Cognitive behavioural therapy (CBT) is now a recommended treatment for people with schizophrenia. This approach helps to link the person's distress and problem behaviours to underlying patterns of thinking.
To review the effects of CBT for people with schizophrenia when compared with other psychological therapies.
We searched the Cochrane Schizophrenia Group Trials Register (March 2010) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. We inspected all references of the selected articles for further relevant trials, and, where appropriate, contacted authors.
All relevant randomised controlled trials (RCTs) of CBT for people with schizophrenia-like illnesses.
Studies were reliably selected and assessed for methodological quality. Two review authors, working independently, extracted data. We analysed dichotomous data on an intention-to-treat basis and continuous data with 65% completion rate are presented. Where possible, for dichotomous outcomes, we estimated a risk ratio (RR) with the 95% confidence interval (CI) along with the number needed to treat/harm.
Thirty papers described 20 trials. Trials were often small and of limited quality. When CBT was compared with other psychosocial therapies, no difference was found for outcomes relevant to adverse effect/events (2 RCTs, n = 202, RR death 0.57 CI 0.12 to 2.60). Relapse was not reduced over any time period (5 RCTs, n = 183, RR long-term 0.91 CI 0.63 to 1.32) nor was rehospitalisation (5 RCTs, n = 294, RR in longer term 0.86 CI 0.62 to 1.21). Various global mental state measures failed to show difference (4 RCTs, n = 244, RR no important change in mental state 0.84 CI 0.64 to 1.09). More specific measures of mental state failed to show differential effects on positive or negative symptoms of schizophrenia but there may be some longer term effect for affective symptoms (2 RCTs, n = 105, mean difference (MD) Beck Depression Inventory (BDI) -6.21 CI -10.81 to -1.61). Few trials report on social functioning or quality of life. Findings do not convincingly favour either of the interventions (2 RCTs, n = 103, MD Social Functioning Scale (SFS) 1.32 CI -4.90 to 7.54; n = 37, MD EuroQOL -1.86 CI -19.20 to 15.48). For the outcome of leaving the study early, we found no significant advantage when CBT was compared with either non-active control therapies (4 RCTs, n = 433, RR 0.88 CI 0.63 to 1.23) or active therapies (6 RCTs, n = 339, RR 0.75 CI 0.40 to 1.43)
Trial-based evidence suggests no clear and convincing advantage for cognitive behavioural therapy over other - and sometime much less sophisticated - therapies for people with schizophrenia.
"The forms of psychotherapy usually recommended for persons with SMI is a combination of support and encouragement (Buckley et al., 2007), the use of cognitive techniques that target core symptoms and enhance skills (Jones et al., 2012), and psychoeducation that addresses symptoms, interpersonal and behavioral problems, family issues, medication effects, and medication adherence (McIntosh et al., 2006; Pharoah et al., 2010; Xia et al., 2011). The American Psychological Association (APA) has developed guidelines for psychotherapeutic work with lesbian clients whatever their diagnosis (APA, 2012). "
[Show abstract][Hide abstract] ABSTRACT: The treatment of the seriously mentally ill tends toward homogeneity and often does not focus on unique needs. The aim of this paper is to review the literature specifically relevant to the treatment of sexual minority women in ongoing, outpatient care for serious mental illness (SMI). Medical and psychosocial databases (2000–2015) were searched by entering search terms focused on treatment issues in both qualitative and quantitative studies relevant to this topic. The emphasis in the literature was found to be the extent and severity of minority stress experienced by sexual minority women in psychiatric treatment. Chief therapeutic concerns were: establishment of a therapeutic relationship, conflicts over whether or not to disclose sexual orientation to staff and to family and to fellow patients, depression and self-harm, abuse of substances, difficulties with intimacy, domestic clashes with partners and relatives, and legal questions unique to this population. Women who suffer from SMI, and who, at the same time, belong to an additional stigmatized group, are exposed to doubled discrimination that needs to be recognized and effectively targeted.
