Supportive therapy for schizophrenia

Schizophrenia is a severe mental illness with ‘positive symptoms’ such as hallucinations (hearing voices and seeing things) and delusions (having strange beliefs). People with schizophrenia also suffer from disorganisation and ‘negative symptoms’ (such as tiredness, apathy and loss of emotion). People with schizophrenia may find it hard to socialise and find employment. Schizophrenia is considered one of the most burdensome illnesses in the world. For some people it can be a lifelong condition. Most people with schizophrenia will be given antipsychotic medications to help relieve the symptoms. In addition to this they can also receive therapy, of which there are various types.

One therapy often given to people with schizophrenia is supportive therapy, where typically after a person is established in the care of mental health services, they will receive general support rather than specific talking therapies such as cognitive behavioural therapy (CBT). For example, in consultations with health professionals there will often be time given to listening to people’s concerns, providing encouragement, or even arranging basic help with daily living. Many people with schizophrenia also receive support from their family and friends. Supportive therapy has been described as the treatment of choice for most people with mental illness and may be one of the most commonly practiced therapies in mental health services.

It is, however, difficult to answer the question of exactly what supportive therapy is. It is difficult to find a widely accepted definition of supportive therapy. For the purposes of this review, supportive therapy includes any intervention from a single person aimed at maintaining a person’s existing situation or assisting in people’s coping abilities. This includes interventions that require a trained therapist, such as supportive psychotherapy, as well as other interventions that require no training, such as 'befriending'. Supportive therapy does not include interventions that seek to educate, train or change a person’s way of coping.

The aim of this review is to assess the effectiveness of supportive therapy compared to other specific therapies or treatment as usual. This update is based on a search run in 2012; the review now includes 24 randomised studies with a total of 2126 people. The studies compared supportive therapy either with standard care alone or a range of other therapies such as CBT, family therapy and psychoeducation. The participants continued to receive their antipsychotic medication and any other treatment they would normally receive during the trials. Overall, the quality of evidence from these studies was very low. There is not enough information or data to identify any real therapeutic difference between supportive therapy and standard care. There are several outcomes, including hospitalisation, satisfaction with treatment and general mental state, indicating advantages for other psychological therapies over supportive therapy. However, these findings are limited because they are based on only a few small studies where the quality of evidence is very low. There was very limited information to compare supportive therapy with family therapy and psychoeducation as most studies in this review focused on other psychological therapies, such as CBT. Apart from one study presenting data on death, there was no information on the adverse effects of supportive therapy. In summary, there does not seem to be much difference between supportive therapy, standard care and other therapies. Future research would benefit from larger studies where supportive therapy is the main treatment.

Ben Gray, Senior Peer Researcher, McPin Foundation: http://mcpin.org/

Authors' conclusions: 

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

Read the full abstract...
Background: 

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

Objectives: 

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

Search strategy: 

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

Selection criteria: 

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

Data collection and analysis: 

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the risk ratio (RR) using a fixed-effect model with 95% confidence intervals (CIs). Where possible, we undertook intention-to-treat analyses. For continuous data, we estimated the mean difference (MD) fixed-effect with 95% CIs. We estimated heterogeneity (I2 technique) and publication bias. We used GRADE to rate quality of evidence.

Main results: 

Four new trials were added after the 2012 search. The review now includes 24 relevant studies, with 2126 participants. Overall, the evidence was very low quality.

We found no significant differences in the primary outcomes of relapse, hospitalisation and general functioning between supportive therapy and standard care.

There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (4 RCTs, n = 306, RR 1.82 CI 1.11 to 2.99, very low quality of evidence), clinical improvement in mental state (3 RCTs, n = 194, RR 1.27 CI 1.04 to 1.54, very low quality of evidence) and satisfaction of treatment for the recipient of care (1 RCT, n = 45, RR 3.19 CI 1.01 to 10.7, very low quality of evidence). For this comparison, we found no evidence of significant differences for rate of relapse, leaving the study early and quality of life.

When we compared supportive therapy to cognitive behavioural therapy CBT), we again found no significant differences in primary outcomes. There were very limited data to compare supportive therapy with family therapy and psychoeducation, and no studies provided data regarding clinically important change in general functioning, one of our primary outcomes of interest.

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