ORIGINAL RESEARCH: EMPIRICAL RESEARCH

QUANTITATIVE

The effects of auditory hallucination symptom management

programme for people with schizophrenia: a quasi-experimental design
Chiu-Yueh Yang, Tien-Hao Lee, Su-Chen Lo & Jason W. Beckstead
Accepted for publication 6 July 2015

Correspondence to C.-Y. Yang:

e-mail: cyyang3@ym.edu.tw
Chiu-Yueh Yang
Department of Nursing, National
Yang-Ming University, Taipei, Taiwan
Tien-Hao Lee
Department of Nursing, Shu-Zen Junior
College of Medicine and Management,
Kaohsiung, Taiwan
Su-Chen Lo
Department of Nursing, Bali Psychiatric
Center, Ministry of Health and Welfare,
New Taipei City, Taiwan
Jason W. Beckstead
College of Nursing, University of South
Florida, Tampa, Florida, USA

Y A N G C . - Y . , L E E T . - H . , L O S . - C . & B E C K S T E A D J . W . ( 2 0 1 5 ) The effects of

auditory hallucination symptom management programme for people with
schizophrenia: a quasi-experimental design. Journal of Advanced Nursing 71(12),
28862897. doi: 10.1111/jan.12754

Abstract
Aim. To examine the effectiveness of an auditory hallucinatory symptom
management programme in patients with chronic schizophrenia.
Background. Thirty per cent of chronic schizophrenia patients are still disturbed
by hallucinations, which influence their psychological and social well-being, even
when they take medication regularly.
Method. Fifty-eight people experiencing schizophrenia with auditory hallucinations
from psychiatric inpatient rehabilitation wards in northern Taiwan participated in
the study, with 29 in the experimental group and 29 in the control group. The
experimental group received an auditory hallucinatory symptom management
programme. The auditory hallucinatory symptom management programme
involved 60-minute meetings once a week, for a total of 10 meetings. The control
group received routine care, which included free recreation for 40 minutes and
walking for 20 minutes. The participants completed three self-report
questionnaires: the Beck Depressive Inventory II, the Beck Anxiety Inventory and
the Characteristics of Auditory Hallucinations Questionnaire. Data were collected
at baseline, immediately following the intervention and at 3 months and 6 months
post intervention. Data collection occurred between March 2010May 2013.
Results. The experimental group showed a non-significant improvement in
anxiety symptoms over time. Generalized estimating equations revealed that the
experimental group achieved a greater drop in Characteristics of Auditory
Hallucinations Questionnaire score than the controls at three and 6 months post
intervention. Beck Depressive Inventory II scores in the experimental group
(n = 29) had significantly improved in 3 months.
Conclusion. The auditory hallucinatory symptom management programme seems
to be effective in improving auditory hallucinatory symptoms and depressive
symptoms in patients with schizophrenia.
Keywords: anxiety symptoms, auditory hallucinations, depressive symptoms,
nursing, schizophrenia, symptom management

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JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH QUANTITATIVE Symptom management programme for auditory hallucinations

Why is this research or review needed?

Some patients with chronic schizophrenia who are on regular medication do not respond well to drugs. As a result,
certain patients are still disturbed by auditory hallucinations, which affect their affective symptoms.
Auditory hallucination symptom management has been
widely employed in psychiatric settings in the USA and
Thailand to reduce auditory hallucinations, anxiety and
depressed mood.
In Taiwan, antipsychotic medications continue to be a critical intervention to reduce auditory hallucinatory symptoms
in people with schizophrenia. Very few non-medicinal
interventions have been employed to alleviate the symptoms of auditory hallucinations.

What are the key findings?

When administered to patients with schizophrenia at psychiatric inpatient rehabilitation wards, the auditory hallucination symptom management programme resulted in
significant improvement of depressive symptoms at 3
months post intervention
The patients auditory hallucinatory symptoms significantly
improved from pre- to post-programme and this improvement was maintained for at least 6 months after the conclusion of the programme.

How should the findings be used to influence policy/

practice/research/education?
Auditory hallucination symptom management programmes
should be considered as an intervention for patients with
schizophrenia to reduce auditory hallucinatory and depressive symptoms.
The results of this study can provide a reference guide for
psychiatric nurses, as an awareness of auditory hallucination symptom management would enhance their professional competence.

