Patient Outcomes Research Team Recommendations Research Articles

Conformance to Evidence-Based Treatment Recommendations in Schizophrenia Treatment Services

To assess quality of health care provided in a representative Canadian mental health service using conformance to evidence-based treatment recommendations, and to examine differences from published US results. We used a cross-sectional cohort design involving a randomly selected sample of patients diagnosed with schizophrenia attending 1 of 3 mental health clinics in 1 Canadian regional health system. The sample size was calculated to detect differences with the US sample. Conformance criteria were based on a published protocol. Data were collected using patient interviews and a structured review of health records. Conformance to 9 key Schizophrenia Patient Outcomes Research Team recommendations was assessed. Conformance ranged between 58% and 90% for pharmacological recommendations, and 0% to 81% for psychosocial recommendations. No patients who met criteria for assertive case management had been referred to an assertive case management team. Significant differences in conformance rates to some treatment recommendations were found between Canadian and published US results. It proved possible to assess health care quality using process measures of conformance to treatment recommendations. Conformance to clinical recommendations for pharmacotherapy is higher than for psychosocial therapies. The absence of barriers to access for pharmacological therapies likely enhances the higher conformance to these recommendations. Limited or variable access to psychosocial services, specifically assertive community treatment, likely negatively affects conformance to psychosocial treatment recommendations. Methodological limitations preclude drawing conclusions on comparisons between Canadian and US services.

The Schizophrenia Patient Outcomes Research Team (PORT): Updated Treatment Recommendations 2009

The Schizophrenia Patient Outcomes Research Team (PORT) project has played a significant role in the development and dissemination of evidence-based practices for schizophrenia. In contrast to other clinical guidelines, the Schizophrenia PORT Treatment Recommendations, initially published in 1998 and first revised in 2003, are based primarily on empirical data. Over the last 5 years, research on psychopharmacologic and psychosocial treatments for schizophrenia has continued to evolve, warranting an update of the PORT recommendations. In consultation with expert advisors, 2 Evidence Review Groups (ERGs) identified 41 treatment areas for review and conducted electronic literature searches to identify all clinical studies published since the last PORT literature review. The ERGs also reviewed studies preceding 2002 in areas not covered by previous PORT reviews, including smoking cessation, substance abuse, and weight loss. The ERGs reviewed over 600 studies and synthesized the research evidence, producing recommendations for those treatments for which the evidence was sufficiently strong to merit recommendation status. For those treatments lacking empirical support, the ERGs produced parallel summary statements. An Expert Panel consisting of 39 schizophrenia researchers, clinicians, and consumers attended a conference in November 2008 in which consensus was reached on the state of the evidence for each of the treatment areas reviewed. The methods and outcomes of the update process are presented here and resulted in recommendations for 16 psychopharmacologic and 8 psychosocial treatments for schizophrenia. Another 13 psychopharmacologic and 4 psychosocial treatments had insufficient evidence to support a recommendation, representing significant unmet needs in important treatment domains.

The 2009 Schizophrenia PORT Psychosocial Treatment Recommendations and Summary Statements

The Schizophrenia Patient Outcomes Research Team (PORT) psychosocial treatment recommendations provide a comprehensive summary of current evidence-based psychosocial treatment interventions for persons with schizophrenia. There have been 2 previous sets of psychosocial treatment recommendations (Lehman AF, Steinwachs DM. Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophr Bull. 1998;24:1-10 and Lehman AF, Kreyenbuhl J, Buchanan RW, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophr Bull. 2004;30:193-217). This article reports the third set of PORT recommendations that includes updated reviews in 7 areas as well as adding 5 new areas of review. Members of the psychosocial Evidence Review Group conducted reviews of the literature in each intervention area and drafted the recommendation or summary statement with supporting discussion. A Psychosocial Advisory Committee was consulted in all aspects of the review, and an expert panel commented on draft recommendations and summary statements. Our review process produced 8 treatment recommendations in the following areas: assertive community treatment, supported employment, cognitive behavioral therapy, family-based services, token economy, skills training, psychosocial interventions for alcohol and substance use disorders, and psychosocial interventions for weight management. Reviews of treatments focused on medication adherence, cognitive remediation, psychosocial treatments for recent onset schizophrenia, and peer support and peer-delivered services indicated that none of these treatment areas yet have enough evidence to merit a treatment recommendation, though each is an emerging area of interest. This update of PORT psychosocial treatment recommendations underscores both the expansion of knowledge regarding psychosocial treatments for persons with schizophrenia at the same time as the limitations in their implementation in clinical practice settings.

