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Q Is brief cognitive-behavioural therapy effective for people with schizophrenia?
METHODS
Design:
Randomised controlled trial.
Allocation:
Concealed.
Blinding:
Single blind (assessors blinded).
Follow-up period:
One year.
Setting:
Six healthcare sites, UK; time period not stated.
Patients:
422 people with schizophrenia (ICD-10). Most participants had ongoing symptoms or were at risk of relapse. Exclusions: currently experiencing schizophrenia relapse, primary diagnosis of alcohol or substance abuse, organic brain disease, or learning disability.
Intervention
Brief cognitive-behavioural therapy (CBT: 6 technique-based sessions over 2–3 months given by trained mental health nurses—including techniques for managing positive and negative symptoms and improving medication compliance) or usual care.
Outcomes:
Primary outcomes: overall symptoms (Comprehensive Psychopathological Rating Scale (CPRS)); insight (Insight Rating Scale (IRS)); depression (Montgomery-Asberg Depression Rating Scale (MADRS)). Secondary outcomes: positive symptoms (Psychotic Symptom Rating Scales (PSYRATS)); negative symptoms (Negative Symptoms Rating Scales (NSRS)); readmission to hospital.
Patient follow-up:
87.5% of the CBT group and 77.6% of the usual care group completed treatment; 100% included in intention-to-treat analyses.
MAIN RESULTS
At 1 year, there were no significant differences between CBT and usual care groups in overall schizophrenia symptoms, depression or positive symptoms (mean difference in change scores for: CPRS −1.72, 95% CI −3.76 to +0.33, p = 0.10; MADRS −0.47, 95% CI −0.89 to +0.59, p = 0.13; PSYRATS voices +0.82, 95% CI −0.88 to +2.53, p = 0.342; PSYRATS delusions +0.57, 95% CI −0.57 to +1.72). CBT significantly improved insight and negative symptoms compared with usual care (mean difference in change scores for: IRS +0.71, 95% CI +0.11 to +1.31, p = 0.02; NSRS −0.77, 95% CI −1.27 to −0.28, p = 0.002). CBT significantly reduced readmission to hospital compared with usual care (14% with CBT v 23% with usual care; p<0.05).
CONCLUSIONS
A brief course of CBT provided by trained mental health nurses does not reduce overall symptoms or depression in people with schizophrenia, but increases insight and reduces readmission to hospital.
Commentary
The study involved several sites across the UK where mental health nurses received 10 days’ training that would equip them to deliver cognitive-behavioural interventions to people who experience psychosis. Patients were then given six sessions over 2–3 months and followed up one year later. Patients receiving sessions showed greater insight and fewer negative symptoms. Occupational recovery remained unchanged. Interestingly, main carers were offered sessions that addressed relapse prevention issues. We are not told how many carers actually accepted the offer and the perceived benefits. The study demonstrates that mental health nurses can be trained in a range of therapeutic interventions and deliver these in a safe way. Clinical supervision was seen to be critical in this respect and this is apparent in other recent studies.1 Earlier studies explored the delivery of cognitive-behavioural interventions and mainly involved psychologists.2 Other studies have involved multidisciplinary training initiatives such as Thorn courses.3 The UK government appears to support training of practitioners in these ways of working.4
This is a very important study that recognises the skills that mental heath nurses possess. Some nurses have indeed undertaken further training in order to address the complex and diverse needs of their clients and carers through national training initiatives—for example, the MSc Psychosocial Interventions programme at the University of Manchester. However, according to reports, the implementation of the interventions in practice still remains problematic. Evidently, there are therapeutic gains for patients and the paper highlights the financial benefits in terms of being well and staying well. However, nurses need an infrastructure in the workplace that allows them to carry out the brief interventions in terms of managerial support and adequate clinical supervision. This would involve careful workforce development strategies. It would also have been useful to hear the views of carers regarding the interventions.
Footnotes
For correspondence: Professor Douglas Turkington, School of Neurology, Neurosciences and Psychiatry, Royal Victoria Infirmary, Richardson Road, Newcastle upon Tyne NE1 4LP, UK; douglas.turkington{at}ncl.ac.uk
Source of funding: Pfizer.