ارزیابی یک برنامه مدیریت استرس برای افراد مبتلا به اسکیزوفرنی

Vulnerability–stress models suggest that training in specific stress management techniques should yield benefits to those suffering from schizophrenia and related disorders. In this paper, we describe an evaluation of the impact of adding a stress management program to other medical and psychosocial interventions for such patients. Outcomes were compared for 121 patients randomly assigned to receive either a 12-week stress management program with follow-up sessions or participation in a social activities group. The two treatment conditions did not differ in levels of symptoms, perceived stress or life skills immediately after completion of treatment or at 1-year follow-up. Patients who received the stress management program did have fewer hospital admissions in the year following treatment. This effect of stress management was most apparent for those who showed high levels of attendance for treatment sessions. It was concluded that training in stress management may provide patients with skills for coping with acute stressors and reduce the likelihood of subsequent acute exacerbation of symptoms with need for hospitalization.

While pharmacological treatment of schizophrenia is necessary for alleviation of psychotic symptoms and prevention of relapse, it is not enough in itself for effective treatment of a majority of patients. It is now generally recognized that effective treatment of schizophrenia requires both biological and psychosocial intervention Falloon et al., 1998, Lehman, 1999 and Malla et al., 1998. In recent years there have been definite advances in the pharmacological treatment of this disorder Kane, 1999 and Jibson and Tandon, 1998 and accumulating evidence for the effectiveness of psychosocial interventions (eg., Barbato and D'Avanzo, 2000, Fenton and Schooler, 2000, Huxley et al., 2000 and Lauriello et al., 1999). With reference to psychosocial interventions, the most consistent evidence can be found for the benefits of social skills training Benton and Schroeder, 1990 and Heinssen et al., 2000; family psychoeducation Barbato and D'Avanzo, 2000, Dixon et al., 2000 and Lam, 1991 and provision of individualized case management support services Chamberlain and Rapp, 1991 and Mueser et al., 1998. Despite the advances that have been made, there is still much work to be done in developing and disseminating interventions to further improve treatment outcome Bustillo et al., 1999, Kissling and Leucht, 1999, Meltzer, 1999 and Schultz and Andreasen, 1999. In this paper, we report the results of a study designed to evaluate the impact of an additional intervention when delivered in the context of a treatment and rehabilitation program that already combines pharmacological treatment with such psychosocial interventions as case management, social skills training and family psychoeducation. The particular intervention being evaluated has its roots in the stress vulnerability model of schizophrenia (eg., Fowles, 1992, Nicholson and Neufeld, 1992 and Nuechterlein and Dawson, 1984). Evidence for the influence of stress on the course of schizophrenia comes from numerous studies examining the relationship between stressful life events and variation in intensity of symptoms (eg., Doering et al., 1998, Dohrenwend and Egri, 1981, Norman and Malla, 1993, Norman and Malla, 1994 and Ventura et al., 1989) as well as research on the effects of stressful family milieu on the course of illness (eg., Falloon and McGill, 1985 and Butzlaff and Hooley, 1998). One of the implications of a stress–vulnerability model of schizophrenia and related disorders is the possible benefits of a program designed to help clients cope more effectively with stress. Many studies have systematically evaluated the effectiveness of stress management programs in the general population or in individuals suffering from disorders other than schizophrenia (eg., Johnston, 1991, McCrady et al., 1991 and Shaw et al., 1991). On the other hand, there have been only sporadic reports of individual case studies and descriptions of programs for schizophrenic clients using such interventions as relaxation training or training in problem-solving skills (eg., Starkey et al., 1995, Slade, 1972 and Bellack et al., 1989). There is evidence that schizophrenic clients may sometimes develop and use comparable techniques for dealing with stressors associated with their symptoms Breier and Strauss, 1983, Carr, 1988 and Falloon and Talbot, 1981. Up until the inception of this study, however, there had not been reports of well controlled evaluations of the effects of adding specific stress management training to pharmacological and other psychosocial interventions that have been found effective in the treatment of schizophrenia.

