The International Journal of Psychosocial Rehabilitation

Integrated Psychological Intervention
 for Schizophrenia

Shantala Hegde 1 MPhil, Shobini. L. Rao, PhD 2*, Ahalya Raguram, PhD 3.

Department of Mental Health and Social Psychology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore-29, India

 

1. M. Phil, PhD scholar, Neuropsychology Unit, Department of Mental Health and Social Psychology, NIMHANS, Bangalore, India.

2*Correspondence should be addressed to Dr Shobini L. Rao, Professor, Department of Mental Health and Social Psychology, NIMHANS, Bangalore-560029, India

 (e-mail: shobini@nbrc.ac.in)

3. Additional Professor, Department of Mental Health and Social Psychology, NIMHANS, Bangalore, India.

 

  Citation:
Hegde S, Rao S L, and Raguram A. (2007) Integrated Psychological Intervention
for Schizophrenia.
  International Journal of Psychosocial Rehabilitation. 11 (2), 5-18




Abstract

Objective. Studies have demonstrated the independent effectiveness of cognitive retraining and family interventions in schizophrenia.  The improvements in cognitive functions following the retraining are poorly sustained, which could be due to the absence of a supportive and congenial family environment to sustain the gains of the retraining program. The present study aimed to develop a treatment program for schizophrenia, which integrated cognitive retraining with family intervention, and test its clinical effectiveness.

Design and methods. The sample consisted of three outpatients diagnosed as having schizophrenia and their caregivers. Cognitive retraining for the patients targeted the functions of attention, information processing, executive functions, learning & memory, comprehension & production of emotions. Family intervention consisted of psychoeducation, improving communication and problem-solving skills, lowering expressed emotions and modifying expectations. The treatment lasted 6 weeks, with cognitive retraining being given everyday and family intervention in bi- weekly sessions. The patients were evaluated on a battery of neuropsychology tests and Global Assessment of functioning scale and the caregivers on the General Health Questionnaire, and Burden Assessment schedule at pre intervention, post intervention and at two-month follow-up.

Results. Following intervention the cognitive and global functioning of the patients improved.  The psychological distress and subjective burden of the caregivers decreased. Two patients sustained the gains on neuropsychological functions and global functioning at the follow up.   At the end of three months all the three patients were in fulltime gainful employment.

Conclusion. The integrated psychological intervention has shown promise and merits further evaluation of its efficacy.

 

Key words:  Neuropsychological assessment, Cognitive retraining, Family Intervention, Global functioning.




Introduction
Schizophrenia is a disabling disease that continues to pose challenges in understanding its etiopathology. Cognitive deficits are a manifestation of the neuropathology in schizophrenia (Gold & Harvey, 1993). Cognitive deficits have been reported in sustained attention, switching attention and working memory, auditory and visual information processing, verbal memory, executive impairment, set shifting, and planning (Morris, et al., 1995; Cadenhead et al., 1997; Nelson et al., 1998; Smith et al., 1998; Pantelis et al., 1999). Cognitive functioning has a significant bearing on the parameters of functional outcome such as work performance, social functioning, social problem solving and social skill acquisition (Green, 1996; Bellack et al., 1999; Twamley et al., 2002). Therefore improvement of cognition has a therapeutic role in schizophrenia.

Cognitive retraining uses graded tasks to improve specific cognitive functions.  Cognitive retraining studies in schizophrenia have followed two approaches. The first approach includes studies carried out in laboratory settings with the aim of improving performance on individual tests. Examples are the following studies. Retraining was given on the Wisconsin Card Sorting Test (WCST), incorporating strategic training, positive and monetary feedback.  However the improvement was not sustained and failed to generalize to other problem solving measures (Goldberg et al., 1987; Bellack et al 1990; Summerfelt et al., 1991) The functions of attention (Benedict et al., 1994; Medalia et al., 1998) working memory (Bell, Bryson & Wexler 2003) and emotion perception (Gaag et al., 2002) have also been improved in schizophrenic patients through cognitive retraining. However, a review of nine cognitive retraining studies in schizophrenia provides inconclusive evidence of the effectiveness of retraining. (Suslow, Schonauer & Arolt 2001). The second approach comprises of studies done in clinical settings, which in addition to improving performance on a variety of tests, have also, examined the generalization of the improved cognition to daily activities. This approach has number of different types of cognitive retraining programs, such as paper pencil task, computer based task also group activities (Wykes, 2000).  Examples are the following studies. The Integrated Psychological Therapy (IPT) developed by Brenner et al., is a highly structured group therapy approach for schizophrenia, which incorporates cognitive retraining. Studies evaluating the IPT have been inconclusive in stating the specific role of cognitive retraining on improved cognitive functions (Hodel & Brenner, 1994). Another individualized program developed by Van der Gaag (1992) uses paper pencil tasks. The program consists of three separate modules targeting cognitive flexibility, working memory and planning. The program improved concept formation and set shifting as on the WCST performance, following treatment, with questionable improvement in social functioning (Delahunty et al., 1993). Other controlled studies of cognitive retraining programmes have shown improvements in cognitive functioning but poor generalization of the improvement to global functioning (Wykes, 2000).

