This revision of the Schizophrenia PORT recommendations importantly demonstrates that a number of psychosocial treatments and approaches show ongoing evidence of effectiveness over the 15 years since the first PORT recommendations were published. PORT has consistently included treatment recommendations for supported employment, skills training, and ACT. Recommendations for CBT and the token economy were added in the first PORT update. Other intervention areas such as family psychoeducation have been refined and expanded since the last PORT. The inclusion of briefer family approaches in the family treatment recommendation illustrates the ways in which early research on longer and more complex interventions that were difficult to implement has stimulated the development of and research into strategies that may be easier to implement and disseminate.
This revision also demonstrates the extent to which the evidence for psychosocial interventions in the care of persons with schizophrenia continues to grow. New recommendations in the areas of SUDs and weight management reflect the acquisition of new knowledge in problem areas that formerly may have been minimized or overlooked. The growth of new knowledge is equally important for those treatment areas where no recommendation is yet offered but in which the research base is evolving. The last decade has produced greater understanding of the fundamental importance of cognitive impairment in the outcomes and recovery of persons with schizophrenia. While cognitive remediation does not yet meet our standard for a treatment recommendation, the evidence summary reflects the strong interest in this approach and the progress that has been made in this endeavor. Similarly, peer-based services provide great promise for recovery and have acquired a substantial research base but require more research. In the case of recent onset psychosis, despite consensus about the need to provide treatment earlier to prevent disability, evidence has not yet emerged to fully substantiate any particular psychosocial approach. While excitement about a new approach may not be fully matched by current evidence, we hope that the PORT review provides a stimulus for more research in these areas.
It is important to acknowledge challenges and limitations in the larger field of psychosocial treatments for people with schizophrenia that impact this PORT review. First, our field has no consistent method to categorize psychosocial treatments. Some psychosocial treatments are organized around the outcome or problem being addressed (eg, alcohol or other drug use, medication adherence). Others are organized around the strategy being used (eg, CBT). Still others are organized around care processes (eg, family psychoeducation, ACT) or phase of illness (early-onset interventions). The lack of a standardized method to organize treatments and approaches can lead to confusion and mask the fact that different interventions and treatments may share common elements. For example, a reader could erroneously conclude that CBT is useful only for those symptoms identified in the CBT recommendation and fail to appreciate that cognitive behavioral strategies are an integral part of other approaches such as family psychoeducation, supported employment, and treatment for substance abuse. Similarly, given the separation of ACT and substance abuse treatment in different sections of the PORT, a reader could erroneously conclude that ACT does not include substance abuse treatment when, in fact, the ACT model routinely includes substance abuse treatment services. In reality, pairings and packages of interventions are being implemented in clinical practice and studied by researchers in the field, a trend that reflects our understanding that people with schizophrenia have many complex treatment needs.
A second consideration regarding the designation of psychosocial treatment recommendations emerged around the threshold for designating an intervention as a treatment recommendation and the criteria by which outcomes qualify as a measure of an intervention's effectiveness. Evaluation of study quality and methods to synthesize the results of different studies are emerging fields. Synthetic efforts such as PORT try to take into account a variety of aspects of study design including the nature of comparison groups, sample and statistical power, outcomes measured, follow-up periods, and treatment fidelity. The challenges of integrating these aspects of study rigor were particularly apparent in our consideration of a recommendation for the treatment of SUDs. The initial conclusion of the PORT review and advisory groups was that the threshold for a recommendation was not achieved. However, after the discussion at our expert panel meeting and reconsideration of additional studies, we viewed that the weight of all the evidence did support a recommendation, a conclusion with which the expert panel concurred in their subsequent rereview of the recommendation.
Similarly, traditional outcomes in the schizophrenia pharmacology literature are focused on symptom reduction and relapse prevention, but these outcomes are often not the primary targets in psychosocial interventions. For example, the goal of supported employment interventions is achieving competitive employment in a nonsheltered work setting regardless of the person's ongoing psychiatric symptoms. In evaluating the evidence for cognitive remediation as a treatment recommendation, the PORT expert panel was less certain about the appropriate outcome measures. There was considerable debate about whether proximal outcomes such as improvement on neuropsychological tests should be considered a treatment benefit worthy of a recommendation. While improvement on neuropsychological tests is the most proximal outcome to the intervention, the effect of such improvement on real-world functioning has yet to be consistently demonstrated. By the same token, psychosocial interventions for weight reduction in schizophrenia have shown relatively modest effects on the amount of weight lost, and the long-term health benefits of this weight loss have yet to be demonstrated for the individuals in these studies. The PORT expert panel also debated the issue of an appropriate outcome measure for this intervention. They ultimately decided that the findings were sufficient to warrant a recommendation for a weight reduction intervention because the benefits of even modest weight reduction have been amply demonstrated in the general population.199,215–218
Our review of peer-based interventions produced even more debate as such programs are often focused on outcomes such as empowerment and hope and important domains for recovery but outcomes that have not been traditionally valued or assessed in standard clinical trials. We attempted to include each intervention's expected outcomes in the structure of each PORT recommendations in order to make these debates more transparent.
