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CPG for Psychosocial Interventions in Severe Mental

1. 1 Respect to the degree of treatment adherence lower percentages of relapses are observed in the psychoeducational type family intervention group Two years after the treatment maintenance of the efiect of the family therapy is observed when preventing relapses but the SST effect is n t maintained observing similar percent ages to those of the control group With respect to pharmacological treatment adherence failure to comply with the medica tion was less frequent in the experimental groups than in the control group 21 and 40 respectively Combined psychosocial intervention of patients and family members achieves greater clinical improvements than the control group and this effect is maintained for 4 years After 4 years follow up the clinical state and the social functioning of the people who followed a combinedcpsychosocial intervention were similar to the control group but they achieved 40 less relapses People with SMi and a diagnosis of bipolar disorder No differences have been found between family psychosocial intervention and individual intervention with respect to relapses readmissions and treatment adherence at the end of the treatment 12 months Family intervention reduces relapses compared with crisis treatment after 24 months There is an improvement with respect to treatment adherence in people who have re ceived family intervention compared
2. Motivational interview in CBT When ihe motivational interview is included in CBT and compared with standard treat meut no differences were found between either of the two interventions in the consump ti n of substances in people who consume drugs 3 months or 6 months after the interven tion No improvement in the mental state in either of the two groups was also found However when the motivational interview alone is compared with standard treatment in people with SMI the motivational interview appears to be efficient in alcohol abstinence 6 months after the intervention and there is greater follow up after the intervention There are differences between the motivational interview alone and standard treatment in the improvement of mental state 48 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 1 People with SMI and a diagnosis of bipolar disorder There are no differences between CBT and ST regarding prevention of maniac relapses but there are differences when avoiding depressive relapses in favour of CBT 30 months follow up period There are no differences between CBT and ST in the reduction of hospital readmissions 1 When comparing CBT ST with ST alone no differences have been found that deter mine which intervention is more effective in connection with social functioning at 6 18 or 24 months follow up 1 When CBT ST are compared onl
3. There are no differences between PVT clubhouse model vs S in relation to achieving competitive employment There are less hospital readmissions in the group that participated in PVT clubhouse than in the group that received standard treatment 1 1 The participants in the paid sheltered work grous presented greater permanence lower number of hospital readmissions and lower scores in symptoms than those who only re ceived PVT Those who received PVT additionai psychological intervention presented differences in favour of obtaining some form ofemployment and some form of employment or education at the end of the study 1 There are no differences between PVT psychological techniques vs control group with respect to clinical improvement 1 Patients with prior labour failure integrated in the sheltered employment programme with cognitive training presented greater probability of having worked having maintained more jobs worked more weeks more hours and higher salaries than patients who were only offered sheltered employment 1 Users witlytransitional employment and accelerated entry did not achieve better employ ment daia than users with transitional employment and gradual entry but they did earn more inoney l4 1 petitive employment after 24 and 36 months as well as greater probability than the ST Vie sheltered employment group showed a sig
4. 5 3 5 Non acute Day Hospitals There are no differences between non acute day hospitals and outpatients treatment for people with SMI with respect to the number of iollow up loss es at 18 months n 2 80 RR 1 75 95 CI between 0 55 and 5 51 8 ad mission rates at 12 months n 162 RR 0 86 9595 CE between 0 61 and 1 23 at 24 months n 162 RR 0 82 95 CI between 0 64 and 1 05 8 and mental state Symptom Check List 90 n 2 30 WMD 0 31 95 CI between 0 20 and 0 82 There is not sufficient evidence eithsy to be able to determine if there is any difference between non acut day hospitals and outpatients treat ment for people with SMI with respect to social functioning Community Adaptation Scale n 30 WMP 0 03 9596 CI between 0 30 and 0 24 5 3 6 Case Management CM Case Management vs Standard treatment ST People inciuded in Case Management are more likely to remain in contact with the services compared with those who receive ST n 1210 Peto od s ratio 0 70 99 CI between 0 50 and 0 98 95 There are no differences with respect to mortality in patients between either intervention n 1341 Peto odds ratio 1 29 99 CI between 0 55 and 3 00 People who were in the CM group were approximately twice as likely to be admitted into a psychiatric hospital n 2 1300 Peto odds ratio 1 84 99 CI between 1 33 and 2 57 as patients who received ST CLINICAL PRACTICE GUIDELINES
5. Lehman AF Vocational rehabilitation in schizophrenia Schizophr Bull 1995 21 4 645 56 Hogarty GE Anderson CM Reiss DJ Kornblith SJ Greenwaid DP Javna CD et al Family psychoeducation social skills training and maintenance cliemotherapy in the aftercare treat ment of schizophrenia I One year effects of a controlled study on relapse and expressed emotion Arch Gen Psychiatry 1986 43 7 633 42 Falloon IR Optimal treatment for psychosis in an international multisite demonstration pro ject optimal Treatment Project Collaborators Psychiatr Serv 1999 50 5 615 8 Barrowclough C Tarrier N Lewis S Seilwood W Mainwaring J Quinn J et al Randomised controlled effectiveness trial of a needs based psychosocial intervention service for carers of people with schizophrenia Br J Psychiatry 1999 174 505 11 Dyck DG Short RA Hendryx MS Norell D Myers M Patterson T et al Management of negative symptoms among patients with schizophrenia attending multiple family groups Psychiatr Serv 2000 51 4 513 9 Pharoah F Mari J Ra hbone J Wong W Family intervention for schizophrenia Cochrane Database Syst Rev 2006 4 CD000088 Chien WT Norman I Thompson DR A randomized controlled trial of a mutual support group for family caregivers of patients with schizophrenia Int J Nurs Stud 2004 41 6 637 49 Xiong H Xiong W Lipeng F Wang R Comprehensive family treatment for schizophrenic patients a prospective randomized sin
6. 62 63 64 65 66 67 68 146 Graeber DA Moyers TB Griffi th G Guajardo E Tonigan S A pilot study comparing mo tivational interviewing and an educational intervention in patients with schizophrenia and alcohol use disorders Community Ment Health J 2003 39 3 189 202 Hickman ME The effects of personal feedback on alcohol intake in dually diagnosed cli ents an empirical study of William R Miller s motivational enhancement therapy tesis doctoral Bloomington Indiana University 1997 Swanson AJ Pantalon MV Cohen KR Motivational interviewing and treatment adherence among psychiatric and dually diagnosed patients J Nerv Ment Dis 1999 187 10 630 5 Barrowclough C Haddock G Tarrier N Lewis SW Moring J O Brien R et al Randomized controlled trial of motivational interviewing cognitive behavior therapy and family in tervention for patients with comorbid schizophrenia and substance use disorders Am J Psychiatry 2001 158 1706 13 Baker A Lewin T Reichler H Clancy R Carr V Garrett R et al Evaluation of a inotivation al interview for substance use within psychiatric in patient services Addiction 2002 97 10 1329 37 Beynon S Soares Weiser K Woolacott N Duffy S Geddes JR Psychosocial interventions for the prevention of relapse in bipolar disorder systematic review of controlled trials Br J Psychiatry 2008 192 1 5 11 Cochran SD Preventing medical noncompliance in the outpatient treatm
7. There appears to be evidence in favour of cognitive behavioural therapy SR 1 when compared with supportive therapy in the improvement of general functioning 2 RCT n 78 SMI 0 50 95 CI between 1 0 and 0 04 There is no difference in the number of hospitalisation between the two intervention groups 2 RCT n 88 RR 1 59 95 CI between 0 79 and 3 22 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 53 Supportive therapy vs any other psychological or psychosocial therapy RCT 1 There are insufficient data to determine if supportive therapy or counselling improves the relapse rates at the end of the treatment period n 361 RR 1 33 95 CI between 0 80 and 2 21 or after a non specified follow up period n 154 RR 1 21 95 CI between 0 89 and 1 66 These results concur with those reviewed by Buckley et al which indicate that there are no differences between either of the two interven tions with respect to relapses 5 RCT n 270 RR 1 18 95 CI between 0 91 and 1 53 There is evidence that indicates that supportive therapy or counsei ling leads to an improvement in the mental state at the end of the treetment BPRS PANSS CPRS n 316 WMD 0 02 95 CI between 5 Z0 and 0 24 or after a non specified follow up period BPRS PANSS CPRS n 284 WMD 0 20 95 CI between 0 03 and 0 44 5 Supportive therapy or counselling does not produce a reducti
8. 0 16 However significant differences were observed in the medium term in favour of CBT 1 RCT n 37 WMD 7 6 95 CI between 14 and 0 9 p 0 03 In the total score of the Positive and negative syndrome scale PANSS in one study no significant short term effects were found 1 RCT n 149 WMD 1 8 95 CI between 4 0 and 7 6 proof of the global effect 0 60 p 0 5 or in the long term 1 RCT n 40 WMD 6 5 95 CI between 18 9 and 5 9 proof of the global effect 1 02 p 2 0 3 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Specific symptoms when CBT was compared with other psychological treatments no positive effect was observed in the improvement of delirium 1 RCT n 40 WMD 14 95 CI between 2 3 and 5 1 proof of the global effect 0 74 p 0 5 but it was found with respect to hallucinations 1 RCT n 40 WMD 1 24 95 CI between 2 1 and 4 6 proof of the global effect 0 12 p 0 9 Cognitive behavioural therapy BCT vs standard treatment ST Relapses There is not sufficient evidence to determine if CBT improves relapses when compared with standard care routine care Case Management and medica tion during treatment n 121 RR 0 88 95 CI between 0 46 and 1 66 when compared with standard care 12 months after treatment n 2 61 RR 1 51 9596 CI between 0 79 and 2 87 and 1 2 years after treatment n 154 RR 0 83 95 CI between 0 6 and 1 13 Longer lasti
9. 180 average final score in the SANS scale WMD 0 86 95 CI between 1 17 and 0 55 93195 1 There is no improvement of social functioning in the music therepy group when 20 or more sessions are applied 1 RCT n 70 average final score in the SDSI scale WMD 0 78 95 CI between 1 27 and 0 28 No differences are found in favour of music therapy with respect to the patient s satisfaction in the medium term less than 20 sessions 1 RCT n 69 average score of the CSQ scale WMD 0 32 9595 CI between 0 16 and 0 80 Music therapy does not improve the quality of life measured with the SPG with an intervention of less than 20 sessions 1 RCT n 2 31 WMD 0 05 95 CI between 0 66 and 0 75 when compared with ST alone Art therapy The mental state measured withthe SANS scale slightly improved in favour of the art therapy group m 73 1 RCT WMD 2 3 95 CI between 4 10 and 0 5 5 Social functionitig measured with the SES scale in the short term did not show any clear differences between the groups in final scores n 2 70 1 RCT WMD z 7 20 95 CI between 2 53 and 16 93 and quality of life measured with the Perc Qol scale did not indicate the effects of art therapy n 74 4 RCT WMD 0 1 95 CI between 2 7 and 0 47 Summary of evidence RCT 1 RCT 12 SR 1 1 Music therapy as a complement to ST improves the global state in the medium term 193 of
10. 95 CI between 0 14 SR 1 and 63 15 e 50 reduction of score the BPRS scale after treatment 1 RCT n 27 RR 0 42 95 CI between 0 14 and 1 21 or after 6 months 1 RCT n 23 RR 0 87 9576 CI between 0 31 and 2 44 e Early abandonment of study 1 RCT n 16 RR 1 00 95 CI between 0 07 and 13 57 Motivational interview in cognitive behavioural therapy CBT Cogn ive behavioural therapy motivational interview vs standard treatment When the motivational interview is included in CBT and it is compared with RCT 1 standard treatment no differences were found in the consumption of sub stances between either of the interventions in people with SMI who consume different types of drugs after 3 months nz119 WMD 0 37 95 CI be tween 0 01 and 0 8 or 6 months after the intervention n 119 WMD 0 19 95 CI between 0 2 and 0 6 No improvement was found either in the mental state between the two RCT 1 groups measured with the PANSS scale n 32 WMD 6 59 95 CI between 16 0 and 2 09 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 45 Motivational interview vs standard treatment RCT 1 However when the motivational interview alone is compared with stand ard treatment in SMI people it appears to be efficient in obtaining alcohol abstinence 6 months after the intervention n 28 RR 0 36 95 CI between 0 2 and 0 8 NNT 2 RCT 1 With respect
11. The psychosocial treatment of schizophrenia an update Am J Psychiatry 2001 158 2 163 75 Jon s C Cormac I Silveira da Mota Neto JI Campbell C Cognitive behaviour therapy for Schizophrenia Cochrane Database Syst Rev 2004 4 CD000524 Daniels L A group cognitive behavioral and process oriented approach to treating the social impairment and negative symptoms associated with chronic mental illness J Psychother Pract Res 1998 7 2 167 76 Drury V Birchwood M Cochrane R Cognitive therapy and recovery from acute psychosis a controlled trial III Five year follow up Br J Psychiatry 2000 177 8 14 Haddock G Tarrier N Morrison AP Hopkins R Drake R Lewis S A pilot study evaluating the effectiveness of individual inpatient cognitive behavioural therapy in early psychosis Soc Psychiatry Psychiatr Epidemiol 1999 34 5 254 8 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Garety P Fowler D Kuipers E Freeman D Dunn G Bebbington P et al London East Anglia randomised controlled trial of cognitive behavioural therapy for psychosis II Predictors of outcome Br J Psychiatry 1997 171 420 6 Pinto A La PS Mennella R Giorgio D DeSimone L Cognitive behavioral therapy and clo zapine for clients with treatment refractory schizophrenia Psychiatr Serv 1999 50 7 901 4 Tarrier N Wittkowski A Kinney C McCarthy E Morris
12. aspects Domestic activities n 10 RR 0 24595 CI between 0 001 and 4 72 Self care n 10 RR 1 00 95 CI between 0 28 and 3 54 Positive symptoms of the PANSS n 38 WMD 0 80 95 CI between 4 38 and 2 78 Negative symptoms of the PANSS n 38 WMD 1 90 95 CI between 1 75 and 5 55 General psycitopathology of the PANSS n 38 WMD 0 00 95 CI 3 12 to 3 12 Quality of life n 232 WMD 0 02 95 CI 0 01 to 0 03 5 2 2 Residential programmes in the community These program aes consist of alternative housing where people with SMI live either temporarily or permanentiy and whose aim is to train them in those skills required for them to independently adapt to daily life insofar as possible In these structured spaces they are provided with a resource where their personal and social deficiencies are compensated in order to improve their physical health self care responsibility with the treatment cognitive functioning social functioning and participation in community activities avoiding relapses readmissions and use of health services Literature distinguishes two types of approaches supported housing where the independ ent housing in the community is accompanied by support and monitoring by community mental health services and residential continuum where it is the actual service or agency that provides the clinical care the person is progressively located at levels of differing support an
13. community will issue the relative judgement and the disablement condition of the person will be temporarily or definitely recognised By virtue of this recognition the person affected by the SMI may benefit from other social coverage systems If the percentage is higher than 33 disablement the condition will be recognised and the person affected may make use of tax related advantages If the percentage is higher than 33 disablement the condition will be recognised and If their disablement condition exceeds 65 and the person affected has not contributed for sufficient time so as to have a contributory benefit he or she may have a non contributory type economic income set by each autonomous community The framework of reference of Spanish Law 39 2006 14 December on the Preimotion of personal autonomy and care for dependent persons recognises among its principles the univer sality in the access of all dependent people in conditions of effective equality and non discrimi nation It also recognises in the actual definition of the dependency situation the specific charac teristics of the people who belong to the group of people affected by a mental illness indicating that dependency is a permanent state of people who due to reasons derived from age illness or disability and linked to the lack or loss of physical mental intellectual or sensorial autonomy require the care of another or of other people or considerable hetp
14. n 587 3 RCT RR 0 81 95 CI between 0 7 and 1 0 No differences have been found either with respect to the use of emergency services n 587 3 RCT RR 0 86 95 CI between 0 7 and 1 1 or respect to the reduction of contacts with Primary Care n 587 3 RCTs RR 0 94 95 CI between 0 8 and 1 1 There is not sufficient evidence to determine if the CMHC are associated with a reduction in the death ratios n 100 RR 0 54 95 CI between 0 5 and 5 78 and n 155 RR 0 89 95 CI between 0 06 and 13 98 It has not been found either in the SR by Malone et al n 587 3 RCT RR 0 47 95 CI between 0 2 and 1 3 in the medium term assessment 3 to 12 months CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Loss of contact With respect to the risk of loss of contact in the population cared for in CMHC compared with ST it seems to indicate that there is insufficient evi dence to determine this association n 100 RR 1 24 95 CI between 0 49 and 3 16 and n 155 RR 1 04 95 CI Between 0 60 and 1 797 Similar results to those obtained in the study by Malone et al n 253 RR 1 10 95 CI between 0 7 and 1 8 Mental state In the data indicated in the NICE Schizophrenia CPG which are those pro vided by the study by Merson et al respect to the evolution of the mental state in the population cared for in CMHC compared with ST no differences are observed between the two interventions n 1
15. of individual psychodynamic psychotherapy or psychoanalysis with standard treatment which may include just medication reality adapted psychotherapy or group psychotherapy and with no intervention in people with schizophrenia or SMI Considerable variations have been found in this review during the treatment in the follow up and in the phase of the disease when the intervention is applied first episode and subsequent ones in the results and the intervention comparator with biases in the rexidomisation and blinding in the studies This study does not provide any result on the effectiveness or not of this intervention Leichsenring et al 71 publish a metanalysis that assesses the effectiveness of long term psy chodynamic psychotherapy 11 RCTs and 12 observational studies are included in this study and the inental disorders included are eating disorders personality disorders depression and anxiety and heterogeneous disorders No data are provided on psychosis or bipolar disorder which is the study population in this guideline Summary of evidence Sufficient evidence has not been found to make recommendations related to psychody namic psychotherapy or the psychoanalytic approach in the treatment of people with SMI 50 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 5 1 3 Interpersonal therapy The lifestyle or social rhythms of stabilised people with bipolar disorder BD are different to those of people who do not suffer from the
16. 2005 4 CD003728 Wood C The history of art therapy and psychosis 1938 95 En Killick K Schaverien J editors Art psychotherapy and psychosis London Routledge 1997 p 144 75 Ley General de Sanidad Ley 14 1986 de 29 de abril Bolet n Ofi cial del Estado n 102 29 04 1986 Tyrer P Evans K Gandhi N Lamont A Rarrison Read P Johnson T Randomised controlled trial of two models of care for discharged psychiatric patients BMJ 1998 316 7125 106 9 Merson S Tyrer P Onyett S Lack S Birkett P Lynch S et al Early intervention in psychi atric emergencies a controlled Clinical trial Lancet 1992 339 8805 1311 4 Gater R Goldberg D Jackson G Jennett N Lowson K Ratcliffe J et al The care of patients with chronic schizophrenia a comparison between two services Psychol Med 1997 27 6 1325 36 Malone D Newron Howes G Simmonds S Marriot S Tyrer P Community mental health teams CMH for people with severe mental illnesses and disordered personality Cochrane Database Syst Rev 2007 3 CD000270 Marshai M Gray A Lockwood A Green R Case management for people with severe men tal disorders Cochrane Database Syst Rev 1998 2 CD000050 Catty JS Bunstead Z Burns T Comas A Day centres for severe mental illness Cochrane Database Syst Rev 2007 1 CD001710 Burns T Catty J Dash M Roberts C Lockwood A Marshall M Use of intensive case man agement to reduce time in hospital in people with severe mental
17. 30 297 303 Kuldau JM Dirks SJ Controlled evaluation of a hospital originated community transitional system Arch Gen Psychiatry 1977 34 1331 40 173 Dincin J Witheridge TF Psychiatric rehabilitation as a deterrent to recidivism Hosp Community Psychiatry 1982 33 645 50 Okpaku SO Anderson KH Sibulkin AE Butler JS Bickman L The effectiveness of a mul tidisciplinary case management intervention on the employment of SSDI applicants and benefi ciaries Psychiatr Rehabil J 1997 20 34 41 Wolkon GH Karmen M Tanaka HT Evaluation of a social rehabilitation program for re cently released psychiatric patients Community Ment Health J 1971 7 312 22 Bell MD Milstein RM Lysaker P Pay as an incentive in work participation by patients with severe mental illness Hosp Community Psychiatry 1993 44 684 6 Kline MN Hoisington V Placing the psychiatrically disabled a look at work values Rehabil Couns Bull 1981 366 9 Blankertz L Robinson S Adding a vocational focus to mental health renabilitation Psychiatr Serv 1996 47 1216 22 Bond GR Dincin J Accelerating entry into transitional employment in a psychosocial reha bilitation agency Rehabil Psychol 1986 31 143 55 Chandler D Meisel J McGowen M Mintz J Madison K Client outcomes in two model capitated integrated service agencies Psychiatr Serv 1996 47 2 175 80 Drake RE Becker DR Biesanz JC Torrey WC McHugo GJ Wyzik PF Rehabilitative day treatment vs supp
18. Arturo Soria 311 1 B 28033 Madrid Tel 91 383 41 45 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 135 Spanish Society of Legal Psychiatry http www psiquiatrialegal org Spanish Society of Psychiatry and Psychotherapy for Children and Adolescents SEPYPNA http www sepypna com sepypna sepypna com C Monte Esquinza 24 4 izq 28010 Madrid Tel 91 319 24 61 Fax 91 319 24 61 International Associations World Fellowship for Schizophrenia and Allied Disorders http world schizophrenia org http espanol world schizophrenia org in Spanish World Psychiatric Association http www wpanet org European Federation of Associations of Families of People with Menta illness http www eufami org American Psychiatric Nurses Association http www apna org HORATIO European Psychiatric Nurses Association http www horatio web eu The European Psychiatric Association http www aep lu World Association for Psychosocial Rehabilitation http www wapr2009 org index htm World Federation for Menta ealth http www wfmh org Mental Health Europe http www mhe sime org National Alliatice on Mental Illness http www nami org http www nami org Content NavigationMenu Inform Yourself NAMI n_espa C3 B1ol NAMI en _espa C3 B lol htm American Psychiatric Association http www psych org Latin America Psychiatric Association http www apalweb org 136
19. Civil Code They regulate two procedures of interest in Mental Health 1 The non voluntary hospitalisation due to psychic disorders is regulated by Law of Civil Procedure Law 1 2000 7 January Article 763 concerns Mental Health regulating this procedure It deals with the bospitalisation of persons who are not able to decide for themselves because of their psychic state as a necessary therapeutic measure indicated by medical staff ap plied with restrictive criteria and for as short a time as possible As this represents a privation of the fundamental right of personal freedom the regulation aims to guarant e this right among others so the entire hospitalisation requires judicial authorisa tion the authorisation will be prior to the hospitalisation except when due to urgent reasons the measure must be immediately adopted With the times established by law the court will hear the person affected by the decision the Public Prosecutor s Office and any other person whose ap pe rance is deemed advisable or is requested by the person affected by the measure Furthermore and without prejudice of being able to perform any other test that is deemed relevant for the case the court must examine for itself the person whose hospitalisation is referred to and hear the judgement of a physician appointed by him or her In all the actions the person affected by the hospitalisation measure may be represented and defended under the terms indi
20. Dissemination of information about the CPG in scientific activities congresses confer ences meetings related to psychiatry psychology nursing social work occupational therapy Forwarding by post of a three page information leaflet about the CPG to professional as sociations health administration care centres local associations of health professionals etc Information about the SPG in magazines and medical daily newspapers of the speciali ties involved Dissemination of the existence and the objectives of the CPG by means of distribution lists for professionals who are potentially interested in it CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 111 7 Recommendations for Future Research This chapter includes proposals for future research that are suggested in the different sections of the guideline 5 1 1 Cognitive behavioural therapy It would be necessary to carry out studies that analyse to what extent the effects of CBT aye maintained in people with SMI after the treatment and if refresher sessions are necessary More studies are required to assess the characteristics of the population on whom CBT is more effective people with positive persistent symptomatology and resistant to psycho drugs and the characteristics of the intervention that make it more effective with respect to duration and number of sessions Quality studies must be carried out to measure the efficiency of social
21. Spencer JH Lewis AB Peyser J et al A randomized clini cal trial of inpatient family intervention V Results for affective disorders J Affect Disord 1990 18 1 17 28 van Gent EM Zwart FM Psychoeducation of partners of bipolar manic patients J Affect Disord 1991 21 1 15 8 Reinares M Vieta E Colom F Martinez Aran A Torrent C Comes M et al Impact of a psy choeducational family intervention on caregivers of stabilized bipolar patients Psychother Psychosom 2004 73 5 312 9 Reinares M Colom F Sanchez Moreno J Torrent C Martinez Aran A Comes M et al Impact of caregiver group psychoeducation on the course and outcome of bipolar patients in remission a randomized controlled trial Bipolar Disord 2008 10 4 511 9 Goldstein MJ Psychoeducation and relapse prevention Int Clin Psychopharmacot 1995 9 Suppl 5 59 69 Pfammatter M Junghan UM Brenner HD Effi cacy of psychological therapy in schizophre nia conclusions from meta analyses Schizophr Bull 2006 32 Suppl 1 564 80 Lincoln TM Wilhelm K Nestoriuc Y Effectiveness of psychoeducation for relapse symp toms knowledge adherence and functioning in psychotic disorders a meta analysis Schizophr Res 2007 96 1 3 232 45 B uml J Pitschel Walz G Volz A Engel RR Kissling W gt Psychoeducation in schizophre nia 7 year follow up concerning rehospitalization and days in hospital in the Munich psy chosis information project study J Clin Psychiatrys2007 68
22. T Corcoran C Wexler BE Neurocognitive enhancement therapy with work therapy effects on neuropsychological test performance Arch Gen Psychiatry 2001 58 8 763 8 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 149 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 150 Sohlberg MM Mateer CA Effectiveness of an attention training program J Clin Exp Neuropsychol 1987 9 2 117 30 Silverstein SM Menditto AA Stuve P Shaping attention span an operant conditioning procedure to improve neurocognition and functioning in schizophrenia Schizophr Bull 2001 27 2 247 57 Kern RS Green MF Mintz J Liberman RP Does errorless learning compensate for neu rocognitive impairments in the work rehabilitation of persons with schizophrenia Psychol Med 2003 33 3 433 42 Krabbendam L Aleman A Cognitive rehabilitation in schizophrenia a quantitative analysis of controlled studies Psychopharmacology Berl 2003 169 3 4 376 82 McGurk SR Twamley EW Sitzer DI McHugo GJ Mueser KT A meta analysis of cogni tive remediation in schizophrenia Am J Psychiatry 2007 164 12 1791 802 Hogarty GE Greenwald DP Eack SM Durability and mechanism of effects of cognitive enhancement therapy Psychiatr Serv 2006 57 12 1751 7 Spaulding WD Reed D Sullivan M Richardson C Weiler M Effects ot cognitive treatment in ps
23. The first European Congress of Families was held in June 1990 which led to the foundation of EUFAMI in 1992 We can sum up the main tasks and contributions of these organisations 1 Collaboration in the preparation of healthcare planning policies and legislation In the political field the associative movements of families and people with mental ill ness have a historical function of demanding improvements in the care of people with mental illness Currently these movements in Europe and in other countries also have an active func tion in the design development and assessment of policies as indicated by the World Health Organisation WHO and as included in the actions of the European Commission Green Paper CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 133 on Mental Health and the future European Strategy on Mental Health Its role in the regulation of the Involuntary Outpatient Treatment IOT is also known as well as in the Law on Promotion and Prevention of Autonomy and Care to Dependency among others 2 Service Providers The associative movements are also characterised because they carry out support services In some countries such as France or Ireland the services provided by the associative movement are focused on support and training groups information services and awareness demand and denunciation actions In Spain as in Great Britain different social or social health services a
24. abuse not specifying percentage of psychiatric diagnoses of sub stance abuse of the sample In some of the studies assessed the intervention of the control group exceeds what in our context would be standard treatment which would favour the lack of appearance of differences between the interventions compared An absence of data from quality studies has also been en countered showing that integrated treatments are more effective than non integrated treatments although both interventions show efficacy compared with the standard treatment for dual SMI patients Another relevant aspect is that these scientific studies originate exclusively from Anglo Saxon countries and generate doubts about the extrapolation to our context as in our context there are no integrated assertive community treatment teams programmes for dual pathology although there are integrated treatment teams In our context there are few services with integrated treatment programmes for dual pa tients and starting them up systematically and in a generalised way would represent an increase in resources when in many fields there are parallel networks with programmes that are already functioning The motivation factor is important in these studies and differences are observed with respect to the moment of the intervention There are authors that sug est that the heterogeneity could be reduced studying interventions and results related to specittc treatment stages support and
25. after finishing ihe treatment 1 There is better compliance with the pharmacological treatment when the family interven tion is more than 5 sessions 1 Family intervention of more than 5 sessions represents a significant reduction of the bur den perceived by family carers 2 1 Family intervention of more than 5 sessions reduces the expressed emotion levels within families l Patients who have received family intervention have a higher quality of life 1 There are no differences that determine that family intervention reduces negative symp tom levels of people with schizophrenia or improves social functioning The evidence found is ot sufficient to determine if family intervention reduces suicide l 80 rates js Family intervention of 6 months or more or more than 10 scheduled sessions reduces relapses at to 15 months follow up after treatment ix There are no differences between multi family intervention and single family interven tion ii connection with relapses at 13 to 24 months 1 There are no differences between multi family intervention and single family interven ion related to pharmacological treatment adherence People with schizophrenia who received single family intervention compared with those 2 who received multi family intervention can lead a more independent life Individual family therapy with a behavioural approach improves the results of social l functioning doses of antipsychotic
26. articles found was carried out Articles werexejected which according to the title or abstract could not respond to the questions With the remaining articles those whose title and abstract appeared to be useful a second screen ing was carried out and a first reading was done to see if they could answer some of the questions of the CPG Afterwards the quality of those articles that had passed the two screenings was assessed using the OSTEBA OST FL Critica critical appraisal tool To classify the evidence of the effectiveness of the interventions selected the modified hier archic classification system of the Scottish Intercollegiate Guidelines Network SIGN appendix 1 was used and the data obtained from the selected articles were dumped onto a grid for assess ment and subsequent development of the guideline recommendations appendix 3 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 27 The highest evidence level found was selected for each intervention questions When there was a systematic review SR or meta analysis in relation to the question these were used as a source of evidence and the less solid and worst quality studies were rejected When SR or meta analyses could not be found observational studies or case series were used The evidence level of the information obtained from other sources such as the aforemen tioned CPGs was maintained so long as the original source that the evid
27. be understood as complementary processes to those established in health cere and that permit certain protection guarantees for the person affected by a Severe Mental Illness to permit a certain degree of autonomy and social solvency It is important to point out the implicit possibility of recognising the condition of disability for a personowith a mental health problem if their capacity to act their ability and autonomy is reduced lese difficulties can be recognised through the acquisition through the Specialised Social 5 rvices of each one of the autonomous communities of the relative disability certificate This condition is reflected procedurally in the Law on Social Integration of the Disabled and which as a basic process for its acquisition would be 1 Existence of a disabling illness of acknowledged chronic nature 2 Mandatory report of the illness by a physician who will perform a diagnostic appreciation and indicate the specific difficulties 3 Mandatory report from Social Work referring to the difficulties and needs for social con currence or support of a third person who will assess the environment of the person and the social consequences of the specific pathology that affects the person 128 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 4 Request to the relative body of an evaluation of this case The teams of Grass roots Social Services Centres will receive the demand The competence evaluation team of each autonomous
28. been pharmacological inter ventiens since they were introduced in the fifties of the last century the partial and limited control of the symptomatology the short and long term side effects and the poor treatment adherence of quite a considerable percentage of people affected pose the need to use a broader approach where pharmacological treatment is complemented with other psychotherapeutic and psychoso cial interventions which must be efficiently coordinated and applied to help them recover from acute episodes and from the functional deficit during the episodes and between them Caring for people with SMI requires the integration of different levels of care and different types of intervention that form an inseparable whole and that are integrated into new objectives CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 21 independence quality of life personal well being social participation around the concept of per sonal recovery Caring for mental illnesses no longer just means relieving symptoms but it also means having to cope with the different resulting needs All in all caring for these people requires integrating psychopharmacological interventions and psychosocial interventions into a mental health network comprised of interdisciplinary teams This text is the full version of the Clinical Practice Guide on Psychosocial Interventions in Several Mental Illness http www guiasalud es 22 CLIN
29. certain limitations with respect to the size of the sample ti 36 the fact that there is no comparison therapy or group and that it is applied to people wth high motivation levels The results indicate that significant differences have been found respect to Before and General satisfaction with life p lt 0 001 after 3 Reduction of solitude p lt 0 001 Promotion of self esteem p lt 0 05 Satisfaction with social relations p 0 05 Satisfaction with leisure activities p lt 0 05 Social functioning p lt 0 001 There is certain professional knowledge based mainly on daily clinical practice of the symp tomatic improvement of some people with SMI arter their participation in programmes that struc ture the execution of constructive leisure activi es Despite the lack of evidence about tne efficacy of these programmes this type of interven tions and resources exist today and they can be accessed through the Spanish national health system or social services The mental health and social services professionals have the skills to carry out these interventions however there are great differences between the different autono mous communities and between rural and city areas respect to resources and to the programmes offered Summary of evidence Daily living skills programmes Th re are no differences between people who have been trained in the daily living skills programme compared with those wh
30. developed by the National Institute for Hsalth and Clinical Excellence of the United Kingdom NICE and it was decided to us them as a secondary source of evidence that would help answer some specific aspects Once the part corresponding to the identification and analysis of published CPGs had ended in order to make the bibliographic search for relevant evidence that might respond to the questions of the CPG formulated previously it was established that the following general databases would be consulted Medline Cochrane Library Embase and PsycINFO Furthermore different web sites entities and associations were consulted such as the Centre for Reviews and Dissemination CRD NICE American Psychiatric Association APA and Clinicaltrlals gov Mesh term and free language were used for the search strategy in order to improve the sensitivity and specific ity of the search The search was restricted to systematic reviews of randomised control trials and original studies of randomised and non randomised control trials and to English French Por uguese and Spanish languages A hand search was also carried out to review the references of the identified included or excluded studies A hand search was carried out in scientific magazines to obtain information on some aspects of the CPG Due to the lack of quality evidence relating to some specific aspects of the questions an ex tended search for original observational studies and case series
31. favour ofmorita therapy in the medium term l Morita therapy standard treatment improve the mental state in the medium term Morita therapy improves the capacity to carry out daily living activities in people with 1 ae schizophrenia in the short and medium term 1 There are differences between the distraction technique and standard treatment related to improving the mental state of people with schizophrenia 1 Drama therapy did not show any improvement in the mental state of hospitalised people with schizophrenia 1 Drama therapy can help improve the self esteem of people with schizophrenia There is no evidence to indicate that hypnosis iriproves the mental state in people with schizophrenia Recommendations Sufficient evidence has not been found to make recommendations related to morita thera py drama therapy distraction therapy and hypnosis in the treatment of people with SMI 5 2 Social interventions These are interventions activities and community support structures whose aim is to facilitate social integration into the context Social interventions include different types of strategies and programmes This CPG includes daily living programmes residential programmes in the com munity and programmes directed to leisure and spare time p Question to be answered e Do social insertion programmes daily living skills programmes residential
32. for people with SMI and a diagnosis of bipolar disorder RCT 14 RCT 14 68 Complex pyschoeducation programmes that include pyschoeducation on bipolar disorder c ramunication improvement and problem solving train ing reduce the number of relapses in 2 years compared with a non direc tive group intervention of the same intensity n 170 RR 0 71 95 CI between 0 6 and 0 84 109 110 No data are observed that support the fact that complex pyschoedu cation reduces the number of readmissions after 2 years follow up when compared with a non directive group intervention of the same intensity n 170 RR 0 47 95 CI between 0 17 and 1 3 9 0 Pyschoeducation interventions that incorporated prodrome recogni tion training reduces relapses in maniac phase n 69 27 vs 57 in the control group WMD 1 97 95 CI between 3 2 and 0 74 although there was no reduction in relapses in the depressive phase after 18 months study n 68 WMD 1 1 95 CI between 1 41 and 3 61 No data are found to support that the pyschoeducation programme with prodrome recognition reduces the number of hospitalisations 12 months after treatment onset compared with standard treatment n 68 RR 9 93 95 CI between 0 66 and 1 31 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Summary of evidence 1 Pyschoeducation compared with non intervention or non specific intervention does not produce a significa
33. for undefined refresher sessions 5 1 7 Cognitive reliabilitation People with SMI and diagnosis of schizophrenia and related disorders that have cognitive impairment must be offered cognitive rehabilitation programmes Cognitive rehabilitation programmes aimed at people with SMI and cognitive impairment must be integrated into more extensive psychosocial rehabilitation programmes From the cognitive rehabilitation interventions or programmes aimed at people with SMI it is advisable to oose those that include or are accompanied by compensatory interventions in other words changes in strategy and training in coping skills or techniques 5 1 8 Other psychotherapies Sufficient evidence has not been found to make recommendations related to morita therapy drama therapy distraction therapy and hypnosis in the treatment of people with SM CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 5 2 SOCIAL INTERVENTIONS 5 2 1 Daily living skills programmes Daily living skills training programmes could be offered to people with SMI in order to improve their personal independence and their quality of life 5 2 2 Residential programmes in the community For people with SMI who require support to remain in their accommodation D it is D advisable that the community residential offers include more extensive psychosocial programmes 52 3 Programmes aimed at leisure and spare time People
34. if CBT reduces symptoms after 9 months follow up there is no important improvement when measured as a 2046 re duction in BPRS n 60 RR 0 53 95 CI between 0 35 and 0 81 NNT 3 95 CI between 2 and 6 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS SR 1 SR 1 SR 1 SR 1 SR 1 43 SR 1 SR 1 There is strong evidence that indicates that CBT improves the mental state in post treatment assessment BRPR CPRS scales n 182 SMI 0 56 95 CI between 0 85 and 0 26 Social functioning There is limited evidence of improvement when CBT is compared with non standard care at the end of treatment Role functioning scale n 15 WMD 4 85 95 CI between 7 31 and 2 39 Cognitive behavioural therapy CBT vs other treatments SR 1 In the systematic review of Zimmermann et al that compares GBT with other treatments in the improvement of the positive symptomssihe results indicate that CBT reduces positive symptoms when compared with other treatments and that the benefit was greater for patients with acute episodes than for chronic patients CBT vs non specific treatment chronic 5 stud les n 246 RR 0 32 95 CI between 0 06 asd 0 57 and CBT vs usual treatment medication chronic 6 studies 3 569 RR 0 26 95 CI between 0 09 and 0 43 Social Skills Training SST Social skills training vs standard treatment ST or o
35. illness systematic review and meta regression BMJ 2007 335 7615 336 Burns T Catty J Watt H Wright C Knapp M Henderson J International differences in home treatment for mental health problems results of a systematic review Br J Psychiatry 2002 181 375 82 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 Weiss RD Griffi n ML Kolodziej ME Greenfi eld SF Najavits LM Daley DC et al A randomized trial of integrated group therapy versus group drug counseling for patients with bipolar disorder and substance dependence Am J Psychiatry 2007 164 100 7 Schmitz JM Averill P Sayre S McCleary P Moeller FG Swann A Cognitive behavioral tratment of bipolar disorder and substance abuse a preliminary randomized study Addict Disord Treat 2002 1 1 17 24 Morse GA Calsyn RJ Dean KW Helminiak TW Wolff N Drake RE et al Treating home less clients with severe mental illness and substance use disorders costs and outcomes Community Ment Health J 2006 42 4 377 404 Cheng AL Lin H Kasprow W Rosenheck RA Impact of supported housing on clinical outcomes analysis of a randomized trial using multiple imputation technique J Nerv Ment Dis 2007 195 1 83 8 Drake RE O Neal EL Wallach MA A systematic review of psychosocial research on psy chosocial interventions for people with co occurring severe mental and su
