Cognitive Behavioral Social Skills Training May Be Helpful in Schizophrenia
Laurie Barclay, MD
Charles Vega, MD, FAAFP

March 4, 2005 — Cognitive behavioral social skills training added to usual care improves social functioning for middle-aged and older outpatients with schizophrenia, according to the results of a randomized trial published in the March issue of the American Journal of Psychiatry.

"Cognitive behavioral social skills training teaches cognitive and behavioral coping techniques, social functioning skills, problem solving, and compensatory aids for neurocognitive impairments," write Eric Granholm, PhD, from the Department of Veterans Affairs San Diego Health Care System, and colleagues. "Whereas cognitive behavior therapy focuses on how beliefs affect behavior and mood, social skills training focuses on practicing pragmatic skills of living."

In this controlled trial, 76 middle-aged and older outpatients with chronic schizophrenia were randomized to either treatment as usual or to combined treatment including cognitive behavioral social skills training administered for 24 weekly group sessions. Raters blinded to treatment assignment assessed social functioning, psychotic and depressive symptoms, cognitive insight, and skill mastery.

After treatment, patients in the combined treatment group performed social functioning activities significantly more often than did the patients in the usual care group. However, general skill at social functioning activities was not significantly different between groups. The combined treatment group also fared better than the treatment as usual group in terms of greater cognitive insight, more objectivity in reappraising psychotic symptoms, and greater skill mastery. Although the overall group effect was not significant for symptoms, the greater increase in cognitive insight with combined treatment was significantly correlated with greater reduction in positive symptoms.

"With cognitive behavioral social skills training, middle-aged and older outpatients with chronic schizophrenia learned coping skills, evaluated anomalous experiences with more objectivity (achieved greater cognitive insight), and improved social functioning," the authors write. "Additional research is needed to determine whether cognitive insight mediates psychotic symptom change in cognitive behavior therapy for psychosis."

Study limitations include moderately small sample size; lack of a control for nonspecific therapist contact factors; exclusion of patients with current comorbid substance dependence, which may also limit generalizability of the findings; and lack of ratings of distress or dysfunction caused by symptoms.

"To our knowledge this is the first published randomized trial to examine a psychosocial intervention designed for the unique needs of older patients with psychotic disorders," the authors conclude. "Given the heterogeneity of schizophrenia, it is unlikely that a single cognitive behavior therapy intervention will work equally well for all types of patients (e.g., young and old, acutely and chronically ill, medication-resistant and -responsive, neurocognitively normal and impaired, insightful and unaware). Researchers should continue to develop and test group and individual cognitive behavior therapy interventions that are tailored to the unique needs of different subgroups of patients with schizophrenia and identify which treatments are most effective for which patients and in what circumstances."

The Department of Veterans Affairs, National Institutes of Mental Health, and the National Alliance for Research on Schizophrenia and Depression supported this study.

Am J Psych. 2005;162:520-529