The Danish National Schizophrenia project (DNS II):

The Danish National Schizophrenia project (DNS II):
Prospective, comparative, longitudinal, multicentre study of psychodynamic psychotherapy of first-episode psychosis. A controlled design of non-selected, consecutively referred/admitted patients.

Harder S, Koester A, Valbak K, Rosenbaum B. Five-year follow-up of supportive psychodynamic psychotherapy in first-episode psychosis: long-term outcome in social functioning. Psychiatry: Interpersonal and Biological Processes, 2014;77(2):155-68

Rosenbaum, B., Harder, S., Knudsen, P., Koester, A., Lindhardt, A., Valbak, K., & Winther, G. Supportive psychodynamic psychotherapy versus treatment as usual for first episode psychosis: two-year outcome. Psychiatry: Interpersonal and Biological Processes, 2012;75(4): 331 – 341

Background

During recent decades, psychodynamic treatment has lacked empirical, systematic outcome studies that prove it as an evidence-based intervention for patients with schizophrenia spectrum disorders. After 1984 radical conclusions were drawn concerning psychodynamic psychotherapy for patients with schizophrenia:
"the evidence from at least half a dozen studies would indicate that no further research on the intensive individual psychotherapy of schizophrenics based on psychodynamic or interpersonal principles is warranted" (Klerman, 1984).
"Individual and group psychotherapies adhering to a psychodynamic model (defined as therapies that utilize interpretation of unconscious material, focus on transference, and regression) should not be used in the treatment of persons with schizophrenia" (Lehman & Steinwachs, 1998, PORT Recommendation, § 22). This recommendation was removed in an update of the treatment recommendation - not because it was considered false, but because it was implicitly understood that everyone knew that psychodynamic treatment had been proven ineffective.

Design and Sample
The study was designed as a prospective, longitudinal, comparative, multi-centre investigation. The included patients were offered either: 1) manualised Supportive Psychodynamic Psychotherapy as a supplement to treatment as usual (named the SPP), or 2) TaU for two years (called the TaU).

All centres involved in the study had all shown a previous interest in investigating the methods of supportive psychodynamic psychotherapy, even though not all of them had sufficient resources to offer individual psychotherapy in a systematic way which would be needed for carrying out a randomised controlled study. Thus, a controlled design was chosen in which the centres in both groups included rural and urban sites, university and non-university clinics, as well as large and small departments.

A total of 269 consecutively referred patients with first-episode psychosis of the F2- type according to the ICD-10 were included over two years (October 1997 to September 1999). Fourteen psychiatric centres participated. The SPP group consisted of 119 patients consecutively admitted to eight centres, and the TaU group consisted of 150 patients consecutively admitted to nine centres (see Figure 1).

The sample consisted of 181 males and 88 females, mainly of Nordic origin (90%). The patients' median age at inclusion was 23.7 yrs. (range 16.2-35.9 years), and median age at onset of illness was 20.0 yrs. (range 6-35 years). A total of 48% were living alone, 26% had no friends, 70 % were without education, 22% had not worked within the past year, and 30 % had some kind of moderate substance abuse. The median values for Global Assessment of Functioning (GAF) were 31 for GAFsymptom and 35 for GAFfunction.

Procedures and measures
Patients with a first-episode psychosis admitted to either the inpatient unit or to the community mental health centre, in 1997-1999, were systematically assessed within two weeks to determine whether they conformed to the diagnosis of ICD-10 F20-F29.
The following assessment and measurement scales were used: demographic and socio-economic charts, Operational Criteria Checklist for Psychotic Illness (OPCRIT) (McGuffin, Farmer & Harvey, 1991), GAF in the DSM-IV (APA, 1994), Strauss-Carpenter (Strauss & Carpenter, 1974; Strauss & Carpenter, 1977) and the PANSS (Kay, Fiszbein & Opler, 1987).

The test battery was repeated after two and five years. All assessments were conducted by trained interviewers who were independent of, but not blinded to, the treatments offered to the patients. Reliability testing was made by means of videos of interviews with patients from the different centres.

Allocation to treatment is visualised in Figure 1. In three centres (27% of the sample), patients from the first part of the intake were allocated to the SPP group and from the second part of the intake to the TaU group. No further selection was made regarding this allocation of patients. In five centres (28% of the sample), all patients were offered SPP (in addition to TaU), whereas six centres (45% of the sample) offered only TaU to the project patients.

Interventions
TaU
In Denmark, all TaU-treatment was consistently conducted by a doctor and contact persons from the staff. TaU consisted of different treatment modalities administered according to the patients' individual needs and available resources at the psychiatric unit at the moment of treatment. Treatment encompassed short psychoeducation programmes, individual meetings with contact persons (mainly nurses and assistant nurses) and other consultants (psychologist, social worker), group meetings, and medical advice (including low-dosis medication).

Psychodynamic supportive psychotherapy
The SPP was based on a model of psychosis that understands the condition as a result of pathogenetic pathways that involve an array of biological, psychological and social risk factors that lead to a disturbed development and functioning in several basic psychological capacities.

