Effectiveness of psychological and psychosocial interventions on quality of life of patients with schizophrenia and related disorders: a systematic review protocol

Abstract

The objective of this review is to synthesize the best available evidence on the effectiveness of psychological and psychosocial interventions on quality of life of patients with schizophrenia and related disorders. This review will consider studies that include patients with schizophrenia or related disorders (schizotypal and delusional disorders) in all stages of their illness and in all treatment settings. The review will consider studies that evaluate psychological or psychosocial interventions. Included interventions will be family interventions, psychoeducation / patient education, cognitive-behavioral therapy, cognitive remediation, social skills training, and supported employment / vocational rehabilitation. The format of the intervention may be individual or group-based. The providers of interventions may include nurses, physicians, psychologists, social workers or other allied health providers. The control comparison will be any other psychological or psychosocial intervention or standard care (also called “treatment as usual”). The review will consider studies that include quality of life as an outcome measure. Studies will be reviewed for evidence of standardized valid and reliable tools measuring subjective quality of life, such as the Quality of Life Scale, the World Health Organization Quality of Life, the Lehmans Quality of Life Interview or the Manchester Short Assessment of Quality of Life. Review objective The objective of this review is to synthesize the best available evidence on the effectiveness of psychological and psychosocial interventions on quality of life (QoL) of patients with schizophrenia and related disorders. Review questions In patients with schizophrenia and related disorders: what is the effect of a psychological intervention as compared to usual care on QoL? what is the effect of a psychological intervention as compared to another psychological or psychosocial intervention on QoL? what is the effect of a psychosocial intervention as compared to usual care on QoL? what is the effect of a psychosocial intervention as compared to another psychosocial intervention or psychological intervention on QoL? Background More than 450 million people suffer from mental health disorders worldwide and many more have mental problems1. These disorders and problems affect all sections of society and every age group2. It has also been estimated that the burden of mental disorders will rise significantly over the next decades3. Thus, mental health disorders are of international concern1,4,5. Schizophrenia is a major mental disorder with considerable impact on individuals and their families6. It is estimated that worldwide 24 million people at any point of time suffer from schizophrenia7. Schizophrenia typically starts in early adulthood or late adolescence8. It is associated with relapses with high hospitalization rates9, loss of ability to work and mortality in younger age than a general population10. Nearly every patient is disabled in multiple functional domains11 and they have significantly more problems in everyday functioning than the general population12. Patients with schizophrenia are also stigmatized, which leads to discrimination13,14 which may affect these people's life opportunities, such as social relationships, education, employment, housing and health care services15. Moreover, the economic costs of schizophrenia are remarkable10. Costs are caused, for example by loss of ability to work10, relapses with high hospitalization rates9 and family burden10. Besides antipsychotic treatment, clinical practice guidelines for schizophrenia recommend psychosocial interventions that are relevant to sufferers' needs and focus on issues of specific relevance to the patient16,17,18,19. Psychosocial interventions have been developed to address the impact of the illness on an individual's well-being, psychosocial functioning and life opportunities19. Family interventions, psychoeducation/patient education, cognitive behavior therapy, cognitive interventions, social skills training and supported employment represents typical psychosocial interventions16,17. Jung and Newton20 reviewed Cochrane Reviews of psychosocial and psychological interventions for either schizophrenia, psychosis, schizoaffective or bipolar disorder. They identified 28 interventions with assertive community treatment (ACT), crisis intervention, music therapy and psychoeducation assessed as having strong support that merits application. Moreover, four interventions for patients with schizophrenia or severe mental illness were found to have moderate support that warranted consideration of application. These interventions being cognitive behavior therapy, family intervention, prompts to encourage appointment attendance and token economy. Interventions that were not supported were case management, compulsory community and involuntary outpatient treatment, distraction techniques as well as psychosocial treatment programs for people with both severe mental illness and substance misuse. The authors concluded that in many reviews the data was inconclusive. Moreover, the authors argued that the validity of randomized controlled trials (RCTs) may be questionable to investigate the effectiveness of varying psychotherapies.20 Woodward 21 produced an evidence summary related to psychological and psychosocial interventions for patients with schizophrenia. Based on the summary, cognitive behavior therapy should be available and cognitive remediation, social skills training and vocational interventions should be considered for patients with schizophrenia to improve social outcomes. Psychoeducation and music therapy were also identified as useful interventions whilst there was insufficient evidence to recommend psychoanalytic or psychodynamic psychotherapy for use in routine treatment.21 Many research findings have confirmed that the presence of schizophrenia is related to poorer QoL22,23,24. There is a number of factors that potentially are related to impaired QoL. For example various kinds of psychiatric symptoms,22,25, 26,27,28,29, side effects of medication25 and perceived stigma13,29 may impair QoL of these patients. Reduced QoL can also be attributed to a weakened physical state, problems in psychosocial functioning30, high level of unmet needs26,31 and low number of daily activities28. Moreover, impaired QoL may be associated with weak social support26, loneliness30,31,32, unsatisfied amount of contact with family members 28,32, unemployment32 and insufficient financial means27. Thus there is a need to develop a holistic approach to care in which patients' QoL is of central concern 33,34. As a result, improving the QoL of these patients is emphasized in clinical practice guidelines all over the world 16,17,18,19. With regards to psychological and psychosocial interventions effectiveness on QoL of patients with schizophrenia and related disorders (schizotypal and delusional disorders), several Cochrane reviews have included the QoL as a secondary outcome whilst other studies have QoL as a primary outcome. Jones et al.35 reviewed RCTs where cognitive behavior was investigated. Only one small study reported effectiveness on QoL and found no differential effect of cognitive behavior therapy. This was also found in the review by McIntosh et al.36 related to compliance therapy. Dieterich et al.37 concluded that based on few skewed data intensive case management confers no advantage over standard care. Tungpunkom et al.38 concluded that it is unclear whether life skills programs improve QoL. The same was also concluded in the reviews by Ruddy et al.39 when related to art therapy, in Mössler et al.40 and Xia et al.41 regarding psychoeducation and Crowther et al.42 regarding vocational rehabilitation. These authors concluded that more research is needed to be confident of the effectiveness of psychoeducation on QoL. There is an urgent need to determine the psychological and psychosocial interventions by which the QoL of patients with schizophrenia and related disorders is best supported. Thus, the purpose of this review is to synthesize the existing body of research evidence on the effectiveness of psychosocial and psychological interventions on QoL of patients with schizophrenia and related disorders. Prior to commencement of this systematic review, the Cochrane Library, Medline, Joanna Briggs Institute (JBI) database, DARE database and PROSPERO database were searched and no previous systematic reviews or reviews currently underway on this specific topic were located.