36. in daily living skills such as hygiene food preparation or management of finances e Inappropriate social behaviour tat determines the intervention of the Mental Health System or the Judicial Systera In more recent formulations this disability can be defined by the moderate to severe affec tion of labour social and fami y functioning and measured through the GAAS using as a cut off value the score corresponding to light affections 70 in the less restrictive cases or moderate 50 which indicates considerable severity of the symptoms with serious affection in social functioning and competence The people thai this CPG is aimed at are people who suffer from Severe Mental Illnesses and satisfy the three classification dimensions described above 4 2 Definition of psychosocial rehabilitation concept 1he concept of psychosocial rehabilitation falls within a space where there level of confusion and imprecision is considerable due to factors such as the polysemous nature of many of the terms that we use the complexity of theoretic positions and practices and their differing level of devel opment in general and especially in our country Psychosocial rehabilitation also called psy chiatric rehabilitation consists in a series of psychosocial and social intervention strategies that complement the pharmacological interventions and management of the symptoms and whose aim is to improve personal and social functioning quality of l
37. in the normal medium that includes medication hospitalisation nursing care and that is conditioned by the personal prefer ences of the people the criteria of the professionals and availability of resources Hospital rehabilitation unit Hospital health mechanism designed to satisfy integrated treatment rehabilitation and containment functions CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 141 Appendix 7 Declaration of interest All the members of the development team expert collaborators and external reviewers have de clared no conflict of interest Milagros Escusa Juli n Francisco Gal n Calvo Laura Gracia L pez Pedro Pibernat Deulofeu Ana Vallesp Cantabrana Juan Ignacio Mart n S nchez Maria Jos Vicente Edo Jos M lvarez Mart nez Daniel Navarro Bay n Antonio Lobo Satu Juli n Carretero Rom n Carlos Cuevas Yust Bego a Iriarte Campo Juan Francisco Jim nez Est vez Jos Manuel Lalana Cuenca Marcelino L pez lvarez Mercedes Serrano Miguel Catalina Sureda Garc a Oscar Vallina Fern ndez have declared no interests Francisco Caro Rebollo has received funding Janssen Boehringer Ingelheim Lundbeck GSK and Novartis for attending meetings courses and congresses He has obtained fees Janssen as a speaker at courses and conferences He has also received economic aid to participate in re search projects Bristol Myers Squibb AstraZeneca Esteve Novartis Janss
38. lack of supportive programmes to the ordi nary market they remain as definite sheltered employment and sometimes marginal employment Supported employment is directed at immediate placement in the competitive market ac companied by training and individual Monitoring measures at work as well as support to the employer with no definite time intervei to guarantee maintenance of the job This approach places emphasis on quick access and attention to personal preferences and motivations on considering that there is not need for long rocesses of evaluation and re training which in some cases are a factor of demotivation ana that the personal stability process is accelerated if care and labour aspects are integrated at th same time enabling them to overcome difficulties Of all the empioyment support models the one that has been investigated into the most is individual placement and support IPS In this vay it can be considered that the interventions to be addressed by this CPG will include ngbonly sheltered employment labour rehabilitation interventions including sheltered workshops special employment centres etc but also include employment support Question to be answered Which employment related intervention format improves labour market insertion of people with SMI The NICE Schizophrenia CPG includes the SR by Crowther et al and also 2 other RCTs 69 9 The inclusion criteria used in the NICE CPG refer to pe
39. learning of cognitive skills in individual or group format Those studies that assessed the impact of operating behav ioural techniques such as modelling were excluded except when some type of behavioural re inforcement was combined with cognitive remediation Interventions limited to training in one single cognitive task were also excluded The effects of the intervention were compared with placebo another intervention or standard treatment The training method must be different to the tests used to measure Seven studies were excluded from this review as they did not include control condition of which 4 had also been excluded by the NICE CPG and 12 studies because the intervention involved training in one single paradigm or the task training was also used as an assessment measure In the meta analysis performed by McGurk et al which included 26 RCTs n 1151 the studies included are controlled and randomised and they use a psychosocial interventios aimed at improving the cognitive function The assessment had to include neuropsychological measures that had the potential of reflecting generalisation rather than assessing the trained task The only RCT included in this question combines data from 121 patients with schizophre nia or schizoaffective disorders randomly assigned either to Cognitive Enhancement Therapy CET n 67 or to Enhanced Support Therapy EST n 54 and the are treated for 2 years The patients were st
40. least one day than the vocational programmes 55 vs 28 lower number of dropouts 13 vs 45 and re hospitalisations 20 31 It was also observed that the local employment rate had a substantial influence on the efficacy of the IPS programme p lt 0 016 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS SR 1 SR 1 RCT 14 RCT 14 RCT 1 RCT 1 87 Summary of evidence I The evidence is insufficient to determine if pre vocational training confers an additional benefit to the labour expectations of people with SMI when we compare it with standard treatment with respect to maintenance of competitive employment 170 171 113 174 PVT favours obtaining some type of employment when compared with standard hospital treatment There are no differences with respect to hours worked per month between PVT and hos pital ST for people with SMI 1 The incorporation of payment into PVT produces a limited but significant improvement of the results The incorporation of payment into PVT produces a limited but significant improvement of the results There is no difference with respect to participation level of users in programmes when PVT programmes are compared with standard hospital treatment 1 Neither PVT nor community ST improve the programme finalisation rates 9 1 PVT does not improve the hospital readmission ratios
41. management CM is more effec tive in people with SMI d INTERVENTIONS WITH SPECIFIC SUB POPULATIONS What type of treatment has proven to be most effective in people with SMI and substance abuse integral or parallel treatment Which intervention is more efficient in people with SMI and homeless e Which psychosocial treatment is more effective in people with SMI and a low IQ 14 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Summary of recommendations 5 PSYCHOSOCIAL TYPE REHABILITATION INTERVENTIONS 5 1 PSYCHOLOGICAL INTERVENTIONS 5 1 1 Cognitive behavioural therapy In people with SMI cognitive behavioural treatment can be used combined with e standard treatment to reduce positive symptomatology mainly hallucinations y People with SMI and persistent positive symptomatology can be offered a specific C cognitive behaviour orientated psychological intervention for this pathology lasting for a prolonged period of time more than one year in order to improve the persistent symptomatology Incorporate cognitive therapy into strategies aimed at preventing relapses of depressive C symptomatology in people with SMI and diagnosis of bipolar disorder B When the main objetive of the intervention in people with SMI iso improve their social functioning it is advisable to incorporate social skills training There is not sufficient evidence to make recommendations in the problem solving area for peo
42. medication and psychotic symptoms compared with group family therapy 1 There is no difference between behavioural family intervention and family supportive intervention of more than 5 sessions with respect to hospital re admissions CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 63 The people who receive systemic family therapy obtain an improvement respect to read missions relapses and treatment adherence however this improvement is not maintained after 2 years follow up 1 When the person affected by the disease is included in family interventions the relapse levels drop Family interventions combined with other interventions 1 Combined psychosocial treatment produces improvements of 40 in the evaluation of the clinical severity social functioning and stress perceived by the caregiver in the 24 month evaluation 1 Combined psychosocial treatment achieves 25 more cases of complete recovery inva 24 month period 1 1 In 25 of the cases of recent onset schizophrenia 10 years evolution andi 40 of the chronic cases gt 10 years the combined psychosocial treatment applied for 24 months does not achieve any type of improvement Psychoeducational type family therapy together with SST and pharmacological treatment in people with schizophrenia who come from homes with high exe ressed emotion did not present any relapse in 12 months
43. of the treatment 28 months n 92 RR 0 67 95 CI between 0 34 and 1 32 Family intervention vs non intervention RCT 1 RCT 1 RCT 1 RCT 1 RCT 1 62 No differences are found in the lt clinical improvement between the two groups at the end of treatment n 26 RR 0 49 95 CI between 0 10 and 2 4 nor after 6 months follow up n 26 RR 0 73 95 CI be tween 0 05 and 10 49 s People from th amp family intervention group presented an increase in anxiety levels compared with the group that did not receive any interven tion n 39 WMD 0 69 9596 CI between 0 05 and 1 34 No attterences are found between the family psychoeducation inter vention groups for carers caregivers and non intervention in the relation shipS in the family environment expressiveness cohesion and conflict Expressiveness n 2 45 WMD 0 03 9596 CI between 0 65 and 0 59 cohesion n 45 WMD 0 10 95 CI between 0 52 and 0 72 and conflict n 45 WMD 0 33 95 CI between 0 95 and 0 29 Van Gent amp Zwart indicate that there are no differences between the marital psychoeducation family intervention groups for couples vs no intervention n 45 WMD 0 33 95 CI between 0 95 and 0 29 There are no differences either between either of the two groups with re spect to treatment adherence at the end of the study 12 months n 36 RR 1 06 95 CI between 0 73 and 1 54
44. offered that include family intervention with a pyschoeducational component and coping and social skills training techniques added to the standard treatment for people with SMI and diagnosis of non affective psychosis Family members and caregivers of people with SMI and a diagnosis of bipolar disorder must be offered group pyschoeducational programmes that include information and coping strategies that permit discussions within a friendly emotional climate 5 1 6 Pyschoeducational interventions Quality information must be provided about the diagnosis and the treatment giving support and handling strategies to people with SMI and diagnosis of schizophrenia and related disorders to the family members and to the people with whom they live Pyschoeducational programmes that are offered to people with SMI and diagnosis of schizophrenia and related disorders must incorporate the family Group pyschoeducational programmes aimed at people with SMI and diagnosis of bipolar disorder must incorporate specific psychological techniques carrying them out in a relatively stable period of their disorder and always as a supplement to the psychopharmacological treatment The pyschoeducational programmes for people with SMI mist be integrated as an additional intervention in an individualised treatment plan whose duration will be proportional to the objectives proposed considering a minimum of 9 months intensive programme and the need
45. only population Cognitive behavioural therapy CBT for people with SMI and a diagnosis of schizophrenia and related disorders Jones et al perform a SR comprised of 19 RCTs quasi randomised studies were excluded No trial was able to use a double blind experiment due to the difficulties inherent to the concealment process in psychosocial interventions Out of all the RCTs 7 studies tried to reduce any resulting bias by using assessors who were unaware of the designation The duration of the trials varied between 8 weeks and 5 years bute average duration was approximately 20 months The 19 trials focused their study on people with psychosis such as schizophrenia delirium disorder or schizoaffective disorder and they all used operative criteria for the diagnoses DSM III R DSM IV or ICD 18 It was reported that many people suffered other comorbid mental disorders such as depression or anxiety disorder In only one trial the duration of the illness was less than 5 years S ie authors intentionally selected people with medication resistant symp toms The ages of the participants varied between 18 and 65 years old The following interventions are assessed in this review e Cognitive behavioural therapy this has been used to make reference to different inter ventions so the reviewers prepared the following specific criteria to be able to define a cognitive behavioural intervention as such The intervention must repres
46. people with schizophrenia 9 55 196 Music therapy produces a positive effect on the improvement of the negative symptoms social functioning of people with schizophrenia Interventions of music therapy with more than 20 sessions improve the mental state and CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 91 There are no differences between music therapy and ST with respect to patient satisfac tion in the medium term or the improvement of the quality of life Art therapy may produce an improvement in the mental state of people with schizophre l nia However there are no differences with respect to social functioning or improvement of quality of life Recommendations Music therapy and art therapy could be offered to people with SMI and schizophrenia and C related disorders as a therapeutic complement to other types of interventions 5 3 Service level interventions The different community care models are based on the need to help people wit SMI have access to health resources and to coordinate the different interventions After a global deinstitutionalisa tion process a series of community services have been developed Co simunity Mental Health Centres CMHC day centres etc which will be reviewed in this section In Spain this process came hand in hand with the General Law on Health and represented the emergen
47. personnel patient ratio for example 10 1 Services supplied in the community not in the surgery e Cases shared by the team not assigned individually 24 hour coverage 7 daysa Week Services provided by the team not external Unlimited in time There are other forms of intervention derived from MC and CAT such as Care Programme Approach CPA with these bases Systematic methodology to assess the social and health 2eds Care plan that identi fies the social and health care required for a series of providers Appointment of a case manager to maintain close contact with the user and monitor and coordinate the care Regularly programmed reviews updates and modifications agreed by consensus of the care plan Intensive Case Management ICM characterised by a burden of less than 20 patients per case manager normally one psychiatrist The ICM Intensive case managem nt model was developed to cover the needs of high frequency patients reducing the actua personnel patient ratio of the agent MC and reaching lim its similar to those of the CAT The difference here is that in the CAT the cases are shared by the team whilst in ICM they continusto be assigned individually to the case manager as in the agent CM Successive modificatioris have been made to models such as strengthening or rehabilitating granting a greater role to the patients preferences and to their capacities Community car of patient
48. psychoa nalysis for schizophrenia and severe mental illness Cochrane Database Syst Rev 2000 2 CD001360 May PR Tuma AH Dixon WJ Schizophrenia a follow up study of results of treatment I Design and other problems Arch Gen Psychiatry 1976 33 4 474 8 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 69 70 71 72 T3 74 75 76 TI 78 79 80 81 82 84 85 Gunderson JG Frank AF Katz HM Vannicelli ML Frosch JP Knapp PH Effects of psy chotherapy in schizophrenia II Comparative outcome of two forms of treatment Schizophr Bull 1984 10 4 564 98 O Brien CP Hamm KB Ray BA Pierce JF Luborsky L Mintz J Group vs individual psychotherapy with schizophrenics a controlled outcome study Arch Gen Psychiatry 1972 27 4 474 8 Leichsenring F Rabung S Effectiveness of long term psychodynamic psychotherapy a metaanalysis JAMA 2008 300 13 1551 65 Frank E Kupfer DJ Thase ME Mallinger AG Swartz HA Fagiolini AM et al Two year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disoraer Arch Gen Psychiatry 2005 62 9 996 1004 Scott J Colom F Vieta E A meta analysis of relapse rates with adjunctive psycho logical therapies compared to usual psychiatric treatment for bipolar disorders Int J Neuropsychopharmacol 2007 10 1 123 9 Buckley LA Pettit T Adams CE Supportive therapy for schizophrenia Cochrane Database Syst Rev 2007 3 CD004716
49. same analysis with the subgroup of patients who presented no difficulty in taking the medication n 78 a smaller percent age of relapses was observed in the group FP PT 11 p 0 012 a simi lar percentage of relapses in the group SST PT 17 SST p 0 084 a similar percentage in the control group PT 32 and again a clear additive effect in the combined group without relapses in 12 months 0 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS After two years treatment and bearing in mind the study design where RCT 1 a reduction in frequency in both interventions was foreseen in the second year maintenance of the effect of family therapy FT is observed in the prevention of relapses 29 and the effect of social skills training SST is not maintained 50 This reduction in the effect is late arriving after 21 months returning to similar rates in the control group 62 and the ad ditive effect of FT and SST is lost with 25 relapses p 0 004 Failure to comply with the medication was less frequent in the experimental groups than in the control group 21 and 40 respectively Failure to comply with the medication was associated with the relapse 26 of the 28 non com plying people suffered a relapse The group with psychosocial intervention experienced a significant clinical improvement in the intervention period and this was maintained af ter 4 years follow up p lt 0 05 compared with the control group where
50. severo en Andaluc a I de scripci n general del programa y del estudio Rehabil psicosoc 2005 2 1 2 15 L pez M Garc a Cubillana P Fern ndez L Laviana M Maestro JC Moreno B Evaluaci n del programa residencial para personas con trastorno mental severo en Andaluc a II cara cter sticas de los dispositivos residenciales Rehabil psicosoc 2005 2 1 16 27 L pez M Fern ndez L Garc a Cubillana P Moreno B Jimeno V Laviana M Evaluaci n del programa residencial para personas con trastorno mental severo en Andaluc a III car acter sticas sociodemogr fi cas cl nicas y de uso de servicios de los residentes Rehabil psicosoc 2005 2 1 28 46 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 151 154 155 156 157 158 159 160 161 162 163 164 165 166 167 170 152 L pez M Garc a Cubillana P Laviana M Fern ndez M Fern ndez L Maestro JC Evaluaci n del programa residencial para personas con trastorno mental severo en Andaluc a IV perfi les funcionales y redes sociales de los residentes Rehabil psicosoc 2005 2 2 44 55 L pez M Garc a Cubillana P L pez A Fern ndez L Laviana M Moreno B Evaluaci n del programa residencial para personas con trastorno mental severo en Andaluc a V actitudes y grado de satisfacci n de los residentes Rehabil psicosoc 2005 2 2 55 63 Ware NC Hopper K Tugenberg T Dickey B Fisher D A
51. skills development both for handling and for preventing relapses People with SMI and substance abuse No differences were found between long term integrated treatment 36 months and standard treatment which 5ciudes the same interventions ex cept for assertive community treatment which were developed by different teams respect to the use of substances n 85 1 RCT RR 0 89 95 CI between 0 6 and 1 3 With reference to abandoning the treatment it is also observed that no differences have been found either between the long term integrated treat ment 36 months and standard treatment n 603 3 RCT RR 1 09 95 IC between 0 8 and 1 5 and the same occurs with respect to the number of rehospitalisations n 198 2 RCT RR 0 88 95 CI between 0 6 and 1 2 Regarding to integrated assertive community treatment ACT and RCT 1 standatd ACT no significant results were observed in favour of either the int rventions regarding satisfaction at 24 months although there are sig aificant results between both interventions when compared with standard treatment p 0 03 No differences have been found either with respect to housing stability at 24 months although they do exist between both inter ventions when compared with standard treatment p 0 03 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 103 RCT 1 There are signs that indicate that integrated clinical servic
52. skills training in dif ferent sub populations and their generalised use in other functioning areas The utility of the use of motivational interviews in people with SMI must be assessed by research studies as well as their indications with respect to specific clinical situations dual disor der lack of awareness of the illness collaboration or treatment adherence 5 1 2 Psychodynamic psychotherapy and psychoznalytical approach Studies must be developed that analyse the efficacy of psychodynamic therapies and psy choanalytical approach in people with SMJ with designs that adapt to the peculiarities of their epistemology to the singular nature of each individual and the Spanish and European area 5 1 5 Family interventions Family intervention is an important component in the treatment of people with SMI so there must be well designed studies that investigate which the components of family intervention are associated with the stability and improvement in the psychosocial functioning in a prolonged manner The efficacy of integrated or combined programmes which include work with the family of people with S MI must be examined to see if it is mediated by the greater treatment adherence fulfilment or is independent from this Dueto the lack of studies related to family intervention in population with SMI and bipolar disorders quality research studies must be carried out that include this population 5 1 7 Cognitive Rehabilitati
53. the number of treatment phases and the treatment duration Standard care consists of pharmacological treatment and the results are grouped into short term up to 12 week medium term 13 to 52 weeks and long term gt 52 weeks This type of therapy is nofa common normal OK practice and it is not very well known among professionals of the Spanish National Health System as it has its origins in an Asiatic culture in particular Japar and China Sufficient studies have not been found either and there are no data about its practice that can be applied to people with SMI in different cultural contexts Distraction techniques for people with SMI Distractieiriechniques were considered to be coping strategies involving a diversion This can be a passive distraction technique such as watching television listening to music using headphones or racticing relaxation Alternatively the distraction can involve activities such as playing an instrument writing reading gardening walking or some other form of exercise Other distrac tion techniques include socialisation suppression of unwanted thoughts and problem solving for future events Crawford Walker et al 5 RCTs n 186 examine the clinical effects of distraction tech niques to divert attention from hallucinations in people with schizophrenia or related disorders In this SR the distraction techniques are compared with standard care type of care that a person 74 CLINICAL
54. to perform basic activities of daily living or in the case of people with intellectual disability or mental illness other supports for their personal autonomy The evaluation and access to these benefits is regulated by each Autonomous Community http www segsocial es Internet l LaSeguridadSocial Quienessomos Institu toNacionalde29413 index htm Functions of the social services professionais Some competences that are attributed to social services professionals and that act as coordi nation with the health spaces would be e Carry out evaluation tasks and social intervention with the referred users and their fami lies e Coordinate with be different resources of the social health network General Social Services training labour mechanisms etc e Attend anovform part of the Rehabilitation Commission of the area of reference if there are any e Participate in the taskforces of each one of the spaces defined Carry out the assessment ofthe families within the assessment protocol of each mechanism e Carry out the follow ups of the assigned users Inform and counsel users on resources especially those that represent greater normalisa tion and integration training labour educational leisure e Detect new resources and be responsible for compiling already existing resources e Coordinate with the Associations of Families and Users of the Areas of reference of the Rehabilitation Centre as well as with other types of
55. to the improvement of the mental state no differences were found between the motivational interview alone and standard treat ment 1 RCT n 30 WMD 4 2 95 CI between 18 7 and 10 3 RCT 1 The motivational interview appears to be more efficient than standard treatment in the achievement of a greater percentage of follow ups afterthe intervention n 93 58 vs 84 RR 0 69 95 CI between 9 5 and 0 9 NNT 4 Cognitive behavioural therapy CBT for people with SMI and a diagnosis af bipolar disorder BD Cognitive behavioural therapy BCT vs standard treatment ST Relapses RCT 14 In one RCT where there is a 30 month fotiow up no significant differ ences were found to prevent maniac relapses n 103 OR 0 48 95 CI between 0 21 and 1 13 but for depressive relapses significant differences were found OR 0 32 95 CI between 0 13 and 0 74 Readmissions RCT 1 No statistically significant differences have been found in the reduction of readmissions between either of the two interventions n 28 OR 0 30 95 CI between 0 65 and 1 91 Cognitive behavioural therapy BCT 4 standard treatment ST vs standard treatment ST Social functioning RCT 1 Two sitidies by the same author found that there is no evidence that de termines which intervention is more effective at 6 months follow up n 193 WMD 0 13 95 CI between 0 37 and 0 1 Nor at 18 months n 68 WMD 0 3 95 C
56. to the information support and lobby they carry out Thanks to these organisations closely linked to the community care of mental health it has been possible to foster the creation of new healthcare resources in response to the psychiatric de institutionalisation in many countries The families who are very often the only more direct support that people with SMI have now play an active part in the therapeutic process of rehabilitation or recovery and are considered as just another therapeutic agent Obviating their involvement in the development and impl men tation of care programmes would mean ignoring the needs to improve the quality of life of the people affected Their contribution in the fight against the stigma of mental illness the demand for accessibility to health and social resources within the parameters of equality and recognition of full rights for people with SMI has been and is fundamental to continue advancing in the achieve ment of these objectives The creation and consolidation in the entire Spanish territory of groups of pyschoeduca tion or school of families has helped provide these families with the aecessary information and strategies to cope with the difficulties represented by living with aaciation diagnosed with SMI Peers groups or self help groups have also been effective and giatifying for the families The Prospect training method for example a programme used indifferent countries and which was promoted by EU
57. vention in the context of a hospital from caretakers to administrative staff with 50 minute weekly group support shows a larger number of people in any type of employment in the PV group alternatives economic rein forcement compared with just PVT n 150 RR 0 40 95 CI between 0 28 and 0 57 and they alse arned significantly more money a month 192 and 32 respectively t 7 56 p 0 0001 The competitive work was not a result studied The participants in the paid sheltered work group presented greater per manence n 156 RR 0 53 9596 CI between 0 39 and 0 71 NNT 3 less number of hospital readmissions n 150 RR 0 55 95 CI between 0 31 and 0 96 NNT 6 and less scores in symptoms measured on the PANSS scale p lt 0 02 than the PVT group In the studies by Kline amp Hoisington and Blankerz amp Robinson PVT and psychological techniques were carried out In the study by Kline amp Hoisington there is a 1 5 hour group intervention for 12 weeks when discussions are held on labour values and which is aimed at reducing anxi ety In the Blankerz Robinson study counselling is applied as well as social technique learning and group sessions with reinforcement by partial objectives Both studies presented favourable results with respect to obtaining competitive employment n 142 RR 0 86 95 CI between 0 78 and 0 95 NNT 7 but heterogeneity was observed in the studies p 0 007
58. with SMI and deficiencies perceived in their social relations should follow community leisure and spare time programmes During the monitoring of the individualised therapeutic programme it is advisable to V systematically assess the need to use spare time programmes and offer hem to people with SMI who require them 5 2 4 Programmes aimed at employment lt Sheltered employment programmes are necessary for people swith SMI who express their desire to return to work or get a first job Programnies based on placement models are recommended with a short preliminary training period immediate placement and with frequent individual support Sheltered employment programmes aimed at seatching for normalised employment C must not be the only programmes related to tabour activity that are offered to people with SMI It would be recommendable for the psychosocial rehabilitation centres that look after D people with SMI and diagnosis of schizophrenia and related disorders to include employment integration programmes When employment insertion programmes are offered to people with SMI the preferences on the type et job to be carried out must be assessed and taken into account For people with SMivaid diagnosis of schizophrenia and related disorders who B have a history of previous job failure it would be advisable to incorporate cognitive rehabilitation as a part of the employment programmes they are going to partici
59. 0 WMD 1 60 IC 95 between 0 49 and 3 69 5 Dramatherapy ST vs group therapy ST The results indicate that there is no significant improvement of the mental state of hospitalised people with schizophrenia who have received drama therapy as n intervention compared with group therapy n 24 RR 0 5 95 C between 0 05 and 4 81 Psychodrama medication hospital stay vs medication hospital stay In the study conducted by Zhou amp Tang improved levels of self esteem were found in favour of the psychodrama group measured through the SES scale than in the control group n 24 WMD 4 95 CI between 0 80 and 7 20 Hypnosis Hypnosis vs ST No evidence is found to indicate that hypnosis improves the mental state after a week of intervention measured with the BPRS scale 1 RCT n 60 WMD 3 63 95 CI between 12 05 and 4 79 3 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Hypnosis vs relaxation No improvement or deterioration OK of the mental state has been found be RCT 1 tween hypnosis and relaxation assessed with the BPRS scale after a week of intervention 1 RCT n 60 WMD 3 38 95 CI between 11 40 and 4 64 Summary of evidence In morita therapy applied to people with schizophrenia no significant results have been found with respect to the improvement of negative symptoms or the improvement of the mental state However significant differences have been found in
60. 00 WMD 80 95 CI between 5 74 and 4 14 Social functioning There is no evidence to determine if the CMHC is associated with 2n im provement of social functioning according to the Social Functioning Questionnaire scale n 100 WMD 0 70 95 CI between 1 18 and 2 58 Service satisfaction In the CMHC group there was a smaller number of people who were dis satisfied compared with the participants who received ST n 87 RR 0 37 95 CI between 0 2 and 0 8 5 3 3 Assertive Community Treatment ACT ACT vs Standard treatment ST Use of services Patients who receive ACT have more probabilities of remaining in contact with services than those that receive community ST number of losses in follow uo n 1757 RR 0 62 95 CI between 0 52 and 0 74 and the probabilities of admission also decreases compared with ST n 1047 RR 0 71 95 CI between 0 52 and 0 97 NNT 7 95 CI between 4 and 100 The ACT decreases the probabilities of hospital admission compared with rehabilitation based in the hospital n 185 RR 0 47 95 CI be tween 0 33 and 0 66 NNT 3 95 CI between 3 and 5 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS SR 1 RCT 1 SR 1 SR 1 SR 1 97 SR 14 SR 1 Housing and work The ACT is associated with a reduction average of 40 in the use of beds The ACT is associated with an increase in satisfact
61. 10 Patients who have received family intervention have a higher quality of life than those who did not receive it n 213 WMD 19 18 95 CI between 9 8 and 28 6 after two years treatment There is not sufficient evidence to determine if family interventions reduce the levels of negative symptoms MSANS n 41 WMD 1 20 95 CI between 2 78 and 0 38 79 or if they improve social functioning Social Functioning Scale n 69 WMD 1 60 95 CI between 7 07 and 3 87 Sufficient evidence has not been found either that determines if faniiy intervention reduces the suicide rate 7 RCT n 377 RR 0 79 93 CI between 0 35 and 1 78 Duration of the interventions When the programme is provided for a period of 6 months or more or for more than 10 scheduled sessions there is evidence that indicates that family intervention reduces relapses at 4 to 15 months follow up after treatment n 165 RR 0 65 95 CI between 0 47 and 0 90 Family intervention formats Single family intervention vs milti family intervention There are no differences between multi family intervention and single fam ily interventions with respect to relapses at 13 to 24 months n 508 RR 0 97 95 CI betwesa 0 76 and 1 25 No differences were found either between the two types of family interventions regarding experiencing greater pharmacological treatment ad herence n 172 RR 1 0 95 CI between 0 5 and 2 0 Lef
62. 188 United Nations Resolution 46 119 December 1991 for the protection of the rights of persons with mental illness It recognises the right to labour health institutional and social non discrimination of these people 1996 Madrid Declaration Developed by World Psychiatric Association the ethical guidelines that must rule between patient and psychiatrist are indicated avoiding a compassionate attitude or an attitude exclusively aimed at avoiding injury to oneself or violence to third parties Royal Decree 63 1995 20 January on management of health benefits of the Spanish National Health System establishes the health benefits directly provided to people bythe National Health System More specifically it includes mental health care and psychiatric care in one of its sec tions covering clinical diagnosis psychopharmacotherapy and individual group or family psy chotherapy and hospitalisation where appropriate Strategy in Mental Health of the National Health System Approved by the Interterritorial Council of the National Health System on 11 December 2006 In this document we find general and specific objectives as well as recommendations whose aim is to improve prevention and care of Severe M tal Illness one of the priority healthcare lines for the Ministry In addition there are different community plans that set out development lines for Mental Health and include care for patients with SMI Law of Civil Procedure and
63. 3 6 619 41 Anthony W Rogers ES Farkas M Research on evidence based practices future directions in an era of recovery Community Ment Health J 2003 39 2 101 14 Farkas M The vision of recovery today what it is and what it means for services World Psychiatry 2007 6 2 68 74 Anthony WA Nemec P Psychiatric Rehabilitation En Bellack AS editor Schizophrenia treatment and care New York Grunne amp Stratton 1984 Ellis A Reason and emotion in psychotherapy New York Lile Stuart 1962 Beck AT Cognitive therapy and the emotional disorders New York International University Press 1976 D Zurita TJ Problem solving therapy a social competence approach to clinical interven tions New York Springer 1986 Meichenbaum D Cognitive behavior modifi cation an integrative apporach NewYork Plenum Press 2008 Labrador F Manual de t cnicas de modifi caci n y terapia de conducta Madrid Pir mide 1999 Bellack AS Mueser KT Psychosocial treatment for schizophrenia Schizophr Bull 1993 19 2 317 36 Caballo VE Manual de evaluaci n y entrenamiento de habilidades sociales 6 ed Madrid Siglo XXI de Espa a 2003 Kopelowicz A Liberman RP Zarate R Recent advances in social skills training for schizo phrenia Schizophr Buil 2006 32 Suppl 1 S12 23 Bellack AS Skiils training for people with severe mental illness Psychiatr Rehabil J 2004 27 4 375 91 x Bustillo I Lauriello J Horan W Keith S
64. 31 RR 0 88 95 CI between 0 78 and 1 00 Users with accelerated entry into transitional employment did not achieve better employment data n 131 RR 2 0 96 95 CI between 0 69 and 1 33 however they earned significantly more money Sheltered employment SE vs standard treatment ST RCT 14 Observational 3 RCT 14 86 Sheltered employment shows a significantly larger number of people in competitive employment after 24 and 36 months n 256 RR 0 88 95 CI between 0 82 and 0 96 NNT 9 but not after 12 months Users in stieltered employment programmes showed a greater prob ability of hotaing some type of employment after 12 months n 256 RR 0 79 9596 CI between 0 70 and 0 90 NNT 6 and also earn significantly mor money per month than the controls 60 5 vs 26 9 p lt 0 05 Sheltered employment did not show any significant differences with the controls in participation ratio n 2 256 RR 0 75 95 CI between 0 55 and 1 01 nor in a smaller number of readmissions n 2 256 RR 0 83 95 CI between 0 63 and 1 1 The greater participation in labour rehabilitation services was associ ated with the participation in competitive employment OR z 1 3 p 0 05 and to a greater extent with non competitive employment OR 1 62 p lt 0 0001 2 Compared with standard treatment programmes the patients included in the individual placement and support programme IPS had a greater pro
65. 6 854 61 Colom F Vieta E Martinez Aran A Reinares M Goikolea JM Benabarre A et al A rand omized trial on the effi cacy of group psychosducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission Arch Gen Psychiatry 2003 60 4 402 7 Colom F Vieta E Reinares M Martinez Aran A Torrent C Goikolea JM et al Psychoeducation effi cacy in bipolar disorders beyond compliance enhancement J Clin Psychiatry 2003 64 9 1101 5 Perry A Tarrier N Morriss 2 McCarthy E Limb K Randomised controlled trial of effi cacy of teaching patients wit bipolar disorder to identify early symptoms of relapse and obtain treatment BMJ 1999 318 7177 149 53 Delahunty A Morice R Rehabilitation of frontal executive impairments in schizophrenia Aust N Z J Psychiatry 1996 30 6 760 7 Medalia A Kevheim N Casey M The remediation of problem solving skills in schizophre nia Schizophr Bull 2001 27 2 259 67 Hogarty GE Flesher S Ulrich R Carter M Greenwald D Pogue Geile M et al Cognitive enhancement therapy for schizophrenia effects of a 2 year randomized trial on cognition and behavior Arch Gen Psychiatry 2004 61 9 866 76 Velligan DI Bow Thomas CC Huntzinger C Ritch J Ledbetter N Prihoda TJ et al Randomized controlled trial of the use of compensatory strategies to enhance adaptive func tioning in outpatients with schizophrenia Am J Psychiatry 2000 157 8 1317 23 Bell M Bryson G Greig
66. 7 Hospitalisation Assertive Community treatment does not reduce hospitalisation when comi pared with standard Case Management in homeless population 1055 re duction C 0 024 Symptomatology and cognition In homeless people with SMI assertive community treatment reduces the psychiatric symptoms compared with standard C se Management p 0 006 Living in a group improves the executive functions measured in agree ment with perseverance in WCST especialiy in patients with no substance abuse with an interaction between typeof housing evolution in time and abuse of substances or not p 0 01 Summary of evidence RCT 14 SR 12 6 SR 1 SR 1 SR 1 RCT 15 1 Patients who arecin an integrated housing system housing clinical services spend less time homeless more time in stable residence and in own apartment have less severe psychiatrie symptoms and show greater general satisfaction with life than participants in the paraliel programme Patients who access housing without prior conditioning factors housing first model drop more quickly in the rates of remaining in homeless status and remain for longer with Pi stable housing than those who have gone through a period of soberness and treatment lt acceptance Pirs ACT reduces the homeless status in 37 compared with CM L The best housing stability results are obtained by programm
67. CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Other websites Schizophrenia http www esquizo com Spanish Foundation of Psychiatry and Mental Health http www fepsm org Association of Obsessive Compulsive Disorder http www asociaciontoc org Psychosis Prevention Programme http www p3 info es Psychiatry website WWW psiquiatria com Psychiatry website www psiquiatria24x7 com CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 137 Appendix 5 Abbreviations ACT AEN AHCRPR AHRQ APA ADL CAT BPRS CDR CET ICD CPA CM CPRS CRT CMHC CSQ DAS SMI WMD DSM RCT GAAS SE SE IS PVT ES EST EWs FCO G LN GAF GAS CPG SK CI 95 Ci ICM IRS IPSRT IPT MHSC MSANS NEAR NET NICE 138 Assertive Community treatment Spanish Association of Neuropsychiatry Agency for health care policy and research Healthcare research and quality American Psychiatric Association Activities of Daily Living Cognitive adaptation training Brief psychiatric rating scale Centre for review and dissemination Cognitive enhancement therapy International Classification of Diseases Care program approach Case Management Comprehensive psychopathological rating scale Cognitive remediation therapy Community mental health centre Client satisfaction questionnaire Disablement assessment schedule Standardised mean deviation Weighted mean deviation Diagnosis and statistics manua
68. Clinical Practice Guidelines for Psychosocial Interventions in Severe Mental Illness NOTE It has been 5 years since the publication of this Clinical Practice Guideline and it is subject to updating The recommendations included should be considered with caution taking into account that it is pending evaluate its validity CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS MINISTRY OF HEALTH AND SOCIAL POLICY y E ED 5 T amp S MINISTERIO Plan de Calidad DE SANIDAD para a Sistema Nacional 1 fies Y POL TICA SOCIAL cie ae en A f sgi Na Clinical Practice Guidelines for Psychosocial Interventions in Severe Mental Illness CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS de Salud Inst tate Aragon s This CPG is an aid for decision making in health care It is not mandatory and it is not a substitute for the clinical judge ment of heathcare personnel Version 2009 Published by Ministry of Science and Innovation NIPO 477 09 049 4 ISBN 978 84 613 3370 7 Copyright deposit Z 3401 09 Printed by Arpirelieve This CPG has been funded through ne agreement signed by the Carlos I Health Institute an independent body of the Ministry of Science and Innovation and the Aragon Health Sciences Institute I CS within the framework of collaboration provided for in the Quality Plan for the National Healthcare System of th Ministry of Health and Social Policy This guideline should be cite
69. ELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 51 Summary of evidence i The IPSRT applied to people with a diagnosis of bipolar disorder in acute phase main tains these patients without affective episodes for a longer period of time Recommendations The strategies aimed at preventing relapses in people with SMI and a diagnosis of bipolar C disorder should evaluate the incorporation of interpersonal and social rhythm therapy IPSRT into the treatment 5 1 4 Supportive therapy There are different types of psychotherapies that can be used to treat people with schizophrenia and that are based on different theoretic and technical models Despite these ctiferences they all share a series of factors such as the fact that the interventions last for a certain length of time and have a certain format and that a therapeutic relationship must be established with the patient According to the NICE CPG on Schizophrenia supportive therapy is defined as the psy chological intervention where the intervention is facilitative non directive and relationship fo cused with the content of sessions largely determined by the service user For supportive therapy to be considered this type of intervention does not have to fulfil the criteria for any other type of psychological interventions CBT psychoanalysis ete A Supportive therapy can include any intervention carried out by one single person with th
