Professional Documents
Culture Documents
QUANTITATIVE
Aim
Auditory hallucinatory symptom management
The aim of this study was to compare the participants’
programme
levels of auditory hallucinations, anxiety symptoms and
depressive symptoms before and after receiving routine The AHSM programme group discussions were held for
treatment and participating in the AHSM programme. 1 hour after dinner. During the discussions, the group
members were encouraged to share their auditory hallucina-
tion experiences. In addition to teaching management
Design
strategies to the group, opportunities were provided for the
A quasi-experimental design was employed to evaluate the members to practice these strategies. The three rounds of
effectiveness of group AHSM treatments for patients who discussions were led by the three authors of this study; the
were on regular medication and exhibited combined symp- third author served as a constant collaborative leader, the
toms of auditory hallucinations and schizophrenia. The par- second author served as the leader of the first two rounds
ticipants were divided into an experimental group and a and the first author served as the leader of the third round.
control group according to their desired treatment. Both The discussions were conducted by following the opera-
participant groups answered an outcome assessment ques- tional procedure proposed by Professor Buccheri from
tionnaire. The experimental group underwent a 10-week UCSF regarding symptom management strategies for audi-
AHSM course and the control group underwent 10 weeks tory hallucinations. The 10-week AHSM course included
of routine treatment. At the 10th week, all of the partici- the following strategies: (a) self-monitoring; (b) distracting
pants were required to respond to an outcome assessment oneself from the voices by doing other things; (c) talking
tool. Afterwards, they were followed up once every with someone; (d) reading; (e) listening to music; (f) watch-
3 months for a total of 6 months. ing television; (g) using earplugs or covering one’s ears; and
Withdrawal of consent (n = 2)
Failure to meet diagnostic criteria (n = 1)
Denial of auditory hallucination problem (n
Table 1 Comparisons of the demographic data of the experimental (EG) and control (CG) groups at baseline (N = 58).
Variables CG (n = 29) EG (n = 29)
n n v2 P
Sex
Female 13 10
Male 16 19 0468 0421
M(SD) M(SD) t P
Age 4638 (808) 4728 (878) 0405 0687
Number of Hospitalizations 552 (466) 424 (188) 1367 0180
Years of Education 1128 (202) 1131 (202) 0065 0948
Duration of disease 2334 (809) 2193 (920) 0621 0537
CAHQ 1666 (900) 2045 (542) 1945 0058
BAI 1759 (1209) 1607 (1425) 0437 0664
BDI 1479 (1137) 1600 (1145) 0403 0689
CPZ Equivalents (T0) 52914 (29591) 62134 (20480) 1380 0173
CPZ Equivalents (T1) 49966 (30965) 62366 (20871) 1788 0079
CPZ Equivalents (T2) 50138 (30806) 61848 (20523) 1704 0094
CPZ Equivalents (T3) 51190 (30385) 60641 (20049) 1398 0168
T0: baseline; T1: post intervention; T2: 3-month follow-up; and T3: 6-month follow-up. CAHQ, characteristics of auditory hallucinations
questionnaire; BAI, beck anxiety inventory; BDI, beck depression inventory; CPZ, chlorpromazine.
Table 2 and Fig 2a present the CAHQ results, the pri- Table 4 and Fig 2c show another one of the secondary
mary outcome indicator of this study. In the control group, outcome indicators in this study, depressive symptoms.
the CAHQ scores obtained before and after intervention There were not any differences in the BDI scores of the
did not differ and the CAHQ scores obtained at the 3- control group at any of the four phases, whereas the scores
month follow-up assessments were lower than those of the experimental group at 3 and 6 months after the
obtained before the intervention (P < 001). After the intervention were lower than those before the intervention
effects of the six covariates were controlled, the GEE results (P < 001). The GEE results indicated that there were not
showed that the CAHQ scores of the experimental group any differences between the experimental and control
had improved significantly more than those of the control groups before the intervention when the effects of the six
group; the interaction between group and time indicated covariates were controlled (P = 0539). The interaction
that compared with before the intervention, the CAHQ between group and time showed that compared with before
scores of the experimental group had decreased significantly the intervention, the BDI scores of the experimental group
more than those of the control group at 3 months had decreased significantly more (B = 477) than those of
(P = 0015) and 6 months (P = 0004) after the interven- the control group at 3 months after the intervention
tion. The regression coefficients for the various interaction (P = 0017). This additional improvement is a moderate
terms show the amount of change in the intervention group effect size.
over and above the amount of change in the control group,
controlling for covariates. The size of these effects (as
Discussion
indexed by Cohen’s d) are also shown in the table and are
in the moderate to large range. This study explored the effectiveness of an intervention
Table 3 and Fig 2b display one of the secondary outcome based on adoption of the AHSM programme. The effective-
indicators in this study, anxiety symptoms. At 3 months ness was assessed 6 months after the conclusion of the pro-
after the intervention, the BAI scores of the control group gramme, using CAHQ score as the primary outcome
were significantly lower than the baseline and at the indicator and BAI and BDI scores as secondary indicators.
