11 October 2011.In Revision this week , comment later.
Cognitive therapy can have beneficial effects on functional recovery for low-functioning, neurocognitively impaired patients with schizophrenia, according to a new report in the Archives of General Psychiatry by Paul M. Grant of the University of Pennsylvania and colleagues.
In a small, single-center study, patients who received cognitive therapy with standard treatment for 18 months demonstrated clinically meaningful improvement versus those who received standard therapy alone.
Specifically, improvement in global functioning and motivation, and a reduction of positive symptoms was observed.
The authors indicate cognitive treatment may have utility in improving quality of life for poorly functioning schizophrenia patients, with potential to reduce costs.Antipsychotic reduces positive symptoms, but is less effective for negative symptoms, leaving a significant minority of patients with debilitating residual symptoms.
Last summer, at the 13th International Congress on Schizophrenia Research, a session entitled "What really improves people's lives?" included 10 talks focused on predictors of how well people with schizophrenia live and what interventions will help them live better
Overall, empirical support was strongest for cognitive remediation.
One study also noted the importance of motivation as a predictor of long-term functional outcome in a small sample of schizophrenia patients.Last year, a large, year-long, Chinese study by Guo and colleagues reported improved clinical outcome for patients who received combination therapy (standard medication treatment with 48 hours of psychosocial treatment)
The psychosocial component, which included group sessions, skills training, and cognitive behavioral therapy, appeared to improve how participants lived and integrated into society, though it was impossible to tease apart which aspect of psychosocial therapy was most beneficial.
More recently, a meta-analysis by Swedish researchers, Sarin and colleagues (Nord et al., 2011) found support for cognitive behavioral therapy in improving positive, negative, and general symptoms over other psychological treatments."A dynamic cycle of recovery" In their study published in the October 2011 issue of Archives of General Psychiatry, Grant and colleagues report on 60 schizophrenia patients who were randomized into equal groups to receive standard therapy (ST) with or without cognitive therapy (CT) for 18 months, and assessed for functional and symptom outcomes at six-month intervals.Eligibility required patients to have a DSM-IV diagnosis of schizophrenia or schizoaffective disorder with at least moderate severity on two global subscales of the Scale for the Assessment of Negative Symptoms (SANS), or marked severity on one subscale.
Standard therapy included, at the minimum, antipsychotic pharmacotherapy, and likely included other services ( e.g., day treatment, supportive counseling, peer support).
In addition to ST, the test group received weekly outpatient Cognitive Therapy sessions of flexible frequency and duration.
Goal-directed, personalized treatment planningm characterized the sessions, which focused on stimulating interest and motivation on achievable long-term, intermediate, and short-term goals.
Dysfunctional beliefs (e.g., "making new friends isn't worth the energy it takes") were addressed in a variety of ways (e.g., outings, role playing, and other exercises), and positive symptoms were addressed using strategies described in a recent text by coauthor Aaron Beck and colleagues
(Beck AT, Rector NA, Stolar NM, Grant PM. Schizophrenia: Cognitive Theory, Research and Therapy. New York, NY: Guilford Press;
2009). Visual aids such as white boards, flash cards, and take-home signs were also used to offset neurocognitive impairment.
The authors used the Global Assessment Scale (GAS), four global subscale scores of the SANS, and the total score of the Scale for the Assessment of Positive Symptoms (SAPS) to assess clinically significant changes in function.
A majority of the patients completed 18 months of treatment (27/31 [87.1 percent] CT+ST; 24/29 [82.8 percent] ST). No meaningful differences in medication at baseline or through the study emerged.
The CT group was significantly younger, which was controlled for in the analyses. Global functioning improved in the CT group over the course of the study, whereas the ST group improved very little (within-group Cohen d = 1.36 vs. d = 0.06), and a statistically significant improvement was observed between groups favoring CT (adjusted mean [SE], 58.3 [3.30] vs. 47.9 [3.60], respectively; d = 0.56, P = 0.03).
With respect to symptomatology, the CT group fared better than the ST group.
Over the 18-month study, the total score of positive symptoms was reduced in the CT group (within-group d = -0.90 vs. 0.37, respectively; P = 0.04; adjusted mean [SE], 9.4 [3.3] vs. 18.2 [3.8], respectively; between-group d = -0.46).
However, only one subscale of the SANS showed advantage for the CT group. Avolition-apathy improved for those who received CT (within-group d = -2.16 vs. -0.45, respectively, at 18 months, P = 0.01; adjusted mean [SE], 1.66 [0.31] vs. 2.81 [0.34], respectively; between-group d = -0.66), but no differences were observed between the CT and ST groups for affective flattening, alogia, or anhedonia-asociality.
The authors propose that patients receiving CT entered into a "dynamic cycle of recovery"— that the CT encouraged patients to set goals and motivated them to engage in tasks that eased them out of their withdrawn state.
By this model, the increase in activity and motivation in turn led to a reduction of positive symptoms, which promoted further engagement and better functional outcomes, extending the cycle to continued improvement of positive symptoms.
Grant and colleagues go on to hypothesize that "CT triggers the cycle of recovery by targeting self-defeating and dysfunctional beliefs that inhibit the patients’ active engagement in constructive activity."
