Where should we put the focus of schizophrenia research in the next five years?

Abstract

Die Psychiatrie 2016; 13: 158–159 P et al. (6) have argued in a recent editorial, that there is a false belief that psychotherapy is a psychosocial treatment whereas pharmacotherapy is a biological treatment. The authors argued that this assertion is not held out by cognitive neuroscience which suggests that both work on neurocognitive processes corresponding to complex functional disturbance and mental illness symptoms. In that perspective, future research to clarify treatment effects would have to combine biological, neurocognitive, imaging and social parameters with the ultimate aim of building effective systems of care. In a recent debate, Kendall et al. (3) have taken issue with an editorial that commented on the 2014 NICE guideline on psychosis and schizophrenia, compared it with its equivalent 2013 Scottish guideline and retained that the NICE guideline was biased towards psychosocial treatments and against drug treatments. In response to that critique, Kendall et al. (3) argued that, in fact, the NICE guideline had more rigorous methodology than the Scottish guideline, and that the authors of the editorial appeared to have succumbed to bias themselves. This suggests that the issue of weighing the evidence on pharmacological and psychosocial interventions is complex and may be contentious. Therefore, valid methods of weighing the evidence and of translating guideline recommendations into mental health care practice should be prioritized. In this comment, the following five specific topics are considered of importance in moving the field forward: 1. The case of supported employment (SE) in getting people with schizophrenia into competitive employment has been eloquently put in recent years by authors from the United States, and there is accruing evidence from other countries in support of this intervention that aims at direct labor market integration for people with psychosis who seek work and are offered ongoing support by both SE workers and community mental health teams. There have been recent efforts at weighing the evidence (Kinoshita et al. 2013). The focus, in research, should continue to be on rigorous testing in non-US settings and on identifying barriers to implementation in European labor market and mental health settings. 2. There is a shortage of high-quality research on how best to provide adequate housing to people with schizophrenia. The case of supported housing (SH) is eloquently put by studies such as the At Home/ Chez Soi project in Canada (http://www.mentalhealthcommis sion.ca/English/system/files/private/document/ mhcc_at_home_report_national_cross-site_eng_2.pdf), and there is substantial implementation and research interest of SH-type models outside North America. Supported housing, a model combining a normal tenant role, focus on client control, social inclusion and in vivo learning with flexible community services and support should be tested in European settings. This would help move ahead in an area of research that has not received the research attention it deserves. 3. Recent psychosis and schizophrenia guidelines such as the NICE guideline have given much attention and strong recommendations regarding the provision of arts therapies in the treatment of people with schizophrenia (with a strong indication that art therapy may help alleviate negative symptoms). There has been a recent debate on the strength of this evidence (Kendall et al. 2016), and research efforts in this field should be maintained during the next five years. Also, it may help to concentrate more widely on a range of resourceoriented therapeutic models in psychiatry as pointed out in a conceptual review by Priebe et al. (5). This refers to therapeutic models that focus on utilizing patients’ personal and social resources rather than reducing deficits. Models may include befriending (by non-professionals), client-centred therapy, creative music therapy, the open dialogue approach, peer support work, so-called positive psychotherapy, self-help groups, solution-focused therapy, systemic family therapy and therapeutic communities. Studying such models may help to identify key features characterizing effective care systems for people with psychotic disorders.