| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
|
|
|
||||||||||
|
||||||||||||
School of Psychological Sciences, University of Manchester, Manchester, UK
Correspondence: Professor Gillian Haddock, School of Psychological Sciences, University of Manchester, Rutherford Rutherford House, Manchester Science Park, Lloyd Street North, Manchester M15 6SZ, UK. Tel: +44 (0)161 929 6836; Fax: +44 (0) 161 275 8487; e-mail: gillian.haddock{at}manchester.ac.uk
Declaration of interest None. Funding detailed in Acknowledgements.
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Aims To evaluate outcomes by age in a randomised controlled trial designed to evaluate the effectiveness of cognitive–behavioural therapy (CBT), supportive counselling and treatment as usual.
Method Outcomes were evaluated in terms of symptoms, social functioning, insight and therapeutic alliance according to age at 3- and 18-month follow-up.
Results Younger participants responded better to supportive counselling than to treatment as usual and CBTover 3 months. Older participants responded better to CBT than to supportive counselling over 18 months. Younger participants showed a greater increase in insight after CBT compared with treatment as usual and supportive counselling, and were more difficult to engage in therapy.
Conclusions Young people may have different needs with regard to engagement in psychological treatments. Treatment providers need to take age-specific factors into account.
|
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
|
|
METHOD |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Participants, recruitment and assignment
Participants were recruited over a period of 26 months. Inclusion criteria
for entry to the trial were as follows: either first or second admission
(within 2 years of a first admission) to in-patient or day-patient unit for
treatment of psychosis; DSM–IV criteria for schizophrenia,
schizophreniform disorder, schizoaffective disorder, delusional disorder or
psychosis not otherwise specified (American
Psychiatric Association, 1994); positive psychotic symptoms for 4
weeks or more; a score of 4 or more on the Positive and Negative Syndrome
Scale (PANSS) (Kay et al,
1989) target item for either delusions (P1) or hallucinations
(P3); neither substance misuse nor organic disorder judged to be the main
cause of psychotic symptoms.
Assessment measures
A number of assessment measures were employed as part of the SoCRATES study
at baseline and during the 18-month follow-up period
(Lewis et al, 2002;
Tarrier et al, 2004).
However, only the following measures will be reported here. Measures of
symptoms and functioning at baseline and follow-up included the PANSS
(Kay et al, 1989)
total, positive, negative and general sub-scale scores, the Psychotic Symptom
Rating Scales (PSYRATS; Haddock et
al, 1999a), the Social Functioning Scale (SFS;
Birchwood et al,
1990), the Birchwood Insight Scale (BIS;
Birchwood et al, 1994)
and two measures of therapeutic alliance, namely the California Therapeutic
Alliance Scales (CALPAS; Gaston,
1990) and the Psychotherapy Status Report (PSR;
Frank & Gunderson, 1990).
Data on demographics, substance use and duration of untreated psychosis were
also collected at baseline.
Intervention groups
The interventions were based on those evaluated in previous treatment
studies (Tarrier et al,
1998; Haddock et al,
1999b). The CBT was manual-based and was undertaken by
five therapists trained in CBT for psychosis, who were supervised by
experienced cognitive–behavioural therapists. At the beginning of the
study the therapists were trained in both interventions, and throughout the
study they received separate expert and peer supervision on a regular basis to
maintain treatment quality. The aim was for a ‘treatment envelope’
of 15–20 hours within a 5-week post-admission period, plus
‘booster’ sessions after a further 2 weeks, and after 1, 2 and 3
months. Details of the CBT have been provided by Haddock et al
(1999b). Supportive
counselling was used as a comparison intervention to control for non-specific
elements of therapist exposure. The same five research therapists administered
both CBT and supportive counselling interventions, according to randomisation.
All treatment sessions, both for CBT and for supportive counselling, were
audiotaped if participants had given their consent, and the treatment fidelity
as judged by independent, expert raters was good
(Lewis et al,
2002).
Analysis
Baseline data were compared according to age using a cut-off point of age
21 years (i.e. ‘over 21’ and ‘21 years and under’).
