Volume 29, Issue 2 (Spring 2021)                   Avicenna J Nurs Midwifery Care 2021, 29(2): 146-159 | Back to browse issues page


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Kashani Lotfabadi M, Aboozarian S S, Farnosh M, Mohammadi A, Hashemi B M, Salarhaji A. The Effectiveness of Cognitive-Behavioral Group Therapy on Symptoms of Depression and Anxiety in Women with Chronic Schizophrenia Admitted to Hejazi Hospital in Mashhad. Avicenna J Nurs Midwifery Care 2021; 29 (2) :146-159
URL: http://nmj.umsha.ac.ir/article-1-2231-en.html
1- Psychiatry and Behavioral Sciences Research Center, Ibn-Sina psychiatric Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
2- Msc in Psychology, Payam Noor University of Garmsar, Garmsar, Iran , Sara.Aboozarian@gmail.com
3- Msc in Counseling, Islamic Azad University of Quchan, Quchan, Iran
4- MSc in Psychiatric Nursing, Psychiatry and Behavioral Sciences Research Center, Ibne-Sina psychiatric Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
5- Ms in Islamic Psychology, Payam Noor University of Gonabad, Gonabad, Iran
6- PhD Student in Nursing, Student Research Committee, Faculty of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
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✅ Cognitive-behavioral group therapy can be effective in reducing anxiety symptoms, but to increase the duration of its effect, the duration of sessions should be increased.


Extended Abstract:   (822 Views)
Introduction

Considering the negative effects of depressive symptoms and anxiety on the course of schizophrenia, it seems that the combination of cognitive-behavioral group therapy with self-care skills can increase the effectiveness of this treatment in reducing the distress of patients with chronic schizophrenia. Therefore, a study was designed and conducted to determine the effect of cognitive-behavioral therapy group of self-care skills on the symptoms of anxiety and depression in women with chronic schizophrenia.

 

Materials and Methods

This randomized controlled clinical trial was performed on 30 women with chronic schizophrenia admitted to Hejazi Psychiatric Hospital in Mashhad.
Based on the preliminary study and using the formula 1 by calculating the mean and standard deviation of the total score of depression and anxiety after the intervention with a 95% confidence interval and 85% test power for each group of thirteen people and taking into account 15% sample size loss, fifteen people were considered in each group (a total of thirty people).
Formula 1 : 

Inclusion criteria were: DSM-5-based diagnosis of schizophrenia, age between 25 and 55 years, verbal ability, education of eight classes or more, and no change in standard antipsychotic dose in the last three months. Exclusion criteria also included: substance and alcohol abuse, epilepsy and mental retardation, conflict with legal issues, and serious physical illnesses requiring treatment.
The samples of the present study were randomly assigned to two groups of intervention and control. The intervention group (n = 15) underwent cognitive-behavioral therapy group of self-care skills during 10 sessions of one and a half hours and the control group (n = 15) received a routine care. The data collection tool was the Hamilton Anxiety and Depression Scale which was completed in three stages.
Research data were analyzed using SPSS software version 25 (SPSS Inc., Chicago, IL., USA). Kolmogorov-Smirnov and Shapiro Wilks tests were used for normal distribution of quantitative data, descriptive statistics were used to describe the frequency of data, and independent Chi-square and t-tests were used to compare data. Also, in order to compare within-group changes in anxiety and depression variables before and after the intervention and six months after the intervention, repeated measures analysis of variance was used and to compare within-group changes in depression and anxiety during the test stages, independent t-test was used. It is worth mentioning that in the performed tests, 95% confidence level and significance level α = 0.05 were considered. The data collector researcher and data analyst divided the subjects into two groups of experimental and blind control.