Off-Label Use of Antipsychotic Medications in the Department of Veterans Affairs Health Care System

This study aimed to determine the prevalence of prescribing antipsychotics to adults without schizophrenia or bipolar disorder and to identify factors associated with such off-label use. Patients with at least one prescription for an antipsychotic medication from the Department of Veterans Affairs (VA) during fiscal year (FY) 2007 were identified in national VA administrative databases. Rates of off-label antipsychotic use were determined along with average doses. Multivariate logistic regression models identified sociodemographic and clinical characteristics associated with off-label use. Of the 279,778 individuals in FY 2007 who received an antipsychotic medication, 168,442 (60.2%) had no record of a diagnosis for which these drugs are approved. The most common mental illness diagnoses among patients given prescriptions for antipsychotics off label were posttraumatic stress disorder (PTSD, 41.8%), minor depression (39.5%), major depression (23.4%), and anxiety disorder (20.0%). Among VA patients with mental illness other than schizophrenia or bipolar disorder, the proportion who received prescriptions for antipsychotic medications ranged from a low of 9.1% among patients with adjustment reaction; to about 20% for those with depression, dementia, or PTSD; and to a high of 40.7% among patients with other psychoses. Doses were low, with over half of patients who received off-label quetiapine, risperidone, or first-generation antipsychotics receiving doses below those recommended for schizophrenia. In logistic regression models, patients diagnosed as having other psychosis or dementia had the highest odds of receiving an antipsychotic medication off label. Off-label use of antipsychotic medications was common. Given that these drugs are expensive, have potentially severe side effects, and have limited evidence supporting their effectiveness for off-label usage, they should be used with greater caution.

Cognitive Therapy of Schizophrenia

Back to table of contents Previous article Next article Book ReviewFull AccessCognitive Therapy of SchizophreniaTimothy B. Sullivan M.D.Timothy B. Sullivan M.D.Search for more papers by this authorPublished Online:1 Feb 2007https://doi.org/10.1176/ps.2007.58.2.277AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail It's hard to say how bad ideas, misinformed or misguided clinical saws, originate. One of the most enduring in psychiatry is the notion that talking to patients with schizophrenia about their symptoms or about their subjective experiences is potentially harmful. It is little wonder that so few medical students or psychiatric residents wish to specialize in work with patients who have seriously mental illness. There have been studies and reviews, most famously the Patient Outcomes Research Team recommendations ( 1 ), which have directed our attention to the lack of efficacy ( 2 ), obvious paucity of controlled observation, and insufficiently documented putative harm associated with "uncovering therapies," by which is meant psychoanalytic therapy and its congeners. Kingdon and Turkington lament the effect these proscriptions have unintentionally had on creative engagement of persons suffering from disorders such as schizophrenia. They note that "many practitioners continue to believe that the content of psychotic symptoms should be ignored and that any psychological work … is liable to lead to increased distress and exacerbation of symptoms, as a result of having opened up disturbing areas." Of course the problem with past, well-intentioned, and compassionate efforts by a legion of gifted therapists is that the therapeutic model, and the theory of mind supporting it, did not accurately reflect the nature of the disorder. It was not the effort to be empathic that was flawed but the various notions about how symptoms were produced or could be ameliorated. If you don't understand what you're treating, you will misdirect, misinform, and inevitably disappoint.Kingdon and Turkington set out to provide clinicians with a treatment model that will make the uncertain knowable and that which is alienating comfortable. They successfully present a cogent, approachable, and flexible model for psychotherapeutic engagement of persons suffering from serious psychotic illness. This is not a "manualized" treatment, and the authors explain why that approach is not appropriate. A careful exposition of the nature of the illness processes, and the theory of cognitive-behavioral therapy and its particular adaptation to this setting, is explicated. There are many clinical examples, guidelines, forms to use, and even patient handouts that can be copied and distributed are included. The succinct review of the psychology of schizophrenia is particularly useful, such as the discussion of "externalizing bias" and the central role of stigmatization in symptom development.The fourth chapter, on therapeutic engagement, and later chapters on work with delusions and hallucinations, are not only brilliantly executed but come as close as one can, in print, to detailed individual case supervision. Even experienced practitioners will find these presentations extremely helpful, because they reflect the careful thought of talented clinicians who have immersed themselves in their subject and achieved valuable insights.I do have one brief quibble. As a heuristic device, Kingdon and Turkington use four clinical subgroups to differentiate "types" of schizophrenia. In the context of the book, these subgroups are useful and unify their presentation. I am not sure I can agree that the subgroups encompass the range of patients I see.Reviewers will often say that the book they are reviewing belongs on everyone's shelf. I urge you to please buy and read this book. Our patients deserve our attention to these issues. Those of you who are talented clinicians but who avoid this population out of confusion or lack of confidence in your ability to help will, I assure you, find this book crucial. You will find yourself able to approach a person with schizophrenia with confidence, and it will change how you think about your work.Dr. Sullivan is chief of services for the seriously mentally ill at Saint Vincent's Catholic Medical Center, Westchester, New York, and assistant professor of psychiatry at New York Medical College, Valhalla.

