Distraction techniques for schizophrenia

Abstract

Background

Distraction techniques are a form of coping strategies used in cognitive behavioural techniques. They may be of value as an adjunctive treatment for people with schizophrenia or schizophrenia‐like illnesses.

Objectives

To review the effects of distraction techniques for people with schizophrenia.

Search methods

We searched the Cochrane Schizophrenia Group's Register (October 2003), manually searched reference lists and contacted relevant authors.

Selection criteria

We included all randomised controlled trials comparing distraction techniques with other treatments for schizophrenia.

Data collection and analysis

We reliably selected, quality assessed and data extracted studies. We excluded data where more than 50% of participants in any group were lost to follow up. For binary outcomes, we calculated a fixed effects risk ratio (RR) and its 95% confidence interval (CI), along with the number needed to treat/harm (NNT/H). For continuous data we calculated the weighted mean difference (WMD).

Main results

In terms of mental state, distraction techniques did not have a clear effect (n=60, 1 RCT, MD endpoint BPRS 1.60 CI ‐0.49 to 3.69). Distraction does not obviously engage people in the studies (n=159, 5 RCTs, RR leaving the study before completion 1.08 CI 0.72 to 1.63).

Authors' conclusions

Clinicians, researchers, policy makers and recipients of care cannot be confident of the effects of distraction techniques from the findings of this review. The few pioneering studies are small, short and poorly reported. Further data from already completed trials might help inform practice, but more trials do seem to be justified as some of these potentially simple techniques, even if their effect is negligible, could be widely implemented and prove more acceptable than other more intrusive treatments.

Plain language summary

Distraction techniques for schizophrenia

People with schizophrenia often suffer from hallucinations. Various forms of distraction from these hallucinations have been evaluated in trials, but reporting is poor, and the few studies are small and short. Although there is no evidence that they have a major effect, further trials are justified as some of these potentially simple techniques, even if their effect is negligible, could be widely implemented and prove more acceptable than other more intrusive treatments.

Background

Schizophrenia affects about one percent of the population (Leff 1991) and the majority of these people experience auditory hallucinations (Dawber 1997). Neuroleptic or antipsychotic medication tends to be the initial treatment for illness such as schizophrenia. However, five to twenty five percent of people with the illness have inadequate response to medication (Brenner 1992, Haddock 1996). 
 
 Psychological interventions such as cognitive behavioural therapy for psychosis have been found to produce responses in about 50% of people (Kuipers 1997), but It is unclear which elements of the therapy prompt this improvement (Garety 1997). Over the last decade, the use of a specific cognitive behavioural technique, Coping Skills Enhancement, has become a well‐established method of helping sufferers cope with hearing voices and/or intrusive thoughts (Brooker 2001, James 1983). Distraction techniques can form a part of Coping Skills Enhancement and, depending upon which treatment is of most benefit to the person with schizophrenia, they can offer various means of distraction from the voices (Sullivan 1997).

Distraction techniques tend to fall into three categories: cognitive strategies, behavioural strategies and physiological strategies (Falloon 1981). However, these are not discrete.

1. Cognitive: Vocal tasks e.g. reading aloud from a book or counting objects can reduce the duration, loudness and clarity of the voices (Tarrier 1987, Margo 1981). It may be that the more meaningful the distraction, the better the effect (Stuart 1991), or that activities which included pointing out objects helped to lessen the effects of the voices (James 1983). Humming may also prove useful (Green 1990). There is some evidence that thought stopping, as a technique for controlling hallucinations, might be beneficial (Allen 1985) as well as focusing on hallucinations and describing them in detail. Other cognitive techniques include talking back to the voices (Falloon 1981) and responding only to the pleasant ones (Romme 1989). It is thought these techniques provide mastery over voices (Rutner 1969). By self‐monitoring, clients may gain insight and control and look for alternative reasons for the auditory hallucinations (Dawber 1997, Holland 1999).

2. Behavioural: Social activities would be included as behavioural strategies. Men may prefer more isolative techniques whereas women may prefer to be more interactive (Bucchanan 1993). Clients might choose to interact with each other or staff, or will perhaps prefer to isolate themselves. Suggested strategies include making a conscious effort to distract oneself from the voices, such as by reading or going for a walk.

3. Physiological: Relaxation, not using imagery, may reduce feelings of anxiety. Imagery may be exasperating as people with schizophrenia can have difficulty distinguishing between internal or external stimuli (Harding 1996). The person with schizophrenia could, however, be asked to provide his or her own images and thus retain control (Harding 1996, Holland 1999). Using an earplug in the dominant ear may be beneficial (Kingdon 1991). Jogging or using an exercise bike has also been tried (Falloon 1981). Personal stereos (with a range of music available) may benefit some people. Certainly music has been found to be a help to some clients (Tarrier 1987).

We think that nursing staff commonly use some of these techniques in one form or another but could not find surveys to support this. In order to support nursing endeavour and intuition, it is important to systematically review appropriate research findings (Fowler 1995, Garety 1997).

Objectives

To review the clinical effects of distraction techniques for people with schizophrenia or schizophrenia‐like illnesses.

Methods

Criteria for considering studies for this review

Types of studies

We included all relevant randomised controlled trials. We included trials that were described as double‐blind, but that did not mention whether the study was randomised, in a sensitivity analysis. If there was no substantive difference within primary outcomes (see 'Types of outcome measures') when these studies were added, then we included them in the final analysis. If there was a substantive difference, we used only clearly randomised trials and described the results of the sensitivity analysis in the text. We excluded quasi‐randomised studies, such as those allocating by using alternate days of the week.

Types of participants

People diagnosed with schizophrenia or schizophrenia‐like illnesses using any criteria. We included trials where it was implied that the majority of the participants had a severe mental illness which was likely to be schizophrenia. We did not exclude trials due to age, nationality or gender of participants. We included trials with participants with all lengths of illness who were being treated in any treatment setting.

