Resumen de Estudio comparativo de consideraciones clínicas y psicoterapéuticas en el tratamiento biopsicosocial de la esquizofrenia. Primera parte
C. Marelo Valencia, Héctor A. Ortega-Soto, María Soledad Rodríguez Verduzco, Leopoldo Gómez Caudillo
- español
Se llevó a cabo el diseño, la implementación y la evaluación de un programa de tratamiento biopsicosocial para pacientes con esquizofrenia. Por medio de él se analizan diversos aspectos clínicos y psicoterapéuticos, como la eficacia del tratamiento, el cumplimiento con el uso de medicamentos antipsicóticos, la asistencia al tratamiento psiquiátrico, la posibilidad de recaídas y rehospitalizaciones, el funcionamiento psicosocial, la actividad global; es decir, la combinación de la sintomatología y la actividad psicológica, así como el cumplimiento con la asistencia a las sesiones, el grado de deserción y la adherencia a la psicoterapia.
El tratamiento del paciente con esquizofrenia ha tenido cambios y avances importantes en los últimos 50 años. Un cambio importante ha consistido en que la aplicación exclusiva del enfoque biológico, por medio de medicamentos antipsicóticos, se ha ampliado a una visión más integral, en la cual se incluyen los factores psicosociales y entre ellos la psicoterapia psicosocial en lo que actualmente conforma el modelo biopsicosocial para el abordaje terapéutico de la enfermedad. Los medicamentos antipsicóticos han demostrado su efectividad al lograr que los pacientes vivan de una manera más satisfactoria en la comunidad. Sin embargo, pese a estar tomando estos medicamentos, recae hasta 45% de los pacientes, en algunos casos debido al incumplimiento con el uso, problema que se ha reportado que llega hasta 50%. El modelo biopsicosocial no solamente permite considerar los aspectos biológicos, sino también los aspectos psicosociales de la enfermedad, los cuales se abordan con alguna forma de terapia psicosocial. La esquizofrenia incapacita a las personas que la padecen a tal grado que presentan dificultades en diversas áreas de su funcionamiento psicosocial. Algunos de los elementos que conforman la problemática psicosocial de estos pacientes son las dificultades para mantener una ocupación remunerada, no contar con recursos económicos que permitan una independencia, carecer de una red de apoyo social por la falta de relaciones interpersonales, la dificultad para establecer relaciones de pareja y el componente familiar que puede ser conflictivo por la carga emocional de la enfermedad y que en algunos casos puede derivar en crisis familiares.
El presente trabajo forma parte del Programa de Rehabilitación Integral de Pacientes Esquizofrénicos del Instituto Nacional de Psiquiatría Ramón de la Fuente, en México, D.F. El Programa Integral está conformado de diversas intervenciones, pero para fines del presente trabajo solamente se utilizan el tratamiento farmacológico y la psicoterapia psicosocial. Para evaluar los aspectos clínicos y psicoterapéuticos, se desarrolló un programa de tratamiento conformado por dos modalidades de intervención. La primera consistió en utilizar una combinación de tratamiento farmacológico y psicoterapia psicosocial, que se denominó grupo experimental. En la segunda se aplicó de manera exclusiva el tratamiento farmacológico, y ésta se denominó grupo control. Mientras que el tratamiento farmacológico tenía como objetivo controlar la sintomatología psicótica y mantener la estabilidad clínica de los pacientes durante el tratamiento, el propósito de la psicoterapia psicosocial era que los pacientes adquirieran habilidades y disminuyeran sus incapacidades para, por lo tanto, mejorar su funcionamiento psicosocial en la comunidad. El programa de tratamiento se implementó en tres ocasiones, que se denominaron primer, segundo y tercer tratamientos. Los tres fueron idénticos por su contenido y abordaje terapéutico, así como por la duración de cada intervención, que fue de un año. Se utilizó un diseño cuasiexperimental para evaluar a los dos grupos en estudio ¿experimental y control¿, antes y después de cada intervención. Los sujetos que participaron en los tres tratamientos fueron pacientes que cumplían con los criterios diagnósticos de esquizofrenia, de acuerdo con el DSM-IV y el CIE-10, y corroborados por el CIDI, y que satisfacían todos los requisitos de inclusión y exclusión del proyecto. Participaron pacientes que asistían a la Consulta Externa del Hospital del Instituto Nacional de Psiquiatría Ramón de la Fuente. El manejo farmacológico se llevó a cabo en la Clínica de Esquizofrenia, y el manejo psicoterapéutico en una sala de terapia del Departamento de Psicoterapia del mismo instituto. Para evaluar a los pacientes, se utilizaron la Escala de Funcionamiento Psicosocial (EFPS) (Valencia, 1989) y la Escala de Evaluación de la Actividad Global (EEAG) (DSM-IV, 1994).
