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  • Journal of Mental Health (2000) 9, 1, 51–61Stability of outcome in a comprehensive, cognitivetherapy based treatment programme for long-termmentally ill patients. A 2-year follow-up studyBENGT SVENSSON, LARS HANSSON & KATARINA NYMANDepartment of Clinical Neuroscience, Division of Psychiatry, Lund University, SwedenAbstractA total of 21 long-term mentally ill patients, from an original sample of 28, were assessed with regardto quality of life, symptomatology, global functioning and target complaints at 6 and 24 months afterdischarge from a comprehensive in-patient treatment programme based on cognitive therapy. Asubgroup of people with a diagnosis of schizophrenia was compared with a matched control groupreceiving conventional rehabilitation, with regard to living situation, work situation and use of in-patient psychiatric care 2 years before and 2 years after treatment. The results showed improvementfor the patients in the treatment group in four out of five outcome measures between admission andthe 2-year follow-up. The investigation of differences in outcome between the patients in thetreatment group and the control group showed a marked reduction in the use of in-patient psychiatriccare for the patients receiving comprehensive cognitive therapy based treatment during the 2 yearsafter treatment. Furthermore, they also had a significantly higher degree of independent living at the2-year follow-up.Introduction tients treated with cognitive therapy in com- parison with treatment as usual or other There is a growing body of knowledge modalities of therapy (Drury et al., 1996;about the effectiveness of cognitive therapy Kuipers et al., 1997; Tarrier et al., 1993).for psychotic patients. Several studies have Other, more comprehensive treatment pro-shown that presenting alternative viewpoints, grams like the Integrated Psychologicalreality testing and enhancing coping strate- Therapy (Brenner et al., 1994) have showngies, particularly for patients with positive patient improvement in several domains in-symptoms, may be helpful (Chadwick & cluding cognitive, behavioural and socialLowe, 1990; Fowler, 1992; Garety et al., functioning (Spaulding et al., 1998). In Swe-1994; Haddock et al., 1996; Kingdon & den, a study of a treatment model based onTurkington, 1991). Three randomised con- cognitive therapy and social skills training introlled trails have been performed and they a milieu therapeutic context (Perris, 1989)show a significantly better outcome for pa- has shown that patients improved concerningAddress for Correspondence: Bengt Svensson, Department of Clinical Neuroscience, Division of Psychiatry,University Hospital, S-221 85 Lund, Sweden. Tel: +46 46 17 38 55; Fax: +46 46 17 38 84; E-mail:bengt.svensson@psykiatr.lu.seISSN 0963-8237print/ISSN 1360-0567online/2000/01051-11 © Shadowfax Publishing and Taylor & Francis Ltd
  • 52 Bengt Svensson et al.basic cognitive functions and in overall func- schizophrenia and to compare their use oftioning (Perris et al., 1990; Perris & services with a matched control group.Skagerlind, 1994). However, few follow-up 3. To make a comparison between the pa-studies have been made and the knowledge of tients with a diagnosis of schizophrenia inthe maintenance effects is limited. Kuipers et the cognitive therapy group and a matchedal. (1998) showed that the improvement in comparison group concerning their abil-symptomatology was maintained in an 18- ity to establish an independent living andmonth follow-up study and Tarrier et al. to function in working life.(1993) showed a significant improvement ofsymptomatology at a 6-month follow-up from Method and subjectsboth pre- and post-treatment levels. In a 3-year follow-up study, carried out by Perris &Skagerlind (1994), the patients’ improve- Designment concerning symptoms and social func- Between August 1990 and September 1994tioning continued from discharge to follow- all patients consecutively admitted to a treat-up. These findings indicate that the outcome ment unit located in the south of Swedenof treatment has a certain endurance and may were approached and invited to participate inimply that these positive changes also will the study. Participating patients were as-benefit the patients in their adjustment to sessed at admission, at discharge, at 6-monthsociety. To our knowledge few investiga- follow-up and at a 24-month follow-up re-tions have targeted how a positive outcome garding quality of life, level of symptoms,of cognitive therapy is reflected in the pa- global functioning and target complaints. Thetients’ ability to work and have an independ- patients’ background characteristics were reg-ent living, or the size of the impact on the istered at admission. The Strauss–Carpenterpatients’ quality of life. In one study inves- scale was obtained at admission and at the 24-tigating the model described by Perris (1989), month follow-up. Diagnoses were made ac-the results showed a significant improvement cording to the DSM-III-R. Concerning