 

Results

Comparing the two experimental and control groups before the intervention, there was no statistically significant difference in terms of demographic information of patients with chronic schizophrenia participating in the study (P<0.05) and the two groups were homogeneous in this regard.
Intra-group comparison of the results of repeated measures analysis of variance showed that in the intervention group, there was a significant difference in terms of changes in the mean score of anxiety during the test (P=0.01). In this regard, the results of two-way comparison of the two stages of the test using Bonferroni correction showed that in the intervention group, there was a difference between the pre-intervention and post-intervention stages (P=0.005) and between the pre-intervention and six-month post-intervention stages. There was a significant difference (P=0.04). However, in the intragroup comparison, the results of repeated measures analysis of variance showed that there was no significant difference in the control group in terms of changes in the mean score of anxiety during the test (P<0.09).
 Inter-group comparison of independent t-test results showed that there was a significant difference between the intervention and control groups in terms of changes in the mean score of anxiety during the pre-intervention and post-intervention stages (P<0.001). However, there was no significant difference between the intervention and control groups in terms of changes in the mean score of anxiety during the pre-intervention and six months after the intervention (P=0.08).
Intra-group comparison of the results of repeated measures analysis of variance showed that in both intervention and control groups there was no significant difference between the test stages in terms of changes in the mean score of depression (P<0.05). Also, the intergroup comparison of independent t-test results showed that there was no significant difference between the intervention and control groups in terms of changes in the mean score of depression during the pre-intervention and post-intervention stages (‌P‌=0.07). Moreover, there was no significant difference between the intervention and control groups in terms of changes in the mean score of depression six months after the intervention (P=0.57).


 

Discussion

The present study was the first study in which cognitive-behavioral therapy was designed based on the self-care skills of patients with chronic schizophrenia, the results of which were consistent with the results of Freedland et al. (2015); as they also found that cognitive-behavioral therapy based on self-care skills is effective in reducing post-intervention anxiety in patients with heart failure (37). The results of other studies on the effect of cognitive-behavioral therapy approaches on anxiety showed that muscle relaxation therapy can reduce stress and acute anxiety status in patients with schizophrenia (38).
Cognitive-behavioral therapy is often used to reduce anxiety and distress in patients with schizophrenia. Successful management of anxiety symptoms involves adopting appropriate coping strategies to reduce anxiety, which can also help reduce the symptoms of psychosis (18). Poor self-care performance in patients with schizophrenia, including skills related to bathing, dressing, nutrition, nail care, and sleep habits, can reduce social relationships and prevent them from successfully joining the community (41) ending in reducing their standard of living and independent living (42). Therefore, it seems that strengthening self-care skills as an adaptive strategy through cognitive-behavioral therapy group can help reduce anxiety symptoms in patients with chronic schizophrenia.
Due to the rejection and lack of emotional support of family and community from patients with chronic schizophrenia participating in the present study, it seems that the treatment of depression in them is facing more major problems. It is noteworthy that although negative symptoms and depression in patients with schizophrenia have been conceptualized as separate clinical syndromes; the overlap of these symptoms in patients with schizophrenia has made it possible to examine their heterogeneity (44) and may not be extractable with questionnaire information.
One of the limitations of this study was the short-term group sessions, cognitive-behavioral therapy, and self-care skills, which were not cost-effective for researchers. In addition, due to the cultural conditions in Iran based on the need for written consent of the family (patient guardian) for the patient to participate in the research, many people were excluded from participating in the study; since the families did not often support the patients in this hospital due to the chronic illness and symptoms, they kept them in the hospital permanently.


 

Conclusion

Cognitive-behavioral group therapy can be effective in reducing anxiety symptoms, but to increase the duration of its effect, the duration of sessions should be increased.

 

Acknowledgments

This article was extracted from a research project with the clinical trial code IRCT20180817040818N1, which was approved on August 15, 2016 with the code 970417 in the field of research of Mashhad University of Medical Sciences. The authors would like to thank Mashhad University of Medical Sciences for their sincere cooperation in providing this research and the officials, nurses and head nurses of Hejazi Psychiatric Hospital, as well as the participants in the study.

 

Conflicts of Interest

The authors declared no connflict of interest.

