Chronicity in schizophrenia: fact, partial or artifact? Hosp Community Psychiatry. 1987;38:477-486.
of the overall effects of the intervention. The SST condition was as effective as either of the family treatment conditions until month 21 of the intervention. Had the treatment ended at that point, rather than 3 months later, the authors might have reached a to¬ tally different conclusion about the potential for rehabilitation. Alterna¬ tively, had they measured adjust¬ ment after recovery from the terminal psychotic episode, they may have found a continuation of the beneficial effects of SST detected at the 1-year point. Given the multiple handicaps associated with schizophrenia and the multifactorial nature of treatment response, relapse is not a sufficient criterion of outcome, and certainly is not a reflection of the capacity to learn. Several aspects of the study design also limit the extent to which the endof-treatment results can be extrapo¬ lated. The sample was limited to pa¬ tients residing with relatives rated high on the Expressed Emotion (EE) test before treatment and who were expected to return to the home with high EE after discharge following the index episode. This group has a par¬ ticularly negative prognosis in the face of continued family contact, and is not representative of schizophrenic
Social Skills
in the SST group were associated with intense family conflict and/or in¬
in schizophrenia. chiatry. 1991;48:247-253. come
Arch Gen
Psy-
2. Breier A, Schreiber JL, Dyer J, Pickar D. National Institute of Mental Health longitudinal study of chronic schizophrenia. Arch Gen Psychiatry.
1991;48:239-246. 3.
Westermeyer JF,
Harrow M, CaB. The clinical course of schizophrenia: two successive followups. In: Grinker RR Sr, Harrow M, eds. Clinical Research in Schizophrenia: A Multidirone
mensional Approach. Springfield, III: Charles C Thomas Publisher; 1987:314\x=req-\ 328. 4. Harrow M, Goldberg JF, Grossman LS, Meltzer HY. Outcome in manic disorders: a naturalistic follow-up study. Arch Gen Psychiatry. 1990;47:665-671. 5. McGlashan TH. The Chestnut
Lodge follow-up study, II: long-term schizophrenia in the affective disorders. Arch Gen Psychiatry. outcome of
1984;41:586-601. 6. Tsuang MT, Woolson RF, Winokur G, Crowe RR. Stability of psychiatric di-
agnosis: schizophrenia and affective disorders followed up over a 30- to 40-year period. Arch Gen Psychiatry. 1988;
38:535-554. 7. Bleuler MN. The Schizophrenic Disorders: Long-term Patient and Family Studies. New Haven, Conn: Yale University Press; 1978. 8. Harding CM, Zubin J, Strauss JS.
fact
Training for Schizophrenia? To the Editor. \p=m-\Hogarty and colleagues1 have conducted an extremely important study on the treatment of Their results shed considerable light on the potential impact of psychosocial interventions, and underscore the need for longitudinal evaluations of outcome. We find little to fault in the research design and data analysis; however, we disagree with what appears to be the overly pessimistic conclusion1(p346) that the effects of psychosocial treatments in general, and social skills training (SST) in particular, dissolve once treatment ends. Based solely on examination of the final point in their 2-year survival analysis, SST does appear to provide little more than medication alone.
schizophrenia.