Los resultados indican que los pacientes que recibieron tratamiento farmacológico y psicoterapia psicosocial, mejoraron de una manera considerable y estadísticamente significativa en su funcionamiento psicosocial (p<.000; p<.001; y p<.001, para el primer, segundo y tercer tratamientos, respectivamente), así como en su actividad global (síntomas y actividad psicológica, social y laboral); p<.000, en el primer tratamiento; p<.000, en el segundo, y p<.001, en el tercero. Asimismo, tuvieron un menor porcentaje de recaídas para el total de tratamientos (11.3%) y rehospitalizaciones (4.5%) y un mayor cumplimiento con el uso de los medicamentos antipsicóticos (88.3%), así como una mayor asistencia a las consultas del tratamiento farmacológico (83.3%), un bajo nivel de abandono de la psicoterapia (17.2%), un alto porcentaje de asistencia a las sesiones terapéuticas (83.3%) y un alto grado de adherencia terapéutica a la psicoterapia psicosocial (82.8%). Por su parte, los pacientes que recibieron únicamente el tratamiento farmacológico se mantuvieron estables en cuanto a su actividad global, donde no se encontraron diferencias estadísticamente significativas, no presentaron mejorías estadísticamente significativas en su funcionamiento psicosocial, reportaron un mayor número de recaídas para el total de tratamientos (32.8%) y rehospitalizaciones (10.6%). Su cumplimiento con el uso de medicamentos antipsicóticos (80%) y su asistencia a las consultas psiquiátricas (70%), fue menor en proporción que los de los pacientes que recibieron la combinación de tratamiento farmacológico y psicoterapia psicosocial. Este estudio corrobora lo que se ha encontrado internacionalmente respecto a que la forma más conveniente de tratar a pacientes con esquizofrenia es combinar el tratamiento farmacológico y la psicoterapia psicosocial. Además de asistir a sus consultas psiquiátricas para el manejo farmacológico, contar con un espacio terapéutico para hablar en detalle de sus problemas psicosociales, de la enfermedad, de sus características, de los síntomas, de cómo evitar recaídas y rehospitalizaciones, de la importancia de cumplir con los medicamentos antipsicóticos, del manejo de los efectos secundarios, de cómo afrontar ciertas crisis y de adquirir conciencia de la enfermedad, permitió a los pacientes adquirir habilidades para funcionar de manera más satisfactoria e integral a nivel biopsicosocial.
- English
A treatment program for patients with schizophrenia was designed, implemented and evaluated. In this paper the results of this program are presented and several clinical and psychotherapeutic aspects related to the treatment of schizophrenia are analyzed.
Among these are treatment effectiveness (pharmacotherapy and psychotherapy), compliance with antipsychotic medication, relapse, rehospitalization, and psychotherapy: compliance desertion, and adherence.