Introduction
In recent years, biological psychiatry has become a major
trend in mental health care. Atypical psychotropic drugs
have been widely used by psychiatrists, enabling the stabilization of symptoms in patients with schizophrenia for
whom typical psychotropic drugs are ineffective. However,
50-60% of patients with chronic schizophrenia who are on
regular medication do not respond well to drugs (Ballon &
Lieberman 2010). As a result, certain patients are still
disturbed by auditory hallucinations, which affect their
emotional states (Lung et al. 2009). The harmful effects of
auditory hallucinations include aggressive behaviour (Cut 2015 John Wiley & Sons Ltd

cliffe & Riahi 2013), suicidal behaviour (Hor & Taylor

2010) and suicidal ideation (Chiang et al. 2013). In addition
to suicide and aggression, auditory hallucinations may cause
patients to display bizarre behaviour, social withdrawal, or
reduced social interaction (Delespaul et al. 2002).
Psychiatric professionals must develop strategies to
reduce the negative effects of symptoms in patients who are
on regular medication but who are still disturbed by auditory hallucinations. Multiple intervention strategies, such as
cognitive behavioural therapy (McLeod et al. 2007) and
other behavioural strategies (Buccheri et al. 2007), have
been employed to improve the quality of life of patients
with auditory hallucinations worldwide. Although Tsai and
Chen (2006) investigated self-care symptom management
strategies for auditory hallucinations and the strategies
adopted by patients to cope with related symptoms, intervention strategies to alleviate the symptoms of auditory hallucinations have not been proposed in Taiwan.

Background
In the 1990s, the School of Nursing and Health Professions
at the University of California, San Francisco (UCSF) began
developing symptom management strategies to help individual patients cope with their symptoms and combined these
symptom management strategies with behavioural strategies
in group settings (Buccheri et al. 1996). Dodd et al. (2001)
described symptom management as a dynamic process
where management strategies are constantly modified
according to factors such as outcomes, people, environment, health and illness. Dodd et al. (2001) divided symptom management into three components: symptom
experience, symptom management strategies and symptom
outcomes. After identifying their symptoms, patients measure the severity of their symptoms and the effects of their
symptoms on their daily lives to further determine whether
an active response and management are required. Once they
decide to manage their symptoms, patients then determine
what management strategies to use and how, when, where,
under what conditions and to what extent these management strategies should be employed. After treating their
symptoms through these management strategies, patients
finally evaluate the effectiveness of the management strategy
by considering their physiological function, self-care, economic benefits, quality of life and emotional states. Fatality
rates are also considered. The three components of symptom experience, symptom management strategies and symptom outcomes constantly influence each other due to the
effects of factors such as people, environments, health and
illness, eventually reaching a dynamic balance.
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Some psychiatric specialists have employed symptom

management strategies with patients with auditory hallucinations and have unanimously reported that the strategies
were effective in reducing the frequency of auditory hallucinations (Trygstad et al. 2002, Buccheri et al. 2007,
Kanungpairn et al. 2007) and anxiety and depressive symptoms (Trygstad et al. 2002). Although these studies
obtained excellent results, the research either adopted a
one-group pretestposttest design (Trygstad et al. 2002,
Buccheri et al. 2004, 2007) or used a small sample size
(Kanungpairn et al. 2007).
The outcome indicators for symptom management strategies or other intervention measurements can be roughly categorized into: (a) characteristics directly related to the
auditory hallucinations, such as the frequency and loudness
of the voices and a persons belief in the perceived voices
(Trygstad et al. 2002, McLeod et al. 2007); and (b) problems caused by the auditory hallucinations, such as depression, anxiety, distress and impaired social functions
(Trygstad et al. 2002, Wykes et al. 2005, McLeod et al.
2007). In addition to the effects of the auditory hallucinatory symptom management (AHSM) programme on the
severity of the auditory hallucinations induced by
schizophrenia, this study explored the effectiveness of the
programme on reducing emotional symptoms.

The study

Participants and recruitment

The participants recruited in this study were: (a) diagnosed
with schizophrenia and symptoms of auditory hallucinations according to the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV); (b) without
intellectual disability or organic brain syndromes; (c) on
regular antipsychotic medication for more than 3 months;
(d) willing to participate in the study and sign an informed
consent document; and (e) literate and without verbal communication problems.
The participants were recruited from a psychiatric centre
in northern Taiwan using convenience sampling. The participants were assigned to the experimental group or the control group based on their desired treatment. The
experimental group, which consisted of participants who
provided informed consent regarding attendance of the
AHSM programme group, was divided into three subgroups
by wards. Nine, eight and 12 participants were in each of
the three subgroups. Each subgroup met for a 60-minute
group programme once a week, for a total of 10 times. In
the control group, participants did not participate in any
intervention programme but underwent routine care for
10 weeks after baseline measurements. Routine care
included free recreation for 40 minutes and walking for
20 minutes. Twenty-nine participants in the control group
completed the whole course of the study. The flowchart for
the participants in this study is diagrammed in Figure 1.