3-month and 6-month follow-ups, the BAI scores of the The results indicated that the experimental group experi-
experimental group were lower than those before the inter- enced greater improvement in CAHQ score than the control
vention (P < 005). The GEE results showed that the group. Regarding depressive symptoms, at the follow-up
changes over time did not differ significantly between the 3 months after the conclusion of the AHSM intervention
two groups when the effects of the six covariates were con- programme, the experimental group exhibited greater
trolled. improvement in depressive symptoms than the control
(a) CAHQ group; however, the interaction between group and time
21 regarding the level of improvement in anxiety symptoms
Experimental was not significant.
20
20·45 Control The participants in the control group showed non-signifi-
19
cant changes in CAHQ score post intervention and at the
18
6-month follow-up and medium-to-large effect sizes were
17 found in favour of the AHSM programme group, with a
16 16·66 16·52 significant effect of group on the decrease in CAHQ score
15 14·41 at the two follow-ups. The results of this study, that an
14 14·76 AHSM programme effectively improved CAHQ scores, is
13·00
13
consistent with the results of previous studies (Trygstad
et al. 2002, Buccheri et al. 2004). Both the participants of
12 12·59 12·79
the study by Buccheri et al. (2004) and of our study had 20
11
T0 T1 T2 T3 or more years since illness onset and similar ages. However,
the team led by Buccheri focused on outpatients, whereas
(b) BAI this study focused on chronic inpatient rehabilitation wards,
20 which ensured that the participants in this study were on
Experimental
17·59
medication and under the care of nursing personnel. There-
Control
18 fore, the experimental and control groups in this study were
15·62 15·21 receiving stable doses of medication when the former par-
16
16·07
ticipated in the AHSM programme. In the programme, the
14
participants came to understand their auditory hallucination
12·83
symptoms through learning in a group setting, became
13·62
12 aware of the timing when the symptoms appeared and real-
ized the effects of the symptoms on their behaviour, emo-
10 8·93 tions and daily life, enabling them to cope with the
10·62
symptoms (Dodd et al. 2001, Trygstad et al. 2002). The
8
participants also learnt how to employ AHSM strategies to
reduce their auditory hallucinations throughout the pro-
6
T0 T1 T2 T3 gramme. This model of symptom management corre-
sponded to that proposed by Dodd et al. (2001).
(c) BDI
In the first postintervention assessment (T1), no signifi-
19
17·72 Experimental cant differences were found between the experimental and
Control control groups. This result could be related to the features
17 16·00
17·76 of antipsychotics. It takes several days until patients taking
general antipsychotics begin to feel the effects of the medi-
15
cine and several weeks are required for them to attain
14·79
symptom stability (Sweileh et al. 2014). During the AHSM
13 11·86
13·11 programme, both of the groups experienced alleviated
11
symptoms because of the stabilizing effects of the medicine;
11·07 however, 50-60% of patients with chronic schizophrenia
9 8·25 still suffer from symptoms even while on regular medication
(Ballon & Lieberman 2010). In every participant in the
7 experimental group, the improvement in CAHQ score was
T0 T1 T2 T3 greater than in the control group participants, which was
shown at the 3-month and 6-month postintervention fol-
Figure 2 Between-group comparison of changes in (a) CAHQ
scores at different times, (b) anxiety symptoms at different times low-ups. Overall, the CAHQ scores of the experimental
and (c)depressive symptoms at different times. T0: baseline; T1: group decreased by approximately 8 points, while the
post intervention; T2: 3-month follow-up; and T3: 6-month scores of the control group decreased by two points during
follow-up. the 9 months of the study, indicating the favourable effects
Table 2 Effects of symptom management on the patients’ auditory hallucinatory symptoms at baseline, postintervention and the 3- and
6-month follow-ups (N = 58).
