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Social skills training for people with schizophrenia

Social skills training is used to improve social skills in people with schizophrenia and similar diagnoses. The method has been reworked to Swedish conditions under the name “Ett självständigt liv” (An independent life). The goal of the method is to take complex target behaviours and break them down into smaller components that the clients can learn, with the help of for instance movies, role plays, and homework’s, and then apply in their everyday lives.

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SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

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Published: Report no: ut201938 Registration no: SBU 2019/639

Question

What systematic reviews are there on social skills training for people with schizophrenia?

Identified literature

Table 1. Systematic reviews with low/medium risk of bias
RCT = Randomised controlled trial; PANSS = Positive and Negative Syndrome Scale; SST = Social skills training; NICE = The National Institute for Health and Care Excellence; CBTp = Cognitive-Behavioural Therapy for Psychosis; QoL = Quality of Life; ASD = Autism spectrum disorder
Included studies Population Outcome
Puolakka et al, 2019 [1]
14 RCTs, where of 4 tested social skills training. The majority of participants had a diagnosis of schizophrenia or a related disorder (ICD-10: F21-F29). Quality of life
Authors' conclusion:
“Based on this review, it seems that there is some but very weak evidence that family intervention, psychoeducation, SST and vocational rehabilitation may enhance the QoL of patients with schizophrenia. These interventions may be worth utilizing with this outcome in mind”
Turner et al, 2017 [2]
27 RCTs comparing social skills training or related interventions to any control conditions. Patients diagnosed with: schizophrenia, schizoaffective disorder, delusional disorder, brief psychotic disorder, or psychosis not otherwise specified. 1. Negative- and Positive symptoms in schizophrenia.
2. PANSS General Symptoms
3. Social performance
Authors' conclusion:
“The results of this meta-analysis suggest that SST has potential for wider clinical application, whereas the level of evidence demonstrated for SST contradicts its exclusion by NICE in the United Kingdom. The effect sizes reported are impressive for a group-based psychological intervention suggesting that SST may have potential as a cost-effective alternative to individual therapies addressing negative and general symptoms in healthcare systems struggling to provide a beneficial adjunct to CBTp focused on appraisal and positive symptoms”
McDonagh et al, 2015 [3]
Included systematic reviews and randomised controlled studies with a sample size of above 50. The systematic review included 3 RCTs of fair quality using social skills training with a total sample size of 433. Adults with a diagnosis of schizophrenia, including those with co-occuring substance use disorder and those experiencing a first episode of schizophrenia. Functioning, reductions in self-harm and suicide, improvements in health-related quality of life, treatment discontinuation, improvements in core illness symptoms and changes in status of co-occurring substance-use disorders.
Authors' conclusion:
“In comparison with usual care, most of the psychosocial interventions to treat schizophrenia reviewed were more effective in improving two or more outcomes, including nontargeted but patient-important outcomes. Various functional outcomes were improved more with assertive community treatment, CBT, psychoeducation, social skills training, supported employment and early team-based multi-component treatment programs for patients with first-episode psychosis then with usual care.”
Almerie et al, 2015 [4]
14 RCTs comparing SST to treatment as usual or discussion groups. Adults diagnosed with schizophrenia or related disorders, such as schizophreniform disorder, schizoaffective disorder and delusional disorder. Social functioning, global state, service outcomes, mental state, general functioning, behaviour, adverse effects, engagement with services, satisfaction with treatment, quality of life, economic outcomes.
Authors' conclusion:
“Compared with standard care, social skills training may improve the social skills of schizophrenic patients and reduce relapse rates, but at present, the evidence is very limited. In addition, there is no evidence to suggest that social skills training is superior to the act of discussing problems in a group. Currently, because of lack of good, consistent, applicable data social skills programme have to be seen to be vulnerable to replacement by other approaches with more robust evidence.”
Turner et al, 2014 [5]
48 RCTs comparing at least two psychological interventions. 14 studies included social skills training. Participants with diagnoses of psychotic disorders. Trials that included patients with mood disorders with psychotic features where included only when such patients where in a minority within the sample. Positive, negative and general symptoms in psychosis.
Authors' conclusion:
“With respect to the much-discussed thesis that all psychotherapies produce similar outcomes, our results provide evidence that could both support and contradict this proposition. The differences shown between interventions are small in terms of clinical significance. This may suggest that the major therapeutic effects of interventions occur through common factors”
“CBT appears most successful in reducing positive symptoms, consistent with the rationale of challenging positive symptoms through a formulation-based approach and cognitive restricting. Similarly, social skills training appeared most suitable for reducing negative symptoms.
Lyman et al, 2014 [6]
17 systematic reviews and meta-analysis. 7 of which included social skills training.
Other reviews included social cognitive training, cognitive remediation and integrated approaches.		 Adults with mental disorders and substance use disorders.
Excluded were studies of populations with ASD, developmental disorder, Alzheimer’s disease, brain injury, intellectual disabilities, Parkinson’s disease and fatal alcohol spectrum disorder.		 Relapse, treatment compliance, global adjustment, social functioning, quality of life, psychotic symptoms, behavioural skills, self-efficacy, social role function, disease management, acquisition of social skills, psychopathology, hospitalization rates, content mastery, skill measures, community functioning and assertiveness.
Authors' conclusion:
“The current body of research has established the value of skill-building approaches. Although further research will help clarify their effects on some outcomes, research is not needed to support the decision to include skill-building approaches as covered services, particularly for individuals with schizophrenia and other psychotic disorders.”
Smith et al, 2009 [7]
1 systematic review including 9 RCTs and 2 subsequent RCTs. Individuals with schizophrenia or schizophrenia-related disorders. Severity of positive- and negative symptoms. Global clinical improvement, global clinical impression, rate of relapse, adherence to treatment and adverse effects.
Authors' conclusion:
"There is limited evidence that social-skills training diminishes relapse rate in schizophrenia. The time-consuming nature of this intervention can limit its availability.”

