High-yield cognitive behavioral techniques for psychosis delivered by case managers to their clients with persistent psychotic symptoms: an exploratory trial

Abstract

Case managers spend more time with clients with schizophrenia than any other professional group does in most clinical settings in the United States. Cognitive behavioral therapy (CBT) adapted for individuals with persistent psychotic symptoms, referred to as CBT-p, has proven to be a useful intervention when given by expert therapists in randomized clinical trials. It is currently unknown whether techniques derived from CBT-p could be safely and effectively delivered by case managers in community mental health agencies. Thirteen case managers at a community mental health center took part in a 5-day training course and had weekly supervision. In an open trial, 38 clients with schizophrenia had 12 meetings with their case managers during which high-yield cognitive behavioral techniques for psychosis (HYCBt-p) were used. The primary outcome measure was overall symptom burden as measured by the Comprehensive Psychopathological Rating Scale, which was independently administered at baseline and end of intervention. Secondary outcomes were dimensions of hallucinations and delusions, negative symptoms, depression, anxiety, social functioning, and self-rated recovery. Good and poor clinical outcomes were defined a priori as a 25% improvement or deterioration. t-Tests and Wilcoxon's signed-ranks tests showed significant improvements in all primary and secondary outcomes by the end of the intervention except for delusions, social functioning, and self-rated recovery. Cohen's d effect sizes were medium to large for overall symptoms (d = 1.60; 95% confidence interval [CI], -2.29 to 5.07), depression (d = 1.12; 95% CI, -0.35 to 1.73), and negative symptoms (d = 0.87; 95% CI, -0.02 to 1.62). There was a weak effect on dimensions of hallucinations but not delusions. Twenty-three (60.5%) of 38 patients had a good clinical result. One (2.6%) of 38 patients had a poor clinical result. No patients dropped out. This exploratory trial provides evidence supportive of the safety and the benefits of case managers being trained to provide HYCBt-p to their clients with persistent psychosis. The benefits reported here are particularly pertinent to the domains of overall symptom burden, depression, and negative symptoms and implementation of recovery-focused services.