This cut-off was considered to be a pragmatic developmental point at which to
divide the groups. It also allowed sufficient numbers of participants in both
groups to ensure that the appropriate comparisons could be made. Comparisons
were performed using analyses of variance following assessment of the
normality of the data. Data on duration of untreated psychosis were analysed
using a Mann–Whitney U-test. Analysis of covariance was
performed to assess the effects of therapy on symptom and functioning outcomes
of the PANSS, PSYRATS and SFS according to age group. The dependent variables
were the 3- and 18-month outcome scores, with baseline scores and logged
duration of untreated psychosis as covariates. Therapy group, centre and age
group were fixed factors. All of the data were analysed using SPSS version 10
for Windows.
|
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
. 25%).
However, an analysis of variance performed on the total sample revealed that
there were no significant differences in baseline, 3- or 18-month PANSS total
scores between daily substance misusers and those who were infrequent or
non-misusers, although there was a non-significant trend for the substance
misusers to have poorer PANSS total scores at baseline (P=0.064).
Duration of untreated psychosis also differed between the age groups, with
median values of 8 weeks (range 2–100) and 12 weeks (range 0–624)
for the younger and older age groups respectively (Mann–Whitney
U-test=6260.5, P=0.002). The duration of untreated psychosis
was calculated according to an algorithm based on accounts from patients,
staff, notes and (where practicable) relatives. The most conservative estimate
was used for each source, with the longest estimate and patient account being
given most weight provided that they were consistent with external evidence
(Drake et al,
2000).
|
Birchwood Insight Scale scores did not differ significantly between the two groups.
Symptom outcomes
Baseline
Baseline data for the PANSS, PSYRATS, SFS and BIS for the two age groups
are shown in Table 2. It can be
seen that the younger age group had significantly higher PANSS total, PANSS
negative and PANSS general sub-scale scores at baseline compared with the
older group (F(1,301)=6.72, P=0.01; F(1,301)=5.90,
P=0.016; F(1,301)=5.51, P=0.02, respectively).
Although there were no significant differences in total PSYRATS scores at
baseline, analysis of the individual items of the PSYRATS revealed that the
younger group reported a higher proportion of distressing content in their
delusions than the older group (F(1,300)=4.38, P=0.037).
|
Follow-up
The number of sessions of therapy received was similar for the two age
groups, with participants aged 21 or under receiving an average of 13.5
sessions and the older age group receiving an average of 13.8 sessions.
However, there was a significant difference in the response to treatment
between the two age groups as rated on the PANSS positive sub-scale
(F(2,210)=3.21, P=0.043), the PANSS general sub-scale
(F(2,210)=3.01, P=0.051) and PSYRATS delusions sub-scale at
3 months (F(2,197)=3.00, P=0.052), and as rated on the PANSS
general sub-scale at 18 months (F(2,218)=3.12, P=0.046).
There was also a trend towards a significantly different response according to
age at 18 months on the PANSS total sub-scale (F(2,217)=2.47,
P=0.087) and the PANSS positive sub-scale (F(2,218)=2.39,
P=0.094).
|
|
Social functioning
Baseline
The younger age group had significantly poorer total social functioning
scores (F(1,224)=4.26, P=0.04) at baseline, which were
probably accounted for by significantly poorer scores on the competence and
performance sub-scales of the SFS (F(1,224)=12.24, P=0.001;
F(1,224)=5.77, P=0.017). No other SFS sub-scale scores
differed between the two groups. The SFS scores are shown in
Table 2.
Follow-up
There were no significant agextherapy interactions with regard to SFS
scores at any of the follow-up points.
Insight
Baseline
There were no significant differences between the age groups at
baseline.
Follow-up
There was a significant interaction between treatment and age as measured
by the Birchwood Insight Scale at 18 months but not at 3 months
(F(2,167)=3.88, P=0.023). This was accounted for by a highly
significant agexoutcome interaction between CBT and treatment as usual
(F(1,107)=7.08, P=0.009). There were no significant
interactions with age for CBT v. supportive counselling or for
supportive counselling v. treatment as usual. These findings are
illustrated in Fig. 3. The
younger patients who were receiving CBT showed greater increases in insight
than those who received treatment as usual. This pattern was not found in the
older patients.
|
Therapeutic alliance
Data on therapeutic alliance were collected during the ‘therapy
envelope’ in two ways from patients who received a psychological
intervention (i.e. not from those who received treatment as usual alone).