 
  The reason for poor generalization may be the slow and gradual pace of improvement of cognitive functions during the retraining process. Family members may be unable to perceive the gradual and subtle improvements and hence fail to provide positive feedback to the patients. On the other hand, those families, which recognize the improvements, may develop overly high expectations about the patients’ level of clinical improvement and their general functioning. Either way the consequences are likely to result in high expressed emotions, which could then have deleterious impact on the gains acquired through the retraining programme.  A way out of this intractable situation would be family intervention.

Family interventions enhance understanding of the illness among the caregivers and foster supportive relationships in the family (Bellack, 2000).  The anxiety, distress and burden of the caregivers reduce and their acceptance of the patient’s illness improves after family intervention (Xiong et al., 1994).  Thus to optimize the clinical benefits for the patient, a combination of cognitive retraining and family intervention would be desirable since this approach would improve the cognitive functions of the schizophrenic patient and sustain the gains with a congenial family environment.

The present study aimed to develop a treatment programme for schizophrenia, which combined cognitive retraining with family intervention, and to examine its clinical efficacy.

   Method:
  Participants
  The sample consisted of three unmarried male patients from urban background diagnosed as having paranoid schizophrenia (ICD- 10; WHO 1992) and their caregivers. Patients were identified in the out-patient department of the adult psychiatry units, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India. Case 1 was 29 years old, educated up to BA, from upper socio economic status, with illness duration of 8 to 10 years.   Case 2 was 29 years old, educated up to B E, from a low socio economic status, with illness duration of 14 years and case 3 was 26 years old, educated up to B. E, from upper socio economic status, with illness duration of 8 to 10 years. The care givers were brother and sister-in –law for case 1, mother in case 2 and parents in case 3. On the Brief Psychiatric Rating Scale (Bech, Kastrup and Rafelsen, 1986), the scores for case 1, 2 and 3 were 7, 8 and 8 respectively.  All patients were stabilized on atypical antipsychotic medication and the dosages were not changed during the course of the study and follow up period. Case 1 and 2 were never in gainful employment and Case 3 had been unemployed for 2-½ years prior to the recruitment to the study. None of the patients had sensory or motor deficits, clinical evidence of mental retardation, psychiatric co-morbidity, neurological or neurosurgical disorder. The caregivers had no present or past history of psychiatric illness. Patients and caregivers gave written informed consent to participate in the study.  
 
  Procedure
  The study employed a single case study method. Prior to and after cognitive retraining, each of the three patients was assessed on a comprehensive battery of neuropsychological tests, and a measure of global functioning. The caregivers were screened for presence of minor psychiatric disorders and evaluated for their perceptions of family burden. The cognitive retraining program was administered daily to the patient for six weeks, while the caregivers underwent family intervention twice a week, for the same duration. Two patients and their caregivers were reassessed after a period of two-months, while the third patient and his caregivers were not available for the follow up assessment. 
 
  Assessment of patients:
The patients were assessed for their overall level of functioning using the Global Assessment of Functioning Scale (GAF) (DSM IV, APA 1994). The following neuropsychological functions were assessed; Sustained attention was assessed using Digit Vigilance Test  (Lezak, 1995), focused attention using Colour Trails 1 and 2 (D’Elia et al., 1996), psychomotor performance and information processing speed using Digit Symbol Substitution  (Wechsler, 1981) and motor speed using Finger Tapping Test  (Spreen & Strauss, 1998). Executive functions assessed were: response inhibition using Stroop Color-Word Test  (Stroop, 1935), working memory using Self-Ordering Pointing Test (SOPT) (Petrides and Milner, 1982), set-shifting ability using Wisconsin Card Sorting Test (WCST) (Milner, 1963) and planning using Tower of London Test (TOL) (Shallice, 1982).  Verbal learning and memory was assessed using Rey’s Auditory Verbal Learning Test (AVLT) (Maj et al., 1994) and visual learning and memory using Rey’s Complex Figure Test (RCFT) (Meyers & Meyers, 1995).

The scores on the neuropsychological tests were compared with norms appropriate to that of the subject’s gender, age and education. The normative data was derived from a group of 540 normal healthy volunteers (Rao et al., 2004). Healthy volunteers were recruited from relatives of patients admitted at the hospital, students, and from the community at large.  Healthy volunteers who obtained a score of > 2 on the General Health Questionnaire (GHQ-12) developed by Goldberg and Williams (1988) were excluded, as these persons met criteria for psychological distress, which itself could influence cognitive functioning. Healthy volunteers were also excluded if they had a previous history of neurological, neurosurgical or psychiatric illness or substance dependence and family history of alcohol dependence, schizophrenia or bipolar disorder. The normative sample was divided into three age ranges (16-30, 31-50 and 51-65 years) and three education groups (no formal schooling, 1-10 years, and greater than 10 years of formal education) separately for males and females. For each test variable, percentile scores were calculated. The 15th percentile score (1 SD below the mean) was taken as the cut off score (Heaton et al., 1995). Cutoff scores were then calculated for each group based on age, education and gender. A deficit was defined as a test score falling below the 15th percentile (Heaton et al., 1995). Validation for each of the tests has been carried out on patient groups with focal lesions, refractory epilepsy, head injury and Parkinson disease (Rao et al., 2004).

