TECHNICAL COMMENTARY Psychosocial Treatments – Group Therapy Introduction Group therapy refers to any psychosocial therapy that is administered in a group setting. It can include specific cognitive or behavioural therapies. It is often utilised in inpatient settings. The usefulness of group therapy has been examined in the context of improving illness outcomes such as symptom severity and quality of life, medication compliance and particularly social interaction and anxiety. It has also been investigated for treatment of patients with dual diagnoses.
Method We have included only systematic reviews (systematic literature search, detailed methodology with inclusion/exclusion criteria) published in full text, in English, from the year 2000 that report results separately for people with a diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder or first episode schizophrenia. As part of a wider search for all topics included in the library, review articles on group therapy for schizophrenia were identified by searching the databases of MEDLINE, EMBASE, CINAHL, Current Contents, PsycINFO and the Cochrane library. Hand searching reference lists of identified reviews was also conducted. When multiple copies of reviews were found, only the most recent version was included. The decision to include or exclude reviews was conducted in duplicate by two independent reviewers with any disagreements settled by discussion. All quality assessments and data extraction have been completed in duplicate by two reviewers who were not masked to review authors. Review reporting assessment was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist (formerly the QUOROM statement) which describes a preferred way to present a meta-analysis[1]. Reviews were assigned a low, medium or high possibility of reporting
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bias* depending on how many items were checked. For instance, a low possibility of bias would be assigned to reviews checking over 66% of items, a medium possibility between 33 and 66% and a high possibility would be given to reviews checking less than 33%. Reviews rated as having a high possibility of reporting bias have been excluded from the library. The PRISMA flow diagram is a suggested way of providing information about studies included and excluded with reasons for exclusion. Where no flow diagram has been presented by individual reviews, but identified studies have been described in the text, reviews have been checked for this item. Note that early reviews may have been guided by less stringent reporting checklists than the PRISMA, and that some reviews may have been limited by journal guidelines. Evidence was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group approach where high quality evidence such as that gained from randomized controlled trials (RCT) may be downgraded to moderate, low or very low if review and study quality is limited, if there is inconsistency in results, indirect comparisons, imprecise or sparse data and high probability of reporting bias. It may also be downgraded if risks associated with the intervention or other matter under review are high. Conversely, low quality evidence such as that gained from observational studies may be upgraded if effect sizes are large or if there is a dose dependent response. We have also taken into account sample size and whether results are consistent, precise and direct with low associated risks (see end of table for an explanation of these terms)[2]. The resulting table represents an objective summary of the available evidence, although the conclusions are solely the opinion of staff of the Schizophrenia Research Institute.
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TECHNICAL COMMENTARY Psychosocial Treatments – Group Therapy Results See table below for a detailed summary of the available evidence pertaining to group therapy. We found four systematic reviews that met our inclusion criteria [3-6]. See PRISMA checklist for assessment of reporting transparency.
Conclusions • Moderate quality evidence suggests that group psychotherapy paradigms showed some effectiveness for improving symptom severity, social interaction and verbalising, and may be more effective than individual therapy for improving symptoms and social interactions associated with schizophrenia spectrum disorders. There was no benefit of group psychotherapy for overall illness severity, illness management skills, medication compliance, or polydipsia. Having single or multiple group leaders had no effect on illness severity. Group CBT showed some benefit for reducing the number and severity of positive and negative symptoms and social anxiety levels. Other group behavioural training paradigms had some effectiveness for improving global state (but not symptoms or quality of life), while group coping skills’ training paradigms improved goal attainment behaviour.
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TECHNICAL COMMENTARY Psychosocial Treatments – Group Therapy Drake R.E., O'Neal E.L., Wallach M.A.
A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders Journal of Substance Abuse Treatment, 2008. 34(1): p. 123-138 View review abstract online Comparison
Integrated group therapy, education and medication management for psychoactive substance abuse vs. treatment as usual for 8 months Note: only samples with defined schizophrenia spectrum disorders are reported
Summary of evidence
Low quality evidence (direct, small sample size, unable to assess consistency or precision) is unclear as to any benefit of integrated group therapy for reducing substance use, or improving mental state or global function
Global outcomes: Mental health and substance use One trial, N = 47, integrated group therapy with treatment as usual and reported no difference in mental health outcomes, psychoactive substance use, or hospitalisation rate but some improvement in attrition Risks
No adverse effects reported
Consistency in results
No measure of consistency reported
Precision in results
No measure of precision reported
Directness of results
Direct
Kösters, M., Burlingame, G.M., Nachtigall, C., and Strauss, B.
