February 6, 2014

expert reaction to CBT for schizophrenia

Publishing in The Lancet, UK researchers have investigated whether Cognitive Therapy is a viable alternative to pharmaceutical therapies for schizophrenia. The SMC ran a briefing to present the research to journalists.

Dr Michael Bloomfield, MRC Clinical Research Fellow & Honorary Specialty Registrar in Psychiatry at the MRC Clinical Sciences Centre, said: 

“Schizophrenia is a potentially devastating illness.  Antipsychotic medicines have been used since the 1950s and have been shown to be effective in treating the illness and preventing early death from suicide.  However, current antipsychotic medicines do not work for everyone and can be associated with unpleasant side-effects. 

“More recently, a type of talking treatment called Cognitive Therapy has been shown to be useful in helping people with schizophrenia. However, there are scientific issues with studying how effective talking treatments are for a few reasons including large placebo effects. Generally speaking, in medical research studies you need to compare one treatment with a ‘control’ or placebo treatment.  If you’re testing a new medicine you can compare it to a sugar pill, but it’s more difficult to compare a talking therapy. For example, a recently published report in the British Journal of Psychiatry pooled the results across different research studies and found that the benefits of Cognitive Therapy in schizophrenia were smaller than expected when factors like placebo treatments were taken into account.

“Until now, Cognitive Therapy has been used in addition to antipsychotic medicines and not instead of antipsychotic medicines. This new pilot study published in The Lancet found that Cognitive Therapy is effective for people with schizophrenia who decide not to take antipsychotic medicines. This is welcome and exciting news as it suggests for the first time that there may be an alternative to antipsychotic medicines for people with schizophrenia. However, we must be careful in interpreting the results of this study as it is relatively small study and did not include a placebo treatment. This means that more research is needed into talking treatments for schizophrenia.  As schizophrenia tends to be long-term illness, we also need to answer questions like ‘how long should therapy go on for?’. 

“People who have schizophrenia and want to stop taking antipsychotic medicines are generally advised to always discuss this decision with their doctor.”

Professor Daniel Freeman, MRC Senior Clinical Fellow, University of Oxford, said:

“This is a pioneering study. People with psychosis who do not want to take medication can really benefit from a talking treatment. These sorts of talking treatments are very popular with patients. One hopes that cognitive therapy becomes much more widely available for people with psychosis. Over recent years there have been great strides made in understanding the psychological causes of delusions and hallucinations; clinical trials like this one show how the knowledge is being used to develop effective treatments.  The note of caution is that although patients certainly can benefit from cognitive therapy there is plenty of room to make these treatments even better. Cognitive therapy is an evolving treatment that certainly looks like it can keep on getting better.”

Professor Andrew Gumley, University of Glasgow and Professor Matthias Schwannauer, University of Edinburgh, said:

“For many patients with a diagnosis of schizophrenia, adherence to the first line treatment, antipsychotic medication, is a major problem. Up to three quarters of patients discontinue their medication. One reason for not taking medication is that patients do not believe that their experiences are caused by an illness, however many do not take antipsychotic medication because of the distressing side effects or stop taking medication because of limited perceived benefits. In these circumstances it can often be difficult for mental health services to maintain engagement with patients, especially if they feel that their options for treatments are limited. The need to develop safe, acceptable alternative treatments using robust scientific methods is a major priority for patients, their families and health services. One viable alternative treatment is Cognitive Therapy (CT) because it has established proven effectiveness in people with a diagnosis who are taking antipsychotic medication.

“CT is a talking therapy that involves the establishment of a collaborative relationship; the development of a normalizing and destigmatised explanation of experiences that are characteristic of schizophrenia; focuses on the patient’s interpretation of these experiences as a way of understanding their emotional distress and involves testing out new ways of coping with these experiences. CT further takes patients interpersonal and wider context into account and considers individuals recovery on many levels beyond dealing with the immediate distress caused by symptoms of schizophrenia.

“This ground-breaking landmark study by Professor Morrison and colleagues is important for three reasons.

1. They demonstrate that CT is safe and acceptable for people diagnosed with schizophrenia who chose not to take antipsychotic medication.
2. They demonstrate that, compared to treatment as usual, CT is associated with important treatment signals including a reduction in psychotic experiences such as hearing voices and paranoia and an improvement in day to day social functioning
3. Finally this study has very strong scientific integrity. Data were analysed according to a predetermined plan which means that investigators cannot ‘cherry pick’ good outcomes in favour of their treatment; all amendments to the study plan were documented in the report; assessments of outcome were taken by assessors who did not know which therapy participants were receiving (rater blindness). Rater blindness in the most important source of bias in trials of psychological therapy Wykes et al., 2008; Jauhar et al., 2014).

