Cognitive Therapy May Power a Cycle of Recovery in Chronic Schizophrenia
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
Comments on News and Primary Papers
Comment by: Robert Paul Liberman
Submitted 14 October 2011
Posted 14 October 2011
This study of a well-established, psychosocial treatment, which has been documented to be effective for depression, anxiety disorders, and positive symptoms of schizophrenia (Salkovskis, 1996; Kingdon and Turkington, 2004), 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
There is no indication whether the subjects had primary negative symptoms (i.e., the deficit state defined by enduring negative symptoms not related to positive symptoms including anxiety and depression, under-stimulating environments, side effects of medication (e.g., sedation, akathisia, akinesia, weight gain) or negative symptoms secondary to the above listed remediable interferences. 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.” This 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 (Dickerson, 1997).
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 (Liberman et al. Social Skills Training for Psychiatric Patients, 1989; Bellack et al. Social Skills Training for Schizophrenia, 2006; Liberman. Recovery from Disability: Manual of Psychiatric Rehabilitation, 2008). 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 assignments
Specificity 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 (Bellack, 2004; Liberman et al., 1998; Glynn et al., 2002; Bellack and Mueser, 1993; Heinssen et al., 2000; Kurtz and Mueser, 2008; Kopelowicz et al., 1997; Falloon et al., 1987; Falloon et al., 1999; Drake et al., 1999; Drake et al., 1996; Stein and Test, 1980).
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 (Rector and Beck, 2001), 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.
Salkovskis PM: Frontiers of Cognitive Therapy. New York: Guilford Press, 1996.
Kingdon D and Turkington D: Cognitive Therapy of Schizophrenia. New York: Guilford Press, 2004.
Dickerson FB. Assessing clinical outcomes: the community
functioning of persons with serious mental illness. Psychiatr Serv . 1997 Jul 1 ; 48(7):897-902. Abstract
Liberman RP, DeRisi WJ, Mueser KT: Social Skills Training for Psychiatric Patients. Norwood MA: Allyn and Bacon, 1989.
Bellack AS, Mueser KT, Gingerich S and Agresta J: Social Skills Training for Schizophrenia. New York: Guilford Press, 2006.
Liberman RP: Recovery from Disability: Manual of Psychiatric Rehabilitation. Arlington VA: American Psychiatric Publishing Inc., 2008.
Bellack AS. Skills training for people with severe mental illness. Psychiatr Rehabil J . 2004 Jan 1 ; 27(4):375-91. Abstract
Liberman RP, Wallace CJ, Blackwell G, Kopelowicz A, Vaccaro JV, Mintz J. Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia. Am J Psychiatry . 1998 Aug 1 ; 155(8):1087-91. Abstract
Glynn SM, Marder SR, Liberman RP, Blair K, Wirshing WC, Wirshing DA, Ross D, Mintz J. Supplementing clinic-based skills training with manual-based community support sessions: effects on social adjustment of patients with schizophrenia. Am J Psychiatry . 2002 May 1 ; 159(5):829-37. Abstract
Bellack AS, Mueser KT. Psychosocial treatment for schizophrenia. Schizophr Bull . 1993 Jan 1 ; 19(2):317-36. Abstract
Heinssen RK, Liberman RP, Kopelowicz A. Psychosocial skills training for schizophrenia: lessons from the laboratory. Schizophr Bull . 2000 Jan 1 ; 26(1):21-46. Abstract
Kurtz MM, Mueser KT. A meta-analysis of controlled research on social skills training for schizophrenia. J Consult Clin Psychol . 2008 Jun 1 ; 76(3):491-504. Abstract
Kopelowicz A, Liberman RP, Mintz J, Zarate R. Comparison of efficacy of social skills training for deficit and nondeficit negative symptoms in schizophrenia. Am J Psychiatry . 1997 Mar 1 ; 154(3):424-5. Abstract
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Falloon IRH, Held T, Coverdale J, ARoncone and Laidlaw T. Family interventions for schizophrenia: A review of long-term benefits of international studies. Psychiatric Rehabilitation Skills. 3:268-290, 1999.
Drake RE, McHugo GJ, Bebout RR, Becker DR, Harris M, Bond GR, Quimby E. A randomized clinical trial of supported employment for inner-city patients with severe mental disorders. Arch Gen Psychiatry . 1999 Jul 1 ; 56(7):627-33. Abstract
Drake RE, McHugo GJ, Becker DR, Anthony WA, Clark RE. The New Hampshire study of supported employment for people with severe mental illness. J Consult Clin Psychol . 1996 Apr 1 ; 64(2):391-9. Abstract
Stein LI, Test MA. Alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical evaluation. Arch Gen Psychiatry . 1980 Apr 1 ; 37(4):392-7. Abstract
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View all comments by Robert Paul LibermanComment by: Alan S Bellack
Submitted 10 November 2011
Posted 10 November 2011
Grant and colleagues are to be congratulated on their noteworthy trial. Anyone who has conducted clinical trials with seriously ill schizophrenia patients must be impressed by the ability of the research team to recruit a large cohort in an intensive treatment and keep them engaged over such a long period of time. The team also deserves credit for demonstrating that a psychosocial intervention can have a meaningful impact with this population. Added to the increasing literature on cognitive therapies with schizophrenia patients, and on recovery-based interventions, this report reinforces the argument that people with schizophrenia can and should be engaged as partners in the treatment process.
