Length of receiving mental health services (years) High-Yield Cognitive Behavioral techniques for psychosis delivered by case managers to their clients with persistent psychotic symptoms: an exploratory trial Douglas Turkington, Mark Munetz, Jeremy Pelton, Vicki Montesano, Harry Sivec, Bina Nausheen, Hesham Y. Elnazer, David Kingdon Abstract Case managers spend more time with clients with schizophrenia than any other professional group in most clinical settings in the United States. 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 centre took part in a five day training course and had weekly supervision. In an open trial, thirty-eight clients with schizophrenia had 12 meetings with their case managers during which High-Yield Cognitive Behavioural techniques for psychosis (HYCBt-p) were used and outcomes were evaluated. Cohen's d effect sizes were medium to large for overall symptoms (d=1.60, 95% confidence interval (CI) -2.29, 5.07), depression (d=1.12, 95% (CI) -.35, 1.73) and negative symptoms (d=.87, 95% CI -.02, 1.62). 23/38 patients (60.5%) had a good clinical result. 1/38 patients had a poor clinical result (2.6%). No patients dropped out. Background Case managers spend more time with clients with schizophrenia than any other professional group in most clinical settings in the United States. Cognitive behaviour 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. Histogram with standard error bars showing results on hallucinations and delusions PSYRATS total scores from beginning to end of therapy Histogram with standard error bars showing results on hallucinations and delusions PSYRATS total scores from beginning to end of therapy Methods Thirteen case managers at a community mental health centre took part in a five day training course and had weekly supervision. In an open trial, thirty-eight clients with schizophrenia had 12 meetings with their case managers during which High-Yield Cognitive Behavioural techniques for psychosis (HYCBt-p) were used. The primary outcome measure was overall symptom burden as measured by the Comprehensive Psychopathological Rating Scale (CPRS), 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. Demographic Variable N Age (years)* 18 – 25 2 26 – 33 34 – 41 4 42 or older 30 Length of receiving mental health services (years) 1 - 3 1 4 - 6 7 - 9 10 – 12 11 > 12 22 Number of medications One Two Three 8 Four 9 Five or more 6 Histogram with standard error bars showing results on primary and secondary outcomes from beginning to end of therapy on CPRS total and subscale scores Histogram with standard error bars showing results on social functioning PSP total scores from beginning to end of therapy Results T-tests and Wilcoxon 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, 5.07), depression (d=1.12, 95% (CI) -.35, 1.73) and negative symptoms (d=.87, 95% CI -.02, 1.62). There was a weak effect on dimensions of hallucinations but not delusions. 23/38 patients (60.5%) had a good clinical result. 1/38 patients had a poor clinical result (2.6%). No patients dropped out. Conclusions This exploratory trial provides evidence supportive of the safety and 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 implementing recovery- focused services. References 1- Kingdon, D. and Turkington. Cognitive therapy for schizophrenia. 2005; Guilford Press: New York. 2- Malik N, Kingdon, D., Mehta, R. Effectiveness of brief cognitive-behavioural therapy for schizophrenia as delivered by mental health nurses: relapse and recovery at 24 months. J Clin Psych. 2008; 69: 3- Addington, J, Gleeson, J. Implementing CBT for first episode psychosis. Br J Psych. 2005; 187:s72 -s76. 4- Turkington D, Kingdon DG, Rathod, S et al. Outcomes of an effectiveness trial of cognitive-behavioural intervention by mental health nurses in schizophrenia. Br J Psych 2006; 189: 36-40. Histogram with standard error bars showing results on self rated recovery QPR total scores from beginning to end of therapy