References

  1. Puolakka K, Pitkänen A. Effectiveness of psychosocial interventions on quality of life of patients with schizophrenia and related disorders: A systematic review. Archives of Psychiatric Nursing 2019.
  2. Turner D, MacBeth A, McGlanachy E, Hutton P, Cuijpers P, Van Der Gaag M, et al. A meta-analysis of social skills training and related interventions for psychosis. European Archives of Psychiatry and Clinical Neuroscience 2017;267:S86.
  3. McDonagh MS, Dana T, Selph S, Devine EB, Cantor A, Bougatsos C, et al. Treatments for Schizophrenia in Adults: A Systematic Review. Agency for Healthcare Research and Quality 2017;17:10.
  4. Almerie MQ, Okba Al Marhi M, Jawoosh M, Alsabbagh M, Matar HE, Maayan N, et al. Social skills programmes for schizophrenia. Cochrane Database of Systematic Reviews 2015:CD009006.
  5. Turner DT, van der Gaag M, Karyotaki E, Cuijpers P. Psychological interventions for psychosis: a meta-analysis of comparative outcome studies. American Journal of Psychiatry 2014;171:523-38.
  6. Lyman DR, Kurtz MM, Farkas M, George P, Dougherty RH, Daniels AS, et al. Skill building: assessing the evidence. Psychiatric Services 2014;65:727-38.
  7. 7. Smith TE, Weston CA, Lieberman JA. Schizophrenia (maintenance treatment). Clinical Evidence 2009;16:16.