Cognitive Therapy of Schizophreniaby David G. Kingdon and Douglas Turkington; New York, Guilford Press, 2004, 219 pages, $37

Back to table of contents Previous article Next article Book ReviewFull AccessCognitive Therapy of SchizophreniaTimothy B. Sullivan M.D.Timothy B. Sullivan M.D.Search for more papers by this authorPublished Online:1 Feb 2007https://doi.org/10.1176/ps.2007.58.2.277AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail It's hard to say how bad ideas, misinformed or misguided clinical saws, originate. One of the most enduring in psychiatry is the notion that talking to patients with schizophrenia about their symptoms or about their subjective experiences is potentially harmful. It is little wonder that so few medical students or psychiatric residents wish to specialize in work with patients who have seriously mental illness. There have been studies and reviews, most famously the Patient Outcomes Research Team recommendations ( 1 ), which have directed our attention to the lack of efficacy ( 2 ), obvious paucity of controlled observation, and insufficiently documented putative harm associated with "uncovering therapies," by which is meant psychoanalytic therapy and its congeners. Kingdon and Turkington lament the effect these proscriptions have unintentionally had on creative engagement of persons suffering from disorders such as schizophrenia. They note that "many practitioners continue to believe that the content of psychotic symptoms should be ignored and that any psychological work … is liable to lead to increased distress and exacerbation of symptoms, as a result of having opened up disturbing areas." Of course the problem with past, well-intentioned, and compassionate efforts by a legion of gifted therapists is that the therapeutic model, and the theory of mind supporting it, did not accurately reflect the nature of the disorder. It was not the effort to be empathic that was flawed but the various notions about how symptoms were produced or could be ameliorated. If you don't understand what you're treating, you will misdirect, misinform, and inevitably disappoint.Kingdon and Turkington set out to provide clinicians with a treatment model that will make the uncertain knowable and that which is alienating comfortable. They successfully present a cogent, approachable, and flexible model for psychotherapeutic engagement of persons suffering from serious psychotic illness. This is not a "manualized" treatment, and the authors explain why that approach is not appropriate. A careful exposition of the nature of the illness processes, and the theory of cognitive-behavioral therapy and its particular adaptation to this setting, is explicated. There are many clinical examples, guidelines, forms to use, and even patient handouts that can be copied and distributed are included. The succinct review of the psychology of schizophrenia is particularly useful, such as the discussion of "externalizing bias" and the central role of stigmatization in symptom development.The fourth chapter, on therapeutic engagement, and later chapters on work with delusions and hallucinations, are not only brilliantly executed but come as close as one can, in print, to detailed individual case supervision. Even experienced practitioners will find these presentations extremely helpful, because they reflect the careful thought of talented clinicians who have immersed themselves in their subject and achieved valuable insights.I do have one brief quibble. As a heuristic device, Kingdon and Turkington use four clinical subgroups to differentiate "types" of schizophrenia. In the context of the book, these subgroups are useful and unify their presentation. I am not sure I can agree that the subgroups encompass the range of patients I see.Reviewers will often say that the book they are reviewing belongs on everyone's shelf. I urge you to please buy and read this book. Our patients deserve our attention to these issues. Those of you who are talented clinicians but who avoid this population out of confusion or lack of confidence in your ability to help will, I assure you, find this book crucial. You will find yourself able to approach a person with schizophrenia with confidence, and it will change how you think about your work.Dr. Sullivan is chief of services for the seriously mentally ill at Saint Vincent's Catholic Medical Center, Westchester, New York, and assistant professor of psychiatry at New York Medical College, Valhalla.