A meta-analytic review of the effectiveness of inpatient group
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TECHNICAL COMMENTARY Psychosocial Treatments – Group Therapy psychotherapy Group Dynamics, 2006. 10(2): p. 146-163 View review abstract online Comparison
Inpatient group psychotherapy interventions vs. various comparisons, including standard inpatient care, alternative therapy or waitlist. Sample contained several psychiatric disorders, but 54% had a schizophrenia diagnosis
Summary of evidence
High to moderate quality evidence (consistent, precise, direct, large sample, unclear outcome measures) suggests a small benefit of group psychotherapy for improving unspecified illness outcomes for a sample of hospital inpatients with mixed diagnoses Illness severity
24 studies, N = 1366, investigated group psychotherapy. Most studies utilized psychotherapy with a cognitive/behavioural orientation Small effect size suggests some benefit of group psychotherapy for improving patient outcome (specific illness outcomes not defined) †
d = 0.31, 95%CI 0.21 to 0.41 Q = 34.4, p = 0.35 Random effects model
Risks
Not reported
Consistency in results‡
Consistent. A pooled effect size was reported because the effect was consistent across diagnoses
Precision in results§
Precise
Directness of results║
Direct
Comparison
Pre-post measurement following inpatient group psychotherapy interventions in schizophrenia patients (no control group)
Summary of evidence
Moderate quality evidence (consistent, precise, direct, small number of pre-post studies) suggests moderate benefit of group psychotherapy for improving unspecified illness outcomes for hospital inpatients with schizophrenia
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TECHNICAL COMMENTARY Psychosocial Treatments – Group Therapy Illness severity 4 studies, N unclear, investigated group psychotherapy. Most studies utilized psychotherapy with either a cognitive/behavioural or a psychodynamic orientation Small effect size suggests some benefit of group psychotherapy for improving patient outcome (specific illness outcomes not defined) d = 0.50, 95%CI 0.33 to 0.66 Q = not reported, p = 0.48 Random effects model Risks
Not reported
Consistency in results
Consistent
Precision in results
Precise
Directness of results
Direct
Lockwood, C., Page, T., and Conroy-Hiller, T.
Systematic review: effectiveness of individual therapy and group therapy in the treatment of schizophrenia. JBI Reports, 2004. 2(10): p. 309-338 View review abstract online Comparison
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Group interventions vs. either passive or active control in schizophrenia patients
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TECHNICAL COMMENTARY Psychosocial Treatments – Group Therapy Summary of evidence
Moderate quality evidence (direct, small to moderate sample sizes, mostly imprecise and unable to assess consistency) suggests that group psychotherapy paradigms showed effectiveness for improving symptom severity (BPRS), social interaction and verbalising, and may be more effective than individual therapy for improving symptoms and social interactions. There was no benefit of group psychotherapy for illness severity (OSIS), illness management skills, medication compliance, or polydipsia. Having single or multiple group leaders had no effect on illness severity. Group CBT showed some benefit for improving the number and severity of positive and negative symptoms and social anxiety levels. Group behavioural training had some effectiveness for improving global state (but not symptoms or quality of life), while group coping skills training paradigms improved goal attainment behaviour.
