Schizophrenia is a serious mental illness with characteristic distortions of thinking and perception and inappropriate or blunted moods. People with schizophrenia can show either depressed or excited (manic) behaviours. A person with schizophrenia may have difficulties in distinguishing between self and non-self. They are very literal in expression and understanding, called concrete thinking.

Medication is the mainstay of treatment for schizophrenia but people continue to experience symptoms, leaving them disabled and unwell. The medications also have adverse effects. People are taking these agents long term, making the adverse effects troublesome and the drugs unpleasant to take. This means they may take themselves off the medication and lose control of their condition. Adverse effects include dry mouth, visual difficulties, difficulty in urinating, constipation, low blood pressure when standing up quickly, impotence, restlessness and changes in body tone, involuntary movements and tremors similar to Parkinson’s.

Recently there has been growing interest in combining medication with psychological, behavioural, supportive and other complementary therapies.

We present some of the evidence from Cochrane systematic reviews about complementary and alternative treatments related to managing schizophrenia symptoms. This evidence comes from carefully researched reviews of information about clinical trials done to evaluate medical treatments. Studies are only included in these reviews if they meet pre-defined criteria.  

ART THERAPY FOR SCHIZOPHRENIA

Schizophrenia is a mental illness and is described as a disorder with fundamental, characteristic distortions of thinking and perception, and inappropriate or blunted affect in clear consciousness (WHO 1992). The characteristic distortions of thinking and perception fundamentally relate to a sense of invasion of self. A person with schizophrenia may experience difficulties in distinguishing between self and non-self; this is called a loss of ego boundaries. One of the other distortions of thinking is called 'concrete thinking' and refers to literalness of expression and understanding. They cannot think symbolically.

Medication is the mainstay of treatment for schizophrenia. However, some people continue to experience symptoms in spite of medication or may also develop intrusive adverse effects.

Art therapy is the use of art materials for self-expression and reflection in the presence of a trained art therapist. People who are referred to art therapy need not have any experience or skill in art. Art therapy can be used in addition to medication for helping people with schizophrenia. The art work offers a buffer to reduce the intensity in the relationship between the therapist and individual. Through an image a person can communicate both the rational and the irrational and find acceptance of that. This can help to affirm a sense of self in a non-threatening way.

Art therapy is used individually and in groups, in inpatient and outpatient settings.

What the synthesised research says

At present it is impossible to say with certainty what effect art therapy has on keeping people involved with art therapy sessions. Both studies found that engagement with the trial was poor after the therapy sessions had finished.

This conclusion is based on two trials with 137 participants comparing art therapy plus standard care with standard care alone. More people completed the therapy if allocated to the art therapy group compared with standard care, from one trial.

In a second trial, mental state improved slightly with art therapy group but social functioning and quality of life did not clearly improve in the short term.

How it was tested

The researchers made a thorough search of the medical literature and found two trials that met the inclusion criteria. These were both community studies, involving 137 participants and were conducted in 1997 and 2002.

The first US-based trial used group art therapy, as an additional treatment over 20 weeks, as a way of helping people increase their self-esteem and interact more positively with other people. These 30 women and 17 men had a variety of mental health problems with half having schizophrenia. They were about 40 years old. The sessions lasted 90 minutes and were held fortnightly.

The second trial used group art therapy as an additional treatment for people with chronic schizophrenia who were actively involved with community mental health teams in the UK. The therapy involved 12 weekly sessions, lasting 90 minutes. Of the 90 participants 59 were male and 31 were female. A large number of participants (40%) left before the end of therapy.

Side effects and general cautions

Both studies are small, making it difficult to find a clinically meaningful effect. It may also be possible that the idea of art therapy is not appealing to some people.

Source

Ruddy R, Milnes D. Art therapy for schizophrenia or schizophrenia-like illnesses. The Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: D003728.pub2. DOI: 10.1002/14651858.CD003728.pub2.

MUSIC THERAPY FOR SCHIZOPHRENIA

Recently there has been growing interest in the effects of psychological behavioural, supportive and other complementary therapies in the management of schizophrenia when these therapies are used together with medication.  

Music therapy involves musical interaction as a way of communication and expression. The trained music therapist aims to promote health using musical experiences and the relationships that develop over the course of the therapy. They encourage people with serious mental illness to develop relationships with themselves and others and to address issues they may not be able to using words alone. The focus of attention may be on the processes occurring within the musical interaction or on verbal reflections that come forward and discussion.Sessions can be made up of free improvisation, singing and listening to music selected by the therapist or a participant, for example working with different rhythms. How structured the session is depends on the individual's needs and also varies between music therapy models. The music therapists usually show a strong psychotherapeutic orientation in their work. Music therapy can be provided either individually or in small groups and often continue over an extended period of time.