Literature search

Embase via embase.com 2019-10-16
Social skills training for individuals with schizophrenia
/de = Term from the EMTREE controlled vocabulary; /exp = Includes terms found below this term in the EMTREE hierarchy; /mj = Major Topic; :ab = Abstract; :au = Author; :ti = Article Title; :ti,ab = Title or abstract; * = Truncation; ’ ’ = Citation Marks; searches for an exact phrase
Search terms Items found
Population:
1. 'schizophrenia'/exp 186,937
2. 'psychosis'/exp OR 'schizophrenia spectrum disorder'/exp OR 'schizotypal personality disorder'/exp OR 'schizoidism'/exp OR 'schizotypy'/exp OR 'schizophrenia assessment'/exp OR 'severe mental illness'/exp 301,574
3. Schizo*:ti,ab,kw OR (Paranoi* OR Psychosis* OR Psychotic OR Delusion* OR (Positive NEXT/2 Negative NEXT/1 Symptom$) OR Hallucin* OR ’Severe mental illness*’):ti,ab 268,335
4. 1 OR 2 OR 3 357,233
Intervention:
5. ((social OR personal OR psychosocial OR amplified OR interpersonal) NEXT/1 (skill$ OR ability* OR competence) NEXT/3 (program$ OR training$ OR education OR treatment$ OR therap* OR intervention$)):ti,ab,kw 2,160
6. (((skill$ OR 'independent living') NEXT/3 (program$ OR training$ OR education OR treatment$ OR therap* OR intervention$)):ti,ab,kw) AND ('social adaptation'/exp OR 'social competence'/exp) 2,159
7. ((functional OR 'functional adaptation' OR life OR 'social cogn*') NEXT/1 (skill$ OR ability* OR competence) NEXT/3 (program$ OR training$ OR education OR treatment$ OR therap* OR intervention$)):ti,ab,kw 649
8. 5 OR 6 OR 7 3,483
Study types:
9. [cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim 320,103
10. ‘systematic review’/exp OR ‘meta analysis’/exp 309,790
11. ((systematic* NEXT/1 review*):ab,ti,kw) OR 'meta analy*':ab,ti OR metaanaly*:ab,ti,kw 319,784
12. 9 OR 10 OR 11 411,138
Combined sets:
13. 4 AND 8 689
Final 12 AND 13 64

 

PsycINFO, SocINDEX & Psychology and Behavioural Sciences Collection via ebsco.com 2019-10-16
Social skills training for individuals with schizophrenia
The search result, usually found at the end of the documentation, forms the list of abstracts.; AB = Abstract; AU = Author; DE = Term from the thesaurus; MM = Major Concept; TI = Title; TX = All Text. Performs a keyword search of all the database's searchable fields; ZC = Methodology Index; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
Population:
1. DE "SCHIZOPHRENIA" 107,830
2. De ”Psychosis”  OR DE "Schizotypal Personality Disorder" OR DE "Schizotypy" OR DE "Positive and Negative Symptoms" OR DE "Schizophreniform Disorder" OR DE "Schizoid Personality Disorder" OR DE "Paranoia (Psychosis)" OR DE "Paranoid Schizophrenia" OR DE "Paranoia" OR DE "Paranoid Personality Disorder" OR DE "Delusions" OR DE "Hallucinations" OR DE "Hallucinosis" 26,523
3. DE "PSYCHOSES" OR DE "DEPERSONALIZATION" OR DE "HALLUCINATIONS & illusions" 13,041
4. (TI (Schizo* OR (Paranoi* OR Psychosis* OR Psychotic OR Delusion* OR (Positive W2 Negative W1 Symptom$) OR Hallucin* OR ’Severe mental illness*’))) OR (AB (Schizo* OR (Paranoi* OR Psychosis* OR Psychotic OR Delusion* OR (Positive W2 Negative W1 Symptom$) OR Hallucin* OR ’Severe mental illness*’))) 222,512
5. 1 OR 2 OR 3 OR 4 233,916
Intervention:
6. DE "SOCIAL skills training" OR DE "SOCIAL skills education" 4,894
7. (TI (social OR personal OR psychosocial OR amplified OR interpersonal) W1 (skill$ OR ability* OR competence) W3 (program$ OR training$ OR education OR treatment$ OR therap* OR intervention$)) OR (AB (social OR personal OR psychosocial OR amplified OR interpersonal) W1 (skill$ OR ability* OR competence) W3 (program$ OR training$ OR education OR treatment$ OR therap* OR intervention$)) 6,117
8. (TI ((skill$ OR 'independent living') W3 (program$ OR training$ OR education OR treatment$ OR therap* OR intervention$)) AND (DE “Social Adjustment” OR DE "Social Skills")) OR (AB ((skill$ OR 'independent living') W3 (program$ OR training$ OR education OR treatment$ OR therap* OR intervention$)) AND (DE “Social Adjustment” OR DE "Social Skills")) 2,253
9. (TI (functional OR 'functional adaptation' OR life OR 'social cogn*') W1 (skill$ OR ability* OR competence) W3 (program$ OR training$ OR education OR treatment$ OR therap* OR intervention$)) OR (AB (functional OR 'functional adaptation' OR life OR 'social cogn*') W1 (skill$ OR ability* OR competence) W3 (program$ OR training$ OR education OR treatment$ OR therap* OR intervention$)) 1,597
10. 6 OR 7 OR 8 OR 9 10,180
Study types:
11. (TI (systematic* n3 review*)) or (AB (systematic* n3 review*)) or (TI (systematic* n3 bibliographic*)) or (AB (systematic* n3 bibliographic*)) or (TI (systematic* n3 literature)) or (AB (systematic* n3 literature)) or (TI (comprehensive* n3 literature)) or (AB (comprehensive* n3 literature)) or (TI (comprehensive* n3 bibliographic*)) or (AB (comprehensive* n3 bibliographic*)) or (TI (integrative n3 review)) or (AB (integrative n3 review)) or (JN “Cochrane Database of Systematic Reviews”) or (TI (information n2 synthesis)) or (TI (data n2 synthesis)) or (AB (information n2 synthesis)) or (AB (data n2 synthesis)) or (TI (data n2 extract*)) or (AB (data n2 extract*)) or (TI (medline or pubmed or psyclit or cinahl or (psycinfo not “psycinfo database”) or “web of science” or scopus or embase)) or (AB (medline or pubmed or psyclit or cinahl or (psycinfo not “psycinfo database”) or “web of science” or scopus or embase)) or (MH “Systematic Review”) or (MH “Meta Analysis”) or (DE "Systematic Review") OR (DE "Meta Analysis") or (TI (meta-analy* or metaanaly*)) or (AB (meta-analy* or metaanaly*)) 319,897
Combined sets:
12. 5 AND 10 895
Final 11 AND 12 49