However, as eloquently pointed out et al, this analysis pro-
by Hogarty vides
a
limited and
misleading view
patients in general.2,3 It is not sur¬ prising that several of the late relapses
creased family pressure for expanded role performance. Moreover, during the first year of treatment, patients in SST were encouraged to avoid con¬ flict in the family, while during the second year they were taught more confrontational skills (eg, conflict res¬
olution).4 Unfortunately, no measures were employed to assess the effec¬ tiveness of the training. It is possible that at least some of the patients with late
relapses had not adequately de¬ veloped the skills needed to cope with
the increased conflict and pressure in the family environment. Such failure could reflect limitations of the partic¬ ular intervention employed, rather than an indictment of SST and reha¬ bilitation per se. There is little question that patients with schizophrenia have significant impairments in information process¬ ing that affect their ability to learn.5 We also agree that long-term treat¬ ment is essential. However, we re-
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Leeds User on 07/31/2017
main optimistic that improved inter¬ ventions tailored to patients' cogni¬ tive impairments can produce dura¬ ble and generalizable outcomes. ALAN S. BELLACK, PHD Kim T. MUESER, PHD Medical College of Pennsylvania at EPPI 3200 Henry Ave Philadelphia, PA 19129 1. Hogarty GE, Anderson CM, Reiss DJ, Kornblith SJ, Greenwald DP, Ulrich RF, Carter M, The EPICS Research
Group. Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of
schizophrenia, II: two-year effects of a controlled study on relapse and adjustment. Arch Gen Psychiatry. 1991;48:340\x=req-\ 347. 2. Hooley J. Expressed emotion: a review of the critical literature. Clin Psychol Rev. 1985;5:119-140. 3. Parker G, Johnston P, Hayward L. Parental 'expressed emotion' as a predictor of schizophrenic relapse. Arch Gen Psychiatry. 1988;45:806-813. 4. Hogarty GE, Anderson CM, Reiss DJ, Kornblith SJ, Greenwald DP, Javna CD, Madonia MJ, The EPICS Research Group. Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia, I: one-year effects of a controlled study on relapse and expressed emotion. Arch Gen Psychiatry. 1986;43:633-642.
5. Neuchterlein HK, Dawson ME. Information processing and attentional functioning in the developmental course of schizophrenic disorders. Schizophr Bull. 1984:10:160-203.
In Reply. We are grateful to Drs Bellack and Mueser for their interest in our work and for their generally supportive comments. They raise the fol-
lowing two apparent concerns: (1) our alleged view that psychosocial treatment, particularly social skills training (SST), is "overly pessimistic," and (2) the possibility that patients experiencing late relapses might not develop the social skills needed for survival, an indictment of our "particu-
lar intervention," rather than SST itself. First, we know of no SST application among schizophrenic patients that has ever demonstrated persistent effects relative to controls for more than 9 months after discharge, including the important study by Bellack et al.1 In fact, the least equivocal effects of SST with schizophrenic pa-
of the overall effects of the intervention. The SST condition was as effective as either of the family treatment conditions until month 21 of the intervention. Had the treatment ended at that point, rather than 3 months later, the authors might have reached a to¬ tally different conclusion about the potential for rehabilitation. Alterna¬ tively, had they measured adjust¬ ment after recovery from the terminal psychotic episode, they may have found a continuation of the beneficial effects of SST detected at the 1-year point. Given the multiple handicaps associated with schizophrenia and the multifactorial nature of treatment response, relapse is not a sufficient criterion of outcome, and certainly is not a reflection of the capacity to learn. Several aspects of the study design also limit the extent to which the endof-treatment results can be extrapo¬ lated. The sample was limited to pa¬ tients residing with relatives rated high on the Expressed Emotion (EE) test before treatment and who were expected to return to the home with high EE after discharge following the index episode. This group has a par¬ ticularly negative prognosis in the face of continued family contact, and is not representative of schizophrenic
Social Skills
in the SST group were associated with intense family conflict and/or in¬
in schizophrenia. chiatry. 1991;48:247-253. come
Arch Gen
Psy-
2. Breier A, Schreiber JL, Dyer J, Pickar D. National Institute of Mental Health longitudinal study of chronic schizophrenia. Arch Gen Psychiatry.
1991;48:239-246. 3.
Westermeyer JF,
Harrow M, CaB. The clinical course of schizophrenia: two successive followups. In: Grinker RR Sr, Harrow M, eds. Clinical Research in Schizophrenia: A Multidirone
mensional Approach. Springfield, III: Charles C Thomas Publisher; 1987:314\x=req-\ 328. 4. Harrow M, Goldberg JF, Grossman LS, Meltzer HY. Outcome in manic disorders: a naturalistic follow-up study. Arch Gen Psychiatry. 1990;47:665-671. 5. McGlashan TH. The Chestnut
Lodge follow-up study, II: long-term schizophrenia in the affective disorders. Arch Gen Psychiatry. outcome of
1984;41:586-601. 6. Tsuang MT, Woolson RF, Winokur G, Crowe RR. Stability of psychiatric di-
agnosis: schizophrenia and affective disorders followed up over a 30- to 40-year period. Arch Gen Psychiatry. 1988;
38:535-554. 7. Bleuler MN. The Schizophrenic Disorders: Long-term Patient and Family Studies. New Haven, Conn: Yale University Press; 1978. 8. Harding CM, Zubin J, Strauss JS.