Types of interventions

1. Distraction techniques, for any length of time, as an adjunctive treatment for schizophrenia or schizophrenia‐like illnesses, regardless of the other interventions being used (e.g. medication, hospitalisation, problem solving therapy, psycho‐education, social skills training, cognitive‐behavioural therapy, family therapy or psychodynamic psychotherapy).

For the purposes of this review, we considered distraction techniques to be coping strategies involving a diversion. This can be a passive diversion, for example watching television, listening to music, using headphones or relaxation. Alternatively the distraction can involve activity such as playing an instrument, writing, reading, gardening, walking or any form of exercise. Other distraction techniques included indulgence (eating, smoking, drinking), socialisation, suppression of unwanted thoughts and problem solving for future events. It has been suggested that all distraction techniques were related to attention (Carr 1988). For this review we will use the basis of diverting attention away from hallucinations as a deciding factor in whether a distraction technique has been utilised.

2. Standard care 
 This is the care that a person would normally receive had they not been included in the research trial. This includes interventions such as medication, hospitalisation, community psychiatric nursing input and/or day hospital.

3. Biological treatments 
 This includes medication and any other medical interventions used.

4. Other psychological treatments 
 For example problem solving therapy, psycho‐education, cognitive‐behavioural therapy, family therapy or psychodynamic psychotherapy.

5. Social treatments 
 This includes social skills training and life skills training.

Types of outcome measures

All outcomes were reported for the short term (up to 12 weeks), medium term (13 to 26 weeks), and long term (more than 26 weeks).

Primary outcomes

1. Mental state 
 1.1 No clinically important change in general mental state

1.2 No clinically important change in specific symptoms (auditory hallucinations)

Secondary outcomes

1. Death ‐ suicide and natural causes

2. Global state 
 2.1 Relapse 
 2.2 Time to relapse 
 2.3 No clinically important change in global state 
 2.4 Not any change in global state 
 2.5 Average endpoint global state score 
 2.6 Average change in global state scores 
 2.7 No decrease in medication 
 2.8 Increase in medication

3. Service outcomes 
 3.1 Hospitalisation 
 3.2 Time to hospitalisation

4. Mental state 
 4.1 Not any change in general mental state 
 4.2 Average endpoint general mental state score 
 4.3 Average change in general mental state scores 
 
 4.4 Not any change in specific symptoms 
 4.5 Average endpoint specific symptom score 
 4.6 Average change in specific symptom scores

5. Leaving the study early 
 5.1 For specific reasons 
 5.2 For general reasons

6. General functioning 
 6.1 No clinically important change in general functioning 
 6.2 Not any change in general functioning 
 6.3 Average endpoint general functioning score 
 6.4 Average change in general functioning scores 
 6.5 No clinically important change in specific aspects of functioning, such as social or life skills 
 6.6 Not any change in specific aspects of functioning, such as social or life skills 
 6.7 Average endpoint specific aspects of functioning, such as social or life skills 
 6.8 Average change in specific aspects of functioning, such as social or life skills

7. Behaviour 
 7.1 No clinically important change in general behaviour 
 7.2 Not any change in general behaviour 
 7.3 Average endpoint general behaviour score 
 7.4 Average change in general behaviour scores 
 7.5 No clinically important change in specific aspects of behaviour 
 7.6 Not any change in specific aspects of behaviour 
 7.7 Average endpoint specific aspects of behaviour 
 7.8 Average change in specific aspects of behaviour

8. Adverse effects 
 8.1 No clinically important general adverse effects 
 8.2 Not any general adverse effects 
 8.3 Average endpoint general adverse effect score 
 8.4 Average change in general adverse effect scores 
 8.5 No clinically important change in specific adverse effects 
 8.6 Not any change in specific adverse effects 
 8.7 Average endpoint specific adverse effects 
 8.8 Average change in specific adverse effects

9. Engagement with services 
 9.1 No clinically important engagement 
 9.2 Not any engagement 
 9.3 Average endpoint engagement score 
 9.4 Average change in engagement scores

10. Satisfaction with treatment 
 10.1 Recipient of care not satisfied with treatment 
 10.2 Recipient of care average satisfaction score 
 10.3 Recipient of care average change in satisfaction scores 
 10.4 Carer not satisfied with treatment 
 10.5 Carer average satisfaction score 
 10.6 Carer average change in satisfaction scores

11. Quality of life 
 11.1 No clinically important change in quality of life 
 11.2 Not any change in quality of life 
 11.3 Average endpoint quality of life score 
 11.4 Average change in quality of life scores 
 11.5 No clinically important change in specific aspects of quality of life 
 11.6 Not any change in specific aspects of quality of life 
 11.7 Average endpoint specific aspects of quality of life 
 11.8 Average change in specific aspects of quality of life

