Why do we not use psychosocial interventions in the treatment of schizophrenia?

The treatment of schizophrenia presents a conundrum. Remarkably, even though we are aware that the major portion of the disability caused by schizophrenia is the result of the negative and cognitive symptoms (Milev et al., 2005), the principle focus of treatment has been to reduce the positive symptoms of the disorder. Negative and cognitive symptoms limit the ability of the individual to form relationships, obtain employment, be financially secure and care for themselves independently. People living with a psychotic illness and those who care for them rate these problems as their major challenges for the coming year. Along with poor physical health, these problems rank ahead of symptomatic treatment and access to specialised services (Morgan et al., 2011). So, notwithstanding the importance of treating negative and cognitive (both neurocognitive and social cognitive) symptoms, our treatment strategies are still directed towards the short-term pharmacological resolution of positive symptoms.

The deficits caused by negative symptoms are little changed by standard antipsychotic medications, including clozapine, dashing earlier hopes that the second-generation antipsychotics would alleviate them (Leucht et al., 2009). Similarly, the cognitive symptoms of schizophrenia are only improved marginally by antipsychotic medications (Sergi et al., 2007; Woodward et al., 2005). Novel pharmacological approaches to both negative and cognitive symptoms have yet to bear fruit despite considerable effort. If this lack of treatment was due to the absence of any effective intervention, this apparent misalignment of treatment focus could be understood. However, there are other evidence-based treatments for these symptoms. These psychological and psychosocial treatments have, in some cases, been available for nearly 40 years but their uptake has been poor. The recently published SHIP study found that only a third (36.5%) of people with a psychotic illness had participated in any community rehabilitation or day programs over 12 months (Morgan et al., 2011). This is despite 63% of them having obvious or severe dysfunction in their ability to socialise and 32% of them having severe impairment in their ability to care for themselves. In that same survey, people with psychosis scored 1.6 standard deviations below the general population on general cognitive ability. There is still a clear gap between the disability suffered by people with schizophrenia and the care that is provided to meet that need.

The role of psychological and psychosocial interventions is not limited to the treatment of negative and cognitive symptoms. Interventions such as cognitive behavioural therapy for psychosis are of benefit in the treatment of so-called ‘treatment resistant’ hallucinations or delusions (Jones et al., 2010) and family therapy has long been acknowledged to be useful in reducing relapse rates in schizophrenia (Pharoah et al., 2010). Even a simple intervention such as psychoeducation reduces the need for readmission and emergency care (Xia et al., 2011).

In this edition of the Journal, we have four commentaries by leading clinicians and researchers working with psychological and psychosocial treatments for schizophrenia. They document the improvements observed in a wide range of symptoms, interpersonal functioning and vocational outcomes with these treatments. Considerable skill resides in the mental health sector in the provision of these and other psychosocial treatments; however, little opportunity is given to many mental health practitioners to use their experience and training and provide these essential treatments in public mental health. We offer five possible reasons why this may be so.

First, is the ongoing crisis in the provision of public mental health services in Australia. Although this differs in extent from state to state, the outcome from four national mental health plans have not seen overall funding to the sector increase as a proportion of the health budget despite clearly identified needs (Department of Health and Ageing, 2010). The past 20 years have seen a move from inpatient to community care and a decrease of inpatient care in specialist psychiatric hospitals and key centres for long-term inpatient rehabilitation (Australian Institute of Health and Welfare, 2010; Whiteford and Buckingham, 2005). While this move to the community is in accord with good quality care in addition to being patient and carer preference, sufficient additional resources have not been directed towards community mental health. Although it is difficult to compare figures, the Australian Institute for Health and Welfare report that while Australia’s estimated real growth in health spending was 5.3% per annum the average rate of increase in state and territory specialised mental health services was only 3.4% per annum, albeit over a shorter time course (Australian Institute of Health and Welfare, 2012a, 2012b). The speed and nature of this transfer to community-based resources has varied widely between states, with some states concentrating on residential services (e.g. Victoria) whilst others have virtually disregarded these important facilities (e.g. New South Wales).

Second, is the emphasis upon acute care at the expense of recovery-focused services. A comparison of data from 1998 and 2010 suggest that while access to rehabilitation services overall improved with an increase in the number of people accessing some sort of rehabilitation service, usually from a non-government organisation (NGO), the proportion accessing rehabilitation services provided by the public mental health services dropped from 19.1% to 14.5% (Jablensky et al., 1999; Morgan et al., 2011). The threat is that community care without sufficient funding will cause a churn of inadequately treated patients seen infrequently in the community by case managers. There is some evidence of this with those offered case management by NGOs being much more likely to see their case manager on a weekly basis than those with a case manager from the public mental health system (64% vs 28%) (Morgan et al., 2011).

