Stress management and schizophrenia

Bellack et al (2000) have addressed the important question of delineating the core therapeutic components of carer-based stress management that account for the improved course of schizophrenic disorders found consistently when these methods have been integrated with optimal pharmacotherapy. Their conclusions deserve close scrutiny, particularly when they make strong statements about the relative cost-effectiveness of different approaches, without the benefits of any economic analysis. Their conclusion that cognitive-behavioural strategies aimed at enhancing the problem-solving of patients and their key caregivers do not contribute to the clinical benefits cannot be drawn definitively from the study they report.

This study is extremely complex and was not designed to evaluate the comparative effectiveness of the key components of cognitive-behavioural family interventions. All cases were offered 25 sessions of structured education in multi-family groups over 24 months. These educational groups aimed to assist patients and their caregivers in the management of their disorders and the stresses in their lives. However, half the sample was assigned at random to an additional 29 sessions of home-based education that employed active learning methods to enable the patient and carers to conduct weekly self-help sessions in the home. During these sessions they were expected to work on the personal problems and goals that they considered important. They were taught to use a problem-solving approach, with guide sheets to structure their discussions and to provide records of their plans. This home-based training ceased after 12 months, but the multi-family educational groups continued to 24 months.

From the outcome measures reported, there was no significant difference between the two stress management conditions in forestalling hospital admissions over the 24 months. Thus, the addition of the problem-solving training, which seldom requires more than 5 hours of teaching, was considered redundant. The method attributed to Falloon et al (1984) does not include the additional monthly educational groups used in this project, and it is probable that the combination of two approaches that emphasised somewhat different objectives may have proved confusing to some participants and excessive to others. We certainly observed that at times of crisis the therapists confused the two approaches. A definitive study that aimed to compare the benefits of the educational and problem-solving strategies would need to ensure that each approach was more clearly defined, and would have to control for the time participants were exposed to the contrasting methods and the therapist's competence and enthusiasm for both methods. It may also be important to consider that maximum benefits might be reached with a lower-than-standard course of education for many cases, and that too much of a good thing may not produce the best results. It is important to note that similar multi-family group education approaches have not always proved successful (McCreadie et al, 1991) except where problem-solving training has been a core component (McFarlane et al, 1995).

Furthermore, it is interesting to refer to the earlier publication of this important study of combinations of various maintenance medication dosage strategies (Schooler et al, 1997). For those cases receiving the care-based stress management approaches who were also maintained on optimal doses of medication throughout the 24 months, 19% of those offered the additional problem-solving training in the first 12 months were admitted to hospital in contrast to 31% of those receiving only the education group sessions. Although this difference does not quite achieve statistical significance, the trend is clear, and this is in accord with the consistent observation of somewhat greater efficacy of the problem-solving approach when it is more clearly integrated with mental health education (Falloon et al, 1999).