 

Type of Study: Original Research | Subject: Nursing
Received: 2020/09/7 | Accepted: 2020/09/24 | Published: 2020/11/28

References
1. Orrico-Sánchez A, López-Lacort M, Muñoz-Quiles C, Sanfélix-Gimeno G, Díez-Domingo J. Epidemiology of schizophrenia and its management over 8-years period using real-world data in Spain. BMC Psychiatry. 2020;20:1-9. [DOI:10.1186/s12888-020-02538-8] [PMID] [PMCID]
2. Kanchanatawan B, Sirivichayakul S, Thika S, Ruxrungtham K, Carvalho AF, Geffard M, et al. Physio-somatic symptoms in schizophrenia: association with depression, anxiety, neurocognitive deficits and the tryptophan catabolite pathway. Metab Brain Dis. 2017;32(4):1003-16. [DOI:10.1007/s11011-017-9982-7] [PMID]
3. Sun MM, Yang LM, Wang Y, Feng X, Cui KY, Liu LF, et al. BDNF Val66Met polymorphism and anxiety/depression symptoms in schizophrenia in a Chinese Han population. Psychiatr Genet. 2013;23(3):124-9. [DOI:10.1097/YPG.0b013e328360c866] [PMID]
4. Kaplan B, Sadock vA, Ruiz P. Synopsis of Psychiatry Behavioral Sciences/ Clinical Psychiatry. Tehran: Arjmand; 2015. 827 p
5. Ghalehbandi MF. Textbook of Clinical Psychiatry & Behavioral Sciences. Tehran: Arjmand; 2017. 760 p
6. Gannon JM, Brar J, Rai A, Chengappa KNR. Effects of a standardized extract of Withania somnifera (Ashwagandha) on depression and anxiety symptoms in persons with schizophrenia participating in a randomized, placebo-controlled clinical trial. Ann Clin Psychiatry. 2019;31(2):123-9.
7. Chiang YH, Beckstead JW, Lo SC, Yang CY. Association of auditory hallucination and anxiety symptoms with depressive symptoms in patients with schizophrenia: A three-month follow-up. Arch Psychiatr Nurs. 2018;32(4):585-90. [DOI:10.1016/j.apnu.2018.03.014] [PMID]
8. Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull. 1987;13(2):261-76. [DOI:10.1093/schbul/13.2.261] [PMID]
9. Pallanti S, Cantisani A, Grassi G. Anxiety as a core aspect of schizophrenia. Curr Psychiatry Rep. 2013;15(5):354. [DOI:10.1007/s11920-013-0354-7] [PMID]
10. Tsai YF, Chen CY. Self-care symptom management strategies for auditory hallucinations among patients with schizophrenia in Taiwan. Appl Nurs Res. 2006;19(4):191-6. [DOI:10.1016/j.apnr.2005.07.008] [PMID]
11. Kanchanatawan B, Thika S, Sirivichayakul S, Carvalho AF, Geffard M, Maes M. In Schizophrenia, Depression, Anxiety, and Physiosomatic Symptoms Are Strongly Related to Psychotic Symptoms and Excitation, Impairments in Episodic Memory, and Increased Production of Neurotoxic Tryptophan Catabolites: a Multivariate and Machine Learning Study. Neurotox Res. 2018;33(3):641-55. [DOI:10.1007/s12640-018-9868-4] [PMID]
12. Kanchanatawan B, Sirivichayakul S, Carvalho AF, Anderson G, Galecki P, Maes M. Depressive, anxiety and hypomanic symptoms in schizophrenia may be driven by tryptophan catabolite (TRYCAT) patterning of IgA and IgM responses directed to TRYCATs. Prog Neuro-Psychopharmacol Biol Psychiatry. 2018;80:205-16. [DOI:10.1016/j.pnpbp.2017.06.033] [PMID]
13. Braga RJ, Reynolds GP, Siris SG. Anxiety comorbidity in schizophrenia. Psychiatry Res. 2013;210(1):1-7. [DOI:10.1016/j.psychres.2013.07.030] [PMID]
14. Tsai J, Rosenheck RA. Psychiatric comorbidity among adults with schizophrenia: A latent class analysis. Psychiatry Res. 2013;210(1):16-20. [DOI:10.1016/j.psychres.2013.05.013] [PMID] [PMCID]