Journal of Gay & Lesbian Mental Health 04/2015; 19(3):303-319. DOI:10.1080/19359705.2015.1026016
"This issue is particularly pertinent in the current context because despite the outlined concerns, several rigorous randomized controlled trials of CBTp have emerged since the Wykes et al. (2008) meta-analysis, which have continued to use syndrome-focused measures such as the P-PANSS (Farhall, Freeman, Shawyer, & Trauer, 2009; Lincoln et al., 2012; Peters et al., 2010; Rathod et al., 2013) as the primary indicator of outcome, in addition to relapse rates of psychosis (Garety et al., 2008). The results of these trials have also been generally modest, likely contributing to the conclusions of the latest Cochrane review that the evidence base for CBTp over nonspecific therapies is poor (Jones et al., 2012). The purpose of this article is to review the theoretical and empirical literature relating to cognitive models of psychosis so as to (a) clarify the goals of CBTp according to the various models that have been proposed and (b) evaluate the empirical evidence to date for these goals. "
[Show abstract][Hide abstract] ABSTRACT: Despite a rise in the popularity of cognitive behavior therapy for psychosis (CBTp) over the past 15 years, recent systematic reviews and meta-analyses have concluded that CBTp has only modest effects on psychotic syndrome outcomes and that empirical evidence of its superiority over
other psychosocial treatments is poor (Jones, Hacker, Meaden, Cormac, & Irving, 2012; Wykes, Steel, Everitt, & Tarrier, 2008). However, for some time now, some authors prominent in the development of CBTp have argued the primary goals of CBTp not to be global syndrome reduction but
the amelioration of emotional distress and behavioral disturbance in relation to individual psychotic symptoms (Birchwood & Trower, 2006). A review of the theoretical and empirical literature related to CBTp reveals broad support for this position. Implications and recommendations for
research into the efficacy of CBTp are discussed.
Journal of Cognitive Psychotherapy 02/2015; 29(1). DOI:10.1891/0889-8318.104.22.168
"Understandably, much evidence synthesis has been undertaken but key maintained reviews (Cochrane reviews) have largely been too broad to provide synthesis of evidence for this important sub-group of people. When that is not the case, and synthesis of all trials relevant to those with treatment resistant illness is undertaken and presented, these reviews report salutary lessons on the limited clinical conclusions to be drawn from even the totality of evidence [16-44]. "
[Show abstract][Hide abstract] ABSTRACT: Background
Schizophrenia is a common serious mental health condition which has significant morbidity and financial consequences. The mainstay of treatment has been antipsychotic medication but one third of people will have a `treatment resistant¿ and most disabling and costly illness. The aim of this survey was to produce a broad overview of available randomised evidence for interventions for people whose schizophrenic illness has been designated `treatment resistant¿.Method
We searched the Cochrane Schizophrenia Group¿s comprehensive Trials Register, selected all relevant randomised trials and, taking care not to double count, extracted the number of people randomised within each study. Finally we sought relevant reviews on the Cochrane Library and investigated how data on this subgroup of people had been presented.ResultsWe identified 542 relevant papers based on 268 trials (Average size 64.8 SD 61.6, range 7¿526, median 56 IQR 47.3, mode 60). The most studied intervention is clozapine with 82 studies (total n¿=¿6299) comparing it against other anti-psychotic medications. Cognitive behavioural therapy (CBT), electroconvulsive therapy (ECT), or transcranial magnetic stimulation (TMS) supplementing a standard care and risperidone supplementation of clozapine has also been extensively evaluated within trials. Many approaches, however, were clearly under researched. There were only four studies investigating combinations of non-clozapine antipsychotics. Only two psychological approaches (CBT and Family Rehabilitation Training) had more than two studies. Cochrane reviews rarely presented data specific to this important clinical sub-group.Conclusions
This survey provides a broad taxonomy of how much evaluative research has been carried out investigating interventions for people with treatment resistant schizophrenia. Over 280 trials have been undertaken but, with a few exceptions, most treatment approaches - and some in common use - have only one or two relevant but small trials. Too infrequently the leading reviews fail to highlight the paucity of evidence in this area ¿ as these reviews are maintained this shortcoming should be addressed.
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