Randomized controlled trial of cognitive behavioral social skills training for older people with schizophrenia: 12-Month follow-up

Veterans Affairs San Diego Healthcare System, San Diego, Calif 92161, USA.
The Journal of Clinical Psychiatry (Impact Factor: 5.5). 05/2007; 68(5):730-7.
Source: PubMed


There is an increasing need for empirically validated psychotherapy interventions that improve functioning in older people with schizophrenia. We developed a 24-session weekly group therapy intervention labeled Cognitive Behavioral Social Skills Training (CBSST), which combined cognitive-behavioral therapy with social skills and problem-solving training to improve functioning.
We previously reported end-of-treatment findings from a randomized controlled trial that compared treatment as usual (TAU) with TAU plus group CBSST in 76 outpatients, 42 to 74 years of age, with schizophrenia or schizoaffective disorder (DSM-IV criteria). Twelve-month follow-up results of that trial (conducted from October 1999 to September 2004) are reported here. Blind raters obtained assessments of CBSST skill mastery, functioning, psychotic and depressive symptoms, and cognitive insight (belief flexibility).
The significantly greater skill acquisition and self-reported performance of living skills in the community seen in CBSST versus TAU patients at the end of treatment were maintained at 12-month follow-up (p < or = .05). Participants in CBSST also showed significantly greater cognitive insight at the end of treatment relative to TAU, but this improvement was not maintained at follow-up. The treatment-group effect was not significant for symptoms at any assessment point; however, symptoms were not the primary treatment target in this stable outpatient sample.
Older people with very chronic schizophrenia were able to learn and maintain new skills with CBSST and showed improved self-reported functioning 1 year after the treatment ended. Longer treatment and/or booster sessions may be required to maintain gains in cognitive insight.

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    • "A combination of social skills training to address basic social competence limitations plus CBT to address dysfunctional beliefs that undermine motivation to actually use newly developed skills may be particularly effective. Efforts to integrate these complementary approaches have already begun (e.g., Granholm et al., 2007) and further development of interventions to address dysfunctional beliefs may help achieve the ambitious goal of functional recovery. "
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    ABSTRACT: According to A.T. Beck and colleagues' cognitive formulation of poor functioning in schizophrenia, maladaptive cognitive appraisals play a key role in the expression and persistence of negative symptoms and associated real-world functioning deficits. They provided initial support for this model by showing that dysfunctional attitudes are elevated in schizophrenia and account for significant variance in negative symptoms and subjective quality of life. The current study used structural equation modeling to further evaluate the contribution of dysfunctional attitudes to outcome in schizophrenia. One hundred eleven outpatients and 67 healthy controls completed a Dysfunctional Attitudes Scale, and patients completed a competence measure of functional capacity, clinical ratings of negative symptoms, and interview-based ratings of real-world functioning. Patients reported higher defeatist performance beliefs than controls and these were significantly related to lower functional capacity, higher negative symptoms, and worse community functioning. Consistent with Beck and colleagues' formulation, modeling analyses indicated a significant indirect pathway from functional capacity-->dysfunctional attitudes-->negative symptoms-->real-world functioning. These findings support the value of dysfunctional attitudes for understanding the determinants of outcome in schizophrenia and suggest that therapeutic interventions targeting these attitudes may facilitate functional recovery.
    Preview · Article · Dec 2009 · Journal of Psychiatric Research
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    • "This study examined neuropsychological predictors of functional outcome in a randomized clinical trial of CBSST for middle-aged and older people with schizophrenia or schizoaffective disorder. We previously reported that participants in CBSST showed greater skills acquisition and superior self-reported functioning relative to participants in TAU at end of treatment (Granholm et al. 2005) and these gains were maintained at 1-year follow-up (Granholm et al. 2007). "
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    ABSTRACT: Cognitive Behavioral Social Skills Training (CBSST) is a 24-session weekly group therapy intervention to improve functioning in people with schizophrenia. In our prior randomized clinical trial comparing treatment as usual (TAU) with TAU plus group CBSST (Granholm, E., McQuaid, J.R., McClure, F.S., Auslander, L., Perivoliotis, D., Pedrelli, P., Patterson, T., Jeste, D.V., 2005. A randomized controlled trial of cognitive behavioral social skills training for middle-aged and older outpatients with chronic schizophrenia. Am. J. Psychiatry 162, 520-529.), participants with schizophrenia in CBSST showed significantly better functional outcome than participants in TAU. The present study was a secondary analysis of neuropsychological predictors of functional outcome in our prior CBSST trial. We examined (1) whether neuropsychological impairment at baseline moderated functional outcome in CBSST relative to TAU, and (2) whether improvement in neuropsychological abilities mediated improvement in functional outcome in CBSST. Attention, verbal learning/memory, speed of processing, and executive functions were assessed at baseline, end of treatment, and 12-month follow-up. Greater severity of neuropsychological impairment at baseline predicted poorer functional outcome for both treatment groups (nonspecific predictor), but the interaction between severity of neuropsychological impairment and treatment group was not significant (no moderation). Effect sizes for the difference between treatment groups on functional outcome measures at 12-month follow-up were similar for participants with relatively mild (d=.44-.64) and severe (d=.29-.60) neuropsychological impairment. Results also did not support the hypothesis that improvement in neuropsychological abilities mediated improvement in functioning in CBSST. Adding CBSST to standard pharmacologic care, therefore, improved functioning relative to standard care alone, even for participants with severe neuropsychological impairment, and this improvement in functioning was not related to improvement in neuropsychological abilities in CBSST.
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