The supportive elements in this approach contained, among others, the following:
 Helping the patient to understand his/her feelings, attitudes and subjective intentions in the concrete interpersonal relationships
 Helping the patient recover from the psychosocial losses related to his or her suffering from psychosis by, in a trusting manner, reformulate the patient's story of development with elements of hope and realistic optimism counterbalancing the patient's negative and self-denigrating attitude
 Applying an array of supportive techniques, including:
clarifications, affirmations and suggestions; holding and containing the patient's painful state of mind; maximising adaptive strategies, encouraging patient activities; helping the the patient to understand how psychotic mechanisms work psychologically in the individual and in the specific interactions with others, and how other people might be expected to react with common sense reactions.

The term 'psychodynamic' refers to the following characteristics of the therapeutic approach:
 It aims to establish a working alliance that functions even in the periods marked by the patient's ambivalent, confusing or negative attitude (transference) towards the therapist
 It uses the dynamics of the therapeutic relationship and setting ('transference' in a broad sense) to understand communication processes in other relationships outside the setting of psychotherapy
 It emphasises the role and influence of the counter-transference on the therapist's understanding and responses
 It understands emotions and thoughts communicated in the therapy as instances that illustrate for both patient and therapist what may happen in daily life situations in which the patient communicates and interact with others
 It emphasises the importance and presence of unconscious processes
 It empathises with the patient's affective states and unresolved states of mind based on a theoretical model for understanding the patient's difficulties in dealing with emotional experience
 It recognises and respects the co-existence of both psychotic and non-psychotic aspects of the personality (Bion)
 It acknowledges the importance of developing levels of mental functioning enabling the patient to deal with emotional experiences in a more adaptive way, i.e. 'turning the raw sense impressions into thoughts' and 'thoughts into thinking' (Bion).

The therapists were psychiatrists and psychologists with an average length of training in psychodynamic psychotherapy, most of them between 1-4 years of training. There was no systematic external control of the therapists' adherence to the psychotherapy manual, but each case was regularly supervised at the centers which offered SPP as part of the study. Seminars in which the contents and ideas of the manual were presented and discussed in depth were conducted for therapists and supervisors in order to enhance uniformity in therapeutic thinking and conduct.

Results
There was no significant difference between groups at inclusion concerning sex, symptom level as measured by GAFsymptom and PANSS, functional level as measured by GAFfunction, work status and substance abuse.

Reliability
ICC was calculated for PANSS-positive = 0.70, PANSS-negative = 0.74, GAFsymptom = 0.56 and GAFfunction = 0.74. The ICC agreement is thus good for PANSS and GAFfunction, and moderate, but acceptable for GAFsymptom.

At year two, data were obtained from 99 patients (83%) in the SPP group and from 113 patients (75%) in the TaU group. The two attrition groups did not differ at baseline.

Improvement of symptomatology and social function after two years
The improvement over the two years for the SPP group alone was at a significant level for PANSSpos (p=0.000; Eta2: 0.50), PANSSneg (p=0.001; Eta2: 0.10), GAFfunction (p=0.000; Eta2: 0.39) and GAFsymptom (p=0.000; Eta2 0.39).

The difference in improvement between the SPP group and the TaU group:
We found significantly higher levels of improvement in the SPP group than in the TaU group for GAFfunction (p=0.000; Eta2: 0.054) and GAFsymptom (p=0.010; Eta2: 0.022), whereas the difference did not reach the level of significance for PANSSpos (p=0.067; Eta2: 0.012) and PANSSneg (p=0.873).

At five years follow-up, 148 (55%) of the patients were re-assessed. No significant differences were found between the degrees of missing in the two intervention groups. Furthermore, patients who dropped out and those who remained did not differ significantly at baseline with regard to social functioning, positive and negative symptoms

At five year, the analysis of the clinical data using the mixed model for repeated measurement revealed a significant difference between the two treatment groups in favor of SPP for our primary outcome measure of social functioning. For our secondary outcome measures, a significant difference was found for overall symptoms, and for positive psychotic symptoms, whereas no significant difference was found for PANSS negative symptoms. No significant interaction was found between treatment group and time. This indicates a stable superior effect of SPP when compared to ST from 1–5 years

Evaluation
Strengths and limitations of the study
The strengths of the present study include 1) a large number of consecutively referred patients who were not pre-selected to treatment (neither by themselves, the therapists nor the centres); 2) different types of treatment centres in both the experiemental group and the comparison group (small/big, urban/rural, university/non-university); 3) a large percentages of the Danish population (approx. 25%) is covered by the investigation; 4) SPP therapists with an average level of training were recruited, not just master clinicians; 5) a manual to guide the therapy was deployed; 6) the two groups were compared at the beginning of the investigation on variables of symptomatology (GAF, PANSS), social factors (sex, ethnicity, marital status, habitation, educational level, work, social network and abuse) in order to explore possible bias. No differences between the two groups were found.

The limitations of the study include a) lack of individual randomisation and b) lack of systematic evaluation of adherence to the SPP psychotherapy manual.

Contact

Bent Rosenbaum,
bent.rosenbaum@dadlnet.dk

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