12. Economic outcomes 
 12.1 Direct costs 
 12.2 Indirect costs

Search methods for identification of studies

Electronic searches

1 We searched The Cochrane Schizophrenia Group's Register (October 2003) with the phrase:

{[thought‐stop* or (coping* and strateg*) or self monitoring* or reading* or earplug* or stereo* or distract* or thought‐block* or (thought and block*) or (thought and stop*) or headphone* or (head and phone*) or socialis* or diversion* or *coping* or (passive and diversion) or suppre* in title or *thought‐stop* or diversion* or *coping* or *self monitoring* or *reading* or (coping* and strateg*) or (passive and diversion) or *earplug* or *stereo* or *distract* or *thought‐block* or (thought and block*) or (thought and stop*) or headphone* or (head and phone*) or socialis* or suppre* in abstract or index terms of REFERENCE] or [Action Oriented Group Therapy or Active Learning or Activity Group or active group or Ambulant Group Therapy or Ambulatory Care or Bioenergetic Exercise Treatment or Biofeedback or Bodily Awareness Techniques or Brief Patient Education or Censure / Punishment or Communication or Companion Program or Concept Formation or Conversation or Conversation Skills Training or Coping Oriented Group Psychotherapy or Cues or Dance Therapy or Decision Making or Didactic Instruction or Discrimination Learning or Discussion or Discussion Group or Education or Enhanced Learning or Enhanced Psychosocial and Pharmacological Treatment or Exercise Therapy or Experimental Problem Solving Treatment Group or Feedback or Film in Cognitive Behavioral Therapy or Game or Goal‐Directed Group or Gradual Vocational Program or Group Living or Group Psychoeducation or Group Work Conditions or High Expectation Environment or Homework or Human Relations Training Program or Imitation Learning or Interaction Group or Interaction With Others or Interpersonal Problem‐Solving Group or Interpersonal Skills Training or Leisure Activities or Life Skills Training or Low Expectation Environment or Management of Symptoms with Behavior Therapy or Milieu Therapy or Mind‐Body Relations or Modeling on Behavior Therapy or Modular Skills Training or Movement Therapy or Multimedia Computer Study or Music Therapy or Need‐Based Intervention or Non‐Contingent Reinforcement or Other Contact with mentally ill person or Other Educational Video or Other Interactive‐Behavioural Training or Other Modified Morita Therapy or Other Random Episode Silent Thought (REST) or Other Symptom group management or Physical Activities or Physical Contact Therapy or Play Therapy or Psychiatric Somatic Therapies or Reading or Reading in Behavior Therapy or Reality Orientation or Reasoned Action Group or Recreation or Relaxation* or Religion or Remotivation Group or Scaffolding Instruction or Semantic Elaboration or Singing or Social Activity Group or Social Milieu Therapy or Social Skills Training or Social Support or Socioenvironmental Therapy or Socioenvironmental Therapy or Sociotherapy or Stress Management or Structured Learning Therapy or Supportive* or Thought Stopping in Behavior Therapy or Training in Community Living Model or Verbal Conditioning or Verbal Material or Verbal Oriented Therapy or Vicarious Therapy Pretraining or Video recording or Vigilance Training or Vocational Education or Work Therapy]}

The Schizophrenia Groups trials register is based on regular searches of BIOSIS Inside; CENTRAL; CINAHL; EMBASE; MEDLINE and PsycINFO; the hand searching of relevant journals and conference proceedings, and searches of several key grey literature sources. A full description is given in the Group's module.

Searching other resources

1. Reference searching 
 We also inspected references of all identified studies, included or excluded, for more studies.

2. Hand searching 
 Where one journal had clearly published more relevant studies than others, if it had not already been hand searched, we would have hand searched the last decade to identify further reports. We also searched The Conference on Self Management of Schizophrenia for relevant studies.

3. Personal contact 
 We contacted the authors of relevant included studies to enquire about other sources of relevant information.

Data collection and analysis

1. Selection of trials 
 We (Charlotte Crawford‐Walker (CC‐W), Adrian King (AK)) independently inspected the citations identified from the search. We identified potentially relevant abstracts and ordered full papers for reassessment for inclusion and methodological quality. We discussed and reported any disagreements.

2. Assessment of quality 
 We allocated trials to three quality categories, as described in the Cochrane Collaboration Handbook (Clarke 2002) by each reviewer. When disputes arose as to which category a trial was allocated, we attempted to resolve them by discussion. When this was not possible and further information was necessary to clarify into which category to allocate the trial, data were not entered and the trial was allocated to the list of those awaiting assessment. Only trials in Category A or B were included in the review.

3. Data management 
 3.1 Data extraction 
 Again working independently we extracted data and, where further clarification was needed, contacted the authors of trials to provide missing data.

3.2 Intention to treat analysis 
 We excluded data from studies where more than 50% of participants in any group were lost to follow up (this does not include the outcome of 'leaving the study early'). In studies with less than 50% dropout rate, people leaving early were considered to have had the negative outcome, except for the event of death. We analysed the impact of including studies with high attrition rates (25‐50%) in a sensitivity analysis. If inclusion of data from this latter group did result in a substantive change in the estimate of effect, we did not add this data to trials with less attrition, but presented them separately.

4. Data analysis

4.1 Binary data 
 For binary outcomes we calculated a standard estimation of the random effects risk ratio (RR) and its 95% confidence interval (CI). Where possible, we also calculated the weighted number needed to treat/harm statistic (NNT/H), and its 95% confidence interval (CI), using Visual Rx (http://www.nntonline.net/) which takes account of the event rate in the relevant control group. If heterogeneity was found (see section 5) we used a random effects model.

4.2 Continuous data

4.2.1 Skewed data: continuous data on clinical and social outcomes are often not normally distributed. To avoid the pitfall of applying parametric tests to non‐parametric data the following standards were applied to all data before inclusion: (a) standard deviations and means were reported in the paper or were obtainable from the authors; (b) when a scale started from a finite number (such as zero), the standard deviation, when multiplied by two, was less than the mean (as otherwise the mean was unlikely to be an appropriate measure of the centre of the distribution (Altman 1996)). Endpoint scores on scales often have a finite start and end point and this rule can be applied to them.

4.2.2 Summary statistic: for continuous outcomes a weighted mean difference (WMD) between groups was estimated. Again, if heterogeneity was found (see section 5) we used a random effects model.

4.2.3 Valid scales: we included continuous data from rating scales only if the measuring instrument had been described in a peer‐reviewed journal and the instrument was either a self report or completed by an independent rater or relative (not the therapist). (Marshall 2000).

4.2.4 Endpoint versus change data: where possible endpoint data were presented, and if both endpoint and change data were available for the same outcomes then only the former were reported in this review.

4.2.5 Cluster trials: studies increasingly employ 'cluster randomisation' (such as randomisation by clinician or practice) but analysis and pooling of clustered data poses problems. Firstly, authors often fail to account for intra class correlation in clustered studies, leading to a 'unit of analysis' error (Divine 1992) whereby p values are spuriously low, confidence intervals unduly narrow and statistical significance overestimated. This causes type I errors (Bland 1997; Gulliford 1999).