A large proportion of those recruited for this study had only recently met the inclusion criteria of 3 months without an exacerbation of acute symptoms. Furthermore, just over 50% of participants in each group had been hospitalized for psychiatric care in the previous 1 year. It is not surprising, therefore, that participants in both groups showed a reduction in symptoms and improvement in functioning particularly as reflected in pretest versus immediate post-test scores. Such changes may well reflect continuation of an improvement trajectory following acute illness and in response to the core treatment for both conditions, which consisted of coordinated pharmacological and psychosocial interventions. Contrary to our first hypothesis, there was no difference between the two groups in the rate of improvement in symptoms, subjective stress and functioning measures following the interventions and 1 year later. There was, however, evidence for the second hypothesis in that the number of individuals in the stress management condition that were hospitalized was half of that for the social activities group. Why might we obtain such different patterns of results with reference to symptom levels and hospitalization? Upon reflection, such findings are actually quite compatible with the stress vulnerability model of schizophrenia that provided the impetus for this study. The central postulate of such a model is that the likelihood of an increase in acute symptomatology occurring is a joint function of both vulnerability and the occurrence of stress. If this is so, reduction in vulnerability would be most readily indexed in a measure such as hospitalization, which should largely reflect acute exacerbation of symptoms over a period of time rather than level of symptoms as assessed at a pre-determined single point in time. Our findings may reflect somewhat of a parallel to recent evidence with respect to cognitive therapy in the treatment of depression. Commonly accepted models of depression suggest that there are cognitively based predispositions that increase the risk for depressive reactions. The benefits of reducing such predispositions through cognitive therapy may not become apparent until an individual is challenged by potential triggers for negative states (Monroe and Simons, 1991). Consistent with this postulate are findings that depressed individuals who are treated with cognitive therapy are less likely to show an increase in dysfunctional cognition in response to mood challenge than clients treated only with pharmacotherapy even when both appear to have brought about similar levels of symptom reduction (Segal et al., 1999). Furthermore, such reactions to mood induction are predictive of likelihood of subsequent relapse into depression. A parallel, although not identical, model might help explain our findings. The benefits of learning techniques for better coping with stress may not be apparent except when assessed over an extended period of time, when the individual is likely to have opportunities to more effectively avoid stressors or cope more effectively with them when they occur. We are not suggesting that the biological and cognitive bases for depression and psychoses are the same or even similar. The analogy is simply to note that interventions designed to reduce reactivity to triggers for any set of symptoms are most likely to be reflected in probability of relapse rather than differential levels of symptomatology at a predetermined point. Consistent with the above suggestions are findings from the more general literature on cognitive interventions for psychosis. Some of these intensive interventions are designed to directly reduce symptoms, particularly in acutely ill or “treatment resistant” patients through belief modification, distraction techniques, etc. (eg., Kuipers et al., 1997 and Drury et al., 1996). These have typically demonstrated an impact on symptom level when using pre-post standardized symptom assessments (see Norman and Townsend, 1999, Table 1, page 248). A report by Hogarty et al. (1997) on a treatment approach, which emphasized identification of symptom triggers (particularly affect disregulation), reduction of physiological arousal and improvement in general coping skills, demonstrated its effect on the rate of subsequent psychotic relapses (see also Hodel et al., 1998). One important aspect of the stress management program was helping clients to become more comfortable in discussions with the psychiatrist responsible for overseeing their pharmacotherapy. For many patients, discussing concerns about their symptoms on their medication with a comparatively high-status figures as their psychiatrist was stressful. This was often the case even though the psychiatrists associated with our program make every effort to be warm, supportive and accommodating. It is possible that one of the benefits of the stress management program was that clients were more apt to report changes in symptomatology, thereby alerting clinicians to any clinical worsening and/or openly discuss concerns over medication and improve treatment adherence. Either or both could result in lower rates of hospitalization. One item on the LSP assesses patient's willingness to take prescribed medication, but there were no significant differences between treatment conditions on this measure at any point. This suggests that differences between treatments were not mediated by adherence to medication. Our experience in delivering the stress management program re-affirmed the importance of keeping language simple and avoiding mental health “jargon”, emphasizing practical examples and skills rather than abstract principles, and maintaining flexibility. In the future, we would consider expanding the number of sessions (for instance, having a minimum of an entire session on alcohol consumption) and trying to more carefully match clients within a group on level of cognitive functioning. It should be noted that stress management was readily accepted by clients as a treatment modality. Given the widespread use of training in stress management and stress reduction in western society, for many clients participation in this group seemed to be a reassuring and normalizing experience, which was often compatible with their own impression that feelings of stress were a major component of their illness experience. Clearly, our findings regarding the potential impact of stress management training on relapse rate requires replication and extension. It is important to bear in mind that in this study, we observed effects when specific stress management interventions were added to a program in which individuals were already receiving excellent pharmacological and psychosocial care. Findings by Hogarty et al. (1997) suggest that the benefits of such interventions may be muted or even reversed if adequate basic support is not being provided. The presence of an ongoing case management system was particularly important in facilitating the effectiveness of the stress management intervention. The current study adds to a growing body of evidence that we have not yet reached the limits for improving the outcome of clients with schizophrenia through psychosocial interventions. Given evidence that stress can be a precipitator for exacerbations of psychosis and that individuals with psychotic disorders such as schizophrenia often have compromised skills for dealing with stress (MacDonald et al., 1998), further development and evaluation of stress management programs for this population is warranted.