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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

A systematic review of the soteria paradigm for the treatment of people diagnosed with schizophrenia

T Calton, M Ferriter, N Huband, and H Spandler.

Review published: 2008.

Link to full article: [PMC free article: PMC2632384]

CRD summary

The authors concluded that the Soteria paradigm appears to be at least as effective as conventional medication-based treatment for people with first- or second-episode schizophrenia-spectrum disorders (achieving this with considerably lower use of medication).Given the few available studies, the inconclusive findings and incomplete reporting in the review, these conclusions should be regarded with caution.

Authors' objectives

To assess the efficacy of the Soteria paradigm for people diagnosed with schizophrenia-spectrum disorders.


MEDLINE, EMBASE, CINAHL, PsycINFO and the Cochrane Library were searched to June 2005 using search terms recommended by the Cochrane Schizophrenia Group (http://szg.cochrane.org/en/index.html) plus the term 'Soteria'. Experts and organisations interested in alternative treatment approaches for schizophrenia were approached. The references of retrieved articles were handsearched, as were the journals: Acta Psychiatrica Scandinavica, The American Journal of Psychiatry, Archives of General Psychiatry, The British Journal of Psychiatry, The Journal of Nervous and Mental Diseases, Psychological Medicine, Social Psychiatry and Psychiatric Epidemiology, and Schizophrenia Bulletin (all from January 1975 to June 2005). There was no language restriction. Only peer-reviewed evaluations were eligible.

Study selection

Controlled studies of the Soteria paradigm were eligible for inclusion provided they included adults or adolescents diagnosed with schizophrenia, schizotypal or delusional disorders by International Classification of Diseases, 10th Revision (ICD-10) criteria or with schizophrenia spectrum disorders by Diagnostic and Statistical Manual for Mental Disorders (DSM) criteria. The Soteria core principles were defined as: provision of a small therapeutic community with a high level of lay-person staffing; efforts to preserve personal power, social networks and group responsibilities; a phenomenological approach aiming to understand and give meaning to the subjective experience of psychosis; and no or minimal use of antipsychotic drugs (with any drugs taken being by choice rather than coercion). Eligible programmes described themselves as Soteria communities, were linked to the original Soteria community, used the core therapeutic elements of the Soteria programme or were explicitly modelled on Soteria principles. Studies using the name Soteria but not adhering to these core therapeutic principles were excluded. There were no specific inclusion criteria with respect to outcomes.

Participants in included studies had a first episode of disorder or a single previous episode, with hospitalisation for no more than 30 days. They were aged from 15 to 35 years. One study excluded people with drug or alcohol dependency or who were non-compliant with treatment.

A large number of outcomes were reported in the included studies (for example, number and duration of readmissions to full time care, score on psychopathology scale, functional measures, relapse rate and average medication dose), measured at two year follow-up.

Two reviewers selected studies for inclusion independently.

Assessment of study quality

The reviewers gave details of randomisation procedures, but did not describe systematic assessment of other aspects of study validity for all primary studies.

Data extraction

Descriptive data were reported in a table and in the text, indicating which study outcomes had significant results. The review used the threshold of p<0.05 to denote statistical significance. The results of the two US studies were reported jointly, but it was unclear whether the data had been pooled by the primary investigators or by the reviewers. Two reviewers extracted the data independently, with adjudication by a third reviewer if necessary.

Methods of synthesis

The studies were combined in a narrative synthesis. Heterogeneity between the studies was discussed briefly in the text.

Results of the review

Three controlled trials (n=223) were included in the review: one RCT (n=100); one quasi-experimental study (n=79); and one study (n=44) with matched controls. One of the RCTs and the quasi-experimental study were undertaken by the same US study group and reported in 13 different publications.


The RCT failed to describe the randomisation procedure. The RCT and quasi-experimental study (US studies) were not reported clearly. The dropout rate in these two studies combined was 12 per cent (19/179). Dropouts were excluded from analysis. No power calculation was reported. The quality of the case-control study was not reported in the review.

Treatment effectiveness

The US studies reported results for participants who completed two years’ follow up for all completers (n=129) plus participants who had not completed follow up (endpoint, n=160) and for completers adjusted for attrition. The intervention group was significantly more likely than hospital-treated controls to be living independently (p<0.05 by endpoint analysis) and to have improved global psychopathology (completers analysis, p<0.05). After statistical adjustment for attrition, significant benefit was evidence for completers for a composite outcome (of unspecified nature), global psychopathology and number of readmissions (p<0.05). There was no significant difference between the groups for any other outcomes of the 30 comparisons in these studies regardless of the type of analysis used, though the direction of effect favoured the intervention. In the case-control study, at two year follow up the mean daily dose of medication and the total dose of medication were significantly lower in the intervention group (p<0.01 versus <0.05). However, there were no statistically significant differences between the groups in Brief Psychiatric Rating Scale scores, housing/job situation, a composite measure of the previous or relapse rate.

Cost information

The US studies described the Soteria intervention as slightly cheaper than conventional care. The case-control study described it as initially more expensive, but an economic evaluation of the study noted that relocation of rehabilitative care to specialised local community-based units could reduce costs.

Authors' conclusions

The Soteria paradigm appears to be at least as effective as conventional medication-based treatment for people with first- or second-episode schizophrenia spectrum disorders (achieving this with considerably lower use of medication).

CRD commentary

The objective of the review and the inclusion criteria for participants, interventions and study design were stated clearly. The literature search was extensive. Steps were taken to minimise the risk of error and bias in study selection and data extraction by having more than one reviewer make decisions independently. However, no systematic assessment of study validity was reported and some important details about the primary studies were unclear (for example, the study with matched controls was also described as randomised). Given the few available studies, the inconclusive findings and incomplete reporting in the review, the authors' conclusions should be regarded with caution.

Implications of the review for practice and research

Practice: the authors stated that although the Soteria paradigm cannot currently be recommended as standard treatment for people diagnosed with schizophrenia-spectrum disorders, it is promising as an alternative treatment.

Research: the authors stated that further research is required into the Soteria paradigm and other minimal-medication approaches. Studies should use rigorous quantitative and qualitative approaches with user-centred outcomes and long-term follow up. Subgroup analyses may help identify which groups of people benefit most from alternative approaches.


Not stated.

Bibliographic details

Calton T, Ferriter M, Huband N, Spandler H. A systematic review of the soteria paradigm for the treatment of people diagnosed with schizophrenia. Schizophrenia Bulletin 2008; 34(1): 181-192. [PMC free article: PMC2632384] [PubMed: 17573357]

Indexing Status

Subject indexing assigned by NLM


Algorithms; Hospitalization /statistics & numerical data; Humans; Patient Admission /statistics & numerical data; Schizophrenia /diagnosis /drug therapy /rehabilitation; Social Behavior



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 17573357


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