Where clustering was not accounted for in primary studies, we presented the data in a table, with a (*) symbol to indicate the presence of a probable unit of analysis error. In subsequent versions of this review we will seek to contact first authors of studies to obtain intra class correlation co‐efficients of their clustered data and to adjust for this by using accepted methods (Gulliford 1999). Where clustering has been incorporated into the analysis of primary studies, we will also present these data as if from a non‐cluster randomised study, but adjusted for the clustering effect.

We have sought statistical advice and have been advised that the binary data as presented in a report should be divided by a 'design effect'. This is calculated using the mean number of participants per cluster (m) and the intra‐class correlation co‐efficient (ICC) Design effect = 1+(m‐1)*ICC (Donner 2002). If the ICC was not reported it was assumed to be 0.1 (Ukoumunne 1999).

If cluster studies had been appropriately analysed taking into account intra‐class correlation co‐efficients and relevant data documented in the report, synthesis with other studies would have been possible using the generic inverse variance technique.

5. Investigation for heterogeneity 
 Firstly, we considered all the included studies within any comparison to judge clinical heterogeneity. Then we visually inspected graphs to investigate the possibility of statistical heterogeneity. This was supplemented, primarily, by employing the I‐squared statistic. This provides an estimate of the percentage of inconsistency thought to be due to chance. Where the I‐squared estimate included 75%, this was interpreted as evidence of high levels of heterogeneity (Higgins 2003). If inconsistency was high, we did not summate the data, but presented them separately and investigated reasons for heterogeneity.

6. Addressing small study bias 
 We entered data from all included studies into a funnel graph (trial effect against trial size) in an attempt to investigate the likelihood of overt publication bias (Davey 1997).

7. Sensitivity analyses 
 The inclusion of data from studies that had implied that allocation was random, rather than making it explicit and also from studies with high attrition rates was analysed in a sensitivity analysis (primary outcomes only).

8. General 
 Where possible, we entered data in such a way that the area to the left of the line of no effect indicated a favourable outcome for distraction techniques.

Results

Description of studies

1. Overview of search results 
 The search strategy identified 296 abstracts of which 37 referred to potentially eligible studies. From these 37 studies 30 did not meet inclusion criteria, two had not been completed and five could be included. For substantive descriptions of studies please see included and excluded studies tables.

2. Awaiting assessment 
 No studies await assessment.

3. Ongoing studies 
 We identified two ongoing studies. Adams 2000 is thought to be ongoing. It is a randomised controlled trial investigating the effects of exercise on the symptoms of people with schizophrenia. We do not think it is a large study and do not know when it will be finished. Haddock 2000 describes a study to investigate the effects of cognitive behavioural therapy, including distraction, on people with a diagnosis of schizophrenia and drug/alcohol misuse problems. We are unsure of when this study will conclude and its projected size.

4. Excluded studies 
 There are currently 30 excluded studies, seven of which were not randomised. Of these seven, one was a description of services, the allocation procedure for one was unclear, two based allocation on clinical observation and one on order of admission, one matched people in experimental and control groups and one subjected everyone to the same stimuli. Of the 23 excluded randomised studies, 15 were not exclusively concerned with distraction techniques, including seven on coping skills training courses, and some on social groups and psychoeducation. Half of the other studies were potentially eligible for inclusion but did not report any usable data.

5. Included studies 
 We identified only five distraction techniques studies for inclusion.

5.1 Duration 
 Four of the studies concentrated on short term follow up results only i.e. <12 weeks. The studies lasted four weeks, six weeks, eight weeks and three months respectively. Only one study included long term follow up at six months.

5.2 Participants and setting 
 Three of the five studies were based in the USA, one in Canada and one in the UK. All participants had been diagnosed with schizophrenia according to DSM criteria. Two trials recruited adults from outpatient's appointments and three studies recruited inpatients. Buccheri 1996 recruited outpatients who experienced auditory hallucinations on a daily basis and Cole 1997 inpatients during a rehabilitation programme. Lamontagne 1983 recruited people who had been inpatients for a period exceeding six months with an average stay of six years. Medalia 2000 enlisted people who had been in hospital for a minimum period of six weeks. Tarrier 1993 was the only UK study with outpatients who had been experiencing auditory hallucinations for at least six months.

5.3 Study size 
 No trial reported a pre‐study power calculation. The trials, in ascending order of size, are Buccheri 1996 (17), Lamontagne 1983 (20), Tarrier 1993 (27), Medalia 2000 (60) and Cole 1997 (62)

5.4 Interventions 
 In Buccheri 1996, the intervention involved each participant learning one distraction technique per week which they would then practice twice a day. A new technique was taught each week. Cole 1997 used exercise as a distraction technique. Both the experimental and control group were involved in the "Partial Hospitalisation Program". No further details are available of what this entailed. The distraction technique utilised by Lamontagne 1983 was thought stopping, this involved classes in thought stopping and the participants were encouraged to use the techniques between classes. Medalia 2000 used computer attention training as a distraction technique with a control group watching documentaries, another recognised technique. Tarrier 1993 involved Coping Skills Enhancement which is a specific distraction technique including attention switching, behavioural strategies and physiological strategies as discussed in the background to the review.

5.5 Outcomes 
 All studies report short‐term outcomes. Some data were solely presented as statements, graphs or tables without standard deviations or standard errors being reported. Raw numbers were unavailable in some cases.

5.5.1 General 
 We could only extract 'leaving the study early' from all five studies.

5.5.1.2 Continuous outcomes 
 Details of the scales that supplied usable data for this review are given below. Reasons for exclusion of data from other scales are given in the outcomes column of the 'characteristics of included studies' table.

5.5.2 Mental state scales and overall functioning

Brief Psychopathological Rating Scale (BPRS, Overall 1962) 
 This is a brief rating scale used to assess the severity of a range of psychiatric symptoms, including psychotic symptoms. The scale has 16 items, and each item can be defined on a seven‐point scale, varying from "not present" (0) to "extremely severe" (6).