Aim
The aim of this study was to compare the participants
levels of auditory hallucinations, anxiety symptoms and
depressive symptoms before and after receiving routine
treatment and participating in the AHSM programme.

Design
A quasi-experimental design was employed to evaluate the
effectiveness of group AHSM treatments for patients who
were on regular medication and exhibited combined symptoms of auditory hallucinations and schizophrenia. The participants were divided into an experimental group and a
control group according to their desired treatment. Both
participant groups answered an outcome assessment questionnaire. The experimental group underwent a 10-week
AHSM course and the control group underwent 10 weeks
of routine treatment. At the 10th week, all of the participants were required to respond to an outcome assessment
tool. Afterwards, they were followed up once every
3 months for a total of 6 months.
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Auditory hallucinatory symptom management

programme
The AHSM programme group discussions were held for
1 hour after dinner. During the discussions, the group
members were encouraged to share their auditory hallucination experiences. In addition to teaching management
strategies to the group, opportunities were provided for the
members to practice these strategies. The three rounds of
discussions were led by the three authors of this study; the
third author served as a constant collaborative leader, the
second author served as the leader of the first two rounds
and the first author served as the leader of the third round.
The discussions were conducted by following the operational procedure proposed by Professor Buccheri from
UCSF regarding symptom management strategies for auditory hallucinations. The 10-week AHSM course included
the following strategies: (a) self-monitoring; (b) distracting
oneself from the voices by doing other things; (c) talking
with someone; (d) reading; (e) listening to music; (f) watching television; (g) using earplugs or covering ones ears; and
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JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH QUANTITATIVE Symptom management programme for auditory hallucinations

Eligible due to auditory hallucination problem (n = 189)

Signed informed consent (n = 64)

Withdrawal of consent (n = 2)
Failure to meet diagnostic criteria (n = 1)
Denial of auditory hallucination problem (n
Group assignment based on participants' choice

Experimental group
(n = 29)
AHSM programme
Assignment by wards
Group I (n = 8)
Group II (n = 9)
Group III (n = 12)

Baseline
data collection

Control group
(n = 29)
Routine care

Experimental group
(n = 29)

Postintervention
data collection

Control group
(n = 29)

Experimental group
(n = 29)

3-month
follow-up

Control group
(n = 29)

Experimental group
(n = 29)

6-month
follow-up

Control group
(n = 29)

Figure 1 Recruitment and participant flow chart.

(h) doing relaxation exercises such as taking deep breaths,
relaxing the muscles or listening to relaxing music. After
the course, we conducted a follow-up on the participants
once every 3 months for 6 months to assess the outcome
indicators.

Data collection
The psychiatrists, nursing staff and relevant professionals of
the rehabilitation units were informed of the objectives and
content of the study. Eligible participants were suggested by
the nursing staff or were selected by the review of medical
records. The demographics and data of the participants
were used for the purposes of the study only. The participants answered pre-test questionnaires before the study formally began. After the 10-week conventional treatment and
AHSM course, data were again collected at week 10, after
which a follow-up was conducted every 3 months for the
next 6 months. Three AHSM programmes, with the corresponding data collection, were conducted from March
2010May 2013.
2015 John Wiley & Sons Ltd

Ethical considerations
Approval from the psychiatric centre (IRB981205-2, IRB
1010328-01) and the Joint Institutional Review Board
(JIRB 11-S-011) were obtained prior to data collection.
Potential participants were then informed of the objectives
of the study and their right to unconditionally withdraw at
any time without harming their medical rights. Should any
symptoms or discomfort appear during the study, medical
personnel would provide proper care, or the participants
could temporarily or permanently withdraw from the study.
Anonymously coded questionnaires were distributed with
the guarantee that the collected data would remain confidential, would only be used for the study and would be
sealed and archived when the study was concluded to protect the rights of the participants.

Measures
The measurement tools adopted in this study included
demographic data and three outcome measures: the Beck
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C.-Y. Yang et al.