Illness outcomes: group therapy interventions vs. passive and active controls Group psychotherapy One RCT, N = 26, compared group psychotherapy to a control group (an individual therapy provided on request), and reported Overall Severity of Illness Scale (OSIS) ratings significantly favoured the control condition over group psychotherapy OR = 7.62, 95%CI 1.21 to 47.98, p = 0.03 A second comparison in this RCT, N = 33, compared group psychotherapy to group tasks without a therapy focus, and reported Overall Severity of Illness Scale ratings non-significantly favoured the active control condition over group psychotherapy OR = 3.89, 95%CI 0.81 to 18.68, p = 0.09 One study, N = 41, compared group psychotherapy to a modular skills training program (UCLA Social and Independent Living Skills Program). Skills’ training was associated with significantly better medication and illness management than psychotherapy at 6 and 12 month follow up, but no difference was reported between groups for symptom severity. Both skills training and psychotherapy significantly improved BPRS (p < 0.001) and SANS (p < 0.02) scores One study, N = 14, examined the effect of rotating group leaders on illness severity and global function. Three groups were compared: rotating leaders; co-leaders; and single leader. No effect of leadership was reported for BPRS, GAS or Maslach Burnout Inventory Scale scores. One RCT, N = 87, investigated intensive group CBT (GCBT) plus routine care, compared with supportive counselling plus routine care, or routine care alone. GCBT was the best predictor for positive outcome (p = 0.0045) and significantly improved the number of positive symptoms (p = 0.009) and their severity (p = 0.006).
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TECHNICAL COMMENTARY Psychosocial Treatments – Group Therapy Follow up at 12 months (N = 70) and 24 months (N = 61) both reported GCBT and supportive counselling improving the number of both positive and negative symptoms experienced (p < 0.05). Group behavioural training One study, N = 40, assessed group interactive behavioural training (cognitive and behavioural strategies, group process strategies) compared to wait list control. Quality of life, CGI, BPRS and Behavioural Assessment Task showed no post-treatment improvement compared to control. GAS showed significant improvement in IBT group, p < 0.05 compared with pre-treatment score One study, N = 14, compared group coping skills training with group problem-solving training. Both treatment groups significantly improved goal attainment scores (GAtS) compared to pretreatment scores, however coping skills training had greater GAtS improvement and also showed maintenance of improvement at follow up, compared to problem-solving Behaviour outcomes: group therapy interventions vs. passive and active controls Group psycho-educational training for medication compliance One study, N = 191, compared group psycho-educational training with a control condition (unstructured group activities). There was better study retention in intervention group compared to control (N = 112, OR = 3.320, 95%CI 1.09 to 9.391, p = 0.03) , but not at 1 year follow up Results favoured the group intervention over control for improving medication compliance at both pre-treatment (N = 191, OR = 0.29, 95%CI 0.16 to 0.54, p < 0.0001) and at post-treatment (N = 191, OR = 0.53, 95%CI 0.29 to 0.99, p = 0.05), but this was not retained at 1 year follow up There was no difference between groups for improving confidence with self-management of medication, symptom scores or social function Group psychotherapy for social withdrawal One study, N = 32, compared group psychotherapy (including re-motivational therapy alone or combined with recreational activities or discussions of social living) with a waiting list control. Patients receiving re-motivational therapy alone or in combination with recreational activities had significantly higher levels of social interaction and verbalisation than those who received social living discussion or controls (p < 0.01). Group psychotherapy for polydipsia One study, N = 12, compared group psychotherapy with standard hospital treatment. Polydipsia was reduced in treatment group compared with controls (p = 0.033) at post-treatment, however by 2 month follow up any effect was lost. Group cognitive behavioural therapy for social anxiety
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TECHNICAL COMMENTARY Psychosocial Treatments – Group Therapy One study, N = 41, compared group CBT (GCBT, 12 weekly 2hr sessions) with a waiting list control in a community health setting (stable symptoms). Post-treatment, GCBT had significantly greater improvement (p < 0.02 for all scales) in social phobia (BSPS, SIAS), fear of negative evaluation (BFNE), depression (CDSS), global severity (GSI), and quality of life (QLESQ). Group psychotherapy vs. individual psychotherapy Group vs. individual psychotherapy for symptom severity and social effectiveness One study, N = 191, compared group psychotherapy with individual psychotherapy (treatment regime unclear) Over a 24-month follow up, group therapy was significantly more effective than individual therapy for improving symptom severity and social effectiveness, measured as no rehospitalisation, and >20% improvement on BPRS and social effectiveness scales (N = 87, OR = 23.33, 95%CI 2.9 to 187.54, p = 0.003). Any positive effects below this cut-off ( 1) in a particular outcome in a treatment group, or a group exposed to a risk factor, relative to the comparison group. For example, a RR of 0.75 translates to a reduction in risk of an outcome of 25% relative to those not receiving the treatment or not exposed to the risk factor. Conversely, a RR of 1.25 translates to an increased risk of 25% relative to those not receiving treatment or not having been exposed to a risk factor. A RR or OR of 1.00 means there is no difference between groups. A large effect is considered if RR > 2 or < 0.5 and a very large effect if RR > 5 or < 0.2[8]. lnOR stands for logarithmic OR where a lnOR of 0 shows no difference between groups. Hazard ratios
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TECHNICAL COMMENTARY Psychosocial Treatments – Group Therapy measure the effect of an explanatory variable on the hazard or risk of an event. Correlation coefficients (eg, r) indicate the strength of association or relationship between variables. They can provide an indirect indication of prediction, but do not confirm causality due to possible and often unforseen confounding variables. An r of 0.10 represents a weak association, 0.25 a medium association and 0.40 and over represents a strong association. Unstandardized (b) regression coefficients indicate the average change in the dependent variable associated with a 1 unit change in the independent variable, statistically controlling for the other independent variables. Standardized regression coefficients represent the change being in units of standard deviations to allow comparison across different scales.