Third, it is our impression (and that of many clinicians) that there has been a loss of experience in the provision of these treatments from our public mental health services. The new cohort of mental health professionals who have entered the workforce in the past 10 years have come into a workplace where acute care and pharmacotherapy dominate the treatment approach and they have not been able to develop skills in psychological and psychosocial treatments. For most new mental health professionals, psychosocial treatments are a theoretical possibility but not an everyday reality in the workings of their own team. Furthermore, experienced staff have begun to lose skills because of the same concentration on acute care and risk management. A return to the use of psychosocial treatments within this sector will require adequate training and supervision that will need to be supported by services.

Fourth, there has been the removal of many psychologists from the public mental health system, where care is directed towards the most seriously ill and to the private health system where the majority of treatment is directed towards depression and anxiety of lesser severity (Australian Institute of Health and Welfare, 2010). The last 7 years have seen a massive uptake of the Better Access scheme with virtually all the increase in Medicare Benefits Schedule (MBS)-subsidised mental health services being due to this program and being paid to psychologists (Australian Institute of Health and Welfare, 2012a). While this is potentially addressing a gap in our health system, allowing people with depression and anxiety to access adequate treatment, it is unclear whether the changes to Medicare that have brought about this redirection of funds are having the desired effect on the overall burden of illness or the standard of care received (Hickie et al., 2011, 2012; Pirkis et al., 2011a, 2011b).

Finally, there are inadequate funds being provided for research into psychological and psychosocial interventions. Funding for mental health research in general and severe mental illness in particular remains low despite being made a targeted area of research (Christensen et al., 2011). Treatment research for low prevalence disorders is dominated by pharmaceutical industry research. Without the funding to conduct well-designed, randomised controlled trials into psychosocial treatments, the evidence base for them withers and experience in developing and establishing these treatments is lost. This treatment-oriented research needs to be bolstered by field-level research into the effectiveness and proper integration of such treatments into mental health services. The recently published McKeon report on Health and Medical Research in Australia emphasises the dearth of such service-level research in Australia (McKeon, 2012).

An interesting finding of the SHIP study was the increased provision of services by NGOs. NGOs provided over two-thirds of the psychosocial treatments to people with chronic psychotic disorders in the community in Australia, a significant rise over 10 years. This change in the provision of mental health services is likely to continue with the growing use of NGOs in this role and the emphasis on the availability of a plurality of services for those with a mental illness (Council of Australian Governments, 2009). This is a development with the potential to increase the depth and choice of services. The attractions of utilising NGOs are numerous. It engages a group in the community who are often deeply interested in improving services due to their own poor experiences of public mental health. Providing services with staff who have a ‘lived’ experience of mental illness or caring for someone with it gives a ready bridge into understanding the situation of those receiving care. From the point of view of government, costs are contained as staff employed by NGOs frequently have training levels that are less than those found in public mental health staff and are on awards that remunerate poorly, though recent changes to the Social and Community Services Workers award will negate the latter point in the medium to longer term. The services provided by NGOs are subject to a competitive tender that allows for market forces to reduce the cost of service provision. It also allows the introduction of large national charities and multinational service providers into this area of health care, helping to further contain costs. National alliances of NGOs have begun to organise themselves to provide a coordinated face for government to interact with and to enhance the level and sophistication of their support for people with a mental illness (e.g. the recently launched MiNetwork by the Mental Illness Fellowships of Australia: www.minetworks.org.au/).

The trend of increased NGO activity has some downsides. There is a danger that by making such organisations dependent upon government funding for a large proportion of their turnover that they may be ‘captured’ by government and rendered quiescent when it comes to their traditional advocacy role in the community. Relatively short-term government contracts make it difficult for NGOs to invest in staff training and service development. However, training is essential if the NGO sector is to take up a broader role in psychosocial treatment provision, as these treatments need a high level of skills and continued supervision if they are to be provided competently. Finally, the process of engaging an increased number of service providers risks further fragmenting the provision of long-term care in the mental health sector. Care is already difficult to access and without the development of ways to coordinate services many people with severe mental illness run the risk of not being able to find their way through our complex system. We hope that the recently announced mental health care coordinating program ‘Partners in Recovery’ will be one way of navigating the multiplicity of services but without adding a further layer of bureaucracy. Systematic evaluation of the services and the new coordination program would be very valuable.

In conclusion, we would like to emphasis the need for good quality psychosocial interventions in the recovery from a psychotic disorder. For us to be able to provide them, a number of basic changes need to occur. Service leaders need to emphasise the importance of resourcing longer-term psychosocial treatment programs, rather than focusing on the quick fixes to clear emergency departments. These psychosocial treatment programs need to be at the centre of our service provision rather than at the periphery and the staff that provide them need to be supported by adequate training and supervision whether in the private, public or NGO sector. We recognise the distance that our system has to travel before these services are available consistently across Australia, but we need to start the process as a matter of urgency.