Anxiety Inventory (BAI), the Beck Depression Inventory II

(BDI-II) and the Characteristics of Auditory Hallucinations
Questionnaire (CAHQ), which are described as follows:
(a) Demographic data were collected from medical records

and interviews. The demographic data included age,

gender, years of education, duration of disease, number
of hospitalizations and chlorpromazine (CPZ) equivalents (Andreasen et al. 2010, Sweileh et al. 2014).
(b) CAHQ: By answering the seven items in the questionnaire, the respondents reported the negative characteristics of the auditory hallucinations they experienced
during the past 24 hours. A 6-point scale (0-5) was
used, where the highest score denotes the most severe
symptoms. Originally developed by Buccheris research
team (Trygstad et al. 2002), this questionnaire was
translated into Chinese by Lee et al. (2011), who also
tested the reliability and validity of the Chinese version.
The results of factor analysis indicated that the seven
questions constituted a factor with an explained variance of 61
02%, an internal consistency (Cronbachs
alpha) of 0
889 and an intra-class correlation testretest
reliability of 0
96.
(c) BDI-II: Beck et al. (1996) revised the BDI to render it
consistent with the criteria enumerated in the DSM-IV
for the diagnosis of mental disorders. The BDI-II is composed of 21 questions where respondents self-evaluate
their symptoms during the past 2 weeks. A 4-point scale
(0-3), with a total test score range of 0-63, was adopted
to rate symptom severity. In the version used in Taiwan,
16/17 is the cut-off point used to diagnose depressive
disorder, with an internal consistency (Cronbachs
alpha) of 0
94 and a split-half reliability of 0
91. Both
the validity of the version in Taiwan and the criterion
validity of the Hamilton Rating Scale for Depression
(HRSD) reached 0
71 (Lu et al. 2002).
(d) BAI: Developed by Beck et al. (1988), this inventory
measures the levels of anxiety in adolescents and adults
based on the diagnosis criteria in the DSM-III or DSMIII-R. The inventory includes 21 questions. Each answer
is scored on a scale from 0-3 and the total score ranges
from 0-63. The test results of the version used in Taiwan are as follows: correlation with Hamilton Anxiety
Rating Scale = 0
72, internal consistency (Cronbachs
alpha) = 0
95 and Guttman split-half coefficient = 0
91.
In this version, the cut-off score used to diagnose anxiety disorder is 13/14 (Che et al. 2006). As a simple
inventory that can be typically completed within 5 minutes, the BAI is widely employed for clinical assessment
and research.

2890

Data analysis
This study employed SPSS Windows 18
0 to analyse the collected data. A t-test or v2 test was conducted to analyse differences in the demographics and outcome indicator
variables between the two groups of participants prior to the
intervention. Subsequently, a paired t-test was adopted to
compare the assessment data obtained from the same group
before and after the intervention and at the 3-month and 6month follow-ups. Finally, a generalized estimating equation
(GEE) with an exchangeable correlation structure was used
to analyse the effects of group and time and the group by
time interaction. Age, gender, number of hospitalizations,
duration of disease, years of education and CPZ equivalents
at baseline were controlled. Effect size calculations were
based on the mean prepost change in the experimental
group minus the mean prepost change in the control group,
divided by the pooled baseline standard deviation (Morris
2007). An effect size of 0
2 was considered small, 0
5 moderate and 0
8 large (Sullivan & Feinn 2012).

Results
Participants demographic and clinical characteristics
This study involved 58 participants: 29 in the experimental
group and 29 in the control group. The demographics and
outcome variables of the two groups are presented in
Table 1. Homogeneity test results showed that no differences existed between the two groups prior to the intervention. In both groups, the average age of the participants
was 46
83 (SD 8
37), with an initial age range of 31-65. The
average number of years of education was 11
29 (SD 2
00),
the average number of hospitalizations was 4
88 (SD 3
58)
and the average number of years since illness onset was
22
64 (SD 8
62). Based on the CPZ equivalents, a standardized measure for medication doses, there was no difference
in the amount of medication between the two groups of
participants at any of the aforementioned four points in
time and the t-test results indicated that no significant differences existed between the two groups.

Effects of the symptom management programme

This study used three outcome indicators. Figure 2 shows
the pattern of results for each outcome. Tables 24 illustrate the differences in the changes within and between the
two groups during the different phases of treatment
and results of GEE adjusting for the effects of the six
covariates.

