University of Newcastle upon Tyne, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK.
Fulbourn Hospital,Cambridge CB1 5EF,UK.
Correspondence: E-mail: douglas.turkington{at}ncl.ac.uk
Correspondence: E-mail: peter.mckenna{at}virgin.net
Edited and introduced by Mary Cannon, Kwame McKenzie and Andrew Sims.
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INTRODUCTION |
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FOR |
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Cognitivebehavioural therapy has been well tested in relation to the treatment of residual symptoms of schizophrenia and is of proven efficacy and cost-effectiveness (National Institute for Clinical Excellence, 2002). Other psychological treatments (supportive therapy and befriending) also seem to have an effect at the end of 20 sessions. However, CBT is the only psychological treatment in chronic schizophrenia with proven durability at short-term follow-up (Gould et al, 2001). It has also recently been proven in a pragmatic randomised controlled trial that the benefits of CBT translate into community settings (Turkington et al, 2002). In this study, community psychiatric nurses were trained in CBT for schizophrenia over a 10-day period and given weekly supervision. They used CBT effectively in terms of insight improvement and reduction in overall symptoms and depression. Cognitivebehavioural therapy would appear to be very acceptable to patients, with an average rate of drop-out across studies of 1215%. The therapy would also appear to be safe, with no evidence of increasing suicidal ideation, agitation or violence in any study to date.
It is, however, certainly true that, for certain types of psychotic symptoms (e.g. command hallucinations linked to trauma, or systematised or grandiose delusions), distressing affects can emerge as the psychotic symptom is worked with. Brief CBT is often not indicated for such presentations and 2050 sessions with a CBT expert can be indicated.
Future progress will depend on the further development of psychological models of psychotic symptom onset and maintenance and on the development of more refined treatment manuals. Cognitivebehavioural therapy would appear to have the possibility of an enhanced effect when given with cognitively sparing antipsychotic medication (Pinto et al, 1999) or when combined with cognitive remediation. It will be very interesting to note any functional imaging changes through a course of CBT when psychotic symptoms are improving. Similarly, CBT for bipolar disorder has been shown to reduce relapse and improve illness management through early-signs monitoring. Cognitivebehavioural therapy has proven efficacy, durability and cost-effectiveness in psychosis. Why would any general psychiatrist not wish to have a member of their community team trained to deliver CBT to their patients with psychosis and their carers?
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AGAINST |
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From the outset, CBT for schizophrenia has been associated with claims made on the basis of evidence that is less rigorous than in the rest of medicine. For example, one of most widely quoted trials in support of its effectiveness is that of Kuipers et al (1997). Yet this employed neither a control intervention nor blind evaluations. It found a significant effect of cognitive therapy on overall scores on the Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962) but not on delusions, hallucinations or any other measure of symptoms or functioning.
Of the 13 trials of CBT in schizophrenia included in a Cochrane meta-analysis (Cormac et al, 2002), only four used a control intervention and were carried out under blind conditions. These are shown in Table 1, together with a more recent study by Lewis et al (2002). The two largest studies (Sensky et al, 2000; Lewis et al, 2002) showed no significant advantage for CBT over the control intervention. Tarrier et al (1999) found a non-significant difference in favour of CBT on a score based on delusions and hallucinations, and no difference for negative symptoms. One of two small studies (Turkington & Kingdon, 2000) found a significant benefit for the CBT group, but the other (Haddock et al, 1999) had findings in the opposite direction. The pooled effect size for these studies is close to zero.
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If CBT were a drug, these studies would have been sufficient to consign it to history. As yet, however, this has not happened and advocates of the treatment continue to plead their case. Thus, despite finding no advantage over befriending at the end of their 9-month study period, Sensky et al (2000) made the extraordinary statement that [c]ognitivebehavioral therapy is effective in treating negative as well as positive symptoms in schizophrenic patients resistant to standard antipsychotic drugs. Lewis et al (2002) felt able to conclude that CBT speeded remission from acute symptoms in early schizophrenia, even though a significant difference between the two treatments was found only for auditory hallucinations, and not for delusions, positive symptoms or total symptom scores.
Finally, on the basis of a significant improvement over befriending that appeared 9 months after the end of treatment, Sensky et al (2000) have also argued that CBT leads to sustained clinical improvement in schizophrenia. However, this finding has to be balanced against the results of the Cochrane meta-analysis (Cormac et al, 2002), which found no convincing evidence of an effect in the longer term.
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REFERENCES |
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Gould, R. A., Mueser, K.T., Bolton, E., et al (2001) Cognitive therapy for psychosis in schizophrenia: an effect size analysis. Schizophrenia Research, 48, 335342.[CrossRef][Medline]
Haddock, G., Tarrier, N., Morrison, A. P., et al (1999) A pilot study evaluating the effectiveness of individual inpatient cognitivebehavioural therapy in early psychosis. Social Psychiatry and Psychiatric Epidemiology, 34, 254258.[CrossRef][Medline]
Kingdon, D. & Turkington, D. (1994) CognitiveBehavioural Therapy of Schizophrenia. New York: Guilford.
Kuipers, E., Garety, P., Fowler, D., et al (1997) LondonEast Anglia randomised controlled trial of cognitivebehavioural therapy for psychosis. I: Effects of the treatment phase. British Journal of Psychiatry, 171, 319327.[Abstract]
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