  Assessment of caregivers:
  The caregivers of the patients were assessed before and after the period of intervention using General Health Questionnaire-28 (GHQ-28) (Goldberg & Hillier, 1979).  This is a screening tool aimed at detecting those with probable psychiatric disorders (depression, anxiety, social dysfunction and somatic symptoms). The responses are endorsed on a 4-point rating scale and the cut off score is 4/5.The scale has been found suitable for use in the Indian context (Shamasunder et al, 1986). Burden Assessment Schedule (BAS) assessed the family’s experience of burden in various domains (Thara, Padmavathi, Kumar & Srinivasan, 1998). It has 40 items rated on a 3- point scale. The scores range from 40 to 120, with higher scores indicating higher burden. It assesses burden in areas of financial aspects, patient’s behavior, social relations, caregiver health, caregiver occupation, leisure activities and emotional burden. The scale has an inter-rater reliability of 0.80 (kappa, p<0.01) (Thara et al 1998), test-retest reliability of 0.91 while the alpha coefficient is 0.92 (Rammohan et al 2002).  
 
  Integrated Psychological Intervention

Cognitive retraining programme: The cognitive functions reported to be deficient in schizophrenia (Gold & Harvey, 1993) were chosen as targets for retraining. Tasks to ameliorate these deficits were introduced in the retraining program in a graded manner, according to the following schedule. The functions of attention, fluency, information processing, working memory and response inhibition were targeted in week 1. Tasks to improve the functions of visual immediate memory and spatial encoding were added in week 2. Finally, tasks to improve the functions of set- shifting, planning, comprehension and production of emotions were added in week 3. The cognitive retraining was carried out daily for 1 ½ to 2 hours. Feedback on the performance of the retraining tasks was given at the end of each session.

Attention:  Tasks of letter and symbol cancellation and dictation were used to improve attention.  The letter/symbol cancellation task required the patient to cancel any two target letters or symbols from an array presented in an A4 size sheet. Time taken to complete the task and errors of commission and omission were recorded. Decreasing the font size and increasing the number of letters or symbols in the given sheet achieved increased task difficulty. Letter cancellation was given till week 5 and symbol cancellation in week 6.  In weeks 4 and 5, music played during the task performance as was used as a distracter.   In week 6, during symbol cancellation, phonemic fluency task was used as a distracter.  In the Dictation task, the patient wrote 20 words to dictation.  Number of correctly written words formed the score.  Dictation was discontinued after 2 weeks as the patients obtained the maximum score.

Information processing: The task was to sort grains of various sizes, with the type of grains ranging from two to four. There were two types of big grains in week 1, 2 types of small grains in week 2, 3 types of small grains in week 3-4, four types of small grains in the weeks 5-6.  The patient listened to music while sorting grains in the weeks 4-6 to increase task difficulty.  The quantity of grains sorted in 30 minutes was measured.

Response Inhibition: The patient colored increasingly complex drawings using pencils from weeks 1-6. Emphasizing careful regulation of pressure and direction of strokes as well as neatness increased response inhibition.  Time taken to complete the task was recorded.  Stop-start task was introduced in the week 5 and 6 of the retraining programme. In this task while the patient was performing a motor sequence for e.g. clapping hands, he was instructed to stop suddenly without a prior signal and then asked to restart the same sequence when the start signal is given. The start-stop signal is given randomly. The task was performed for 5 minutes in each therapy session.

Working memory: Mental arithmetic (10 problems) and jumbled sentences (10 sentences) were administered in week 1 and 2.  The tasks were discontinued subsequently as the patients reached the ceiling level.   Tasks for improvement of visuo spatial encoding and visual memory for locations required the patient to reproduce the location and sequence of an arrangement of objects on a table, from memory. An increasing number of objects were exposed for 10 seconds. Following maintenance in memory for another 10 seconds, the patient was asked to reproduce the arrangement.  The task was given from weeks 2-6, with accuracy of reproduction as the score.   

Set-shifting: Categorization of beads, categorization of playing cards and motor set-shifting were administered.  In week 3, 50 beads of various shapes, colours and sizes were combined together. The patient’s task was to categorize the beads employing a different rule everyday.  In weeks 4 -5, two decks of playing cards were sorted. Week 4 required the patient to identify the sorting rule of the therapist, while in week 5 the patient generated a sorting rule.  Weeks 4-5 also included the motor set-shifting task for 5 minutes.  The patient suddenly shifted from one motor sequence such as clapping hands to another sequence such as tapping feet.

Planning:  In weeks 3 and 4 the patient was given real life situations and asked to narrate the steps taken to achieve the desired goal. For example, a situation such as planning for a picnic within a given budget was given.  The therapist suggested improvements to the plan. In the weeks 5-6, the patient wrote essays on topics of his interest.  The therapist corrected the sequence and planning of the essay.