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Table 1 Comparisons of the demographic data of the experimental (EG) and control (CG) groups at baseline (N = 58).
Variables

Sex
Female
Male

CG (n = 29)
n

EG (n = 29)
n

13
16

10
19

M(SD)
Age
Number of Hospitalizations
Years of Education
Duration of disease
CAHQ
BAI
BDI
CPZ Equivalents (T0)
CPZ Equivalents (T1)
CPZ Equivalents (T2)
CPZ Equivalents (T3)

46
38
5
52
11
28
23
34
16
66
17
59
14
79
529
14
499
66
501
38
511
90

0
468

M(SD)
(8
08)
(4
66)
(2
02)
(8
09)
(9
00)
(12
09)
(11
37)
(295
91)
(309
65)
(308
06)
(303
85)

47
28
4
24
11
31
21
93
20
45
16
07
16
00
621
34
623
66
618
48
606
41

v2

(8
78)
(1
88)
(2
02)
(9
20)
(5
42)
(14
25)
(11
45)
(204
80)
(208
71)
(205
23)
(200
49)

0
421

0
405
1
367
0
065
0
621
1
945
0
437
0
403
1
380
1
788
1
704
1
398

0
687
0
180
0
948
0
537
0
058
0
664
0
689
0
173
0
079
0
094
0
168

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 primary outcome indicator of this study. In the control group,
the CAHQ scores obtained before and after intervention
did not differ and the CAHQ scores obtained at the 3month follow-up assessments were lower than those
obtained before the intervention (P < 0
01). After the
effects of the six covariates were controlled, the GEE results
showed that the CAHQ scores of the experimental group
had improved significantly more than those of the control
group; the interaction between group and time indicated
that compared with before the intervention, the CAHQ
scores of the experimental group had decreased significantly
more than those of the control group at 3 months
(P = 0
015) and 6 months (P = 0
004) after the intervention. The regression coefficients for the various interaction
terms show the amount of change in the intervention group
over and above the amount of change in the control group,
controlling for covariates. The size of these effects (as
indexed by Cohens d) are also shown in the table and are
in the moderate to large range.
Table 3 and Fig 2b display one of the secondary outcome
indicators in this study, anxiety symptoms. At 3 months
after the intervention, the BAI scores of the control group
were significantly lower than the baseline and at the
3-month and 6-month follow-ups, the BAI scores of the
experimental group were lower than those before the intervention (P < 0
05). The GEE results showed that the
changes over time did not differ significantly between the
two groups when the effects of the six covariates were controlled.
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Table 4 and Fig 2c show another one of the secondary

outcome indicators in this study, depressive symptoms.
There were not any differences in the BDI scores of the
control group at any of the four phases, whereas the scores
of the experimental group at 3 and 6 months after the
intervention were lower than those before the intervention
(P < 0
01). The GEE results indicated that there were not
any differences between the experimental and control
groups before the intervention when the effects of the six
covariates were controlled (P = 0
539). The interaction
between group and time showed that compared with before
the intervention, the BDI scores of the experimental group
had decreased significantly more (B = 4
77) than those of
the control group at 3 months after the intervention
(P = 0
017). This additional improvement is a moderate
effect size.

Discussion
This study explored the effectiveness of an intervention
based on adoption of the AHSM programme. The effectiveness was assessed 6 months after the conclusion of the programme, using CAHQ score as the primary outcome
indicator and BAI and BDI scores as secondary indicators.
The results indicated that the experimental group experienced greater improvement in CAHQ score than the control
group. Regarding depressive symptoms, at the follow-up
3 months after the conclusion of the AHSM intervention
programme, the experimental group exhibited greater
improvement in depressive symptoms than the control
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C.-Y. Yang et al.

(a) CAHQ
21
20

Experimental
Control

2045

19
18
17
16

1666

1652
1441

15
14

1476

1300

13
12

1259

11

T0

T1

1279

T2

T3

(b) BAI
20

Experimental
Control

1759

18

1562

16

1521

1607
14

1283
1362

12

893

10

1062

8
6

T0

T1

T2

T3

(c) BDI
19

Experimental
Control

1772
17

1600
1776

15
1479
13

1186
1311

11
1107
825

9
7

T0

T1

T2

T3

Figure 2 Between-group comparison of changes in (a) CAHQ

scores at different times, (b) anxiety symptoms at different times
and (c)depressive symptoms at different times. T0: baseline; T1:
post intervention; T2: 3-month follow-up; and T3: 6-month
follow-up.