“Some investigators will criticize the study because CT was compared to Treatment as Usual (TAU), and not to a “placebo” psychological therapy. However, Jauhar and colleagues (2014) have demonstrated that the effects of CT in schizophrenia are robust and are not affected by whether the comparison group is TAU or ‘placebo’.

“The sample size in this study is relatively small (n=74) and limited to two UK centres. Therefore it is of utmost importance that a larger scale, multicentre UK wide randomized controlled trial is funded to establish effectiveness and of CT for people who chose not to take antipsychotic medication. Such a trial could fundamentally change patients’ experiences of treatment by providing a real choice in treatment.”

Prof Robin Murray, Professor of Psychiatric Research, Institute of Psychiatry, King’s College London, said:

“It is established that CBT is a useful addition to treatment with antipsychotics in psychosis.   However, many patients don’t like to take antipsychotics in the long-term; this is not surprising as they have significant side effects. So what to do for patients with continued psychotic symptoms who don’t want to take antipsychotics? Until now little was done except lecture them on how silly this was, with the usual result that the patients would simply stop attending. This study suggests that there may be a better option and that offering CBT is better than just leaving such patients to languish.  

“Of course, the patients were a highly selected group who were willing to try CBT; often patients who won’t take antipsychotics are difficult to engage in any form of therapy.  Furthermore, there was no active comparison group such as befriending or supportive therapy. Nevertheless, this approach is certainly worth exploring further. This is especially so because we are realising that long-term antipsychotic treatment may cause receptor changes that make it difficult to stop the drugs, and consequently psychiatrists may become more cautious about the long-term prescription of antipsychotics.”

Prof Shitij Kapur, Professor of Schizophrenia, Imaging and Therapeutics, and Head of School at the Institute of Psychiatry, King’s College London, said:

“This is an important trial that shows that CBT works – and works for a very difficult to treat population – the patients who do not take drugs. This is important as clinicians can often get nihilistic about patients who are “non-compliant”. What the paper tells us is that we can engage psychotic patients who do not take antipsychotics and deliver clinical benefits.

“However, I would like to draw attention to wording in the abstract and the editorial that need further clarification. The abstract and editorial state that there is an effect size of 6.52. There are few treatments in medicine that have effect sizes of 1, so 6.5 would be massive indeed! In actual fact the between group effect size is 0.46 (and on the full reading of the paper the authors rightly report this). However, a casual reader may take away a mistaken impression that of the effect size as being 6.5 from just reading the abstract. The value 6.52 comes from the statistical modelling they used and is technically the ‘treatment effect’ in a statistical model, and NOT the effect size in the conventional use of that word.

“Having said that 0.46 of an effect size is about as good for most psychiatric medications – so it is indeed something worth seeking, especially in those patients who do not take our conventional treatments.”

Prof Til Wykes, Professor of Clinical Psychology and Rehabilitation, Institute of Psychiatry, King’s College London, said:

“This paper is a well-designed and rigorous study that suggests CBT can be used as the sole treatment for schizophrenia. The effects are modest and, as the authors state, the results need to be replicated in a larger study. At this stage though, anyone suffering from schizophrenia should not be stopping their medication without speaking to a mental health expert first.

“The use of CBT for schizophrenia is accepted as an important treatment that needs to be offered to all potential candidates but it still seems somewhat contentious to a few individuals. I was one of the authors on a meta-analysis in 2008 which supported the idea that CBT could work along with anti-psychotic drugs, whilst the authors of a more recent meta-analysis concluded the opposite with essentially the same results. The Morrison study is particularly interesting as offers CBT treatment to people who are engaged with mental health services but have chosen not to take any medication. Most people who do not take medication usually stay as far away from mental health services as possible in case they ‘get sectioned’ and are made to take the drugs so their sample is narrowly defined and it may not generalise to people who completely drop out of contact.

“The paper did not include a placebo, which limits the research, but this is very difficult to overcome for psychological treatments. To be different from the normal psychological treatment, placebo treatments normally become structured in such a way that they become really obvious to the individual taking part, which stops them acting as a placebo.

“The other point that this research raises is whether or not there should be more compulsory treatment. There were a large number of adverse events in the control group that received neither CBT nor medication. If further research supports CBT having a positive impact on its own, then it does raise the question of what, ethically, the mental health community should be doing.”

‘Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial’ by Morrison et al. published in The Lancet on Thursday 6th February.