 

Medline via OVID 2019-10-16
Social skills training for individuals with schizophrenia
The search result, usually found at the end of the documentation, forms the list of abstracts.; AB = Abstract; AU = Author; DE = Term from the thesaurus; MM = Major Concept; TI = Title; TX = All Text. Performs a keyword search of all the database's searchable fields; ZC = Methodology Index; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
Population:
1. exp "schizophrenia spectrum and other psychotic disorders"/ 144,088
2. exp Schizophrenic Psychology/ OR paranoid personality disorder/ OR schizoid personality disorder/ OR schizotypal personality disorder/ OR delusions/ OR schizophrenic language/ OR Hallucinations/ OR exp Depersonalization/ 50,620
3. Schizo*.ti,ab,kw OR (Paranoi* OR Psychosis* OR Psychotic OR Delusion* OR (Positive ADJ1 Negative ADJ Symptom$) OR Hallucin* OR Severe mental illness*).ti,ab 193,878
4. 1 OR 2 OR 3 235,948
Intervention:
5. ((social OR personal OR psychosocial OR amplified OR interpersonal) ADJ (skill$ OR ability* OR competence) ADJ2 (program$ OR training$ OR education OR treatment$ OR therap* OR intervention$)).ti,ab,kw. 1,498
6. (((skill$ OR independent living) ADJ2 (program$ OR training$ OR education OR treatment$ OR therap* OR intervention$)).ti,ab,kw.) AND (exp social adjustment/ OR exp social competence/) 527
7. ((functional OR functional adaptation OR life OR social cogn*) ADJ (skill$ OR ability* OR competence) ADJ2 (program$ OR training$ OR education OR treatment$ OR therap* OR intervention$)).ti,ab,kw. 502
8. 5 OR 6 OR 7 2,134
Study types:
9. (((comprehensive* or systematic*) adj3 (bibliographic* or review* or literature)) or (meta-analy* or metaanaly* or "research synthesis" or ((information or data) adj3 synthesis) or (data adj2 extract*))).ti,ab. or (cinahl or (cochrane adj3 trial*) or embase or medline or psyclit or (psycinfo not "psycinfo database") or pubmed or scopus or "sociological abstracts" or "web of science").ab. or "cochrane database of systematic reviews".jn. or ((review adj5 (rationale or evidence)).ti,ab. and review.pt.) or meta-analysis as topic/ or Meta-Analysis.pt. 424,439
Combined sets:
10. 4 AND 8 383
Final 9 AND 10 48
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