Treating negative symptoms of schizophreniaBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e664 (Published 28 February 2012) Cite this as: BMJ 2012;344:e664
- Tim Kendall, director
Schizophrenia is the most common psychotic disorder and the most pervasive. It is characterised by “positive” symptoms, such as hallucinations and delusions, and “negative” symptoms, such as apathy and social withdrawal. Negative symptoms contribute greatly to the functional impairment and poor psychosocial outcomes in schizophrenia. Advances in the management of schizophrenia in the past 60 years have included drug treatments, psychosocial interventions, and integrated treatment strategies.1 Interestingly, psychosocial treatments—such as cognitive behavioural therapy (CBT) and, more recently, arts therapies (music therapy, art therapy, and body movement or dance therapy)—have shown more promise than drug treatments in reducing negative symptoms and their impact, and the National Institute for Health and Clinical Excellence (NICE) has recently recommended these treatments.2 It is therefore surprising that the linked study (doi:10.1136/bmj.e846), the “Matisse trial” by Crawford and colleagues found that art therapy, as adjunctive treatment for people with schizophrenia, had little benefit over a comparator activity or treatment as usual in the treatment of negative symptoms or global functioning.3
The Matisse trial does, however, refine our understanding of what does and does not work for people who experience negative symptoms of schizophrenia. The trial included data on 417 people from 16 centres throughout the United Kingdom, and it is equivalent in size to all previous randomised trials of arts therapies for schizophrenia combined. It is also of better methodological quality and closer to clinical reality than previously conducted trials.4 5 Evaluators were blinded to treatment allocation, “routine” service users were included rather than selected groups, and an intention to treat analysis was used.
As a pragmatic trial, the treatment group received art therapy as it is currently practised in the NHS in the UK. Nearly 40% of those offered art therapy failed to attend any sessions, with a slightly higher figure failing to attend the comparator activity groups, which is disheartening. Moreover, it took an average of 60 days after randomisation before service users attended their first session of either treatment. Given that treatment was delivered in this unassertive way, and that a large proportion of people failed to “take the medicine,” it is hardly surprising that the intervention did not affect negative symptoms or overall functioning.
Evidence underpinning recent NICE guidelines on schizophrenia2 suggests that antipsychotic drugs reduce positive symptoms of schizophrenia and relapse rates, but that even the so called atypical antipsychotics have little effect on negative symptoms.6 Family interventions have been shown to reduce relapse rates substantially in patients with schizophrenia but they do little to alter positive or negative symptoms, whereas cognitive behavioural therapy seems to reduce positive, negative, and depressive symptoms modestly, but not relapse rates. A review of three trials of music therapy,7 8 9 two of art therapy,4 5 and one of body movement therapy,10 although it included data on only 400 service users, showed that negative symptoms were significantly reduced in patients who received these interventions. Importantly, interventions that combined the different treatment modalities (antipsychotics, family intervention, cognitive behavioural therapy, and arts therapies), each of which is thought to be effective for different aspects of the illness, offered greater overall benefits than giving any one treatment alone.1 2 11 Nevertheless, the weakest evidence is for treatments targeted at negative symptoms, which is highlighted by the findings of the Matisse trial.
Negative symptoms of schizophrenia are often profoundly disabling because they affect people at the level of their daily functioning and their capacity to relate to others. They include limited emotional responsiveness (often called “blunted” or “flat affect”), difficulty in communicating with others or developing a rapport owing to limited volume and content of speech (“poverty of speech”), social and emotional withdrawal, and feelings of emotional numbness and apathy. Commonly, negative symptoms adversely affect motivation, and feelings of pleasure are often diminished or absent. Affected people have a reduced ability to care about or cope with everyday tasks, such as getting out of bed in the morning, washing, and dressing.12 They are also less able to engage in psychosocial treatments.
The findings of the Matisse trial unfortunately suggest that art therapy, as currently practised in the UK, is unlikely to be of clinical benefit for people with negative or other symptoms of schizophrenia—a conclusion that the profession of art therapy will no doubt find unsettling. However, arts therapies, because they rely on creative expression rather than verbal communication, and some cognitive behavioural approaches, still have the greatest potential for success in the treatment of negative symptoms. For people with schizophrenia with disabling negative symptoms, what is most needed now is a substantial investment in hypothesis driven trials to ascertain which therapy, or combination of approaches, can help most with particular constellations of negative symptoms.
Cite this as: BMJ 2012;344:e664
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.