T0 T1 T2 T3 T0 T1 T2 T3
M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)
95% Wald CI
of the AHSM programme on ameliorating the symptoms of improvement of anxiety symptoms did not vary between
auditory hallucinations. the groups.
In the model of symptom management (Dodd et al. Depression is a typical comorbid symptom of schizophre-
2001), auditory hallucinations and affective symptoms were nia. Previous research showed that 3810% of patients with
influenced. The Taiwanese scholars Lung and colleagues schizophrenia had comorbid depression (Kim et al. 2006),
(2009) confirmed the effects of auditory hallucinations on which indicates the severity of the problem. The influence
anxiety and depression. People experiencing schizophrenia of the AHSM programme on depressive symptoms was
with auditory hallucinations tend to exhibit anxiety and reflected in the different patterns of BDI scores between the
depressive symptoms (Badcock et al. 2011, Hartley et al. two groups. The BDI scores of the experimental group
2013). Regarding the effects of the AHSM programme, decreased within 3 months post intervention, but slightly
anxiety symptoms had improved 3 months after the inter- increased at the 6-month follow-up. These findings differ
vention in both groups, but the interaction between study from the results of Buccheri et al. (2004) and Trygstad
group and time was not significant (P = 0435). This result et al. (2002), where BDI scores did not vary at the 3-month
may be explained by two reasons: first, the participants had and 6-month postintervention follow-ups. In this study, the
stayed in the rehabilitation institute for a long period of affective symptoms of the two groups were slightly aggra-
time, which increased their familiarity with the surrounding vated 6 months after the intervention. Life events are
people and things; and second, 792% of patients with regarded as an important risk factor for depression (Yun-
schizophrenia take benzodiazepines in Taiwan (Wu et al. ming et al. 2012, Wardenaar et al. 2014). The 6-month fol-
2011), which have sedative, hypnotic and anxiolytic effects low-up occurred approximately 1 month before the Dragon
(Tas et al. 2013). In other words, this group of patients Boat Festival, a festival that marks family reunions in Chi-
was under long-term anxiolytic treatment, which is why the nese societies. For the participants who have been separated
Table 3 Effects of symptom management on the patients’ anxiety symptoms at post-intervention and the 3- and 6-month follow-ups
(N = 58).
T0 T1 T2 T3 T0 T1 T2 T3
M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)
95% Wald CI
from their families to receive long-term medical treatment Therefore, a randomized clinical study on this topic is sug-
in a rehabilitation institute, whether they could return home gested. In addition, the participants were invited to join the
for the festival may be related to their family members’ atti- study from a psychiatric rehabilitation centre; thus, the
tudes towards them; therefore, the uncertainty of returning findings cannot be generalized to all patients with
home for the festival might be a factor that raises the par- schizophrenia experiencing auditory hallucinations.
ticipants’ levels of anxiety and depression (Carleton et al. Although all of the patients in the psychiatric centre had
2012). the opportunities to be invited to participate in the study,
whether the AHSM programme would be effective for
patients who declined to participate in the study requires
Limitations
further research. Moreover, to manage the symptoms of
Although the findings need to be considered in the context auditory hallucinations, the participants must possess self-
of a small sample size and non-randomization, important monitoring abilities (Buccheri et al. 2004). Consequently, if
group differences in CAHQ score remained significant after the participants lacked the capabilities to identify their
controlling for covariates using GEE. This study had some symptoms, the AHSM programme would not achieve its
limitations. First, the sample size was small and there was a maximum potential.
potential for bias due to the self-selection of participants
into the experimental group. Additional studies need to be
Conclusion
conducted, with larger and more representative samples.
Second, a quasi-experimental design was used, where the Using a quasi-experimental design, this study aimed to
experimental and control groups were not randomly investigate the short-term effects of the strategies learnt
assigned; this might affect the interpretation of the results. over a 10-week AHSM programme and the effects that
Table 4 Effects of symptom management on the patients’ depressive symptoms at post-intervention and the 3- and 6-month follow-ups
(N = 58).
