Randomized controlled trial of cognitive behavioral social skills training for older consumers with schizophrenia: defeatist performance attitudes and functional outcome

Abstract

Objectives: To determine whether Cognitive Behavioral Social Skills Training (CBSST) is an effective psychosocial intervention to improve functioning in older consumers with schizophrenia, and whether defeatist performance attitudes are associated with change in functioning in CBSST.

Design: An 18-month, single-blind, randomized controlled trial.

Setting: Outpatient clinic at a university-affiliated Veterans Affairs hospital.

Participants: Veteran and non-veteran consumers with schizophrenia or schizoaffective disorder (N = 79) age 45-78.

Interventions: CBSST was a 36-session, weekly group therapy that combined cognitive behavior therapy with social skills training and problem-solving training to improve functioning. The comparison intervention, goal-focused supportive contact (GFSC), was supportive group therapy focused on achieving functioning goals.

Measurements: Blind raters assessed functioning (primary outcome: Independent Living Skills Survey), CBSST skill mastery, positive and negative symptoms, depression, anxiety, defeatist attitudes, self-esteem, and life satisfaction.

Results: Functioning trajectories over time were significantly more positive in CBSST than in GFSC, especially for participants with more severe defeatist performance attitudes. Greater improvement in defeatist attitudes was also associated with better functioning in CBSST, but not GFSC. Both treatments showed comparable significant improvements in amotivation, depression, anxiety, positive self-esteem, and life satisfaction.

Conclusions: CBSST is an effective treatment to improve functioning in older consumers with schizophrenia, and both CBSST and other supportive goal-focused interventions can reduce symptom distress, increase motivation and self-esteem, and improve life satisfaction. Participants with more severe defeatist performance attitudes may benefit most from cognitive behavioral interventions that target functioning.

Trial registry: ClinicalTrials.Gov #NCT00237796 (http://clinicaltrials. gov/show/NCT00237796).

Copyright © 2013 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1

Flow of older consumers with schizophrenia or schizoaffective disorder through an 18-month randomized controlled trial comparing cognitive behavioral social skills training (CBSST) with a goal focused supportive contact (GFSC) control treatment.

Figure 2

Functioning (Independent Living Skills Survey; ILSS) trajectories across assessment points from mid-treatment to 18-month follow up for hypothetical participants in cognitive behavioral social skills training (CBSST) and goal focused supportive contact (GFSC) with baseline DPAS scores set to high (58) and low (42) values (higher scores indicate greater severity of defeatist performance beliefs). Trajectories were estimated from mixed-effects regression modeling with covariates set to their median values (see Table 2).

Figure 3

Mean Independent Living Skills Survey (ILSS) scores at 18-month follow up for participants in cognitive behavioral social skills training (CBSST) and goal focused supportive contact (GFSC) divided into subgroups of high and low severity of defeatist performance attitudes (DPAS) based on splitting the sample at the median DPAS score (50). Error bars indicate 95% confidence intervals.