Comprehension and Production of emotions: In week 3, the therapist depicted basic emotions of joy, anger, sorrow, fear, surprise, disgust and disappointment. The patient was asked to identify the depicted emotion.  Week 4 required the subject to depict various emotions.  In week 5, the patient depicted an emotion to an imagined social situation.   

Immediate visual memory: In the weeks 2-6, the patient recalled from memory, 10 abstract designs, which had been sequentially presented 10 seconds before and remembered for another 10 seconds. Increase in task difficulty was achieved by increasing the number of components in each design over the weeks. The correct number of designs formed the score.

Family Intervention Programme: Bi – weekly family intervention sessions for the patient and the caregivers were held concurrently with the 6-week cognitive retraining programme. These 12 one-hour sessions were broadly divided into four phases.  Phase one, comprising of three sessions, focused on assessment of current functioning of the family as well as the difficulties being experienced by the caregivers in various areas. Two sessions of phase two focused on psychoeducation about the illness.  In phase three, comprising of three sessions, caregivers were helped to normalize the family routines disrupted due to the illness and appraised about the importance and the need to lower expressed emotions directed towards the patients as well as helping the patients to develop a structured schedule of daily activities. Three sessions in phase four were devoted to improving the communication and problem solving skills of the family members, clarification of their roles and attempted to enhance their social networks and support systems.  Finally one session was held for preparing the families for termination and for clarification of any further queries that the caregivers had.

Results

Pre intervention assessment of patients:

  
  Neuropsychological assessment:          Table 1 gives the normative percentiles of the raw scores on the neuropsychological tests.  In the pre training assessment, all three patients had deficits in at least three domains of cognitive functions out of the nine cognitive domains assessed. All three cases had deficits in concept formation and set-shifting ability. Case 1 and 3 had deficits in information processing speed. Case 1 and 2 had deficits in visual memory and case 3 had deficits in visuo-spatial construction. 
 
 
    
  Table 1. Neurocognitive Functions of the three cases 
 

Normative Percentiles corresponding to the raw scores

 

 

 

Case 1

Case 2

 

Case 3

Neuropsychology

Test name

Variable

Pre

Post

(a)

F/u

 (b)

Pre

Post

(a)

F/u

 (b)

Pre

Post

 (a)

DVT

 

Time in seconds

27

57

+

57

=

19

84

+

41

-

11

38

+

CT 1

 

Time in seconds

97

100

=

100

=

44

50

=

38

=

38

56

=

CT 2

 

Time in seconds

77

100

=

100

=

65

97

+

47

-

65

41

-

DSST

 

Time in seconds

10

90

+

63

-

38

53

+

33

-

3

23

+

FT (right hand)

 

Mean No. of taps

70

95

+

50

-

70

85

+

95

=

40

25

-

FT (left hand)

 

Mean No. of taps

20

70

+

30

-

30

70

+

85

=

75

40

-

SOPT (words)

 

Total No. of Errors

100

100

=

78

=

78

100

=

100

=

78

100

=

SOPT (designs)

 

Total No. of  Errors

59

94

+

94

=

59

100

+

94

=

100

100

=

Stroop color word test

 

Stroop effect in seconds

81

65

-

84

+

48

94

+

45

-

19

23

=

WCST

 

% Error

18

100

+

91

=

3

94

+

97

=

6

85

+

 

 

% Perseverative Responses

9

100

+

79

=

3

64

+

88

=

15

79

+

 

 

Failure to maintain set

12

100

+

100

=

46

100

+

100

=

46

100

+

 

 

No. of categories completed

25

95

+

95

=

10

100

+

100

=

10

95

+

TOL

Total No. of problems solved with minimum moves

80

80

=

95

=

80

95

=

90

=

60

90

+

AVLT

 

No. of words recalled in Trial 5

50

100

+

100

=

95

95

=

95

=

95

95

=

 

 

Immediate recall No. of words

50

95

+

95

=

80

95

=

80

=

95

95

=

 

 

Delayed recall No. of words

50

95

+

95

=

95

80

=

80

=

80

80

=

 

 

Long Term Retention

50

75

+

75

=

60

50

=

50

=

50

50

=

RCFT

 

Copy

100

100

=

100

=

100

100

=

100

=

5

100

+

 

 

Immediate Recall

5

75

+

80

=

25

85

+

95

=

20

75

+

 

 

Delayed Recall

5

85

+

80

=

10

100

+

90

=

15

75

+

Pre: Pre Cognitive retraining Assessment; Post: Post cognitive retraining Assessment; F/u: Follow-up assessment; (a): Changes of percentile score from Pre intervention assessment and post intervention assessment; (b): Changes of percentile score from Post intervention assessment to Follow-up assessment
Quartile change: +, Percentile increase of a quartile or more; -, Percentile decline of a quartile or more; =, No change in the quartile
  Percentile score < 15 indicates deficit.    

Assessment of Global functioning: Global functioning was average in all the 3 cases i.e. scores were in the middle range. (Table 2).

