Cognitive therapy has dynamically improved the most neurologically impaired, poorly functioning schizophrenic patients. For the first time, researchers from the Perelman School of Medicine at the University of Pennsylvania have shown that a psychosocial treatment can significantly improve daily functioning and quality of life in the lowest-functioning cases of schizophrenia.
The study appears in the October 3 edition of Archives of General Psychiatry.
"Mental health professionals often give up on the lowest-functioning cases of schizophrenia and may say that they are not capable of improving," said Paul Grant, PhD, lead author of the study and assistant professor in Psychiatry at Penn's Perelman School of Medicine. "Our results suggest that cognitive therapy can improve quality of life, reduce symptoms, and promote recovery in these patients. This intervention can help these patients improve to the point where they may be able to move up to the next level in psychosocial functioning -- i.e. going from being unemployed to volunteering part-time; not being in school to enrolling in night classes; not socializing to having a weekly social contact and making a friend or two."
Between 2 and 3 million American adults have schizophrenia. Although antipsychotic medications have been demonstrated to reduce hallucinations and delusions, one-third to one-half of patients with schizophrenia continue to experience residual symptoms or cannot tolerate medications. In the United States, nearly $63 billion is spent annually on overall direct treatment costs and indirect costs incurred due to lost employment and productivity, for an average of between $26,000 and $31,000 per patient, which is 5 times greater than the per-patient cost of depression.
"Our study suggests that cognitive therapy might have utility to help reduce public health costs for the most expensive per-patient psychiatric population while simultaneously improving patients' quality of life," said Aaron T. Beck, MD, senior author of the study and professor emeritus of Psychiatry at Penn. Dr. Beck is considered the 'Father of Cognitive Therapy,' which transformed the understanding and treatment of many psychiatric conditions, including depression, suicidal behavior, generalized anxiety, panic attacks, and eating disorders.
In this randomized, single-blind, controlled trial, 60 adults with schizophrenia from Philadelphia received either cognitive therapy plus standard treatment, or standard treatment alone. Standard treatment included antipsychotic medication, at least, as well as psychosocial services provided by local community mental health centers.
In adapting cognitive therapy for this patient population, researchers focused on highlighting the patients' interests, assets and strengths. The intervention was intentionally designed to promote recovery by helping patients identify and achieve concrete goals for improving quality of life and reintegration into society. Treatment targeted specific defeatist beliefs ("if I partially fail it is as bad as being a complete failure") that earlier research by Grant and Beck identified as blocks to the patients engaging in constructive activity.
By 18 months, patients in the cognitive therapy group entered into what researchers called "a dynamic cycle of recovery." The treatment encouraged patients to set goals related to their everyday functioning, and they became motivated to engage in tasks that moved them out of their withdrawn state. This increase in activity and motivation put the patients more in touch with reality and reduced hallucinations, delusions, and disorganized speech. The cycle continued as engagement in activity led to better functional outcomes and motivation, which facilitated continued improvement of symptoms.
These patients have more potential than their care providers and family members may have thought possible, according to Drs. Grant and Beck. The next stage is to train community therapists to deliver the recovery-oriented cognitive therapy in community mental health agencies.
The research was supported by a Distinguished Investigator Award from the National Alliance for Research on Schizophrenia and Depression (Dr Beck) and by grants from the Heinz Foundation and the Barbara and Henry Jordan Foundation.
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