Patients’ views of the relationship with the therapist were assessed at
two time points (in sessions 4 and 10) using the CALPAS
(Gaston, 1990).
Therapists’ views of the degree to which they were able to engage the
patient in therapy were also assessed at three time points (in sessions 4, 10
and 15) using the PSR (Frank &
Gunderson, 1990). There were no significant differences between
the two age groups on the CALPAS at any time point. However, there were
significant differences between the age groups on the PSR at all three time
points (F(1,134)=9.62, P=0.002); F(1,105)=11.07,
P=0.001; F(1,111)=6.525, P=0.012), the younger
group having significantly higher scores (indicating that therapists believed
there was a poorer relationship) at all measurement points.
To test whether therapeutic alliance might explain the therapyxage group interactions described earlier, cases in which therapeutic alliance scales were available were selected and re-analysed (using the methods outlined in the above section on symptom outcomes). Analyses were performed with and without covarying for initial therapeutic alliance scores. No changes in significance levels for the interactions were found between the two analyses, which suggests that therapeutic alliance cannot explain the agextherapy interactions.
|
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Treatment delivery issues
Although there may be a number of explanations for these differences, some
of the findings may relate to the method of delivery of treatment. The younger
group was rated by therapists as significantly more difficult to engage in
therapy. It may be postulated that a treatment such as CBT requires a higher
level of engagement than supportive counselling, as by its very nature CBT is
a collaborative, agenda-led intervention which requires the active
participation of the recipient. In contrast, in supportive counselling the
approach is predominantly supportive and empathic, and is not directed by a
collaborative agenda. It is possible that young people with recent-onset
psychosis require more strategies to aid their engagement in therapy than
older people, although it is not clear why this is the case. One option would
be to evaluate the impact of treatment once participants had reached a
specified level of engagement in therapy.
Developmental issues
Although further research is needed to help to interpret the relationships
described in this study, it is possible that young patients may have different
developmental needs to those who develop psychosis later in life. They may be
more likely to be in contact with significant others and to be involved in
full-time education, and they may not yet have become established in terms of
their home circumstances, relationships or career. They are highly likely to
be experiencing significant life changes relating to these developmental
issues, which may have prevented them from being able to engage fully in more
structured treatments. More attention may need to be given to motivating young
patients to engage in therapy, and it is possible that supportive approaches
such as supportive counselling may be more effective in providing this
initially. However, it is also possible that once patients are engaged in
therapy, CBT may be the most helpful approach. Further investigation of
process variables in relation to therapy outcomes is needed to clarify these
points.
Insight
In addition to the differences in symptomatic outcomes in response to
treatment, there were also differences in the impact on insight according to
age and treatment. Although CBT did not have the greatest impact on symptoms
in the younger group, its impact on insight was significantly greater than
that of supportive counselling or treatment as usual in this age group. This
pattern was only apparent in the younger group. However, it was only found at
the 18-month follow-up point, and the actual changes involved were small.
Further investigation of this issue is warranted.
Limitations
This study has a number of limitations. First, the small number of
participants in the younger age group may limit the generalisability of the
findings. In addition, the selection criteria were limited to those
individuals who required hospitalisation for recent-onset psychosis. This may
mean that the recruited sample was not representative of the recent-onset
population as a whole. In addition, there may have been differences between
the comparison groups that limit the conclusions that can be drawn. For
example, there were significantly higher rates of schizophrenia in the older
age group compared with the younger group (43% v. 25%). However, when
the differences between individuals with schizophrenia and schizophreniform
disorder were examined in the two groups, it was found that participants with
the two diagnoses differed in the younger group only in that those with a
diagnosis of schizophrenia were experiencing significantly more negative
symptoms. In the older group, significant differences between individuals with
schizophrenia and schizophreniform disorder were found on all of the PANSS
sub-scales. Participants with a diagnosis of schizophreniform disorder scored
significantly lower than those with a diagnosis of schizophrenia. This
suggests that the differences in diagnosis were not based on the severity of
symptomatology alone, and that they may reflect differences in diagnostic
procedures for younger compared with older patients. However, the impact of
these factors was taken into account in the analysis by controlling for
baseline symptoms and other factors that were known to differ between the two
age groups.
