11 October 2011. 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 public health costs.
Antipsychotic drug treatment 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 (see SRF meeting report). Overall, empirical support was strongest for cognitive behavioral therapy. 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) (SRF related news story). 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 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 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.
Grant PM, Huh GA, Perivoliotis D, Stolar NM, Beck AT. Randomized Trial to Evaluate the Efficacy of Cognitive Therapy for Low-Functioning Patients With Schizophrenia. Arch Gen Psychiatry. 2011 Oct 3. Abstract
Turkington D, Morrison AP. Cognitive Therapy for Negative Symptoms of Schizophrenia. Arch Gen Psychiatry. 2011 Oct 3. Abstract