An article in the Archives of General Psychiatry has caused a stir
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.
These are some of the ' presentation summaries and comments on the internet
:John Gever, Senior Editor, MedPage Today
go to comment Grant and colleagues based their approach on a hypothesis that negative symptoms result from a cycle of despair in patients with schizophrenia -- they develop dysfunctional beliefs about their condition that leave them pessimistic about the likely outcomes of treatment and their abilities to live normally in society. These beliefs then become self-fulfilling.
The therapy they designed took "a person-oriented therapeutic approach by highlighting the patients' interests, assets, and strengths," they wrote in their report. "We focused our treatment methods on identifying and promoting concrete goals for improving quality of life and reintegration into society."
Patients meeting DSM-IV criteria for schizophrenia or schizo-affective disorder were included if they had prominent negative symptoms without neurological disease or physical handicaps that would interfere with study participation.
Of 177 patients initially considered for participation, 55 refused, 44 failed to meet inclusion criteria, and 18 could not be included for other reasons.
With 60 available to participate, 31 were randomized to cognitive therapy plus standard treatment and the remaining 29 to standard treatment alone. Participants were assessed at six, 12, and 18 months after starting the trial with standard scales for positive and negative schizophrenia symptoms.
Standard treatment was provided by community physicians. In all cases it included drug therapy, but most patients also received other services from community mental health centers such as counseling, peer support, and vocational rehabilitation.
The cognitive therapy consisted of weekly individual sessions lasting 50 minutes, delivered by doctoral-level therapists, and continuing for the full 18 months of the study.
Ten patients in the cognitive therapy group and 11 in the control arm failed to complete the study. Outcomes were reported on an intent-to-treat basis with a hierarchical linear model for taking account of noncompleters. For global functioning, this analytical method produced a treatment difference of 9.0 points favoring cognitive therapy (95% CI 0.98 to 17.11). There was also a significant advantage for cognitive therapy in a composite measure of positive symptoms (-7.7 points, 95% CI -14.97 to -0.50). At baseline, scores averaged 21 points in the control group and 14 among those assigned to cognitive therapy.
Four negative symptoms were evaluated individually. The only one with a significant difference between groups over the 18-month study duration was avolition-apathy, favouring cognitive therapy by -0.9 points (95% CI -1.64 to -0.18) from a baseline of about 3.2.
This is the first time, to our knowledge, that patients with chronic schizophrenia selected from the extreme end of the low-functioning continuum have shown statistically significant and clinically meaningful improvement in psychosocial functioning in response to a psychosocial intervention," the researchers wrote.
Limitations to the study included the lack of blinding, potential flaws in the symptom assessment instruments, and the cognitive therapists' high degree of training.
Grant and colleagues also pointed out that the cognitive therapy involved more contact with patients than did the control treatments, which in itself might have contributed to its apparent effectiveness
. Finally, two-thirds of patients in the study were African American and two-thirds were male, possibly limiting the study's generalizability to other groups.
Finding therapists trained in cognitive therapy is a problem. Mr. Grant's group has a contract to train staff members who work with schizophrenic patients at Horizon House and at Temple University Hospital's Episcopal Campus.
One reason the treatment took so much time is that therapists had to work hard to gain patients' trust. Mr. Grant said therapists played video games at the beginning with some clients. If a patient was a little higher functioning, "we might watch Family Guy with him."
Patients were not just more motivated after the treatment. "They were a little more engaged with reality" so their psychotic symptoms improved, Mr. Grant said. The small successes built on one another, offering patients hope for a better standard of living and quality of life.
Cognitive therapy is a practice without an examined theoretical basis. That is why the more details one learns about papers such as the one by Grant and colleagues, the better what is going on is uncovered.