In a previous post, Bob Liberman identified a number of crucial limitations of this trial that raise questions about the findings and limit enthusiasm for the intervention. I concur with almost all of Bob's observations and analysis. The 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 (e.g., The New York Times) 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.
In sum, this is an important trial that should and will have an important heuristic role for the field. It is a trial that should have been done and probably could not have been done by any other research group. While acknowledging and applauding its strengths and value for the field, it is important to consider its limitations and be cautious about what conclusions can be drawn from the results.
View all comments by Alan S BellackComment by: Paul Grant
Submitted 31 January 2012
Posted 2 February 2012
We thank Professors Liberman and Bellack for their thoughtful critiques of our work and welcome the opportunity to answer their questions and concerns, and thereby clarify our study beyond the space limitations of the original paper.
Liberman and Bellack express several concerns regarding the number and types of techniques employed in therapy, as well as the length of therapy. Liberman states that our therapy is “confounded” with other treatment approaches because the intervention contains many treatment techniques (e.g., skills training, cognitive remediation, motivational enhancement) that overlap with other psychosocial treatments for schizophrenia; Bellack indicates that he does not believe our treatment should properly be called “cognitive therapy” because “so little of it entails cognitive therapy per se.” We appreciate that they have raised this issue because it affords us an opportunity to explain in greater detail why we use the term cognitive therapy and what we mean by it.
Our formulation of cognitive therapy is based on the cognitive model of schizophrenia (Beck et al., 2009) rather than specific techniques. Basically, we view the low-functioning problems in these patients as due to the interaction of neurocognitive deficits and negative attitudes about performance and social relations. Our basic research has shown both in cross-sectional (Grant and Beck, 2009; Grant and Beck, 2009) and longitudinal (Grant and Beck, 2010) studies that these low-functioning patients have very powerful negative attitudes about the possibility of achieving any goals (e.g., “there is no point in trying because I will only fail”), as well as negative attitudes about the desirability of social contact. In non-technical terms, these patients have given up and have walled themselves off from usual activities of everyday life because of their expectations that they are only going to fail if they try something. While there evidently is an upper limit on how much they can achieve due to their neurocognitive deficits, they do have considerable latent capacity that they are not utilizing. Since the negative attitudes seem to account for their loss of motivation, we use a variety of methods to ameliorate them. Since we frame the problems in cognitive terms, and our understanding of each case is based on a cognitive model, we utilize the term cognitive therapy. We would, therefore, expect that any change would be mediated by cognitive variables. To produce this change, we formulate each case in terms of the individual’s goals and identify the various obstacles to reaching these goals. We select specific techniques ranging from skills training, problem solving, explicit cognitive restructuring, etc., to overcome these obstacles. If the patient is blocked by social inhibition, we use assertiveness training; if the problem is fear of failing, we use cognitive restructuring. According to our thesis, each specific successful experience tends to undercut the negative attitudes that sap the patient’s motivation. Support for our formulation is based on an experimental study which showed that success experiences not only modify negative attitudes, but increase motivation and performance (Perivoliotis et al., 2011). Once the patients start to modify their attitudes, they become more engaged in real life and begin to take advantage of various rehabilitative services that are offered. The question of when and how to apply these strategies is described in the volume by Perivoliotis, Grant, and Beck (Perivoliotis et al., in press).
The multifaceted nature of our CT intervention prompts both Bellack and Liberman to wonder about the mechanism of change. In response to Bellack’s concern that it would be impossible to determine the “active ingredients” of the treatment, we propose that the beliefs targeted by the formulation-driven interventions are producing change. Mediation analysis (beliefs as mediators) would allow us to test this hypothesis. Liberman, in a similar vein, proposes several alternative explanations for our results: behavioral methods, social anxiety, positive symptoms, and medication adherence. He also proposes that, since we did not observe changes in alogia, we did not really affect social functioning. In regard of this last point, we think it is notable that the mean alogia ratings were in the questionable to mild range at baseline and remained in this range throughout the course of the trial. This finding suggests that if improvements were made, it is unlikely that they would be clinically meaningful due to a floor effect.