so-in quality of life between pre-and post-treat- cial functioning, occupational situation andment (Svensson & Hansson, 1999) but it is use of in-patient services, a matched com-unclear if these changes sustain the patients parison group was used in the follow-upadaptation to society. study. The study was approved by the Ethical Committee at the Medical Faculty, Univer-Aims of the study sity of Lund. Participation in the study was based on informed consent given by the pa- The aims of the present paper were: tients before entry to the study.1. To investigate the endurance and stability of treatment effects at a 6-month and a 24- Instruments month follow-up period after discharge All assessments were made by an inde- from an in-patient comprehensive treat- pendent rater unconnected with the treatment ment programme based on cognitive unit, the first author. The rater was not blind therapy. to the treatment conditions.2. To investigate the use of psychiatric serv- Symptoms were rated according to ices 2 years before and 2 years after treat- Hopkin’s Symptom Check List-90 (HSCL- ment for a subgroup of individuals with 90) (Derogatis & Fasth, 1977) and the Com-
  • Stability of outcome 53prehensive Psychopathological Rating Scale (GAF), Axis V in the DSM-III-R (American(CPRS) (Asberg et al., 1978) Psychiatric Association, 1987). The HSCL-90 is a 90-item self-rating scale The patients’ pre-admission functioningcontaining various symptoms related to psy- was rated according to the Strauss–Carpen-chiatric illness. Symptoms are rated on a ter, scale which assesses the situation duringfive-point scale from 0, not at all to 4, ex- the month before index contact, with regardtremely. The instrument consists of nine to social contacts and psychiatric symptoms,subscales: somatisation, obsessive –compul- and the previous year with regard to employ-sive symptoms, interpersonal sensitivity, de- ment and use of psychiatric in-patient serv-pression, anxiety, hostility, phobic anxiety, ices. In each subsection the scale ranges fromparanoid ideation and psychoticism. Scores 0 to 4, where 4 represents the highest level ofof the sum of all items and for each subscale functioning (Strauss & Carpenter, 1972,can be calculated. 1974). The CPRS is a clinical symptom rating Diagnoses were made by an experiencedscale consisting of 40 reported items and 27 clinician according to DSM-III-R (Americanobserved items. The assessment is based on Psychiatric Association, 1987).a structured interview and the rating of eachitem is made in four operationally defined Settingsteps with the possibility of rating three inter- The treatment programme was construedmediate steps. in accordance with the ideas of cognitive Quality of life was assessed according to therapy in the context of milieu therapy andKajandi (1994). This is a structured inter- group therapy as outlined by Perris (1989,view and targets 17 different dimensions of 1992). Although community-based care isquality of life. Each dimension is rated on a rather well developed in Sweden, the crea-five-point scale where scores of 1, 3 and 5 tion of small in-patient units based on thehave operationally defined anchor points. principles of milieu therapeutic communitiesThe 17 dimensions are divided into three life has also been a part of the deinstitutional -areas, namely, external life conditions, inter- isation process. The unit under study was inpersonal relationships and internal psycho- accordance with these principles an in-pa-logical state. tient unit with two separate apartments, each Target complaints (TC) were assessed ac- having accommodation for six residents. Thecording to Battle et al. (1966) and were used unit provided home-like living conditionsas an individualised measure of outcome. and each patient had a room of their own withDuring the initial interview the patient was a bathroom. The patients participated in allasked to define the complaints of relevance normal daily living activities such as tidying,for the actual treatment. The patient then shopping and cooking.rated the severity of each complaint on a five- Each patient had two therapists and tookpoint scale with a defined maximum and part in at least two therapy sessions a week.minimum and with three intermediate rating The leading principles used during the ses-possibilities. In the analysis the first com- sions were as follows: developing a collabo-plaint mentioned by the patient was regarded rative empiricism; accepting the basic tenetsas the patients main target complaint. of cognitive therapy concerning the relation- Global functioning was rated according to ship between thoughts, emotions and behav-the Global Assessment of Functioning Scale iour and their reciprocal influence; taking
