Mental Health Nursing - Research Paper Example

Topic:  "A critical review of the research literature both qualitative and quantitative relating to mental health nursing reflecting theoretical perspectives on mental health problems". Introduction. Cognitive behavioural therapy is a standard therapeutic approach for the treatment of many types of psychological disorders. Most recently, this therapeutic modality has been evaluated as an appropriate tool for the treatment of patients with schizophrenia (Cormac, 2002). The purpose of this essay is to evaluate CBT approaches to the treatment of this type of mental disorder based on the most recent clinical studies relevant to its application. Schizophrenia has been defined as a disorder of the mind that results in distorted thinking patterns, often accompanied by paranoid or delusional thinking which may or may not be associated with auditory or, rarely, visual hallucinations. As the disorder represents a disturbance of thought, some psychologists and psychiatrists have reasoned that the CBT might be a useful therapeutic tool. CBT is built upon the fundamental concept that self-perceptions, our relationships and coping mechanisms are very much influenced by cognitive thoughts and beliefs about the nature of self, others and external reality. From this perspective, CBT may represent a useful therapeutic approach to the treatment of schizophrenia insofar as it attempts to address these issues so relevant to basic thoughts and experiences of reality. Currently, most clinicians envision the use of CBT in conjunction with pharmacologic agents designed to alleviate underlying biochemical and neuro-physiological dysfunction that contribute to the medical origins of psychosis. A critical question involves the relevance and appropriateness of the use of CBT as an adjuvant to the pharmacologic management of schizophrenia. To answer this question, one must carefully evaluate the data obtained from studies involving the use of CBT to treat patients with schizophrenia. Although many important clinical research studies have been carried out to address the potential efficacy of CBT in the treatment of schizophrenia, these types of studies are very difficult both to execute and to evaluate for a number of reasons. The primary difficulty is that schizophrenia is a very complicated disorder whose medical and psychological origins are very poorly understood. Moreover, this disease presents with a plethora of symptoms that may vary extensively in type and severity among different individuals, making it difficult to standardise behaviours and treatment responses in an incremental fashion. Another important factor is that the assessment of benefit may be difficult to ascertain, as questionnaires, scales to assess range of effect and personal statements may be difficult to assess in a reliable, reproducible manner. Moreover, many studies involving the use of CBT are short-term therapeutic situations that may not provide a sufficient time–frame to effect a meaningful therapeutic response. Finally, the therapeutic response parameters generally measure short term immediate effects of therapy that may not last for long periods once the therapeutic sessions are ended. General Description of Schizophrenia and its Relationship to CBT: Literature Review A diagnosis of schizophrenia requires the occurrence of an episode of psychosis which is the primary characteristic that distinguishes this disorder from other types of mental illness (Rataconda et al, 1998). Psychosis involves some form of delusional thoughts or hallucinations in the context of unusual and abnormal behaviour and speech. If a psychotic episode lasts for a period of at least one month, and the behavioural changes affect social interactions and daily functioning for at least six months, a diagnosis of schizophrenia is usually indicated. During the course of this disease, psychotic episodes may be intermittent and recurring, and often respond favourably to medication (Keefe et al, 1992). Additional characteristics typical of schizophrenia include social withdrawal, inappropriate moods, cognitive impairment, abnormal movements or gestures and an inability to discern the abnormal mental state (Keefe, 1992). The risk of suicide is eklevated in individuals with schizophrenia, approximately 10% commit suicide and another 20-40% attempt to take their own lives at some point during the course of illness. Some individuals with schizophrenia may also commit acts of violence, although this is not common in individuals with this disorder (Rataconda et al, 1998). Schizophrenia may occur in conjunction with other mental health issues, including anxiety, depression, phobias obsessive-compulsive disorder, panic disorder or personality disorders. These co-morbidities complicate the assessment and treatment of schizophrenia (Moller, 2003). There is currently no definitive diagnostic test for schizophrenia. In addition to observable symptoms of psychosis, certain neurological abnormalities are common in individuals with this disorder (Lawrie et al, 2008). These include decreased amounts of brain tissue associated with an enlargement of the lateral ventricles, decreased volume of