Specially adapted cognitive therapy improved global function, motivation, and positive symptoms in low-functioning patients who had schizophrenia and significant cognitive impairment, according to a study in the February issue of the Archives of General Psychiatry.
"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," said Paul M. Grant, Ph.D., of the University of Pennsylvania, Philadelphia, and his associates.
In their clinical trial, 60 such patients were randomly assigned to either a control group receiving standard outpatient treatment (29 subjects) or an experimental group receiving a novel form of cognitive therapy (31 subjects) for 18 months. Standard treatment included antipsychotic medication, case management, supportive counseling, day treatment services, housing services, peer support, and vocational rehabilitation – all provided by community clinicians (Arch. Gen. Psychiatry 2012;69:121-7).
The specially adapted cognitive therapy aimed to stimulate patients’ interest in and motivation to achieve easy short-term goals, such as participating in an enjoyable activity, as well as long-term goals, such as obtaining independent housing or employment. All the goals focused on moving them out of their withdrawn state.
A key feature of the therapy was overcoming patients’ dysfunctional, nihilistic beliefs such as "taking even a small risk is foolish because the loss is likely to be a disaster" and "making new friends isn’t worth the energy it takes."
The cognitive therapy was adapted to patients’ neurocognitive impairments and provided by PhD- and MD-level clinicians. Study subjects typically attended weekly 50-minute sessions, but the duration and frequency of sessions were flexible and tailored to the patients’ needs and progress.
The mean age of the study subjects was 38 years. Twenty (one-third) of the subjects were women, and 39 (two-thirds) were black. The mean duration of schizophrenia was 15 years. Approximately 92% of the subjects were taking at least 1 atypical antipsychotic agent.
The patients’ neurocognitive impairments included difficulties with information processing on tasks of memory, attention, and executive function. Many subjects also had residual positive symptoms, such as hallucinations, delusions, and disorganized thinking.
The primary outcome measure was improvement on the 100-point Global Assessment of Functioning scale at the end of the study. Only the subjects who received cognitive therapy showed such improvement, Dr. Grant and his colleagues wrote.
The experimental group also showed significantly greater improvement than the control group on the avolition-apathy subscale of the Scale for the Assessment of Negative Symptoms and on the total score of the Scale for the Assessment of Positive Symptoms.
"We hypothesize that [cognitive therapy] triggers the cycle of recovery by targeting self-defeating and dysfunctional beliefs that inhibit the patients’ active engagement in constructive activity. Alternatively, it is possible that improvement in avolition-apathy was largely secondary to improvement in positive symptoms. These are questions that can be addressed by future research," the investigators said.
The study findings indicate that cognitive therapy might be useful in reducing public health costs "for the most expensive per-patient psychiatric population while simultaneously improving patients’ quality of life," they noted.
This study was limited in that the experimental treatment involved more individual interaction between patient and therapist than did the control condition, "raising the possibility that nonspecific patient contact factors are contributing to the observed group differences," Dr. Grant and his associates added. In addition, both the study subjects and the clinicians were unblinded and aware that they were participating in an experiment, "introducing possible bias in the reported outcomes," the researchers said.
This study was supported by the National Alliance for Research on Schizophrenia and Depression, the Heinz Foundation, and the Barbara and Henry Jordan Foundation. Dr. Grant and two associates reported receiving royalties from Guilford Press.