Is there evidence that cognitive 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
Source: PubMed


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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    • "This led to CBTp becoming an established evidence-based treatment for residual psychotic symptoms [1,9] and it has been recommended for routine provision in clinical practice guidelines now for many years [10-12]. With the advent of more rigorous trials and further meta-analyses however, the initial optimism about the impact of CBT has become increasingly cautious [3,13]. Recent reviews have concluded that CBT has only a small effect on symptoms [14,15] and questioned its advantages over other less complex therapies [16,17], although this has also been vigorously debated (e.g., [18,19]). "
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    ABSTRACT: Background Cognitive behavior therapy for psychosis has been a prominent intervention in the psychological treatment of psychosis. It is, however, a challenging therapy to deliver and, in the context of increasingly rigorous trials, recent reviews have tempered initial enthusiasm about its effectiveness in improving clinical outcomes. Acceptance and commitment therapy shows promise as a briefer, more easily implemented therapy but has not yet been rigorously evaluated in the context of psychosis. The purpose of this trial is to evaluate whether Acceptance and Commitment Therapy could reduce the distress and disability associated with psychotic symptoms in a sample of community-residing patients with chronic medication-resistant symptoms. Methods/Design This is a single (rater)-blind multi-centre randomised controlled trial comparing Acceptance and Commitment Therapy with an active comparison condition, Befriending. Eligible participants have current residual hallucinations or delusions with associated distress or disability which have been present continuously over the past six months despite therapeutic doses of antipsychotic medication. Following baseline assessment, participants are randomly allocated to treatment condition with blinded, post-treatment assessments conducted at the end of treatment and at 6 months follow-up. The primary outcome is overall mental state as measured using the Positive and Negative Syndrome Scale. Secondary outcomes include preoccupation, conviction, distress and disruption to life associated with symptoms as measured by the Psychotic Symptom Rating Scales, as well as social functioning and service utilisation. The main analyses will be by intention-to-treat using mixed-model repeated measures with non-parametric methods employed if required. The model of change underpinning ACT will be tested using mediation analyses. Discussion This protocol describes the first randomised controlled trial of Acceptance and commitment therapy in chronic medication-resistant psychosis with an active comparison condition. The rigor of the design will provide an important test of its action and efficacy in this population. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12608000210370. Date registered: 18 April 2008
    BMC Psychiatry 07/2014; 14(1):198. DOI:10.1186/1471-244X-14-198 · 2.21 Impact Factor
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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 · 3.92 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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