the thalamus and temporal lobe. The frontal lobes show evidence of decreased blood flow. They also generally perform poorly on psychological tests indicating cognitive deficit (Lawrie et al, 2008). The use of anti-psychotic medications is very helpful in controlling the psychotic features of the disorder, but do not significantly affect the other symptoms associated with schizophrenia (Rataconda et al, 1998). Lack of compliance with medication is a serious problem encountered in the treatment of individuals with schizophrenia and is often associated with relapse and recurrence of psychotic episodes. For this reason, additional therapeutic approaches to the treatment of schizophrenia are needed (Moller, 2003). More than half a century ago, Beck first proposed that CBT might be a useful therapeutic approach to the treatment of schizophrenia. Since that time, and largely based on the historic influence of Kraepelin, schizophrenia has come to be regarded as a disease of neuro-physiological origins and often treated as a medical disorder requiring a pharmacologic approach. This is particularly true in the USA, where two vastly different schools of psychiatric opinion regarding the nature of schizophrenia and appropriate therapeutic approaches generated a vast divide between those affirming a psychoanalytic view versus a physiological approach. Over the past several decades, the balance of power has shifted to support a physiological approach to the treatment of schizophrenia. In the UK, however, no such divergence emerged and a more integrated view of schizophrenia as a disease that might benefit from both psychological and pharmacologic intervention has evolved. More recently, the American Psychiatric Association (APA) in 2008 recognised the importance of modified CBT approaches in the treatment of schizophrenia (APA, 2008). The use of CBT as an adjuvant therapeutic for the treatment of schizophrenia involves a specialised adaptation of this psychotherapeutic approach to the particular requirements of individuals with this type of mental disorder (Paley & Shapiro, 2002). The cognitive/behavioural component is designed to address the distorted and paranoid manifestations of this disease in ways that acknowledge these symptoms from the client’s viewpoint and attempts to explore ways of approaching these issues that may have beneficial therapeutic effect in allowing the individual to adapt coping mechanisms that may be efficacious. In this regard, CBT approaches to schizophrenia differ substantively from traditional psychoanalytic approaches that attempt to relate past experiences to current thoughts and feelings, an approach that has not proven to be especially beneficial in the treatment of patients with this disorder. Among the differences in this specialised form of CBT is a radical collaboration between therapist and client such that the therapist accepts the “reality” of the patient’s experience and tries to develop explanations and coping mechanisms in collaboration with the patient to develop a normalisation of thinking processes in the client (Cormac, 2002). Proponents of CBT are of the opinion that this behavioural approach may provide a much-needed adjuvant to many problems that occur in individuals with schizophrenia including lack of compliance in taking prescribed medications and distorted thought patterns that may be amenable to cognitive behavioural intervention. The underlying premise of this approach is the concept that schizophrenia represents a response to stress that may involve both neuro-physiological and psychological factors that require an integrated therapeutic approach approach. The “stress-vulnerability” factors that may result in delusional, psychotic thought patterns may vary among individuals such that one person may respond more readily to stresses by displaying this type of response. In this view, schizophrenia represents a continuum of behavioural responses that occur in highly vulnerable individuals. Moreover, it has been argued that these two therapeutic approaches may be complementary in terms of overall patient benefit (Rector & Beck, 2002). Literature Review on the Use of CBT in Schizophrenia In considering the potential therapeutic benefit of CBT in patients with schizophrenia, it is important to compare this therapeutic approach with others to evaluate their comparative and/or complementary efficacies. A major area of controversy regarding the use of CBT in patients with schizophrenia is the long duration of therapy required in order to achieve a positive therapeutic benefit. In this regard, a clinical research study conducted by Dickerson (2000) involving a retrospective assessment of twenty studies of CBT in relation to schizophrenia indicated that the therapeutic benefit of CBT as compared to other non-specific psychological approaches was less effective when controlled for time required to achieve a demonstrable therapeutic benefit. This conclusion contrasts the results of many other researchers who have studied the comparative results of CBT compared to other non-medical therapeutic modalities for the treatment of CBT. For example, this conclusion by Dickerson (2000) was directly contradicted by a