  • 54 Bengt Svensson et al.into account the singularity of each patient, phrenia (n=4) in the drop-out group, registerindependently of present status or diagnostic data and data from medical files were ob-categorisation; addressing the healthy aspects tained for the 24-month follow-up. Thus theof the patient rather than focusing on symp- total attrition for the assessment part of thetoms; trusting that every individual has the follow-up study was seven patients (25%).potential to influence his or her own condi- The background characteristics of the pa-tion, at least to a certain extent; promoting the tients in the cognitive therapy group whodevelopment and maintenance of the patient’s participated in the 6-month and the 24-monthautonomy; promoting the unfolding and en- follow-up studies are shown in Table 1. Ashancement of the patient’s competence can be seen from the table, the patients were(Perris,1992). in general young (m=24.6) but with several A number of group activities were sched- years duration of illness (m=5.0), and a numberuled every week. They included body-aware- of previous in-patient episodes (m=5). It isness training, activities of recreational and also clear that most of the patients had beensports nature and expressive art therapy. The unable to establish any higher level of socialformal group therapy sessions consisted of a function in terms of finding a partner, gettingsocial skills training group once a week and a married, finding a job or creating an inde-weekly specially designed group activity fo- pendent living after their first psychotic epi-cusing on the identification, differentiation sodes. At admission 13 of the 17 patientsand expression of feelings and emotions. The with the diagnosis of schizophrenia also pre-treatment also included a psycho-educationa l sented with unremitting (at least 6 months)programme for relatives. positive psychotic symptoms despite medi- cation and they fulfilled the criteria for drug-Subjects resistance as suggested by Garety et al. (1994). In total 33 patients were admitted and dis- The patient’s length of stay at the rehabilita-charged during the study period. All patients tion unit ranged from 15 to 140 weekswere invited to participate in the study. Of (m=70.1)these, one patient refused to participate in the In total, 15 of the patients fulfilled thestudy, two patients were transferred to other DSM- III-R criteria for schizophrenia. Twounits shortly after their arrival because of patients received a diagnosis of schizotypalviolent and dangerous behaviour, one patient personality disorder. These two patients werewas discharged shortly after admission, and clinically considered to be schizophrenic, butone patient died from a physical illness dur- due to lack of evidence of regressive symp-ing admission. Thus a total of 28 patients toms they did not fulfil the DSM-III-R crite-were finally included in the study. Outcome ria; in the analyses they are included in theat discharge is presented elsewhere (Svensson group of individuals with the diagnosis of& Hansson, 1999). schizophrenia. The remaining patients suf- Four patients were lost by the time for the fered from bipolar affective disorder, hyper-6-month follow-up. Three of them refused to activity disorder, anxiety disorder and finallyparticipate in the follow-up interview and one patient had a mixed personality disorderone patient could not be traced. At the 24- (border-line and histrionic PD). The mainmonth follow-up another three patients re- reasons for the admission of the non-schizo-fused to participate in the study. However, phrenic patients into the treatment unit werefor the people with the diagnosis of schizo- that they were long-term mentally ill, had a
  • Stability of outcome 55Table 1: Background characteristics of the cognitive therapy group (n=21) N Gender Men 12 Women 9 Age (mean, range) 24.6 (17–38) Marital status Not married 21 Living conditions Alone 10 With parents 11 Occupational situation Sheltered work 1 Student 2 Unemployed (sick-leave or disability pension) 18 Age at onset of illness (mean, range) 19.9 (15–26) Duration of illness (mean, range) 5.0 (1–15) Number of previous in-patient episodes (mean, range) 5 (1–30) In-patient days during the 18-month period preceding index admission (mean, range) 239 (0-510) Previous suicidal attempts (n, range) 4 (1–6) Diagnosis Schizophrenia 15 Schizotypal personality disorder 2 Bipolar affective disorder 1 Other 3severe social dysfunction, that other rehabili- also had at least 1 year of practical experiencetation efforts had failed and that the majority in providing supervised cognitive therapyof them had, in spite of their classification , before the study started. The therapists ad-repeated psychotic episodes. herence to cognitive therapy was monitoredTherapists by regular use of videotaped sessions in the The therapists were experienced psychiat- supervision of each therapy and therapist.ric nurses who had a training in cognitive The supervisors were experienced psychia-therapy equivalent to the regulations of the trists and psychologists who also were regis-Swedish National Board of Health and Wel- tered psychotherapists, authorised in provid-fare for performing psychotherapy under su- ing cognitive therapy by the Swedish Na-pervision of an authorised supervisor. They tional Board of Health and Welfare.