Finally, although some data that would help to explain our findings were collected during the study, there is a need for a much more detailed exploration of the factors that influence engagement in and outcome of psychotherapy in early psychosis. Our findings suggest that age-related issues may be an important area for further research, and may also be important for service planning.
|
|
Clinical Implications and Limitations |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
LIMITATIONS
|
|
ACKNOWLEDGMENTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
|
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Birchwood, M., Smith, J., Cochrane, R., et al
(1990) The Social Functioning Scale. The development and
validation of a new scale of social adjustment for use in family intervention
programmes with schizophrenic patients. British Journal of
Psychiatry, 157, 853
–859.
Birchwood, M., Smith, J., Drury, V., et al (1994) A self-report insight scale for psychosis: reliability, validity and sensitivity to change. Acta Psychiatrica Scandinavica, 89, 62 –67.[Medline]
Cormac, I., Jones, C., Campbell, C., et al (2004) Cognitive–behaviour therapy for schizophrenia (Cochrane Review). Cochrane Library, issue 2. Chichester: John Wiley & Sons.
Drake, R. J., Haley, C. J., Akhtar, S., et al
(2000) Causes and consequences of duration of untreated
psychosis in schizophrenia. British Journal of
Psychiatry, 177, 511
–515.
Frank, A. F. & Gunderson, J. G. (1990) The role of the therapeutic alliance in the treatment of schizophrenia. Archives of General Psychiatry, 47, 228 –236.[Abstract]
Gaston, L. (1990) The concept of the alliance in psychotherapy: theoretical and empirical considerations. Psychotherapy, 27, 143 –153.
Haddock, G., McCarron, J., Tarrier, N., et al (1999a) Scales to measure dimensions of hallucinations and delusions: the Psychotic Symptom Rating Scales (PSYRATS). Psychological Medicine, 29, 879 –889.[CrossRef][Medline]
Haddock, G., Tarrier, N., Morrison, A., et al (1999b) A pilot study evaluating the effectiveness of individual cognitive–behavioural interventions in early psychosis. Social Psychiatry and Psychiatric Epidemiology, 34, 255 –258.
Kay, S. R., Opler, L. A. & Lindenmayer, J. P. (1989) The Positive and Negative Syndrome Scale (PANSS): rationale and standardisation. British Journal of Psychiatry, 155 (suppl. 7), 59 –65.
Lewis, S., Tarrier, N., Haddock, G., et al (2002) Randomised controlled trial of cognitive–behavioural therapy in early schizophrenia: acute-phase outcomes. British Journal of Psychiatry, 181 (suppl. 43), s91 –s97.
Tarrier, N., Yusopoff, L., Kinney, C., et al
(1998) Randomised controlled trial of intensive
cognitive–behaviour therapy for patients with chronic schizophrenia.
BMJ, 317, 303
–307.
Tarrier, N., Lewis, S., Haddock, G., et al
(2004) Cognitive–behavioural therapy in first episode
and early schizophrenia: 18-month follow-up of a randomised, controlled trial.
British Journal of Psychiatry,
184, 231
–239.
Received for publication July 29, 2004. Revision received April 1, 2005. Accepted for publication May 11, 2005.
This article has been cited by other articles:
|
|
 |
|
  M. Alvarez-Jimenez, S. E. Hetrick, C. Gonzalez-Blanch, J. F. Gleeson, and P. D. McGorry Non-pharmacological management of antipsychotic-induced weight gain: systematic review and meta-analysis of randomised controlled trials The British Journal of Psychiatry, August 1, 2008; 193(2): 101 - 107. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
, CBT; 
, supportive
counselling; 
, treatment as usual.