 

Table 2. Global Assessment of Functioning Scale scores (GAF scores)

 

CASE

 

 

Pre- Intervention

Post- Intervention

2- month Follow-up

1

 

53

75

57

2

 

51

67

61

3

 

45

57

-

Score Range: 0- 100. Higher score indicating better overall functioning

 Pre Intervention assessment of caregivers         

Table 3 gives the scores of GHQ and BAS.  At pre intervention assessment, the GHQ scores of the caregivers ranged from 0 to 14. Presence of a probable psychiatric problem was indicated for two of the caregivers, as their scores equaled or exceeded the cut off score of 4. The brother of Case 1 reported problems related to anxiety, somatic symptoms and insomnia while the mother of Case 2 reported predominantly somatic symptoms. The scores on the BAS were high for all the caregivers, indicating the presence of increased burden.  Analysis of the items of BAS found that burden was experienced with regard to concerns about the patients’ future and their social and occupational functioning.  During the family assessment interviews, caregivers expressed concerns regarding patients’ negative symptoms, nature and course of the illness and apprehension in choosing the issues to be discussed with the patient in the everyday family interaction.

 

Table 3. Scores of the caregivers on General Health Questionnaire (GHQ) and Burden Assessment Schedule (BAS)

 

Caregiver

 

 

Pre-intervention

Post-intervention

Follow-up

Brother

(Case1)

 

GHQ

BAS

14

57

3

62

2

63

Sister-in-law

(Case1)

GHQ

BAS

 

2

59

1

66

1

64

Mother (Case2)

GHQ

BAS

4

68

0

47

3

53

 

Father (Case3)

GHQ

BAS

3

65

0

65

-

-

Mother (Case3)

GHQ

BAS

1

70

0

70

-

-


GHQ: (cut off score – 4/5)
BAS: (Score range 40-120; Higher the score, higher the burden)

Changes after Intervention 

Comparison of Pre-Post Retraining Assessments of patients: 

Neuropsychological assessment: Change in the neurocognitive functions was characterized as normalization, improvement or decline. Normalization was defined as a shift of percentile from the deficit range to the normal range, improvement was defined as shift of percentile to a higher level by one quartile or more and decline was defined as a shift of percentile to a lower level by one quartile or more. (Table 1)

In Case 1 the post retraining assessment did not show deficits.  Comparison of the pre and post intervention neuropsychological assessment showed that the functions of information processing, set-shifting as well as visual memory were normalized after retraining. The functions of sustained attention, motor speed as well as verbal learning and memory improved. Other functions such as focused attention, working memory, planning and visuo spatial construction remained status quo. There was a decline in response inhibition..

 In Case 2 the post intervention assessment did not show deficits. The functions of visual memory and set-shifting were normalized. The functions of sustained attention, focused attention, information processing, motor speed, working memory and response inhibition improved. There was no decline in any of the cognitive functions.

In Case 3 the post intervention assessment did not show deficits. The functions of information processing, set-shifting, planning and visual memory were normalized while sustained attention and planning improved. Cognitive functions of working memory, response inhibition, and verbal learning and memory remained status quo. The functions of focused attention and motor speed declined from the pre-assessment.

Global Functioning:     The scores on the global functioning scale increased between the pre and post training assessments in all 3 cases.  Qualitatively, all the 3 patients improved minimally in self-care, in performing household chores and helping other family members. The occupational status did not improve.

Comparison of Pre-Post Intervention assessment of caregivers:  The mental health of caregivers of case1 and   case 2 improved. Table 3 shows the scores on the GHQ scale, which indicate non- caseness in all the caregivers. There were variable changes in the scores on the BAS among the caregivers (Table 3).  The caregivers of cases 1 & 3, who had had very high occupational expectations for the patients, lowered their expectations to more realistic levels.  Qualitatively the caregivers continued to be worried about financial liabilities, issues of long-term care giving and the lack of gainful employment of the patient. However, they reported a feeling of being supported by the therapist, as well as better awareness and acceptance of the fact that the process of improvement observed in the patients would be a slow and gradual process.  All the caregivers reported decreased psychological distress and subjectively reduced feelings of burden.  Improvement was observed in the emotional interactions between patient and the caregivers.

Maintenance of Improvement

Comparison of Post intervention- follow-up Assessment of patients:

Neuropsychological assessment

There were no cognitive deficits either at the post or the follow up assessments in cases 1 & 2. 

In Case 1 the improvement of sustained and focused attention, working memory, set-shifting, verbal learning and memory as well as visual memory were sustained. Response inhibition improved from the post assessment to the follow-up assessment. There was a decline in information processing and motor speed.

In Case 2 the improvement of focused attention, motor speed, working memory, concept formation and set shifting, planning, verbal learning and memory as well as visual memory were sustained. The functions of sustained attention, information processing and response inhibition declined.  

Case 3 was not available for the follow up assessment.

Global functioning:

 At follow up, the GAF score declined significantly in Case 1 and marginally in case 2 compared with the post-retraining score. However the follow up scores remained higher than the pre training scores in both cases (Table 2). 
 
  All the 3 patients were able to obtain full time paid employment within 3 months after completing retraining. While Case 3 joined gainful employment in one month, Cases 1 & 2 joined within three months after completing the cognitive retraining. 