70. FAMI European Federation of Associations of Families of People with Mental IlIness appears as an instrument of union and training far the three groups involved people with mental illness family members and mental health professionals The role of these groups in the international scenario covers not only mutual heip activities and other services but also the de fence of the rights and interests of the group education for the community impacting the Mental Health policy makers reporting the stigma and the discrimination demanding an improvement of the services The groups of people with mental illness who in many countries are identified as groups of consumers or users follow in their origins a similar dynamic to the organisations of family members although somewhat ister They have progressively played a more influential role in healthcare and legislative poiicies as well as in the development of actions to help other people with mental illnesses These groups have stood out for their educational and social awareness raising role due to their actions reporting practices perceived as negative practices and protecting their rights and forthe development and management of help services The Spanisi Federation of Associations of Families and People with Mental Illnesses FEAFES was created in Spain in 1983 as a state organisation to group together and represent the entire associative movement of families and people with mental illness
71. FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS SR 1 SR 1 SR 14 SR 1 SR 1 With respect to imprisonment the CM had no clear effect n 757 Peto odds ratio 0 90 99 CI between 0 36 and 2 28 but it does seem more favourable to improve medication adherence N 71 Peto odds ratio 0 25 99 CI between 0 06 and 0 97 There was no difference between CM and ST in the improvement of the mental state n 126 WMD 0 461 99 CI between 4 9 and 5 9 social functioning SMD 0 097 99 CI CL 0 47 0 27 N 197 or quality of life N 2135 SMD 0 096 99 CI between 0 35 and 0 54 Summary of evidence No randomised clinical trials have been found to assess the efficacy of the day centres and or psychosocial rehabilitation centres No statistically significant differences were found between CMHC ant ST in the reduc tion of hospital admissions or in the loss of contact in the population cared for in the CMHC There are no differences between CMHC and ST with respecto death ratios There seem to be no differences either between CMHC and ST with respect to the evolu tion of the mental state in the population cared for in GMHC It is not clear that the CMHC is associated with am improvement in social functioning when compared with ST However there does seem to be a smaller number of dissatis fied people in the group of CMHC than the ST The ACT in peopl
72. FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 125 The coordination of these resources and devices must offer a series of psychosocial interven tions objective of this CPG that must be accessible for users and family members and which are the following COMMUNITY REHABILITATION PROGRAMMES Rehabilitation in daytime regime Supportive employment programmes Primary Care Team REHABILITATION WITH RESIDENTIAL OR HOSPITAL SUPPORT Therapeutic communities Mental Health Centre Residential alternatives GENERAL HOSPITAL CARE Hospitalisation Unit 24 hour Extended care unit Emergency Inter consultation Day Hospital e Psychoeducation or standard interventions that include information about the disorder the treatment training in problem soiving and improvement of communication includ ing family members or caregivetz e Family single family or muii family intervention programmes aimed at incorporating the family into the treatment with a psychoeducational model with training in problem solving handling stress and improving communication skills Specific Cognitive Eehavioural Therapy Programmes for persistent symptomatology positive and negailve Community intervention programmes in the form of Case Follow up and Assertive Community ireatment Teams for those people with SMI with multiple readmissions or reduced monitoring adherence Therapeutic programmes that include alternative accommod
73. I Sungur M Mastroeni A Malm U Economou M et al Implementation of evidence based treatment for schizophrenic disorders two year outcome of an interna tional fi eld trial of optimal treatment World Psychiatry 2004 3 2 104 9 Hogarty GE Anderson CM Reiss DJ Kornblith SJ Greenwald DP Ulrich RF t al Family psychoeducation social skills training and maintenance chemotherapy in the aftercare treat ment of schizophrenia II Two year effects of a controlled study on telapse and adjust ment Environmental Personal Indicators in the Course of Schizophrenia EPICS Research Group Arch Gen Psychiatry 1991 48 4 340 7 Lemos S Vallina O Garc a Saiz A Guti rrez P rez AM Alonso S nchez M Ortega JA Evaluaci n de la efectividad de la terapia psicol gica integrada en la evoluci n a largo plazo de pacientes con esquizofrenia Actas Esp Psiquiatr 2004 32 3 166 77 Brenner HD Roder V Hodel B Kienzle N Integrated psychological therapy for schizo phrenic patients IPT Seattle Hogrefe amp Huber 1994 Roder V Mueller DR Mueser KT Brenner Hi Integrated psychological therapy IPT for schizophrenia is it effective Schizophr Buil 2006 32 Suppl 1 S81 93 Miklowitz DJ Simoneau TL George EL Richards JA Kalbag A Sachs Ericsson N et al Family focused treatment of bipolat disorder 1 year effects of a psychoeducational program in conjunction with pharmacotherapy Biol Psychiatry 2000 48 6 582 92 Miller IW Sol
74. I between 0 5 and 0 1 nor at 24 months n 71 WMD 0 2 95 CI between 0 46 and 0 06 Readmissions RCT 14 There is certain evidence in favour of CBT in connection with readmissions n 103 RR 0 42 95 CI between 0 23 and 0 8 12 months after hav ing begun the treatment Relapses RCT 1 There is moderate evidence in favour of CBT compared with standard treatment with respect to the presence of relapses 6 months after the start of treatment n 155 RR 0 61 95 CI between 0 41 and 0 91 12 months after the start of the study n 180 RR 0 62 95 CI between 0 39 and 0 98 and after 30 months n 103 RR 0 79 95 CI be tween 0 63 and 0 99 9 46 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Summary of evidence People with SMI and a diagnosis of schizophrenia and related disorders CBT ST vs ST does not reduce the rates of relapses or readmissions in the medium or long term An improvement in the global state of people with SMI and a diagnosis of schizophrenia and related disorders is observed when they receive CBT in the short and medium term However this effect is no longer significant in the long term The application of CBT together with standard treatment is more effective in the improve ment of the clinical state than when only standard treatment is applied However this difference was no longer significant after one year s treatment There are no dif
75. ICAL PRACTICE GUIDELINES IN THE SPANISH NHS 2 Scope and objectives As mentioned in the introduction a therapeutic approach to SMI is complex and must include different types of interventions which require an interdisciplinary team The last few years have brought about numerous therapeutic novelties in the pharmacologi cal field new atypical or second generation antipsychotics new mood stabilisers etc which have contributed to an improvement in the evolution of people with SMI but which require other interventions to improve aspects related to functioning in different behavioural social occupa tional and family integration areas The evidence on the effectiveness of psychopharmacological treatment is specific for each disorder included in the SMI concept which are unique and can not be extrapolated to other disorders There are different clinical practice guidelines for people with schizophrenia and for people with bipolar disorders that have been prepared by different institutions where this type of intervention is included The new therapeutic and rehabilitation approaches commit to the paradigm of recovery and well being and concepts such as integral and integrated care have been introduced whose aim is to cover the entire deficit and the social disadvantages produced by the impact of mental ill ness on the person that suffers from it This represents a shift towards the participation of other agents apart from health car
76. ICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 9 Collaborators Documentalist Irene Mu oz Guajardo Instituto Aragon s de Ciencias de la Salud Zaragoza Other collaborations Carlos Albi ana Rodr guez Documentalist Zaragoza Jos M Mengual Gil Specialist Physician in Paediatrics Instituto Aragon s de Ciencias de la Salud Zaragoza Coordinaci n log stica Asociaci n Aragonesa Pro Salud Mental ASAPME Federaci n de Asociaci n s Aragonesas Pro Salud Mental FEAFES ARAGON Zaragoza Expert Collaboration Jos M lvarez Martinez Clinical Psychologist Hospital Universitario R o Hortega Valladolid Fernando Ca as de Paz Specialist physician in psychiatry Hospital Dr R Lafora Madrid M Consuelo Carballal Balsa Nurse Subdirecci n Xeral de Sa de Mental y Drogodependene as Santiago de Compostela A Coru a Alberto Fern ndez Liria Specialist physician in psychiatry Hospital Universitario Pr ncipe de Asturias Alcal de Henares Madrid Daniel Navarro Bay n Psychologist Fundaci n Socio Sanitaria de Castilla La Mancha para la Integraci n Socio Laboral del Enfermo Mental FISLEM Toledo Antonio Lobo Satu Specialist physician in psychiatry Hospital Cl nico Universitario Lozano Blesa Zaragoza Lilisbeth Perestelo P rez Clinical psychologist Servicio de Evaluaci n y Planificaci n deta Direcci n del Servicio Canario de la Salud Santa Cr
77. INICAL PRACTICE GUIDELINES IN THE SPANISH NHS Respect to ICM teams organised in agreement with the ACT model they were more like 1 ly to reduce the use of hospital care but this finding was not encountered when analysing the personnel levels recommended for ACT l There are no differences between non acute day hospitals and outpatients treatment for people with SMI with respect to readmission rates mental state and social functioning l4 People who receive Case Management are more likely to remain in contact with the ser vices and improve medication adherence l4 There are no differences with respect to social functioning improvement of mental state quality of life imprisonment between CM and ST in people with SMP Recommendations When people with SMI need to be readmitted several times into acute units and or there B is a past history of difficulties to engage with the services with the subsequent risk of relapse or social crisis as for example becoming a homeless person it is advisable to provide assertive community treatment teams The continuity of the treatment must be favoured via the integration and coordination of the use of the different resources by the people with SMI maintaining continuity of care and interventions and in the psychotherapeutic relations established Care must be maintained from the perspective of the CMHC as a configuration of the most commonly implemented s
78. J Humphreys L Durability of the effects of cognitive behavioural therapy in the treatment of chronic schizophrenia 12 month follow up Br J Psychiatry 1999 174 500 4 Kemp R Kirov G Everitt B Hayward P David A Randomised controlled trial of compli ance therapy 18 month follow up Br J Psychiatry 1998 172 5 413 9 Kuipers E Fowler D Garety P Chisholm D Freeman D Dunn G et al London eastAnglia randomised controlled trial of cognitive behavioural therapy for psychosis III Follow up and economic evaluation at 18 months Br J Psychiatry 1998 173 61 8 Gumley A O Grady M McNay L Reilly J Power K Norrie J Early intervention for relapse in schizophrenia results of a 12 month randomized controlled trial of cognitive behavioural therapy Psychol Med 2003 33 3 419 31 Durham RC Guthrie M Morton RV Reid DA Treliving LR Fowler D et al Tayside Fife clinical trial of cognitive behavioural therapy for medication resistant psychotic symptoms Results to 3 month follow up Br J Psychiatry 2003 182 303 11 Pilling S Bebbington P Kuipers E Garety P Geddes Orbach G et al Psychological treat ments in schizophrenia I Meta analysis of famiiv intervention and cognitive behaviour therapy Psychol Med 2002 32 5 763 82 Carpenter WT Jr Heinrichs DW Hanlon TE A comparative trial of pharmacologic strate gies in schizophrenia Am J Psychiatry 1987 144 11 1466 70 Turkington D Kingdon D Turner T Effectiveness of
79. LINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 153 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 154 Bond GR Drake RE Predictors of competitive employment among patients with schizo phrenia Curr Opin Psychiatry 2008 21 4 362 9 Bruscia K Defi ning music therapy 2 ed Barcelona Gilsum 1998 Gold C Heldal TO Dahle T Wigram T Music therapy for schizophrenia or schizophrenia like illnesses Cochrane Database Syst Rev 2005 2 CD004025 Yang WZ Li Z Weng YZ Zhang HY Ma B Yang WY et al Psychosocial rehabilita tion effects of music therapy in chronic schizophrenia Hong Kong Journal of Psychiatry 1998 8 1 38 40 Maratos A Crawford M Composing ourselves what role might music therapy have in po moting recovery from acute schizophrenia London West Mental Health R amp D Consortiuin s 9th annual Conference 2004 Tang W Yao X Zheng Z Rehabilitative effect of music therapy for residual schizophrenia A one month randomised controlled trial in Shanghai Br J Psychiatry Suppl 1997 24 38 44 Ulrich G De toegevoegde waarde van groepsmuziektherapie bij schizofrene pati nten een gerandomiseer onderzoek Heerlen Open Universiteit 2005 Edwards D Art therapy creative therapies in practice London Sage 2004 Ruddy R Milnes D Art therapy for schizophrenia or schizophtenia like illnesses Cochrane Database Syst Rev
80. More day centres More and better access to different types of therapies Social and family exclusion rurziareas Allapted employment some members of the normalised contexts of Relatives amp environments family a Legal vacuum in timetables etc Loss of role family e Si d ospital Crisis intervention social etc within the oo at home by health family Legal Capacity professionals Only disability police presence in these interventions leads to an increase in the stigma Information to user Sheltered flats with 24 hours supervision The stigma of the Treatments and invol e Work paid and not ill People with untary admissi ulness y admissions paid CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Appendix 3 Template to develop recommendations via formal assessment or well founded judgement Question Volume of evidence Comment on the quantity of evidence available and its methodological quality Applicability and generalisation Comment to what extent the evidence found is applicable in the Spanish National Health System and to what extent can the results obtained from the studies be generalised to the target population of the CPG Consistency Comment if there have been conflicting results between the different studies and if so the reasoris why the working group has decided on one option or another Clinical Impact Relevance Indica
81. PRACTICE GUIDELINES IN THE SPANISH NHS would normally receive and which includes interventions such as medication hospitalisation community psychiatric nursing input and or day hospital other psychological treatments prob lem solving therapy psycho education cognitive behavioural therapy family therapy or psycho dynamic psychotherapy or social treatments including social skills training and life skills train ing In this study about 30 of all the people included left before study completion Distraction techniques did not seem to promote or hinder leaving the study early it could be argued that the distraction techniques failed to engage participants in studies in a more meaningful way than the control activities The distraction technique is a practice used in the field of mental health in Spain which requires specific professional training Drama therapy for people with SMI Drama therapy is a form of treatment that encourages spontaneity and creativity It can promote emotional expression but does not necessarily require the participants to have insight into their condition or psychological mindset In the study conducted by Ruddy et al 5 RCT n 120 they compare drama therapy with standard treatment All the studies were conducted with hospitalised patients with schizophrenia compared the intervention and standard hospital care Due to the deficiencies of the reports very few data could be used from the 5 studies and ther
82. S 5 1 5 Family interventions There appears to be general consensus about the fact that SMI has a considerable effect on the family relations of people who suffer from it and that family relations can also in some way or another affect the course of the disease Some studies show that people with schizophrenia that come from families with high levels of expressed emotion in other words that show high levels of over protection criticism and hostility are more likely to suffer relapses than those people with the same type of pathology but with lower levels of expressed emotion within the family Nowadays there is a great variety of methods to help people with mental diseases ana their families manage the disease in a more effective manner These interventions are designed to im prove the relationships between family members reduce the levels of expressed emotion and in some way reduce the relapse ratios and improve the quality of life both of the natient and of the families Pyschosocial interventions have been reviewed as well as the evidence that exists about their efficiency in people with SMI with respect to their isolated application Compared with standard treatment or other interventions However studies have been found ine review where the exper imental group receives two or more interventions The question of bow these interventions must be combined not only together but also added to other types of interve
83. ST in con nection with the improvement of negative and positive symptoms in the short or long term When CBT is compared with other psychological interventions no improvement is ob served in the specific symptoms with respect to delirium but there is with respect to hal lucinations There is not sufficient evidence to indicate that CBT when compared with ST reduces relapses during treatment or 12 months or 2 years after finishing treatment CBT programmes lasting for more than 3 months reduce relapses CBT when compared with ST reduces the symptoms at the end of the treatment BT when compared with ST improves the mental state at the end of the treatment CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 47 There is no evidence of improvement in symptoms when CBT is compared with other psychological interventions at the end of the treatment and 9 to 12 months after it has ended There is no evidence that indicates that CBT reduces persistent symptoms after 9 months follow up when compared with ST CBT when compared with ST improves the mental state persistent symptomatology after treatment There is limited evidence that indicates that CBT produces an improvement in social functioning of people with SMI and diagnosis of schizophrenia or related disorders When CBT is compared with other treatment greater benefit i
84. Social skills trainiriz for chronic mental patients Hosp Community Psychiatry 1985 36 4 396 403 Liberman RP Mueser KT Wallace CJ Jacobs HE Eckmau T Massel HK Training skills in the psychiatrically disabled learning coping an competence Schizophr Bull 1986 12 4 63 1 47 Liberman RP Wallace CJ Blackwell G Kopelowicz A Vaccaro JV Mintz J Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia Am J Psychiatry 1998 155 8 1087 91 Rog DJ The evidence on supported housing Psychiatr Rehabil J 2004 27 4 334 44 McHugo GJ Bebout RR Harris M Cleghorn S Herring G Xie H et al A randomized con trolled trial of integrated versus parailel housing services for homeless adults with severe mental illness Schizophr Bull 2004 30 4 969 82 Rodr guez A Munoz M Panadero S Descripci n de una red de recursos de atenci n social para personas con enferniedad mental grave y cr nica el caso de la Comunidad de Madrid Rehabilitaci n Psicosocial 2007 4 1 2 41 8 Chilvers R Macd nald GM Hayes AA Supported housing for people with severe mental disorders Cochrane Database Syst Rev 2006 4 CD000453 Fakhoury WKH Murray A Shepherd G Priebe S Research in supported housing Soc Psychiatry Psychiatr Epidemiol 2002 37 7 301 15 L p z M Laviana M Garc a Cubillana P Fern ndez L Moreno B Maestro JC Evaluaci n del programa residencial para personas con trastorno mental
85. T fer prosocial behaviour n 133 WMD 4 9 95 CI between 2 and 79 Cognitive behavioural therapy BCT standard treatment ST vs supportive psychciherapy standard treatment ST RCT 1 SR 1 RCT 1 RCT 1 SR 1 RCT 1 RCT 12 RCT 1 42 Relapses The studies found no significant differences in th amp relapse ratios between CBT and supportive psychotherapy in the medium term 1 RCT n 59 RR 0 6 95 CI between 0 2 and 2 proof of the global effect 0 75 p 0 5 or long term 2 RCT n 83 WMD 1 1 95 CI between 0 5 and 2 4 proof of the global effect 0 12 9 0 9 One RCT informed of data based on the GAF scale and found no sig nificant effects either 1 RCT n 30 WMD 0 5 95 CI between 7 6 and 6 6 proof of the globai effect 0 14 p 0 9 Mental state CBT did not significantly improve the clinically significant improvement ratios in the midterm 1 RCT n 59 RR 0 8 95 CI between 0 6 and 1 1 proof ofthe global effect 1 60 p 0 11 38 or in the long term 2 RCT n 2 90 RR 0 9 95 CI between 0 8 and 1 1 proof of the global effect 0 62 p 0 5 Scores for general symptoms In a continuous measurement of the mental state measured with the BPRS scale no significant differences were found between CBT and supportive psychotherapy in the short term 1 RCT n 20 WMD 8 5 95 CI between 3 and 20 proof of the global effect 1 42 p
86. When the re analysis was performed with a random effects model no significant differences were found n 142 RR 0 76 95 CI between 0 44 and 1 33 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS RCT 1 RCT dS RCT 14 RCT 14 85 RCT 1 RCT 1 RCT 14 Those that received PVT additional psychological intervention pre sented difficulties in favour of obtaining some type of employment n 122 RR 0 89 95 CI between 0 81 and 0 97 NNT 9 and some form of employment or education at the end of the study n 122 RR 0 83 95 CI between 0 52 and 0 77 NNT 3 No differences were observed between PVT psychological interven tion and the control respect to clinical improvement n 142 RR 0 83 95 CI between 0 33 and 2 18 Patients with prior labour failure integrated in the sheltered employ ment programme with cognitive training presented greater probability of having worked 69 6 vs 14 3 having maintained more jobs worked more weeks more hours and with higher salaries than patients who were only offered sheltered employment p lt 0 001 The study by Bond amp Dincin provides data when it compares transi tional employment with accelerated entry with no pre Vocational training paid employment at least 2 days per week with graduai entry into sheltered employment A difference is observed in favour of accelerated entry n 1
87. With respect to the recovery of the person at the end of the study 28 months no differences have been found between multi family group psy choeducation intervention and no intervention n 59 RR 1 49 9596 CI between 0 76 and 2 95 or in people with mania n 2 45 RR 1 57 9596 CI between 0 67 and 3 68 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Family intervention vs other psychosocial interventions There are no differences in the recovery ratios between systemic family RCT 1 therapy focused on problem solving and multi family psychoeducational group therapy at the end of the study 28 months in all the people n 63 RR 1 72 95 CI between 0 91 and 3 25 or in people with mania n 47 RR 1 57 IC between 0 67 and 3 68 Summary of evidence People with SMI and a diagnosis of schizophrenia and related disorders 1 Family intervention in people with schizophrenia reduces relapses l Family intervention reduces persistent symptoms after 12 months treatment 1 Family intervention of less than 5 sessions or of unknown number reduces elapses after one year s treatment after 1 3 and 10 years follow up 1 Family intervention of more than 5 sessions reduces hospitalisations after 18 months follow up l There are no differences between family intervention andisiandard intervention in the reduction of hospital readmissions 2 years
88. a brief cognitive behavioural therapy intervention in the treatment of schizophrenia Br J Psychiatry 2002 180 523 7 Zimmermann G Favrod J Tr eu VH Pomini V The effect of cognitive behavioral treatment on the positive symptoms oef schizophrenia spectrum disorders a meta analysis Schizophr Res 2005 77 1 1 9 Pilling S Bebbington P Kuipers E Garety P Geddes J Martindale B et al Psychological treatments in schizephrenia II Meta analyses of randomized controlled trials of social skills training and cognitive remediation Psychol Med 2002 32 5 783 91 Kurtz MM Mueser KT A meta analysis of controlled research on social skills training for schizophrenia J Consult Clin Psychol 2008 76 3 491 504 Leliman AF Kreyenbuhl J Buchanan RW Dickerson FB Dixon LB Goldberg R et al The Schizophrenia Patient Outcomes Research Team PORT updated treatment recommenda tions 2003 Schizophr Bull 2004 30 2 193 217 Priebe S Social outcomes in schizophrenia Br J Psychiatry Suppl 2007 50 515 20 Xia J Li C Problem solving skills for schizophrenia Cochrane Database of Syst Rev 2007 2 CD006365 Cleary M Hunt G Matheson S Siegfried N Walter G Psychosocial interventions for peo ple with both severe mental illness and substance misuse Cochrane Database Syst Rev 2008 1 CD001088 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 145 53 54 25 56 57 58 59 60 61
89. abilised and satisfied social cognitive and neuro cognitive disability criteria to take part in the study In the NICE Schizophrenia CPG no consistent evidence was found to suggest that cognitive remediation improved the cognitive functions indicated orthe symptoms in people with schizo phrenia It was also observed that the evidence was insuf cient to determine improvements in the mental state at the end of the treatment and suggest n t patients with schizophrenia improve at the end of the treatment in areas such as visual memory verbal memory independent life or non verbal reasoning The final recommendation of that CPG 1s that there is not sufficient evidence so as to rec ommend the use of cognitive remediston in routine treatment of people with schizophrenia However subsequent reviews whick include more studies and more patients seem to show more favourable results for cognitive rehabilitation 26 articles were included in the review by McGurk et al of which two were excluded from the NICE schizophrenia CPG Of the 7 articles included in the review made by the NICE CPG 4 are included in the SR by McGurk er al and a total of 14 RCTS are performed after the NICE CPG There seems to 5e an overlapping of the studies included between the NICE schizophrenia CPG and the articles by McGurk ef al and Krabbendam amp Alem n with greater study inclu sion capacity it he last two perhaps because they apply less restrictive cri
90. acute phase were included in the Scott et i study as well as some patients without medication The data provided by this author were Gotained by excluding those patients who were in the acute phase Cogniiive behavioural therapy for people who suffer SMI and a diagnosis of schizophrenia and related disorders Cognitive behavioural therapy BCT standard treatment ST vs standard treatment ST Relapses readmissions CBT administered with standard treatment compared with standard treat ment alone did not significantly reduce the rates of relapse or hospital re admission in the mid term 1 RCT n 61 RR 0 1 95 CI between 0 01 and 1 7 nor in the long term 4 n 357 RR 0 8 95 CI between 0 5 and 1 5 RCT 1 SR 1 40 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS General global state In the short run a difference was observed in favour of CBT in agreement with the measurements carried out with the Global Assessment Scale GAS when compared with standard treatment 2 RCT n 100 WMD 7 58 95 CI between 2 93 and 12 22 p 0 001 in mid term 1 RCT n 67 WMD 12 6 95 CI between 5 8 and 1 43 p 0 0003 in the long term this effect was no longer significant 2 RCT n 83 WMD 4 51 95 CI between 0 3 and 9 32 p 0 07 Mental state In the no clinically significant improvement measurement the combined data showed a significant difference in favour of CBT administered with st
91. adequate conditions The prevalence of schizophrenia in homeless people is variable although higher quality stud ies have established the prevalence in this population within a range of between 4 and 16 with an average of 11 The highest rates corresponded to the younger subgroups to women and to the chronically homeless In 2002 one review concluded that schizophrenia is 7 to 10 times more frequent in homeless people than in the population with stable housing Data are included in this review from a Spanish study that offers figures situated within a lower range A more recent review offers greater heterogeneity in its results with figures of 12 average prevalence of psychotic disorders in a range of 2 8 to 42 3 Another important fact is that ofttiis popula tion only one third receives treatment The attention to homeless people and who have SMI is based on the combination of the services that provide housing and those that provide clinical care this combination has two ap proaches the traditional approach called the continuum housing mods in Anglo Saxon litera ture which is based on the offer of a range of housing provided bv itie same team that provides the clinical care favouring the users progression towards mere independent housing as they gain clinical stability More modern approaches supported housing propose considering hous ing separately from clinical stability based on normalised community ho
92. adly implemented in our context and come from the Ans o Saxon Severe Mental Illness which is being replaced by the term Severe and Persistent Menta TlIness which refers to a theoretic con struct that groups together a series of clinical conditions with high prevalence and considerable repercussion in healthcare practice and which wouid coincide with the term of chronicity with more positive connotations1 In addition the Strategy in Mental Health of the National Health System 2006 3 report points out the need to differentiate it from Trastorno mental Com n Common mental disorder and includesinterventions aimed at integrating the care given to peo ple with SMI among its best practices All the definitions of SMI2 make reference apart from referring to the clinical diagnosis and to the duration of the illness to the social family and job functioning of the person affected The greatest level of consensus was reached with respect to the definition formulated by the United States National Institute of Mental Health NIMH in 1987 which defines this group as a group of heterogeneous people who suffer from severe psychiatric disorders together with long term mental disturbances which entail a variable degree of disability and social dysfunction and who must be caved for by means of different social and health resources of the psychiatric and social healtlicare network Despite the fact that the main treatment for people with SMI has
93. akdown of the problem establishing accessible objectives generating solutions assessing them implementing them and assessing the result of the solution implemented The main objectives of the therapy are to make the people have a better understanding about the relationship between their symptoms and their problems increasing their capacity to define CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 39 current problems and identify the resources available to address the problem teaching them a specific procedure to solve the problem in an organised fashion increasing their confidence and self control in a problematic situation and preparing them for future problems Xia et al carry out a systematic review on the effectiveness of problem solving therapy and compare it with other equivalent therapies or with normal care for people with schizophrenia Three RCTs n 61 are identified of which in two although said to be randomised no randomi sation or blinding methods are indicated Motivational interview Cleary et al perform a systematic review including 25 RCTs within cognitive behavioural therapy search period until April 2006 in order to assess the effect of psychosocial interventions on the reduction of substance consumption in people with SMI schizophrenia bipolar disorder or depression Five of the RCTs included provide information with respect to efficiency of the motivational inte
94. al implica tions entailed When a research study is proposed in this specific area these limitations should be taken into account considering the execution of good quality observational studies which although they fall below the RCTs in the evidence pyramid can provide evidence about the ef fectiveness of some interventions bearing in mind the limitations of these designs The use of qualitative research techniques which are widely used in the field of social zci ences and to a lesser extent in health sciences should also be considered as they cover the com pilation analysis and interpretation of data that are difficult to reduce to numbers This type of techniques permit studying contexts and interventions which due to their nature are difficult to prove with quantitative techniques as is the case of some psychosocial interventions addressed in this CPG 34 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 5 Psychosocial type rehabilitation interventions As indicated by Gisbert er al the aim of psychosocial rehabilitation interventions as part of the integral care of people with SMI is to overcome or compensate for the psychosocial and social integration difficulties that these people undergo giving them support in their daily lives in the community in the most independent and decent manner as well as in undertaking and handling the different roles and demands represented by living working and mixing in different comniu nity
95. all these aspects in adults who suffer from this dis order and it is the result of the work of a multidisciplinary team of professionals from the social heaith and labour areas who have dedicated many hours to the preparation of the recommenda tions The aim of this guideline is to answer many of the questions that arise from the day to day care of people who suffer Severe Mental Illnesses given in the form of systematically prepared recommendations with the best available scientific evidence the experience of the professionals from the guideline development group and bearing in mind the needs of the users and families of people who suffer SMI CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 7 We hope that this guideline will help people suffering from SMI and their families control the symptoms and overcome the illness promoting people with SMI and their families recover and lead significant decent and satisfactory lives This is the goal that encourages us PABLO RIVERO CORTE Director General of the Quality Agency of the NHS 8 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Authorship and collaborators CPG development group for Psychosocial Interventions in Severe Mental Illness Concepcion de la Camara Izquierdo Specialist physician in psychiatry Hospital Cl nico Universitario Lozano Blesa Zaragoza Francisco Jos Caro Rebollo Specialist physician in psychiatry Hospital Univer
96. andard treatment compared with standard treatment alone when this re sult was measured between weeks 13 and 26 2 RCT n 123 RR 0 7 95 CI between 0 6 and 0 9 NNT 4 95 CI between 3 and 9 The dif ference was no longer significant after one year 5 RCT n 342 RR 0 91 95 CI between 0 74 and 1 1 Scores for general symptoms No significant differences were observed in the short or medium term when CBT administered with standard treat ment was compared with standard treatment alone short term 2 RCT n 126 WMD 0 05 95 CI between 2 9 and 3 p 1 medium term 1 RCT n 52 WMD 1 7 95 CI between 5 4 20 0 2 proof of the global effect 0 90 p 0 4 However after 18 months a statistically sig nificant improvement was observed in the peopl assigned to CBT 1 RCT n 47 WMD 4 7 95 CI between 9 2 nd 0 2 p 0 04 Specific symptoms When groups with specific symptoms were as sessed in the case of hallucinations a significant effect was observed in the long term in favour of CBT combined with standard treatment 1 RCT n 62 RR 0 53 95 CI between 6 3 and 0 9 4 No effect of CBT was observed in the conviction of delusional beliefs during the same period cf time 1 RCT n 62 RR 0 8 95 CI between 0 4 and 1 3 Two trials described significant effects in favour of cognitive behav ioural therapy svnen the subscales of the PANSS were considered A signifi cant effect was obser
97. arried out in the clinic 36 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS From another point of view social skills training can be based on three models the basic model based on corrective learning social problem solving and cognitive rehabilitation There are very few definitions in literature of any of these three approaches with respect to their effects on the generalisation of behaviours and the improvement in social functioning The grounds for using social skills training in schizophrenia are based on multiple empiric and conceptual sources Social skills and social competence can be considered as protective fac tors within the stress vulnerability diathesis model for schizophrenia Reinforcing the skills and social competence of people with schizophrenia together with other evidence based interven tions reduces and compensates the harmful effects of the cognitive deficit neurobiological vul nerability stressful events and social maladjustment Question to be answered e Is cognitive behavioural therapy based psychological intervention effective inthe treatment of people with SMI The studies found analyse the effectiveness of CBT either aimed atqpeople with SMI and a diagnosis of schizophrenia and related disorders or at people with SM and a diagnosis of bipolar disorders No studies have been found that discriminate psychosocial interventions for severe compulsive obsessive disorder or Severe Mental Illnesses as
98. ated to immediate circumstances in a space time sense of the ntervention under study Multidisciplinary Which cover or affect several disciplines Level of evidence Hierarchic classification of the evidence according to the scientific rig our of t5 design of the studies Relapse Increase of symptoms of the illness after a period of reduction or elimination of such symptoms It can be operatively defined as equivalent to rehospitalisation increase in the intensity of the care increase in psychopathological severity as reduction of social functioning or even as a need for change in clinical care External reviewers Clinical professional with knowledge and experience in the specific subjects of the CPG and ideally with prestige in the field where the guideline is developed They only participates in the final phase of the guideline reviewing the provisional draft of the CPG 140 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Effect Size ES it is the measurement of the force of the relationship between two vari ables Following the recommendations of Cohen the values are equivalent to D 0 2 small ef fect around d 0 5 medium effect and d 0 8 on large effect although this interpretation depends on the context The size of the weighted effect ESw will refer to the statistical control exercised on the influence of the different in sample sizes Standard or normal treatment Treatment that is received
99. ation for SMIs complicated with other situations homeless great difficulty of family co existence extended psychi atric admission lack of resources and frequent readmissions e Assessment programmes and employment insertion for all those people who wish to work recommending Supportive Employment if the objective is competitive work and Sheltered Employment and Occupational Programmes for all the other occupational objectives 126 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 6 Social Benefits for people with severe mental illness The first thing is to define the scope of this perspective of the treatment and to do this we must point out that in social intervention the rehabilitation concept refers to the improvement of ca pacities or skills to the series of supports or conditions necessary for a person to maintain a certain level of functioning including both improving and maintaining or preventing a worse situation from being prolonged even temporarily Its target of action is not only the specific individual who has a long term severe mental illness but it also covers the person and the context The rehabilitation work focuses therefore apart from on the user on the family friends supports social environment and any other relevant elements to satisfy the intervention objectives established in this individualised process Importance of health resources and coordination with social care The Mental Health Ser
100. av ioural components and the content is understood and accepted better the impact of the interven tion is optimised Studies that assess exclusively user orientated pyschoeducational programmes do not con tinue with the patient when they end and do not involve support and intervention to incorporate the different tissues dealt with in their daily lives Thus the long term assessment of the results may produce evidence of ineffectiveness when compared with interventions that incorporate fam ily menibers and which therefore get co therapists in the home outside the intervention hours The relapse ratios seem to be strongly related to the medication adherence and the question of whether the efficiency of the family pyschoeducational interventions is the consequence mainly of the increase in adherence still cannot be answered Providing suitable information about the disorder with a view to improving its handling by patients or by their family members is an act that is carried out from the moment of the refer ral at the time when admission is decided when the treatment is proposed and prescribed or when pharmacological treatment is advised or when a periodical check up is carried out etc Therefore a good knowledge of the effectiveness of this intervention may help improve the use of resources and clinical practice 66 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Question to be answered Are pyschoeducational interven
101. bability of obtaining competitive employment 75 096 vs 27 596 or any kind of paid work 75 0 vs 53 6 p 0 0001 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Patients included in the individual placement and support programme IPS who obtained jobs that coincided with their previous preferences on the type of work desired obtained higher levels of satisfaction p 0 01 and the job lasted for longer p lt 0 05 than those where the job did not coincide with their preferences This relationship was not observed among patients in psychiatric rehabilitation programmes or in standard treatments Sheltered employment SE including individual placement and support SE IPS vs pre vocational training PVT Significant differences were observed in favour of SE in the number of people with competitive employment after 4 12 and 18 months After 12 months 34 of the patients in SE were employed compared with only 12 of the PVT group n 484 RR 0 76 95 CI between 0 64 and 0 89 NNT 5 The IPS Individual Placement and Support variant of sheltered em ployment also showed a larger number of people with competitive employ ment than pre vocational training after 4 12 and 18 months 30 and12 respectively were employed after 12 months n 295 RR 0 7995 CI between 0 70 and 0 89 NNT 6 Areview with 11 studies that were very similar to the IPSinodel showed a greater ratio of competitive employment among p
102. benefits of applying evidence based optimal psychosocial and biomedical strategies to treat schizophrenia and other non affective psychosis through the implementation and assessment of optimal therapeutic in terventions in ordinary mental health resources not investigators after the adequate training of multidisciplinary professionals teams and with a 5 year follow up period Although the project proposed incorporating patients as soon as possible after the onset of the disease in the first ten years some venues incorporated patients with more than 10 years evolution where the treat ment was focused on improving their quality of life through social and occupational skills train ing and on providing pharmacological and psychosocial strategies for persistent symptoms The interventions included pharmacological strategies psychoeducation of patients and caregivers Assertive Community Treatment social skills training pharmacological and psychosocial han dling of persistent and residual symptoms CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 55 Question to be answered Do family interventions in their different formats present benefits compared with non intervention or other types of psychosocial intervention in people with SMI At what time during the course of the illness is it best to start family intervention for peo ple with SMI and their families What is the most appropriate
103. bstance use disor ders J Subst Abuse Treat 2008 34 1 123 38 Wright NM Tompkins CN How can health services effectively meet the health needs of homeless people Br J Gen Pract 2006 56 525 286 93 Folsom D Jeste DV Schizophrenia in homeless persons a systematic review of the litera ture Acta Psychiatr Scand 2002 105 6 404 13 V zquez C Mu oz M Sanz J Lifetime and 12 month prevalence of DSM III R mental disorders among the homeless in Madrid a European study using the CIDI Acta Psychiatr Scand 1997 95 6 523 30 Fazel S Khosla V Doll H Geddes J The Prevalence of Mental Disorders among the Homeless in Western Countries Systematic Review and Meta Regression Analysis PLoS Med 2008 5 12 e225 Tsemberis SJ Moran L Shinn M Asmussen SM Shern DL Consumer preference programs for individuals who are homeless and have psychiatric disabilities a drop in center and a supported housing programcAm J Community Psychol 2003 32 305 17 Rosenheck R Cost effectiveness of services for mentally ill homeless people the applica tion of research to policy and practice Am J Psychiatry 2000 157 10 1563 70 Tsemberis S Gulcur L Nakae M Housing First consumer choice and harm reduction for homeless indiv duals with a dual diagnosis Am J Public Health 2004 94 651 6 Coldwell lt M Bender WS The effectiveness of assertive community treatment for homeless populations with severe mental illness a meta analysis Am J Psych
104. c powers to carry out a prediction treatment rehabilitation and integration policy for people with physical sensorial and psychic disabilities or impairments to whom they will provide spe cialised care General Law on Health Law 14 1986 This is the law that provides a response to the constitutional requirement to recognise the right for all citizens and foreigners resident in Spain to obtain the benefits of the health system and to establish the principles and criteria that enable general and common characteristics io be con ferred upon the new health system which will be the basis for the health services in the entire State territory Characteristics The focal point of the model are the Autonomous Communities Integral concept of health e Health promotion illness prevention Community participation Health Area as the basic nucleus of Health Services One of the basic guidelines of this law is to promote the actions necessary for the functional rehabilitation and social reinsertion of the patient Chapter one art 6 This law also includes the fundamental rights Chapter one art 10 and obligations Chapter one art 11 of the users Some of the section ar repealed and developed by Law 41 2002 on the Patient s Autonomy Mental Health has a specific chapter Chapter III of Title One which states the following as its basis the full integration of the actions relating to mental health in the general health sys