  • 56 Bengt Svensson et al.The matched control group care, was chosen for comparisons between the groups. Data concerning days in in- The comparison group matching the schizo- patient care 2 years before admission and 2phrenic patients, including the patients with years after discharge was collected and dif-schizotypal personality disorder in the cogni- ferences between the groups were analysed.tive therapy group (n=21), was obtained from It was also possible to make an estimation ofa rehabilitation unit focused on long-term the patient’s ability to function in terms ofmentally ill patients. The unit served the living conditions and work situation whichcatchment area of the city of Lund, which allowed comparisons between the two groups.comprises about 100,000 inhabitants. The The amount of support from psychiatric out-unit had a long tradition of psychiatric reha- patient services during the follow-up periodbilitation and admitted patients who were in was for both the cognitive therapy group andneed for long-term treatment. It offered the control group categorised as follows. 1.individualised systematic social communi- Continuous contact indicating referral to day-cation and skills training interventions in- care units or other daily support. 2. Regularcluding problem solving and ego-strengthen- contact indicating regular and scheduleding weekly therapy sessions in the highly meetings with therapist or keyworker. 3. Spo-structured and predictable, psychodynami - radic contacts indicating scarce and irregularcally orientated milieu of an open in-patient contacts with out-patient services. The medi-ward. This treatment condition was consid- cation regime for the patients was also regis-ered as ‘treatment as usual’ for patients with tered at follow-up.a severe long-term mental illness. The match-ing variables used were diagnosis, sex, age of Statisticsonset, duration of illness and age at indextreatment. Diagnoses according to DSM-III- The statistical software used was SPSS forR were matched very rigorously so that all Windows, release 7.0 (Norusis, 1995). Non-subclassifications were taken into account in parametric tests were used due to the smallthe matching procedure. In order to make the sample size and the lack of normal distribu-matching as accurate as possible the control tion in the variables used in the analyses.group was collected from a large cohort of Wilcoxon matched-pairs signed-rank test waspatients treated during the period from 1982 used to compare differences between ratingsto 1991. This had, as a consequence, that the at admission and 24-month follow-up, andcontrols on average had been admitted to between discharge and the 24-month follow-rehabilitation 3.8 years before the cognitive up. It was also used in comparisons betweentherapy group. The patients in the cognitive the cognitive therapy group and the matchedtherapy group had spent longer time in the control group.index treatment (m=72.0, r=15–140 weeks)than the controls (54.5, r=15–128 weeks). Results No interview assessment variables were The follow-up of the cognitive therapyavailable for the matched control group. groupTherefore, it was only possible to use dataobtainable from case registers and medical The results from the assessments at admis-records. Due to different routines in the sion, discharge, the 6-month and the 24-registration of the use of services, the most month follow-up are shown in Table 2. Asreliable variable, days spent in in-patient seen from the table, the patients in all out-
  • Stability of outcome 57Table 2: Assessment of outcome measures at admission, discharge and follow-up ( n=21) Measure Admission Discharge 6-months follow-up 24-months follow-up mean (SD) mean (SD) mean (SD) mean (SD) Quality of life 36.2(6.3) 40.4(7.7) 40.4(9.1) 43.3(7.9)*** CPRS 26.4(13.7) 29.5(30.4) 26.1(12.6) 20.8(10.5)* SCL-90 114.7(68.5) 100.3(76.5) 103.0(68.4) 91.7(69.7) GAF 46.2(10.4) 53.3(10.8) 48.3(11.9) 55.2(13.0)** Target complaints 4.0(0.7) 3.0(1.1) 3.0(1.0) 2.9(1.2)*** Comparisons between admission and 24-month follow-up. Wilcoxon matched-pairs signed-rank test. * p < 0.05, ** p < 0.01, *** p< 0.001.come measures showed a positive change other psychopharmacological drug and fivefrom admission to the 24-month follow-up had no medication. The use of medicationand with the exception of the SCL-90 the was stable between discharge and the 24-improvements were significant. There was month follow-up but throughout the studyalso a significant improvement between ad- period there was a change from traditionalmission and the 24-month follow-up accord- neuroleptics to clozapine and olanzapine.ing to the four measures included in the Also more patients were able to manageStrauss Carpenter scale: see Table 3. without medication at discharge and the 24- The changes in medication between admis- month follow-up