Comparison of Post Intervention -Follow up assessment of Caregivers:        

The caregivers of cases 1 & 2 were available for follow up.  Case 3 and his caregiver did not report for follow up.  The GHQ scores of the caregivers of cases 1 & 2 indicated non-caseness and hence absence of psychological distress.  Scores on BAS increased very minimally from the post-intervention assessment levels in caregivers of Case 1 and 2 (Table 3). Qualitatively, the improvement observed after the intervention in the emotional interactions between the patients and the caregivers was maintained. The caregivers showed increased tolerance towards the patients’ problems and had realistic expectations in the social and occupational functioning of the patients. The caregivers reported that the psycho education had been very beneficial.

 

 Discussion
  We developed and examined the clinical efficacy of an integrated intervention programme, which included cognitive retraining and family intervention in the present study. Cognitive retraining targeted improvement of cognitive functions.  Family intervention aimed to reduce the feeling of burden and improve psychological well-being of the caregivers.

In the present study, all three patients had cognitive deficits. However, it was not uniform. Prior to the intervention, all three patients had deficits in concept formation, set shifting. In addition to the deficit of concept formation and set shifting, Cases 1 and 2 had deficits in visual learning and memory and cases 1 and 3 had deficits in information processing.  Assessment following the intervention showed improvement in the cognitive functions that were initially assessed to be in the deficit range. Sustained attention, which was in the non-deficit range in all three patients prior to intervention, showed further improvement in all the three patients. Improvements in other functions were again, not uniform across the three subjects. For instance, in case 1, there was improvement in motor speed, verbal learning and memory; in case 2 there were improvement in mental speed, information processing, working memory and response inhibition; and in case 3 there was improvement in planning. Cognitive functions improved following intervention and remained in the normal range at the post intervention assessment in all the 3 cases.   At two-month follow up all the cognitive functions remained in the non-deficit range in both case 1 and 2. The sustenance of improvement was not uniform. For instance in Case 1 response inhibition improved. However, in case 2 there was decline in sustained attention and response inhibition from the level observed at the post assessment. About two thirds of the cognitive functions sustained this improvement at the two-month follow-up in cases 1 & 2.  Improvements in cognitive abilities following cognitive retraining are similar to the finding of other studies.   Cognitive retraining was found to improve sustained attention (Medalia, 1998) and executive functions (Lopez Luengo, Va’zque, 2003). Improvements in attention, memory and executive functions have occurred following cognitive retraining, which was given as part of Integrated Psychological Therapy (IPT) (Spaulding et al., 1999).
 
  The pre-intervention assessment of the caregivers indicated significant psychological distress in two out of five caregivers as indicated on the GHQ (brother of case 1 and mother of case 2). At the post intervention and follow up assessments there was a significant reduction in their distress levels. Qualitatively too, there was a substantial reduction in their subjective reports of distress following the intervention. Similarly in the pre assessment all the caregivers reported significant burden.  The BAS scores have remained in the same range during the post-intervention and at the 2-month follow-up assessment, indicating that caregivers experienced burden even after family intervention. However it is noteworthy that despite the high scores, all the caregivers have subjectively reported a decline in the feelings of burden, and an improved mental health. In order to understand the discrepancy between the subjective report and the objective scores a qualitative analysis of responses on the BAS was carried out.  It was seen that the objective scores on the BAS decreased in the domains of patient behavior, caregiver health, caregiver’s occupation, leisure activities and emotional burden. The scores did not change in the domains of financial burden and social support. As these two are critical areas, lack of improvement in these areas could have led to the perception of burden.  Changes in the families’ financial position or in their social support network are unlikely to show quick or marked changes within a short span of time.  The 6-week duration of family intervention in the present study is perhaps insufficient to effect a change in these two domains.      

Although the level of burden did not change objectively, decreased psychological distress may have contributed to the perception by the caregivers of an improved ability to cope with problems. Greater tolerance of the patients’ symptoms and acceptance of the gradual pace of improvement were evident in the caregivers’ subjective reports. This in turn may have contributed to an overall congenial family environment, reflected in the subjective reports of decrease in the sense of burden. The results of family intervention in the present study are similar to those of Budd and Hughes (1997). In their study, following family intervention, the family members reported an increase in the knowledge about the illness, feeling supported and reassured and encouraged by the helpful nature of therapeutic alliance. In a study of a family psycho educational support group, the family members showed greater satisfaction with the services provided. However there was no change in the objective scores on psychological distress, coping behaviour and family satisfaction. (Posner et al., 1992) .