clinical research study by Bechdolf et al (2004) who compared the efficacy of CBT to psycho-education (PE) in a group of 88 in-patients diagnosed with schizophrenia. This randomised study involved 8 weeks of therapy in which patients received either CBT or PE. Patient evaluations were conducted at the beginning, immediately after the treatments ended and in a 6month follow-up assessment,. The researchers found that patients who received CBT experienced significantly less re-hospitalisation during the six month follow-up interval post-treatment for psychotic episode recurrence than the group who received PE. This assessment also indicated lower relapse rates in the group that received CBT and higher treatment compliance ratings than the group who were given PE. However, it was noted that both treatment approaches resulted in a significant improvement in psycho-pathological parameters of illness even at the six-month follow-up assessment. The authors concluded that CBT produced a significant therapeutic improvement in patients hospitalised for schizophrenia. Moreover, under a similar time frame, better results were achieved with CBT than with PE. Increasingly, CBT has become incorporated into the medical school curriculum in psychiatric training and also in nursing school curricula (Pilling et al, 2002). This approach has received further validation by inclusion in the National Service framework for Mental Health and the National Health Service Psychotherapy Review. It is important to consider whether the patient outcomes and evidence of efficacy for CBT as applied to therapeutic intervention for schizophrenia warrant these endorsements. The Cochrane Collaboration has reviewed the evidence pertaining to this question and concluded that CBT may have some efficacy in schizophrenias therapy, but has been insufficiently researched and evaluated to draw any conclusions regarding the overall efficacy of this therapeutic approach to schizophrenia (Cormac et al, 2002). Nevertheless, the consensus among the research community is that CBT represents an important therapeutic strategy in the management of clients with the residual effects of schizophrenia (Rector & Beck, 2002). Moreover, there have been many clinical studies conducted over the past decade to address the overall efficacy of CBT in patients with schizophrenia and the specific symptomatologies of the disorder that are most impacted by this therapeutic approach. For example, a small scale study by Garrett & Lerman (2007), a group of 8 forensic patients diagnosed with severe paranoid schizophrenia were enrolled in a clinical evaluation to determine whether CBT would increase their coping mechanisms following discharge from long-term care in a psychiatric facility. A total of 20 individual weekly sessions were conducted mostly by staff experienced in CBT approaches. The results of this study indicated that three-fourths of the patients appeared to benefit from CBT treatment. Patients were generally more realistic about their personal responsibility for crimes committed post CBT counselling sessions. Mood improvements were also observed generally in this group of patients. This small scale study is a valuable contribution to the overall assessment of the efficacy of CBT as it demonstrated that severely ill individuals may benefit from this therapeutic approach in ways that relate to their thinking processes and their mood and coping mechanisms. Although the duration of the treatment time was relatively short, involving approximately 10 sessions total, the therapists concluded that even a short window of intervention using CBT was helpful to this group of patients. Another issue explored by researchers involves the necessity of expert training in order to deliver CBT effectively to this group of patients. Research by Turkington, Kingdon & Turner (2002) suggested that a brief, intensive training period may be sufficient to to provide non-specialist clinicians with the sufficient skills to serve as CBT counsellors. This research involved a clinical study that evaluated the use of CBT as a means to achieve improved client coping strategies with schizophrenia. The purpose of this study was to address important aspects of client non-compliance with medical and therapeutic follow-up programmes that results in poor outcome in this group of individuals with schizophrenia. This clinical research study involved an assessment of client improvement in response to CBT administered by highly skilled therapists as compared to community-based treatments involving therapists who received only a brief, introductory training session in CBT. The group of clients evaluated in this programme ranged in age from 18-61 years and were receiving secondary stage care psychiatric services according to ICD-10 standarised criteria. The control group received treatment as usual and the experimental group received CBT. Primary outcome measurements were determined by overall symptomatology based on the Comprehensive Psychopathological Rating Scale, insight, based on the Insight Rating Scale and carer burden based on the Burden of Care Questionnaire. Secondary outcomes measured in this study were change in schizophrenia symptoms (Schizophrenia Change Scale) and changes in depression (Montgomery-Asberg Scale). The results of this study indicated that clients who received CBT from therapists who had received an intensive 10 day training programme fared significantly better in a number of areas compared to the group who received TAU in the primary outcome measurement of insight; however, no significant change in symptomatology was observed in this group compared to the control. Among the secondary outcome parameters, overall symptoms and depression were improved in the group who received CBT. Almost 60% of the patients were very satisfied with the CBT program. Overall, CBT did not appear to have an effect on the schizophrenia symptoms, or burden of care compared to the control group. The researchers concluded that short-term CBT by non-specialised therapists may be an effective delivery method for CBT in secondary stage care of individuals with schizophrenia. The overall therapeutic gains in overall symptomatology, insight and depression in the CBT group were comparable to the results obtained in studies where CBT was delivered by highly trained experts. These results were higher than those achieved by other studies that utilised only psycho-education tools or family therapy approaches. Among the stated positive results of this study is the implication that community psychiatric nurses might contribute as CBT therapists once they receive a short-term CBT training programme. This optimistic assessment must be carefully evaluated in the context that it was a short-term study lacking long-term follow-up to assess the benefits of CBT delivered by non-expert therapists on patient outcome. Moreover, many important clinical goals such as major schizophrenia symptoms were not achieved in this study and reflect the limited scope of CBT effect in individuals with schizophrenia. The conclusions of the Turkington study are consistent with the findings of Cormac (2002) who reviewed a large number of studies in this area and concluded that CBT has a narrow spectrum therapeutic effect in patients with schizophrenia that does not include the more severe paranoid and hallucinatory components. Other studies support these conclusions. In a study by Garrett & Lerman (2007) a group of 8 forensic patients diagnosed with severe paranoid schizophrenia were enrolled in a clinical evaluation to determine whether CBT would increase their coping mechanisms following discharge from long-term care in a psychiatric facility. A total of 20 individual weekly sessions were conducted mostly by staff experienced in CBT approaches. The results of this study indicated that three-fourths of the patients appeared to benefit from CBT treatment. Patients were generally more realistic about their personal responsibility for crimes committed post CBT counselling sessions. Mood improvements were also observed generally in this group of patients. This small scale study is a valuable contribution to the overall assessment of the efficacy of CBT as it demonstrated that severely ill individuals may benefit from this therapeutic approach in ways that relate to their thinking processes and their mood and coping mechanisms. However, it should be noted that CBT did not produce any documented changes in the more profound and disabling components of this disorder in these severely ill patients. Similar results were obtained in other studies designed to assess the efficacy of CBT in addressing symptoms specific to schizophrenia. The Tayside-Fife clinical trial Durham et al, 2003) and the study by Power (2003), both described in detail in the last section of this essay, also produced results that indicated a small, but significant effect of CBT on mood and general symptomatology in individuals with schizophrenia. Both these studies concluded that CBT did not significantly affect the major or severe symptoms of schizophrenia, based on the time frame and other study limitations and variables. Epidemiology of Schizophrenia and Theories of Causation Schizophrenia was originally defined more than a century ago by the term “dementia praecox”. Although many definitions and diagnostic protocols have been developed since the disease was first described, even today schizophrenia represents a diverse group of clinical manifestations that may be collectively described as “disorders of thought” (Carroll et al, 1998). Today, schizophrenia is generally characterised by the concepts of disorder, subtype, and clinical symptoms. The most commonly used diagnostic criteria for this disorder involve symptoms of delusional and/or paranoid thinking, hallucinations that may be auditory, visual or somatic, distortions of reasoning processes. These symptoms are generally accompanied by flatness of affect and social withdrawal. More severe symptoms are associated with very disordered or violent thinking and passive responses to abnormally perceived commands. Epidaemiological studies suggest that schizophrenia occurs worldwide with approximately the same frequency, affecting between 0.5-1% of individuals in any given population. The incidence rates in men and women are approximately the same, although the average age of onset is generally several years