105. cable legislation has a national or international nature Its competences include the recognition management and control of benefits which in the case of a person affected by Several Mental Illness could be subject to the following Retirement If the person in question has made the specific contributions and amounts required in agreement with their working life Permanent disablement as with retirement but in this case not having surpassed re tirement age and when specific difficulties combine to hold a 165 that adapts to their edu cation and training in the event that it is for the normal work or for all types of work in the event that the person cannot carry out an adequate working role Death and survival widow widower orphans in favour of family members and aid for death in those cases when the person loses a fanitty member and the situation whereby the applicable legislation gives the right to orntians benefit regardless of the age is rec ognised e Temporary disablement if a person is working and needs to temporarily interrupt their employment due to the concurrence ct an illness Maternity e Risk during pregnancy Family benefits dependent child birth of third or successive children and multiple birth contributory and non contributory level Economic compensations derived from non disabling permanent lesions e The recognition of the right to healthcare Each one of the benefits described must
106. cal services and supported housing approach improves the consump l tion of substances when compared with standard treatment in homeless patients with diagnosis of SMI and or substance abuse at 36 months Integrated clinical services and supported housing approach seems to be more favourable l compared with CM and wiih standard treatment in homeless patients with diagnosis of SMI and or substance abuse respect to a shorter stay in the institutions Recommendations B People with SMI with dual diagnosis must follow psychosocial intervention programmes and drug dependent treatment programmes both in an integrated manner and parallel B The tieatment programmes offered to people with SMI with dual diagnosis must have a mul component nature be intensive and prolonged C For people with SMI and dual diagnosis and in a homeless situation the treatment pro grammes should incorporate sheltered housing as a service When the care for people with SMI and dual diagnosis is provided in parallel it is neces V j sary to guarantee continuity in the care and coordination among the different health and social levels 104 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 5 4 2 Homeless with SMI The term homeless refers to the mixture of states that includes those who literally have no roof rooflessness those that have no stable home houselessness or those who live in precarious or in
107. caregivers in group format on results in patients with bipolar disorders Those studies that included non specific cognitive behavioural interventions were excluded for the pyschoeducation of people with bipolar disorders An important overlapping is observed between user orientated pyschoeducation and stand ard treatment when the standard treatment includes transmission ot relevant information as well as coping and handling strategies for the disease both if carried out individually and with the incorporation of family members There is a lack of knowledge about whether the mere family involvement in the treatment is per se the determining factor for the improvement of treatment adherence pharmacological and these condition the results or if what is important is to give adequate information or achieve a change in the transactional patterns It is difficult to find control groups that incorporate the family without having carried out any specific intervention with them The protocolisation and standardisation of pyschoeducational intervention for example in clusion of contents in a manual with a specific timeframe may be a reason for not accepting the intervention for quite a large suberoup of patients above all if the content does not adapt to the evolutionary moment of the disorder or to the attitudinal state of the patient Another factor to be taken into account is that when the presentation is more interactive it incorporates more beh
108. cated in article 758 of this Law This is a civil procedure and by virtue of strictly medical reasons Attp www boe es aeboelconsultas bases datos doc php coleccion iberlex amp id 2000 00323 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 123 Several protocols have been published that set out the involuntary hospitalisation procedure The majority coincide in urgent cases in general lines although some points may differ in the dif ferent health services Initial approach by the general Emergency services or Primary Healthcare services on request of the family or of close friends who detect a serious decompensation of the pa tient who does not accept any approach of his or her clinical situation With support of security forces if necessary and Transfer to a hospital of reference with psychiatric emergency services where admission is decided upon following the regulation of article 763 of the aforementioned Law 2 Civil Incapacitation and Tutorship Incapacitation is the legal mechanism forese n for those cases where persistent physical or psychic illnesses or impairments prevent a persen from coping on their own and where the aim is to protect the interests and rights of the incapacitated person both personally and for hereditary purposes Its legal regulation is included n articles 199 to 214 and following of the Civil Code and 756 to 763 of the Civil Procedure The declaratio
109. ce of a new care culture characterised by a shift of the care centre from the psychiatric hospital mental hos pital to the community The multi disciplinary and inter disciplinary teems community mental health teams CMHT characterised by the involvement of all the mental health care professional categories nursing psychology psychiatry occupational therapy and social work have become the most prevalent way of organising work in Europe and United States The most elementary form of the CMHT provides a whole range of interventions including contributions from psychiatry psychol ogy nursing social work and occupational therapy for a geographic area of reference giving priority to adults with SMI The concerns about the functioning of the CMHT have arisen about the following aspects Impact on the community violence etc of people with SMI e Quality of life of pzuents with SMI and their caregivers e Lack of clear evidence about the benefits of the organisation in CMHC e Scarce knowiedge of the component that would make the functioning more effective The devetapment of additional services in the community has resulted in an increase in the complexity titat people with SMI encounter when they try to access services that were previously available in hospitals and precisely some of the problems of this population is the limited initia tive the difficulty to request help and the problems they encounter to be linked up w
110. cial support Psychiatric and drug dependent treatments have traditionally been separate and may differ in theoretic cases and implementation methods In those places where the Mental Healttyand Drug Dependent networks have been or are administratively separate the psychiatric oz psychosocial treatment of SMI and treatment programmes for drug dependences have been offered separately in parallel or in sequence with the possibility of neither being optimised on naving to negotiate the patient with two separate teams On other occasions the presence of hoth diagnoses compro mised the parallel care requiring the tempering or control of the other problem by a network to incorporate it to the second control of drug addiction to be able to be incorporated into spe cific psychosocial rehabilitation programmes without the handicap of active drug addition or on the contrary rejection in treatment for drug dependency units until clinical stability has been achieved Thus the efficacy of integrated programmes foi ine treatment or reduction of substance abuse in patients with SMI is being questioned The objective is to know the evidence of the importance of providing addiction treatment programmes and psychosocial rehabilitation pro grammes by one single coordinated team to achieve the objectives of both programmes In this question no difference has been established between the studies aimed at diagnostic groups that a priori may hav
111. cts of social skills on people with schizophrenia or schizoaffective disorders and they are compared with other active therapies or standard intervention Social skills training to be considered an in tervention must include behavioural techniques such as instructions on skills role play training and positive or negative feedback 23 randomised studies n 1599 are included in this review and the effects magnitudes are differentiated for different proximal such as the execution of trained skills intermediate such as social functioning or distal such as relapses measurements There seems to be a divergence among the studies chosen regarding the force ot the recom mendation or the effect magnitude This leads to divergences as occurs in the case of the data provided by the NICE Schizophrenia CPG which does not detect any evidence to support this intervention that is advised in the PORT criteria49 Kurtx and Mueser argue that the Pilling ef al study which the NICE Schizophrenia CPG is based upon is more testrictive and mixes dis tal measurements with proximal measurements thus making it more difficult to find significant effects Furthermore the Kurtz and Mueser review is later than ihe NICE Schizophrenia CPG and includes more studies Measuring isolated symptoms is not sufficient to refiect significant results To assess long term results it is essential to have information on the social situation of the people namely ass
112. d as Guideline development group of the Clinical Practice Guideline on Psychosocial Interventions in Severe Mental Illness Clinical Practice Guideline on Psychosocial Interventions in Severe Mental Illness Quality Plan for the National Health System Ministry of Health and Social Policy Aragon Health Sciences Institute I CS 2009 Clinical Practice Guidelines in the Spanish NHS I CS No 2007 05 i a Plan de Calidad MINISTERIO s DE SANIDAD para Sistema Nacional e Y POL TICA SOCIAL de Salud E E Isto Aragones la a a ars ac ale E Table of Contents Presentation Authorship and collaborators Questions to answer Summary of recommendations 1 Introduction 2 Scope and objectives d Methodology 3 1 Formulation of questions 3 2 Search strategy 3 3 Evidence assessment and synthesis 3 4 Forming guideline recommendations 3 5 Collaboration and external review 4 Characteristics of the CPG 4 1 Definition of Severe Mentai illness 4 2 Definition of psychosocial rehabilitation concept 4 3 The concept of recovery 4 4 Research into psychosocial interventions 5 Psychosocia type rehabilitation interventions 5 1 Psyenological interventions 5 3 1 Cognitive behavioural therapys 5 1 2 Psychodynamic psychotherapies and psychoanalytical approach 5 1 3 Interpersonal therapy 1 4 Supportive therapy 1 5 Family interventions 6 Pyschoeducational interventions Cognitive rehabilitation 8 Other psyc
113. d supervision intensities The most common residential programmes in Spain are independent flats super vised flats mini homes and supervised places in hostels and housing in alternative families All of this falls within a coordinated socio health functional model 78 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Supervised flats are a community housing and social support resource located in flats or hous es where several people with sufficient level of independence and with Severe Mental Illness live together and who do not have sufficient family support to live independently They offer on a temporary or indefinite basis and depending on the needs of each case housing personal and social support support to integration and flexible and continued supervision Mini homes are small community residential centres with around 20 places destined for people with severe mental illness and with their personal and social autonomy impaired Their main objective is to temporarily or indefinitely provide housing maintenance care personal and social support support to community integration to people who do not have family and social support or who due to their degree of psychosocial impairment require the services of this type of residential centre Supervised places in hostels are hostels where in order to avoid marginalisation processes housing as well as the coverage of basic needs are offered to people with severe mental illness wit
114. development group of the expert collaborators and external reviewers The invaluable contribution of the Aragonese Pro Mental Health Association ASAPME and the Federation of Aragonese Pro Mental Health Associations FEAFES ARAGON must also be mentioned An update of the CPG is planned every three years and if new scientific evidence that modi fies any of the recommendations it contains appears the update will be made earlier The updates will be carried out on the electronic version of the CPG available on the GuiaSalud website http www guiasalud es CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 29 4 Characteristics of the CPG 4 1 Definition of Severe Mental Illness There are different ways of defining Severe Mental Illness The most commonly agreed defini tion in bibliography has been used in this GPC which considers three dimensions clinical diagnosis duration of the disorder chronicity and the level of social family and labour disability of the person affected Diagnostic criteria It includes psychotic disorders excluding organic disorders All the diagnostic categories in cluded in SMI are considered as psychotic in the broad sense This bears n mind not only the presence of positive and negative symptoms but also a seriously altered pattern of relationships inadequate behaviour for the context or serious inappropriate affectiwity which imply a distorted perception of
115. disease The Interpersonal and Social Rhythm Therapy IPSRT is an adaptation of interpersonal psychotherapy that is based on the fact that stability and regularity of the social routine and interpersonal relations act as a protection factor in mood disor ders The treatment focuses on the relationship between the mood symptoms the quality of social roles and relations and the importance of maintaining daily routines on a regular basis as well as identifying and managing potential events that trigger the circadian or biological rhythm In short the IPSRT aims to stabilise the social rhythms and sleep patterns of people with BD as well as teach how to manage internal and external stress in order to avoid relapses Question to be answered e Is interpersonal therapy effective in the treatment of people with SMI Frank et al perform a cross over RCT n 175 in two phases where participants are ran domised into four treatment strategies e T1 Acute phase and IPSRT maintenance phase IPSRT TP5RT T2 Acute phase and ICM maintenance phase ICM ICM e T3IPSRT acute phase followed by ICM maintenance IPSRT ICM e T4ICM acute phase followed by IPSRT maint sance ICM IPSRT In the first acute phase patients are randomisex to one of the two interventions Once the pa tients are stabilised they enter the second phase where they are once again randomised to IPSRT or ICM intensive clinical management The elements that include i
116. doors programme and the Zerostigma campaign promoted by EUFAMI in 2004 Equally itsportant is the work carried out with the social media though the Style Guide for Media published by FEAFES or the participation in studies on stigma project harassment and discrimination faced by people with psychosocial disability in of health services promoted by Mental Health Europe MHE It is still necessary to jor and coordinate the forces of the different players who intervene in the integrated treatment of people with SMI and the support to their families The aim is no other than to guarantee the healthcare continuity that these people require with the most effective therapeutic techniques and strategies providing the most normalised and personalised possible support 9 Addresses and websites of interest National Associations Spanish Federation of Associations of Families and People with Mental Illness grouping together federations and association of people with mental illnesses and their families from the entire national territory The contact addresses of the member associations in each Autonomous Community can be consulted on their webpage http www feafes com feafes feafes com C Hern ndez M s 20 24 28053 Madrid Tel 91 507 92 48 Fax 91 785 70 76 134 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Spanish Association of Neuropsychiatry http www aen es aen aen es C Magallanes 1 S tano 2 local 4 28015 Mad
117. drama therapy distraction therapy or hypnosis effective in people with SMI CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 75 Morita Therapy Morita therapy MT standard treatment ST vs ST SR 1 There are no differences between morita therapy ST vs ST related to short term improvement of negative symptoms measured according to the SANS scale 1 RCT n 50 RR 0 89 95 CI between 0 41 and 1 93 However significant differences have been found in favour of MT in the medium term 1 RCT n 42 RR 0 25 95 CI between 0 08 and 0 76 Results have been obtained in favour of morita therapy ST related to mental state according to the BPRS scale in medium term 1 RCT n 76 reduction 22546 to 30 in BPRS RR 0 35 95 CI between 0 14 and 0 89 NNT 5 95 CI between 4 and 25 Morita therapy ST significantly improved the capacity to carry out daily living activities social functioning in the short term compared with stand ard treatment alone 1 RCT n 104 WMD 4 1 95 CI between 7 7 and 0 6 and in the medium term n 48 WMD 10 50 95 CI between 12 50 and 8 50 Distraction techniques DT SR 1 Drama therapy RCT 1 RCT RCT 1 76 There are no differences between DT tandard treatment ST vs health promotion ST related to the short term improvement of the mental state measured through the BPRS scale 1 RCT n 6
118. e Interconsultation and liaison in general Hospitals Daytime hospitalisation for adults Children adolescents daytime hospitalisation Children adolescents hospitalisation in general and or paediatric hospital Community rehabilitation programmes including community monitoring programmes and or assertive community treatment programmes or similar Daytime regime rehabilitation Rehabilitation with residential or hospital support Extended care unit Therapeutic community for adults Therapeutic community for teenagers Residential alternatives with grading support and therapeutic or rehabilitation activity Home care programme Home hospitalisation Gntensive care 24 hour communityccare including community monitoring programmes and or ATC programmes or similar Employment programmes with support People with SMI may use these resources at different moments of their illness in some cases successively in other simultaneously The way in which the interventions are coordinated and in which eircumstances one resource or another is used may vary from one Autonomous Community to another In any case it maintains a series of constant factors that are aimed at what is 2alled continuity of care and which are based on situating the Community Mental Health Centre in the decision making centre with respect to each patient and at there being no interrup tions or sudden changes in the level and intensity of the care CLINICAL PRACTICE GUIDELINES
119. e main goal of maintaining the present functioning or helping the patients with their pre existing skills and it can be aimed at individuals o groups of people The key support elements are to maintain an existing situation or offer helj in connection with pre existing skills Supportive therapy is not a costly technique and when used correctly and there are profes sionals available it can be usefu temporarily and if there is a lack of other more effective treat ment methods Question to be answered Is supportive therapy effective in the treatment of people with SMI The SR by Buckley et al 21 ECA n 21683 assesses the effectiveness of supportive ther apy in people with schizophrenia compared with standard care treatment received in the normal enviroament including the patients preferences and is conditioned by them the professionals criterion and the availability of resources or other treatments CBT pyschoeducation family intervention social rehabilitation programme etc The majority of the studies of this review are designed to examine specific supportive therapies such as cognitive behavioural therapy and supportive therapy is used as a comparison group Normally the trials last from 5 weeks up to 3 years The results measurements that are presented are short term up to 12 weeks medium term 13 to 26 weeks or long term more than 26 weeks In the experimental group all the patients receive suppor
120. e control group that con sisted in normal treatment Three RCTs were included in the NICE bipolar disorder CPG two of which n 2 170 by Colom et al compare the effect of a complex group pyschoeducation programme including pyschoeducation on bipolar disorder and training in communication improvement and problem solving with a non directive support intervention control group in addition to the psychophar macological treatment The programraes consisted in 20 sessions of pyschoeducation each week with a 24 month follow up and with euthymic patients Perry et al performed RCT n 69 comparing an individual pyschoeducational pro gramme on people who suer bipolar disorder that incorporated training in recognition of pro dromes and pharmacological treatment compared with pharmacological treatment alone The in tervention lasted for 2 to 6 months with an 18 month follow up Pyschoeducation for people with SMI and diagnosed with schizophrenia and related disorders Psychogducation vs non intervention Pysehoeducation when compared with non intervention or non specific in SR 14 tervention does not produce a significant drop in relapses or readmissions follow up of more than 12 months 3 RCT n 144 p 0 07 There are no data to support that pyschoeducation represents a reduc tion in symptoms at the end of the programmes 6 RCT n 2 313 p 0 08 or in follow ups at 7 to 12 months 3 RCT n 128 p 2 0 14 Py
121. e different characteristics for example bipolar disorder For that SMI subgroup RCT have been feund included in selected reviews such as Weiss et al and Schmitz et aP whose data have been treated globally The evidence review jected the study of the use of other psychosocial techniques that patients with SMI and dua diagnosis may receive on specific occasions such as cognitive behav ioural therapies socia skills training or motivational interview whose efficacy will be assessed in other sections Questioii to be answered e What type of treatment has proven to be most effective in people with SMI and substance abuse integral or parallel treatment Cleary et al developed a SR that included 25 RCTs which assesses the effect of psychoso cial interventions in the reduction of the consumption of substances in patients with SMI Likewise Morse et al performed a RCT n 149 with 24 month follow up on people with SMI and substance abuse as well as homeless They were randomised either to an inte grated ACT or standard ACT programme or to standard treatment This study has an important bias risk as it does not specify the losses in the groups 102 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Finally in the RCT by Cheng et al n 460 and with 3 year follow up the integrated intervention was assessed with sheltered housing at a medical care centre for homeless veterans with SMI and or substance
122. e finalisation rate n 284 RR 0 95 95 CI between 0 52 and 1 7 Despite finding a lower ratio of hospital readmission among patients who received PVT n 887 RR 0 79 95 CI between 0 65 and 0 95 this difference was no longer significant when a random effect model was used due to the high heterogeneity in 3 studies n 887 RR 0 71 95 CI between 0 48 and 1 04 so the evidence is insufficient to determine if there are significant differences between PVT and ST in hospital readmis sion ratios Pre vocational Training PVT vs PVT alternatives clubhouse economic reinforcement psychological intervention transitional employment In the work by Beard et al no significant differences have been found be tween the PVT according to the clubhouse model device where and from where they offer a social activities b daily job instructions in teams c transitional employment for 3 4 months until phases a and b are completed and placement in a job with adaptation and support compared with standard community treatment with respect to obtaining competitive employment and any other employment variable with a 3 to 12 month foliow up n 215 RR 0 95 95 CI between 0 77 and 1 17 There are less readmissions in the PVT clubhouse group compared with the standard community treatment n 2 215 RR 0 69 95 CI be tween 0 46 and 0 96 The 6 month study by Bell et al a paid part time sheltered job inter
123. e personnel and other interventions apart from the pharmacological intervention The objective of this CPG is to assess the existing and available evidence and formulate the appropriate recommendations on the effectiveness of the different psychosocial therapeutic and rehabilitating interventions on people who suffer from SMI This CPG sums up the available evidence for key questions related to psychosocial interventions and intend to facilitate health professionals the people affected and their families the shared decision making process These recommendations are not mandatory nor do they replace the clinical opinion of health or social professionals This CPG is aimed at people who suffer Severe Mental Illness and satisfy the three classifi cation dimensions chosen inthis guideline diagnosis chronicity and disability The following cases are excluded from tbe target population group of this CPG e People with mental disorders in childhood and adolescence under 18s e Peoplecver the age of 65 as they are subject to receiving treatment in different services other than the Mental Health Service People affected by mental disorders that are secondary to medical illnesses People who have organic psychoses e People whose disorder is included in psychotic categories but has a transitory or episodic nature e People whose main diagnosis is substance abuse moderate serious intellectual impair ment general development dis
124. e risk Systematic review Scale for the assessment of negatives symptoms Self esteem scale Social functioning scale Social disability schedule for inpatients Scottish intercollegiate guidelines network Mental Health National Health System Skalen zur psychischen Gesundheit Bipolar disorder Cognitive behaviour therapy Standard treatment Severe Mental illness Wisconsin card sorting test 139 Appendix 6 Glossary Therapy adherence Active and voluntary involvement of the patient in a mutually agreed and accepted behaviour course in order to produce a desired therapeutic result Psychosocial rehabilitation centres Specific resource aimed at the population with severe and chronic psychiatric disorders who have difficulties in their psychosocial functioning and in their integration into the community The aim is to offer psychosocial rehabilitation and commu nity support programmes that facilitate the improvement of their level of autonomy and function ing as well as support their maintenance and social integration into the community in the best possible conditions of normalisation independence and quality of life Expert collaborators Clinical professionals with knowledge and experience on specific subjects of the CPG and ideally with prestige in the field where the guideline is developed They participate in defining the initial clinical questions and reviewing the recommendati ns Comorbility in psychiatry The World Hea
125. e were no conclusive findings about the harm or benefits of drama therapy for hospitalised patients with schizophrenia There are differences between the description of pyschodrama in China which is where some of the studies included in this review originate from Qu et al and Zhou amp Tang y fi must also be taken into account that the results reflect different versions of drama therapy psychodrama social drama and role play ing which makes it difficult to generalise the results of these studies to western drama therapy Hypnosis for people with SMI The American Psychological association defines hypnosis as the procedure during which a health professional or researcher suggests that a client patient or subject experience changes in sensa tions perceptions thoughts or behaviour 2 Izquierdo amp Khan 3 RCTs n 149 assess hypnosis in patients with schizophrenia com paring it with standard treatment the normal level of psychiatric care that is provided in the area where the trial is carried out medication hospitalisations family intervention etc or other interventions The hypnosis intervention consisted in one single 90 minute session Results are only provided in this SR when hypnosis is compared with ST or relaxation related to mental state these data core from thesis as those articles that had large losses 250906 during the follow up were excluded Caestion to be answered e Are morita therapy
126. e with SMI gt In the NICE Schizophrenia CPG different service level interventions are addressed which are included in this CPG such as e Non acute hospital day care based on a review which in turn includes 5 RCTS of which 4 are selected e Community mental health centres CMHC 3 RCTs n 334 e Assertive community treatment ACT 22 RCTs n 372 The comparer is standard treatment hospital rehabilitation or standard Case Management CM e Intensive case management ICM 13 RCTs n 2546 Day centres and or psychosocial rehabilitation centres There is another later systematic review than the NICE CPG that of Catty et al where de spite having identified more than 300 quotes o randomised clinical trials on non medical day centres were found Community Mental Health Centres CMHC Referring to the CMHC there is 4 systematic review developed by Malone et al which includes 3 RCTs n 587 where these centres are compared with a standard hospital service that gener ally assessed patients in surgeries and outpatients with less emphasis on multidisciplinary work In the review of th CMHC studies there is agreement in almost all the points assessed which is understandable if we bear in mind that both the NICE Schizophrenia CPG and the re view by Malone e al use 3 studies 2 of which are common to both reviews 9 22 The foltowing considerations must be made e Where is divergence in t
127. e with SMI compared with ST is associated with more likelihood of remaining in contact with the services and reducing hospital admissions The ACT reduces the probabilities of hospital admission compared with hospital based rehabilitation The ACT reduces the use ef beds it decreases the risk of becoming homeless greater probability of independent living a reduction in the risk of being unemployed and an improvement of the mental state The ACT is associated with an increase in satisfaction with the services Homeless p ople who receive ACT are likely to experience clinically significant im provements in quality of life 1 ICM is associated with an increase in contact with the services when compared with the CM8 1 Mere are no differences between ICM and Case Management with respect to losses of contact with their case manager 1 When ICM is compared with Case Management there is no evidence to indicate that an improvement takes place in the readmission rates the mental state or social functioning in people with SMTP There is no evidence to indicate that ICM in people with SMI compared with Case Management improves treatment adherence 1 ICM functions better when participants tend to use hospital care a lot When the use of hospital services is high the ICM can reduce this but no effect is produced when the use of hospital care is low 100 CL
128. e with SMI and diagnosis of non affective psy chosis Family members and caregivers of people with SMI and a diagnosis of bipolar disorder must be offered group pyschoeducational programmes that include information and cop ing strategies that permit discussions within a friendly emotional climate CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 65 5 1 6 Pyschoeducational interventions The pyschoeducational type approach is frequently used in interventions with patients affected by schizophrenia and bipolar disorders both in hospitals and outpatients This intervention involves transmitting information about the disease to patient and families it is not always done in an organised manner and the inclusion of family members is not normal practice It is important to know the effectiveness of these interventions which are usual in practice Problems have been encountered to focus the search for scientific evidence due to the fact that the majority of studies associate pyschoeducation as an essential part of family intervention although the surveys on clinical activity inform us that family incorporation is very scarce andwot generalised in clinical practice This CPG development group decided to focus the search on pyschoeducation programmes for users that were compared with an inactive control group They included studies hat evaluated the impact of the pyschoeducation of family members
129. eams in coordination with the institutions and other social agents iunvolved must advise about all types of employment resources aimed at gainful occupa tion and production and adapted to the local employment opportunities Likewise they must be orientated towards interventions that put into motion different devices adapted to the needs and to the ability level of people with SMI to increase stable and productive occupation expectations CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 89 5 2 5 Other therapeutic interventions art therapy and music therapy Music therapy and art therapy are creative interventions used together with other more common treatments in the rehabilitation process and treatment of people with Severe Mental Illnesses There is still a lively debate about whether the curative aspect of this type of interventions lies in the process of making music or art or in the actual relationship that is established between the therapist and the patient or in an interaction between both elements Music therapy for people with SMI Music therapy is a systematic intervention process where the therapist helps promote the pa tient s health via musical experiences and the relationships that are developed by means of such experiences as dynamic forces of change It is often perceived as a psychotherapeutic method in the sense that it addresses intra and inter psychic
130. ed controlled trial Lancet 2007 370 9593 1146 52 Crowther R Marshall Bond G Huxley P Vocational rehabilitation for people with severe mental illness Cochrane Database Syst Rev 2001 2 CD003080 Mueser KT Clark RE Haines M Drake RE McHugo GJ Bond GR et al The Hartford study of supported employment for persons with severe mental illness J Consult Clin Psychol 2004 72 3 479 90 Lehman AF Goldberg R Dixon LB McNary S Postrado L Hackman A et al Improving emp oyment outcomes for persons with severe mental illnesses Arch Gen Psychiatry 2002 59 2 165 72 Becker RE An evaluation of a rehabilitation program for chronically hospitalised psychiat ric patients Soc Psychiatry 1967 2 32 8 Griffi ths RD Rehabilitation of chronic psychotic patients An assessment of their psycho logical handicap an evaluation of the effectiveness of rehabilitation and observations of the factors which predict outcome Psychol Med 1974 4 3 316 25 Beard J Pitt MA Fisher S Goertzel V Evaluating the effectiveness of a psychiatric rehabili tation program Am J Orthopsychiatry 1963 33 701 12 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 171 172 174 175 176 177 178 179 180 181 182 183 184 185 186 185 188 189 Walker R Winick W Frost ES Lieberman JM Social restoration of hospitalised psychiatric patients through a program of special employment in industry Rehabilit Lit 1969
131. ed out in Spain although faithfulness to the IPS model is difficult in the few places where there are labour insertion programmes or services it is more similar with respect to standard treatment and pre vocational training The authors of the studies point out the difficulty of working with community samples that are heterogeneous and that include people who do not want to work and the difference that exists with patients in employment programmes that may represent a self selected sample Furthermore the employment rates obtained are low even with the more effective programmes except fer the EP IPS programmes with high fidelity to the model with which the majority of the participants gt 50 obtain employment and employment is not a personal or valid objective for ail people with SMI There are authors who point out that a general unemployment rate of over 10 in the society has a clear and negative effect on the acquisition and maintenance of empleyment in the popula tion with SMI and in our context this case arises However although he incorporation into an employment programme is a personal decision after the information nd appropriate consent the acquisition and maintenance of the role of worker favours a normalising process in the person and improves independence so the implementation of employment orientated programmes appears to be important and necessary Pre vocation training PVT vs standard treatment ST RCT 1 T
132. ed when there is not another way to highlight the aspect mentioned above CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 117 Appendix 2 Information obtained from working groups with family members and people with SMI Summary of the information obtained by two group interviews held with people affected by mental illnesses and families of this type of people The aim of these interviews was to identify problems and needs both of people with mental illnesses and of their families The participants were contacted through different associations of families and or patients with mental illnesses in Aragon Group of patients 9 people 4 men and 5 women participated who satisfied the Severe Mental ilness criteria rep resentatives of different groups Group of families 10 fathers mothers brothers or sisters of mental patients 4men and 6 women took part Table 1 Information obtained from the working groups ot families and users Related to the institution and its interventions Related to the social environment PROBLEMS NEEDS PROBLEMS NEEDS There are not sufficient residetces for young people with mental prebiems e Limited tesources in Lack of information for families Participate in normalised contexts such as labour activities Social rejection and isolation Denial of illness by Participate in mental illness 118
133. en Liily Concepci n de la C mara Izquierdo has received funding for attending ineetings courses and congresses Esteve Boerhringer Pfizer Janssen Almirall Boehringer Ingelheim She has obtained fees as a speaker at courses and conferences Andromaco Bexai and Janssen Andr s Mart n Gracia has received funding for meetings congresses and for attending courses Boehringer Ingelheim GSK Janssen and fees as a speaker at conferences and courses Pfizer and Lilly He has also received funding for educationsi programmes or courses Janssen Miguel Mart nez Roig has obtained financing for participating in meetings congresses and courses Almirall Janssen Lundbeck Lilly Boheringer Bristol Myer Wyeth He has also re ceived economic support to participate in research vrojects Lilly Pfizer and Janssen M Esther Samaniego de Corcuera has rece ved funding for participating in meetings con gresses and courses Lilly Fernando Ca as de Paz has received funding Servier Lundbeck and Janssen to attend to meetings courses and congresses and for participating in research projects He has also received fees as a speaker Janssen BMS end for consultancy work Janssen M Consuelo Carballal Ba sa has received funding for participating in courses conferences and meetings Janssen Alberto Fern ndez Liria has received support Janssen to participate in conferences and fees as a speaker Lilly Bristol Myers Squibb W
134. ence came from was clearly specified In those cases where this was not clear that information was used but the evi dence level was lowered to a lower level and subsequently the degree of recommendation 3 4 Forming guideline recommendations Following the critical appraisal of the available evidence the recommendations were tormulated A discussion group was made up with the entire CPG development group using a well reasoned opinion and bearing in mind the quality of the evidence found and the clinica experience of the CPG development group the recommendations were gradually developed with their relative clas sification Several recommendations were prepared for each answer incicating the level of evidence and degree of recommendation When the recommendations were controversial or there was no evidence it was solved by consensus of the development group In those questions with respect to which there was no clear evidence about a particular topic the group proposed research recom mendations 3 5 Collaboration and external review The guidelines established in the Methzdology Manual for the Preparation of Clinical Practice Guidelines in the Spanish Nationaldfealth System include the participation of expert collabora tors and external reviewers The expert collaborators participated in the review of the questions and the recommendations of th CPGs and the external reviewers contributed to the review of the draft Before sendi
135. ent of bipolar affec tive disorders J Consult Clin Psychol 1984 52 5 873 8 Lam DH Bright J Jones S Hayward P Schuck N Chisholm D et al Cognitive therapy for bipolar illness a pilot study of relapse preventi u Cognit Ther Res 2000 24 503 20 Lam DH Watkins ER Hayward P Bright 4 Wright K Kerr N et al A randomized con trolled study of cognitive therapy for reiapse prevention for bipolar affective disorder out come of the fi rst year Arch Gen Psychiatry 2003 60 2 145 52 Scott J Garland A Moorhead A pilot study of cognitive therapy in bipolar disorders Psychol Med 2001 31 3 459 7 Scott J Paykel E Morriss R Bentall R Kinderman P Johnson T et al Cognitive behavioural therapy for severe and recurrent bipolar disorders randomised controlled trial Br J Psychiatry 2006 188 313 20 Lewis S Tarrier N Haddock G Bentall R Kinderman P Kingdon D et al Randomised con trolled trial of cognitive behavioural therapy in early schizophrenia acute phase outcomes Br J Psychiatry Suppl 2002 43 591 7 Alanen3f0 La esquizofrenia sus or genes y su tratamiento adaptado a las necesidades del paciente Madrid Fundaci n para la Investigaci n y Tratamiento de la Esquizofrenia y otras Psicosis 2003 Bachmann S Resch F Mundt C Psychological treatments for psychosis history and over view J Am Acad Psychoanal Dyn Psychiatry 2003 31 1 155 76 Malmberg L Fenton M Individual psychodynamic psychotherapy and
136. ent psychosocial interventions depending on the stage of motiva tion and with respect to the abandonment of programmes or reduction in consumption 114 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Appendices Appendix 1 Key to evidence statements and grades of recommendations from SING Levels of evidence 1 High quality meta analyses systematic reviews of RCTs or RCTs with a very low risk of bias 1 Well conducted meta analyses systematic reviews or RCTs with a low risk of bias 1 Meta analyses systematic reviews or RCTs with a high risk of bias High quality systematic reviews of case control or cohort or studies High quality 2 case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal Well conducted case control or cohort studies with a low risk of confowsding or bias 2 s e and a moderate probability that the relationship is causal 2 Case control or cohort studies with a high risk of confounding ofbias and a significant risk that the relationship is not causal 3 Non analytic studies e g case reports case series 4 Expert opinion Grades of recommendations A At least one meta analysis systematic review or RCT rated as 1 and directly applicable to the target population or A body of evidence consisting principally of studies rated as 1 directly applicable to the target population and demonstrating overall consistency of
137. ent the establishment of relationships between thoughts feelings and actions of the person with respect to the symptom in question It must also represent the correction of false perceptions irrational beliefs and reason ing biases of the person in connection with the symptom in question It must involve at least one of the following conditions Control by the person of his or her thoughts feelings and behaviours related to the symptom in question and the proposal of alternatives to cope with it CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 37 Standard treatment the treatment that a person normally received if he or she were not included in the research trial The standard care category also includes control groups on waiting list where participants receive pharmacological treatment or other interven tions Specific medication when the control group receives a specific drug compared with CBT No intervention control groups without treatment e Additional pharmacological interventions when the standard treatment has been comple mented with additional medication e Other psychosocial interventions when the standard treatment has been complemented with additional social or psychological interventions such as non directive therapy sup portive therapy and other conversation therapies From all of the RCTs included in the review of Jones et al those obtained
138. environments This type of intervention focuses on the functioning of persons improving their pe sonal and social skills and providing support to the different roles undertaken in their social and community lives All in all they aim to improve the quality of life of people affected and their families sup porting their social participation in the community in the most active normalised and independent possible way They are organised through an individualised process that combines on the one hand train ing and development of the skills and competences that each perso requires to effectively func tion in the community and on the other hand actions on therenvironment It includes several aspects that vary from pyschoeducation and advice to families to the development of social sup ports aimed at offering the necessary aid to compensateor strength the level of psychosocial functioning of chronic mental patients Psychosocial interventions in rehabilitation have gained in operativity and efficiency with the incorporation of different extrapolated strategies adapted from the field of psychology social learning behaviour modification social intervention and human resources including among oth ers training and development of personaland social skills pyschoeducational and psychosocial intervention strategies with families arid users development of social networks social support etc This series of psychosocial intervention strategi