than at admission.sion, discharge and the 24-month follow-upwere as follows: at admission 10 patients had Comparisons between the individualstraditional neuroleptics, seven had clozapine, with a diagnosis of schizophrenia in theone other psychopharmacological drug and cognitive therapy group and thethree had no medication. At discharge five matched control grouphad traditional neuroleptics, 10 had clozapine, When the patients, in both groups, wereone other psychopharmacological drug and discharged a treatment plan for each indi-five had no medication. At 24-month follow- vidual was made in order to provide a needup three patients had traditional neuroleptics, adapted support in out-patient treatment. Fif-nine had clozapine, three had olanzapine, one teen patients in the cognitive therapy groupTable 3: Assessments according to the Strauss–Carpenter scale at admission and the 24-month follow-up (n=21) Admission 24-month follow-up mean (SD) mean (SD) p-value* Work situation 0.38 (0.9) 1,4 (1,7) <0.01 Social contact 1.7 (1.3) 2.6 (1,7) <0.05 Symptoms 1.6 (1.6) 2.6 (1.4) <0.05 In-patient care 1.9 (1.6) 3.0 (0.3) <0.01 S.C. total 5.5 (2.5) 9.6 (3.9) <0.001 Wilcoxon matched-pairs signed-rank test.
  • 58 Bengt Svensson et al.and eight patients in the control group was level of functioning signified by a sporadicprovided treatment on a regular basis during participation in occupational therapy. Thethe follow-up period. Continuous contact difference in occupation between the groupswith services was given to five patients from was not significant.the cognitive therapy group and to 11 patients The use of in-patient services during the 2from the control group. Finally one patient years before and the 2 years after treatmentfrom the cognitive therapy group and two was for the cognitive therapy group, 212.8from the control group had a sporadic contact days before and 129.5 days after and for thewith their psychiatric treatment teams. control group, 125.9 days before and 205.1 The medication for the patients in the con- days after. There was a marked decrease introl group at follow-up were as follows: seven the days of the in-patient care in the cognitivepatients had clozapine, 13 patients had tradi- therapy group during the 2-year follow-uptional neuroleptics in lowest effective dos- period, while there was a corresponding in-age. One patient had no medication and was crease in the matched control group. None ofconsidered not to be in need of such treat- these changes was significant. The numberment. The medication for the subgroup of of days in in-patient treatment decreased inindividuals with a diagnosis of schizophrenia average by 83.6 days in the cognitive therapyreceiving the cognitive therapy programme group and increased by 79.2 days in thewere at follow-up as follows: nine patients matched control group. Comparisons be-had clozapine, three patients had olanzapine tween the groups demonstrated that this dif-and five patients had traditional neuroleptics ference in change in service use was signifi-in lowest effective dosage. Four of the pa- cant (p=0.01). In total figures this indicatestients were not on medication and were con- a reduction of in-patient days by 1755 dayssidered to manage without. for the cognitive therapy group, a reduction Concerning the patients’ living conditions by 39.3% compared to the 2-year periodat the 24-month follow-up, 16 of the 21 before index admission. The matched con-patients in the cognitive therapy group were trol group in total increased their use of in-living in their own apartment and could func- patient days by 1664 days, an increase bytion independently. In the control group 10 of 63% compared to the 2-year period beforethe 21 patients had an independent living index admission.condition. The differences between the groupswere statistically significant (p=0.03). Those Discussionpatients who had not established independentliving were in both groups, either living with The present study was a longitudinal 2-yeartheir parents or in different forms of sheltered follow-up investigation of long-term men-accommodation. tally ill patients treated in an in-patient treat- The patients’ working situation was as- ment programme based on cognitive therapy.sessed in terms of having a full-time occupa- Due to the naturalistic nature of the study thetion. Planned studies, work training and results must be considered in the light of itswork were all placed on an equal footing. In limitations. The sample size was small andthe cognitive therapy group eight of the 21 there was diagnostic heterogeneity amongpatients and in the control group six of the 21 the patients. The attrition rate of 25% in thepatients had an occupation. The other pa- assessment part of the follow-up study alsotients in both groups had on average a low reduced the external validity of the results.
