Posted on Thursday 2 April 2015
Living in the UK in the1970s practicing in an a US Air Force Hospital near one of the UK’s primo Hospitals [Addenbrooks, in Cambridge] was interesting. Suffice it to say that our systems and expectations are very different. I never quite ‘got it‘ – except to say ‘very different‘ and ‘interesting.’ I think I understand the term, ‘service users‘ in the papers I’m about to discuss. It means, ‘people who rely on the National Health Service‘ for their health care – according to Wikipedia, that’s 92%. If I understand correctly, NICE [National Institute for Health and Clinical Excellence] sets treatment guidelines one of which is to offer CBT [16 sessions] to service users with Schizophrenia, but it’s not really available through the NHS. That adds a commercial element to the issues brought up by the BPS report [or I could’ve misread the whole thing].
There was the phenomenal work of Anthony Morrison, who is the first researcher to empirically show that psychotherapy can be effective with individuals diagnosed with schizophrenia, even when they choose to not take psychotropics. Although many know this intuitively, the scientific community is not really interested in intuition; for him to show this repeatedly through empirical data is profound.
Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial.by Morrison AP, Turkington D, Pyle M, Spencer H, Brabban A, Dunn G, Christodoulides T, Dudley R, Chapman N, Callcott P, Grace T, Lumley V, Drage L, Tully S, Irving K, Cummings A, Byrne R, Davies LM, and Hutton P.Lancet. 383:1395–1403
BACKGROUND: Antipsychotic drugs are usually the first line of treatment for schizophrenia; however, many patients refuse or discontinue their pharmacological treatment. We aimed to establish whether cognitive therapy was effective in reducing psychiatric symptoms in people with schizophrenia spectrum disorders who had chosen not to take antipsychotic drugs.METHODS: We did a single-blind randomised controlled trial at two UK centres between Feb 15, 2010, and May 30, 2013. Participants aged 16-65 years with schizophrenia spectrum disorders, who had chosen not to take antipsychotic drugs for psychosis, were randomly assigned [1:1], by a computerised system with permuted block sizes of four or six, to receive cognitive therapy plus treatment as usual, or treatment as usual alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. Our primary outcome was total score on the positive and negative syndrome scale [PANSS], which we assessed at baseline, and at months 3, 6, 9, 12, 15, and 18. Analysis was by intention to treat, with an ANCOVA model adjusted for site, age, sex, and baseline symptoms. This study is registered as an International Standard Randomised Controlled Trial, number 29607432.FINDINGS: 74 individuals were randomly assigned to receive either cognitive therapy plus treatment as usual [n=37], or treatment as usual alone [n=37]. Mean PANSS total scores were consistently lower in the cognitive therapy group than in the treatment as usual group, with an estimated between-group effect size of -6.52 [95% CI -10.79 to -2.25; p=0.003]. We recorded eight serious adverse events: two in patients in the cognitive therapy group [one attempted overdose and one patient presenting risk to others, both after therapy], and six in those in the treatment as usual group [two deaths, both of which were deemed unrelated to trial participation or mental health; three compulsory admissions to hospital for treatment under the mental health act; and one attempted overdose].INTERPRETATION: Cognitive therapy significantly reduced psychiatric symptoms and seems to be a safe and acceptable alternative for people with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs. Evidence-based treatments should be available to these individuals. A larger, definitive trial is needed.
Participants allocated to cognitive therapy received a mean of 13.3 sessions [SD 7.57; range 2–26], with each session lasting roughly 1 h [these figures do not include the four booster sessions that were available]. Adherence to cognitive therapy was reasonably good, with no patients not attending any sessions, and 30 [82%] having at least six or more sessions.
… 74 individuals were randomised to the cognitive therapy plus treatment as usual group [n=37], or the treatment as usual alone group [n=37]. We stopped before the target of 80 individuals in accordance with our recruitment timeline, on the basis of restricted resources, to ensure that we had the possibility to obtain 9 month data for all participants. Baseline characteristics were similar between groups.
By examination of the proportion of participants achieving good clinical outcomes in each disorder [defined by use of an improvement of >50% in adjusted PANSS total scores], we noted that, at 9 months, seven [32%] of 22 participants in the cognitive therapy group, and three [13%] of 23 from the treatment as usual group had achieved good clinical outcomes. At 18 months seven [41%] of 17 receiving cognitive therapy and three [18%] of 17 receiving treatment as usual had achieved good clinical outcomes.
With regards to use of antipsychotic drugs throughout the lifetime of the trial, ten [4%] of 37 participants in the cognitive therapy group were prescribed antipsychotics after randomisation [eight during the treatment window and two during the follow-up phase] as were ten [4%] of 37 in the treatment as usual group [nine during the treatment window and one during the follow-up phase].
So in-so-far as I’m able to vet this study, I would see it as a pilot project showing a signal that deserves repeating, but I can’t confirm the opening quote above, the article’s conclusion, or the commentary on the article. Here’s the thing of it, my bias is on the side of confirmation. I support psychotherapeutic intervention in Schizophrenia. I’m not sure I would’ve picked CBT, but I’m not an CBT-er, and from what I can read, Morrison et al have adapted the technique to be used in this condition.