139. eople who followed IPS compared with the other control vocational interventions 61 and 23 em ployed difference in averages 38 range 20 to 55 There is evidence to indicate that IPS achteves a higher number of pa tients who work more than 20 hours per week compared with the controls 43 6 and 14 2 respectively The SE IPS models obtain their first jobs more quickly than the con trols 138 days vs 206 double the time with work per year 12 1 vs 4 8 weeks year and keep competitive work for longer 22 0 vs 16 3 weeks Patients in sheltered employment worked more hours in competitive work than those who received PVT p lt 0 001 p 0 001 2 p 0 03 55 and they also earned significantly more money that those that were in PVT p 0 05 p 20 019 5 and p 0 001 181 although in another study the differences were not significant p gt 0 05 Compared with the psychiatric rehabilitation programmes the patients included in the IPS programme had greater probability of obtaining com petitiv employment or any other form of paid employment respectively p lt 0001 There are no differences in maintenance in programmes between SE and PVT 5575 None has been found either related to global functioning meas ured with the GAF or self esteem measured with the Rosenberg scale Patients included in IPS programmes after 18 months follow up pre sented greater probability of having worked at
140. eople with mental health problems in Europe Mental Health Europe 2008 Trad FEAFES In Spain Strategy in Mental Health of the National Health System Strategy line 1 Promotion of mental health of the population prevention of mental illness and eradication of the stigma associated with people with mental disorder Ministry of Health 2007 Model for care of people with severe mental illness Ministry of work and social affairs General Catalogue of Official Publications Chapter 15 Fight against social stigma CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 131 Service Management The first anti stigma measure corresponds to the Administration as Provider of quality accessible universal non excessive recovery orientated services which decisively incorporate advances in treatment rehabilitation and social integration and leading the start up of awareness raising campaigns and maximising surveillance over the respect for the dignity of persons both in the state administration as a whole and in healthcare in particular Integrate the anti stigma approach in community plans Over the last few years a lot of progress has been made to fight against the stigma The familv associative movements and self help associations as well as movements of users and of profes sionals have now taken centre stage The social fabric itself has joined this effort local adminis tration NGOs neighbou
141. er 10 years n 196 RR 0 83 95 CI be tween 0 15 and 0 38 NNT 2 indicate too that they significantly favoured family interventioncompared with standard intervention Readmissions SR 1 Family intervention of more than 5 sessions proves to be more effective in reducing hospitalisations after 18 months follow up 3 RCT n 228 RR 016 95 CI between 0 3 and 0 69 NNT 4 SR 14 Family intervention compared with standard intervention does not reduce the likelihood of readmission 2 years after having finished the treat ment n 330 RR 0 01 95 CI between 0 79 and 1 28 Effect of family intervention on users and caregivers SR 1 In patients whose family members received a family intervention of more than 5 sessions when compared with standard treatment an improvement is observed in pharmacological treatment adherence 7 RCT n 369 RR 0 74 9596 CI between 0 6 and 0 9 NNT 7 58 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS A family intervention of more than 5 sessions indicates a significant reduction in the burden perceived by family caregivers n 48 WMD 7 01 95 CI between 10 8 and 3 3 and n 60 WMD 0 4 95 CI between 0 7 and 0 1 A family intervention of more than 5 sessions compared with standard treatment favours the reduction of expressed emotion levels within the fam ily 3 RCT n 164 RR 0 68 95 CI between 0 5 and 0 9 NNT 4 95 CI between 3 and
142. ervices in our context based on teamwork on service integration and not losing the perspective of being able to integrate other ways of config uring the services that might be developed When the needs of the people with SMf cannot be covered from the CMHC continuity of assistance must be given from units that provide day care and whose activity is organised around the principles of psychosocial rehabilitation whatever the name of the resource are Day Centres Psychosocia Rehabilitation Centres etc N A certain level of care cambe offered to people with SMI whose needs cannot be satis fied by resources that provide day care in rehabilitation orientated residential resources whatever the name of the resource are hospital rehabilitation units medium stay units therapeutic communities etc CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 101 5 4 Interventions with specific subpopulations 5 4 1 SMI with dual diagnosis Substance abuse is for different reasons a frequent comorbility in people with SMI and entails a worsening of the clinical condition of their clinical management and prognosis One of the con sequences of dual diagnosis is an increase in non treatment adherence and abandonment more relapses suicides contagion of viric diseases via parenteral way home abandonment disruptive behaviour with aggression legal problems less economic resources and less so
143. es and sup ported housing approach is more favourable than standard treatment in homeless patients with diagnosis of SMI and or substance abuse in re sults of substance consumption at 36 months using a multiple imputation system for handling lost data use of alcohol p 0 047 intoxications p 0 053 consumption days p 0 028 spending on alcohol and drugs p 0 048 22 The integrated clinical service and supported housing approach ap pears to be more favourable too compared with case management and with standard treatment in homeless patients with diagnosis of SMI and or substance abuse with a shorter stay in institutions p lt 0 05 Summary of evidence There are no differences between long term integrated treatment 36anonths and stand ard treatment that included the same interventions except for Assertive Community 1 a Treatment which were not developed and coordinated by the same team but by different teams with respect to the use of substances l4 There are no differences between long term integrated treatment 36 months and stand ard treatment with respect to abandonment of treatmet and rehospitalisations There are no differences between integrated assertive community treatment ACT and l standard ACT with respect to satisfaction an housing stability at 24 months although there is between both interventions when compared with standard treatment The integrated clini
144. es have proved to be efficient in improving the psychosocial functioning of people with SMI and in their adaptation and maintenance in the community 5 1 Psycholegical interventions 5 1 1 Cognitive behavioural therapys Cognittve behavioural therapy CBT is a psychological intervention that is based on the hypoth esis that cognitive activity determines behaviour Many differences can be found when approach ing the cognitive aspects as some of them focus on structures beliefs or basic cases as the main causal entities of emotions and behaviour whilst others focus on processes such as problem solving cognitive distortions or thought content self instructions automatic thoughts etc In addition there are important differences in the intervention strategies Despite these differences the following characteristics which they all have in common can be pointed out CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 35 Behavioural change has been mediated by cognitive activities In other words the sys tematic alteration and identification of disadaptive cognitive aspects will produce the desired behavioural changes The acceptance of reciprocal determinism between thought environment and behaviour The therapy is designed to help people identify test reality and correct dysfunctional conceptions or beliefs Patients are helped to recognise the connections between cogni tions a
145. es that include housing and support followed by ACT ltt ACT when compared with standard Case Management in the homeless population does not reduce hospitalisation CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 107 In homeless people with SMI ACT reduces the psychiatric symptoms when compared I with standard Case management Living in group improves the executive functions especially in patients with no sub stance abuse Recommendations For homeless people with SMI who require psychiatric care and psychosocial interven A tion it is advisable for both to be supplied together via integral programmes where resi dential programme housing is offered When there is no active substance abuse it would be advisable to provide grouped a com modation to homeless people with SMI included in integral intervention programmes When it is not possible to use accommodation and support programmes ii the integral C psychosocial intervention of homeless people with SMI the intervention of assertive community treatment team should be offered 5 4 3 SMI and low IQ mental retardation There seems to be general agreement about the high prevalence of mental disorders in people with intellectual disability or mental retardation understood 3 a person whose intellectual coefficient is 70 or below at the same time as less access to s
146. ess how they live how they function in society and how they undertake their different roles placing importance on distant distal and costly results compared with nearer proximal psychopatho logical results The development group of this CPG chose to include both studies as it considered that they are congruent and complementary in many aspects due to the varied measurement approach they offer The impact of this intervention is determined on the one hand by the low effect on distal measurements detected and by the population it addresses The impact may be low if the inten tion is for it to be an intervention aimed at preventing relapses because the target population may present other types of probisms and the impact may be higher if the intention is to improve the psychosocial functioning c Problem solving therapy in people with SMI and a diagnosis of schizophrenia and related disorders The probiein solving therapy is considered as a brief and focused form of psychotherapy It in volves Holding a few practical sessions where the therapist organises a process with the patients to ideniify their more immediate problems and they design agreed tasks and ways of solving them Problem solving therapy has a cognitive and behavioural component it tries to establish a link initially between the symptoms and the practical difficulties to be developed in several stages ex planation about the therapy and its fundamentals identification and bre
147. euro cogni tive intervention focusing on social skills in people with schizophrenia vs contro group was greater for the global effect of the therapy during the treatment nz170 p lt 0 01 and showed improvement in the 3 domains as sessed neurocognition ESw 0 48 95 CI between 0 27 and 0 70 psy chosocial functioning ESw 0 62 95 CI between 0 33 and 0 92 and psychopathology ESw 0 49 95 CI between 0 26 and 0 72 p lt 0 01 SR 1 However patients who only received sub programmes of IPT of cog nitive differentiation social perception and verbal communication obtained greater effects in the neurocognitive domain RCT 12 ES 0 72 95 CI between 0 51 and 0 90 and less effects in the psychosocial functioning domain RCT 7 ES 0 38 95 CI between 0 13 and 0 61 SR 1 McGurk et al also indicate that the cognitive rehabilitation pro grammes which provided adjuvant psychiatric rehabilitation showed greater improvements in the psychosocial functions p 0 01 than those that did not provide psychiatric rehabilitation b The values of the effect size of Cohen d vary between small effect d 0 2 medium d 0 5 and large d 0 8 up 72 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS With reference to the type of training the interventions that include the SR 1 design of compensatory strategies offered better results than those that did not do so or than those based on rehabilitating repe
148. f et al indicate that the people who received single family inter veittion compared with those who received multi family intervention were able to lead more independent lives n 23 RR 2 18 95 CI between 1 1 and 4 4 In the study by Montero et al they indicate that although both tech niques improved the patient s clinical situation the families that received individual behavioural approach therapy had better results in social function ing doses of antipsychotic medication and psychotic symptoms p lt 0 05 than the families that received group format there were no differences in the relapse or readmission rates CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS SR 1 RCT 1 SR 1 SR 14 SR 1 RCT 1 RCT 1 59 Behavioural family intervention vs family support intervention gt 5 sessions RCT 1 There are no differences between the two interventions related to hospital readmissions n 528 RR 0 98 95 CI between 0 1 and 1 12 Systemic family therapy vs standard treatment RCT 1 It is observed that patients who receive systemic family therapy improve during the treatment in readmission rates p 0 273 relapses p 0 030 and treatment adherence p 0 009 However after 2 years there are no differences between the two groups Inclusion of the patient in family interventions SR 14 When the user is included in
149. ferences between CBT ST vs ST in general symptoms in short me dium term However there is an improvement after 18 months in favour ef the CBT group In the case of hallucinations CBT ST vs ST favours specific symbtoms in the long term No effect was observed between CBT ST vs ST respect to the conviction of delusional beliefs There is a positive effect in favour of CBT ST vs ST i connection with positive and negative symptoms and global symptoms No significant differences have been found between CBT ST vs ST with respect to the improvement of quality of life There are no differences between CBT _ T vs ST in the social functioning of people who suffer SMI and a diagnosis of schizophrenia and related disorders with respect to iso lation interpersonal behaviour independence in performance and competence However there is a positive effect in favour f CBT for prosocial behaviours No differences have been observed between CBT ST vs Supportive psychotherapy ST with respect to medium or long term relapse ratios There are no differences between CBT ST vs Supportive psychotherapy ST respect to clinical improverae ts in medium or long term However with respect to general symptoms there ar no significant differences in favour of CBT in the short term but there are in thc medium term There are no differences between CBT ST vs supportive psychotherapy
150. ffection and behaviour together with their consequences to make them aware of the role of images and negative thoughts on maintaining the problem The techniques applied in this approach include cognitive restructuring problem solving self instructional training etc In general environmental manipulations are used in cognitive behavioural modification as in other approaches but here these ma nipulations represent information feedback tests or experiments that providc an op portunity for people to question reassess and acquire self control over disadaptive behaviour feelings and cognitions at the same time as they practice trained skills The therapeutic relationship is collaborative and the active role of tne client is empha sised Social Skills Training Social skills are understood as the specific response capacities required for effective social per formance Social skills therefore are a series of behaviours carried out by an individual in an interpersonal context that express feelings attitudes desires opinions or rights of that individual in a way that adapts to the situation respecting that be aviour in others and which generally solve the problems of the situation at the same time as they reduce the probability of future problems to a minimum Social skills training consists in behavioural learning techniques that permit people with schizophrenia and other incapacitating mental disorders to acquire an
151. focuses on improving cognitive functioning by applying repeated practice of cognitive tasks or by the training of strate gies for compensating cognitive impairments 96 Over the last decade different cognitive training approaches have been developed to improve cognitive impairments in people with schizophrenia which have following different methods Repetitive exercises of cognitive tasks presented in a computerised or paper and pencil version e Compensatory strategies which imply the learning of strategies to organise information for example categorization or adaptative strategies with use of reminders or other en vironment aids e Behavioural and didactic learning techniques such as positive reinforcement instruc tions etc These methods have been used alone or combined in different training programmes such as IPT Integrated Psychological Therapy by Brenner et al Brenner 1994 1073 id e CRT Cognitive Remediation Therapy by Delahunty y Morice NEAR Neuropsychological Educational Approach to Rehabilitation by Medalia et al e CET Cognitive Enhancement Therapy by Hogarty et al e CAT Cognitive Adaptation Training by Velligan et al gt NET Neurocognitive Enhancement Therapy by Bei et al e APT Attention Process Training by Sohlberg amp Miateer e Attention Shaping by Silverstein et al e Errorless learning by Kern et al Question to be answered Are cognitive rehab
152. g the most relevant CPGs local national and interna tional in different databases and information sources prepared by other groups that could be relevant for this CPG National Guideline Clearinghouse Tripdatabase Gu aSalud NICE and G I N see figure 1 26 CPGs were identified on some of the diagnoses that were included within the criterion of SMI Of these 26 guidelines those where the population topics interventions development date or methewology did not comply with the objectives and scope of this CPG were rejected Finally 5 guidelines were selected CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 25 Figure 1 Search Strategy Search for CPGs in Gu aSalud National 26 CPGs Guidelines identified Clearinghouse Trip Database G I N selected those that contained psychosocial interventions First selection 5 CPGs selected AGREE Instrument Cut off values was established score 75 in area 3 Each CPG was Assessed by 4 reviewers 3 CPGs selected Each one of the 5 CPGs selected was assessed by 4 independent reviewers The cut off val ues to accept the guidelines was set at 60 except for the methodology section area 3 rigour and preparation where the cut off had to be over 7596 Finally only 3 CPG passed the established cut off value The CPGs on Schizophrenia Bipolar Disorder and Compulsive Obsessive Disorder
153. gle blind control trial of 63 patients Chinese Mental Health Journal 1994 1994 2 5 201 Shi Y Zhao B Xu D Sen J A comparative study of life quality in schizophrenic patients after family intervention Chinese Mental Health Journal 2000 14 2 135 7 McFarlane WR Lukens E Link B Dushay R Deakins SA Newmark M et al Multiple family groups and psychoeducation in the treatment of schizophrenia Arch Gen Psychiatry 1995 52 8 679 87 Leff J Berkowitz R Shavit N Strachan A Glass I Vaughn C A trial of family therapy v a relatives group for schizophrenia Br J Psychiatry 1989 154 58 66 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 147 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 148 Schooler NR Keith SJ Severe JB Matthews SM Bellack AS Glick ID et al Relapse and rehospitalization during maintenance treatment of schizophrenia the effects of dose reduc tion and family treatment Arch Gen Psychiatry 1997 54 5 453 63 Bressi C Manenti S Frongia P Porcellana M Invernizzi G Systemic family therapy in schizophrenia a randomized clinical trial of effectiveness Psychother Psychosom 2008 77 1 43 9 Montero I Asencio A Hernandez I Masanet MJ Lacruz M Bellver F et al Two strategies for family intervention in schizophrenia a randomized trial in a Mediterranean environment Schizophr Bull 2001 27 4 661 70 Falloon IR Montero
154. gnosis of recent onset non affective psychosis and with a ma jority of patients with more than 10 years evolution of the disease results which could be more easily extrapolated to the criteria of our CPG 56 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS In the RCT carried out by Hogarty et al they included 103 patients with a diagnosis of schizophrenia or schizoaffective disorder and who come from homes with high expressed emo tion were randomised to four treatment conditions family psychoeducation FP and pharma cology treatment FP PT social skills training and pharmacological treatment SST PT fam ily psychoeducation social skills training and pharmacological treatment FP SST PT and pharmacological treatment PT The same author publishes the results of the same study two years after the treatment In the Spanish study by Lemos et al they submit to verification the effectiveness of psy chosocial therapy programmes added to the pharmacological treatment in the prevention of re lapses the control of symptoms and the functional improvement of patients with schizophrenia after 4 years follow up The 46 initial patients were assigned by order of arrival at the centre to the standard treatment control group n 15 and to the psychosocial intervention programme n 20 consisting in psychoeducation and integrated psychological therapy IPT of Brenner and Roder for patients and psychoeducation and family thera
155. guration of the most commonly implemented services in our context based on teamwork on service integration and not losing the perspective of being able to integrate other ways of configuring the services that might be developed When the needs of the people with SMI cannot be covered from the CMHC continuity of assistance must be given from units that provide day care and whose activity is organised around the principles of psychosocial rehabilitation whatever the name of the resource are Day Centres Psychosocial Rehabilitation Centres etc A certain level of care can be offered to people with SMI whose needs cannot be satisfied by resources that provide day care in rehabilitation orientated residential resources whatever the name of the resource are hospital rehabilitation units medium stay units therapeutic communities etc 5 4 INTERVENTIONS WITH SPECIFIC SUB POPULATIONS 5 4 1 SMI with dua diagnosis People with SMI with dual diagnosis must follow psychosocial intervention programmes and drug dependent treatment programmes both integral and parallel The treatment programmes offered o people with SMI with dual diagnosis must have a multi component nature be intensive and prolonged For people with SMI and duardiagnosis and in a homeless situation the treatment programmes should incorporate sheltered housing as a service When the care for pecvie with SMI and dual diagnosis is provided in pa
156. h a good level of autonomy and a very independent lifestyle but with no family support or economic resources There is a systematic review conducted by Chilvers s et al 149 with resgect to which despite obtaining 139 quotes after selecting the studies and assessing their quality none were found that satisfied the inclusion criteria established in the review so no conclusions could be drawn Although no data have been found in systematic reviews or controlled Descriptive 3 clinical trials that provide any proof there is information te ndicate that dif ferent residential programmes are able to maintain a considerable number of people with SMI in the community as occurs with the work carried out by Fakhoury et al These authors conduct a review of 30 studies mainly de scriptive where the efficacy of the community residential programmes for SMI patients is assessed In this study positive results are found with respect to the improvement of functioning and sacial integration and greater satis faction of the patients compared with patients from mid and long stay units Furthermore in the cross sectional and descriptive study by L pez et al 151 155 the community residential programme for people with SMI in Andalusia is analysed Practically all the devices and residents attached to this programme were assessed in this study 16 homes 67 flats and 399 residents The result of this work among others indicate that there is an impr
157. he results shown with respect to hospitalisations favourable to CMHC in the study by Malone et al and neutral in the NICE Schizophrenia CPG Both results are obtained from the same RCT so the only explanation is that the NICE Schizophrenia CPG has handled unpublished supplementary data as it specifies that it has done in the case of this study e The NICE Schizophrenia CPG also considers that patients originating from the study by Tyrer et al were more serious and with more probabilities of readmission so it chose not to add the data to those of the article by Merson et al and present them indepen dently whilst in the review by Malone et al they were added 94 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS e The satisfaction data originating from the study by Merson et al are only taken into ac count in the SR by Malone et al as in the NICE Schizophrenia CPG it considers that the tool used to extract them was not valid so these data are excluded This CPG development group has chosen to taken into account the data provided by the NICE schizophrenia CPG and the SR by Malone et al indicating their methodological diver gences as in the majority of their findings there is agreement Assertive Community Treatment ACT Intensive Case Management ICM non acute Day Hospitals and Case Management CM With respect to ACT ICM non acute Day Hospitals and CM the discrepancy that exists in litera ture referring to
158. herapists need a high level of tolerance to frustration and independence of the narcis sistic reward Question to be answered e Are psychodynamic psychotherapy and the psychoanalytic approaches effective it the treatment of people with SMI The benefit of psychodynamic or psychoanalytical interventions to treat senizophrenia has been and is still being discussed in depth due to the fact that the existing scientific evidence is very scarce and of low quality In the United States in an attempt to improve the quality of health interventions and pro mote the adoption of treatments that have scientifically proven their effectiveness some years ago the Department of Health and Human Services through the Agency for Health Care Policy and Research AHCPR known as the Agency for Healthcare Research and Quality AHRQ started up the programme Patient Outcomes Research Team PORT The PORT schizophrenia programme compiles scientific literature on the efficiency of treatments and examines the practices and implications of their variability in health quality The PORT recommendation on psychodynamic intervention in people with schizophrenia and based on very low quality and non conclusive studies is that psychodynamic intervention should not be applied to people with schizophrenia due to the lack of evidence and to the high cost of the intervention There is a SR by Malmberg amp Fenton67 3 RCTs n 492 68 70 which compares the effects
159. here is no evidence in favour of PVT when maintaining competitive em ployment after 8 months compared with standard hospital treatment in a small study n 50 RK 0 79 95 CI between 0 63 and 1 00 85 RCT 1 No differences are observed in obtaining competitive employment af ter 18 months between PVT and community treatment n 2 28 RR 1 18 95 CI between 0 87 and 1 61 and 24 months n 215 RR 0 95 95 CI between 0 77 and 1 17 RCT 1 She PVT favours obtaining some type of employment when compared with standard hospital treatment n 59 RR 0 42 95 CI between 0 26 and 0 68 65 RCT 1 No differences were observed in hours worked per month between PVT and standard hospital treatment n 28 hours 36 8 and 31 6 average hours respectively p 0 92 RCE i There is certain evidence that PVT users earn significantly more mon ey a month than those that receive standard hospital treatment 176 and 97 3 on average respectively p lt 0 01 SR 1 There is no difference respect to the level of participation of users in programmes when the PVT programmes and standard hospital treatment are compared n 78 RR 0 5 95 CI between 0 05 and 5 25 There are no differences between PVT and community treatment in any form or data related to employment 84 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS When PVT is compared with standard community treatment there are no differences in the programm
160. here is no generalised or approved practice Labour insertion resources have a different typology and experience varies from one country to another This is due to the differences between the health and social services systems the different regulations that govern access to employment social cultural differences and the actual labour market By way of analysis there are two approaches to address a labour rehabilitation intervention One is the train then place or supported employment which places emphasis on the stability and recovery of skills in prior programmes that permit subsequent generalisation The other place then train which places emphasis on immediate occupation of a job activating the learning and monitoring programmes in the job CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 81 The different formulations orientated to labour insertion can be grouped into three types of instrumental programmes supported employment social enterprises and vocational rehabilita tion These programmes are not antagonist conceptions as they can be complementary and re spond to different degrees of difficulty both individual stability employment prior to the illness labour and social skill etc and availability of human resources as well as to situations derived from the labour market Vocational rehabilitation or labour rehabilitation starts up social skills training and profes sional preparati
161. his service did not exist would not be attended by the system they are left outside and would permit providing more efficient care for those patients who overload the short stay units People with SMI constitute a relatively small population but they represent a considerable burden for the Spanish NHS and for their families The specific problems of the design of this type of studies to assess the service level inter ventions are related to the following difficulties The difficulty in defining these interventions with precision e Variations relating to the application of one same model or fidelity to the model e Variations between different settings and different moments with respect to standard care with respect to what it is compared with The frequency with which some interventions and others overlap depending on the place 5 3 1 Day Centres and or Psychosocial Rehabilitation Centres No randomised clinical trials have been found that assess these services 206 5 3 2 Community Mental Health Centres CMHC CMHC vs ST Use of services SR 1 Deaths SR 1 96 In the NICE schizophrenia CPG it indicates that there is insufficient evi dence to determine if the CMHCs reduce hospital admissions when com pared with standard treatment n 100 RR 0 711 95 CI between 0 42 to 1 19 and n 155 RR 0 88 95 CI between 0 76 and 1 01 These resulis agree with those found in the SR by Malone et al
162. hotherapies morita therapy drama therapy distraction therapy and hypnosis 5 2 Social interventions 5 2 1 Daily living skills programmes CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 21 23 25 25 25 27 28 28 31 31 32 33 34 35 35 35 49 51 52 55 66 69 74 77 78 5 2 2 Residential programmes in the community 78 5 2 3 Programmes aimed at leisure and spare time 79 5 2 4 Programmes aimed at employment 81 5 2 5 Other therapeutic interventions art therapy and music therapy 90 5 3 Service level interventions 92 5 3 1 Day Centres and or Psychosocial Rehabilitation Centres 96 5 3 2 Community Mental Health Centres CMHC 96 5 3 3 Assertive Community Treatment ACT 97 5 3 4 Intensive Case Management ICM 98 5 3 5 Non acute Day Hospitals 99 5 3 6 Case Management CM 99 5 4 Interventions with specific subpopulations 102 5 4 1 SMI with dual diagnosis 102 5 4 2 Homeless with SMI 105 5 4 3 SMI and low IQ mental retardation 108 6 Dissemination and implementation 114 T Recommendations for Future Research 113 Appendices 115 Appendix 1 Key to evidence statements and grades of recommendations from SING 117 Appendix 2 Information obtained from working groups with family members and people with SMI 118 Appendix 3 Template to develop recommendations via formal assessment or well founded judgement 119 Appendix 4 Informatien for people with SMI and their famil
163. iatry 2007 164 3 393 9 Nelson G Aubry T Lafrance A A review of the literature on the effectiveness of hous mg and support assertive community treatment and intensive case management inter ventions for persons with mental illness who have been homeless Am J Orthopsychiatry 2007 77 3 350 61 Caplan B Schutt RK Turner WM Goldfi nger SM Seidman LJ Change in neurocognition by housing type and substance abuse among formerly homeless seriously mentally ill per sons Schizophr Res 2006 83 1 77 86 Wechsler D WAIS III test de inteligencia para adultos manual t cnico Buenos Aires Paid s 2002 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 155 225 Hurley AD Individual psychotherapy with mentally retarded individuals a review and call for research Res Dev Disabil 1989 10 3 261 75 226 Royal College of Psychiatrists DC LD diagnostic criteria for psychiatric disorders for use with adults with learning disabilities mental retardation London Gaskell 2001 227 Martin G Costello H Leese M Slade M Bouras N Higgins S et al An exploratory study of assertive community treatment for people with intellectual disability and psychiatric dis orders conceptual clinical and service issues J Intellect Disabil Res 2005 49 7 516 24 228 Haddock G Lobban F Hatton C Carson R Cognitive behaviour therapy for people with psy chosis and mild intellectual disabilities a case series C
164. idence found which could also answer this question a series of cases by Haddock n 5 have been included where the people that are described suffer from light MR and schizophrenia they are being treated with antipyschotics and chronic and resistant sensoper 108 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS ceptive disorders This series of cases describes the reliability of cognitive behavioural therapy adapted to this population including 2 cases where family intervention was integrated Little volume and quality of evidence have been found regarding the number of studies and types of interventions to be compared Assuming that the productive symptomatology in people with SMI and learning disabilities light MR may be disruptive chronic and resistant to treatment the application of effective psychosocial interventions may provide clear benefits especially when the learning disabilities variable is often a criterion for exclusion when creating programmes services and studies In our context and at the present time the basic conditions do not exist to be able to apply cognitive behavioural techniques and assertive programmes to the SMI population with learning disabilities No differences were found between ACT and standard treatment Favourable RCT 1 results have been observed in both treatments with respect to covering needs and improving the burden of care and the functioning level of this popu lation Regarding the qual
165. ies 120 Appendix 5 Abbreviations 138 Appendix 6 Glossary 140 Appendix 7 Declaration of interest 142 Bibliograpry 143 6 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Presentation Healthcare practice is increasingly more complex due to a multitude of factors one of the most relevant of which is undoubtedly the exponential increase in scientific information available to us Science is something that is permanently changing and thus requires permanent updates This means that clinicians have to constantly refresh their knowledge objectives and interventions to be able to cover people s needs This means that professionals have to face up to the situation of taking clinical decisions each day These decisions are becoming more and more complicated ne to the constant changes and the needs and expectations generated in society In 2003 the Interterritorial Council of the Spanish National Health Service SNHS created the GuiaSalud Project whose ultimate purpose is to improve clinical decision making based on scientific evidence through training activities and by setting up a register of clinical practice guidelines CPG Since then the GuiaSalud Project financed by the Minisiry of Health and Consumer Affairs has evaluated dozens of CPGs according to explicit Criteria determined by its scientific committee It has registered those guidelines and it has disseminated them over the Internet At the beginning of 2006 the General Direct
166. ife and support to the community integration of people affected by severe and chronic mental illnesses 32 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS The main focus of rehabilitation is the functioning of people in their normal environments improving their personal and social skills giving support for them to undertake the different roles of social and community life and in short to improve the quality of life of the persons affected and of their families as well as support for their social participation in the community in the most active normalised and independent way possible in each case In other words the aim of psychosocial rehabilitation is to help people with severe and persistent mental illnesses develop intellectual social and emotional skills that they need to live learn and work in the community with the least possible professional support In this CPG the importance of the psychosocial rehabilitation concepts is based on defining its field as a series of psychosocial interventions aimed at improving the autonomy and functicn ing of people in their environment and support to their normalised social integration and partici pation and their role in the framework of a community service system that cares for this popula tion Thus the term refers to a spectrum of psychosocial and social intervention programmes for people who continuously suffer from Severe Mental Illnesses Psychosocial rehabilitation therefore i
167. ife expectations overcoming these changes through the different techniques that the services must provide Any intervention based on the recovery model increas es its efficiency as it is aimed at recovering the person s meaning in life It is therefore an integral concention of the interventions which bears in mind people s lives interests and motivation and not just the efficiency of partial interventions Reintegration into society is a result that can be reached through the use of therapeutic men tal health services such as community psychiatry and rehabilitation among others as well as a political and community initiative to promote solidarity and openness with respect to individuals who suffer from several mental illnesses Recovery is neither a service nor a unitary result of the services it is a personal status This term must be referred to in this CPG because it is an objec tive of psychosocial interventions although it is difficult to find an operative universal definition of the term that is agreed by consensus CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 33 4 4 Research into psychosocial interventions The preparation of quality randomised control trials to be able to determine the possible effective ness of the different interventions and psychosocial formats is complicated This may be due in part to the type and complexity of the actual interventions referred to and to the ethic
168. ilitation interventions efficient in people with SMI and cognitive im pairment e Which is the most adequate Format of these interventions for people with SMI and cognitive impairment The NICE schizophrenia CPG addresses this question and includes the systematic review by Pilling et al which also contains 5 RCTs Furthermore the NICE CPG development group adds another 2 RCTS making a total of 7 RCT n 295 Rodet et al carry out a SR of 29 RCTs n 1367 where they compare Integrated Psychelegical Therapy IPT with standard treatment and or placebo The review differentiates 7 high quality studies n 362 of which only one is excluded in the NICE CPG with controlled studies including randomisation of patients to different treatment groups fixed doses of antip sychotics or statistically controlled changes in medication clearly defined blind assessments and complete explanation of the data of the different symptomatic and functional domains that were assessed The data referred to in this evidence assessment related to this study will be the data from this high quality group of studies unless specified otherwise 12 RCTs are included n 543 in the SR by Krabbendam y Aleman and the inclusion criteria of the studies were that they had to assess the efficacy of cognitive remediation in patients 70 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS with schizophrenia and that the treatment should involve the practice or
169. increase in contact with the services compared with that provided with standard CM number of losses in follow up after 2 years n 1060 RR 0 54 95 CI between 0 59 and 0 74 SR 14 98 There is no significant difference between ICM and standard CM in terms of numbers of participants who lose contact with their case manager n 780 RR 1 27 95 CI between 0 85 and 1 90 or in terms of read mission rates either n 747 RR 0 95 95 CI between 0 85 and 1 05 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS There is not sufficient evidence either in terms of pharmacological treatment adherence n 68 RR 1 32 95 CI between 0 46 and 3 75 With respect to mental state no differences have been found between ICM and standard CM with respect to mental state BPRS CPRS endpoint score n 823 WMD 0 02 95 CI between 0 12 and 0 16 or to social functioning Disability Assessment Schedule Life Skills Profile 641 WMD 0 08 95 CI between 0 24 and 0 07 ICM functions better when participants tend to use hospital care a lot When the use of a hospital services is high the ICM can reduce it p 0 001 but no effect is produced when the use of hospital care is low Respect to ICM teams that are organised in agreement with the ACT model they were more likely to reduce the use of hospital care p 0 029 but this finding was not encountered when the personnel levels recommend ed for ACT were analysed
170. instruments must be used CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 109 6 Dissemination and implementation Clinical practice guidelines aim to help professionals and users to take decisions on the most ap propriate healthcare Their development means investing effort and resources which are some times not appropriately used because they are not sufficiently used by the health professionals and because they do not represent an improvement in the care quality and results in health of the population they are aimed at To improve the implementation of a CPG in other words introduce it into a clinical setting it is advisable to design a series of strategies aimed at overcoming the possible barriers for its adoption The plan to implement this CPG for psychosocial interventions in Severe Mental Illnesses includes the following interventions Presentation of the CPG by the health authorities to the media Collaboration with scientific societies that have participated inthe preparation of this CPG to review and disseminate it Forwarding the CPG to different databases that compile CP amp s for its evaluation and in clusion therein Contact with the Spanish Federation of Associations of Family Members with Mental Illness and other associations of stakeholders to siiow them the guide Free access to the different versions of this CPG on the GuiaSalud website http www guiasalud es
171. interpersonal handling of the illnesses and independent living Skills to improve their functioning in the community The module postulates that social competence is based on a set of three skills social perceptions or reception skills social cogmition or processing skills and behavioural response or expression skills Following these premises social skills training has been included in CBT because it is in this paradigm where werx 1s mainly done on social skills of people with schizophrenia To be able to zcquire this series of attitudes and behaviours there are social skills training programmes that ntegrate structured psychosocial interventions either in groups or individually or both created to improve social behaviour and reduce the stress and difficulty in handling so cial situations The components of the social skills training procedure are derived from the basic principles of learning that include operational conditioning experimental analysis of behaviour the theory of social learning social psychology and social cognition There are four key components e Meticulous behavioural assessment of a list of interpersonal social skills Emphasis on both verbal and non verbal communication Training focused on the individual s perception and on the processing of relevant social situations as well as the individual s ability to offer adequate social reinforcements e Work done at home as well as the interventions that are c
172. ion with respect to treatment adher ence When the multi family group psychoeducation intervention is compared with non inter vention no differences have been found with respect to the recovery of the patient at the end of the study 28 months There are no differences between systemic family therapy focused on problem solving and multi family psychoeducation group therapy in the recovery ratios at the end of the study 28 months 1 Psychoeducation in group format of relations of people with bipolar disorder in euthymic phase reduces the number of relapses in particular hypomaniac and maniac relapses and prolongs the time until these occur Recommendations B For people with SMI and a diagnosis of schizophrenia and related disorders and their families family intervention should be offered as an integral part of the treatment In family interventions that are carried out with people with SMI and diagnosis of schizo phrenia and related disorders the intervention should be done in a single family format The recommended duration in family interventions aimed at people with SMI and diag nosis of schizophrenia and related disorders must be at least 6 months and or 10 or more sessions Psychosocial intervention programmes must be offered that include family intervention wit a pyschoeducational component and coping and social skills training techniques added to the standard treatment for peopl