15. Hou C-L, Ma X-R, Cai M-Y, Li Y, Zang Y, Jia F-J, et al. Comorbid moderate-severe depressive symptoms and their association with quality of life in Chinese patients with schizophrenia treated in primary care. Community Ment Health J. 2016;52(8):921-6. [DOI:10.1007/s10597-016-0023-5] [PMID]
16. Temmingh H, Stein DJ. Anxiety in Patients with Schizophrenia: Epidemiology and Management. CNS Drugs. 2015;29(10):819-32. [DOI:10.1007/s40263-015-0282-7] [PMID]
17. Rahim T, Rashid R. Comparison of depression symptoms between primary depression and secondary-to-schizophrenia depression. Int J Psychiatry Clin Pract. 2017;21(4):314-7. [DOI:10.1080/13651501.2017.1324036] [PMID]
18. Howells FM, Kingdon DG, Baldwin DS. Current and potential pharmacological and psychosocial interventions for anxiety symptoms and disorders in patients with schizophrenia: structured review. Hum Psychopharmacol. 2017;32(5). [DOI:10.1002/hup.2628] [PMID]
19. Chen SR, Chien YP, Kang CM, Jeng C, Chang WY. Comparing self-efficacy and self-care behaviours between outpatients with comorbid schizophrenia and type 2 diabetes and outpatients with only type 2 diabetes. J Psychiatr Ment Health Nurs. 2014;21(5):414-22. [DOI:10.1111/jpm.12101] [PMID]
20. Donato K. Self-Care as a Burdened Virtue. Episteme. 2017;28(1):3.
21. Rathod S, Phiri P, Kingdon D. Cognitive behavioral therapy for schizophrenia. Psychiatr Clin North Am. 2010;33(3):527-36. [DOI:10.1016/j.psc.2010.04.009] [PMID]
22. Laws KR, Darlington N, Kondel TK, McKenna PJ, Jauhar S. Cognitive Behavioural Therapy for schizophrenia - outcomes for functioning, distress and quality of life: a meta-analysis. BMC Psychol. 2018;6(1):32. [DOI:10.1186/s40359-018-0243-2] [PMID] [PMCID]
23. Jones C, Hacker D, Meaden A, Cormac I, Irving CB, Xia J, Zhao S, Shi C, Chen J. Cognitive behavioural therapy plus standard care versus standard care plus other psychosocial treatments for people with schizophrenia. Cochrane Database of Systematic Reviews. 2018(11). [DOI:10.1002/14651858.CD008712.pub3] [PMCID]
24. Opoka SM, Lincoln TM. The Effect of Cognitive Behavioral Interventions on Depression and Anxiety Symptoms in Patients with Schizophrenia Spectrum Disorders: A Systematic Review. Psychiatr Clin North Am. 2017;40(4):641-59. [DOI:10.1016/j.psc.2017.08.005] [PMID]
25. Upthegrove R, Marwaha S, Birchwood M. Depression and Schizophrenia: Cause, Consequence, or Trans-diagnostic Issue? Schizophr Bull. 2017;43(2):240-4.
26. Lodha P, De Sousa A. Cognitive Behavioural Therapy and Its Role in the Outcome and Recovery from Schizophrenia. Schizophrenia Treatment Outcomes: Springer; 2020. p. 299-312 [DOI:10.1007/978-3-030-19847-3_26]
27. Addington J, Epstein I, Liu L, French P, Boydell KM, Zipursky RB. A randomized controlled trial of cognitive behavioral therapy for individuals at clinical high risk of psychosis. Schizophr Res. 2011;125(1):54-61. [DOI:10.1016/j.schres.2010.10.015] [PMID]
28. Bible LJ, Casper KA, Seifert JL, Porter KA. Assessment of self-care and medication adherence in individuals with mental health conditions. J Am Pharm Assoc (2003). 2017;57(3S):S203-S10 e3. [DOI:10.1016/j.japh.2017.02.023] [PMID]
29. Orfanos S, Banks C, Priebe S. Are Group Psychotherapeutic Treatments Effective for Patients with Schizophrenia? A Systematic Review and Meta-Analysis. Psychother Psychosom. 2015;84(4):241-9. [DOI:10.1159/000377705] [PMID]