T0 T1 T2 T3 T0 T1 T2 T3
M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)
95% Wald CI
continued over the subsequent 3-6 months. The outcome symptom management and Characteristic of Auditory Hal-
indicators included CAHQ scores, anxiety symptoms and lucination Questionnaire (CAHQ) to this project.
depressive symptoms. The experimental group demon-
strated greater improvement than the control group with
Funding
respect to CAHQ and BDI scores (except for the BAI
results), indicating that participation in an AHSM pro- This study was supported by a grant from Yen Tjing Ling
gramme is an effective strategy for individual patients who Medical Foundation CI-100-40.
are on regular medication but still suffer from auditory hal-
lucinations. An AHSM programme might have potential
Conflict of interest
benefits for patients with schizophrenia experiencing audi-
tory hallucinations when applied in psychiatric rehabilita- None conflicts of interest to declare by the authors.
tion centres. This study, however, employed a non-
randomized research design and a small sample size; further Author contributions
studies using a randomized controlled trial (RCT) design
and a larger sample size would be beneficial. All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/recommendations/)]:
Acknowledgements
• substantial contributions to conception and design,
The authors thank professor R Buccheri at the University of acquisition of data, or analysis and interpretation of
San Francisco, California who has provided the DVD of data;
• drafting the article or revising it critically for important Taylor D. (2001) Advancing the science of symptom
management. Journal of Advanced Nursing 33(5), 668–676.
intellectual content.
Hartley S., Barrowclough C. & Haddock G. (2013) Anxiety and
depression in psychosis: a systematic review of associations with
References positive psychotic symptoms. Acta Psychiatrica Scandinavica 128
(5), 327–346.
Andreasen N.C., Pressler M., Nopoulos P., Miller D. & Ho B.C. Hor K. & Taylor M. (2010) Suicide and schizophrenia: a
(2010) Antipsychotic dose equivalents and dose-Years: a systematic review of rates and risk factors. Journal of
standardized method for comparing exposure to different drugs. Psychopharmacology 24(Suppl. 4), 81–90.
Biological Psychiatry 67(3), 255–262. Kanungpairn T., Sitthimongkol Y., Wattanapailin A. & Klainin P.
Badcock J.C., Paulik G. & Maybery M.T. (2011) The role of (2007) Effects of a symptom management program on auditory
emotion regulation in auditory hallucinations. Psychiatry hallucinations in Thai outpatients with a diagnosis of schizophrenia:
Research 185(3), 303–308. a pilot study. Nursing and Health Science 9(1), 34–39.
Ballon J.S. & Lieberman J.A. (2010) Advances in the management Kim S.W., Kim S.J., Yoon B.H., Kim J.M., Shin I.S., Hwang M.Y.
of treatment-resistant schizophrenia. FOCUS: The Journal of & Yoon J.S. (2006) Diagnostic validity of assessment scales for
Lifelong Learning in Psychiatry 8(4), 475–487. depression in patients with schizophrenia. Psychiatry Research
Beck A.T., Epstein N., Brown G. & Steer R.A. (1988) An 144(1), 57–63.
inventory for measuring clinical anxiety: psychometric properties. Lee T.H., Lin C.J. & Yang C.Y. (2011) Introduction of the
Journal of Consulting and Clinical Psychology 56(6), 893–897. Chinese version assessment instruments for auditory
Beck A.T., Steer R.A. & Brown G.K. (1996) Beck Depression hallucination. Yuan Yuan Nursing 5(1), 22–29.
Inventory–II (BDI-II). The Psychological Corporation, San Lu M.L., Che H.H., Chang S.W. & Shen W.W. (2002) Reliability
Antonio. and validity of the Chinese version of the beck Depression
Buccheri R., Trygstad L., Kanas N., Waldron B. & Dowling G. Inventory-II. Taiwanese Journal of Psychiatry 16(4), 301–310.
(1996) Auditory hallucinations in schizophrenia: group Lung F.W., Shu B.C. & Chen P.F. (2009) Personality and
experience in examining symptom management and behavioral emotional response in schizophrenics with persistent auditory
strategies. Journal of Psychosocial Nursing & Mental Health hallucination. European Psychiatry 24(7), 470–475.
Services 34(2), 12–26. McLeod T., Morris M., Birchwood M. & Dovey A. (2007) Mental
Buccheri R., Trygstad L., Dowling G., Hopkins R., White K., health. Cognitive behavioural therapy group work with voice
Griffin J.J., Henderson S., Suciu L., Hippe S., Kaas M.J., Covert hearers. Part 1. British Journal of Nursing 16(4), 248–252.
C. & Hebert P. (2004) Long-term effects of teaching behavioral Morris S.B. (2007) Estimating effect sizes from the pretest-posttest-
strategies for managing persistent auditory hallucinations in control group designs. Organizational Research Methods 11(2),
schizophrenia. Journal of Psychosocial Nursing & Mental Health 364–386.