Additionally, it does not seem likely that the global improvement in the patients’ functioning was due to compliance with medication, since previous research has shown minimal impact from medication (Swartz et al., 2007). However, if medication compliance was improved, this would indicate a positive result from our multifaceted intervention. A similar argument extends to positive symptoms and social anxiety. Finally, while it is possible that behavioral methods could be the mechanisms of change in our study, it is also possible that cognitive change is produced by social skills training and cognitive remediation. We think that exploring beliefs in psychosocial treatments for schizophrenia is a rich area to pursue.
Bellack makes three final points regarding the CT treatment: he questions whether it would be possible to “replicate or disseminate the intervention”; he proposes that our data do not support providing more than six months of CT; and he suggests that “all of the changes induced during that early period may have resulted from non-specific effects rather than any specific cognitive therapy activities.” In regard to dissemination, we have already successfully trained masters-level community therapists in the manualized intervention, and have applied for funding to conduct a systematic study. As to the length of treatment, 50 sessions was the average for the entire group in the study: some participants completed therapy in fewer sessions and some required more. Thus, consistent with an individualized recovery orientation, we argue that some patients can benefit from shorter course of therapy whilst others will require more sessions. This is a matter for future study. And, in regard to non-specific factors, the best way to test this alternative hypothesis is to conduct a new study that compares CT to a supportive therapy control group.
Turning to the methods of the study, both authors are concerned about the measurement of functioning in our study. Liberman states that we did not use a well-established and psychometrically sound assessment instrument measuring social functioning for inclusion, while Bellack and Liberman both criticize our outcome measure as inadequate. We did not specifically describe social functioning as a key outcome, but rather global functioning. The Global Assessment Scale (GAS) was a conventional measure of global functioning at the time we initiated our study. Since that time, new measures have been developed, such as the Schizophrenia Objective Functioning Instrument (SOFI; Kleinman et al., 2009), and research by Phil Harvey’s group (Harvey et al., 2011; Leifker et al., 2011) has indicated that the preferred measure of functioning is the Specific Levels of Functioning scale (SLOF; Schneider and Struenging, 1983). In our next study, we plan to use the SLOF as the primary outcome measure.
Liberman proposes that our sample may not have been composed of patients with primary negative symptoms. In other words, the patients in the study had negative symptoms that were secondary to positive symptoms, with the observed improvement in negative symptoms being produced by improvement in positive symptoms. We did not formally assess primary versus secondary negative symptoms in the clinical trial. However, clinically, we observed that defeatist beliefs occurred independently of the presence of positive symptoms. And, as the beliefs were modified by the CT treatment, patients improved.
Finally, Bellack suggests our data do not support the conclusion that “cognitive therapy can be successful in promoting clinically meaningful improvements in functioning.” We disagree with his inference. We believe the intervention, by whatever name, produced successful results, as was evident in the collateral reports factored into the ratings of functioning.
The authors wish to acknowledge the contributions of Drs. Jessica Murakmi-Brundage and Yael Perry in developing this response.
1. Beck AT, Rector NA, Stolar NM, Grant PM. Schizophrenia: Cognitive Theory, Research and Therapy. NY: Guilford Press; 2009.
2. Grant PM, Beck AT. Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and functioning in schizophrenia. Schizophr Bull. Jul 2009;35(4):798-806. Abstract
3. Grant PM, Beck AT. Evaluation sensitivity as a moderator of communication disorder in schizophrenia. Psychol Med. Jul 2009;39(7):1211-1219. Abstract
4. Grant PM, Beck AT. Asocial beliefs as predictors of asocial behavior in schizophrenia. Psychiatry Res. 2010;177(1-2):65-70. Abstract
5. Perivoliotis D, Grant PM, Beck AT. The impact of success in low-functioning schizophrenia: an analogue study. International Conference on Schizophrenia Research. Colorado Springs, CO. April 02, 2011.
6. Perivoliotis D, Grant PM, Beck AT. Cognitive behavior therapy for schizophrenia: a comprehensive treatment manual. New York: Guilford; in press.
7. Swartz MS, Perkins DO, Stroup TS, Davis SM, Capuano G, Rosenheck RA, Reimherr F, McGee MF, Keefe RSE, McEvoy JP, Hsiao JK, Lieberman JA, Investigators ftC. Effects of antipsychotic medications on psychosocial functioning in patients with chronic schizophrenia: findings from the NIMH CATIE study. Am J Psychiatry. 2007;164(3):428-436. Abstract
8. Kleinman L, Lieberman J, Dube S, Mohs R, Zhao Y, Kinon B, Carpenter W, Harvey PD, Green MF, Keefe RSE, Frank L, Bowman L, Revicki DA. Development and psychometric performance of the schizophrenia objective functioning instrument: an interviewer administered measure of function. Schizophr Res. 2009;107(2-3):275-285. Abstract
9. Harvey PD, Raykov T, Twamley EW, Vella L, Heaton PK, Patterson TL. Validating the measurement of real-world functional outcomes: phase I results of the VALERO study. Am J Psychiatry. 2011;168:1195-1201. Abstract
10. Leifker FR, Patterson TL, Heaton PK, Harvey PD. Validating measures of real-world outcome: the results of the VALERO expert survey and RAND panel. Schizophr Bull. 2011;37:334-343. Abstract
11. Schneider LC, Struenging EL. SLOF: a behavioral rating scale for assessing the mentally ill. Soc Work Res Abstr. 1983;19:9-21.
