on the psy-1. Stimulus Control. The bed and bedroom are
chological management of insomnia in schizophre-associated with sleep, rather than other activities
nia or other psychoses, whether primary or secondary.

such as watching TV or reading. The patient is
Only two case series were identified in serious men-instructed to only go to bed when it is time to
tal disorder
[72, 73]
, and there are several trials with
sleep and to get out of bed and leave the room if
mixed psychiatric diagnoses
[74].
These studies found
sleep has not been achieved within 20 minutes.

that cognitive-behavioral methods that are used to
Other distracting stimuli, such as TVs and

treat primary insomnia were also effective in achieving
computers are also removed from the

positive sleep outcomes in patients with mental illness
bedroom.

[72, 73, 74].
Evidence also suggests that psychological
2. Relaxation Training and Biofeedback. In the
treatments for primary insomnia provide better short-former, patients are taught progressive muscular
and long-term outcomes than pharmacological treat-relaxation, abdominal breathing, or similar
ments
[75].

strategies, and encouraged to use them when

Not everyone with sleep deprivation would

trying to sleep. In the latter, somatic arousal is
describe themselves as having difficulty in getting to
addressed by providing the patient with feedback
sleep. People with a decreased perceived need for sleep
on parameters such as muscle tension.