An improvement in the global functioning of all the three patients during the post-intervention assessment has been observed. Improvements following intervention and changes in cognitive flexibility are known to have positive effect on social functioning as well as self-esteem (Wykes et al., 1999). It is significant to note that the improvements in the cognitive functions and the family environment have generalized to the daily functioning of the patient as reported by the patient themselves and their caregivers. It is equally significant to note that in the present study all three patients obtained gainful employment. One patient obtained a job one month after the retraining and two patients within three months after the retraining.  Of the three patients, case 3 had not worked for the previous 2-½ years and the other two patients had never been in a gainful job.  It is also pertinent to note that medication dosages for all the three patients remained constant in this period and they were not treated with any other additional therapy.  Therefore the improvement of global functioning could not be attributed to changes in medication.  Further, as the illness in all the patients was a long-standing one (exceeding six years duration), the changes in the global function cannot be inferred as occurring spontaneously. Therefore the improved global functioning and gainful employment of the patients can be attributed to the integrated intervention.  It is likely that remarkable changes have occurred due to the improved cognitive functions, which have been sustained in a supportive family environment and probably generalized to day-to-day functioning.  This in turn could have aided in the acquisition of job skills. The gradual changes in the patients’ day to day functioning as well as the families’ improved understanding of the illness are likely to have contributed to a reduction in the levels of criticism, intrusiveness and over involvement on the part of the family members and helped in modifying their expectations towards more realistic levels. The emergence of a more tolerant and positive family environment could have supported and encouraged further improvements in the patients’ functioning. Thus a recursive cycle of positive changes appears to have been initiated.

The present exploratory study is the first to integrate cognitive retraining and family intervention. . The small sample size is a limitation of this study.  A randomized control study with larger samples would establish the efficacy and generalizability of the results and remove any expectation biases.  The Integrated psychological intervention has shown promise and encouraging results that merits further investigation.




References

Bellack, A. S.,  Meuser, K., T., Morrison, R.L., Tierney, A., & Podell, K. (1990). Remediation of cognitive deficits in schizophrenia. American Journal of Psychiatry 147, 1650-1655

Bellack, A.S., Gold, J.M., Buchanan, R.W. (1999) Cognitive rehabilitation for schizophrenia: problems, prospects, and strategies. Schizophrenia Bulletin. 1999, 25(2):257-74.

Bellack, A.S., Haas, G.L., Schooler, N. R., & Flory, J. D.(2000). Effects of behavioural family management on family communication and patient outcomes in schizophrenia. British Journal of Psychiatry, 171, 434-439

Benedict, R.H., Harris, A.E., Markow, T, Mc Cormick, J.A., Nuechterlein, K.H, & Asarnow R.F. (1994). Effects of attention training on information processing in schizophrenia. Schizophrenia Bulletin, 20 (3), 237-546.

Bell, M., Bryson, G. & Wexler .B. E (2003). Cognitive remediation of working memory deficits: durability of training effect sin severely impaired and less severely impaired schizophrenia. Acta Psychiatrica Scandinavia,108: 101-109.

Budd, R. J., & Hughes, I.C.T. (1997). What do relatives of people with schizophrenia find helpful about family intervention? Schizophrenia Bulletin, 23, 341-347.

Cadenhead, K. S., Geyer, M. A.., Butler, R. W., Perry, W., Sprock, J., & Braff, D. L. (1997). Information processing deficits of schizophrenia patients: relationship to clinical ratings, gender, and medication status. Schizophrenia Research, 28(1), 51-62.

D’Elia, L. F., Satz, P., Uchiyama, C.L. & White, T. (1996). Colour Trails Test. U S A: Psychological Assessment Resources Inc.

Delahunty, A., Morice, R. 7 Frost, B. (1993). Specific  cognitive flexibility rehabilitation in schizophrenia. Psychological Medicine, 23, 221-227.

Gaag, M. V. D, Kern, R. S, Bosch R. J, & Liberman, R P. (2002) A Controlled Trial of Cognitive Remediation in Schizophrenia. Schizophrenia Bulletin, 28(1), 167-176.

Gold, J. M., & Harvey, P. D. (1993). Cognitive deficits in schizophrenia. Psychiatric Clinics of North America, 16(2), 119-131.

Goldberg, D. P., & Hillier, V. F. (1979). A Scaled version of the GHQ. Psychological Medicine 9, 139-145.

Goldberg, T. E., Weinberger, D. R., Berman, K. F., Pliskin, N. H., & Podd, M.  H. (1987).Further evidence for dementia of the prefrontal type? Archives of General Psychiatry 44, 1008-1014.

Goldberg, D. F., & Williams, P. (1988). A User’s Guide to General Health Questionnaire. London: Nfer Nelson.

Green, M. F., (1996). What are the functional consequences of neurocognitive deficits in schizophrenia? American Journal of Psychiatry, 153, 321-330.

Heaton, R.K., Grant, I., Nelson, B., White, D.A., Kirson, D., and Atkinson, H.J. (1995). The HNRC500-neuropsychology of HIV infection at different disease stages. Journal of the International Neuropsychological Society, 1, 231-251.

Hodel, B. and Brenner, H. D. (1994) Cognitive therapy with schizophrenic patients: conceptual basis, present state, future directions. Acta Psychiatrica Scandinavia Supplement, 90, 108-115

Lopez-Leungo, B. & Vazquez .C. (2003). Effects of attention process Training on cognitive functioning of Schizophrenic patients. Psychiatry Research 119 (1-2), 41- 53.

Lezak, M. D. (1995). Neuropsychological assessment (3rd Ed.). New York: Oxford University Press.