An alternative explanation, the authors acknowledge, is that improvement in avolition-apathy is secondary to amelioration of positive symptoms.
In their editorial accompanying the article, Douglas Turkington of Newcastle University and Anthony P. Morrison of the University of Manchester, both in the U.K., endorse the results of this study, writing that,
"Grant et al. demonstrate that cognitive therapy, which is based on a cognitive model that implicates fear of failure and corresponding behaviors aimed at preventing this, can improve persistent negative symptoms in a challenging clinical population."
Whatever the mechanism, if the results can be confirmed, a treatment that reduces negative symptoms or otherwise increases motivation for low-functioning, chronically ill schizophrenia patients could help break down a major impediment to their functional reintegration into society.—J. Meggin Hollister.
Comment by someon with a a Rehabilitation expereince.
This study of a well-established, psychosocial treatment, which has been documented to be effective for depression, anxiety disorders, and positive symptoms of schizophrenia presents credible evidence of efficacy for some, but not all, negative symptoms and possibly for social functioning in schizophrenia.
The study has a number of strong methodological features; for example, protecting the “blind” for assessors, appropriate frequency and duration of treatment sessions necessary to achieve therapeutic outcomes in this population, controls for differences in types and doses of antipsychotic medication,
a “standard treatment” comparison group which is consistent with the vast majority of community mental health, a sample that includes different racial and ethnic groups consistent with an inner-city population, and appropriate statistical analyses for measuring outcome.
My comments address a number of concerns that may attenuate the clinical significance of the authors’ findings and interpretations.Selection Criteria for Subjects
In fact, it is likely that they had secondary negative symptoms because, as noted by the authors, the subjects showed significant reductions in positive symptoms and social anxiety, which often are associated with reductions of negative symptoms.
While the subjects were described as “low functioning” and “highly regressed,” the eligibility criteria for entry into the study did not use a well-established and psychometrically sound assessment instrument for measuring social functioning.
For some inexplicable reason, the Global Assessment Scale was chosen as the measure of “social functioning,” despite the authors appropriately pointing out how the GAS confounds symptoms with functioning and has woefully inadequate anchor points for rating psychosocial adjustment and poor inter-rater reliability.
The finding that, at baseline, their subjects were rated by the GAS in the mid- to high 40s suggests functioning that reflects “serious symptoms” and “serious impairment in social occupational or school functioning,” with the latter exemplified by “no friends” and “unable to keep a job.” T
his range in the GAS is hardly consistent with schizophrenia patients who are “repressed” and “severely socially impaired.”
Individuals with schizophrenia who are low functioning would ordinarily fall into the 25-40 range on the GAS (e.g., “unable to work,” “socially isolated with little contact with other persons outside the family”).
Many persons with schizophrenia who would not be considered “low functioning,” even those in remission of their positive and negative symptoms, have no friends and are unable to keep a job.
While the authors point out in their discussion that the GAS is a poor indicator of social functioning, it is not clear why they chose this instrument for their design, since it is well known that the GAS has poor inter-rater reliability, poor anchor points, and confounds symptoms with functioning ().
The authors fail to describe specific improvements in social functioning that would convince readers that the cognitive therapy resulted in clinically significant improvements in work, school, friendships, family life, self-care skills, medication and money self-management, independent living, and other convincing examples of successes in community living.
The therapeutic methods as described by the authors clearly confound cognitive therapy procedures with those developed and validated for social skills training
For example, as described in the description of cognitive therapy, the following techniques were used that are key elements of social skills training in particular, and other evidence-based practices for the treatment of schizophrenia as well (e.g., supported employment, behavioral family therapy and its variants, assertive community treatment, cognitive adaptive therapy):
• Goal-directed framework and personalized treatment planning
• Engaging the patient and strengthening the therapeutic relationship
• Therapy aimed to stimulate patients’ interest and motivation on achievable long-term, intermediate, and short-term goals
• Interpersonal exercises, games, role playing, community outings, and action plans for practice outside the session (i.e., “homework assignments”)
• Treatment tailored to the participant’s level of functioning with special adaptations for problems due to poor engagement, neurocognitive impairment, thought disorder, and lack of insight
• Prompts and signs in the home to remind the subjects to complete daily activities and other therapy assignmentsSpecificity of Cognitive Therapy for Negative Symptoms
It is possible that the many elements in the experimental treatment condition that were similar to those used in social skills training, rather than the specific cognitive interventions, could have brought about the improvements reported in negative symptoms and social functioning.
Contrary to the assertion of the authors that “studies of other psychosocial, behavioral, or cognitive remediation interventions…[have failed]…to find that treatment effects generalized adequately to psychosocial functioning,” there are a number of evidence-based, psychosocial treatments that have been shown to significantly improve psychosocial functioning and negative symptoms.
These include social skills training, behavioral family management, supported employment, and assertive community treatment (Falloon et al., 1999; ; ; ).
