Pending enough primary studies, we invite reviews on this topic to be conducted. Alternatively, we will endeavour to conduct our own review to fill this gap in the Library.

September 2020

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What is animal-assisted therapy?

Animal-assisted interventions use trained animals to help improve physical, mental and social functions in people with schizophrenia. It is a goal-directed intervention in which an animal that meets specific criteria is an integral part of the treatment process, which usually involves pharmaceutical and psychosocial treatment components. It has been shown to improve outcomes for people with autism-spectrum symptoms, medical difficulties, and behavioural problems.

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Art therapy is defined by the British Association of Art Therapists as “the use of art materials for self-expression and reflection in the presence of a trained art therapist. Clients who are referred to art therapy need not have previous experience or skill in art, the art therapist is not primarily concerned with making an aesthetic or diagnostic assessment of the client’s image. The overall aim of its practitioners is to enable a client to effect change and growth on a personal level through the use of art materials in a safe and facilitating environment”. Drama therapy is defined by the British Association of Drama Therapists as “the use of drama and theatre as a therapeutic process. It is a method of working and playing that uses action methods to facilitate creativity, imagination, learning, insight and growth.” Art therapy uses artwork to create a relationship between therapist and patient. The artwork may act as a buffer which reduces the intensity of the relationship between patient and therapist, which may be more productive for schizophrenia patients. Any benefit of drama therapy may come from the fundamental ‘make-believe’ aspect, which distances participants from the subject matter, allowing them to work with material that may be sensitive to them.

What is the evidence for art and drama therapies?

Moderate to low quality evidence finds no differences in long-term symptoms or functioning (1-2 years) between art therapy and an activity control or standard care. There may be some benefit of art therapy over standard care for symptoms in the shorter-term (6 weeks), and following 2-6 months of.Chinese caligraphy.

Low quality evidence from one very small study is unable to determine the benefits of drama therapy.

September 2020

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Case management is a community-based program in which a nurse, social worker or other clinician oversees the treatment programs and overall wellbeing of patients. Intensive case management is a variation on standard case management, where case managers have a smaller load, generally fewer than 20 patients. It is often used to care for people at high risk of hospital readmission. Assertive community treatment is a form of intensive case management with a focus on service coordination involving extensive integration with multidisciplinary teams who share a small caseload.

What is the evidence for case management?

Compared to standard care, high quality evidence shows that intensive case management is associated with increased contact with psychiatric care, increased independent living, and a lower likelihood of being admitted to hospital or dropping out of treatment for up to 12 months. Moderate quality evidence suggests it may also improve quality of life and general functioning, and decrease homelessness for up to 6 months. By 7 to 12 months there is decreased unemployment and contact with police. After 12 months, there is an increased likelihood of living in stable accommodation, with better functioning, improved symptoms, and increased medication compliance. Moderate to high quality evidence suggests intensive case management reduces long-term study dropout rates and medication non-adherence more than standard case management. For patients with a dual diagnosis (substance misuse and psychiatric disorder), moderate to low quality evidence suggests no significant benefit of intensive case management has over standard care for study retention, hospitalisation or service use, substance use, quality of life or functioning.

September 2020

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CBT aims to generate links between patterns of thoughts, feelings, and behaviours using cognitive restructuring to facilitate the understanding and management of behaviours. It can be used for improving positive or negative symptoms, as well as other factors including depression, psychotic relapse and coping.

What is the evidence for CBT for people with schizophrenia?

Moderate to low quality evidence shows small improvements in global state with CBT in the long-term (>1 year), but not in the short-term (<6 months). There may also be some improvements in symptoms, but no consistent benefit was found for reducing relapse or rehospitalisation rates, or for improving overall functioning. There may be greater compliance with medication with CBT than with standard care.

Individually tailored CBT (rather than CBT guided by a standardised protocol) shows a medium-sized benefit from high quality evidence for reducing the severity of hallucinations when compared to standard care or supportive therapy. Moderate to high quality evidence finds a small benefit for improving delusion severity when compared to standard care, but not when compared to supportive therapy.

For people who are not responding well to medication, high quality evidence shows CBT improved positive and general symptoms compared to standard care. For people with a dual diagnosis of schizphrenia and a substance use disorder, moderate quality evidence finds CBT combined with motivational interviewing (but not CBT alone) can improve general life satisfaction; however, there were no additional benefits for improving quality of life, functioning, criminality, study retention, mental state or substance use.