View all comments by Paul Grant
Comments on Related News
Related News: Added Value: Combined Therapy Benefits People With SchizophreniaComment by: Wendy Camp
Submitted 18 October 2010
Posted 18 October 2010
In Connecticut we have a wonderful Medicaid/T19/Behavioral Health program that allows home health nurses to monitor and/or administer medications for noncompliant mental health patients and home health aides to be in the home up to 14 hours a week to assist with medication reminders, ADLs, and IADLs.
I would be interested to know what impact our behavioral health nurses might have on an early-stage schizophrenia population versus our chronic noncompliant population. If we had our nurses in the home sooner, could we correct potentially problematic behavior before it became chronic?
View all comments by Wendy Camp
Related News: Added Value: Combined Therapy Benefits People With Schizophrenia
Comment by: Douglas Turkington (Disclosure)
Submitted 16 November 2010
Posted 17 November 2010
This paper is important because of its power and because this most basic question has never been satisfactorily answered. My concern is the very high dropout rate in both groups. Dropout across CBT of schizophrenia trials normally averages about 15 percent. CBT also usually attempts to work from a mini-formulation or macro-formulation which extends beyond the A-B-C. The CBT given here, however, does parallel the pragmatic technique-orientated CBT given in the Insight trial (Turkington et al., 2002). The problem here would appear to be the delivery of all four interventions in group format on the same day once per month. This is a massive burden on patients with cognitive deficits, negative symptoms, and treatment-resistant hallucinations and delusions. We must therefore be guarded about the conclusions. There is a signal, however, of the need for a psychosocial component in the management of every patient with schizophrenia. We are grateful to the authors for this publication.
Turkington D, Kingdon D and Turner T. (2002) Effectiveness of a brief cognitive-behavioural therapy intervention in the treatment of schizophrenia. British Journal of Psychiatry 180, 523-527. Abstract
View all comments by Douglas Turkington
Related News: ICOSR 2011—In Schizophrenia, What Really Improves People’s Lives?
Comment by: Ray Lay
Submitted 14 September 2011
Posted 15 September 2011
As a person living with schizophrenia, I can heartily state that the acceptance of my illness, fine-tuning of my medicines, psychotherapy, and family support have greatly helped me to live better with my illness. I am not symptom-free, but symptoms are fewer and psychoeducation has allowed me to better understand my illness, and although still confusing, it is not as confusing. I can at least now tell what the symptom is and properly react. I am grateful for my treatment and my providers, and I am an active participant in my recovery.
View all comments by Ray Lay
Related News: ICOSR 2011—In Schizophrenia, What Really Improves People’s Lives?
Comment by: Elizabeth Molnar
Submitted 16 September 2011
Posted 3 October 2011
Dr. Matthew Kurtz is reported in the current dialogue on what really matters as discussing his two recent papers with Ms. Arielle Tolman, which imply that better neurocognitive functioning on some parameters, together with better insight, are associated with more severe depression and, subjectively, poorer quality of life. I respectfully suggest that if the carers of such persons were asked, they might offer that improved neurocognitive function and insight enable the carer to function more empathically, and that the carers’ burden is lessened while their quality of life and the sense of efficacy and meaning in continuing to care is enhanced. For example, in my practice, I do discuss such matters with family members and with the person being treated, and I hear, especially when clozapine is part of the treatment package, that families are able to include the proband more readily in family discussions and occasions, and are far less likely to exclude the family member, when insight is preserved, retained, or recovered, together with cognitive function and better adherence to treatment. Depressive phenomena, such as awareness of disappointment, may be accessible to treatment, and may be framed as understandable and part of the process of recovery and re-adaptation after an injury, even when some residue or scars remain.
Kurtz MM, Tolman A. Neurocognition, insight into illness and subjective quality-of-life in schizophrenia: what is their relationship? Schizophr Res . 2011 Apr 1 ; 127(1-3):157-62. Abstract
Tolman AW, Kurtz MM. Neurocognitive Predictors of Objective and Subjective Quality of Life in Individuals With Schizophrenia: A Meta-Analytic Investigation. Schizophr Bull . 2010 Jul 11. Abstract
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