ABSTRACTS - World Psychiatric Association

ly on pain. In the longer term, somatisation is an important predictor
of health status, but even patients with marked somatisation show
improved health status and reduced costs.
US5.3.
CONSIDERING CONTEXTUAL FACTORS
IN THE MANAGEMENT OF UNEXPLAINED SOMATIC
SYMPTOMS
O. Gureje
Department of Psychiatry, University of Ibadan, Nigeria
The management of medically unexplained somatic symptoms is
challenging. Results of intervention trials have been mixed, making
the development of efficacious guidelines problematic. The difficulty
in designing effective treatment may reflect our poor understanding of
the etiology of the symptoms. In this paper, data from large crossnational
studies are used to highlight the possible role of treatment
settings and of pattern of comorbidity in the profile of unexplained
somatic symptoms. The point is made that developing effective management
for these symptoms requires a consideration of the contextual
factors in their evolution.
US6.
THE FUTURE OF PSYCHOTHERAPIES
FOR PSYCHOSES
US6.1.
THE FUTURE OF COGNITIVE-BEHAVIOURAL
THERAPY IN PSYCHOSIS: WHAT MAKES IT WORK
P. Bebbington, G. Dunn, D. Fowler, P. Garety, D. Freeman,
E. Kuipers
Institute of Psychiatry, London; University of Manchester;
University of East Anglia, Norwich, UK
Our Psychosis Research Partnership (PRP) conducted a large multicentre
randomized controlled trial (RCT) of the effectiveness of cognitive-behavioral
therapy (CBT) in preventing psychotic relapse.
Over 300 people with a recent relapse of positive psychotic symptoms
were randomized. Those with consenting carers were allocated to
receive CBT, family intervention or treatment as usual; those who
lacked carers or whose carers declined were randomized to CBT or
treatment as usual. The CBT and family intervention had no effects
on rates of remission and relapse or on days in hospital at 12 or 24
months. For secondary outcomes, CBT showed a beneficial effect on
depression at 24 months, but there were no effects for family intervention.
In people with carers, CBT significantly improved delusional
distress and social functioning. These results suggest that generic
CBT for psychosis is not indicated for routine relapse prevention in
people recovering from a recent relapse of psychosis and should currently
be reserved for those with distressing medication-unresponsive
positive symptoms. Secondary analyses of RCTs require very careful
consideration, as approaches such as per protocol analyses lose the
benefits of randomisation and lead to impermissible inferences. Nevertheless,
techniques are now available that enable the effects of moderating
variables such as therapeutic alliance and treatment quality to
be modelled in a valid manner. Applying these techniques to our data,
it became clear that CBT, if effectively delivered, as it was in a third
of cases, reduced Positive and Negative Syndrome Scale (PANSS)
scores by 24 and 13 (12 month and 24 month follow-up respectively).
The equivalent results for depression as measured by Beck Depression
Inventory (BDI) score were 4 and 12.
US6.2.
THE FUTURE OF COGNITIVE-BEHAVIOURAL
THERAPY IN PSYCHOSIS: FOCUSSING ON SOCIAL
RECOVERY
D. Fowler
School of Medicine, Health Policy and Practice, University
of East Anglia, Norwich, UK
The development of cognitive-behavioural therapy (CBT) for psychosis
has now reached a critical juncture. Recent meta-analyses provide
now firm evidence for the efficacy of CBT for treatment resistant
psychosis. On the other hand, the effect sizes on symptoms are relatively
modest and the results from some recent large scale trials
appear equivocal. One way forward is to focus on more specific subgroups.
Another way forward is refocusing the target of CBT toward
social recovery rather than on symptom management. A focus on
social recovery would fit well into a growing agenda which highlights
the importance of addressing outcomes which have the greatest relevance
for users, and wider interest in understanding social capital as
well as traditional clinical outcomes. Recent meta-analyses have
already shown that CBT has a consistent effect on social outcomes
where these have been measured as secondary outcomes. We have
recently undertaken a trial of a new approach to CBT which directly
addresses social recovery in psychosis as a primary outcome. This
trial has shown substantive gains in improving time spent in constructive
and social activity and in clinical outcomes at post treatment,
and in promoting time in employment at 2 years. It suggests
that CBT could provide a useful adjunct to existing interventions to
improve social functioning such as supported employment.
US6.3.
FAMILY-BASED PSYCHOSOCIAL INTERVENTIONS
FOR PSYCHOSIS: AN UPDATE
W.R. McFarlane
Maine Medical Center, Portland, ME, USA
As emphasis in treatment of schizophrenia shifts increasingly to early
identification and intervention in, or prior to, the first episode of psychosis,
the design and implementation of psychosocial treatment has
become crucial. Within this preventive orientation, emphasis has also
moved beyond prevention of psychosis to promoting recovery to the
level of functioning that most closely resembles that of the previous or
potential level. It has become clear that therapeutic drugs alone are
inadequate to achieving goals pertaining to cognition and psychosocial
functioning. At the same time, it has also become clear that family-based
psychosocial therapies not only promote improved functioning and
restoration of personality, but also contribute independently to prevention
of psychotic episodes, whether they are relapses or the first. These
treatment approaches have been developed by independent teams in
several nations, leading to a broad consensus of effective elements and
practices, lending additional credibility to their results. They share the
core strategy of helping the patient and the immediate social network to
enhance their knowledge and to develop coping skills to compensate
for, or even reverse, core neurocognitive deficits. Unlike psychiatric
drugs, they have not been implemented widely, even in their countries of
origin. Starting from biosocial theory, this presentation describes proven
and currently developing family-based psychosocial interventions, their
distinctive features and differences and published or available interim
results. Particular emphasis is given to those based on cognitive-behavioral
precepts, including family psychoeducation, supported education
and employment, and assertive community treatment. Also reviewed is
their combination: family-aided assertive community treatment.
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