173. ion with the ser vices compared with ST Client Satisfaction Scale n 120 WMD 0 56 95 CI between 0 77 and 0 36 The ACT reduces the probability of users becoming homeless compared with ST n 2 374 RR 0 22 9596 CI between 0 09 and 0 56 NNT 10 95 CI between 7 and 20 Patients who receive ACT have more probabilities of living iidepen dently than those that receive community ST not living independently at the end of the study n 362 RR 0 70 95 CI betweeri 0 57 and 0 87 NNT 7 9596 CI between 5 and 17 People who receive ACT have less probabilities of being unempioyed at the end of the study than those that receive community ST n 604 RR 0 86 95 Ci between 0 80 and 0 91 NNT 8 95 CI between 6 and 13 Symptoms and quality of life SR 1 People who receive ACT improve their mental state more than those who receive standard communitv care but the difference is small in terms of clinical significance BP1S Brief Symptom Inventory Colorado Symptom Index n 255 WMD 0 16 95 CI between 0 41 and 0 08 Homeless people who receive ACT have probabilities of experi encing clinically significant improvements in the quality of life compared with those tnat receive ST General Well being in Quality of Life Scale n 125 WMD 0 52 95 CI between 0 99 and 0 05 5 3 4 Intensive Case Management ICM ICM vs Standard Case Management CM ICM isssociated with an
174. ional de Salud manual metodol gico Madrid Plan Nacional para el SNS del MSC Instituto Aragon s de Ciencias de la Salud I CS 2007 Gu as de Pr ctica Cl nica en el SNS LCS N 2006 01 Scottish Intercollegiate Guidelines Network SIGN 50 a guideline developer s handbook Edinburgh SIGN 2008 NICE Bipolar disorder the management of bipolar disorder in adults children and ado lescents in primary and secondary care London Mational Institute for Health and Clinical Excellence 2006 Nice Clinical Guideline 38 NICE National Collaborating Centre for Metital Health Schizophrenia full national clini cal guideline on core interventions in primary and secondary care London Gaskell The Royal College of Psychiatrists 2003 NICE Obsessive compulsive disorder core interventions in the treatment obsessive com pulsive disorder and body dysraorphic disorder London National Institute for Health and Clinical Excellence 2005 NICE Clinical Guideline 31 NICE Schizophrenia core interventions in the treatment and management of schizophrenia in adults in primary and secondary care update Borrador en Internet London NICE 2008 consultado 20 noviembre 2008 Disponible en http www nice org uk guidance in dex j sp a ction download amp o0 42139 Gisbert C Arias P Camps C Cifre A Chicharro F Fernandez J et al Rehabilitaci n psicoso cial del irastorno mental severo situaci n actual y recomendaciones Madrid A
175. ith commu nity services The recognition of the need to coordinate these different services is what has given tise to the Case Management CM and consequently a new health profession the case manager Thus over the last 20 years other types of services have been generated that can be classified into 2 categories Services with highly defined objectives intervention in crisis home care labour rehabili tation or early intervention Services aimed at covering a wide range of patient s needs such as Assertive Community Treatment CAT or Case Management 92 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS A series of Case Management systems have arisen over the last two decades The first of the approaches was the agent that does not fulfil clinical functions and it is not necessary for him her to have skills in this regard The clinical model of CM was developed in recognition of this fact and trying to provide the person in charge of clinical functions with skills in areas such as pyschoeducation and psychotherapy A community programme was created in the seventies as an alternative to the hospital Programme for Assertive Community Treatment which has become an extensive therapeutic approach and goes beyond the agent system or clinical system In the United Kingdom these teams have been called Assertive Outreach Teams The CAT is imple mented by a multi disciplinary team with basic characteristics Low
176. itive improvement according to the number of sessions of cognitive rehabilitation 1 The interventions that include design of compensatory strategies offered better results than those that did not do so or those that were based on rehabilitation repetition for the psychosocial functioning area but not for the cognitive functioning area 1 The IPT is higuer for the global effect of the therapy during the treatment phase and in the follow up phase after 8 months 1 The IP is more effective in the neurocognition psychosocial functioning and psychopa thology domains Ane application of only the IPT subprogrammes of cognitive differentiation social per Pception and verbal communication obtained greater effects in the neurocognitive domain and less effects in the psychosocial functioning domain 1 When Cognitive Enhancement Therapy CET is compared with enhanced supportive therapy a greater effect is observed in CET respect to the processing speed social cog nition cognitive style and social adjustment measurements but not for neurocognition These results are maintained 36 months after the end of the intervention CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 73 Recommendations People with SMI and diagnosis of schizophrenia and related disorders that have cognitive impairment must be offered cognitive rehabilitation programme
177. ity of life the results were even favourable for standard treatment compared with ACT adjusted difference of standard means vs ACT 5 27 IC95 between 9 7 and 0 82 p 0 023 Adapted individual cognitive behavioural therapy or with family nmter Cases series 3 vention is effective in population with learning disabilities andschizovnrenia and can be efficient as a supplementary therapy in treatment of chronic psy chotic symptomatology resistant to antipsychotic treatment Summary of evidence 1 ACT and standard treatment improve the burden of care and functioning levels in people with SMI and learning disbailities 1 The results appear to be more favourable in standard treatment compared with ACT respect to quality of life Adapted individual cognitive behavioural therapy or with family intervention is effec tive in population with carning disbilities and schizophrenia and may be efficient as a complementary therapy in the treatment of chronic psychotic symptomatology resistant to antipsychotic treatment Recommendaticws Condition For people with SMI and a low IQ and when there is a presence of persistent productive symptoms it is recommendable to indicate cognitive behaviour therapy adapted to that y To improve the diagnosis of psychiatric disorders included within the concept of SMI in people with a low IQ adapted criteria and specific and validated
178. izophrenia Shanghai Archives of Psychiatry 1999 11 12 84 7 Tang W Wang Z Modifi ed morita therapy for rehabilitation of schizophrenia in comparison with rehabilitation therapy Shangai Archives of Psychiatry 2002 14 2 88 90 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 Lv JJ Chu YZ Bai YG Lv FQ Lu DZ The rehabilitative effect of Morita therapy for chronic schizophrenia Chinese Journal Nervous and Mental Diseases 2002 28 2 122 4 Wei Q Effect of new Morita therapy plus antipsychotic drugs in ameliorating post schizo phrenia depression Zhongguo Linchuang Kangfu 2005 9 32 72 5 Wang X Sun HX Lu QZ Ma WY Zhang SH An JR et al The application of Morita therapy in chronic schizophrenia Health Psychology Journal 1994 2 1 47 50 Medalia A Dorn H Watras GD Treating problem solving defi cits on an acute care psychi atric inpatient unit Psychiatry Res 2000 97 1 79 88 Nitsun M Shapleton JH Brender MP Movement and drama therapy with long stay schizo phrenics Br J Med Psychol 1974 47 101 19 Tungpunkom P Nicol M Life skills programmes for chronic mental illnesses C chrane Database Syst Rev 2008 2 CD000381 Liberman RP Kopelowicz A Young AS Biobehavioral treatment and re abilitation of schizophrenia Behav Ther 1994 25 1 89 107 Liberman RP Massel HK Mosk MD Wong SE
179. l for meatal disorders Randomised clinical trial Global activity assessment scale Sheltered employment Sheltered employment and individual support Pre vocations Training Effective Size Enriched support iherapy Effect size weighied Pharmacolegical treatment Guidelines international network Global Gssessment functioning Global assessment scale Ciinical Practice Guideline Social skills Confidence Interval 95 confidence interval Intensive case management Individual placement and support Interpersonal and social rhythm therapy Integrated psychological therapy Menninger health sickness scale Modified scale for the assessment of negative symptoms Neuropsychological educational approach to rehabilitation Neurocognitive enhancement therapy National institute for health and clinical excellence CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS NIMH NNT WHO NGO OTP OR P PANNS Perc Qol FP PORT MR RR SR SANS SES SFS SDSI SIGN MH NHS SPG BD CBT ST SMI WCST CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS US National Institute of Mental Health Necessary number to treat World Health Organisation Non government organisations Optimal treatment project Odds ratio Probability of the results being due to chance Positive and negative syndrome scale Lancashire quality of life profile Family psychoeducation Patient outcomes research team Mental retardation Relativ
180. lin Psychol Psychother 2004 11 4 282 98 156 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS ISB 4 6 N8 9 788461 M PVPSIO MINISTERIO DE CIENCIA E INNOVACI N MINISTERIO ETE DE SANIDAD JU P Y POL TICA SOCIAL
181. lity of art therapy and music therapy in people with SMI to know which aspects must be addressed in the intervention how the sessions must be structured and the minimum number of sessions necessary to be able to be effective 5 3 Service level interventions It would be recommendable ta design high quality studies that compare the different inter vention possibilities with respect to existing service configurations in our context CMHC psy chosocial rehabilitation centre day centres rehabilitation hospital unit ACT teams etc and to the components that can make them more effective including their impact in areas such as quality of life person s satisfaction integration into social networks etc With respect to the population with SMI that are in long stay units psychiatric hospital and who at least in our context are still in a de institutionalisation process it would be advisable to conduct research studies that can indicate which psychosocial interventions are effective as alternatives to hospital centres Itvestigations must be carried out into those people with SMI with whom ACT is not indi cated to find out which alternative integrated programme proves to have greater effectiveness to maintain these people in the community and improve long term social functioning 5 4 1 SMI with dual diagnosis It would be advisable to conduct studies that include people with SMI and dual pathology to measure the efficiency of differ
182. lth Organisation WHO defin s comorbility or dual diagnosis as the co existence in the same individual of a disorder induced by the consump tion of a psychoactive substance and a psychiatric disorder Prosocial behaviours Acts carried out in benefit of other people ways of responding to them with sympathy condolence cooperation help rescue comfortig and delivery or generosity Disability According to the WHO Within the health experience a disability is any restric tion or absence due to a deficiency of the ability to carry on van activity in the way or within the margin that is considered normal for a human being Randomised control trial An experimental stody in which the participants are randomly assigned to receive a treatment or intervention from among 2 or more possible options Control Group A control group in a clinica trial is the group that has not received the inter vention of interest and serves as the standard_of comparison to evaluate the effects of a treatment Experimental group In a clinicalarial the group that receives the treatment under study in comparison with the reference grotip that receives placebo or an already known accepted and established active treatment Interdisciplinary Carried out with the collaboration of several disciplines Distal measurements Measurements related to distant circumstances in a space time sense of the intervention under study Proximal measurements Measurements rel
183. ly intervention favours a remission of the symptoms after 3 months RCT 1 n 101 RR 0 54 95 CI between 0 33 and 0 89 and after 15 months n 101 RR 0 59 95 CI between 0 39 and 088 It is not clear if the intervention began during the acute phase of the disease CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 61 Group psychoeducation for relations of people with SMI and a diagnosis of bipolar disorder RCT 1 RCT 1 Patients whose family members followed a group psychoeducational pro gramme presented a significantly longer period of time until any recurrence than those of the control group p 0 044 When the analysis described the type of relapse only the time until hypomaniac or maniac relapse was sig nificant P 0 015 but not for depressive relapses Furthermore 42 of the patients whose family members followed a group psychoeducational programme presented relapses compared with 66 in the control group after 12 months follow up p 0 011 In a de tailed analysis this difference was exclusively due to the lower percent age of hypomaniac and maniac relapses in the experimental group 37 596 p 0 017 Family intervention vs multi family intervention In a study performed when the patient was in an acute phase individual family intervention has not been found to be more effective than multi family intervention with respect to the improveme t in symptoms at the end
184. mple to be studied is assigned either to the continuity of care group housing and clinical care following continuum model or housing with no clinical conditioning factors housing first model The systematic review by Coldwell amp Bender where 6 RCTs and 4 observational stud les are assessed 940 and 4854 patients respectively ACT is compared with standard Case Management or standard treatment in homeless people Nelson et al carries out another SR with 16 assessments of controlled studies on housing and support for people who have been homeless In this study ACT Case Management and sup ported housing are compared with each other No information is provided about the magnitude of the effect Caplan et al n 112 randomise the sample all receive ICM and assign it to an indi vidual residential housing programme without clinical personnel or housing with 6 to 1G residents with individual room and assigned clinical personnel There are several problems regarding the generalisation and application of the results of these studies which have been conducted in Anglo Saxon countries e The variability in the prevalence of psychotic disorders in thefomeless population al ready mentioned e The differences in social and health support between the different areas where they are conducted with a greater degree of protection in European countries e Derived from the above the problem of the homeless population has dete
185. n and maintenance of employment are examined in a sample of 204 patients with SMI The patients were randomised between IPS a psychiatric rehabilitation programme and standard treatment The patients assigned to the IPS programme those who obtained employment that coincided with their prior preferences with respect to the type of work desired obtained higher levels of satisfac tion and longer duration of the employment This relationship was not observed in the other two programmes In the RCT n 40 developed by McGurk etet in people with SMI and with a prior his tory of labour failure they were assigned randomiy either to a sheltered employment programme or to another employment programme fostered with cognitive training The labour results were measured after 2 to 3 years The results obtained indicate that patients in the sheltered employ ment programme with cognitive training obtained greater access to employment 69 vs 14 maintained more jobs worked more weeks more hours and with better salaries than patients who were only offered sheltered employment p 0 001 Finally two multi centre studies have been included one performed in the USA and the other at six European sites The American multi centre study designed to compare the cost effi ciency of the current atypical and conventional antipsychotics CATIE assessed in 1411 people with SMI and a diagnosis of schizophrenia the existing relationship at the onset of the stud
186. n of incapacitation is the competence of the Judge of First Instance by virtue or verification of the causes that cause incapacity Causes of incapacitation are persistent physical or psychic illnesses or impairments that prevent a person from coping on their own art 260 and in the case of mi nors when this cause is foreseen to persist after the coming of age ert 201 The following are legitimised to start the incapacitation provess Spouse or descendants And when absent ancestors or brothers sisters ofte assumed incapable person The Public Prosecutor when the persons meritioned do not exist or they have not re quested it Any person is empowered to inform the Public Prosecutor s Office of the facts that may be decisive for the incapacitation The incapacitation of minors may oniy be fostered by those who exert custody or guardian ship This process gives rise to a judicial judgement which will determine its extension and limits as well as the guardianship that t i amp incapacitated person must be submitted to Tutorship will require the attendance of the guardian for any activity Curatela guardiansnip needs the attendance of the tutor only for those acts established in the judgemeni The incapacitation judgement will not prevent any new circumstances that may occur from leaving the scope of the incapacitation without effect or modify it Tutorshis is the consequence of an incapacitation proces
187. nce of the efficacy of the interventions is where the clinician and the user must decide which decisions to make concerning a specific health problem in a specific scenario or with specific conditions and with respecto one single person The preparation ofthis guideline on Psychosocial Interventions in Severe Mental Illness SMI presents additonal difficulties as it does not respond to the needs for knowledge on one single and defined mental disorder due to the lack of consensus about the meaning of the tech niques and activities included as Pyschosocial Interventions and the different definitions of the concept of Severe Mental Illness Theymajority of the documents and scientific evidence found refer to affective and non af fective psychotic disorders schizophrenia and related disorders bipolar disorders and severe and persistent affective disorders thus they are all specifically defined or framed within the concept of Severe Mental Illness There are other CPGs that deal with specific psychiatric disorders and can be found at http portal guiasalud es web guest home 120 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 2 What is SMI When we refer to Severe Mental Illness SMI we are referring to a series of clinical diagnoses that fall within the group of psychoses mainly Schizophrenia and Bipolar Disorder but also other related diagnoses For the people with these diagnoses to be considered as pertaining to the group of SMI the
188. nd this approach is to improve the personal and social functioning and the quality of life of people with SMI as well as support their integration This means doing more than just controlitng symptoms and considering overcoming the illness in other words foster the possibility o people with SMI to lead a significant and satisfactory life being able to define their own obiectives and finding help to develop them in the professionals This concept has been called recovery in scientific literature and at the same it becomes a channel and an objective to work wittreach patient These programmes Itamed within a bio psycho social approach and aiming towards recov ery have their maximum expression in Community Mental Health whose aim is to care for pa tients in their norma environment contrary to hospital psychiatric hospital care As referred to in other chapters of this manual this community model is the direct consequence of the changes in mental illness care over the last few decades and that foster a shift from the psychiatric hospital to the cominunity and which have been reflected in among other documents the General Law on Health iid the Strategies document of the Spanish NHS CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 121 4 Regulatory and legal framework 1978 Spanish Constitution The right to health protection is recognised in article 43 Furthermore in its article 49 it urges the publi
189. ng CBT programmes more than 3 months reduce relaps es compared with other interventions n 177 RR 0 72 95 C o tween 0 52 and 0 99 NNT 7 9596 CI between 4 and 100 Symptoms There is certain evidence that indicates that CBT when compared with ST reduces symptoms at the end of the treatment there is no significant im provement taken as the reduction of 40 in the totai score of the BPRS scale or as the reduction of 50 in the positive symptoms of the BPRS scale n 121 RR 2 0 78 9596 CI between 0 66 and 0 92 NNT 5 95 CI between 4 and 13 CBT improves the mental state when compared with standard treat ment at the end of the treatment final scores of the PANSS BPRS CPRS scales n 580 SMI 0 21 95 CI between 0 38 and 0 04 There is not sufficient evidence that indicates that CBT reduces symp toms when comparec with other psychological interventions at the end of the treatment there gt 1s no significant improvement when measured as the reduction of 50 in positive symptoms of the BPRS scale n 121 RR 0 76 95 Ct between 0 62 and 0 93 NNT 5 95 CI between 3 and 15 nor at 9 7 nonths after treatment there is no important improvement taken as the eduction of 20 in the total score of the BPRS scale or 20 in the reduction of the score of the positive symptoms of the BPRS scale n 149 RR 0 79 95 CI between 0 63 and 1 00 Persistent Symptomatology It is not possible to determine
190. ng SE IPS vs PVT in gl bal function ing People included in sheltered employment programmes and pre voc ational training pre sent greater probability of having worked having lower abanderement and readmission figures The local employment rates also affect the efficacy ofthe sheltered employment programmes Recommendations Sheltered employment programmes are necessary for people with SMI who express their desire to return to work or get a first job Programmes based on placement models are recommended with a short preliminary training period immediate placement and with frequent individual support Sheltered employment programmes aimed at searching for normalised employment must not be the only programmes related to labour activity that are offered to people with SMI It would be recommendabie for the psychosocial rehabilitation centres that look after people with SMI and diagnosis of schizophrenia and related disorders to include employ ment integration programmes When employmentinsertion programmes are offered to people with SMI the preferences on the type of gob to be carried out must be assessed and taken into account For people with SMI and diagnosis of schizophrenia and related disorders who has a his tory ofprevious job failure it would be advisable to incorporate cognitive rehabilitation as a part of the employment programmes they are going to participate in Tue mental health t
191. ng the draft CPGs to the external reviewers the clinical leaders ofthe CPG also carried out a review of the text The guideline development group meticulously took into con sideration all the comments and contributions made during the consultation period with the CPG collaborators and reviewers and introduced any changes they deemed appropriate derived from their comments rhe recommendations made in this CPG do not necessarily have to coincide or be in agreement with the contributions of the reviewers and collaborators The final responsibility for the recommendations lies in the CPG development group The informative document for people with SMI and their families prepared by the CPG development group was anonymously reviewed by people who suffer from SMI and their family members introducing appropriate changes as a result of their comments The following scientific associations collaborated in the preparation of this CPG Aragonese Mental Health Association Spanish Neuropsychiatry Association National Mental Health Nursing Association Spanish Psychiatry Society Aragonese Psychosocial Rehabilitation Association FL Cr tica Versi n 1 0 7 OSTEBA Health Technologies Assessment Service Department of Health Basque Government http www euskadi net r33 2288 es contenidos informacion metodos formacion es 1207 metfor html 28 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Aragon and La Rioja Psychiatry Society represented by members of the
192. nificantly larger number of people in com group of being in some type of employment and of earning more money Sheltered employment did not show significant differences with respect to the control group in participation ratios or in number of readmissions The greater access and participation in labour rehabilitation services was associated with a greater probability of achieving competitive employment and to a greater extent non competitive employment 88 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 1 The people included in the individual placement and support programme IPS obtained greater probability of competitive employment some type of paid work higher levels of satisfaction longer duration of the employment than those people where the job did not coincide with their preferences 1 There is strong evidence that SE including SE IPS is superior to PVT in Improving the expectations of competitive employment and hours worked per week 9 1 The SE IPS models speed up the possibility of obtaining a first job and double the time worked per year maintaining the competitive work for longer 1 People in sheltered employment worked more hours in competitive work than those who receive PVT 1 People in sheltered employment earn more money that those in pre vocational training 181 182 184 185 1 1 There are no differences between SE includi
193. no substantial changes were observed In the evaluation after 4 years psycho social intervention the clinical state and social functioning were similar in both groups p gt 0 05 there were significant differences in the presence of clinical relapse criteria at some moments of the follow up which were satis fied by 29 4 of the patients from the experimental group and by 50 from the control group Family intervention for people with SMI and a diagnosis of bipolar disorder Family intervention vs individual intervention There are no differences between family and individual psychosocial inter RCT 1 ventions in people who suffer SMI and a diagnosis of bipolar disorder at the end of the treatment 12 months with r spect to relapses n 53 RR 0 89 95 CI Between 0 51 and 1 54 readmissions n 53 RR 0 71 95 CI between 0 33 and 1 52 and atthe end of the treatment 24 months with respect to treatment adherence 1 29 SMI 0 08 95 CI between 0 65 and 0 82 Family interventions vs crisis orientated treatment also administered to the family but in a less intensive and compi x manner Family intervention represented a reduction of the relapses after 24 months RCT 1 n 101 RR 0 59 95 CI between 0 39 and 0 88 NNT 3 There is an improvement with respect to treatment adherence during the follow up in the family intervention group n 65 WMD 0 45 95 CI between 0 97 and 0 07 Fami
194. ns Assertive Outreach in the United Kingdom Assertive Community Treatment in the United States and the different versions of the same intervention adapted to each context Case Management Intensive Case Management These liraii tions in the applicability are translated into practical aspects For example Malone etai recall when talking about the generalisation of result of the CMHC studies that care musi ve taken as community care in mental health has spread substantially and it is very likely that teaditional therapy is quite close to what is considered as treatment with CMHC teams Thus additional studies can be associated with smaller differences between these two forms of care The majority of the service level configurations and interventions referred to in this chapter are to a greater or lesser extent implemented in our context so the impact must be focused on the implementation of Assertive Community Treatment teams Indeed care in the majority of the Spanish NHS territory is focused on the CMHC the availability of psychosocial rehabilitation centres rehabilitation hospital units etc varies from one area to another but it can be considered as generalised for the entire territory CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 95 This CPG development group considers that the impact of the implementation of ACT teams must be high because it would improve the care of patients who if t
195. nt decrease in relapses or readmissions an improvement of symptoms or of social functioning or improves treatment adherence in people with schizophre 14107 nia Le Pyschoeducation improves the knowledge of the disease in people with schizophrenia 1 In people with schizophrenia and when the family is incorporated into the pyschoeduca tional intervention the relapses or readmissions are reduced 1 The effects of parallel group pyschoeducation with users and family members reduces the number of readmissions which are effective up to 7 years after the intervention 1 Complex pyschoeducation programmes which include pyschoeducation on bip tar dis order training in communication improvement and in problem solving reduce the num ber of relapses in 2 years in people with bipolar disorders However there 3 no evidence to indicate that it reduces the number of readmissions 0 1 Pyschoeducational intervention that incorporated prodrome recognition training in people with bipolar disorders reduces relapses in maniac phase but noti depressive phase 1 The pyschoeducational programme that incorporated prodraime recognition reduces the number of hospitalisations in people with bipolar disorders Recommendations A Quality information must be provided aboui the diagnosis and the treatment giving sup port and handling strategies to people with SMI and diagn
196. ntial support other than hospitalisation for sufficient time so as to have significantly interrupted their life situations From the viewpoint of the duration of the illness the CPG development group will consider any of the criteria mentioned as valid assuming that the duration dimension of the illness is the dimension that presents the most weaknesses of the three and that many of the interventions in cluded within this guideline are applicable to patients in initial stages of their disorders and that in a strict sense would not enter the concept of SMI This CPG will pay attention to the consistency of this criterion in future reviews Presence of disability Defined by the moderate to severe affectation of personal labour social and family unctioning and measured through different scales such as the Global Activity Assessment Scale GAAS with scores 50 and the WHO disability assessment scale DAS I with scores gt 3 in all the items According to the definition of the NIMH4 this disability produces functional limitation in important activities of life and includes at least two of the following ctueria either continuously or intermittently e Unemployment or sheltered or supported employment clearly limited skills or poor la bour history e Need for public economic support to stay out of hospital and may require support to get this aid Difficulties to establish or maintain personal social support systems Need for help
197. ntions is directly related to the need to integrate treatments and to the debate on the rtificial delimitation between treat ment and rehabilitation No specific question has been contemplated in this CPG to define which combination of psychosocial interventions is more efficient It is however considered advisable to indicate that there are studies that propose the application of interventions that combine family therapy and other therapies For some authors there is an international agreement about the need to offer a combination of three essential interventions in the treatment of patients with schizophrenia and related disorders optimal doses of antipsychotic medication education of users and their caregivers to cope more effectively with environmental stress and Assertive Community Treatment that helps resolve social needs and crisis including symptomatic exacerbation Despite the evidence that supports this there are very few menta health plans that foresee these programmes in a routine manner However for other authors it is the combination of family treatment social skills training and pharmacological treatment that can be the appropriate treatment to avoid relapses A combined psychosocial treatment project started up in 1994 which included family inter vention and other psychosocial interventions Optimal Treatment Project OTP It was multicen tre in 21 countries and with 35 venues and its aim was to assess costs and
198. o have received standard intervention related to do Pmestic activities self care positive and negative symptoms general psychopathology and quality of life Residential programmes in the community Community residential programmes improve social functioning social integration and 3 the degree of satisfaction of patients compared with rehabilitation programmes in me dium and long stay units Community residential programmes produce an improvement in the user s satisfaction and increases pharmacological treatment adherence 5 155 80 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Programmes directed to leisure and spare time Leisure and free time programmes in people with SMI and with deficiencies perceived in their social relations help improve the general satisfaction with their lives 1t reduces the perception of solitude fosters self esteem improves satisfaction with social relations with leisure activities and improves social functioning Recommendations d Daily living skills training programmes could be offered to people with SMI in order to improve their personal independence and their quality of life D For people with SMI who require support to remain in their accommodation it is advisable that the community residential offers include more extensive psychosocial programmes D People with SMI and deficiencies perceived in their social relations shoul follow com m
199. of these types of intervention CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 57 Family intervention for people with SMI and a diagnosis of schizophrenia and related disorders Family intervention vs other interventions standard treatment psycho education family support supportive psychotherapy etc Relapses SR 1 Family intervention compared with other interventions reduces relapses during treatment n 383 RR 0 57 95 CI between 0 37 and 0 88 8 and 4 to 15 months after finishing the treatment n 305 RR 0 67 95 CI between 0 52 and 0 88 SR 1 It reduces the relapses after 12 months treatment in people wo had relapses during the 3 months prior to the intervention n 320 RR 0 55 95 CI between 0 31 and 0 97 NNT 5 RCT 1 Dyck et al indicate that family intervention compared with standard intervention reduces persistent symptoms after 12 monihs treatment n 63 RR 0 57 95 CI 0 33 to 0 97 NNT 5 SR 1 Family intervention of less than 5 sessions or an unknown number of sessions significantly reduces relapses SET n 600 RR 0 41 95 CI between 0 31 and 0 53 NNT 4 one year after intervention The relapse ratios after 2 years vere also less in the intervention group n 225 RR 0 45 9596 CI between 0 28 and 0 71 NNT 5 The results after 3 years n 326 RR 0 31 95 CI between 0 20 and 0 49 NNT 4 and afi
200. ogramme to follow and its objectives e Use complet models of continuing assessment with the active participation of the per sons affeoted and of their families avoiding stereotypes in the diagnosis the use of indis crimiraie treatments establishment of routines and incorporating strategies for handling the stigma that include the family e e disseminating agents in the fight against the stigma Use the resources of the normalised network for training cultural leisure and entertain ment activities those of citizens participation Create intermediate group structures that act as mediators to facilitate participation in the community theatrical artistic groups choirs sports groups Create a quality image of the intermediate devices and for them to participate in the social network Promote the user s active participation in the rehabilitation services Foster self help ac tivities in a group among those affected exchanging personal experiences and associa tive movements However small the experiences they have the value of being projected to the whole society 132 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 8 The role of user and family associations The Associations of Families and Users have represented an important advance over the last 30 years both due to their contributions in the development of a previously unknown perspective identifying the needs and rights of people with severe mental illness and due
201. ollow up analyses more than 12 months 127 of them with CBT compared with 226 receiving another treatment The inclusion criteria used in the meta analysis were that the comparisons were CBT vs control g oup waiting list usual treatment or another therapeutic treatment the people satis fied DSM HI R or DSM IV criteria for schizophrenia schizoaffective disorder or delirium disor der that the studies were completed between 1990 and 2004 and that the results had statistical information The development group of this CPG decided to exclude the data referring to acute symp tomatology from this review and extract those defined for chronic cases Social skills training in people with SMI and a diagnosis of schizophrenia and related disorders The contributions of the NICE CPG on Schizophrenia which includes the Pilling et al review were taken into account in this sub section with the addition of one RCT All the controls were 38 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS defined as standard care or discussion groups The studies included varied with respect to the duration of the treatment from 4 weeks to 2 years follow up from 6 months to 2 years place of treatment outpatients hospitalised day or mixed and sex of the participants mixed or all the participants were males All the studies come from the Anglo Saxon field The Kurtz and Mueser review was also taken into account which assesses the effe
202. omon DA Ryan CE Keitner GI Does adjunctive family therapy enhance recovery from bipolar I mood episodes J Affect Disord 2004 82 3 431 6 Rea MM Tompson MC Miklowitz DJ Goldstein MJ Hwang S Mintz J Family focused treatment versus individual treatment for bipolar disorder results of a randomized clinical trial J Consult Ci in Psychol 2003 71 3 482 92 Justo LP Sotes BG Calil HM Family interventions for bipolar disorder Cochrane Database Syst Rev 2007 4 CD005167 Goldstein MJ Rea MM Miklowitz DJ Family factors related to the course and outcome of bipolar disorder En Mundt C Goldstein MJ Hahlweg K editors Interpersonal factors in affective disorders London Royal College of Psychiatrists 1996 p 193 203 Miklowitz DJ Simoneau TL Sachs Ericsson N Warner R Suddath R Family risk indi cators in the course of bipolar affective disorder En Mundt C Goldstein MJ Hahlweg K Fiedler P editors Interpersonal factors in the origin and course of affective disorders London Gaskell Books 1996 p 204 17 Ryan CE Keitner GI Solomon DA Kelley JE Miller IW Factors related to a good poor or fl uctuating course of bipolar disorder 156th Annual Meeting of the American Psychiatric Association May 17 22 San Francisco CA 2003 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 Clarkin JF Glick ID Haas GL
203. on It would be useful to investigate which moderating and mediating variables make cognitive rehabilitation interventions more effective in people with SMI and cognitive impairment Studies must be conducted to indicate in which areas cognitive rehabilitation is more effec tive psychosocial functioning employability cognitive performance reduction of symptoms CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 113 5 1 8 Other psychotherapies It is necessary to know the efficacy of dramatherapy distraction therapy and hypnosis by quality research studies and developed within the national and European context 5 2 3 Programmes aimed at leisure and spare time It would be advisable to conduct quality research in our field to be able to establish the effec tiveness and efficiency of rehabilitation through leisure and free time of residential programmes and of daily living skills 5 2 4 Programmes aimed at employment Studies are necessary to assess the employability of people with SMI to improve the effi ciency of the employment programmes It is necessary to research into the influence of environmental factors 931 employment pro grammes aimed at people with SMI and about the way to adapt them so the social economic cultural and local reality as well as to the employment policies 5 2 5 Other therapeutic interventions Studies must be developed that determine the efficiency and applicabi
204. on of the positive symptoms of schizophrenia at the end e the treatment BPRS positive symptoms n 59 RR 1 27 95 CI between 0 95 and 1 70 or after a follow up period the period is not indicated in the review once the treatment has ended CPRS positive symptoms n 90 RR 1 66 95 CI between 1 06 and 2 59 It is impossible to determine tnat supportive therapy or counselling reduces the cases of death at th end of the treatment and after a follow up period once the treatment has ended the follow up period is not indicated n 281 RR 2 86 95 1 between 0 12 and 69 40 Summary of evidence 1s There is no evidence that the use of supportive therapy or counselling when compared with standard treatment inproves the hospitalisation ratios relapses mental state and death When supportive therapy or counselling is compared with CBT the results are positive in favour of CBT with respect to general functioning There are insufficient data to determine if supportive therapy or counselling when com pared with any other psychological or psychosocial therapy improves the rate of relapses and r ental state reduces positive symptoms or decreases the cases of death Recommendations Sufficient evidence has not been found to make recommendations related to supportive therapy or counselling in the treatment of people with SMI 54 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NH
205. on programmes for the subsequent incorporation into a job They adapt both to the special difficulties of the candidate and to their counselling support and monitoring needs in the job and they can incorporate occupational learning workshops with occupational activities They risk losing their efficiency and just providing training and repetitive learning if theresis no perspective of immediate incorporation into employment either sheltered or ordinary The concept of social enterprise is a concept that encompasses although with certain risks different business figures whose objective is to create employment for people with difficulties for the competitive market The regulation that governs them forces individua capacity building and adjustment programmes and compensates individual and structural aitficulties with sup portive measures which can be economic grants rebates contract of employment times and conditions as well as in supportive human resources Social Firms UK and Germany and Cooperatives Italy In Spain the predominant figure has been the Special Empivyment Centre Spanish acronym CEE with which the expression sheltered employment is identified created for the group of disabled people through the Law on Social Integration forthe Disabled The CEE is understood in law as transition employment to the ordinary market but in many cases due to either structural difficulties the rigidity of the labour market and the
206. ope with it to treat people and their families or ceiers partners or family members of a bipolar person or group of families of different bipolar people with the attendance or not of the bipolar person They also include couple therapiessand therapies with groups of families and they can be administered by psychiatrists psychologists or other health professionals Reinares ef 11 performed a study RCT n 113 with the aim of evaluating the efficiency of a group c psychoeducational intervention for families of people with a diagnosis of bipolar disorder id euthymic phase and with a 12 month follow up period Up to two family members per patient of the 113 were randomised between a group of twelve 90 minute sessions where they were offered information and coping guidelines compared with the control group The assignation when they were randomised was not concealed but the evaluation was blind The condition of SMI is not specified but the description of the sample indicates clinical severity and prolonged course 10 years evolution 82 type I 66 had had psychotic symptoms with an average of 7 episodes and 1 5 hospitalisations per patient The interventions with families and users can be applied to the National Health System However and for them to be effective a considerable amount of time must be invested as well as training of the professional who are going to use them No study indicates or analyses possible adverse effects
207. ople with a diagnosis of 82 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS SMI schizophrenia affective schizophrenia and bipolar disorders Studies whose population consisted of people with low intellectual level mentally retardation or abuse of substances as first and only diagnosis were excluded The studies included vary with respect to the follow up period from 5 months to 4 years losses diagnosis and age 19 46 years The systematic review elaborated by Crowther et al 9 which includes 18 RCTS 6555 is designed to assess the efficiency on employment of pre vocational training PVT and sheltered employment SE compared with each other and with standard treatment ST With respect to people with SMI and a diagnosis of bipolar disorder data have been found in the NICE Bipolar Disorder CPG that include data from the NICE Schizophrenia CPG and add another 3 RCTs that are useful due to the specific nature of the studies but lack applicability tothe subgroup of SMI with a diagnosis of bipolar disorder as they include SMI with little representa tion of this diagnosis in the samples 596 4396 Bond et al 186 perform an SR which includes 11 RCTS on sheltered emplovment studies which are very faithful to the Individual Placement and Support IPS on patients with SMI in order to assess their efficacy in achieving competitive employment Mueser et al 187 performed a RCT where the relationships between wreferences satisfactio
208. or which the only alternative is conven tional weatment The necessary resources to start up integrated housing and care programmes for homeless people are multiple and involve the start up of assertive community treatment teams only available today in some health sectors of some autonomous communities People with SM and homeless RCT 14 Patients who are in an integrated housing system housing clinical ser vices spend less time homeless p 0 01 more time in stable residence p lt 0 01 in own apartment p 0 01 have less severe psychiatric symptoms p 0 05 and show greater general satisfaction with life p 0 05 than par ticipants in the parallel programme 106 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Patients who access housing with no prior conditioning factors hous ing first model drop more quickly in the rates of staying in the homeless status and stay in stable housing for longer than those who have gone through a period of soberness and treatment acceptance p lt 0 001 although there are no significant differences between both groups with respect to psychiat ric symptoms and evolution in time p 0 85 Housing stability Assertive Community treatment ACT reduces the homeless state in 37 p 0 0001 compared with standard Case Management The best results in housing stability are obtained by programmes that include housing and support ES 0 67 followed by ACT ES 0 4