Musical skills are not needed on the side of the person, but a motivation to work actively within a music therapy process is important.

What the synthesised research says

Music therapy as an addition to standard care helped people with schizophrenia to improve their overall (global) state. It may also improve mental state, negative symptoms and social functioning. This was dependent on a sufficient number of music therapy sessions being provided. Music as a medium of therapy may address specifically issues related to emotion and interaction, and may be particularly suited to the treatment of negative symptoms.

In order to benefit from music therapy, it is important to participate in regular sessions over some time, up to three months in the included trials. The exact minimum number of sessions is difficult to determine and will probably vary from person to person. Active participation is crucial for the success of music therapy.

These conclusions were based on four trials that compared music therapy added to standard care with standard care alone. The number of sessions varied from 7 to 78.

How it was tested

The researchers made a thorough search of the medical literature and found four trials that compared standard care with and without music therapy. The duration of studies varied from one to three months. The total number of participants was 266 adults with schizophrenia or related psychoses who were inpatients. The trials were conducted in Europe and China and dated from 1994 to 2004.

Music therapy was given either individually or in groups from once to six times weekly.

One trial with 72 participants found that music therapy added to standard care was superior to standard care alone for overall psychological state in that an important improvement was more likely to occur than with standard care alone, over three months. Two people had to receive music therapy for one to benefit. These results come from a study where many sessions were provided.

Results for negative symptoms were available from three studies and the overall effect was in favour of music therapy even when less than 20 sessions of music therapy were given. Negative symptoms are related to lack of emotion (affective flattening) and bluntness, poor social interaction and a general lack of interest.

In single trials, mental state and social general functioning were improved when 20 or more sessions of music therapy were given.

Single trials reported that patients were not clearly any more satisfied with their care or had a better quality of life when they participated in music therapy.

Side effects and general cautions

Only a few people did not participate in the music therapy offered to them.

These trials took place in a hospitalised setting and how applicable the findings are to outpatients is uncertain. The effects of music therapy seem to depend heavily on the number of music therapy sessions. In order to benefit from music therapy, it is important to participate in regular sessions over some time.

Source

Gold C, Heldal TO, Dahle T, Wigram T. Music therapy for schizophrenia or schizophrenia-like illnesses. The Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD004025.pub2. DOI: 10.1002/14651858.CD004025.pub2.

Medication was monitored in all studies. One trial reported a higher drop of medication level in the group receiving music therapy than in the other control group, but no significant difference at follow-up. The other studies reported no significant differences in medication level.

HYPNOSIS FOR SCHIZOPHRENIA

Schizophrenia is a mental illness with fundamental and characteristic distortions of thinking, perception and inappropriate or blunted mood (affect), in clear consciousness (WHO 1992). Although medication is the mainstay of treatment for schizophrenia, a significant number of people continue to experience symptoms with medication. They may still be disorganized or withdrawn. The medications are taken long term, making the adverse effects troublesome and unpleasant for the individual, which means they may take themselves off the medication and lose control of their condition.

Recently there has been growing interest in the effects of psychological, supportive and other complementary therapies in the management of schizophrenia when these therapies are used in conjunction with medication.

Hypnosis is a process during which a therapist suggests that a person experience changes in sensations, perceptions, thoughts or behaviour, often described as an altered state of consciousness. Peoples respond to hypnosis in different ways. Some find that it allows unconscious thoughts and feelings to be accessed, others describe it as a normal state of focused attention in which they feel very calm and relaxed, and some respond to suggestion as a social behaviour.

Induction procedures include eye fixation and use of the voice to guide progressive muscular relaxation and slowing of breathing. Therapeutic suggestions are given using guided imagery, anchoring techniques and post-hypnotic suggestions.

Ongoing concern and controversy surrounds the use of hypnosis in the management of schizophrenia which centres on whether psychotic patients can be hypnotised and whether the technique could precipitate or aggravate psychotic symptoms. Yet numerous case reports are in the literature describing the success of hypnotherapy for managing both acute and chronic schizophrenia.

What the synthesised research says

There is no clear evidence that hypnosis is beneficial for patients with schizophrenia. Hypnosis as a therapeutic tool does not appear to be harmful and is overall well received.

This conclusion is based on three trials involving 106 participants.