There is a general consensus that the treatment of schizophrenia has experienced considerable changes and some important therapeutic advances have been made in the management of this disease in the last 50 years. It has also been considered that a very important change has consisted in that the exclusive utilization of the biological approach, with the application of antipsychotic medication, has been widened to integrate psychosocial factors, with the implementation of psychosocial interventions, and using as a result the biopsychosocial model approach for the management of the disease. Antipsychotic medications have proved to be useful in alleviating symptoms and they are an essential part of the treatment of schizophrenia, as patients under antipsychotic medications live more tolerable and satisfying lives in the community. However, it has been found that about 45% of the patients taking antipsychotic medication relapse, some of them because they do not fully comply with the treatment, and noncompliance with antipsychotic medication has been reported around 50%. The biopsychosocial model allows to consider both the biological as well as the psychosocial aspects of the illness.
Approximately 50 years ago, the situation of schizophrenic patients was very well determined: once they developed the illness, they were institutionalized. Therefore, they were permanently confined to mental hospitals for the rest of their lives. This was, obviously, very inconvenient for the patients, because of the enormous suffering caused by the illness: no human being would be willing to stay forever in a psychiatric institution. Today, fortunately, the great majority of schizophrenic patients live in the community.
Some important developments have taken place in the last half a century, specially during the early 1950´s, such as the introduction of neuroleptic medications and a wide spectrum of psychotherapeutic modalities. Some argue that neuroleptics and psychotherapy appeared approximately at the same time. Other researches consider that the initial psychotherapeutic attempts took place 60 years ago, when schizophrenic patients were confined in mental institutions. Today, the fact is that scientific research, with the use of clinical and psychosocial trials has yielded a considerable body of well replicated evidence which has been useful for the biopsychosocial treatment of schizophrenia. In the 21st century, it cannot be conceived to treat these patients exclusively with the use of typical or atypical antipsychotic medications.
Psychosocial treatments for schizophrenia have demonstrated, undoubtedly, to be very effective, especially when combined with antipsychotic medication, providing considerable help in the maintenance and compliance with antipsychotic medication, reducing relapse and rehospitalizations, improving psychosocial functioning through the acquisition of psychosocial skills and new coping behaviours for the patients to sustain a successful adjustment to community life.
A book recently published, The psychosocial basis of schizophrenia, which includes 20 scientific articles, on topics such as integrating pharmacological and psychosocial treatments for schizophrenia, psychological therapy in schizophrenia, and compliance with antipsychotic treatment. As a result, a model is proposed about the advantages of combining pharmacological and psychosocial strategies. The following are the conclusions: “a) patients receiving an effective psychosocial treatment might require a lower dose of antipsychotic medication; b) patients receiving adequate medication might tolerate more intrusive and stimulating forms of psychosocial treatment than those who are unmedicated or improperly medicated; c) patients receiving psychosocial interventions may be more compliant with prescribed medication;
d) the effects of combining treatments may be more than additive since each would enhance the effectiveness of the other, and e) drugs and psychosocial treatments may affect different outcome domains. For example, drugs may affect psychotic symptoms or relapse rates and psychosocial treatments may affect social and vocational skills”.
It has been established that schizophrenia is a disease characterized by the presence of psychotic symptoms, but also by severe impairments that generally lead to a decline in psychosocial functioning. Patients with schizophrenia usually face several psychosocial problems. They have, for instance, difficulties to keep a paid job and therefore they lack the economic resources to live an independent life apart from their families in the community.
Their social network is very limited, they usually have only a few friends, and as a consequence they have difficulties to establish loving relationships. The family environment could be described as an style of interaction between family members characterized by intense over involvement and excessive criticism with higher levels of expressed emotion, and because of the illness burden, some family crises might occur. Psychosocial problems in schizophrenic patients generally occur in the following areas of functioning: occupational, social relations, economic, loving relationships including sex roles, and family problems.
In order to assess and analyze the clinical and psychotherapeutic variables, a treatment program for schizophrenic patients was developed. The program included two therapeutic modalities:
patients assigned to the first one received a combination of pharmacological treatment and psychosocial psychotherapy (experimental group), while patients assigned to the second modality received pharmacological treatment alone (control group). The aim of the pharmacological treatment was to control and stabilize the psychotic symptoms. The therapeutic goals of the psychosocial psychotherapy promoted the improvement and recovery of psychosocial functioning. The treatment program was replicated on three different occasions, described as first, second and third treatments. All of them were identical in their rationale, structure, and therapeutic management of a one year treatment program. A cuasiexperimental design was utilized. Patients of the experimental and control groups were assessed at the beginning and the end of each treatment, considering the following variables:
symptomatology and global functioning, psychosocial functioning, compliance with antipsychotic medication, pharmacotherapy compliance (attendance to psychiatric appointments), relapse, rehospitalization, therapeutic compliance (attendance to psychotherapy sessions), desertion, and psychotherapy adherence.