Present State Examination (PSE, Wing 1974) 
 This is a clinician‐rated scale measuring mental status. One hundred and forty symptom items are rated and combined to give various syndrome and sub‐syndrome scores. Higher scores indicate greater clinical impairment.

5.5.3 Missing outcomes 
 No data were available on global state, service outcomes, general functioning, behaviour, adverse effects, engagement with the service, quality of life or economic outcomes.

Risk of bias in included studies

1. Randomisation 
 We could not rate any study as quality Category A. All met quality level B (moderate risk of bias). This means that each of the studies simply stated that randomisation took place, without assuring the reader that every effort was made to conceal the order of allocation from everyone. 
 
 2. Blindness 
 Trialists were aware of the possibility of the introduction of observer bias by not blinding the raters to the group to which people were allocated. None of the studies described the process of blinding in adequate detail. Despite the considerable difficulty of blinding, only the Lamontagne 1983 blinded the research nurses conducting the assessments on participants. No study tested the integrity of blinding.

3. Follow up 
 Overall, reasons for withdrawal from studies are well reported, although those who left the treatment early were not monitored in order to acquire data for a full intention to treat analysis.

Effects of interventions

1. The search 
 The initial search identified 296 citations. We were only able to include five of these in the review. We contacted authors for further information regarding studies but had limited response. We also checked the reference lists of included studies in an attempt to identify other relevant work but were unable to identify further studies for inclusion.

2. COMPARISON 1: DISTRACTION TECHNIQUE + STANDARD CARE VS HEALTH PROMOTION + STANDARD CARE

2.1 Mental state 
 Only one study reported usable data on mental state (Medalia 2000). There appeared to be no significant difference in terms of treatment response as defined by BPRS endpoint score between computer attention training and national geographic documentaries in the short term (n=60, MD 1.60 CI ‐0.49 to 3.69). Tarrier 1993 also used BPRS to calculate a total symptom severity score as well as PSE to count the number of symptoms for a Coping Skills Enhancement group and Problem Solving group at six and 26 weeks and found that this was not statistically significant in either case. The data were too skewed to be represented graphically.

2.2 Leaving the study early 
 Four studies reported data for the short term (0 to 12 weeks) and one reported long term data. About 30% of the people in these studies left before study completion. There was no significant advantage to distraction techniques over health promotion in either the short term (n=159, 5 RCTs, RR 1.02 CI 0.68 to 1.55) or over a longer period (RR 2.40 CI 0.28 to 20.24). Over any time period, we found no clear difference in the numbers of people dropping out after being randomised to the intervention or control groups (n=186, 5 RCTs, RR 1.08 CI 0.72 to 1.63). 
 
 2.3 Missing outcomes 
 We found no data on global state, service outcomes, general functioning, behaviour, adverse effects, service engagement, quality of life or economic outcomes.

Discussion

1. The search 
 We undertook an extensive electronic search. It is perfectly feasible, however, that despite these efforts, we could have failed to identify some studies. With only a few exceptions, each database yielded a few more unique reports to inspect. We think it unlikely, however, that we have failed to find large studies by our search methods.

2. COMPARISON 1: DISTRACTION TECHNIQUE + STANDARD CARE VS HEALTH PROMOTION + STANDARD CARE

2.1 Mental state 
 Trialists invested time and effort rating mental state using several scales. Efforts of everyone in Buccheri 1996, Cole 1997, and Lamontagne 1983 were entirely wasted as all data for this outcome proved unusable and only some of the mental state data from Tarrier 1993 could be reproduced for this review. It does not seem right that such efforts on the part of trialists and participants are squandered and more clear data reporting could go a long way to ensure that the findings can be used and inform future care. The overall impression suggests that distraction techniques do not cause significant effects in mental state. However, due to the limited data, we cannot be sure of this.

2.2. Leaving the study early 
 About 30% of participants left the studies before completion, even over quite short periods of time. This is similar to many recent drug studies (Thornley 1998). This appears to be a high attrition rate, though some studies had a much higher number of participants leaving the study (Cole 1997, Buccheri 1996) than others. Distraction techniques did not seem to promote or hinder leaving the study early. It could be argued that the distraction techniques failed to engage participants in studies in a more meaningful way than the control activities. We are unable to speculate whether some distraction techniques are more likely to keep people engaged in the long term than other techniques.

2.3 Missing outcomes 
 Of the 12 broad classes of outcomes prior to the review, data were only available on two, i.e. mental state and leaving the study early. Although mental state was the primary outcome for this review, it is disappointing that data were not available for other outcome measures. Some included studies measured other outcomes, but these were not recorded in the results of the trials. Lamontagne 1983 used a behaviour scale (NOSIE) and also intended to measure general functioning through social contact (MACC II). Results from these scales were unavailable. Buccheri 1996 failed to record many results in the report and we were unable to obtain raw data despite considerable efforts to contact the authors. Cole 1997 reported some usable data in the dissertation report but, because of the high number who left the study early, the results could not be used. Finally Haddock 1998 intended to collect data on outcome measures other than mental state and attrition, but failed to report numbers of people allocated to each group. We have had no response from the authors (see excluded studies).

Authors' conclusions

Implications for practice.

1. People with schizophrenia and their families 
 The main benefit of distraction techniques for people with schizophrenia is that a large number of techniques exist which people can use independently and this may assist the person experiencing auditory hallucinations to feel involved in the management of their own care. Results from these trials have not shown them to have dramatic effects, but there are only a few small scale studies.

2. Clinicians 
 Clinicians may feel that distraction techniques are worth the time and effort, as an addition to standard care, assuming that the patient wants to try them. As there is no evidence to support or refute their effects clinicians may want to organise their own study.

3. Managers 
 As always, service managers and funders have to weigh up the costs to healthcare and the benefits of this treatment for people with schizophrenia. They may feel that the resources required to adequately implement distraction techniques might be better used in other ways. However if people could be clearly shown to benefit, distraction techniques could be implemented within inpatient units and amongst outpatients for a relatively low cost. A definitive study is needed.

Implications for research.

