Behavioral rehabilitation of the "treatment-refractory" schizophrenia patient: Conceptual foundations, interventions, and outcome data.

Abstract

This article describes an intensive, inpatient behavioral rehabilitation program for patients with schizophrenia who have been considered “treatment-refractory” at state hospitals. The program is a public–private partnership involving state and private hospitals and community residence providers. The essential elements of this program are described, along with the conceptual and philosophical bases of its treatment and examples of staff behaviors critical to treatment success. Outcome data are then discussed to emphasize the point that when evidence-based psychological treatment is implemented with this population, outcomes can be positive in most cases, and therefore, the number of treatment-refractory patients is actually far less than is estimated on the basis of response to medication alone. Schizophrenia is a serious mental disorder that affects approximately 1% of the population worldwide, with a current global incidence calculated at over 20 million people (Jablensky, 2000). The consequences of schizophrenia, in terms of both public health costs and effects on lives are enormous. For example, it has been estimated that as many as 10% of all disabled persons in the United States have schizophrenia (Rupp & Keith, 1993), and the disorder accounts for 75% of all mental health expenditures and approximately 40% of all Medicaid reimbursements (Martin & Miller, 1998). Among people with the disorder, only between 10%–30% are employed at any one time (Attkisson et al., 1992), and few of these people are able to maintain consistent employment (Policy Study Associates, 1989). Studies have consistently found that quality of life among people with schizophrenia is significantly poorer than among the rest of the population (Lehman, Ward, & Linn, 1982). Schizophrenia typically is diagnosed in late adolescence or early adulthood, and traditionally, approximately 50 –70% of cases are characterized by a chronic, relapsing course with high morbidity and permanent disability. In addition, rates of mortality and somatic morbidity are higher in schizophrenia than in the general population (Lieberman & Coburn, 1986), and the rate of attempted suicide equals that of major depression (Simpson & Tsuang, 1996). The economic costs of treating schizophrenia have been estimated to be $62.7 billion (e.g., including direct treatment costs and lost business productivity due to patient and family caretaker work absence; Wu et al.,