Fitting the biopsychosocial jigsaw together

Supportive therapy for schizophrenia

BACKGROUND

Supportive therapy is often used in everyday clinical care and in evaluative studies of other treatments.

OBJECTIVES

To review the effects of supportive therapy compared with standard care, or other treatments in addition to standard care for people with schizophrenia.

SEARCH METHODS

For this update, we searched the Cochrane Schizophrenia Group's register of trials (November 2012).

SELECTION CRITERIA

All randomised trials involving people with schizophrenia and comparing supportive therapy with any other treatment or standard care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the risk ratio (RR) using a fixed-effect model with 95% confidence intervals (CIs). Where possible, we undertook intention-to-treat analyses. For continuous data, we estimated the mean difference (MD) fixed-effect with 95% CIs. We estimated heterogeneity (I(2) technique) and publication bias. We used GRADE to rate quality of evidence.

MAIN RESULTS

Four new trials were added after the 2012 search. The review now includes 24 relevant studies, with 2126 participants. Overall, the evidence was very low quality.We found no significant differences in the primary outcomes of relapse, hospitalisation and general functioning between supportive therapy and standard care.There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (4 RCTs, n = 306, RR 1.82 CI 1.11 to 2.99, very low quality of evidence), clinical improvement in mental state (3 RCTs, n = 194, RR 1.27 CI 1.04 to 1.54, very low quality of evidence) and satisfaction of treatment for the recipient of care (1 RCT, n = 45, RR 3.19 CI 1.01 to 10.7, very low quality of evidence). For this comparison, we found no evidence of significant differences for rate of relapse, leaving the study early and quality of life.When we compared supportive therapy to cognitive behavioural therapy CBT), we again found no significant differences in primary outcomes. There were very limited data to compare supportive therapy with family therapy and psychoeducation, and no studies provided data regarding clinically important change in general functioning, one of our primary outcomes of interest.

AUTHORS' CONCLUSIONS

There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies where we graded the evidence as very low quality. Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.

A national survey of Canadian psychiatry residents' perceptions of psychotherapy training

OBJECTIVE

To explore Canadian psychiatry residents' perceptions of their psychotherapy training and identify factors that may influence decisions to practise psychotherapy after graduation.

METHOD

We surveyed psychiatry residents at all training sites across Canada, using a self-report questionnaire.

RESULTS

The response rate was 63%. Of the respondents, 68% indicated that the prospect of learning and practising psychotherapy was a factor in their decisions to become psychiatrists, and 87% considered their ability to practise psychotherapy to be important to their identities as psychiatrists. The majority of residents (71%) were generally satisfied with their psychotherapy training. Among the graduating class of residents, 84% anticipate practising psychotherapy in some capacity. Satisfaction with their overall training experience and supervision and feeling competent to perform psychotherapy were significantly associated with their decisions to practise psychotherapy after graduation.

CONCLUSIONS

Most psychiatry residents currently enrolled in postgraduate training programs across Canada view psychotherapy as having an important role in the way they anticipate practising psychiatry.

Supportive therapy for schizophrenia

BACKGROUND

Supportive therapy is often used in everyday clinical care and in evaluative studies of other treatments.

OBJECTIVES

To estimate the effects of supportive therapy for people with schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register of trials (January 2004), supplemented by manual reference searching and contact with authors of relevant reviews or studies.

SELECTION CRITERIA

All randomised trials involving people with schizophrenia and comparing supportive therapy with any other treatment or standard care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the relative risk (RR) fixed effect with 95% confidence intervals (CI). Where possible, we undertook intention-to-treat analyses. For statistically significant results, we calculated the number needed to treat/harm (NNT/H). We estimated heterogeneity (I-square technique) and publication bias.

MAIN RESULTS

We included 21 relevant studies. We found no significant differences in the primary outcomes between supportive therapy and standard care. There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (3 RCTs, n=241, RR 2.12 CI 1.2 to 3.6, NNT 8) but not relapse rates (5 RCTs, n=270, RR 1.18 CI 0.9 to 1.5). We found that the results for general functioning significantly favoured cognitive behavioural therapy compared with supportive therapy in the short (1 RCT, n=70, WMD -9.50 CI -16.1 to -2.9), medium (1 RCT, n=67, WMD -12.6 CI -19.4 to -5.8) and long term (2 RCTs, n=78, SMD -0.50 CI -1.0 to -0.04), but the clinical significance of these findings based on few data is unclear. Participants were less likely to be satisfied with care if receiving supportive therapy compared with cognitive behavioural treatment (1 RCT, n=45, RR 3.19 CI 1.0 to 10.1, NNT 4 CI 2 to 736). The results for mental state and symptoms were unclear in the comparisons with other therapies. No data were available to assess the impact of supportive therapy on engagement with structured activities.

AUTHORS' CONCLUSIONS

There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies. Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.

Supportive therapy for schizophrenia

BACKGROUND

Supportive therapy is often used in everyday clinical care and in evaluative studies of other treatments.

OBJECTIVES

To estimate the effects of supportive therapy for people with schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register of trials (January 2004), supplemented by manual reference searching and contact with authors of relevant reviews or studies.

SELECTION CRITERIA

All randomised trials involving people with schizophrenia and comparing supportive therapy with any other treatment or standard care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the relative risk (RR) fixed effect with 95% confidence intervals (CI). Where possible, we undertook intention-to-treat analyses. For statistically significant results, we calculated the number needed to treat/harm (NNT/H). We estimated heterogeneity (I-square technique) and publication bias.

MAIN RESULTS

We included 21 relevant studies. We found no significant differences in the primary outcomes between supportive therapy and standard care. There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (3 RCTs, n=241, RR 2.12 CI 1.2 to 3.6, NNT 8) but not relapse rates (5 RCTs, n=270, RR 1.18 CI 0.9 to 1.5). We found that the results for general functioning significantly favoured cognitive behavioural therapy compared with supportive therapy in the short (1 RCT, n=70, WMD -9.50 CI -16.1 to -2.9), medium (1 RCT, n=67, WMD -12.6 CI -19.4 to -5.8) and long term (2 RCTs, n=78, SMD -0.50 CI -1.0 to -0.04), but the clinical significance of these findings based on few data is unclear. Participants were less likely to be satisfied with care if receiving supportive therapy compared with cognitive behavioural treatment (1 RCT, n=45, RR 3.19 CI 1.0 to 10.1, NNT 4 CI 2 to 736). The results for mental state and symptoms were unclear in the comparisons with other therapies. No data were available to assess the impact of supportive therapy on engagement with structured activities.

AUTHORS' CONCLUSIONS

There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies. Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.

EBM in practice: psychiatry

Psychiatry was one of the first medical specialties to use the tools of evidence-based medicine (EBM)--randomised controlled trials (RCTs), systematic reviews with meta-analyses--and as many treatment decisions in psychiatry are evidence-based as in general medicine. Psychiatrists have some reservations about the EBM approach because of perceived limitations in methodology of RCTs and systematic reviews; gaps in the evidence base; problems interpreting the available evidence; and neglect of individual patient uniqueness in quantitative research based on groups or populations. Research supports the value of psychotherapy and there are now a number of empirically validated efficacious psychotherapies for a range of disorders.