Statistical Benchmarks for Process Measures of Quality of Care for Mental and Substance Use Disorders

Statistical Benchmarks for Process Measures of Quality of Care for Mental and Substance Use Disorders

Impact of Medical Comorbidity on the Quality of Schizophrenia Pharmacotherapy in a National VA Sample

More than half of patients with schizophrenia have comorbid chronic medical illness. During the past decade, several studies have evaluated the quality of the medical treatment of these conditions. This work examines the impact of comorbid medical conditions on the quality of schizophrenia pharmacotherapy in the Department of Veterans Affairs (VA). Data for this study came from national VA administrative databases. All VA outpatients diagnosed with schizophrenia during fiscal year 2002 were identified, and the presence of 9 chronic medical conditions was determined by ICD-9 codes. Measures of quality of schizophrenia pharmacotherapy were based on the Schizophrenia Patient Outcomes Research Team (PORT) and included the proportion of patients who received any antipsychotic medications, multiple antipsychotic medications, atypical antipsychotic medications, and dosages in compliance with PORT recommendations. Multivariate logistic regression analysis was used to determine the effects of comorbid medical illness on these measures. Overall, 92.2% of the patients were prescribed an antipsychotic medication. Patients with 6 of the 9 chronic medical conditions were significantly less likely to be prescribed antipsychotic medications, and the odds of this treatment decreased with increasing medical complexity. 63.8% received doses which were within the recommended PORT guidelines. In a large national sample of veterans with schizophrenia, several chronic medical conditions were associated with a decreased likelihood of being prescribed an antipsychotic medication, suggesting less intensive schizophrenia treatment. Patients with medical comorbidity who were treated with antipsychotic medications were as likely to receive doses within the PORT guidelines as schizophrenic patients without medical comorbidity.

Adherence of Schizophrenia Pharmacotherapy To Published Treatment Recommendations: Patient, Facility, and Provider Predictors

Very little is known about patient, provider, and facility characteristics that may affect the likelihood that a schizophrenia patient who receives an antipsychotic medication is dosed according to treatment recommendations. In this study, prescription drug records for schizophrenia patients were collected from the Department of Veterans Affairs, and indicators were constructed describing whether the average daily dose was outside of the range recommended by the schizophrenia Patient Outcomes Research Team (PORT). Generalized estimation equations were used to identify patient, facility, and provider characteristics that are associated with adherence to PORT recommendations. We found that the majority (62.1%) of patients were dosed within the PORT-recommended dosing range. Patients who were older, were female, had comorbid psychiatric disorders, or were prescribed conventional antipsychotics were less likely to adhere to PORT recommendations. Provider and facility characteristics were generally not significantly associated with adherence. When patients were dosed outside of the recommendations, patients treated at facilities with more emphasis on mental health and research and education were more likely to be dosed above the recommendations.

FRONTLINE--the schizophrenic person and the benefits of the psychotherapies--seeking a PORT in the storm.