209. orate of the Quality Agency of the National Health System prepared the Quality Plan for the National Health System which is deployed ac cording to twelve strategies The purpose of this Plan is to ncrease the cohesion of the National Health System and help guarantee the highest quality healthcare for everyone regardless of their place of residence As part of the Plan the preparation of several CPGs was commissioned to various expert agencies and groups on prevalent pathologi s related to health strategies This project was renewed in 2007 and the guideline on Psychosocial Interventions in Severe Mental Illnesses is the result of this assignment This guideline follows the common guideline de velopment methodology set for th NHS which was prepared among the expert groups in CPGs in our country combining their efforts and coordination Severe Mental Illness SMI encompasses different psychiatric diagnoses that persist in time to a certain extent and present serious difficulties in personal and social functioning as a result of the illness reducing the quality of life of the person affected This situation means that it is neces sary to work on different areas of the person incorporating other psychotherapeutic and psycho social interventions and not just the pharmacological intervention This generates a considerable consumptiori of social health resources causing an important economic impact This clinical practice guideline addresses
210. orders who reach adult age or organic mental disorder e People with personality disorders This does not mean that personality disorders that present a psychotic symptomatology are excluded but that this diagnosis per se does not mean that it is included CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 23 This guideline is aimed at mental health teams rehabilitation residential and community services as well as outpatients that attend people with SMI It could also be useful for certain primary and specialised healthcare areas as well as social services employment services prisons education and voluntary sector associations NGO etc that are or come into contact with the care or services provided to people with SMI Likewise it may help people who are responsible for planning and guaranteeing health and social services as well as users and families This guideline does not include any pharmacological intervention in the treatment of Severe Mental Illness 24 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 3 Methodology The methodology used to prepare this CPG is contained in the manual Preparation of Clinical Practice Guidelines in the National Health System Methodology Manual from the Ministry of Health and Consumer Affairs and the Aragon Health Sciences Institute The scientific levels of evidence and modified degrees of recommendation of the Scottish Intercollegiate Guidelines Netwo
211. orted employment I Vocational outcomes Community Ment Health J 1994 30 519 32 Drake RE Becker DR Clark RE Mueser KT Research on the individual placement and support model of supported emplovuient Psychiatr Q 1999 70 4 289 301 Gervey R Bedell JR Psychological assesment and treatment of persons with severe men tal disorders Supported employment in vocational rehabilitation Washington DC Taylor amp Francis 1994 p 170 5 Bond GR Dietzen LLE Vogler K Kautin CH McGrew JH Miller D Toward a framework for evaluating cost and benefi ts of psychiatric rehabilitation J Vocat Rehabil 1995 5 75 88 McFarlane WR Dushay RA Deakins SM Stastny P Lukens EP Toran J et al Employment outcomes infamily aided assertive community treatment Am J Orthopsychiatry 2000 70 2 203 14 Bond GR Drake RE Becker DR An update on randomized controlled trials of evidence based supported employment Psychiatr Rehabil J 2008 31 4 280 90 Mueser KT Becker DR Wolfe R Supported employment job preferences job tenure and satisfaction J Ment Health 2001 10 4 411 7 McGurk SR Mueser KT Feldman K Wolfe R Pascaris A Cognitive training for supported employment 2 3 year outcomes of a randomized controlled trial Am J Psychiatry 2007 164 437 41 Rosenheck R Leslie D Keefe R McEvoy J Swartz M Perkins D et al Barriers to employ ment for people with schizophrenia Am J Psychiatry 2006 163 3 411 7 CLINICAL PRACTICE GUIDE
212. osis of schizophrenia and re lated disorders to family members and to the people with whom they live Pyschoeducational programmes tliat are offered to people with SMI and diagnosis of schizophrenia and related disorders must incorporate the family Group pyschoeducational programmes aimed at people with SMI and a diagnosis of bi polar disorder must incerporate specific psychological techniques carrying them out in a relatively stable period of their disorder and always as a supplement to the psychophar macological treatment The pyschoeducational programmes for people with SMI must be integrated as an addi tional intervention in an individualised treatment plan whose duration will be proportion al to the objectives proposed considering a minimum of 9 months intensive programme and the need for undefined refresher sessions 5 47 Cognitive rehabilitation A high percentage of people with schizophrenia show low efficiency in different aspects of cogni tive processing such as processing speed attention maintenance work memory verbal learning cognitive functioning or social cognition These cognitive alternatives also limit learning in other psychosocial interventions and rehabilitation programmes as well as in social and labour func tioning CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 69 Therefore cognitive rehabilitation consists in an intervention that
213. ovement in the user s satisfaction with supervised housing n 327 p 0 035 and the pharmacological treatment adherence increases n 372 p 0 001 5 2 3 Programmes aimed at leisure and spare time The objective of these programmes is to help people with SMI recover fostering social relations and the use of free time fostering participation in community atmospheres and meeting activities holidays and activities of personal enrichment CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 79 These activities are per se a tool and a result at the same time insofar as social integration 1s a component of the quality of life and this is one of the results to be obtained with psychosocial interventions This concept of recreational rehabilitation has been proposed as a counterpoint to other instrumental rehabilitation interventions such as occupational or residential interven tions and the characteristic that distinguishes them is that they are designed for one s own satis faction No SR or RCT has been found that refers to the importance of social integration through alternatives that organise leisure and free time as a systematised study There is a longitudinal study by Petryshen et al that measures the efficacy of a leisure and free time programme aimed at socially isolated individuals aged 18 to 65 with Severe Mental Illnesses and with a follow up period of one year The study has
214. pate in The mente health teams in coordination with the institutions and other social agents involved must advise about all types of employment resources aimed at gainful occupation and production and adapted to the local employment opportunities Likewise they must be orientated towards interventions that put into motion different devices adapted to the needs and to the ability level of the people with SMI to increase stable and productive occupation expectations 5 2 5 Other therapeutic interventions Music therapy and art therapy could be offered to people with SMI and schizophrenia and related disorders as a therapeutic complement to other types of interventions CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 17 5 3 SERVICE LEVEL INTERVENTIONS When people with SMI need to be readmitted several times into acute units and or there is a past history of difficulties to engage with the services with the subsequent risk of relapse or social crisis as for example becoming a homeless person it is advisable to provide assertive community treatment teams The continuity of the treatment must be favoured via the integration and coordination of the use of the different resources by the people with SMI maintaining continuity of care and interventions and the psychotherapeutic relations established Care must be maintained from the perspective of the CMHC as a confi
215. pecialised mental health services Several factors may be interfering with this one of which may be the perception by professionals that psy chological interventions may be inefficient due to the cognitive deficits and verbal limitations On the other hand the correct diagnosis of the symptoms syndromes and nosological enti ties in this population may be limited by the use of the current diagnostic classification criteria More specifically the diagnosis of psychotic disorders schizophrenia and related disorders in cluded in SMI is hindered by the problem of distinguishing real hallucinations from other non pathological behaviours such s talking to themselves or to imaginary friends Added to this is a high prevalence of symptomatology but limited detection capacity lack of diagnostic criteria and adapted and validated instruments for this population of greater psychiatric disorders The use of diagnostic criteria and instruments adapted to mental retardation has been proposed therefore 2 as a way of improving the reliability of the diagnoses in this population Question to be answered e Which psychosocial treatment is more effective in people with SMI and a low IQ To be able to answer this question the RCT by Martin et al has been included which compares the efficacy of the ACT model with the standard community treatment to treat mental illness in light to moderate mental retardation MR and SMI Due to the little ev
216. people s participation associations CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 129 Specific regulation SPANISH LAW 7 1985 2 April regulating the bases for the local regime BOE no 80 3 April 1985 whereby reference is made to specific care competences linked to local type administrations Councils regions communities provinces and other types of similar administra tive structures Attp www boe eslaeboelconsultas bases datos doc php coleccion iberlex amp id 2003 03596 SPANISH LAW on Promotion of personal autonomy and care for dependent peo ple with special reference to people with mental health problems Law 39 2006 14 December on Promotion of Personal Autonomy and Care for dependent people http www imsersomayores csic es landing pages ley autonomia personal html SPANISH LAW 13 1982 7 April on Social Integration of the Disabled http noticias juridicas com base_datos Admin 113 1982 html 7 The stigma and Severe Mental Illness and how to cope with it Despite the advances in the development of human rights an analysis of social behaviour indi cates that there are still discriminatory attitudes towards people vith mental illnesses especially if these are severe resulting from stereotypes and prejudices that form an often insurmountable barrier for the development of their rights as citizens for their social integration and they add new suffering not att
217. pisodes so they are partially applicable to the target population of the CPG Furthermore it must be recalled that these studies come from different cultures and environments which must be taken into account when preparing strategies and taking decisions Bressi et al performed a REF n 40 which compared the effectiveness of the systematic family therapy standard treatment with standard treatment alone which only consisted in phar macological treatment inspeople with schizophrenia in connection with readmissions relapse and treatment adherence arid with a two year follow up period The family intervention consisted in a series of 12 sessions with family members lasting for one and a half hours once a month and over a one year period In our context DA IGUAL in the study by Montero et a 5 two family therapy techniques are compared one intervention in group format group of families and another individual inter vention gra cognitive behavioural style These interventions are applied to a sample of 87 people with ad agnosis of schizophrenia and their families for 12 months weekly the first 6 months then every two weeks for the following 3 months and finally during the last 3 months intervention every month Falloon together with the OPT Collaborative Group publish the preliminary results n 603 of one multicentre RCT after two years follow up of their project The results reached are for groups of patients with a dia
218. ple with SMI and diagnosis of schizophrenia and elated disorders 5 1 2 Psychodynamic psychotherapy and psychoanalytic approach Sufficient evidence has not been found to make recommendations related to psychodynamic psychotherapy or the psychoanalytic approach in the treatment of people with SMI 5 1 3 Jnterpersonal therapy The strategies aimed at preventing relapses in people with SMI and a diagnosis of C bipolar disorder should evaluate the incorporation of interpersonal and social rhythm therapy IPSRT into the treatment 5 1 4 Supportive therapy Sufficient evidence has not been found to make recommendations related to supportive therapy ox Zounselling in the treatment of people with SMI 5 1 5 Family interventions FFor people with SMI and diagnosis of schizophrenia and related disorders and their families family intervention should be offered as an integral part of the treatment In family interventions that are carried out with people with SMI and diagnosis of B schizophrenia and related disorders the intervention should be done in a single family format The recommended duration in family interventions aimed at people with SMI and B diagnosis of schizophrenia and related disorders must be at least 6 months and or 10 or more sessions CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 15 Psychosocial intervention programmes must be
219. processes through the interaction with music as a means of communication and expression The objective of therapy is to help people with severe mental illnesses develop relationships and address questions that they may not be able to develop or address by words There is a SR by Gold et al 4 RCTs n 321 which examines the effects of music therapy on people with schizophrenia in the short term duration of less than 20 sessions and medium term 20 or more sessions The treatment varies between 7 and 78 sessions Art therapy for people with SMI According to the British Association of Art Therapists artistic materials for self expression and reflection are used in art therapy in the presence of trained art therapist The general objective of the professionals is to enable the patient to maksa change and grow up on a personal level using artistic materials and in a safe and facilitating atmosphere Art therapy allows patients to ex plore their interior world in a non threateving manner through a therapeutic relationship and the use of artistic materials It was carrie tout mainly in psychiatric units for adults and was designed to work with people with whom verbal psychotherapy would be impossible Ruddy et al in the SRecarried out by them compare art therapy and standard treatment with standard care alone i people with schizophrenia Only 2 studies n 137 satisfied the inclusion criteria in this veview These s
220. programmes in the community or programmes directed to leisure and spare time improve the evolution of the illness and the quality of life of people with SMI CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 77 5 2 1 Daily living skills programmes The daily living skills training programmes referred to in this section are instrumental skills that can include aspects such as self care handling money organising the house domestic chores and even interpersonal skills The aim of acquiring these skills is to facilitate rehabilitation main tenance and adaptation of the people with SMI to their normal environment and within each person s possibilities for them to be able to lead a more independent life Tungpunkom amp Nicol141 conducted an SR including 4 RCTs n 318 which assesses the effectiveness of daily skills training programmes comparing them with standard programmes or other programmes in people with severe mental illness Different articles by Robert Libermann 142 145 have also been reviewed This author has several publications in this field and they have been rejected as they refer to social skills training and not to instrumental skills which isthe focus of this question SR 1 The results found do not indicate differences between people who have been trained in the daily living skills programras compared with people who have received standard intervention regarding the following
221. py improvement of communication problem solving and stress handling for family members With respect to the people who suffer from SMI and a diagnosis of bipolar disorder the NICE Bipolar Disorder CPG which includes 3 RCT n 246 from vhich the development group of this CPG rejected the study by Rea et al because 40 ofthe sample corresponds to people with a first episode of the disease from a sample of n 53 4nd does not satisfy the inclu sion criteria established in this CPG The studies observe different family intervention formats and compare them with other interventions or with standard t atment The sessions that are held with the family and with specific support based on systemic cognitive behavioural and or psy choanalytical principles are considered as family intervention The interventions included must have psychoeducational content and or crisis treatment orientated work Justo et al in the SR that they perform analyse the effectiveness of family intervention compared with non intervention or other psychosocial interventions in people who suffer bipolar disorder The search period lasts until 2006 and includes 7 RCTs n 393 which provided data to respond to this section from 6 RCT All the people were taking medication at the time of the study The family psychosocial interventions include any type of psychological therapy or psychoeducational method abeutthe disease and the possible strategies to c
222. r execution of trained skills to distal which entails the improvement and ab sence of relapses were as follows There is no difference in the execution of trained skills 7 studies n 330 ES 1 20 95 CI 0 96 to 1 43 There is some significance in favour of social skills training in the other measurements social skills and daily liv ing 7 studies n 481 ES 0 52 95 CI Between 0 34 and 0 71 Social functioning 7 studies n 371 ES 0 52 95 CI between 0 31 and 0 73 negative symptoms 6 studies n 363 ES 0 40 95 CI between 0 19 and 0 61 Other symptoms 10 studies n 604 ES 0 15 95 CI between 0 01 and 0 31 Relapses 9 studies n 485 ES 0 23 95 CI between 0 04 and 0 41 Problem solving in people with SMI and a diagnosis of schizophrenia an related disorders Problem solving vs standard treatment ST Xia et al indicate that there are no differences between problem solving SR 1 and ST with respect to 1 RCT n 12 the problem solving capacity RR 0 20 95 CI between 0 03 and 1 2 aggressive behaviour RR 0 09 95 CI between 0 01 and 1 35 interaction with staff RRv 0 09 95 CI between 0 01 and 1 35 interaction with companions RR 0 54 95 CI between 0 22 and 1 11 Problem solving vs coping skills No differences were detected either between problem solving and coping skills in the following parameters Number of admissions 1 RCT n 14 RR 3 00
223. rallel it is necessary to guararitee continuity of care and coordination among the different health and social levels x 5 4 2 Homeless SMI For homeless people with SMI who require psychiatric care and psychosocial intervention it is advisable for both to be supplied together via integral programmes where residential programme housing is offered When there is no active substance abuse it would be advisable to provide grouped accomodation to homeless people with SMI included in integral intervention programmes When it is not possible to use accommodation and support programmes in the integral psychosocial intervention of homeless people with SMI the intervention of assertive community treatment team should be offered CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 5 4 3 SMI and low IQ mental retardation For people with SMI and a low IQ and when there is a presence of persistent B productive symptoms it is recommendable to indicate cognitive behavioural therapy adapted to that condition To improve the diagnosis of psychiatric disorders included within the concept of SMI V fin people with a low IQ adapted criteria and specific and validated instruments must be used CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 20 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 1 Introduction Mental disorders are a problem of extreme importance d
224. re managed which contribute to covering the needs of users and families where public resources are not sufficient There a series of basic services are offered which vary from information ad counselling awareness raising and promotion of mental health legal advice for programmes of psychoeducation self help groups family break activities and home care programmes Other services are based on the organisation of activities framed within the psychosocial rehabilitation process labour rehabilitation and leisure and spare time activity programmes as well as on the management of the resources that can carry them out 3 Social awareness raising This is one of the cornerstones of the associative movement Th dissemination and social awareness raising activities which these organisations organise and promote are assumed as a fundamental task both by the actual organisations and by the professionals and politicians agents and planners There are many different initiatives and projects aimed at raising social awareness from the promotion and prevention of mental health to addressing discrimination and prejudices towards mental illness and people who suffer from The aim is to get public administrations state regional or local to assume these initiativesthrough awareness raising activities for spe cific groups students professionals media employers Initiatives to be highlighted due to their impact are the Schizophrenia opens the
225. reality People who satisfy the diagnostic criteria of at least one of the following diagnostic categories taken from the International Classification of Diseases ICDS 10 WHO 1992 will be included Schizophrenic disorders F20 x Schizotypal disorders F21 Persistent delirious disorders F22 Induced delirious disorders F24 Schizoaffective disorders F25 Other non organic psychotic disorders F28 and F29 Bipolar disorder F31 x Serious depressive episode with psychotic symptoms F32 3 Recurrent serious depress ve disorders F33 Compulsive obsessive eisorder F42 Duration of th disease The criteriorcused to established SMI was a 2 year or more evolution of the disorder or progres sive and marked impairment in functioning over the previous 6 months abandonment of social roles a a chronification risk although the symptoms remit The disorder duration criterion attempts to distinguish that group of people who have pro onged duration disorders and rules out those cases that may present severe symptoms or diag noses but still have a short evolution time and therefore the prognosis is still not very clear The NIMHA criteria define the following criteria as an alternative Having received more intensive psychiatric treatment than at outpatient level more than once throughout their lives CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 31 Having received continuous reside
226. results B A body of evidence including studies rated as 2 directly applicable to the target population and demonstrating overall consistency of results or Extrapolated evidence from studies rated as 1 or 1 C A body of evidence incivding studies rated as 2 directly applicable to the target population and demonstrating overall consistency of results or Extrapolated evidence from studies rated as 2 D Evidence level or 4 or Extrapolated evidence from studies rated as 2 Studies classified as 1 and 2 should not be used in the process of developing recommendations due to their high poss bility of bias Good practice points Recommended best practice based on the clinical experience of the guideline development Y group Source Scottish Intercollegiate Guidelines Network SIGN 50 A guideline developers handbook Section 6 Forming guideline recommendations SIGN publication n 50 2001 Sometimes the guideline development group becomes aware that there are some significant practical aspects they wish to emphasise and for which there is probably no supporting scientific evidence available Generally these cases are related to some aspect of the treatment considered to be a good clinical practice and that nobody would normally question These aspects are considered good clinical practice points These messages are not an alternative to evidence based recommendations but must be only consider
227. rhood associations etc One of the main components is information knowledge both from the specialised pro fessional media and through awareness raising campaigns Information and awareness raising campaigns must be combined with social interaction processes that persist in visible actions in society An information strategy must be cross sectional significant and continued reaching the entire social fabric the public administration the judiciary the health soc al education cultural labour employers unions systems residents and the media An effective way is the presence and direct participation of the people affected and their families in the education and awareness raising campaigns e MENTALIZATE change your mindset Information campaign on mental ill ness http www feafescyl org Mental health and media style guide Spanish Association of Groups of Families and People with Mental Illness FEAFES 2003 e Mental health and media Handbook for entities Groups of Families and People with Mental Illness FEAFES 2003 On the other hand mental health professionals are not oblivious to the stigma and they must review their action eliminating any attitude that fosters this Include reviewable action protocols in the services which guarantee respect for the dig nity and rights of the person right to be attended to to choose between options to be informed of the rights of the functioning of the services of the pr
228. ributable to the actual illness per se e Stereotypes are definitions about the illness and its evolution resulting from partial anal yses or false beliefs incurability the unpredictability of their actions non responsibility lack of interests inability to make decisions and a whole life is qualified by one diagnosis or by the symptoms at a time of e fisis Prejudices are irrational attitudes derived from those beliefs fear disdain aggressive ness annulment of the other paternalism etc Discriminatory behaviours social exclusion actions segregation non access to ser vices to work to eni vment of cultural benefits leisure personal enrichment etc The stigma is the mark that these beliefs attitudes and behaviours leave on the person who suffers the illness and or the family The social origin of this stigma dates back to times gone by so overcoming it isa slow process and it still has an impact on all social fields to a greater or lesser extent fan lies neighbours work media and also in the health fields and mental health professionals Thus the person has to work to overcome the illness in a precarious situation of personal impoverishment that compromises the progresses of the recovery process As a whole the group of affected people has no power to recruit influence either at work in their environment and sometimes not even in the services This is one of the reasons for the limited resources in budgets and the
229. rid Tel 636 72 55 99 Fax 91 847 31 82 Spanish Association of Clinical Psychology and Psychopathology http www aepcp net aepcpO aepcp net C Beato G lvez 3 pta 4 46003 Valencia Spanish Association of Dual Pathology AEPD http www patologiadual es asociacionOpatologiadual es C Londres 17 28028 Madrid Tel 91 361 2600 Fax 91 355 9208 National Association of Mental Health Nursing http www anesm net anesm gmail com C Gallur N 451 local 5 28047 Madrid Tel 91 465 75 61 Fax 91 465 94 58 Spanish Federation of Associations of Psychosocial Rehabilitation FEARP http www fearp org Hospital of Zamudio Arteaga Auzoa 45 48170 Zamudio Bizkaia Sociodrogalcohol Spanish Scientific Society for Studies on alcohol alcoholism and other drug addictions http www socidrogalcohol org Avda Vallcarca 180 08023 Barcelona Tel 93 210 38 54 Fax 93 210 38 54 Spanish Society of Psychomati Medicine http www semp org es sempsecretaria wanadoo es Avda San Juan Bosco 15 50009 Zaragoza Spanish Society of Esychogeriatrics http www sepg 2s jacb ugr es Department 6 Psychiatry Faculty of Medicine Avda de Ram n y Cajal s n 47011 Valladolid Spanis Society of Psychiatry http www sepsiq org sep sepsiq es Arturo Soria 311 1 B 28033 Madrid Tel 91 383 41 45 Fax 91 302 05 56 Spanish Society of Biological Psychiatry SEPB http www sepb es info sepb es C
230. rk SIGN appendix 1 were used to classify the effectiveness of the interventions selected The first steps taken to prepare this guideline was to constitute a guideline development group that was made up of professionals from the fields of psychiatry nursing psychology social work and labour insertion from different fields hospital and community as well as from f unda tions public health and employment system from the mental health field 3 1 Formulation of questions The following format was used for the clinical question formulation phase Patient Intervention Comparison Outcome The process started with a methodology werkshop to prepare the ques tions All the members of the development group participated creating a first draft with the ques tions and the question category subgroups In parallel groups of people suffering from mental illnesses and family members of people suffering these illnesses also participated Two group in terviews were arranged one with people with mental illnesses and another with family members separately where they were informed of the scope anc objectives of the CPG and they were asked to give their opinions about the areas that the questions should address appendix 2 Based on the suggestions of family members and people affected and those of the CPG development group 20 questions were developed which are answerea in this CPG 3 2 Search strategy The search strategy started 5y identifyin
231. rmined the need to create specific teams to care for them in certain contexts this may create differences regarding the comparative intervention and tne generalisation of the results to settings such as ours where the existence of these resources is not so usual e Most of the studies focus on the greater efficiency of the ACT compared with CM In our context there are a few ACT teams disseminated in certain autonomous communities compared with the absence of tearis that focus on the traditional CM model broker due mainly once again to the different social support and health systems With respect to the housing provision systems the prevailing model in our context is similar to the model of housing supporting assisted flats whilst the housing in parallel to the clinical care model is difficult to find as there are no agencies that provide economi cally accessible individual or group housing for people with SMI As there are differences between the social environment and the support of homeless people in our context and that of the countries where the studies have been conducted there will also be differences in th need to develop and or adapt resources for them Therefore the relevance of the intervention for the Spanish social and health system is linked to the prevalence of homeless with SMI ossibly not as high as that of the Anglo Saxon countries However there is a benefit derived from the application of programmes in a group f
232. roup Supportive therapy for people who suffer from SMI and a diagnosis of schizophrenia and related disorders Supportive therapy vs standard care There are no significant differences in the hospitalisation atios between SR 1 people who received supportive therapy or counselling and those who re ceived standard care n 48 RR 1 00 9596 CI betw en 0 07 and 15 08 The NICE Schizophrenia CPG indicates that here is not sufficient evi SR 1 dence to determine that supportive therapy or counselling improves the re lapse ratios at the end of the treatment n 2 54 RR 0 86 9596 CI between 10 13 and 1 29 or after a follow up period when the treatment has ended the follow up period is not indicated n 54 RR 1 08 95 CI 0 51 and 2 297 There is not sufficient evidence to determine that supportive therapy or counselling improves the mental state at the end of the treatment PANSS n 123 WMD 2 90 95 5 CI between 10 01 and 4 2 or after a follow up period once the treatment has ended the follow up period is not indicated PANSS n 131 WMD 4 42 95 CI between 10 13 and 1 297 It is impossible to determine whether supportive therapy or counsel ling reduces the cases of death at the end of treatment and after a follow up period once the treatment has ended the follow up period is not indicated n 208 RR 2 89 95 CI between 0 12 and 70 09 Supportive therapy vs cognitive behavioural therapy
233. rpose is to reduce the variability of clinical practice providing summarised informa tion Each recommendation is based on the scientific quality of the studies and publications the professionals experience and the users preferences Deciding which questions on psychosocial interventions in SMI are pertinent and require an answer searching for information summing up data and agreeing to the final content have been the work of the Guidetine development group over the last few months This CPG has been funded through the agreement signed by ihe Carlos III Health Institute an organisation pertaining to the Ministry of Science and Innovation and the Aragon Health Sciences Institute within the framework of collaboration provided for in the Quality Plan for the National Healthcare System The CPG is not a substitute for scientific knowiedge and the life long training of profes sionals on the topic but rather it is a part of this nother tool for decision making when doubts arise For users and families it is a tool that car help them discover the characteristics of the dif ferent interventions Sometimes our intuitiors practical knowledge and common sense do not coincide with the conclusions of the guideiine This may be due to a lack of knowledge in this area of knowledge or simply to the absence of good quality studies designed to be able to answer our problems The application of oui knowledge to those problems where there is no proof or evide
234. rson can leave his or her role as a patient and integrate significant roles becoming a neighbour a worker a citizen who mixes has fun etc and has his ox her own life project The close knowledge of the environment and stable social exchange decrease rejection The impact of the illness on a family presents tragic characteristics at the onset something that is not unlike the stigma That is why the family must be actively integrated right from the start in the information processes and in the rehabilitation programmes establishing suitable strategies regarding the way in which each family has to cope with the illness Programmatic Statements In all democratic countries and especially in Europe there are programmatic statements that foster cross section policies to fight against stigmatisation that contain the principles to be taken into account in the applicable legislation of each country Europe e Conclusions of the Councit of Employment Social Policy Health and Consumers June 2003 on the fight lt igainst stigmatisation and discrimination in connection with mental illness European Declaration on Mental Health Ministerial Conference of the WHO Helsinki January 2005 e Green Paper Improving the mental health of the population Towards a European Union strategy oriental health Commission of the European Communities COM 14 10 2005 484 pags 11 e Fran exclusion to inclusion The road to promoting social inclusion of p
235. rvention is limited by the number of hours required for their application which makes it difficult to include them in the normal practice in the Mental Health Centres compared with specific units Furthermore these are techniques that require specific capacity building of the staff and their effect is moderate the distal objective is the improvement in social functioning an aspect that other interventions also address such as for example social skills training There is also a risk of taking resources from other interventions Cognitive rehabilitation in people with SMI and a diagnosis of schizophrenia asi related disorders Cognitive rehabilitation produces the following effects ES data according to the effect size by Cohenb SR 1 With reference to global cognition in the meta analysis performed by Krabendam amp Aleman it is suggested that cognitive rehabilitation may improve the development of tasks ES 0 45 95 CI between 0 26 and 0 64 but no significant difference has been detected in cognitive improve ment according to the number of sessions if there are lt 15 sessions com pared with gt 15 sessions p 0 978 MacGurk et al also indicate that cognitive rehabilitation improves global cognition significant for 6 of the 7 cognitive domains assessed nz1 214 p 0 001 and psychosocial func tioning n 615 p 0 05j and the symptoms n 709 p 0 001 SR 14 Patients wko received IPT programme that combines n
236. rview in connection with the improvement of the mental aspect or consumption reduction The studies selected to be able to respond to this subsection of the question have a good level of generalisation to the population of the CPG as the participants are in their majority people with schizophrenia and or schizoaffective diagnosed with OSM and ICD criteria and in adult population The population size is significant and the effect magnitude is moderate in the majority of the studies so the impact that this type of intervention may have on the Spanish National Health System may be significant if the subtype of patients tie intervention is aimed at and its character istics duration number of sessions etc is well defined Cognitive behavioural therapy CBT for people with SMI and a diagnosis of bipolar disorder BD For this population group the data obtained by the Beynon et al SR are used including 20 RCTs or quasi randomised studies withwat least 3 months follow up of which only 5 assessed CBT The patients were type I BD combined type I and II patients none presented just type II patients The data that were extracted rom this review are those provided by the Cochran RCT The NICE Bipolar Disorder CPG7 has also been taken into account which included 5 stud ies one of them net eublished The majority of these studies chose euthymic patients who were well mainteimed with medication and a proportion of patients in
237. ry Aragonese Association of Psychosocial Rehabilitation Aragonese and Rioja Society of Psychiatry Members of these societies have participated as authors expert collaborators or external reviewers of the CPG Declaration of Interest All the members of the guideline development group as well as the people who have participated in the expert collaboration and in the external review have made the declarations of interests that are presented in Appendix 7 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 11 Questions to answer a PSYCHOLOGICAL INTERVENTIONS Is cognitive behavioural therapy based psychological intervention effective in the treat ment of people with SMI Are the psychodynamic psychotherapy and the psychoanalytic approaches effective in the treatment of people with SMI Is interpersonal therapy effective in the treatment of people with SMI Is supportive therapy effective in the treatment of people with SMI Family interventions Do family interventions in their different formats present benefits compared with non intervention or other types of psychosocial intervention in people wit S MI At what time during the course of the illness is it best to start family intervention for people with SMI and their families What is the most appropriate time framework for the family inigrvention programmes and or sessions for people with SMI and their families Pyschoeducational inter
238. s Cognitive rehabilitation programmes aimed at people with SMI and cognitive impairment must be integrated into more extensive psychosocial rehabilitation programmes From the cognitive rehabilitation interventions or programmes aimed at people with SMI C itis advisable to choose those that include or are accompanied by compensatory inter ventions in other words changes in strategy and training in coping skills or techniques 5 1 8 Other psychotherapies morita therapy drama therapy distraction therapy and hypnosis Morita therapy for people with SMI Morita therapy is a systematic psychotherapy based on Eastern psychology The therapy was cre ated to treat neurosis and its use has been extended to schizophrenia aithough to date its efficacy has not been systematically verified The therapy includes a structured behavioural programme to promote relationships with others and consequently greater social functioning There is a systematic review carried out by He et al 11 RCT n 1041 which analyses the effects of morita therapy in hospital environments for people with SMI and a diagnosis of schizophrenia and related disorders comparing them with standard care in connection with social functioning daily living activities DLA and mental state negative symptomatology measured through SANS and the general mental state according to scores obtained in the BPRS The stud ies included vary with respect to
239. s which is established and consti tuted as a auty that is established in benefit of the tutored person always under the supervision of the judicial authority Tutorship is a legal institution whose aim is to guard and protect the person and tlie goods of the incapacitated person The tutor is the representative of the incapacitated person The following may hold this posi tion Spouse children parents brothers or sisters Any physical person considered appropriate by the Judge Non profit legal persons whose purposes include the protection of incapacitated people The Autonomous Community is one of these legal persons 124 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Other Regulation on Incapacitation and Tutorship Creation of the Tutorship and Judicial Defence Commission for Adults Decree 168 1998 6 October Patrimonial protection of persons with disabilities Law 41 2003 18 November Update of the Commission for Tutorship and Judicial Defence of Adults Decree 13 2004 27 February 5 Therapeutic mechanisms and resources As recommended in the 2006 Strategic Mental Health Plan all citizens who require it must have access to a rehabilitation process and in their territory Basic Health Area Health Sector of Autonomous Community they must have the following devices at their disposal Unit Centre Community Mental Health Service Hospitalisation unit in general hospital 24 hour a day emergency car
240. s an instrument made available to help people re cover and its integration into the whole Mental Health Community Service System is necessary 4 3 The concept of recovery The SMI recovery concept has become a dominating concept in the health care system but it lacks a consistent definition This refers more to the process of overcoming the illnesses than the mere control of symptoms and going beyond the actual illness it pursues a significant and sat isfactory life Recovery has been conceptualised asa process as a result and as both at the same time It involves the development of a new meaning and purpose in one s life as one surpasses the catastrophic effects of mental illness and it does not just refer to the alleviation of symptoms but also to social and personal competence i reas that the person defines as important The recovery concept has been defined as the process where people are capable of living working learning and participating fully in their community Anthony et al indicate that practices aimed at recovery recognise that people with mental illness have the same wishes and needs for work accommodaiton relationships and leisure as any other person who does not suffer from a mental illness Mental illness r presents important changes that break with life expectations both on a per sonal level and i5 the environment especially the family environment The recovery concept shows the need t renew these l
241. s found in the reductien of positive symptoms in patients with acute episodes than in chronic patients Social skills training in people with SMI and a diagnosis of schizophrenia and re lated disorders There is no clear evidence that indicates that when social skills training is compared with ST or with other treatments it reduces relapses or readmissions It is impossible to determine that social skills training when compared with ST improves the quality of life or when compared with other treatments There is no evidence that indicates that social skills traifiing when compared with ST improves social functioning There are no differences between social skills training vs ST with respect to the improve ment of the mental state 1 Training in social skills produces an improvement in the daily living skills social func tioning negative symptoms and relapses when compared with other active therapies Problem solving in people with SIMI and a diagnosis of schizophrenia and related disorders 1 No differences were detected between problem solving and standard treatment with re spect to the ability to solve problems aggressive behaviour interaction with professional staff and with companions 1 No differences were detected either between problem solving and coping skills in con nection with the number of admissions and reduction of the score in the BPRS scale after treatment
242. s with SMI is often structured around the resources that provide care during the day As Marshall et al recall the term day care is better defined by recalling its functions and associating them with the structures that provide them an alternative to hospi talisation skorten the hospital stay and promote recovery and maintenance in the community These three functions can be implemented from three different resources day hospitals employ ment services and social resources This chapter and in general this CPG do not address questions related to acute treatment hospital of the patients or to alternatives community such as crisis intervention teams home or day hospital treatments In order to unify terminology in this CPG the terms used in the Rehabilitation Recommendations of the Spanish Association of Neuropsychiatry have been adopted and ref erence will be made to CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 93 e Psychosocial Rehabilitation Centres equivalent to the functions of Day Centre Rehabilitation Hospital Units equivalent to Medium stay Units Therapeutic communi ties etc Question to be answered Which service supply system day centres and or psychosocial rehabilitation centres community Mental Health centres Assertive Community Treatment Intensive Case Management ICM non acute day hospitals or Case management CM is more effective in peopl
