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Evid Based Nurs 10:51 doi:10.1136/ebn.10.2.51
  • Treatment

Brief cognitive behaviour therapy improved insight and reduced negative symptoms and readmissions in schizophrenia


 
 Q In patients with schizophrenia, does brief cognitive behaviour therapy (CBT) delivered by mental health nurses reduce symptoms, recovery time, and readmissions at 1 year?

METHODS

GraphicDesign:

randomised controlled trial.

GraphicAllocation:

{concealed}.*

GraphicBlinding:

blinded {data collectors}.*

GraphicFollow up period:

1 year.

GraphicSetting:

6 sites in the UK.

GraphicPatients:

422 patients {18–65 years of age} {mean age 40 y, 77% men} with an ICD-10 diagnosis of schizophrenia who were receiving treatment from secondary care services. Patients were excluded if they were in the process of active relapse or had a primary diagnosis of substance or alcohol dependence, organic brain disease, or severe learning disability.

GraphicIntervention:

CBT {n = 257} or usual care as organised by a community key worker, with an offer of CBT at the end of the study period {n = 165}. CBT was manual-based and comprised 6 sessions over 2–3 months. Sessions were delivered by mental health nurses who received 10 days of training that focused on achieving good engagement and working flexibly with cognitive behaviour techniques to help patients to develop coping skills and take more control over their illness; audiotapes were checked for treatment fidelity.

GraphicOutcomes:

primary outcomes were overall symptoms (Comprehensive Psychopathological Rating Scale), insight (Insight Rating Scale), and depression (Montgomery-Asberg Depression Rating Scale). Secondary outcomes included positive symptoms (Psychotic Symptom Rating Scales), negative symptoms (Negative Symptom Rating scale), hospital readmission, and return to work or education.

GraphicPatient follow up:

80% completed follow up. Missing data were imputed using a group mean (intention to treat analysis).

MAIN RESULTS

At 1 year, patients who received CBT had greater improvements in insight and negative symptoms than patients who received usual care (table); they were also less likely to be readmitted to hospital (table) and had longer mean times to relapse (176 v 161 d, odds ratio 1.84, 95% CI 1.11 to 3.04) and fewer inpatient days (50 v 71, p<0.05). The groups did not differ for overall symptoms, depression, positive symptoms, or return to work or education (4.3% v 5.5%, {p = 0.6}*).

Brief cognitive behaviour therapy (CBT) v usual care in patients with schizophrenia*

CONCLUSION

Brief cognitive behaviour therapy improved insight and reduced negative symptoms and readmissions in schizophrenia.

*Calculated from data in article.

A modified version of this abstract appears in Evidence-Based Medicine.

Commentary

  1. Janet Landeen, RN, PhD
  1. McMaster University, School of Nursing, Hamilton, Ontario, Canada

      CBT for people with schizophrenia has consistently shown promise in controlled research trials, although transfer to clinical practice settings remains a challenge.1 The well designed, community based trial by Turkington et al examined the effects of 6 sessions of CBT at 1 year. The training that mental health nurses required to implement the intervention was minimal compared with usual CBT training.1 It is surprising that at 1 year follow up,2 ongoing improvements were evident in the usually treatment-resistant outcomes of insight and negative symptoms.1,3 Reductions in hospital admissions and longer times to relapse in the CBT group are also promising results. As the authors note, the effect of increased time with a therapist should be controlled for in follow up studies. The lack of change in occupational outcomes was not surprising, as such changes would likely require alternative, more lengthy, approaches.

      Increased insight without improvement in depression has been reported to increase the risk of suicide,3 but this hypothesis was not tested in this study. Clinically, depression was worse in the control group but not among participants in the CBT group whose insight had improved >25%. This suggests that the CBT intervention may be protective for the depressive contributions to risk of suicide, but further study is needed to more fully understand the interaction of improved insight and depression on suicide risk in schizophrenia. In conclusion, brief CBT is a promising intervention that could be implemented by mental health nurses in naturalistic settings at minimal cost.

      References

      Footnotes

      • * Information provided by author.

      • For correspondence: Professor D Turkington, Royal Victoria Infirmary, Newcastle upon Tyne, UK. douglas.turkington{at}ncl.ac.uk

      • Source of funding: Pfizer.

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