younger in men than in women. Approximately 20% of individuals who experience an episode of schizophrenia make a full recovery. Another 20% suffer chronic lifelong illness, with the remainder suffering one or more relapses with or without significant progressive mental deterioration. The origins of schizophrenia are not fully understood, although a number of models have been developed to explain the occurrence of this very serious psychiatric disorder. These include medical, psychological, and social models that attempt to explain the fundamental origins of this disease. It is very important to assess relevant explanatory models of complex disorders such as schizophrenia as they often form the basis of therapeutic and preventive approaches to disease management. The medical model stresses the potential causes as they relate to genetics/inheritance, birth injury or other trauma to the developing brain, infectious diseases that may affect brain function. Social causes may include familial situations, poverty, and other environmental factors that may play a contributory role. Psychological origins may involve interpersonal relationships or experiences that may have a devastating effect on the mind. Elements of each of these models have been incorporated in “biopsychosocial” models of disease that attempt to generate a wholistic view of the complex factors that may interact to produce this mental dysfunction (Garety et al, 2001). Evidence Based Interventions Related to the Nursing Care of Clients with Schizophrenia. A clinical study by Power et al examined the potential benefits of CBT in the prevention of suicide in first episode psychosis in suicidal patients with early stage schizophrenia. This research was conducted as part of an intervention programme called LifeSPAN in the Early Psychosis Prevention and Intervention centre (EPPIC). The CBT therapeutic approach was evaluated by this programme as a potential strategy for intervention in this group of high-risk patients diagnosed with acutely suidicidal psychosis. A total of 56 patients were enrolled in this study and were randomised into two groups, one of which received standard care and the experimental group who received CBT/LifeSPAN therapy. Clinical assessments including estimated suicide risk were made at the beginning of treatment, immediately after its conclusion and in a six-month post-therapy follow-up assessment. The results of this study indicated an improvement of mood associated with a lower of hopelessness in the group who received the CBT/LifeSPAN therapy. A slight improvement that was not statistically significant was also observed in the area of “suicide ideation’’ in the treatment group. Although the results were inconclusive, the study indicated a qualitative benefit to this group of suicidal patients who received CBT. The Tayside-Fife clinical trial explored the use of CBT in patients diagnosed with psychosis who were extremely resistant to medication (Durham et al, 2003). The study was undertaken to explore CBT therapeutic approaches for schizophrenics for whom medication does not completely alleviate hallucinations and delusional behaviour, a group that comprises approximately 30% of the patient population. The goal was to assess the potential efficacy of CBT in this treatment-resistant group of patients. There are a number of studies that indicate that CBT may be of limited value in the treatment of this group of patients with schizophrenia. This research study attempted to evaluate the validity of these conclusions by exploring CBT in a comparative assessment with treatment as usual (TAS) carried out by clinical nursing specialists. Patients from two mental health facilities in Scotland were recruited for this study. Inclusion criteria involved a diagnosis of schizophrenia or delusional disorderwho were on anti-psychotic medication for at least six months and who continued to suffer hallucinations and/or delusions while medicated. A total of 66 patients were randomised into three groups: one received CBT, a second received supportive psychological therapy and the third received only treatment as usual (TAU). Treatment duration was for 9 months and a follow-up assessment was conducted 3 months post-treatment. The results of this clinical trial indicated a positive therapeutic benefit of CBT in this group of patients. Approximately one-third of the patients who received CBT showed 25% decrease in overall symptomotology. Moreover, combined CBT and SPT reduced the severity of delusions as compared to TAU. These changes were not immediately apparent post-therapy but were observed at the six month follow-up. In contrast, CBT showed no positive clinical effect on hallucinations. These results were not associated with any change in overall functioning based on standard assessment criteria. Patient satisfaction levels with CBT were 70% overall as compared with 37% for SPT and 2% for TAU. The Tayside-Fife trial was one of the first in which CBT was included as part of an overall treatment protocol in standard care of patients with schizophrenia. The assessment standards were rigorous and uniform for all three groups included in the study and clinical personnel was drawn from