Integrated psychological therapy for schizophrenia patients

Antipsychotic drugs are described as the cornerstone of the treatment for schizophrenia. Although the development of the so-called second-generation antipsychotic drugs has promised a more benign side-effect profile with enhanced efficacy and safety, 25–50% of schizophrenia patients suffer from persistent positive symptoms associated with depression, demoralization, impaired social functioning, low employment and isolated lives. The recovery outcomes are still poor. This indicates heterogeneous course patterns of schizophrenia, demanding multimodal treatments rather than a single intervention. Therefore, today psychiatric care combines pharmacotherapy, sociotherapy and psychotherapies. From a rehabilitative perspective, reducing impairments in social and community functioning were mentioned to be among the targets of schizophrenia treatment [1], and social and community reintegration to be one of the main objectives. On this background, important advances during the past 20 years in the rehabilitation of schizophrenia led to a change in treatment philosophy and technology:

•	First, the main rehabilitation field has changed from the hospital to the community, including the development of the Assertive Community Treatment model for ensuring continuity of care for severely ill;
•	Second, based on a consumer-oriented rehabilitation, the recovery movement has been recently promoted by the mental health commission, recommending that treatment should focus on recovery rather than just managing symptoms [101]. Therefore, rehabilitation programs have to take the (unmet) needs of patients into consideration. As an outcome, recovery in schizophrenia can be defined as patients’ symptom remission, independence, work involvement, and social activities [2];
•	Third, a growing body of evidence demonstrates the efficacy of specifically targeted, standardized, predominantly cognitive behavioral interventions, which clearly add benefits to pharmacological and sociotherapeutic standard treatments [3].

These psychological therapy approaches can be divided into four main groups [4]: family therapy approaches; social skills and problem-solving training; cognitive remediation; and cognitive behavior therapy to reduce (persistent) positive symptoms. The preponderance of research focuses on an isolated single treatment approach out of these four areas. Accordingly, patients’ main benefit is more related to the proximal outcome of each treatment’s specific objective than on the distal outcome, including generalization and transfer of the treatment’s effects into daily life. The question arises as to how social reintegration and recovery of schizophrenia patients can be optimized through psychological intervention? Social skills training (SST) represents one psychological intervention that includes improvement of social skills and competence as main treatment objectives. Studies have demonstrated the successful acquisition of social skills through SST, but they still failed to support strong evidence of robust long-term social and community reintegration. Consequently, SST researchers define specific social intervention topics from patient’s daily living (e.g., medication management, work, leisure and housing), including additional booster sessions after therapy and cooperating with a community case manager [5,6]. However, even with these further developments, SST is limited by two methodological bias. First, it is a challenge in psychotherapy research to assess the social and community behavior of people suffering from schizophrenia in daily living. Up to now, only few change-sensitive and standardized assessment instruments for measuring social competence exist. Second, neurocognitive deficits in schizophrenia patients could be identified as possible rate-limiting factors in psychosocial rehabilitation. Nowadays, they are considered as one of the core deficits in schizophrenia [7]. Therefore, additional interventions addressing neurocognition might potentiate the efficacy of SST. Several cognitive remediation approaches have been developed recently, using cognitive-enhancing strategies by rehearsal learning tools, compensation strategies to bypass neurocognitive impairments, or both [8]. Most of these cognitive remediation efforts are used in individual settings and some of them are computer assisted. But empirical findings associated with cognitive remediation failed to support strong evidence of direct relationships between neurocognition and functional outcome. Only approximately 20–40% of the variance in functional outcome can be explained by neurocognitive deficits [9]. One of the reasons might be that the objective of cognitive remediation is generally addressed as ‘cold’ basic neurocognition, which is independent of the social context. In recent years, the paradigm of social cognition led to the hypothesis that this concept probably contributes directly to the variance beyond the relationship of neurocognition and functional outcome. Social cognitions are separated from neurocognitions in describing them as ‘hot’ cognitions that are influenced by affect and arousal embedded in a social context. Nowadays, several subcategories of social cognition are defined in schizophrenia research, and social perception (the ability to judge social rules, roles and context) is probably best investigated.