September 2020

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Community care refers to community-based interventions that involve medication, psychosocial treatments, monitoring of clinical progress, and housing and supportive services. These programs encourage patients to establish meaningful relationships, occupations and activities, while also establishing routines at home. Community treatment may also involve involuntary outpatient commitment (compulsory community treatment) to ensure patients receive their necessary treatment.

What is the evidence for community care for people with schizophrenia?

Moderate to low quality evidence suggests community care provides some benefit for medication adherence. There were no differences between compulsory and voluntary community care in the number of hospital readmissions, the number of hospital bed days, satisfaction with care, or overall functioning.

After 18 months of community-based psychoeducation or case management in low to middle income countries, there were improvements in symptoms, functioning, and fewer hospital readmissions. Barriers to feasibility of community care in low and middle income countries include; low education, unavailability of caregivers, resource constraints, and logistical issues. Barriers to acceptability include; fear of stigma and lack of appreciation of intervention benefits. Facilitators of acceptability include; satisfaction with, and appropriateness of, interventions, participation rates, and health worker characteristics (knowledge, trustworthiness, fluency in local dialects, listening skills).

September 2020

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The burden of schizophrenia includes direct costs, indirect costs, and intangible costs. Direct costs are estimated by the amount of services used and the price of treatment. Indirect costs are estimated by the averaged reduced future earnings of both patients and caregivers. Intangible costs are those that may be associated with the illness, such as trauma and depression. This topic presents the current evidence on the direct costs of psychosocial treatments.

What is the evidence for the costs of psychosocial treatments?

Low quality evidence is unclear as to the cost effectiveness of psychosocial treatments. Review authors conclude that economic evaluations are few and generally poor in quality; further research is needed.

September 2020

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People with severe mental illnesses such as schizophrenia may be in need of emergency care at some stage in their illness, particularly in the early stages. Crisis intervention is a treatment model designed to offer intensive crisis-focused treatment to people living in the community, and is usually provided in the context of home-based care. Crisis intervention programs comprise teams of specialist staff who often provide 24-hour availability of support. This may be a mobile treatment, a dedicated unit based in a hospital or day centre, or a residential.

What is the evidence for crisis interventions?

Moderate to low quality evidence finds improved overall symptoms and social adjustment by 20 months (but not 12 months), more sociable behavior and less agitation and disorientation by 4-6 months, less family burden and disruption by 3 months (but not 6 months), and more patient and relative overall satisfaction.

September 2020

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Crisis planning involves people planning for their care in the event of a future mental health crisis. Types of crisis planning vary, however, they all strive to incorporate a person’s preferences for the care they would like to receive, as well as care they want to refuse, during a crisis. Joint plans are developed collaboratively between the patient and mental health professionals.

Crisis planning may help prevent relapse by promoting better self-management. They may reduce the need for hospital admissions by encouraging prompt help-seeking or improved community service responses. They may also encourage patients to accept voluntary hospital admissions should a crisis occur.

What is the evidence for crisis planning?

High quality evidence finds a 25% reduction in compulsory psychiatric hospital admission rates in people receiving crisis planning compared to standard care. There were no differences in the rates of voluntary psychiatric hospitalisations.

September 2020

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Dance therapy refers to the use of physical movement is a therapeutic context, aiding the expression of emotions and experiences. The American Dance Therapy Association defines dance therapy as the “psychotherapeutic use of movement for furthering emotional, social, cognitive and physical integration of the individual.” Dance therapy does not entail any specific or choreographed therapeutic ‘dance’; instead, the therapeutic nature of dance is completely individualised, and guided by a therapist based on an individual’s needs.

What is the evidence for dance therapy?

Moderate to low quality evidence suggests dance therapy may have a small benefit for reducing negative symptom severity. The ‘negative symptoms’ of schizophrenia refer to an absence of normal functions. These include a scarcity of facial expressions of emotion, reduced frequency and range of gestures and voice modulation, restricted eye contact, poverty of speech, reduced social interaction, reduced motivation, poor hygiene, and reduced experience of pleasure often manifesting as scarcity of recreation, inability to experience closeness, and reduced interest in any sexual activity.

September 2020

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