Cognitive Therapy
In a 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 CT sessions of flexible frequency and duration.
Goal-directed, personalized treatment planning 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 groupsfavoring 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.
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