FRONTLINE—The Schizophrenic Person and the Benefits of the Psychotherapies—Seeking a PORT in the StormAnn-Louise S. Silver and Tor K. LarsenAnn-Louise S. SilverSearch for more papers by this author and Tor K. Larsen1. Rogaland Psychiatric HospitalSearch for more papers by this authorPublished Online:March 2011https://doi.org/10.1521/jaap.31.1.1.21937PDFPDF PLUS ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutReferencesAlanen , Y. (2000), Quo vadis, ISPS? ISPS Newsletter, 4, pp. 4–8. Google ScholarBenedetti , G., and Peciccia, M. (2000), On the psychopathological essence of schizophrenia, unpublished. Google ScholarBuber , M. (1970), I and Thou, Charles Scribner's Sons, New York. Google ScholarLehman , A. F., and Steinwachs, D. M. (1998), Translating research into practice: The Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations, Schizophrenia Bulletin, 24(1), 1–10. Crossref Medline, Google ScholarLevin , A. (November 17, 2000a), Experts assess options for treating schizophrenia, Psychiatric News, pp. 21, 24. Google ScholarLevin , A. (November 17, 2000b), Psychotherapy shows great benefit in treatment of schizophrenia patients, Psychiatric News, p. 21. Google ScholarLevin , A. (November 17, 2000c), Schizophrenia and analysis: Not strange bedfellows, Psychiatric News, p. 26. Google ScholarLevy , C. (2002a), For mentally ill, death and misery, The New York Times, April 28. Google ScholarLevy , C. (2002b), Ingredients of a failing system: A lack of state money, a group without a voice, The New York Times, April 28. Google ScholarLevy , C. (2002c), Here, life is squalor and chaos, The New York Times, April 29. Google ScholarLevy , C. (2002d), Voiceless, defenseless and a source of cash, The New York Times, April 30. Google ScholarWhitaker , R. (2002), Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill, Perseus, Cambridge, MA. Google ScholarWorcester , S. (June, 2001), Therapists fight to reverse PORT recommendations: Task force challenges claims that psychodynamic psychotherapy is harmful, Clinical Psychiatry News, 29(6), pp. 1, 4. Google ScholarZito , J. M., Safer, D. J., dosReis, S. C., Gardner, J. F., Boles, M., and Lynch, F. (2000), Trends in the prescribing of psychotropic medications to preschoolers, JAMA, 283, 1025–1030. Crossref Medline, Google Scholar Next article FiguresReferencesRelatedDetails Cited byCited byZoë Thomas1. Breaking Through to the Other Side: A Resident Explores the Benefits of Time-Limited Psychodynamic Therapy for Patients with SchizophreniaOnline publication date: 1 March 2017. Go to citation Crossref Google ScholarRichard B. Corradi2. Schizophrenia as a Human ProcessOnline publication date: 14 December 2011. Go to citation Crossref Google ScholarZvi Lothane3. The Partnership of Psychoanalysis and Psychiatry in the Treatment of Psychosis and Borderline States: Its Evolution in North AmericaOnline publication date: 8 September 2011. Go to citation Crossref Google Scholar4. ‘In good times and in bad’: boundary relations of psychoanalysis in post-war USAOnline publication date: 17 May 2011. Go to citation Crossref Google Scholar5. The Psychotic Wavelength: a Psychoanalytic Perspective for PsychiatryOnline publication date: 31 December 2017. Go to citation Crossref Google ScholarJane G. Tillman6. A View from Riggs: Treatment Resistance and Patient Authority—IX. Integrative Psychodynamic Treatment of Psychotic DisordersOnline publication date: 29 December 2008. Go to citation Crossref Google Scholar7. Family environment and psychosisOnline publication date: Go to citation Crossref Google Scholar8. A review of dramatherapy research in schizophrenia: methodologies and outcomesOnline publication date: Go to citation Crossref Google ScholarAnn-Louise S. Silver9. Teaching About Psychodynamic Work with Severely Ill PatientsOnline publication date: 20 March 2006. Go to citation Crossref Google ScholarAnn–Louise S. Silver10. In the Footsteps of Arieti and Fromm–Reichmann: Psychodynamic Treatments of Psychosis in the Current EraOnline publication date: 31 January 2006. Go to citation Crossref Google Scholar Volume 31Issue 1Mar 2003 Information© The American Academy of Psychoanalysis and Dynamic PsychiatryPDF download

Use of pharmacy data to assess quality of pharmacotherapy for schizophrenia in a national health care system: individual and facility predictors.

This paper presents a profile of the use of antipsychotic medications in the treatment of schizophrenia in a national health system. Prescription drug records written for antipsychotic medications between June 1999 and September 1999 were collected for patients diagnosed with schizophrenia in the Department of Veteran Affairs (VA). Indicators were constructed describing whether patients received multiple antipsychotic medications and whether the total weekly dose was outside of the range specified in the treatment recommendations developed by the schizophrenia Patient Outcomes Research Team (PORT). Generalized estimation equations were used to identify patient and facility characteristics that are associated with adherence to PORT recommendations. Of the 34,925 patients in the final sample, 2,383 (6.8%) received prescriptions for more than one antipsychotic (polypharmacy). A higher number of patients (4,554 or 13.0%) were dosed above the PORT recommendations on an antipsychotic medication and even more (8,148 or 23.3%) were dosed below the recommended PORT dosage. Older patients, minorities, and those with comorbid depression or substance abuse were generally less likely to receive multiple antipsychotics or be dosed above PORT recommendations. Neither academic emphasis (the percentage of the mental health budget spent on research and education) nor fiscal stress was significantly associated with adherence to recommendations. In the nation's largest mental health system, a relatively small number of patients were prescribed multiple antipsychotic medications, but more than a third were dosed outside of the PORT recommended range.

Schizophrenia treatment less than ideal?

The effective treatment of patients with schizophrenia is a worldwide public health challenge. Improvements in treatment can have a significant impact on patient morbidity, mortality and quality of life, as well as on both direct and indirect health costs. Recently, the US Schizophrenia Patient Outcomes Research Team (PORT)*conducted a survey that was designed to assess to what extent usual care for schizophrenia complies with the team’s recent treatment recommendations.1The Schizophrenia PORT recommendations themselves are the result of a 5-year analysis of published research on schizophrenia conducted by more than 15 scientists from 3 major research centres in the US.2According to the results of this landmark survey, fewer than 505 of US patient with schizophrenia receive adequate dosages of antipsychotic medications or appropriate psychosocial interventions.