1. General 
 If the CONSORT recommendations, first published in 1996 (Begg 1996, Moher 2001) had been followed in the reporting of the included studies and at least one of the excluded trials (Haddock 1998), we may have had more data to present and a better impression of the effects of these techniques. Certainly the CONSORT standard of reporting of future studies should help decrease some of the problems and waste we have noted. Indeed, much important data within the included studies were so poorly reported that clinicians, funders and recipients of care might have reason to feel let down by the research community.

2. Specific 
 2.1 Individual patient data 
 This work would be more informative if more individual patient data had been available.

2.2 Future versions of this review 
 Further updates of this review should be able to include, at least, the two new trials on distraction techniques we have identified already.

2.3 Future trials 
 Large simple, well‐designed and reported trials continue to be justified. All data in this review are unstable and a large, pragmatic study should be undertaken to settle arguments about the value of this widely used therapy. Entry criteria should be broad, interventions accessible and outcomes clear and well reported.

All the included studies focused primarily on the improvement of mental state when assessing the effects of distraction techniques. Other outcomes such as general functioning, behaviour, satisfaction, engagement with the service and adverse effects should be investigated in future trials. More complete follow‐up data would produce a more valid picture of the lasting effect of distraction techniques on the course of the illness. All such measures, however, should be readily understandable by all users of this research, and binary as well as continuous data should be reported. Data collection should allow for economic evaluations (cost‐effectiveness and cost‐benefit) of the two intervention strategies being compared.

What's new

Date	Event	Description
15 February 2010	Amended	Contact details updated.

History

Protocol first published: Issue 2, 2004
 Review first published: Issue 1, 2005

Date	Event	Description
30 October 2008	Amended	Converted to new review format.

Data and analyses

Comparison 1. DISTRACTION TECHNIQUE + STANDRD CARE vs HEALTH PROMOTION GROUP + STANDARD CARE.

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mental state: 1. Average endpoint score ‐ short term (BPRS, high = poor)	1	60	Mean Difference (IV, Fixed, 95% CI)	1.60 [‐0.49, 3.69]
2 Mental state: 2. Average total symptom severity scores (BPRS, high = poor, skewed data)			Other data	No numeric data
2.1 short term			Other data	No numeric data
2.2 long term			Other data	No numeric data
3 Mental state: 3. Symptom count (high = poor, skewed data)			Other data	No numeric data
3.1 short term			Other data	No numeric data
3.2 long term			Other data	No numeric data
4 Leaving the study early	5	186	Risk Ratio (M‐H, Fixed, 95% CI)	1.08 [0.72, 1.63]
4.1 short term	4	159	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.68, 1.55]
4.2 long term	1	27	Risk Ratio (M‐H, Fixed, 95% CI)	2.4 [0.28, 20.24]

1.1. Analysis.

Comparison 1 DISTRACTION TECHNIQUE + STANDRD CARE vs HEALTH PROMOTION GROUP + STANDARD CARE, Outcome 1 Mental state: 1. Average endpoint score ‐ short term (BPRS, high = poor).

1.2. Analysis.

Comparison 1 DISTRACTION TECHNIQUE + STANDRD CARE vs HEALTH PROMOTION GROUP + STANDARD CARE, Outcome 2 Mental state: 2. Average total symptom severity scores (BPRS, high = poor, skewed data).

Mental state: 2. Average total symptom severity scores (BPRS, high = poor, skewed data)
Study	Intervention	Mean	SD	N	Notes
short term
Tarrier 1993	Coping skills enhancement	9.8	10.88	15
Tarrier 1993	Problem solving	8	7.97	12
long term
Tarrier 1993	Coping Skills Enhancement	7.58	8.36	12	F=14.08 P=0.0001
Tarrier 1993	Problem Solving	5.55	6.15	11

1.3. Analysis.

Comparison 1 DISTRACTION TECHNIQUE + STANDRD CARE vs HEALTH PROMOTION GROUP + STANDARD CARE, Outcome 3 Mental state: 3. Symptom count (high = poor, skewed data).

Mental state: 3. Symptom count (high = poor, skewed data)
Study	Intervention	Mean	SD	N	Notes
short term
Tarrier 1993	Coping skills enhancement	2.83	2.36	15
Tarrier 1993	Problem solving	2.46	2.2	12
long term
Tarrier 1993	Coping Skills Enhancement	2.08	1.94	15	F=11.999 P=0.0001
Tarrier 1993	Problem Solving	1.82	1.96	12

1.4. Analysis.

Comparison 1 DISTRACTION TECHNIQUE + STANDRD CARE vs HEALTH PROMOTION GROUP + STANDARD CARE, Outcome 4 Leaving the study early.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Buccheri 1996.

Methods	Allocation: randomised, two people added to control group post randomisation. Blindness: no information given. Duration: 12 weeks treatment, 1 year follow up. Consent: signed consent form.
Participants	Diagnosis: schizophrenia (DSM‐III‐R). N=17.* Age: 28‐77 years, average 46, SD 12. Sex: 19 men, 2 women. Setting: outpatients day treatment program, USA. History: hearing voices on daily basis for 6/12, recieving psychiatric outpatient treatment and taking antipsychotic medication. Exclusion: anyone with primary neurological problem, severe cognitive deficit, primary mood disorder or severe substance abuse.
Interventions	1. Distraction techniques: 12 weekly 45 minute classes. N=9.* 2. Health education class. Held at the same time as distraction techniques class N=8. Control group offered distractions techniques after 12 week trial.
Outcomes	Leaving the study early. Unable to use ‐ Mental state: AHIG, AHDD (no data reported by 12 weeks, only experimental group data by 12 months).
Notes	* One year follow up paper reports on 12 in "experimental management class". We are unsure if more were randomised to this class. Authors have been contacted but have not supplied further details.
Risk of bias
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Cole 1997.