  • Stability of outcome 59However, the sample represents a patient some extent, explain the improvements. How-group often seen in clinical settings and often ever, most of the patients were medicated atconsidered hard to treat. These patients all the admission and despite that they remainedhad severe disabilities in everyday life, they severely disabled. The minor changes in thehad not showed gains from earlier treatment symptomatology might indicate that the medi-attempts and a majority of them presented cation only had a limited impact.severe psychotic symptoms. The changes in The comparisons between the cognitivethe cognitive therapy group showed a stable therapy group and the matched control groupimprovement from admission to the 24-month demonstrated a reduction of in-patient care infollow-up. The most important gains for the the cognitive therapy group during the 2-patients were seen in the areas of global year period after treatment. This was not seenfunctioning, quality of life and target com- in the control group, where the use of in-plaints. On the other hand, symptoms de- patient days actually increased. These changescreased only slightly, and concerning self- were significantly in favour of the cognitiverated symptoms the decrease was not signifi- therapy group. It could be argued that thiscant. In this respect the results differ from difference was due to the fact that the controlearlier follow-up studies (Kuipers et al., 1998; group on average was admitted a few yearsPerris & Skagerlind, 1994; Tarrier et al., earlier and that the ongoing cut-downs in1993) which have demonstrated significant health care budgets and as a consequence ofimprovements in symptomatology. How- that, fewer beds available and changes inever, comparisons with earlier studies inves- admission policies, might explain the differ-tigating only cognitive therapy delivered in ence. However, the ongoing decrease in bedsout-patient settings are problematic, since could not explain the 63% increase in use ofthe present study was investigating a compre- in-patient days during the follow-up in thehensive in-patient programme also using other matched control group.interventions. This makes it hard to single The comparisons between the groups without the specific effectiveness of the cognitive regard to living conditions and work situationtherapeutic interventions. Despite the differ- showed that significantly more patients in theences in the treatment design, as compared to cognitive therapy group had an independentearlier studies, a similar maintenance was living condition. With regard to the workingdemonstrated throughout the 2-year follow- situation, few patients in both groups hadup. At the 6-month follow-up the patients, achieved a normal or close to normal func-however, showed a slight deterioration. This tioning. This underlines the severity of themight be due to the problems patients have schizophrenia and emphasises the need forwhen confronting life in the community after treatment programmes that systematicallya long period of in-patient treatment in a unit take these aspects into account.characterised by a therapeutic and holding Although the comparison group was veryatmosphere. Furthermore, implementation carefully matched with the cognitive therapyand integration of experiences from the treat- group, the lack of randomisation limits thement period into the daily living situation possibilities of drawing firm conclusions fromprobably takes a longer time. It is reasonable the evidence of differences in favour of theto believe that treatment effects concerning cognitive therapy group. However, patientssocial competence and coping do not mani- in both groups had access to a diversified out-fest themselves during a short follow-up pe- patient support, which seemed to be moreriod. The changes in medication could, to intense in the matched control group during
