Antipsychotic pharmacotherapy improves some symptoms of schizophrenia in late life but others can still remain. The same is true of antidepressant augmentation. Thus, psychosocial therapies in combination with pharmacotherapy are very important additional treatments needed for this patient population in order to alleviate residual symptoms and to improve social functioning and quality of life. There is very little research available for psychosocial treatments targeted toward patients with schizophrenia and depression, and even less for the older patient with schizophrenia and depression.
The care of older patients with schizophrenia is organized within the context of rehabilitation. This involves a “care program approach” involving a team of physicians, nurses, occupational therapists, social workers and others (149
). There are seven important ideal elements with this plan: 1) optimal treatment of the psychiatric illness; 2) optimal treatment of the physical illness(es) with improved education and awareness of these illnesses; 3) maintenance of daily living skills; 4) maintenance of social contacts; 5) participation in day activities; 6) appropriate management of finances; and, 7) risk assessment. Psychoeducation is a key component of this approach and may need to be modified for older patients because of potential cognitive deficits. Liberman and Eckman (65
) have described a practically oriented social skills training program for elderly patients with schizophrenia. The model uses role play to enhance patients’ behavioral performance and to enhance communication skills (109
Assertive Community Treatment is a psychosocial treatment modality important for patients with schizophrenia which has not been studied exclusively in elderly patients with schizophrenia, nor have there been studies targeting elderly patients with schizophrenia and depression. Six studies examining this in patients with schizophrenia in general have been published, which have included subjects age 50 or older. Five studies had favorable results and one study demonstrated mixed findings (14
), suggesting that the approach may be helpful for the older patient with schizophrenia in general. With regards to Case Management (CM), there are eight intervention studies involving CM programs with subjects aged 50 or older with schizophrenia. Of these, four reported positive outcomes for CM (19
), two reported mixed results (71
), and two found no advantages (11
). Mohamed et al. (109
) pointed out that, although CM does not appear to be as beneficial for older individuals with schizophrenia, studies that included older patients versus younger using 50 as the age cut-off appeared to have better outcomes overall. Clearly more research is needed in this area, especially with regards to older patients with schizophrenia and depressive symptoms.
Other important psychosocial therapeutic strategies that are used to treat patients with schizophrenia include Cognitive Behavioral Therapy, Family Intervention, Social Skills Training, and Cognitive Remediation. These approaches could likely have potentially promising effects in geriatric patients with schizophrenia and depressive symptoms. Each therapeutic approach effectively targets selected domains (156
). For Cognitive Behavioral Therapy (CBT), those domains are psychopathology and symptoms. The most consistent effect of CBT has been the improvement of positive and negative symptoms (157
). Recent meta-analyses of CBT support the findings of individual studies (169
). For Social Skills Training, goals of treatment include improvement in social skills and attainment of employment.
Granholm et al. (171
) performed a randomized, controlled trial of Cognitive Behavioral Social Skills Training for middle-aged and older outpatients with chronic schizophrenia. Geriatric patients were included in this study; participants’ ages ranged from 42–74 years old. The mean age of subjects in the experimental group, which consisted of the intervention plus “treatment as usual,” was 54.5±7.0 with a mean HAMD score of 13.5±9.0. The average age for the “treatment as usual” group was 53.1±7.5 and the average HAMD score was 14.2±8.8. Patients receiving the intervention performed social functioning activities more frequently than the patients in “treatment as usual.” In addition, the intervention group had significantly greater cognitive insight, more objectivity in reappraising psychotic symptoms, and greater skill mastery. The greater increase in cognitive insight with combined treatment was significantly correlated with greater reduction in positive symptoms. There were, however, no significant differences between the two groups with regards to changes in HAMD scores. However, improvement in overall cognitive insight was associated at mid-treatment with a transient increase in depression scores, but this resolved by the end of treatment.
For Family Therapy, goals are to improve treatment adherence and prevention of relapse and rehospitalization. For Cognitive Remediation, improvement of neurocognitive functioning is the goal. Integrated psychotherapies also offer promise in addressing a wider range of outcomes. Integrated strategies may also be more cost-effective if they can be shown to consistently increase adherence and reduce relapse (172
). However, with the possible exception of Integrated Psychological Therapy (173
), the integrated therapies used to date have not yet demonstrated clear superiority to individual therapeutic approaches in the domains addressed by the individual approaches. Future research needs to examine these psychosocial treatments in geriatric patients with schizophrenia and depressive symptoms.