Third, there is no accepted standard to measure program fidelity to psychosocial interventions. Unlike a medication, whose purity is evaluated by the US Food and Drug Administration (FDA) and which is either taken or not taken and may sometimes be monitored by blood levels, there is no single accepted standard for measuring adherence to psychosocial interventions. This is an important issue in clinical settings because psychosocial interventions may be implemented or delivered in ways that differ from the ways they were implemented in the research studies upon which a treatment recommendation is based. Issues in implementation and delivery may concern both adherence, providing the agreed upon components of an intervention, as well as competence, providing intervention components in skilled and supportive manner; both are important in order to fully determine the efficacy of an intervention. Fidelity scales were included in toolkits created as part of the National Evidence-Based Practices project which was designed to develop and test strategies to implement evidence-based practices for persons with SMIs. Extensive research has demonstrated the robust correlation of high fidelity with outcomes for supported employment,57–60,219–221
with a slightly less robust but still positive relationship between fidelity and outcomes for ACT.8,53,222,223
It is imperative to thoroughly and systematically consider fidelity in future studies that promote implementation of evidence-based practices.
Fourth, the PORT review highlights the gap between research and clinical services. The many sections of the PORT reflect interventions that have some research base, with some more extensive than others. However, overall there is limited use of these interventions in clinical services. For example, some interventions with well-established efficacy, such as the token economy for persons with severe impairments who are living in residential settings, are rarely used, and others, such as skills training, are often incompletely applied. Others, such as supported employment, are more commonly available but are implemented differently and in many cases without full fidelity to the evidence-based model. The National Evidence-Based Practices project field tested a multi-faceted strategy to disseminate 5 psychosocial evidence-based practices in 53 sites in 8 states and found that supported employment and ACT were the most easily implemented. The implementation of evidence-based practices is a complex process and is dependent on structural aspects of the local public mental system. As noted by Drake et al. (2009)3
in a review of the implementation of evidence-based practices in schizophrenia, factors that are important to successfully disseminating psychosocial evidence-based practices include the state mental health authority's provision of leadership, funding, and practice standards224–226
skilled mentoring and training;227
site level administrative support224,227–231
and monitoring of fidelity and outcomes.232,233
Until clinical service settings can administer evidence-based practices as they are developed and studied, the problem of the imperfect and inadequate application of research to clinical practice will persist.
Finally, these treatment recommendations do not provide clear direction about the selection or sequence of psychosocial interventions that are offered to the individual patient or that may be most instrumental in facilitating recovery. They do not address the possible benefits to or erosions of effectiveness as interventions and strategies are combined to address multiple problems. Moreover, we know little about how different psychosocial interventions compare in achieving the same outcomes. For example, how do family psychoeducation and ACT compare in achieving relapse reduction? This review does not offer guidance to consumers or providers in deciding which interventions to implement and in what order for an individual who is experiencing difficulty in multiple areas of functioning. While clinically the problems that are causing the person's greatest short-term difficulties are addressed first, once initial stabilization has been achieved, it is unclear how to order the implementation of subsequent interventions in order to achieve optimal results. Should persistent symptoms be targeted with cognitive behavioral treatment first, or must substance abuse be addressed first? When should interventions for employment or weight management be provided, and should these be done in conjunction with efforts to enhance medication adherence? While much has been accomplished in terms of treatment outcome research in schizophrenia and is reflected in this PORT review, more work is needed in terms of establishing how to order implementation of services to best support all aspects of recovery.
In spite of the limitations of the PORT methodology for reviewing psychosocial interventions for schizophrenia, the PORT meets an important need in our field to review and synthesize the treatment literature in as objective and rigorous manner as possible. Arguably, the PORT product, a set of treatment recommendations, should be considered a basic package for systems of care that are committed to providing evidence-based practices for persons with schizophrenia.