30. Sadock BJ, Sadock VA, Ruiz P. Synopsis of psychiatry: behavioral sciences. New York: Wolters Kluwer; 2015.
31. Halperin S, Nathan P, Drummond P, Castle D. A cognitive-behavioural, group-based intervention for social anxiety in schizophrenia. Aust N Z J Psychiatry. 2000;34(5):809-13. [DOI:10.1080/j.1440-1614.2000.00820.x] [PMID]
32. Kunikata H, Yoshinaga N, Nakajima K. Effect of cognitive behavioral group therapy for recovery of self-esteem on community-living individuals with mental illness: Non-randomized controlled trial. Psychiatry Clin Neurosci. 2016;70(10):457-68. [DOI:10.1111/pcn.12418] [PMID]
33. Penn DL, Meyer PS, Evans E, Wirth RJ, Cai K, Burchinal M. A randomized controlled trial of group cognitive-behavioral therapy vs. enhanced supportive therapy for auditory hallucinations. Schizophr Res. 2009;109(1-3):52-9. [DOI:10.1016/j.schres.2008.12.009] [PMID]
34. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959;32(1):50-5. [DOI:10.1111/j.2044-8341.1959.tb00467.x] [PMID]
35. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23(1):56-62. [DOI:10.1136/jnnp.23.1.56] [PMID] [PMCID]
36. Hawton K. Cognitive behaviour therapy for psychiatric problems (a practical guide). Tehran: Arjmand; 1989.
37. Freedland KE, Carney RM, Rich MW, Steinmeyer BC, Rubin EH. Cognitive Behavior Therapy for Depression and Self-Care in Heart Failure Patients: A Randomized Clinical Trial. JAMA Intern Med. 2015;175(11):1773-82. [DOI:10.1001/jamainternmed.2015.5220] [PMID] [PMCID]
38. Vancampfort D, De Hert M, Knapen J, Maurissen K, Raepsaet J, Deckx S, et al. Effects of progressive muscle relaxation on state anxiety and subjective well-being in people with schizophrenia: a randomized controlled trial. Clin Rehabil. 2011;25(6):567-75. [DOI:10.1177/0269215510395633] [PMID]
39. Kingsep P, Nathan P, Castle D. Cognitive behavioural group treatment for social anxiety in schizophrenia. Schizophr Res. 2003;63(1-2):121-9. [DOI:10.1016/S0920-9964(02)00376-6]
40. Baruah A, Bhaduri A, Deuri S. Effect of psycho-educative intervention on knowledge about illness and self-care in patients with schizophrenia. Nurs J India. 2012;103(4):188.
41. Hsu Y-C, Lin W-Q, Kuo H-W. Schizophrenic Patients' Poor Perception in Personal Hygiene. Ment Health Fam Med. 2017;13(1):369-74. [DOI:10.25149/1756-8358.1301006]
42. Ayres H, Ngo H, John AP. Limited changes in activities of daily life performance ability among people with schizophrenia at clinical settings and the factors moderating the changes. Schizophr Res: Cognition. 2019;16:29-35. [DOI:10.1016/j.scog.2018.12.001] [PMID] [PMCID]
43. Storch EA, Arnold EB, Lewin AB, Nadeau JM, Jones AM, De Nadai AS, et al. The effect of cognitive-behavioral therapy versus treatment as usual for anxiety in children with autism spectrum disorders: A randomized, controlled trial. J Am Acad Child Adolesc Psychiatry. 2013;52(2):132-42. e2. [DOI:10.1016/j.jaac.2012.11.007] [PMID]
44. Krynicki CR, Upthegrove R, Deakin J, Barnes TR. The relationship between negative symptoms and depression in schizophrenia: a systematic review. Acta Psychiatr Scand. 2018;137(5):380-90. [DOI:10.1111/acps.12873] [PMID]
45. Chen T-H, Lu R-B, Chang A-J, Chu D-M, Chou K-R. The evaluation of cognitive-behavioral group therapy on patient depression and self-esteem. Arch Psychiatr Nurs. 2006;20(1):3-11. [DOI:10.1016/j.apnu.2005.08.005] [PMID]

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