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Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? A cautious or cautionary tale?

Academic Division of Clinical Psychology University of Manchester, Education and Research Building (2nd Floor), Wythenshawe Hospital, Manchester M23 9LT, UK.
Behaviour Research and Therapy (Impact Factor: 3.85). 01/2005; 42(12):1377-401. DOI: 10.1016/j.brat.2004.06.020
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ABSTRACT Schizophrenia is a severe and disabling disorder with considerable psychological, social and economic costs. Over the last 15 years there has been a significant development in the use of cognitive behaviour therapy for psychosis (CBTp) in the treatment of schizophrenia, with 20 randomised controlled trials having been published. The majority of this work has been with alleviating medication resistant symptoms in chronic patients, but preliminary work has also been carried out with speeding recovery in acute schizophrenia and in relapse prevention and early intervention. A review of these studies indicates modest effect sizes, with the strongest evidence available for chronic patients. There is evidence that the effect size of the trials is significantly and negatively correlated to their methodological quality. We conclude cautiously that overall there is good evidence for the efficacy and effectiveness of CBTp in the treatment of schizophrenia.

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Available from: Til Wykes, Mar 27, 2015
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    • "To date meta-analyses of CBT for psychosis (CBTp) have evaluated the effects in terms of effects on the frequency and severity of positive symptoms (Gould et al., 2001; Rector and Beck, 2001; Zimmermann et al., 2005; Wykes et al., 2008; NICE, 2009), negative symptoms (Rector and Beck, 2001; Wykes et al., 2008) and general symptoms (Tarrier and Wykes, 2004; NICE, 2009; Jones et al., 2012), but none focussed on and differentiated between auditory hallucinations and delusions . CBTp does not aim to reduce the frequency and severity of symptoms, but rather to reappraise the meaning and purpose of hallucinations and delusions to reduce distress and improve coping in daily life (Birchwood and Trower, 2006). "
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    ABSTRACT: There is no meta-analysis of cognitive behavioural therapy for delusions and hallucinations separately. The aim of this meta-analysis is to evaluate the end-of-treatment effects of individually tailored case-formulation cognitive behavioural therapy on delusions and auditory hallucinations using symptom-specific outcome measures. A systematic search of the trial literature was conducted in MEDLINE, PSYCHINFO and EMBASE. Eighteen studies were selected with symptom specific outcome measures. Hedges' g was computed and outcomes were pooled meta-analytically using the random-effects model. Our main analyses were with the selected studies with CBT using individually tailored case-formulation that aimed to reduce hallucinations and delusions. The statistically significant effect-sizes were 0.36 with delusions and 0.44 with hallucinations, which are modest and in line with other recent meta-analyses. Contrasted with active treatment, CBT for delusions lost statistical significance (0.33), but the effect-size for CBT for hallucinations increased (0.49). Blinded studies reduced effect-size in delusions (0.24) and gained some in hallucinations (0.46). There was no heterogeneity in hallucinations and moderate heterogeneity in delusion trials. We conclude that CBT is effective in treating auditory hallucinations. CBT for delusions is also effective, but the results must be interpreted with caution, because of heterogeneity and the non-significant effect-sizes when compared with active treatment.
    Schizophrenia Research 04/2014; DOI:10.1016/j.schres.2014.03.016 · 4.43 Impact Factor
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    • "One exception was a recent review examining the methodological sophistication of studies of CBT for schizophrenia, which included the examination of the quality of the treatment adherence measures used (Wykes et al., 2008). Thirty-four RCTs were rated on the Clinical Trial Assessment Measure (CTAM; Tarrier and Wykes, 2004), which includes a subscale that assesses whether the therapy is manualized and adherence is measured (called Treatment Description). The maximum score on the subscale is 11 and of the 34 studies included in the review, scores ranged from 0–11, with a mean of 6.4 (SD = 3.5; Wykes et al., 2008). "
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    ABSTRACT: Background: High quality randomized controlled trials (RCT) of psychotherapeutic interventions should ensure that the therapy being tested is what is actually delivered. However, contamination of one therapy into the other, a critical component of treatment adherence, is seldom measured in psychotherapy trials of psychosis. Aims: The aim of the study was to determine whether a purpose-designed measure, the ACE Treatment Integrity Measure (ATIM) could detect therapy contaminations within a controlled trial of cognitive behavioural therapy (CBT) versus Befriending for first-episode psychosis and to compare the ATIM to a more traditional adherence measure, the Cognitive Therapy Scale (CTS). Method: Therapy sessions were audio-recorded and at least one therapy session from 53 of the 62 participants in the RCT was rated by an independent rater using the CTS and ATIM. Results: Ninety-nine therapy sessions were rated. All Befriending sessions and all but three CBT sessions were correctly identified. The ATIM showed that 29 of the 99 (29%) sessions were contaminated by techniques from the other therapy. Within the CBT sessions, 19 of the 51 sessions (37%) were contaminated by one or more Befriending techniques. Of the Befriending sessions, 10 of 48 (21%) were contaminated by ACE techniques. The mean CTS score was higher in the CBT than the Befriending group. Conclusions: The ATIM was able to detect contaminations and revealed more meaningful, fine-grained analysis of what therapy techniques were being delivered and what contaminations occurred. The study highlights the benefit of employing purpose-designed measures that include contamination when assessing treatment adherence.
    Behavioural and Cognitive Psychotherapy 10/2013; 43(03):1-14. DOI:10.1017/S1352465813000921 · 1.69 Impact Factor
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    • "The quality of the studies was assessed with the Clinical Trials Assessment Measure (CTAM) (Tarrier and Wykes, 2004; Wykes et al., 2008). This instrument has been developed to assess the quality of clinical trials of psychosocial interventions and is based on the CONSORT statement. "
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    ABSTRACT: Over the last decade many studies were conducted to assess the feasibility of early detection of people at risk of developing psychosis and intervention to prevent or delay a first psychotic episode. Most of these studies were small and underpowered. A meta-analysis can demonstrate the effectiveness of the efforts to prevent or postpone a first episode of psychosis. A search conducted according the PRISMA guideline identified 10 studies reporting 12-month follow-up data on transition to psychosis, and 5 studies with follow-ups varying from 24 to 48months. Both random and fixed effects meta-analyses were conducted. The quality of the studies varied from poor to excellent. Overall the risk reduction at 12months was 54% (RR=0.463; 95% CI=0.33-0.64) with a Number Needed to Treat (NNT) of 9 (95% CI=6-15). Although the interventions differed, there was only mild heterogeneity and publication bias was small. All sub-analyses demonstrated effectiveness. Also 24 to 48-month follow-ups were associated with a risk reduction of 37% (RR=.635; 95% CI=0.44-0.92) and a NNT of 12 (95% CI=7-59). Sensitivity analysis excluding the methodologically weakest study showed that the findings were robust. Early detection and intervention in people at ultra-high risk of developing psychosis can be successful to prevent or delay a first psychosis. Antipsychotic medication showed efficacy, but more trials are needed. Omega-3 fatty acid needs replication. Integrated psychological interventions need replication with more methodologically sound studies. The findings regarding CBT appear robust, but the 95% confidence interval is still wide.
    Schizophrenia Research 07/2013; 149:56-62. DOI:10.1016/j.schres.2013.07.004 · 4.43 Impact Factor
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