  • 60 Bengt Svensson et al.the follow-up period. Furthermore, patients logical Therapy for Schizophrenic Patients (IPT).in both groups were offered novel antipsy- Toronto: Hogrefe & Huber. Chadwick, P.D.J. & Lowe, C.F. (1990). Measurementchotic medication (7 v. 12) and a larger and modification of delusional beliefs. Journal ofproportion of the patients in the experimental Consulting and Clinical Psychology, 58, 225–232.group were able to function without Derogatis, L.R., Fasth, B.G. (1977). Confirmation ofneuroleptics (1 v. 4) compared with the con- the dimensional structure of the SCL-90: A study in construct validation. Journal of Clinical Psychol-trol group during follow-up. It is therefore ogy, 33, 981–989.unlikely that the differences in in-patient Drury, V., Birchwood, M., Cochrane, R. & Macmillan,service use and living conditions could be F. (1996) Cognitive therapy and recovery fromexplained by differences in use of out-patient acute psychosis: A controlled trial I. Impact on psychotic symptoms. British Journal of Psychia-services and medication during the follow-up try, 169, 593–601.period. Fowler, D. (1992). Cognitive behaviour therapy in the In summary, the results demonstrate that management of patients with schizophrenia: pre-the cognitive therapy group, mainly unre- liminary findings. In: A. Werbart & J. Cullberg (Eds.), Psychotherapy of Schizophrenia: Facilitat-sponsive to earlier treatment attempts and ing and obstructive factors (pp. 145–153). Oslo:despite a low initial functioning in work and Scandinavian University Press.a proportionately high level of persisting Garety, P.A., Kuipers, L., Fowler, F., Chamberlain, F.,psychotic symptoms, could benefit from treat- Dunn, G. (1994). Cognitive behavioural therapyment in terms of a better quality of life, stay for drug-resistant psychosis. British Journal of Medical Psychology, 67, 259–271.in the community and in a more independent Haddock, G., Bentall, R.P. & Slade, P.D. (1996). Psy-living. chological treatment of auditory hallucinations: Focusing or distraction? In: G. Haddock & P. Slade (Eds), Cognitive-Behavioural Interventions withAcknowledgments Psychotic Disorders (pp. 45–70). London : Routledge. This study was supported by grants from Kajandi, M. (1994). A psychiatric and interactionalMalmöhus County Council, the Council for perspective on quality of life. In L. NordenfeldtMedical Health Care Research in South Swe- (Ed.), Concepts and Measurement of Quality of Life in Health Care (pp. 257–276). Dordrecht,den, the Lindhaga Foundation, the Swedish Holland: Kluwer Academic Publishers.Council for Social Research and the Federa- Kingdon, D.G. & Turkington, D. (1991). The use oftion of County Councils. cognitive behaviour therapy with a normalising rationale in schizophrenia. Journal of Nervous and Mental Disease, 179, 207–211.References Kuipers, E., Fowler, D., Garety, D., Chisholm, D., Freeman, D., Dunn, G., Bebbington, P. & Hadley,American Psychiatric Association (1987). Diagnostic C. (1998). London–East Anglia randomised con- and Statistical Manual for Mental Disorders, (3rd trolled trial of cognitive-behavioural therapy for Edn, rev.) Washington DC: APA. psychosis III: Follow-up and economic evaluationAsberg, M., Montgomery, S.A., Perris, C., Schalling, at 18 months. British Journal of Psychiatry, 173, D. & Sedvall, G. (1978). A comprehensive psycho- 61–68. pathological rating scale. Acta Psychiatrica Kuipers, E., Garety, P., Fowler, D., Dunn, G., Scandinavica, 271, 5–27. Bebbington, P., Freeman, D. & Hadley, C. (1997).Battle, C.C., Imber, S.D., Hoehn-Saric, R.H., Stone London–East Anglia randomised controlled trial of A.R., Mash E.R. & Frank J.D. (1966). Target cognitive–behavioural therapy for psychosis I: Ef- complaints as criteria of improvement. American fects of the treatment phase. British Journal of Journal of Psychotherapy, 20, 184–192. Psychiatry, 171, 319–327.Brenner, H.D., Roder, V., Hodel, B., Kienzle, N., Reed, Norusis, M.J. (1995). Statistical Package for the Social D. & Liberman, R.P. (1994). Integrated Psycho- Sciences, SPSSPC+ 7.0. Chicago: SPSS Inc.
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