Consequently, the question arises whether integrated treatment focusing directly on neurocognitive, social cognitive and social functioning is an evident psychological treatment within the context of recovery orientation? In psychiatric rehabilitation of schizophrenia, only few broad-based integrated therapy approaches exist up to now. The conception of the successfully evaluated neurocognitive enhancement therapy (NET) [10] combines neurocognitive remediation with work therapy. Its neurocognitive part goes back to the cognitive enhancement therapy (CET) [11], which includes individual computer-based neurocognitive training followed by group sessions addressing social cognition. A part of the therapy concept of CET refers to the one of the integrated psychological therapy (IPT) [12,13]. The IPT concept is based on the pervasiveness hypothesis [14], which is stated as a reference to integrative models explaining the relationship of neurocognition, social cognition, psychopathology and functional outcome, together with neuroleptic medication [15].

On this background, the development and research on IPT offers some pioneering achievements: IPT was one of the first systematic, comprehensive and manual-driven therapy approaches for schizophrenia patients. Since IPT has been used for more than 25 years, it has been widely adopted, especially in Europe. The German edition of the IPT manual is in its sixth edition [13] and has been translated into 12 languages. In the USA, IPT is increasingly recognized as a state-of-the-art approach to cognitive rehabilitation [102]. However, IPT is associated more with integrated therapy rather than with cognitive remediation alone. It combines cognitive remediation with therapy elements for social cognition, social skills and problem solving. IPT is based on the underlying assumption that basic deficits in neurocognitive and social cognitive functioning have a pervasive effect on higher levels of behavioral organization, including social skills, and social and independent functioning. Based on this, successful psychosocial rehabilitation requires remediation of both underlying neurocognitive impairments and related social cognitive deficits, as well as building social skills, self-care and recovery. IPT is organized into five subprograms: as the later subprograms build on the earlier ones, they are taught sequentially, beginning with basic neurocognition (e.g., attention, cognitive flexibility and executive function) and social perception, followed by communication and social skills, and then problem-solving skills. All subprograms are practised through engaging in group exercises.

The efficacy of IPT was emphasized by several randomized, controlled trials. The aim of a recently published quantitative review was to evaluate the effectiveness of IPT under varying treatment and research conditions [4]. For that purpose, 32 independent studies conducted by research groups in ten countries with a total sample of 1420 patients could be included in a meta-analysis. Results demonstrate significant superiority of IPT in global therapy effect (mean of all assessed outcome variables) during therapy and the maintenance of the effects at follow-up compared with unspecific group activities (placebo-attention conditions) and/or standard care. In accordance with the underlying assumption of the pervasive relationship of neurocognitive, social cognitive and social functioning, significant improvements in all of these functional levels are evident for IPT compared with both control conditions. Furthermore, IPT patients obtain a significant reduction of negative and positive symptoms. These favorable IPT effects are independent of assessment formats (expert ratings, self-reports, psychological tests), settings (inpatient vs outpatient, academic vs nonacademic) and phases of treatment (acute vs chronic). The comparison of the five IPT subprograms indicates that use of the complete IPT better supports the maintenance of the therapy effects during follow-up and demonstrates clearly favorable distal outcome compared with the use of single IPT subprograms.

In order to capitalize on advances made in understanding and rehabilitation of neurocognitive and social cognitive functioning in schizophrenia, the original IPT model has been modified according to recommendations of the National Institute of Mental Health consensus initiative of Measurement And Treatment Research to Improve Cognition in Schizophrenia (NIMH-MATRICS) [16]. Different neurocognitive functions in daily life (speed of processing, attention and vigilance, working memory, verbal and visual learning, and memory, reasoning and problem solving) are integrated with social cognitive functions (emotional processing, social perception, theory of mind, social schema and attribution) in the integrated neurocognitive therapy (INT). In addition, INT addresses motivational aspects such as self-efficacy expectation and activating resources to enhance the recovery orientation and treatment adherence of the patient. Some exercises focusing directly neurocognition domains are computer based. All exercises are practised through engaging in group exercises. INT has actually been evaluated in an international multi-center study.

In summary, the conceptualization of IPT is still in progress. The original IPT is the prototype of integrated psychotherapy that targets different intermediate levels within a single modality [17]. The marked effects of IPT are robust across a wide range of patients and treatment conditions. The further development of INT will probably give some support to bridge the gap between evidence-based psychological therapy under rigorously controlled conditions of the laboratory and schizophrenia patients’ daily life conditions. The improvement of the patients’ therapy motivation and the subjective experience of self efficacy by coping possibilities in daily life are evidently supported by group exercises and might be one of the key therapeutic elements to bridge this gap. Integrated psychological group therapy focusing directly on neurocognition, social cognition and functional outcome in daily life gives some evidence to support symptom remission and social and community reintegration, and finally, to promote recovery orientation within multimodal rehabilitation programs.