Social Skills Training for Negative Symptoms of Schizophrenia.

Negative symptoms of schizophrenia account for much of the poor functional outcome in schizophrenia and are a significant unmet treatment need in a large proportion of patients.1,2 Reduction in negative symptoms could result in improved engagement in vocational, independent living, social and recreational activities. There is no doubt that effective treatment of negative symptoms in schizophrenia would have a profound effect on quality of life in people with schizophrenia and their families, as well as the mental health system and broader economy. Several expert recommendations, such as the NIMH-MATRICS Consensus Statement on Negative Symptoms,2 call for treatments for negative symptoms. The meta-analysis by Turner and colleagues in this issue reconfirms the efficacy of social skills training (SST) for improving social skills and reducing negative symptoms in people with schizophrenia. Numerous clinical trials have shown that SST has large effects on improving social skills and medium effects on reducing negative symptoms and improving functioning in people with schizophrenia. For example, a meta-analysis of 19 clinical trials by Pfammatter and colleagues3 found large significant benefits for skills acquisition, and medium effects for social functioning and general psychopathology. Another metaanalysis of 22 clinical trials by Kurtz and Mueser4 found very large effects for skill content mastery, moderate effect sizes for negative symptoms and community functioning, and small effects on other symptoms and relapse. These consistently-replicated findings that SST improves social skills, negative symptoms and functioning relative to standard care suggests that existing standard services for schizophrenia can be improved by adding SST. As Turner et al point out, these effects are in addition to any improvement in negative symptoms produced by pharmacological treatments, because nearly all patients in these trials receive medications. This new meta-analysis of 27 clinical trials by Turner and colleagues goes further to demonstrate significant medium effects on negative symptoms for SST relative to both standard care and active controls, as well as durable effects up to a year after treatment ended. Despite this evidence for efficacy, SST is not recommended in the UK NICE guidelines and is rarely delivered in the United Kingdom.5 SST is recommended in US guidelines (eg, American Psychiatric Association6; Patient Outcomes Research Team7), although not specifically for reducing negative symptoms. Despite decades of recommendations to deliver SST in the United States, SST is still rarely delivered. As Turner and colleagues point out, it is possible that a culture of individual cognitive-behavioral formulation-driven interventions may limit the availability of more behavioral group interventions in the United Kingdom. Cost-effective group therapy interventions are more common in community mental health systems in the United States, but SST is still rarely delivered. SST is also recommended in the Veterans Health Administration (VHA) system (eg, in the handbook for Psychosocial Rehabilitation and Recovery Centers, or PRRCs, for Veterans with severe mental illness), and the VHA provides a systematic rollout program to train and certify providers in SST delivery. This program has been fairly successful in improving access to SST for Veterans with severe mental illness. VHA provides funding for providers, a systematic training and consultation program, and mandates delivery of SST, and these factors likely facilitate the success of SST implementation in VHA. One of the barriers to implementation in the United States is the availability of qualified providers, but this may be a more important factor for implementation of