Subjects included in all treatments were outpatients who fulfilled the criteria for schizophrenia diagnosis according to the DSM-IV and CIE-10 and corroborated by the CIDI. The following criteria were used to include patients in the treatment program: 1. they had to be under antipsychotic medications; 2. their positive symptoms had to be controlled, and they had to be clinically stabilized; 3. they had to be outpatients; 4. male or female; 5. in an age-range of 16 to 55 years; 6. with elementary school education;
7. they had to live in the metropolitan area of Mexico City, 8.
they had to agree to participate by their own free will, and sign a letter of voluntary participation, and 9. they should have never been under psychotherapy prior to their participation in the treatment program. The pharmacological treatment was carried out by a team of two clinical psychiatrists at the Schizophrenia Clinic. Two trained psychotherapists were in charge of the psychosocial psychotherapy. Group-therapy was utilized with weekly sessions that took place at the Department of Psychotherapy at the hospital of the National Institute of Psychiatry Ramón de la Fuente, in Mexico City. To assess the effectiveness of the treatment program, the following instruments were administered: The Psychosocial Functioning Scale (PSFS), Valencia (1989), and The Global Assessment Functioning Scale (GAF), Axis V, DSM-IV (1994).
Results showed that patients who received the combination of pharmacological treatment and psychosocial psychotherapy (experimental group) improved considerably in their psychosocial functioning: p<.000 for the first treatment; p>.001 for the second, and p<.001 for the third, as well as in their global functioning (symptoms and psychological, social and occupational functioning): p<.000, p<.000, p<.001, for the first, second and third treatments. They also presented a lower relapse rate, 11.3%, as well as less rehospitalizations, 4.5%, a higher compliance with the antipsychotic medications, 88.3%, a higher compliance with the pharmacological treatment (attendance to psychiatric appointments), 83.3%, for the total of treatments, a lower desertion from psychotherapy, 17.2%, a higher degree of compliance with psychotherapy (attendance to psychotherapy sessions), 83.3%, and a higher percentage of psychosocial psychotherapy adherence, 82.8%. On the other hand, patients who received the pharmacological treatment alone, maintained their symptoms and global activities stable, and their psychosocial functioning did not improve. No statistically significant differences were found for the total of treatments in this two variables. They reported a higher relapse rate, 32.8%, more rehospitalizations, 10.6%, compliance with antipsychotic medication, 80%, as well as their attendance (keeping appointments) to the pharmacological treatment, 70%. Results in all these variables were in a lower proportion compared with patients who received the combination of pharmacological treatment and psychosocial psychotherapy.
The findings of the present study showed similar results to those reported in international literature. Therefore, it can be concluded that the most convenient and effective form of treatment for schizophrenic patients is to combine pharmacotherapy and psychosocial psychotherapy. It is possible that various clinical and psychotherapeutic factors influenced the outcome. Patients did not only attend their psychiatric appointments in order to receive the pharmacological treatment, they also had a therapeutic setting (group sessions), which allowed them to talk about their psychosocial problems, the illness, their symptoms, the process of the disease, how and when they got sick and the implications at that moment, when they relapsed and when they were rehospitalized, their response to treatment, the attitude of their relatives, when they stopped taking antipsychotic medications and the consequences, the side effects of the medication, how to face personal and family crises because of the illness, and the importance of accepting the disease might have influenced the acquisition of certain skills that enabled them to recover their psychosocial functioning, improve their role performance and symptomatology, and to function in a more effective and satisfying manner under the biopsychosocial treatment model.
