Developing Cognitive Approaches to Treating Schizophrenia

Pharmacologic treatments for schizophrenia often reduce hallucinations and delusions, but they do not meaningfully improve daily life functioning. Psychosocial evidence-based practices (EBPs) tailored specifically to treat schizophrenia improve functioning, but they are not available to most patients suffering from the condition. A new study announced in Trials will look at an existing EBP‑Cognitive Behavioral Social Skills Training (CBSST) to see if it can be implemented in a way to make it accessible to many more patients.

For the study, patients with schizophrenia will be recruited from existing publicly funded Assertive Community Treatment (ACT) teams operating in community settings. A closer look at the defining components of ACT make clear why it may be difficult to implement. Those components include:

• A clear focus on those participants (clients) who require the most help from the service delivery system;
• An explicit mission to promote the participants’ independence, rehabilitation, and recovery;
• An emphasis on home visits and other interventions outside care facilities, eliminating the need to transfer newly learned skills from an artificial rehabilitation or treatment setting to the “real world”
• A participant-to-staff ratio that is low enough to allow a “core services team” perform virtually all of the necessary rehabilitation, treatment, and community support tasks themselves in a coordinated and efficient manner
• A "total team approach" in which all of the staff work with all of the participants, under the supervision of a mental health professional who serves as the team's leader; and
• A promise to work with people on a time-unlimited basis, as long as they continue to demonstrate the need for this type of professional help.

For the study, participants will be randomized to one of the 2 treatments (ACT alone or ACT + Adapted CBSST) and followed longitudinally for 18 months with assessments every 18 weeks after baseline (5 in total). The primary outcome domain is everyday living skills and activities related to employment, education, and housing as measured by self-report, testing, and observation. Additional outcome domains of interest include mediators of change in functioning, symptoms, and quality of services.

“SST and CBT are well-validated EBPs that have been shown to improve functioning and are recommended in several treatment guidelines for schizophrenia,” the study authors note. “In a meta-analysis of 35 clinical trials of CBT for schizophrenia, the majority of studies focused on positive symptoms as primary treatment targets, but CBT had beneficial impact on functioning outcomes with moderate to large sizes (d = 0.378) comparable to that for positive symptoms (d = 0.372)... Adapting CBSST to fit into the ACT service delivery context found throughout the United States creates an opportunity to substantially increase the number of persons with schizophrenia who could have access to and benefit from EBPs.”

In addition to testing the effectiveness of the approach, the researchers will identify barriers and facilitators to implementation of the CBSST program, enabling them to develop guidelines that will maximize successful implementation of the program in the future.

Study recruitment, assessment, and intervention delivery activities are ongoing.