‡ Inconsistency refers to differing estimates of effect across studies (i.e. heterogeneity or variability in results) which is not explained by subgroup analyses and therefore reduces confidence in the effect estimate. I² is the percentage of the variability in effect estimates that is due to heterogeneity rather than sampling error (chance) - 0% to 40%: heterogeneity might not be important, 30% to 60%: may represent moderate heterogeneity, 50% to 90%: may represent considerable heterogeneity and over this is considerable heterogeneity. I² can be calculated from Q (chi-square) for the test of heterogeneity with the following formula[7];
§
Imprecision refers to wide confidence intervals indicating a lack of confidence in the effect estimate. Based on GRADE recommendations, a result for continuous data (standardised mean differences, not weighted mean differences) is considered imprecise if the upper or lower confidence limit crosses an effect size of 0.5 in either direction, and for binary and correlation data, an effect size of 0.25. GRADE also recommends downgrading the evidence when sample size is smaller than 300 (for binary data) and 400 (for continuous data), although for some topics, these criteria should be relaxed[8].
║ Indirectness of comparison occurs when a comparison of intervention A versus B is not available but A was compared with C and B was compared with C which allows indirect comparisons of the magnitude of effect of A versus B. Indirectness of population, comparator and/or outcome can also occur when the available evidence regarding a particular population, intervention, comparator, or outcome is not available and is therefore inferred from available evidence. These inferred treatment effect sizes are of lower quality than those gained from head-tohead comparisons of A and B.
Many thanks to Dr Helen J. Stain for reviewing this summary of evidence The Rural and Remote Mental Health (Orange, NSW) and the University of Newcastle, NSW Schizophrenia Research Institute
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TECHNICAL COMMENTARY Psychosocial Treatments – Group Therapy References 1. Moher, D., et al., Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009. 151(4): p. 264-269. 2. GRADEWorkingGroup, Grading quality of evidence and strength of recommendations. BMJ 2004. 328: p. 1490. 3. Kosters, M., et al., A meta-analytic review of the effectiveness of inpatient group psychotherapy. Group Dynamics, 2006. 10(2): p. 146-163. 4. Lockwood, C., T. Page, and T. Conroy-Hiller, Systematic review: effectiveness of individual therapy and group therapy in the treatment of schizophrenia. JBI Reports, 2004. 2(10): p. 309-338. 5. Zygmunt, A., et al., Interventions to improve medication adherence in schizophrenia.[see comment]. American Journal of Psychiatry, 2002. 159(10): p. 1653-64. 6. Drake, R.E., E.L. O'Neal, and M.A. Wallach, A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. Journal of Substance Abuse Treatment, 2008. 34(1): p. 123-138. 7. CochraneCollaboration, Cochrane Handbook for Systematic Reviews of Interventions, 2008. 8. GRADEpro, [Computer program]. Jan Brozek, Andrew Oxman, Holger Schünemann. Version 3.2 for Windows 2008.
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