2892

group; however, the interaction between group and time

regarding the level of improvement in anxiety symptoms
was not significant.
The participants in the control group showed non-significant changes in CAHQ score post intervention and at the
6-month follow-up and medium-to-large effect sizes were
found in favour of the AHSM programme group, with a
significant effect of group on the decrease in CAHQ score
at the two follow-ups. The results of this study, that an
AHSM programme effectively improved CAHQ scores, is
consistent with the results of previous studies (Trygstad
et al. 2002, Buccheri et al. 2004). Both the participants of
the study by Buccheri et al. (2004) and of our study had 20
or more years since illness onset and similar ages. However,
the team led by Buccheri focused on outpatients, whereas
this study focused on chronic inpatient rehabilitation wards,
which ensured that the participants in this study were on
medication and under the care of nursing personnel. Therefore, the experimental and control groups in this study were
receiving stable doses of medication when the former participated in the AHSM programme. In the programme, the
participants came to understand their auditory hallucination
symptoms through learning in a group setting, became
aware of the timing when the symptoms appeared and realized the effects of the symptoms on their behaviour, emotions and daily life, enabling them to cope with the
symptoms (Dodd et al. 2001, Trygstad et al. 2002). The
participants also learnt how to employ AHSM strategies to
reduce their auditory hallucinations throughout the programme. This model of symptom management corresponded to that proposed by Dodd et al. (2001).
In the first postintervention assessment (T1), no significant differences were found between the experimental and
control groups. This result could be related to the features
of antipsychotics. It takes several days until patients taking
general antipsychotics begin to feel the effects of the medicine and several weeks are required for them to attain
symptom stability (Sweileh et al. 2014). During the AHSM
programme, both of the groups experienced alleviated
symptoms because of the stabilizing effects of the medicine;
however, 50-60% of patients with chronic schizophrenia
still suffer from symptoms even while on regular medication
(Ballon & Lieberman 2010). In every participant in the
experimental group, the improvement in CAHQ score was
greater than in the control group participants, which was
shown at the 3-month and 6-month postintervention follow-ups. Overall, the CAHQ scores of the experimental
group decreased by approximately 8 points, while the
scores of the control group decreased by two points during
the 9 months of the study, indicating the favourable effects
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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).
Control group (n = 29)

Intervention group (n = 29)

T0
M (SD)

T1
M (SD)

T2
M (SD)

T3
M (SD)

T0
M (SD)

T1
M (SD)

T2
M (SD)

T3
M (SD)

16
66
(9
00)

14
76
(9
39)
1
29

13
00
(9
72)

14
41
(9
24)

20
45
(5
42)

16
52
(5
06)
4
07***

12
59
(6
52)

12
79
(5
31)

t1
t2
t3

3
05**

6
14***
1
59

5
91***

95% Wald CI
B
Intercept
Group
T1
T2
T3
Group 9 T1
Group 9 T2
Group 9 T3
Scale

10
32
3
94
1
90
3
66
2
24
2
03
4
21
5
41
57
88

SE
4
53
1
91
1
44
1
18
1
38
1
73
1
72
1
88

Lower

Upper

1
44
0
19
4
72
5
96
4
95
5
42
7
59
9
10

19
20
7
68
0
93
1
35
0
47
1
35
0
83
1
73

Wald v2
5
19
4
25
1
73
9
65
2
63
1
39
5
96
8
29

P
0
023
0
039
0
189
0
002
0
105
0
239
0
015
0
004

ES

0
267
0
551
0
711

**P < 0
01; ***P < 0
001.

T0: baseline; T1: post intervention; T2: 3-month follow-up; and T3: 6-month follow-up. t1: baseline and postintervention comparison. t2:
baseline and 3-month follow-up comparison. t3: baseline and 6-month follow-up comparison. Covariates: sex, age, years of education, number of hospitalizations, duration of disease and chlorpromazine(100 mg) equivalents (T0).