Mental state, movement disorders and attention, concentration and cognition (neurocognitive function) were unaffected by hypnosis whether it was compared with a non-active (placebo) treatment or relaxation.

How it was tested

The researchers made a thorough search of the medical literature and found three trials that met the inclusion criteria. These were carried out between 1973 and 1983. The longest trial lasted eight weeks with participants, two thirds women and the rest men, receiving one session per week, possibly as outpatients. One of the other trials involved male inpatients over one week. The third trial was of four weeks duration with sessions occurring twice weekly. The participants were institutionalised and treatment resistant.

All studies were small with 10 to 60 participants and compared a hypnosis group with a relaxation and a non-active (placebo) group. In one study from Finland everyone received music (Sibelius).

Side effects and general cautions

Hypnosis as a therapeutic tool does not appear to be harmful and, overall, is well received with few people leaving the trials.  

The trials were few, had a small number of participants, poorly reported and outdated (1980 to 1983).

Source

de Izquierdo Santiago A, Khan M. Hypnosis for schizophrenia.The Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD004160.pub2. DOI: 10.1002/14651858.CD004160.pub2.

POLYUNSATURATED FATTY ACID SUPPLEMENTATION FOR SCHIZOPHRENIA

Although medication is the mainstay of long-term treatment for schizophrenia, a significant number of people continue to experience symptoms despite treatment with medication still leaving them disabled and unwell. The medication adverse effects troublesome making the drugs unpleasant to take. This means they may take themselves off the medication and lose control of their behaviour.

What is known

Diet can affect the occurrence and course of schizophrenia. Polyunsaturated fatty acids are an essential component of our diet and are important for normal nerve cell membrane structure and function. Dietary supplementation may have a direct, positive, effect on the symptoms of schizophrenia. In addition, essential fatty acid supplementation may make medication more effective for people with schizophrenia.

The two types of essential polyunsaturated fatty acids are omega-3 and omega-6 fatty acids. Omega-3 fatty acids are abundant in oily fish such as mackerel and sardines. Those of the omega-6 type are found in soft margarine and vegetable oil. Fish oil and evening primrose oil capsules are mixtures of essential fatty acids.

What the synthesised research says

The value of polyunsaturated essential fatty acids for helping people with schizophrenia is as yet unclear.

This conclusion is based on six small, well-conducted trials that involved 353 participants taking the essential fatty acid supplement or a non-active supplement (placebo) over six to 16 weeks.

Four trials comparing omega-3 essential fatty acids with placebo as a supplement to antipsychotic medications were too small to be conclusive. However, the mental state of both medicated and un-medicated people may show some improvement in the short term. One recent study showed a positive effect in mental state score for those receiving 3g/day EEPA supplementation compared with those receiving placebo; however in another study, no difference was found when less than 1g/day EEPA supplementation was compared to placebo.

One small study with 30 participants suggested that an omega-3 essential fatty acid enriched oil may reduce requirements for medication with antipsychotic (neuroleptic) drugs when compared with taking a non-active supplement (placebo). These were recently ill people not on medication.

One small trial with 16 participants investigated the effects of an omega-6 essential fatty acid compared with placebo for involuntary movements characterised by arms and legs moving away from the body in any direction (tardive dyskinesia) and found no clear effects.

Different omega-3 essential fatty acids (E-EPA and DHA) had the same effects.

How it was tested

The researchers made a thorough search of the medical literature and found six well-conducted randomised trials involving a total of 353 people. The largest trial included 122 people and the number in the other trials ranged from 16 to 90.

Participants were generally chronically ill and were still symptomatic despite exposure to antipsychotic drugs. The age range was from 18 to 65 years.

Trials took place in a mixture of hospital and community settings and lasted from six to 16 weeks.

Most trials compared supplements of omega-3 essential fatty acids with a non-active supplement (placebo); one trial compared an omega-6 essential fatty acid with placebo. One trial of 31 participants compared two types of omega-3 essential fatty acids, finding no differences on measures of mental state.

Side effects and general cautions

Adverse effects seemed to be rare but diarrhoea may be a problem when omega-3 supplement is taken for more than a few weeks, as suggested by the only trial that lasted over 3 months.

The trials were of short duration considering that this is a chronic condition and had too few participants to give clear, conclusive results.

Source

Joy CB, Mumby-Croft R, Joy LA. Polyunsaturated fatty acid supplementation for schizophrenia. Cochrane Database of Systematic Reviews2006, Issue 3. Art. No.: CD001257. DOI: 10.1002/14651858.CD001257.pub2.