The authors give examples of how subjects’ symptoms interfered with social functioning, such as social anxiety and positive symptoms of schizophrenia. Since anxiety disorders are very common comorbidities in schizophrenia and have been shown to be responsive to cognitive therapy (), it is possible that the cognitive therapy improved social interaction and adjustment by reducing anxiety.
It is also possible, as noted by the authors, that the cognitive therapy brought about reductions in three of the four domains of negative symptoms secondarily as a function of rather marked decrease in positive symptoms.
The reductions in positive symptoms were much greater than the rather small reductions in negative symptoms.
This reverse direction of causality is acknowledged as a possible explanation of their results on negative symptoms by the authors in their Comment section.
One finding of the authors strongly suggests that the cognitive therapy did not produce improvements in psychosocial functioning by reducing negative symptoms.
In Figure 3, it is clearly seen that the cognitive therapy had nil therapeutic impact on alogia, which is the critical negative symptom that would be expected to mediate improved social functioning.
If subjects’ speech and conversational skills showed little improvement, it is questionable to attribute improvements in social interaction and relationships to the other three negative symptoms.
The non-specific effects of 18 months and 50 sessions of community-based activities and homework assignments to attain incremental goals, instigated by competent, upbeat, and engaging therapists, would be expected to reduce apathy, anhedonia, and flat affect temporarily—which might rapidly erode once the spirited and therapeutically active sessions ended.
Also acknowledged by the authors in their Comment section is the possibility that improvements in three of four negative symptoms and marginal changes in social functioning (difficult to conceptualize without more behaviorally specific examples and typologies of goals attained in the arenas of social functioning) might be attributed to non-specific factors in the therapeutic relationships and instigative array of interventions used in the active therapy condition.
As they point out, it may be appropriate to withhold an evidence-based attribution of the therapeutic benefits found in this study until a study is conducted with a comparison treatment equated for therapist enthusiasm, duration, time involvement, and other elements not specifically related to cognitive therapy.
Finally, one further cautionary note stems from the failure of the investigators to assess adherence to medication in the two treatment conditions.
While the prescribed types and doses of medication did not differ between the conditions, it is well known that adherence to medication regimens is rather poor among persons with schizophrenia.
Improved adherence to pharmacotherapy may have contributed to the superior therapeutic outcomes, given the fact that the therapists in the cognitive therapy program offered “personalized treatment” that included “laminated cards” and “colorful signs that patients posted at home to remind them of daily activities and other therapy assignments” which may have included concrete or implicit reminders to take their medication.
Further CommentThe primary outcome variable (the GAS) has marked limitations and does not provide objective or detailed information about any changes in social or occupational functioning in the community.
Thus, the authors' conclusion that "cognitive therapy can be successful in promoting clinically meaningful improvements in functioning" is not supported by the data.
We simply do not know much about community functioning beyond what the patients report, and the reports are especially suspect given that subjects receiving the cognitive therapy attended weekly sessions with a study therapist in which a primary focus of discussions was enhancing community activities and role functioning.
A related concern pertains to the course of change noted on both the GAS and SANS ratings. The graphic representation of the data indicates that most, if not all, of the change manifested across measures occurred before the first (six-month) assessment.
This raises questions about the operating mechanism of the CT intervention, as well as the value of the succeeding 12 months of treatment.
As stated in the article, "Early sessions focused on engaging the patient and strengthening the therapeutic relationship." This implies that any changes induced during that early period may have resulted from non-specific effects rather than any specific cognitive therapy activities.
Given that (almost) no community program could afford to administer a weekly individual treatment for 18 months, it should be underscored that at best, the data do not support anything beyond six months of treatment.Another important issue noted by Liberman was the multifaceted composition of the CT intervention.
It included elements of cognitive therapy, skills training, behavior therapy, motivational enhancement, and cognitive remediation, among others. In fact, it is difficult to justify calling the intervention "cognitive therapy" when so little of it entails cognitive therapy per se.
While most of the elements have face validity and independent empirical support, the resulting combination has two significant limitations.First, it is impossible to determine the active components of the treatment.
Second, it would be virtually impossible to replicate or disseminate the intervention. This latter point is of particular concern, as the trial has been reported in the media as demonstrating that cognitive therapy is effective for schizophrenia patients with negative symptoms.To the contrary, this trial does not demonstrate that CT is effective for reducing negative symptoms, or that CT is a cognitive therapy.
Grant inn replies at interview siad that the first approaches were to invoke Trust - this might be by playing video games until comfortable or alongside other issues.
He agrees the sample - largely black americans - may not be representtive, and so the outcomes may not repeat more generally. My comments are similarly about what is more detail within the regular meetings is not disclosed. - giving and sustaining a routine - even of just of regular attendance attendance especially if rewarded in some way, by it being a friendly experience may well be sufficient in itself to stabilise the illness. It provides a repeated outside routine of engagement
There are many regimes which are basically getting sufferers to continue to engage regularly - one was teaching chess - which claim benefit. After all what else would they be doing ? Rather a leaderless life.
Was there any monetary reward direct or indirect.
There was a 10% frop out - equal to controls but - there you are.
Finally more required about the quality of the outcome after two years Nevertheless, this is an attempt, deliverd with optimism, to say something can be done that just may encourage more funding of longterm people