Maj M., Satz, P., Janssen R. et.al. (1994). WHO neuropsychiatric AIDS study, cross sextional phaseII. Neuropsychological and Neurological findings. Archives of  General Psychiatry 1994, 51, 51-61.

Medalia, A., Alluma, M., Tryon, W., & Merriam, A. E. (1998). Effectiveness of Attention Training in Schizophrenia. Schizophrenia Bulletin, 24(1), 147-152.

Meyers, J. E., & Meyers, K. R. (1995). Rey complex figure: A recognition subtest. The Clinical Neuropsychologist, 8, 153-166.

Milner, B. (1963). Effects of different brain lesions on cad sorting. Archives of Neurology, 9, 90-100.

Morris, R. G., Rushe, T., Woodruffe, P. W., & Murray, R. M. (1995). Problem solving in schizophrenia: a specific deficit in planning ability. Schizophrenia Research, 14(3), 235-246.

Nelson, E. B., Sax, K. W., & Strakowski, S. M. (1998). Attentional Performance in patients with psychotic and nonpsychotic major depression and schizophrenia. American Journal of Psychiatry, 155(1), 137-139.

Overall, J.E.  & Gorham, D.R. (1962). The Brief Psychiatric Rating Scale. Psychological Reports 10: 799-812

Pantelis, C., Barber, F.Z., Barnes, T. R., Nelson, H.E., Qwe, A. M., & Robbins, T. W. (1999). Comparison of set-shifting in patients with chronic schizophrenia and frontal lobe damage. Schizophrenia Research, 37(3), 251-270.

Petrides, M., & Milner, B. (1982). Deficits on patient ordered tasks after frontal and temporal lobe lesions in man. Neuropsychologia, 20, 249-262.

Posner, C. M., Wilson, K.G., Krai, M. J., Lander, S., & Mclllwraith, R. D. (1992). Family psychoeducational support groups in schizophrenia. American Journal of Orthopsychiatry, 62, 206-218.

Rammohan, A., Rao, K. & Subbakrishna, D.K. (2002). Family burden and coping in schizophrenia. Indian Journal of Psychiatry, 44, 220-227.

Rao, S. L., Subbakrishna, D.K., Gopukumar, K. (2004). NIMHANS Neuropsycholoy Battery-2004. NIMHANS Publication, Banglaore.

Shallice, T. (1982). Specific impairments of planning. Philosophical transactions of Royal Society of London.13, 298,199-209.

Shamsuder,C., Murthy, S. K., Prakash, O. M., Prabhakar, N., & Subbukrishna, D.K. (1986) Psychiatric morbidity in a general practice in an Indian city. British Medical Journal, 292, 1713-1715.

Smith, G. L., Kavanagh, D. J., Karayanidis, F., Barret, N. A., Michie, P. T., & O’Sullivan, B. T. (1998). Further evidence for a deficit in switching attention in schizophrenia. Journal of Abnormal Psychology, 107(3), 390-398.

Spaudling, W. D., Reed, D., Sullivan, M., Richardson, C., & Weiler, M. (1999), Effects of Cognitive Treatment in Psychiatric Rehabilitation.  Schizophrenia Bulletin, 25(4): 657-676.

Spreen. O., & Srrauss, E. (1998). A compendium of Neuropsychological Tests: Administration, norms and commentary (2nd Ed.). New York: Oxford University Press.

Stroop, J.R. (1935). Studies of interference in serial verbal reaction. J. Exp. Psychol., 18, 643-662.

Summerfelt, A. T., Alphs, L. D., Wagman, A. M., & Funderburk, F. R. (1991). Reduction of perseverative error in patients with schizophrenia using monetary feedback. Journal of Abnormal Psychology 100, 613- 616.

Suslow, T., Schonauer, K., Arolt, V. (2001). Attention traning in the cognitive rehabilitation of schizophrenic patients: A review of efficacy of studies. Acta Psychiatrica Scandinavia 103, 15-23.

Thara. R., Padmavathi, R., Kumar, S., & Srinivasan, L., (1998). Burden Assessment Schedule: An Instrument to Assess burden in caregivers of chronic mentally ill. Indian Journal of Psychiatry, 40,21-29.

Twamely, E. W., Jeste. D.V, Bellack. A. S, (2003) A review of cognitive training in Schizophrenia. Schizophrenia Bulletin 29(2): 359- 382.

Wechsler, D. (1981). WAIS-R manual. NewYork: The psychological corporation.

Wykes, T., Reeder, C., Corner, J., Williams, C., & Everitt, B. (1999).  The effects of Neurocognitive remediation on executive processing in patients with Schizophrenia. Schizophrenia Bulletin, 25(2), 291-307.

Wykes, T. (2000) Cognitive rehabilitation and remediation in schizophrenia. In Cognition in Schizopnrea, Impairments, Importance and Treatment Strategies. Edited Sharma ,T & Harvey. P. Oxford University Press

Xiong, M. R., Hu, .X., Wang, R et al, (1994) Family –Based Intervention for Schizophrenic Patients in China, A Randomized Controlled Trial British Journal of Psychiatry (1994), 165, 239-247.

 




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