Methods	Allocation: randomly assigned, blocks. Blindness: no information available. Duration: outcomes recorded at end of interventions ‐ 8 weeks (preceeded by fitness tests). Consent: signed consent form.
Participants	Diagnosis: chronic mental illness (e.g. schizophrenia, schizo affective or bipolar disorder), "primary chart diagnosis". N=62. Age: 18‐59 years, average 31, SD 9. Sex: 17 men, 11 women. Setting: the Centre for Psychiatric Rehabilitation, Illinios, USA. History: chronically ill. Exclusion: anyone considered not suitable for physical exercise by physician or by PAR‐Q.
Interventions	1. Exercise group + standard care : 16, 35 minuite sessions over 8 weeks. N=31 participants had to complete a minimum of 10 sessions to be included 2. Standard care: unstructured exercise program 1/week for 2 hours + partial hospitalisation program. N=31.
Outcomes	Leaving the study early. Unable to use ‐ Mental state: BPRS, DHS (>50% attrition).
Notes	*27 decreased attendance to the extent that they were ineligible, six others dropped out of the exercise program and continued in the Partial Hospitalisation Program Also used a Bench Step Test, Heart Rate Assessment, Sit and Reach and screening to ensure that the participants were fit to complete the study
Risk of bias
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Lamontagne 1983.

Methods	Allocation: randomised. Blindness: assessing nurse was blind to treatment conditions but the independent assessor was not for 3 of the patients. Duration: intervention for 4 weeks, then follow up at 1, 3 and 6 months. Consent: signed a consent form.
Participants	Diagnosis: paranoid schizophrenia classified by DSM‐III. N=20* Age: average 37 years. Sex: 11 men 9 women. Setting: inpatients History: had been hospitalised for more than 6 months. Exclusion: none given.
Interventions	1. Thought stopping + phenothazine. 60 minute sessions once a week for 4 weeks. N=10. 2.Symptom management class + phenothazine.* N=10.
Outcomes	Leaving the study early. Unable to use ‐ Behaviour: NOSIE (no data reported). Mental state: BPRS, NGIS (no data reported). General functioning: MACC II (no data reported).
Notes	*one patient from each group left after the 1st session. One more was lost at 3 and 6 month follow up ‐ not known from which group
Risk of bias
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Medalia 2000.

Methods	Allocation: individuals with like rankings on the CPT were paired and then were randomly assigned. Blindness: psychiatrists were blind to the research hypothesis and study design. Duration: 6 week intervention, no follow up. Consent: signed consent form.
Participants	Diagnosis: chronic schizophrenia classified by DSM III‐R. N= 60* Age: 20‐45 years, average 33. Sex: 46 men 14 women. Setting: Bronx Psychiatric Centre, State hospital, USA History: inpatients for 6 weeks prior to the study Exclusion: anyone who fell below average intelligence, as measured by the Quick Test; anyone diagnosed with brain disease.
Interventions	1. Computer attention training modules + neuroleptic medication,18 20 minute sessions over 6 weeks. N=30. 2. National geographic documentaries + neuroleptic medication. N=30.
Outcomes	Leaving the study early. Mental state: BPRS.
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Tarrier 1993.

Methods	Allocation: randomly allocated to a treatment group and a psychologist. Blindness: assessments were not blind. Duration: treatment lasted 5 weeks with post assessments at 6 weeks and 6 months. Consent: no information given.
Participants	Diagnosis: schizophrenia classified by DSM III‐R criteria. N=27. Age: 16‐65, average 43 years. Sex: no information given. Setting: outpatients. History: psychotic symptoms for over 6 months which were non responsive to medication, were recieving neuroleptic medication. Exclusion: evidence of organic pathology.
Interventions	1. Coping Skills Enhancement (CSE). N=15. 2. Problem Solving Treatments (PS) N=12.
Outcomes	Leaving the study early. Mental state: BPRS, PSE. Unable to use ‐ Quality of life: SFS (no data reported). Mental state: PAS (no data reported).
Notes	23 completed 6 month follow up. 3 from CSE and 1 from PS were lost to follow up The total number of coping strategies used was calculated by summing the positive strategies and subtracting the negative maladaptive strategies Half of each group waited an extra 6 weeks before treatment.
Risk of bias
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

AHIG ‐ Auditory Hallucinations Inventory Guide 
 AHDD ‐ Auditory Hallucinations Daily Diary 
 BPRS ‐ symptom rating scale (Brief Psychiatric Rating Scale) 
 CPT ‐ Continuous Performance Test 
 DHS ‐ Daily Hassles Scale 
 DSM ‐ diagnostic sets of operational criteria (Diagnostic and Statistical Manual of Mental Disorders) 
 DSM‐III ‐ third edition, 1980 
 DSM‐III‐R ‐ third edition, revised, 1987 
 MACC II ‐ Behavioural Adjustment Scale 
 NGIS ‐ Nurses Global Impression Scale 
 NOSIE ‐ behaviour rating scale (Nurses´ Observation Scale for Inpatient Evaluation) 
 PAS‐ Psychiatric Assessment Scale 
 PAR‐Q ‐ Physical Activity Readiness Questionnaire 
 PSE‐ Present State Examination 
 SD ‐ a measure of dispersion (standard deviation) 
 SFS‐ Social Functioning Scale

Characteristics of excluded studies [ordered by study ID]