P value: GEE (generalized estimating equations) model used to test for differences between the intervention group and the control group with
respect to changes from baseline to post intervention and from baseline to the 3- and 6-month follow-ups, adjusted for the six covariates.
ES, effect size, based on between-group differences in mean change and the pooled baseline SD of the two groups.

of the AHSM programme on ameliorating the symptoms of

auditory hallucinations.
In the model of symptom management (Dodd et al.
2001), auditory hallucinations and affective symptoms were
influenced. The Taiwanese scholars Lung and colleagues
(2009) confirmed the effects of auditory hallucinations on
anxiety and depression. People experiencing schizophrenia
with auditory hallucinations tend to exhibit anxiety and
depressive symptoms (Badcock et al. 2011, Hartley et al.
2013). Regarding the effects of the AHSM programme,
anxiety symptoms had improved 3 months after the intervention in both groups, but the interaction between study
group and time was not significant (P = 0
435). This result
may be explained by two reasons: first, the participants had
stayed in the rehabilitation institute for a long period of
time, which increased their familiarity with the surrounding
people and things; and second, 79
2% of patients with
schizophrenia take benzodiazepines in Taiwan (Wu et al.
2011), which have sedative, hypnotic and anxiolytic effects
(Tas et al. 2013). In other words, this group of patients
was under long-term anxiolytic treatment, which is why the
2015 John Wiley & Sons Ltd

improvement of anxiety symptoms did not vary between

the groups.
Depression is a typical comorbid symptom of schizophrenia. Previous research showed that 38
10% of patients with
schizophrenia had comorbid depression (Kim et al. 2006),
which indicates the severity of the problem. The influence
of the AHSM programme on depressive symptoms was
reflected in the different patterns of BDI scores between the
two groups. The BDI scores of the experimental group
decreased within 3 months post intervention, but slightly
increased at the 6-month follow-up. These findings differ
from the results of Buccheri et al. (2004) and Trygstad
et al. (2002), where BDI scores did not vary at the 3-month
and 6-month postintervention follow-ups. In this study, the
affective symptoms of the two groups were slightly aggravated 6 months after the intervention. Life events are
regarded as an important risk factor for depression (Yunming et al. 2012, Wardenaar et al. 2014). The 6-month follow-up occurred approximately 1 month before the Dragon
Boat Festival, a festival that marks family reunions in Chinese societies. For the participants who have been separated
2893

C.-Y. Yang et al.

Table 3 Effects of symptom management on the patients anxiety symptoms at post-intervention and the 3- and 6-month follow-ups
(N = 58).
Control group (n = 29)

Intervention group (n = 29)

T0
M (SD)

T1
M (SD)

T2
M (SD)

T3
M (SD)

T0
M (SD)

T1
M (SD)

T2
M (SD)

T3
M (SD)

17
59
(12
09)

15
62
(14
96)
1
08

12
83
(13
08)

15
21
(14
09)

16
07
(14
25)

13
62
(12
78)
1
11

8
93
(10
71)

10
62
(12
88)

t1
t2
t3

2
76*

2
77*
1
32

3
03**

95% Wald CI
B
Intercept
Group
T1
T2
T3
Group 9 T1
Group 9 T2
Group 9 T3
Scale

33
93
0
47
1
97
4
76
2
62
0
48
2
38
2
83
169
85

SE

11
11
3
41
1
78
1
70
1
93
2
80
3
05
2
61

Lower

Upper

Wald v2

12
17
7
16
5
46
8
08
6
40
5
97
8
35
7
95

55
70
6
23
1
53
1
43
1
15
5
01
3
59
2
30

9
34
0
02
1
21
7
87
1
85
0
03
0
61
1
17

P
0
002
0
892
0
271
0
005
0
174
0
863
0
435
0
280

ES

0
038
0
181
0
235

*P < 0
05; **P < 0
01.

T0: baseline; T1: post intervention; T2: 3-month follow-up; and T3: 6-month follow-up. t1: baseline and postintervention comparison. t2:
baseline and 3-month follow-up comparison. t3: baseline and 6-month follow-up comparison. Covariates: sex, age, years of education, number of hospitalizations, duration of disease and chlorpromazine(100 mg) equivalents (T0).

P value: GEE (generalized estimating equations) model used to test for differences between the intervention group and the control group with
respect to changes from baseline to post intervention and from baseline to the 3- and 6-month follow-ups, adjusted for the six covariates.
ES: effect size, based on between-group differences in mean change and the pooled baseline SD of the two groups.

from their families to receive long-term medical treatment

in a rehabilitation institute, whether they could return home
for the festival may be related to their family members attitudes towards them; therefore, the uncertainty of returning
home for the festival might be a factor that raises the participants levels of anxiety and depression (Carleton et al.
2012).