243. schoeducation improves the knowledge of the disease when this knowledge is assessed at the end of the programmes 4 RCT n 278 p 0 00 but there are no data from the follow up periods CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 67 No evidence has been found that indicates that pyschoeducation has any effect on improving social functioning when measured at the end of the programmes at 7 to 12 months follow up 2 RCT n 112 p 0 32 There are no data that indicate that pyschoeducation achieves an im provement in treatment adherence at the end of the programmes 2 studies Rey ip S041 Pyschoeducation with incorporation of family vs pyschoeducation without family vs Standard Treatment ST SR 14 4 Only pyschoeducation that incorporates the family produces a significant reduction in relapses or readmissions after 7 12 months follow up 6 RCT n 322 p 0 32 this is not the case when pyschoeducation exclusively focuses on the patient 2 RCT n 101 p 0 30 Parallel group pyschoeducation of users and family members RCT 14 Of the 48 patients who remained in follow up yior 7 years the group that followed a parallel group pyschoeducationa programme for users and for family members had less rehospitalisations 5496 compared with the 88 that existed in the control group readmission ratio per patient of 1 5 and 2 9 respectively p 0 05 Pyschoeducation
244. sitario Miguel Servet Zaragoza Milagros Escusa Juli x Nurse Acute Psychiatry Unit Hospital Obispo Polanco Teruel Francisco Jos Gal n Calvo Social worker Fundaci n Ram n Rey Ardid Zaragoza Laura Gracia L pez Psychologist Care Centre fer Psychically Disabled Instituto Aragon s de Servicios Sociales Zaragoza Andr s Mart n Gracia Specialist physician in psychiatry Centro de Rehabilitaci n Psicosocial N Sra del Pilar Zaragoza Miguel Mart nez Roig Specialist physician in psychiatry Cen xy de Salud Mental Actur Sur Zaragoza Pedro Pibernat Deulofeu Employment Therapist Fundaci n Agust n Serrate Huesca M Esther Samaniego D az de Corcuera Nurse Fundaci n Ram n Rey Ardid Zaragoza Ana Vallesp Cantabrana Clinical psychologist Centro de Salud Mental Actur Sur Zaragoza Mar a Jos Vicente Edo Nurse Instituto Aragon s de Ciencias de la Salud Zaragoza Coordination Clinical Area Francisco Jos Caro Rebollo Specialist physician in psychiatry Hospital Universitario Miguel Servet Zaragoza Miguel Mart nez Roig Specialist physician in psychiatry Centro de Salud Mental Actur Sur Zaragoza Methodological Area Juan Ignacio Mart n S nchez Specialist Physician in Preventive Medicine and Public Health Instituto Aragon s de Ciencias de la Salud Zaragoza Mar a Jos Vicente Edo Nurse Instituto Aragon s de Ciencias de la Salud Zaragoza CLINICAL PRACT
245. slow development of the services Facing the fight against stigmatisation The fight against the stigma means adopting a conscious and active change in outlook respect for human rights personal dignity and the right of people with SMI to develop their potentialities and to contribute to society Working in this direction is one of the basic responsibilities of the public 130 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Administration of the health and social services system of the family and of the social environ ment and it is in this direction that progress is being made Support to the person affected This change in outlook is inefficient if the person suffering the illness is not counted on as this person must overcome the internalisation of any negative beliefs that he or she may have about him herself self stigma Positive experiences in this field indicate that progress occurs when the following concur awareness of their own difficulties pyschoeducation development of individual abilities self esteem knowledge of one s own rights e decision making in agreement with their interests and preferences Empowerment self assertion and when this approach is integrated continuously and early on in the care and rehabilitation pro grammes counting on the family and situating the anti stigma action in the actual fields of life residence work leisure procuring the collaboration of the environment The pe
246. sociaci n Espa ola de Neuropsiquiatr a 2002 Cuadernos T cnicos n 6 C1E 0 Clasifi caci n estad stica internacional de enfermedades y problemas relacionados con la salud 10 ed rev Washington Organizaci n Mundial de la Salud 2003 Barrowclough C Haddock G Lobban F Jones S Siddle R Roberts C et al Group cog nitivebehavioural therapy for schizophrenia randomised controlled trial Br J Psychiatry 2006 189 527 32 L pez M Laviana M Rehabilitaci n apoyo social y atenci n comunitaria a perso nas con trastorno mental grave propuestas desde Andaluc a Rev Asoc Esp Neuropsiq 2007 27 99 187 223 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 143 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 34 35 144 Rossler W Psychiatric rehabilitation today an overview World Psychiatry 2006 5 3 151 7 Drake RE Mueser KT Brunette MF Management of persons with co occurring severe mental illness and substance use disorder program implications World Psychiatry 2007 6 3 131 6 Mueser KT Corrigan PW Hilton DW Tanzman B Schaub A Gingerich S et al Illness management and recovery a review of the research Psychiatr Serv 2002 53 10 1272 84 Salyers MP Tsemberis S ACT and recovery integrating evidence based practice and re covery orientation on assertive community treatment teams Community Ment Health J 2007 4
247. t are education about the disease symptoms medication sleep patterns adverse events effects and how to manage them The sessions last between 20 and 25 minutes The patients are intervened weekly until they are stabilised Visits in the preventive phase take place every two weeks for 12 weeks and then every month until the end of the 2 years maintenance phase Interpersonal therapy for people with SMI and a diagnosis of bipolar disorder BD Frank et al when comparing between T1 T3 vs T2 T4 indicate that RCT 1 the patients assigned to the IPSRT group in the acute phase of the treatment spend more time without affective episodes P 0 01 However when Scott Colom and Vieta re analyse the results of the study by Frank et al where they compare ICM vs IPSRT they indicate that there are no statistically significant differences in the relapse ratios in those who received the same treatment in both phases acute and mainte nance T1 41 and T2 28 They also state that according to Frank et Experts al the participants that were re assigned to the treatment alternative in the opinion 4 second phase IPSRT followed by ICM or ICM followed by IPSRT had higher relapse ratios and symptoms when they were monitored after two years This suggests that the stable and constant model of the therapy may be more important than the treatment that was used in this population no data are provided CLINICAL PRACTICE GUID
248. te the impact that the intervention could have in our context agreement with the population size magnitude of the effect relative benefit compared with other options recourses that wouid b3 involved and balance between risk and benefit Other factors Indicate in this space aspects that may have been taken into account when assessing the available evidence Classification ef evidence Sum up the avaiizble evidence with reference to the question to be answered Indicate Level of evidence the level of evidence assigned RECOMMENDATION Set out the recommendation that the taskforce understands is derived from the evi dence assessed Indicate degree of recommendation Point out discrepancies if any in the recommendation formulation CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 119 Appendix 4 Information for people with SMI and their families 1 What is a Clinical Practice Guideline This document is an essential part of the composition of a Clinical Practice Guideline CPG it includes those contents that the authors believe may be important for the people interested in order to be able to have information and help cope with and in this health problem A CPG is a scientific instrument comprised of a series of systematically developed secom mendations based on the best evidence available in order to help clinicians and patients take de cisions Its pu
249. tem and placing mental patients on thersame status than all other people promoting care in the com munity and ambulatory care resources and indicating that care in a hospital regime if required should be carried out in the psychiatric units of the general hospitals The mental health and psychiatric healthcare services of the general health system will also cover in coordination with the social services the aspects of primary prevention and attention to psychosocial problems that accompany the lossfr health in general http wwyv boe es aeboe consultas bases_datos doc php coleccion iberlex amp id 1986 10499 The Heath Laws of the different Autonomous Communities These are responsible together with the State and other competent public Administrations for organising and developing all the health actions Extensive competences in health related matters are recognised in the different statutes Spanish basic regulatory law on the Patient s Autonomy and on rights and obligations in clinical documentation information matters Law 41 2002 14 November The aim of this law is to regu late the rights and obligations of patients users and professionals as well as of public and private health services and centres in matters related to patients autonomy and clinical documentation 122 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS and information http www boe es aeboe consultas bases_datos doc php coleccion iberlex amp id 2002 22
250. teria especially in the case of the study by McGurk er al The review by Roder et al is worth a separate mention as it deals with IPT an integrated programme that includes cognitive rehabilitation social skills and probleni solving strategies and whose field is clearly different to the field framed by the NICE Schizophrenia CPG This CPG development group has chosen to use the three reviews mentioned above 9 as the basis as they are more recent including articles that had not been published when the NICE Schizophrenia CPG was written and because it addresses all types of psychosocial interventions aimed at improving cognitive functioning There is no homogeneous theoretic framework about the way in which cognitive rehabilita tion interventions improve cognition and social functioning areas so the interventions incorporate CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 71 specific elements depending on the existing paradigm On the one hand there are interventions based on the rehabilitating paradigm repetition and others based on the compensating paradigm Furthermore it is not the same as focusing the measurements in molecular cognitive functions cognitive functions that can be atomised and analysed as a simple answer system performance in certain tests or in psychosocial functioning which requires generalisation The applicability to the Spanish health system of this type of inte
251. the family sessions there is evidence that shows that family intervention reduces the levels of relapses once the treat ment has finished n 269 RR 0 68 95 CI between 0 50 and 0 91 Family interventions combined with other interventions RCT 14 RCT 14 60 When comparing family interventions thatincorporated another psychoso cial intervention OPT group vs standard treatment the latter presented significant improvements in the cjmical severity rates 41 disability 39 and stress perceived by carers 48 24 months after the interven tion 35 of the patients rom the OPT group satisfied the criteria of com plete recovery after 24 months compared with 10 of the patients from the standard treatm nt group The observation of significant improvements in all the paramerers when applying the standard treatment for 24 months reflects the high clinical standards that exist in the centres that participated in the project Tr one out of every four cases with recent onset schizophrenia or with a first episode of schizophrenia as well as 40 of the chronic cases no type f improvement was observed at the end of two years OPT treatment Of the patients who received treatment n 90 those from the group that received FP SST PT did not present any relapse in 12 months those from the group of FP PT 19 those from the group of SST PT 20 and those from the control group 38 p 0 007 On performing the
252. theory of social integration as quality of life Psychiatr Serv 2008 59 1 27 33 Rudnick A Psychiatric leisure rehabilitation conceptualization and illustration Psychiatr Rehabil J 2005 29 1 63 5 Petryshen PM Hawkins JD Fronchak TA An evaluation of the social recreation conyponent of a community mental health program Psychiatr Rehabil J 2001 24 3 293 8 Campbell A McCreadie RG Occupational therapy is effective for chronic schizophrenic daypatients Br J Occup Ther 1983 46 11 327 9 Patterson TL McKibbin C Taylor M Goldman S Davila Fraga W Bucardo J et al Functional adaptation skills training FAST a pilot psychosociai intervention study in middleaged and older patients with chronic psychotic disorders Am J Geriatr Psychiatry 2003 11 1 17 23 Boardman J Grove B Perkins R Shepherd G Work and employment for people with psy chiatric disabilities Br J Psychiatry 2003 182 467 8 L pez M Laviana M lvarez F Gonz lez S Fern ndez M Vera MP Actividad productiva y empleo de personas con trastorno mental severo algunas propuestas de actuaci n basadas en la informaci n disponible Rev Asoc Esp Neuropsiq 2004 89 31 65 Ley de Integraci n Social de los Minusv lidos Ley 13 1982 de 7 de abril Bolet n Ofi cial del Estado n 103 30 04 1982 Burns T Catty J Becker T Drake KE Fioritti A Knapp M et al The effectiveness of sup ported employment for people with severe mental illness a randomis
253. ther treatments SR 1 RCT 1 SR 1 RCT 1 RCT 1 44 Relapses readmissions There is no clear evid nce to show that social skills training vs standard treatment reduces retapses or readmissions n 64 RR 1 14 CI 95 between 0 52 and 2 49 or when compared with other treatments n 80 RR 0 94 95 CI between 0 63 and 1 40 Improvement of the quality of life It is mpossible to determine that social skills training when compared with standard treatment improves people s quality of life n 40 WMD 9 67 CI 9596 between 22 56 and 3 22 33 or when compared with other treatments n 80 WMD 0 09 CI 95 between 0 42 and 0 24 Social functioning There is no evidence to show that social skills training when compared with standard treatment improves social functioning Behavioural Assessment Task Scale n 40 WMD 2 61 95 CI between 4 56 and 0 66 Mental state There are no differences between social skills training or standard treat ments with respect to the improvement of the mental state BPRS n 40 WMD 7 18 95 CI between 13 62 and 0 74 SANS n 40 WMD 8 03 95 CI between 15 27 and 0 79 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS In the systematic review by Kurtz and Mueser which compares so SR 1 cial skills training with other active therapies or ST 1t indicates that the ES Effect Size obtained in the different measurements from proximal o
254. ther with other elements of Social Welfare aim to Promote and fully develop all people and groups in society to obtain greater social wel fare and a better quality of life within a setting of co existence Prevent and eliminate the causes that lead to social marginalisation and exclusion All of this is done through public services and structures of the State Administration Autonomous Communities and Local Corporations CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 127 Social protection systems Pursuant to our Constitution our country is a Social and Legal State that assures through its protection systems certain guarantees to its citizens through basic structures that guarantee basic rights such as health employment or housing through solidarity redistribution processes based on work revenues and the contributions of each one of the people This process is carried out through the structures that are based on the National Social Security Institute which directly or by competence transfers to the autonomous communities is responsible for distributing these benefits The National Social Security Institute is a Managing Entity attached to the Ministry of Work and Immigration with its own legal personality and whose job it is to manage and administer the economic benefits of the public Social Security system and recognise the right to healthcare regardless of the fact that the appli
255. time framework for the family intervention programmes and or sessions for people with SMI and their families All the evidence found refers to SMI with schizophrenia and or bipolar disorder The NICE Schizophrenia CPG includes one SR and 2 RCTs total of 18 RCTs n 1458 This CPG assesses family intervention in different formats individual group or multi family as weil as the duration and frequency of the interventions The sessions that are held with the family and with specific support based on systemic cognitive behavioural and or psychoanalytical principles are considered as family intervention The interventions included must have a psychoeducational content crisis treatment orientated work and with a duration of 6 weeks at least In the systematic review by Pharoah et al which includes a total of 43 RCTs n 1765 the effectiveness of family intervention is assessed in people with schizophrenia and is compared with standard treatment understood as normal psychiatric intervention levels that includes phar macological treatment In the studies included in this review family therapies have an educa tional component with a view to improving the family atmosphere and reducing the relapse of schizophrenia The results from studies such as the study by Pharoah et al must be taken with precau tion because they include a great variety of ages and people with a background of long lasting disease and first e
256. tions effective in people with SMI What are the key components in pyschoeducational interventions in people with SMI What is the most adequate level of pyschoeducational intervention individual group or family The review carried out by Lincoln et al 18 studies n 1543 was designed to assess the long and short term efficiency of exclusively user orientated pyschoeducation and user and family orientated pyschoeducation The result variables taken were the reduction of relapses and symptomatic severity improvement of knowledge about the disorder medication adheretice and global functioning of the patients diagnosed with schizophrenia and related disorders schizo affective delirium disorder brief psychotic disorder and schizotypal disorder Both interventions were compared with normal treatment or non specific intervention without prover efficiency The studies included had to satisfy the requirement that pyschoeducation understood as the transmis sion of relevant information about the disorders and its treatment whilst better coping is pro moted was the main element of the intervention Bauml et al carried out a study n 101 in a European context whose objective was to evaluate the effectiveness of parallel bifocal pyschoeducational intervention and its long term effect People diagnosed with schizophrenia and their family Members were randomised either to group pyschoeducational intervention both groups sepa aiely or to th
257. tition for the psycho social functioning area but not for the cognitive area ES 0 52 95 CI between 0 25 and 0 78 vs ES 0 34 95 CI between 0 03 and 0 70 The data provided with respect to the maintenance of the effect of the SR 1 programmes after they end indicate that In the review by McGurk et al the post treatment results are main tained for 8 months p lt 0 001 and in the Roder IPT it shows that the ef fects observed are maintained in the follow up phase 8 months after the pro grammes end p lt 0 05 In the study conducted by Hogarty et al where Cognitive Enhancement RCT 14 Therapy CET is compared with enhanced supportive therapy a greater effect is observed in favour of CET with respect to the processing speed measurements p 0 012 social cognition p 0 002 cognitive style p 0 007 and social adjustment p 0 006 but not for neurocognition p 0 195 It is also indicated that the effect is maintained for 36 months after the end of the intervention Summary of evidence 1 Cognitive rehabilitation improves global cognition maintained after 8 months follow up psychosocial functioning and the sympioms 1 Cognitive rehabilitation programmes thataiso provide psychiatric rehabilitation improve the psychosocial functions 1 Cognitive rehabilitation can improve the development of tasks 1 No significant difference has been detected in cogn
258. tive therapy as well as standard care including antipsychotic medication The majority of the studies include 2 sessions per week 52 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS weekly or fortnightly sessions The SR bears in mind that there may be differences in the practice of the supportive therapy depending on the country with respect to the frequency and duration of the sessions In the NICE CPG on Schizophrenia the supportive therapy or counselling is compared with standard treatment 14 RCTs were included n 1143 from 1973 to 2002 The studies included duration and frequency of the sessions 10 90 minutes 1 to 4 times per week The duration of the treatment varied between 3 weeks and 3 years It included a schizophrenia diagnosis from first episodes to chronic cases The treatments were normally applied in hospitals outpatients at home and in the community The great majority of the studies included in this section of the CPG have selected RCTs where they use or contemplate supportive therapy control group and com pare it with other forms of psychological intervention experimental group Supportive therapy and counselling only appear in 4 studies as an experimental group 3 of these studies compare it with cognitive behavioural therapy the other with standard treatment This means that the stud les were not selected based on the applicability of this intervention but based on the intervention of the experimental g
259. to answer this section come from just 9 RCTs The development team of this CPG decided to exclude the other RCTs from the review by Jones et al because it considered that they did not afford data that could be of interest to this topic The NICE CPG on Schizophrenia which contains a SR by Pilimg et a was also included from whose 8 RCTs NICE includes 7 the RCT by Carpenter e al was excluded because the definition that they had proposed did not coincide with theirs and a further 6 RCTs were added A total of 13 RCTs n 1297 were included All the participants in the study also received aptipsychotics and the cognitive behavioural treatment was offered mainly to the people with a longer illness evolution time or who were more resistant to the treatment The control group receives standard care recreational activities or ad vice The CBT studies included in this review used trained therapists with regular supervision and using therapy manuals with the exception of Turkington et al who had a 10 day training programme for a group of nurses specialised in psychiatry Finally a meta analysis_by Zimmerman et al was selected which includes 14 studies n 1484 published between 1990 and 2004 From all the studies 11 provided follow up data A total of 54 people took part in the early follow up analyses 3 12 months 256 with CBT com pared with 284 receiving another treatment and a total of 353 people took part in the late f
260. transfer that arises in the relationship between the patient and the therapist the observaticn of the countertransference reactions and the processes related to this phenom enon The studies must be orientated towards the patients needs and the starting point must be the patient s needs and not the investigator s needs In the article by Bachmann et al 66 on psychological treatment for psychosis it indicates that psychodynamic and psychoanalytical approaches have common fields even though they are dif ferent There are three main models in psychodynamic approach the concept of conflict defence the concept of ego impairment and the concept of self object representations Currently there is agreement in the following aspects 1 Psychotherapy is possible in psychosis 2 The classical psychoanalytical framing is contraindicated 3 Greater emphasis must be placed on the present than on the past CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 49 4 Interpretation must be used with precaution 5 The objectives of this type of interventions include the experience of the self object as two separate and independent entities that are at the same time related to each other the stabili sation of the limits of the self and identity the integration of psychotic experience 6 The frequency of the sessions must not exceed three sessions a week and must last for at least two years 7 T
261. tudies did not include sufficient participants so as for the results to be significari and clear conclusions could not be drawn with respect to benefits or harm of art therapy based on them It is difficuit to estimate the availability of this intervention however there are descriptions for its use in people with schizophrenia individually or in groups in outpatients and hospitals as well as in the private sector Question to be answered Do therapeutic interventions such as art therapy and music therapy improve the evolution of the illness and the quality of life of people with SMI 90 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Music therapy Music therapy standard treatment ST vs ST Music therapy as a complement to standard treatment is superior to ST only in the medium term with respect to the improvement of the global state n 72 RR 0 10 95 CI between 0 03 to 0 31 In an intervention of less than 20 sessions no significant differences are found in favour of music therapy with respect to the mental state in the medium term n 69 average final score in the PANSS scale WMD 0 36 95 CI between 0 85 and 0 12 however when the intervention includes more than 20 sessions there are differences in favour of music therapy 1 RCT n 70 average final score in the BPRS scale WMD 1 25 95 CI between 1 77 and 0 73 Music therapy favours the improvement of negative symptoms 3 RCTs n
262. ue to their high prevalence there are estimations that suggest that between 15 and 25 of the general population suffer from them and due to the impact of suffering and disintegration in the people their families and their closest environment It can be said that in Spain excluding the disorders caused by the improper use of substances at least 9 of the population suffer from a mental disorder at the present time and a little over 1596 will suffer from it throughout their lives An increase in these figures is predicted in the future Improving mental health care in Spain is one of the strategic objectives of the Ministry of Health and Consumer Affairs the Quality Agency of the Ministry and with the coordination of the Autonomous Communities scientific societies and associations of people and families have developed the Strategy in Mental Health of the National Health System 2006 report whose aim is to provide an answer to the population s health needs in mental health related matters One of the suggestions it includes is the standardisation of the following care processes common men tal disorder of adults Severe Mental Illness in adults Severe Mental IlIn ss in the elderly Severe Mental IlIness of the personality common mental disorder in childhood and adolescence severe child youth mental illness and generalised development disorder The Spanish terms trastorno mental grave TMG or trastorno mental severo TMS are bro
263. unity leisure and spare time programmes During the monitoring of the individualised therapeutic programme it is advisable to v j systematically assess the need to use the spare time programmes atid offer them to people with SMI who require them 5 2 4 Programmes aimed at employment Over the last decades in all Mental Health programrnes the employment oriented programmes and devices for people with SMI are considered tc be strategic and form part of the basic reha bilitation objectives Labour insertion is an instrument to achieve full social integration in conditions of personal autonomy and participation in the community It also responds to a right and to an ethical ques tion derived from the permanent exclusion from the work market The need for labour insertion programmes to include health and social care aspects in their methods and not just occupational training aspects is admitted Work in the recoverv process is not just an activity that develops generalizable competenc es and improves persone functioning but it is also an element for social exchange and economic independence Remuneration and salaries are considered a key motivational element for a person to stay in a job Isvany case due to the different experiences it is common to place emphasis on motivation and personal choice and take into consideration from the onset personal interests and objectives Despite the obvious need for these resources t
264. using and independent clinical services that give support when required On the other hand there are proposals that give preference to housing housing first with no prior clinical stability requirements or no drug consumption The clinical care for the subgroup of homeless patients can be structured into three over lapping programmes and interventions e Outreach services aimed at homeless people who resist looking for treatment by them selves e Case Management and ACT Services that are based on personalised relations as a means of accessing the services Housing and community work to facilitate stability in housing Assertive community treatment is worth a special attention as a way of addressing the prob lem In this section reference will be made to the specific ACT modalities aimed at dealing with homeless peopie These ACT programmes often present modifications with respect to the origi nal programme to address the specific need of this patient subgroup Cuestion to be answered Y Which intervention is more efficient in people with SMI and homeless In the RCT by McHugo et al 147 n 121 2 community ICM Intensive Case Management programmes are analysed that differ in the way they approach the housing intervention inte grated vs parallel CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 105 In the study by Tsemberis et al 220 n 225 the sa
265. uz de Tenerife External Review Miguel Bernardo Arroyo Specialist physician in psychiatry Hospital Cl nic Barcelona Manuel Camacho Lara a Specialist physician in psychiatry Universidad de Sevilla Sevilla Juli n Carretero Rom n Mental HealthNurse Hospital Infanta Leonor Madrid Carlos Cuevas Yust Clinical Psychologist Hospital Virgen del Roc o Sevilla Bego a Iriarte Campo Clinical psychologist Asociaci n Bizitegi Bilbao Juan Fco Jim nez Est vez Clinical Psychologist Hospital Universitario San Cecilio Granada 10 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Jos Manuel Lalana Cuenca Specialist physician in psychiatry Centro de Salud Mental Pirineos Huesca Marcelino L pez lvarez Specialist physician in psychiatry Fundaci n P blica Andaluza para la Integraci n Social de Personas con Enfermedad Mental FAISEM Sevilla Mercedes Serrano Miguel Social Worker Centre d Higiene Mental Les Corts Barcelona Catalina Sureda Garc a Nurse Unitat Comunit ria de Rehabilitaci Palma de Mallorca Jos Juan Uriarte Uriarte Specialist physician in psychiatry Hospital de Zamudio Zamudio Bizkaia Oscar Vallina Fern ndez Clinical Psychologist Hospital Sierrallana Torrelavega Cantabria Collaborating Societies Aragonese Mental Health Association Spanish Association of Neuropsychiatry National Association of Mental Health Nursing Spanish Society of Psychiat
266. ved for the positive symptoms 2 RCT n 167 WMD 9595 CI between 1 9 and 0 04 proof of the global effect 2 04 p 0 04 tie negative symptoms 2 RCT n 167 WMD 2 3 95 CI be tween 3 8 and 0 8 proof of the global effect 3 05 p 0 002 the global symptoms 2 RCT n 2 167 WMD 2 59 95 CI between 4 91 and 03 proof of the global effect 2 20 and p 0 03 Quality of life No significant effects were observed in the quality of life according to the Quality of Life Scale 1 RCT n 40 WMD 9 7 9596 CI between 3 2 and 2 2 proof of the global effect 1 47 p 2 0 14 CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS SR 1 RCT 1 SR 1 SR 1 SR 1 RCT 1 RCT 1 SR 1 RCT 1 41 RCT 1 Social functioning One study informed of the results obtained from using the 7 subscales of the Social Functioning Questionnaire No significant effects were observed for the withdrawal n 133 WMD 0 54 95 IC between 0 4 and 1 5 interpersonal behaviour n 133 WMD 0 5 95 CI between 0 1 and 1 2 independence performance n 133 WMD 1 9 95 CI between 0 2 and 4 independence competence n 133 WMD 0 3 95 CI between 1 5 and 1 recreation n 133 WMD 1 17 95 CI between 0 7 and 3 or employment n 133 WMD 0 9 95 CI between 0 2 and 2 However a significant effect was observed in favour of CB
267. ventions Are pyschoeducational interventions effective inzpeople with SMI What are the key components in pyschoeducational interventions in people with SMI What is the most adequate level of pyschoeducational intervention individual group or family Cognitive rehabilitation Are cognitive rehabilitation interventions efficient in people with SMI and cognitive im pairment Which is the most adequate format of these interventions for people with SMI and cogni tive impairment Other psychotherapies Are morita therapy drama therapy distraction therapy or hypnosis effective in people with SMI b SOCIAL INTERVENTIONS Do social insertion programmes daily living skills programmes residential programmes in the community or programmes aimed at leisure and spare time improve the evolution of the illness and the quality of life of people with SMI Which employment related intervention format improves labour market insertion of peo ple with SMI Do therapeutic interventions such as art therapy and music therapy improve the evolution of the illness and the quality of life of people with SMI CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 13 c SERVICE LEVEL INTERVENTIONS Which service supply system day centres and or psychosocial rehabilitation centres community Mental Health centres Assertive Community Treatment Intensive Case Management ICM non acute day hospitals or Case
268. vices in any of its forms depending on the implementation peculiarity in the different Autonomous Communities mental health centres mental healt services mental health teams mental health units or any similar entity are the axis that articulates the care for people with severe mental illness and therefore the parties responsibte for the treatments and those that must guarantee continuity of care Therefore those that must channel the care with other social devices but base them on the specific care if it is confirmed that the care has to be provided under this principle of continuity How to define continuity of care The Mental Health Services Care Continuity Programmes are aimed at facilitate the person in cluded therein with the treatment rehabilitation care and community support that adapts best to their pathology and their time of life This care continuity must be expressed by specifically organising actions that can be di vided in general into the following intervention groups Mental health services of centres e General or grass roots social services Hospitals e Primary health care e Specific rehabilitation resources in mental health e Other resources that are linked to the user s situation and that complement their needs for care and romotion of autonomy e Familv members and users associations Normalised resources Definition of the social services system 54s the series of services and benefits which toge
269. was carried out and grey literature conferences unpublished reports etc at national and international level was consulted Before finishing the CPG a final search was carried out for recently published articles until December 2008 that might help answer some of the questions of the CPG It was then critically 26 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS appraised them to assess the quality of the article and determine if it could be included in the evi dence used to formulate the recommendations No articles published after that date was included as a source of evidence for the CPG See figure 2 Prior to the publication of this guideline a preliminary draft was brought out with the update of the Schizophrenia CPG prepared by the NICE This document was reviewed by this guideline development group to analyse the possible contributions and or changes that had arisen in this new update and that might modify the recommendations of the previous schizophrenia guideline published by the NICE too Figure 2 Article selection Search in database 499 articles selected Selection by title and abstract Medline Embase 1726 articles PsycINFO identified Cochrane Library Selection by full text 113 articles selected 76 articles selected Manual search 3 3 Evidence assessment and synthesis Once the bibliographic search had finalised a first screening of the
270. whether there is a reduction or not of hospitalisation is already classical To respond to the section on ACT and non acute Day Hospitals the data obtained from the NICE schizophrenia CPG are provided There have been studies that have followed the NICE schizophrenia CPG including the review by Burns et al 2 it includes 29 RCT where the efficacy of ICM was assessed when pre venting hospitalisation compared with standard treatment or CM with 1 intensity The review by Marshall et al also exists which analysed the effectiveness of EM compared with standard care in people with SMI 11 RCTs n gt 1300 The different ways of providing psychiatric and social care in different countries limits the generalisation of the findings of this type of research Loca and international contexts affect the extrapolation of the findings to different settings With iespect to the applicability in our context of the evidence found there are several problems The different health frameworks of the United States and United Kingdom countries where the majority of the studies have been conducted which determine differences on establishing what is the standard treatment with which the majority of the experimental interventions are compared The different supportive systems and social welfare which determine differences with respect to the needs and the areas for which an intervention has to be designed e The different nam s of interventio
271. with those who received crisis intervention 1 Family intervention favours the remission of symptoms after 3 and 15 months of the in tervention compared with crisis intervention Patients whose family members followed a group psychoeducational programme pre sented a significantly longer period of time until any hypomaniac or maniac type recur rence than those of the control group and they presented fewer relapses after 12 months follow up 64 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS No differences have been found between individual family intervention and multi family intervention with respect to improvement of symptoms There are no differences in the clinical improvement between family intervention and non intervention in people with bipolar disorder either at the end of the treatment or after 6 months follow up There is a greater increase of anxiety levels among those people who receive family inter vention than among those who did not receive it With respect to the relationships in the family environment expressiveness cohesion and conflict no differences have been found between the family psychoeducation interven tion groups for caregivers and non intervention There appear to be no differences between the marital psychoeducation family inferven tion groups for couples and non intervention Or between family intervention and non intervent
272. y between the participation in competitive employment or other vocational activities and the avail ability of psychosocial rehabilitation services This study indicates that the greater participation in labour rehabilitation services was associated with the participation in competitive employment OR 3 p lt 0 05 and to a greater extent with non competitive employment OR 1 52 p lt 0 0001 In the other multi centre study carried out at six European sites 312 people with SMI were randomised 80 with a diagnosis of schizophrenia and schizo affective disorders and 20 with bipolar and other disorders to a sheltered employment programme EP IPS or pre vocational training PVT An 18 month follow up was carried out as well as an analysis for intention to treat in order to evaluate the efficacy of the IPS programme in Europe and examine if its effects are modified by the local state of the labour markets and social benefits CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 83 All these studies include patients who satisfy similar SMI criteria to those used in our set ting However the studies originate mainly from the United Status where the peri environmen tal factors legislation economic and social protection situation unemployment rate social and health structures etc are considered important and are very different to the Spanish context The interventions can be similar to those carri
273. y must also satisfy two requirements persistence in time 2 years by consensus and present serious difficulties in personal and social functioning due to this illness Thus it can be stated that not all people who have been diagnosed with a psychosis such as for instance schizophrenia enter the group of SMI and that not all people with SMI suffer from schizophrenia As indicated apart from the diagnosis the persistence of the disorder in time and the existence of a disability are required 3 Why do we talk about a bio psycho social approach The main treatment for people with SMI has been pharmacological interventions since its in troduction in the 50s However the partial and limited control of the symptomatology with the medication the difficulties for certain patients to adapt to the pharmacological patterns the need to work in areas such as awareness of the illness the short arid tong term side effects the dif ficulties in co existence and the difficulty to carry out a productive activity and be independent among others pose the need to use a more far reaching approach than pharmacological treatment an approach that permits including biological psychological and social aspects of the treatment bio psycho social approach So other psychotherapeutic and psychosocial interventions must be incorporated which in many aspects are included in the psychosocial rehabilitation concept The sole objective of these interventionssa
274. y with ST it improves the readmissions and relapses at 6 12999 and 30 months after starting the treatment Recommendations C In people with SMI cognitive behavioural treatment can used combined with standard treatment to reduce positive symptomatology mainly hallucinations People with SMI and persistent positive symptomatology can becoffered a specific cog nitive behavioural orientated psychological intervention for this pathology lasting for a prolonged period of time more than one year in order to improve the persistent symp tomatology Incorporate cognitive therapy into the strategies aimed at preventing relapses of depres sive symptomatology in people with SMI and diagnosis of bipolar disorder When the main objective of the intervention in people with SMI is to improve their social functioning it is advisable to incorporate social skills training There is not sufficient evidence to make recommendations in the problem solving area for people with SMI and a diagnosis of senizophrenia and related disorders 5 1 2 Psychodynamic psychotherapies and psychoanalytical approach In individual therapy psyeboanalytical principles are applied that have evolved from basic theo retic technical principles of psychoanalytical treatment so normally the treatment is called psy chodynamic psychetherapy or psychoanalytical counselling The central part of these treatments is the analysis of he
275. ychiatric rehabilitation Schizophr Bull 1999 25 4 657 76 Benedict RH Harris AE Remediation of attention defi cits chronic schizophrenic pa tients a preliminary study Br J Clin Psychol 1989 28 Pt 2 187 8 Cohen J Statistical power analysis for the behavioral sciences 2 ed Hillsdale Lawrence Erlbaum 1988 He Y Li C Morita therapy for schizophreniz Cochrane Database Syst Rev 2007 1 CD006346 Carr V Patients techniques for coping wit schizophrenia an exploratory study Br J Med Psychol 1988 61 Pt 4 339 52 Crawford Walker CJ King A Chan S Distraction techniques for schizophrenia Cochrane Database Syst Rev 2005 1 CD004717 Ruddy RA Dent BK Drama therapy for schizophrenia or schizophrenia like illnesses Cochrane Database Syst Rev 2006 1 CD005378 Qu Y Li Y Xiao G The effi cacy of dramatherapy in chronic schizophrenia Chinese Journal of Psychiatry 2000 33 4 237 9 Zhou Y Tang W A controlled study of psychodrama to improve self esteem in patients with schizophrenia Chinese Mental Health Journal 2002 16 669 71 Izquierdo SA Khan M Hypnosis for schizophrenia Cochrane Database Syst Rev 2004 3 CD604160 Lancaster D Hypnotizability and the effects of hypnotic suggestions on the cognitive style behavior patterns and mood states of hospitalized schizophrenics tesis doctoral Mississippi University of Mississippi 1983 Wu H Wang Z Zhang H Morita therapy in treatment of sch
276. yeth and Lundbeck He has also received fund ing for participating in research projects Wyeth Pharma Consult Services Miguel Bernardo Arroyo has received fees as a speaker Lilly BMS Wyeth Janssen and Pfizer He amp as also received economic aid to finance research BMS and educational pro grammes or courses Pfizer Manuel Camacho Lara a has received economic support to finance his participation in con fer nces Janssen Lilly and GSK and fees as a speaker GSK and AstraZeneca Juan Jos Uriarte Uriarte has obtained funding to participate in a congress and in a research project AstraZeneca 142 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS Bibliography 10 11 12 14 Parabiaghi A Bonetto C Ruggeri M Lasalvia A Leese M Severe and persistent mental illness a useful defi nition for prioritizing community based mental health service interven tions Soc Psychiatry Psychiatr Epidemiol 2006 41 6 457 63 Schinnar AP Rothbard AB Kanter R Jung YS An empirical literature review of defi nitions of severe and persistent mental illness Am J Psychiatry 1990 147 12 1602 8 Estrategia en salud mental del Sistema Nacional de Salud 2006 Madrid Ministerio ae Sanidad y Consumo 2007 National Institute of Mental Health Towards a model for a comprehensive community based mental health system Washington DC NIMH 1987 Grupo de trabajo sobre GPC Elaboraci n de gu as de pr ctica clinica en el Sistema Nac

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