Study	Reason for exclusion
Aldavoud 1989	Allocation: randomised. Participants: people with schizophrenia. Interventions: biofeedback vs verbal feedback following relaxation, not distraction techniques.
Alter 1993	Allocation: randomised. Participants: inpatients with schizophrenia. Interventions: coping skills training vs avoidance training, not distraction techniques.
Andres 2000	Allocation: not randomised, allocated alternately by order of admission.
Apter 1978	Allocation: randomised. Participants: people with psychosis. Interventions: individual movement therapy vs group movement therapy, not distraction techniques.
Beal 1977	Allocation: randomised. Participants: people with chronic schizophrenia. Interventions: remotivation group vs social discussion group vs activity group, not distraction techniques.
Bechdolf 2002	Allocation: randomised. Participants: people with schizophrenia or schizo affective disorder. Interventions: coping orientated group therapy vs psychoeducation, not distraction techniques.
Drury 2000	Allocation: randomised. Participants: inpatients with non‐affective psychosis. Interventions: cognitive therapy (individual and group) vs family psychoeducation vs lifeskills programmes, not distraction techniques.
Gallagher 1995a	Allocation: randomised, participants were subjected to a number of conditions in a random order. Participants: male outpatients with schizophrenia. Interventions: various card sorting activities. Outcomes:duration, loudness and clarity of hallucinations, no usable data.
Gallagher 1995b	Allocation: randomised, participants were allocated to a number of conditions in a random order. Participants: male outpatients with schizophrenia. Interventions: dealing cards under conditions with pressing a button. Outcomes: severity of halluciantions were measured, no usable data.
Gelkopf 1993	Allocation: not randomised, two wards given different interventions, unclear how people were allocated to each ward.
Glicksohn 2000	Allocation: not randomised, all subjects participated in Stroop test.
Granholm 2001	Allocation: randomised. Participants: middle aged/ older adults with schizophrenia. Interventions: thought challenging plus regular pharmacology vs regular pharmacology, not distraction techniques.
Haddock 1998	Allocation: randomised. Participants: people with schizophrenia. Interventions: distraction techniques and focussing techniques. Outcomes: no usable data, not clear how many were allocated to each group.
Hayes 1991	Allocation: randomised. Participants: day patients with schizophrenia. Interventions: activity therapy vs social skills training, not distraction techniques.
Jenner 1999	Allocation: randomised. Participants: people with schizophrenia. Interventions: cognitive behavioral therapy plus neuroleptic drugs vs neuroleptic drugs, not distraction techniques.
Klingberg 1999	Allocation: randomised. Participants: people with schizophrenia. Interventions: psychoeducational medication management vs cognitive psychotherapy vs key person counselling, not distraction techniques.
Kremer 1984	Allocation: randomised. Participants: people with chronic schizophrenia. Interventions: cooking vs craft vs sensory awareness. Outcomes: evaluation of usefulness/ enjoyment of activities.
Lecomte 1999	Allocation: randomised. Participants: people with schizophrenia. Interventions: self esteem module vs control with no module, not distraction techniques.
McLatchie 1981	Allocation: randomised. Participants: patients at a psychiatric hospital centre. Interventions: problem solving group therapy vs relaxation training. Outcomes: problem solving ability.
Pelham 1993	Allocation: randomised. Participants: clients in a psychiatric rehab program. Interventions: aerobic vs non‐aerobic exercise. Outcomes: weight loss, levels of fitness focus on investigation.
Provenza 1990	Allocation: not randomised, people selected for experimental and control groups dependant on clinical observations.
Schnore 1961	Allocation: not randomised, control group matched to experimental group characteristics.
Shanker 1980	Allocation: randomised. Participants: people with schizophrenia in hospital. Interventions: varying matrix patterns, not distraction techniques.
Tarrier 1996	Allocation: randomised. Participants: people with schizophrenia. Interventions: coping training vs problem solving, not distraction techniques.
Van 1982	Allocation: randomised. Participants: people with schizophrenia. Interventions: anxiety management vs relaxation. Outcomes: anxiety levels focus of investigation, no usable data.
Velligan 1995	Allocation: not randomised, control group matched to experimental group based on clinical observations.
Wahass 1997	Allocation: not randomised, controlled trial ‐ 3 people.
Wiersma 2000	Allocation: randomised. Participants: people with schizophrenia experiencing auditory hallucinations. Interventions: cognitive therapy vs coping training, not distraction technique.
Wirshing 2000	Allocation: randomised. Participants: people with schizophrenia. Interventions: psychoeducational class vs illness education class, not distraction technique.
Wotman 1999	Allocation: randomised. Participants: people with schizophrenia or schizoaffective disorder experiencing auditory hallucinations. Interventions: ear plugs vs no ear plugs. Outcomes: no usable data.

Characteristics of ongoing studies [ordered by study ID]

Adams 2000.

Trial name or title	A randomised control trial of the of the effects of an exercise programme on the symptomology of people with schizophrenia. The pilot study.
Methods
Participants	Forensic inpatients with schizophrenia.
Interventions	1. Therapeutic exercise. 2. Cooking ‐ control.
Outcomes	Physical fitness and well being.
Starting date	Not known.
Contact information	None given.
Notes	Allocation: randomised. 20 patients to be allocated.

Haddock 2000.

Trial name or title	Evaluation of a family support and cognitive‐behavioural treatment service for recent onset schizophrenia sufferers with substance misuse problems.
Methods
Participants	People with dual diagnosis of schizophrenia and drug/alcohol misuse problems.
Interventions	1. Cognitive‐behavioural therapy including distraction. 2. Standard care.
Outcomes	General effect: GAF, GHQ, HoNOS. Mental state: PANSS.
Starting date	2000.
Contact information	Dr Gillian Haddock Lees Street Centre Clinical Psychology Therapy Centre Lees Street Ashton‐under‐Lyne OL6 8NU
Notes	Allocation: randomised.

GAF ‐ Global Assessment of Functioning 
 GHQ ‐ General Health Questionnaire 
 HoNOS ‐ Health of the Nation Outcome Scale 
 PANSS ‐ Positive and Negative Symptom Scale

Contributions of authors

Charlotte Crawford‐Walker ‐ instigated the review, protocol formulation, searching, trial selection, data extraction, report writing.

Adrain King ‐ helped with the review, independantly assessed the trials for inclusion.

Sally Chan ‐ assisted with supervision of the review.

Sources of support

Internal sources

• Hull and East Yorkshire Community NHS Trust, UK.

• Chinese University of Hong Kong, Hong Kong.

External sources

• West Yorkshire Workforce Development Confederation, UK.

Declarations of interest

Charlotte Crawford‐Walker would like to find evidence that distraction techniques are a successful way of helping people manage their schizophrenic illness.

Edited (no change to conclusions)