Services 42(1), 18–27. Sullivan G.M. & Feinn R. (2012) Using effect size: or why the p
Buccheri R., Trygstad L. & Dowling G. (2007) Behavioral value is not enough. Journal of Graduate Medical Education 4
management of command hallucinations to harm in (3), 279–282.
schizophrenia. Journal of Psychosocial Nursing & Mental Health Sweileh W.M., Odeh J.B., Shraim N.Y., Zyoud S.H., Sawalha A.F.
Services 45(9), 46–54. & Al-Jabi S.W. (2014) Evaluation of Defined Daily Dose,
Carleton R.N., Mulvogue M.K., Thibodeau M.A., McCabe percentage of British National Formulary maximum and
R.E., Antony M.M. & Asmundson G.J. (2012) Increasingly chlorpromazine equivalents in antipsychotic drug utilization.
certain about uncertainty: intolerance of uncertainty across Saudi Pharmaceutical Journal 22(2), 127–132.
anxiety and depression. Journal of Anxiety Disorders 26(3), Tas C., Brown E., Cubukcuoglu Z., Aydemir O., Danaci A.E. &
468–479. Brune M. (2013) Towards an integrative approach to
Che H.H., Lu M.L., Chen H.C., Chang S.W. & Lee Y.J. (2006) understanding quality of life in schizophrenia: the role of
Validation of the Chinese version of the Beck Anxiety Inventory. neurocognition, social cognition and psychopathology.
Formosa Journal of Medicine 10(4), 447–454. Comprehensive Psychiatry 54(3), 262–268.
Chiang Y.H., Chen Y.J. & Yang C.Y. (2013) The relationship Trygstad L., Buccheri R., Dowling G., Zind R., White K., Griffin
between auditory hallucinations and suicide ideation in chronic J.J., Henderson S., Suciu L., Hippe S., Kaas M.J., Covert C. &
schizophrenia patients. Journal of Nursing & Healthcare Hebert P. (2002) Behavioral management of persistent auditory
Research 9(2), 96–105. hallucinations in schizophrenia: outcomes from a 10-week
Cutcliffe J.R. & Riahi S. (2013) Systemic perspective of violence course. Journal of the American Psychiatric Nurses Association 8
and aggression in mental health care: towards a more (3), 84–91.
comprehensive understanding and conceptualization: part 1. Tsai Y.F. & Chen C.Y. (2006) Self-care symptom management
International Journal of Mental Health Nursing 22(6), 558–567. strategies for auditory hallucinations among patients with
Delespaul P., deVries M. & van Os J. (2002) Determinants of schizophrenia in Taiwan. Applied Nursing Research 19(4), 191–
occurrence and recovery from hallucinations in daily life. Social 196.
Psychiatry & Psychiatric Epidemiology 37(3), 97–104. Wardenaar K.J., van Veen T., Giltay E.J., Zitman F.G. &
Dodd M., Janson S., Facione N., Faucett J., Froelicher E., Penninx B.W.J.H. (2014) The use of symptom dimensions to
Humphreys J., Lee K., Miaskowski C., Puntillo K., Rankin S. & investigate the longitudinal effects of life events on depressive
and anxiety symptomatology. Journal of Affective Disorders cognitive behaviour therapy for voices? A randomised control
156, 126–133. trial. Schizophrenia Research 77(2–3), 201–210.
Wu C.S., Lin Y.J. & Liu S.K. (2011) Benzodiazepine use among Yunming L., Changsheng C., Haibo T., Wenjun C., Shanhong F.,
patients with schizophrenia in Taiwan: a nationwide population- Yan M., Yongyong X. & Qianzhen H. (2012) Prevalence and
based survey. Psychiatric Services 62(8), 908–914. risk factors for depression in older people in Xi0 an China: a
Wykes T., Hayward P., Thomas N., Green N., Surguladze S., community-based study. International Journal of Geriatric
Fannon D. & Landau S. (2005) What are the effects of group Psychiatry 27(1), 31–39.
The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of
evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance
and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original
research reports and methodological and theoretical papers.
For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan
• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·527 – ranked 14/101 in the 2012 ISI Jour-
nal Citation Reports © (Nursing (Social Science)).
• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries
worldwide (including over 3,500 in developing countries with free or low cost access).
• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.
• Positive publishing experience: rapid double-blind peer review with constructive feedback.
• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.
• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley
Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).