Limitations
Although the findings need to be considered in the context
of a small sample size and non-randomization, important
group differences in CAHQ score remained significant after
controlling for covariates using GEE. This study had some
limitations. First, the sample size was small and there was a
potential for bias due to the self-selection of participants
into the experimental group. Additional studies need to be
conducted, with larger and more representative samples.
Second, a quasi-experimental design was used, where the
experimental and control groups were not randomly
assigned; this might affect the interpretation of the results.
2894

Therefore, a randomized clinical study on this topic is suggested. In addition, the participants were invited to join the
study from a psychiatric rehabilitation centre; thus, the
findings cannot be generalized to all patients with
schizophrenia
experiencing
auditory
hallucinations.
Although all of the patients in the psychiatric centre had
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
further research. Moreover, to manage the symptoms of
auditory hallucinations, the participants must possess selfmonitoring abilities (Buccheri et al. 2004). Consequently, if
the participants lacked the capabilities to identify their
symptoms, the AHSM programme would not achieve its
maximum potential.

Conclusion
Using a quasi-experimental design, this study aimed to
investigate the short-term effects of the strategies learnt
over a 10-week AHSM programme and the effects that
2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH QUANTITATIVE Symptom management programme for auditory hallucinations

Table 4 Effects of symptom management on the patients depressive symptoms at post-intervention and the 3- and 6-month follow-ups
(N = 58).
Control group (n = 29)
T0
M (SD)
14
79
11
37
t1
t2
t3

T1
M (SD)
17
76
12
64
1
744

Intervention group (n = 29)

T2
M (SD)

T3
M (SD)

T0
M (SD)

T1
M (SD)

T2
M (SD)

T3
M (SD)

11
86
11
02

13
11
14
49

16
00
11
45

14
72
12
22
0
761

8
25
8
35

11
07
9
29

1
916

5
596***
1
253

2
962**

95% Wald CI
B
Intercept
Group
T1
T2
T3
Group 9 T1
Group 9 T2
Group 9 T3
Scale

9
62
1
77
2
97
2
93
2
06
4
24
4
77
3
16
124
00

SE

9
85
2
89
1
67
1
50
1
94
2
35
2
00
2
61

Lower

Upper

9
68
3
88
0
31
5
88
5
86
8
84
8
69
8
27

28
92
7
43
6
24
0
02
1
73
0
36
0
84
1
94

Wald v2
0
95
0
38
3
15
3
80
1
13
3
27
5
67
1
47

P
0
329
0
539
0
076
0
051
0
287
0
071
0
017
0
225

ES

0
287
0
426
0
375

**P < 0
01; ***P < 0
001.

T0: baseline; T1: post intervention; T2: 3-month follow-up; and T3: 6-month follow-up. t1: baseline and postintervention comparison. t2:
baseline and 3-month follow-up comparison. t3: baseline and 6-month follow-up comparison. Covariates: sex, age, years of education, number of hospitalizations, duration of disease and chlorpromazine(100 mg) equivalents (T0).

P value: GEE (generalized estimating equations) model used to test for differences between the intervention group and the control group with
respect to changes from baseline to post intervention and from baseline to the 3- and 6-month follow-ups, adjusted for the six covariates.
ES, effect size, based on between-group differences in mean change and the pooled baseline SD of the two groups.

continued over the subsequent 3-6 months. The outcome

indicators included CAHQ scores, anxiety symptoms and
depressive symptoms. The experimental group demonstrated greater improvement than the control group with
respect to CAHQ and BDI scores (except for the BAI
results), indicating that participation in an AHSM programme is an effective strategy for individual patients who
are on regular medication but still suffer from auditory hallucinations. An AHSM programme might have potential
benefits for patients with schizophrenia experiencing auditory hallucinations when applied in psychiatric rehabilitation centres. This study, however, employed a nonrandomized research design and a small sample size; further
studies using a randomized controlled trial (RCT) design
and a larger sample size would be beneficial.

Acknowledgements
The authors thank professor R Buccheri at the University of
San Francisco, California who has provided the DVD of

2015 John Wiley & Sons Ltd

symptom management and Characteristic of Auditory Hallucination Questionnaire (CAHQ) to this project.

Funding
This study was supported by a grant from Yen Tjing Ling
Medical Foundation CI-100-40.

Conflict of interest
None conflicts of interest to declare by the authors.

Author contributions
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/)]:

substantial contributions to conception and design,

acquisition of data, or analysis and interpretation of
data;

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C.-Y. Yang et al.

drafting the article or revising it critically for important

intellectual content.

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