رفتاردرمانی شناختی می تواند برای گروه های اقلیت قومی روان پریشی سازگار باشد: مطالعه کنترل شده تصادفی

Abstract Cognitive behavioural therapy (CBT) is recommended in treatment guidelines for psychotic symptoms (NICE, 2009) but clients from some minority groups have been shown to have higher dropout rates and poorer outcomes. A recent qualitative study in ethnic minority groups concluded that CBT would be acceptable and may be more effective if it was culturally adapted to meet their needs (Rathod et al., 2010). Aim This study assessed the effectiveness of a culturally adapted CBT for psychosis (CaCBTp) in Black British, African Caribbean/Black African and South Asian Muslim participants. Method A randomised controlled trial was conducted in two centres in the UK (n = 35) in participants with a diagnosis of a disorder from the schizophrenia group. Assessments were conducted at three time points: baseline, post-therapy and at 6 months follow-up, using the Comprehensive Psychopathological Rating Scale (CPRS) and Insight Scale. Outcomes on specific subscales of CPRS were also evaluated. Participants in the treatment arm completed the Patient Experience Questionnaire (PEQ) to measure satisfaction with therapy. Assessors blind to randomisation and treatment allocation conducted administration of outcome measures. In total, n = 33 participants were randomly allocated to CaCBTp arm (n = 16) and treatment as usual (TAU) arm (n = 17) after (n = 2) participants were excluded. CaCBTp participants were offered 16 sessions of CaCBTp with trained therapists and the TAU arm continued with their standard treatment. Results Analysis was based on the principles of intention to treat (ITT). This was further supplemented with secondary sensitivity analyses. Post-treatment, the intervention group showed statistically significant reductions in symptomatology on overall CPRS scores, CaCBTp Mean (SD) = 16.23 (10.77), TAU = 18.60 (14.84); p = 0.047,with a difference in change of 11.31 (95% CI:0. 14 to 22.49); Schizophrenia change: CaCBTp = 3.46 (3.37); TAU = 4.78 (5.33) diff 4.62 (95% CI: 0.68 to 9.17); p = 0.047 and positive symptoms (delusions; p = 0.035, and hallucinations; p = 0.056). At 6 months follow-up, MADRAS change = 5.6 (95% CI: 2.92 to 7.60); p < 0.001. Adjustment was made for age, gender and antipsychotic medication. Overall satisfaction was significantly correlated with the number of sessions attended (r = 0.563; p = 0.003). Conclusion Participants in the CaCBTp group achieved statistically significant results post-treatment compared to those in the TAU group with some gains maintained at follow-up. High levels of satisfaction with the CaCBTp were reported.

Cultural influences are reported in the clinical manifestation, prevalence, treatment access and outcomes for individuals with schizophrenia. Cantor-Graae and Selten (2005) meta-analysis of 18 studies demonstrated a significantly increased risk of schizophrenia in migrant groups from developing countries with variation of risk by both host countries and countries of origin. Cognitive Behavioural Therapy (CBT) for schizophrenia is an evidence-based adjunct to medication and recommended internationally (Dixon et al., 2009 and National Institute for Clinical Excellence, 2009). However, clients from some black and minority ethnic (BME) groups e.g. the African Caribbean and Black African groups have shown higher dropout rates and poorer outcomes compared with the White group (Rathod et al., 2005). Cultural adaptation and understanding of ethnic, cultural and religious interpretations remains an underdeveloped area (Rathod et al., 2008). Griner and Smith (2006) have shown an effect size of 0.45 for culturally adapted evidence based interventions in comparison to traditional treatments (Wykes et al., 2008) whilst the meta-analysis by Huey and Polo (2008) was inconclusive. Evidence from small pilot studies suggests that locally adapted CBT with minority populations has been successful (Carter et al., 2003 and Kubany et al., 2003; Hinton et al., 2004 and Hinton et al., 2005; Patel et al., 2007, Rojas et al., 2007 and Rahman et al., 2008). Rathod et al. (2010) following a recent qualitative study reported that in principle, culturally adapted CBT for psychosis would be acceptable to BME clients. The recommendations from this study were incorporated into a CBT manual (Kingdon and Turkington, 2005) using Tseng et al.'s (2005) framework of cultural adaptations of psychological therapies. The authors considered several adaption models (including Bernal et al., 1995, Domenech Rodriguez and Weiling, 2004, Barrera and Castro, 2006, Hays and Iwamasa, 2006, Hwang, 2006 and Leong and Lee, 2006) and agreed that Tseng's framework would allow fidelity to the core principles of CBT with adequate flexibility for adapting the therapy to cultural beliefs, thereby preserving validity to the original treatment. The authors acknowledged that in practice, even if desirable, it may not be feasible to develop a different CBT for every cultural group and subgroup within them as every cultural group and subgroup had their own uniqueness and could not be considered as one. 2. Aims This study aimed to: a) Assess the feasibility of the culturally adapted CBT for psychosis (CaCBTp) with specified BME groups. b) Further modify CaCBTp in accordance with emerging findings.

The study contributes to the growing evidence for the need for adaptation of evidenced based interventions and efficacy and acceptability of culturally adapted CBT for psychosis. When working with diverse cultures, therapist cognisance and flexibility in the delivery of therapy in the context of culturally derived attitudes, beliefs, values and norms are vital for therapy to be effective and acceptable.