fact
Training for Schizophrenia? To the Editor. \p=m-\Hogarty and colleagues1 have conducted an extremely important study on the treatment of Their results shed considerable light on the potential impact of psychosocial interventions, and underscore the need for longitudinal evaluations of outcome. We find little to fault in the research design and data analysis; however, we disagree with what appears to be the overly pessimistic conclusion1(p346) that the effects of psychosocial treatments in general, and social skills training (SST) in particular, dissolve once treatment ends. Based solely on examination of the final point in their 2-year survival analysis, SST does appear to provide little more than medication alone.
schizophrenia.
However, as eloquently pointed out et al, this analysis pro-
by Hogarty vides
a
limited and
misleading view
patients in general.2,3 It is not sur¬ prising that several of the late relapses
creased family pressure for expanded role performance. Moreover, during the first year of treatment, patients in SST were encouraged to avoid con¬ flict in the family, while during the second year they were taught more confrontational skills (eg, conflict res¬
olution).4 Unfortunately, no measures were employed to assess the effec¬ tiveness of the training. It is possible that at least some of the patients with late
relapses had not adequately de¬ veloped the skills needed to cope with
the increased conflict and pressure in the family environment. Such failure could reflect limitations of the partic¬ ular intervention employed, rather than an indictment of SST and reha¬ bilitation per se. There is little question that patients with schizophrenia have significant impairments in information process¬ ing that affect their ability to learn.5 We also agree that long-term treat¬ ment is essential. However, we re-
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Leeds User on 07/31/2017
main optimistic that improved inter¬ ventions tailored to patients' cogni¬ tive impairments can produce dura¬ ble and generalizable outcomes. ALAN S. BELLACK, PHD Kim T. MUESER, PHD Medical College of Pennsylvania at EPPI 3200 Henry Ave Philadelphia, PA 19129 1. Hogarty GE, Anderson CM, Reiss DJ, Kornblith SJ, Greenwald DP, Ulrich RF, Carter M, The EPICS Research
Group. Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of
schizophrenia, II: two-year effects of a controlled study on relapse and adjustment. Arch Gen Psychiatry. 1991;48:340\x=req-\ 347. 2. Hooley J. Expressed emotion: a review of the critical literature. Clin Psychol Rev. 1985;5:119-140. 3. Parker G, Johnston P, Hayward L. Parental 'expressed emotion' as a predictor of schizophrenic relapse. Arch Gen Psychiatry. 1988;45:806-813. 4. Hogarty GE, Anderson CM, Reiss DJ, Kornblith SJ, Greenwald DP, Javna CD, Madonia MJ, The EPICS Research Group. Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia, I: one-year effects of a controlled study on relapse and expressed emotion. Arch Gen Psychiatry. 1986;43:633-642.
5. Neuchterlein HK, Dawson ME. Information processing and attentional functioning in the developmental course of schizophrenic disorders. Schizophr Bull. 1984:10:160-203.
In Reply. We are grateful to Drs Bellack and Mueser for their interest in our work and for their generally supportive comments. They raise the fol-
lowing two apparent concerns: (1) our alleged view that psychosocial treatment, particularly social skills training (SST), is "overly pessimistic," and (2) the possibility that patients experiencing late relapses might not develop the social skills needed for survival, an indictment of our "particu-
lar intervention," rather than SST itself. First, we know of no SST application among schizophrenic patients that has ever demonstrated persistent effects relative to controls for more than 9 months after discharge, including the important study by Bellack et al.1 In fact, the least equivocal effects of SST with schizophrenic pa-
