• Relapse rates averaging 41% in the first year after discharge among schizophrenic patients receiving maintenance neuroleptic treatment led to the development of two disorderrelevant treatments: a patient-centered behavioral treatment and a psychoeducational family treatment. Following hospital admission, 103 patients residing in high expressed emotion (EE) households who met Research Diagnostic Criteria for schizophrenia or schizoaffective disorder were randomly assigned to a two-year aftercare study of (1) family treatment and medication, (2) social skills training and medication, (3) their combination, or (4) a drug-treated condition. First-year relapse rates among those exposed to treatment demonstrate a main effect for family treatment (19%), a main effect for social skills training (20%), and an additive effect for the combined conditions (0%) relative to controls (41%). Effects are explained, in part, by the absence of relapse in any household that changed from high to low EE. Only the combination of treatment sustains a remission in households that remain high in EE. Continuing study, however, suggests a delay of relapse rather than prevention.

Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia. I. One-year effects of a controlled study on relapse and expressed emotion.

To determine if neuroleptic treatment changes the natural course of schizophrenia, 22 studies were reviewed in which relatively similar patients were or were not given neuroleptics at specific times during the course of their illness. Nineteen of the studies were from first- or predominantly first-break populations. While there was little consensus among the authors of the studies reviewed, a reanalysis of the data indicates that early intervention with neuroleptics in first-break schizophrenic patients increases the likelihood of an improved long-term course. This finding is similar to that of earlier investigators who indicated there was a decrease in patients with the more severe forms of the illness following the introduction of convulsive therapies. Furthermore, there is evidence that stable schizophrenic patients whose neuroleptics are discontinued and have relapses may have a difficult time returning to their previous level of function. The findings describe in this paper have implications for both the treatment of schizophrenia and for understanding the pathophysiological processes that determine the course of the disorder.

https://psycnet.apa.org/journals/szb/17/2/325.pdf

Neuroleptics and the Natural Course of Schizophrenia

Schizophrenia, just the facts: What do we know, how well do we know it?

Background Deficits in social cognition and neurocognition are believed to underlie schizophrenia disability. Attempts at rehabilitation have had circumscribed effects on cognition, without concurrent improvement in broad aspects of behavior and adjustment. Objective To determine the differential effects of cognitive enhancement therapy (a recovery-phase intervention) on cognition and behavior compared with state-of-the-art enriched supportive therapy. Design A 2-year, randomized controlled trial with neuropsychological and behavioral assessments completed at baseline and at 12 and 24 months. Setting An outpatient research clinic housed in a medical center's comprehensive care service for patients with severe mental illness. Patients A total of 121 symptomatically stable, non–substance-abusing but cognitively disabled and chronically ill patients with schizophrenia or schizoaffective disorder. Interventions Cognitive enhancement therapy is a multidimensional, developmental approach that integrates computer-assisted training in neurocognition with social cognitive group exercises. Enriched supportive therapy fosters illness management through applied coping strategies and education. Main Outcome Measures Six highly reliable summary measures—Processing Speed, Neurocognition, Cognitive Style, Social Cognition, Social Adjustment and Symptoms—were tested using analysis of covariance and linear trend analysis. Results At 12 months, robust cognitive enhancement therapy effects were observed on the Neurocognition and Processing Speed composites ( P P =.001), Social Cognition ( P =.001), and Social Adjustment ( P =.01). As expected, no differences were observed on the residual Symptoms composite. Effects were unrelated to the type of antipsychotic medication received. Enriched supportive therapy also demonstrated statistically significant within-group effect sizes, suggesting that supportive psychotherapy can also have positive, although more modest, effects on cognitive deficits. Conclusion Many cognitive deficits and related behaviors of patients with stable schizophrenia are improved when sufficient exposure to relevant rehabilitation is provided.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/482052/YOA30032.pdf

Cognitive Enhancement Therapy for Schizophrenia: Effects of a 2-Year Randomized Trial on Cognition and Behavior

Background. The concept of duration of untreated psychosis (DUP) has recently attracted much interest because of its possible relationship to treatment outcome and implications for preventive efforts with reference to psychotic disorders, especially schizophrenia. In this paper we review critically the literature concerning the concept and its importance.Methods. Articles concerned with measuring DUP and those that have been suggested to provide indirect or direct evidence of the effect of DUP on treatment outcome are reviewed.Results. Evidence thus far suggests that DUP may be related to ease of reducing psychotic symptoms once treatment begins for first episode patients, but there is no evidence of a relationship to likelihood of relapse. There has been little investigation of the relationship of DUP to other long-term outcomes such as negative symptoms and cognitive functioning neither have the possible confounds of DUP been widely investigated or controlled.Conclusions. It is important that there should be more thorough investigations of DUP, its correlates, and the extent to which it does mediate any advantages of earlier intervention.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/2F2C3D713ACF8C5A851C8C043FBD21ED/S0033291701003488a.pdf/div-class-title-duration-of-untreated-psychosis-a-critical-examination-of-the-concept-and-its-importance-div.pdf

Duration of untreated psychosis: a critical examination of the concept and its importance.

In a prospective follow-up the outcome of 60 chronic schizophrenic patients who discontinued neuroleptic therapy after remaining stable 12-48 months was compared with controls continuing medication. Not only did the drug-discontinued patients have more relapses (P less than 0.001), but the form of relapse was both more severe and acute, resulting in differences of self-injury (P less than 0.05), anti-social behaviour (P less than 0.01), inpatient admissions (P less than 0.001), and the use of compulsory powers (P less than 0.01). In patients who relapsed, both social and work function was affected adversely for some months. Patients who remained relapse-free without drugs (20%) had a level of work and social function similar to medicated patients. At the end of 18 months the patients who discontinued depot maintenance therapy were found to have been prescribed one-third more neuroleptic drugs than controls, with a possible increase in the risk of long-term tardive dyskinesia.

G. Pasterski

Papers

The discontinuance of maintenance neuroleptic therapy in chronic schizophrenic patients: drug and social consequences.