nursing, clinical psychology and psychiatry, all of whom were trained in CBT and SPT approaches. The study was limited, however, by low enrolment of only 66 patients who were on different pharmacologic treatment regimens. In comparison to three major clinical trials conducted to explore the therapeutic benefit of CBT in patients with schizophrenia produced some interesting results. These trials included: London-East Anglia study by Kuipers et al (1997, 1998) Manchester Wellcome study by Tarrier et al (1998) London-Newcastle Wellcome study by Sensky et al (2000) Each of these clinical trials demonstrated a positive effect of CBT as compared to other psychological therapy approaches and were associated with high levels of patient satisfaction. Follow-up assessments post therapy revealed that positive treatment responses were observed in 65% of clients enrolled in the London-East Anglia study and were associated with 25% reduction in symptom severity. A positive response rate of 33% was obtained in the Manchester Wellcome study based on a 50% reduction in symptom severity. A response rate of 63% was found in the London Newcastle Wellcome study, also based on 50% improvement in symptoms. Although the critieria for assessment and evaluation are difficult to standardise for purposes of comparison, it was noted that the positive response rate in the Tayside-Fife trial was significantly lower than in any of the earlier studies. The authors of the Tayside-Fife study suggested that difference in CBT delivery based on differing preparation and experience of clinical staff may explain differences in the observed clinical outcomes. It was also noted that a standardised form of CBT was utilised in this clinical study as compared to the other studies which incorporated the specialised versions of CBT adapted for the treatment of patients with schizophrenia. Overall, the Tayside-Fife clinical study indicated that CBT administered by trained clinical nursing staff produced a small, but significant reduction in overall symptomatology in approximately one-third of the patients who received the therapy. A modest effect was observed for improvement in delusional behaviour, but no effect was observed on hallucinations. Conclusion There is a general consensus among researchers that CBT approaches are frequently efficacious when applied to clients with schizophrenia, as evidenced by an overall large effect size (ES) with regard to positive and negative symptom that has been shown to increase with the duration of CBT (Chadwick, 2003). Moreover, the consensus of several major research studies is that this approach is cost-effective and has broad-sprectrum practical clinical therapeutic applications in the treatment of individuals with schizophrenia (Dickerson, 2000). The major therapeutic benefit of CBT applied to the treatment of schizophrenia involves the amelioration of residual symptoms in the context of approximately nine months of therapy with periodic follow-up. The research data suggest, however, that CBT may not be useful in the management of prodromal phases, acute relapses or first-episode events (Startup et al, 2002). In addition, clients with co-morbid mental health conditions such as personality disorders, addictive behaviours, learning disabilities or adolescent psychoses do not appear to experience significant therapeutic benefit from CBT approaches. Further research studies are needed to address important questions regarding the most effective use of CBT in the treatment of patients with schizophrenia. Among these are the specific CBT approaches and modifications that may be most efficacious in treating individuals with schizophrenia. In addition, further studies are needed to define the optimal training requirements to deliver effective CBT to this selected group of mental health clients most effectively (Durham et al, 2000). Additional consideration should be given to defining the specific symptoms and characteristics of clients receiving CBT in order to obtain more precise clinical data to evaluate patient responses more consistently. These areas of study are complex as schizophrenia is a very complex disorder with a spectrum of diverse clinical manifestations. Patient histories are complex and difficult to quantify (Gould et al, 2001). Treatment responses that involve changes of thought, mood or affect are difficult to quantify. Most importantly, the therapeutic applications of CBT as they relate to the specialised needs of individuals with schizophrenia require exploration. The positive clinical benefit observed using CBT in individuals with schizophrenia warrants further studies designed to achieve a maximal therapeutic benefit using this cognitive behavioural approach as an effective adjunct in the treatment of schizophrenia. REFERENCES American Psychiatric Association (2008) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM—IV). Washington, DC: APA. Bechdolf, A., Knost, B., Kuntermann, C., Schiller, S., Klosterkotter, J., Hambrecht, M. & Pukrop, R. (2004) A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in patients with schizophrenia. Acta Psychiatrica Scandinavica, 110(1), 21-28. 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