Article 4: cognitive-behavioural therapy for sz

Question 1

Goals of the study

Answer 1

(1) Test the effectiveness of CBT for people with long-term illness who did not respond to medication
(2) Try to engage as many people as possible

Question 2

Why is this important? (the goals)

Answer 2

If this is so great – it should work for even difficult cases

Question 3

Hypotheses?

Answer 3

1) CBT would be more effective than standard treatment (duh …)
2) CBT could be effective even in people with long-term disease and who were not helped by medication
3) Perhaps CBT would be particularly effective in changing beliefs about delusions and hallucinations

Question 4

Who were the participants in the study and how were they selected? How were the treatment and control groups assigned? What treatment did the control group receive?

Answer 4

People with SZ who had at least one persistent (6 mths) and distressing positive symptom (hallucinations or delusions)
Unresponsive to medication
No drug or alcohol problems

Referred by clinics and hospitals
60 (28 CBT; 30 Control)
Randomized by the study statistician (not one of the clinicians)

Question 5

Treatment goals

Answer 5

Goals:
Reduce distress and interference caused from psychotic symptomatology
Reduce emotional disturbance (i.e., depression, anxiety, hopelessness) and modify dysfunctional schemas
Promote active participation of the patient in the regulation of their social disability and risk of relapse

Question 6

Treatment strategies

Answer 6

1) Improving coping mechanisms and learning new ones
2) Relaxation, scheduling, skills training, reading
3) Developing a shared model about psychotic symptoms (psychoeducation)
4) Understanding the disease and perhaps understanding the cause of the symptoms
5) Modifying delusional beliefs and beliefs about hallucinations
6) Gentle challenge; alternative explanations or less distressing interpretations; links to life events; understanding that hallucinations were internal events; reality testing
7) Identifying and modifying dysfunctional schemas (classic CBT approach
8) Managing social disability, stigma and relapse

Question 7

Treatment protocol

Answer 7

Duration: 9 months.
Individual intervention.
1-hour sessions: (At first weekly sessions; later on, every 2 weeks)
Therapists supervised by the people who developed the treatment
Used a treatment manual
Number of therapy sessions carried out: 0 – 50 (brief therapy <12 sessions, full therapy >12 sessions).

Question 8

what were the four measures in this study?

Answer 8

1) Present State Exam (PSE)
2) Personal Questionnaire
3) Brief Psychiatric Rating Scale (BPRS)
4) Cognitive measures: current and estimated IQ

Question 9

Present State Exam (PSE)

Answer 9

Assesses symptoms, leads to DSM-III diagnosis

Question 10

Personal Questionnaire

Answer 10

Assess changes in symptoms from the PSE
Delusions: conviction (how much does the person believe them); preoccupation (how much time/attention do they spend on them) distress
Hallucinations: frequency, intensity and distress

Question 11

Brief Psychiatric Rating Scale (BPRS)

Answer 11

Rating scale of SZ symptoms, anxiety and depression

Question 12

Cognitive measures:

Answer 12

current and estimated IQ

Question 13

Results: What changes were observed in the Brief Psychiatric Rating Scale measure? Which specific symptoms measures showed changes? What was the rate of clinical improvement? How satisfied were people with the treatment?

Answer 13

Reduction in the BPRS over time for the CBT compared to controls
Specific changes delusional conviction; distress and frequency of hallucinations
25% in treatment group; 8% in control
80% were satisfied

Question 14

Results: Symptoms & Functioning

Answer 14

Trend for greater improvement in delusional conviction, delusional distress and frequency of hallucinations
Based on client’s primary presenting problems as measured by PSE and personal questionnaires:
18 / 28 (64%) of CBT-treated patients
15 / 32 (47%) of Control patients
showed clinically significant improvements.

Question 15

What were the conclusions drawn from this study?

Answer 15

With 9mths of CBT you can get improvement of overall symptoms
Rate of improvement was similar to reports of improvement with medications
CBT doesn’t cure, but can contribute to coping
Works even for people with severe, medication resistant disorder
But only trends for improvement in Conviction for delusional ideas, Social Functioning or Depression
Advantages: CBT has no side-effects
Disadvantages: requires intensive time from clinicians and patients

Question 16

Limitations

Answer 16

1) Assessors were independent but NOT blind to treatment condition.
2) Medication regime was not stable for all patients throughout the trial.
3) No active control condition
* *This means you cannot say that CBT is specifically effective
4) Lack of change in Delusional conviction or Depression prevents the authors to assume that CBT-interventions were the key aspects driving the improvements.
5) Despite the significant changes observed in the CBT-group, only 50% of these participants were treatment responders
6) Could be a non-specific effect of extra intervention
7) Only reported BPRS scores.