Psychological and social interventions for schizophrenia

BMJ 2006; 333 doi: http://dx.doi.org/10.1136/bmj.333.7561.212 (Published 27 July 2006)
Cite this as: BMJ 2006;333:212

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The response of Professor Peter McKenna [1] to Professor Kingdon’s editorial [2] on Cognitive Behaviour Therapy for Schizophrenia raises the important issue as to what the core treatment for schizophrenia should be.

When writing on this issue, proponents of different forms of treatment tend to take an ‘either or’ approach, suggesting that either psychological or pharmacological treatments have good evidence for the treatment of this illness, and therefore, by implication, that one or other treatment should be delivered in preference to others.

We would suggest that the evidence is that the approach should be inclusive of both psychological and pharmacological interventions.

We have recently carried out an analysis of symptoms of a group of patients followed through three points in the development of schizophrenic illness; during the prodrome, during the acute phase of the illness, and during recovery.[3] [4][5]

We found that different groups of symptoms behave differently throughout the illness. Positive and negative symptoms show a peak in number and intensity of symptoms as patients pass from the prodromal to the acute phase of schizophrenia, and then reduce in number and intensity of symptoms during the recovery phase.

Depression and anxiety, however, are present and are of importance during the prodrome, the acute phase of illness, and then the recovery phase without any significant change in the number and intensity of the symptoms observed. This suggests that the mechanisms causing the development of positive and negative symptoms in schizophrenic illness are different from those causing depression and anxiety. It is therefore entirely reasonable to expect that the treatment of schizophrenia will need to include treatment for positive and negative symptoms, which is usually pharmacological, as well as psychological treatment, including CBT, which, by providing the patient with greater understanding of his symptoms will alleviate stress, and therefore anxiety and depression. Both the mechanisms which we have referred to would be addressed by such combined treatment.

To deliver only one treatment-pharmacological or psychological- will cause us to fail in maximising treatment benefit for patients with schizophrenia.

References

[1]McKenna PJ. Cognitive Behaviour Therapy not effective. BMJ 2006;333:353

[2]Kingdon.C. Psychological and Social Interventions for Schizophrenia BMJ 2006;333:212-213

[3]Blinc Pesek M, Agius M, Avgustin B, Perovsek Solinc N 2006 Symptoms of early psychosis-a pilot study. Poster presented in ‘The early phase of psychosis-research and treatment’April 3-4 Institute of Psychiatry.

[4] Blinc Pesek M, Agius M, Avgustin B, Perovsek Solinc N. [2006] Symptoms of early psychosis-a pilot study. Acta Psysciatrica Scandinavica Suppvol 114; p83.

[5]M.Blinc-Pesek, M Agius, M.Kocmur, B Avgustin. [2006] An analysis of the symptoms of early psychosis. Schizophrenia Research Vol 86 S104.

Competing interests: None declared

Competing interests: None declared

Mark Agius, Associate Specialist Bedfordshire and Luton Partnership Trust

Marjeta Blinc

Charter House Alma St Luton LU11PJ

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Professor Kingdon has very rightly pointed out that there is robust research evidence showing cognitive behavioural therapy to be effective in reducing symptoms of schizophrenia. Garety et al postulated a cognitive model of psychosis and demonstrated that cognitive therapy is effective in diminishing positive symptoms and their re-emergence by changing appraisals, negative self-schemata and biased reasoning processes. A link between relapse of schizophrenia and increased negative beliefs, which could be reduced by CBT, was shown in a study conducted by Andrew Gumley et al. However, evidence with regards to effect of CBT on negative symptoms is limited.

Also, if we consider the client group that would benefit most from psychological therapy, we would be inclined to choose clients who do not respond to pharmacological treatments or are reluctant to accept drugs.

Most of such clients would be difficult to engage, non-compliant, probably treatment resistant and suffer from frequent relapses. They would be ideal candidates for psychological therapy. The problems Professor Kingdon has talked about in implementing psychological treatments are lack of resources to train staff, heavy workload resulting in waiting lists and reduced access to psychological services.

However, the client group mentioned above, mostly belong to settings like assertive outreach teams, rehabilitation teams.etc., which are better funded in terms of staff to client ratio and hence, such teams would be ideally suited to deliver psychological therapies. The problem arises when despite available resources, such clients rarely engage with psychological therapy and efforts to engage them in CBT could even result in their withdrawing from services. Lack of insight and previous compulsory admissions in hospital could lead to resistance in talking about experiences that might be perceived by others as "psychotic". Also, if they are suffering from negative symptoms, the evidence for CBT is limited. So what is the solution for this subgroup of chronic, difficult to engage, non-compliant, revolving door clients, for whom we have the resources, but lack means and methods of engagement? Would it be better to establish therapeutic relationship and foster engagement by practical help with housing, finances.etc. Is CBT for psychosis only reserved for use by early intervention teams and generic Community Mental Health Teams, or are there any innovative psychological methods that could have an impact on this subgroup of clients too without jeopardising engagement?

References

1. David Kingdon. Psychological and social interventions for schizophrenia BMJ 2006; 333: 212-213

2. Early intervention for relapse in schizophrenia: results of a 12-month randomized controlled trial of cognitive behavioural therapy.Gumley A, O'Grady M, McNay L, Reilly J, Power K, Norrie J. Psychol Med. 2003 Apr;33(3):419-31.

3. A cognitive model of the positive symptoms of psychosis Psychological medicine,2001, 31, 189-195. P.A. Garety, E. Kuipers, D. Fowler, D. Freeman, P.E. Bebbington.

Competing interests: None declared

Competing interests: None declared

Tanushree Sarma, Associate specialist

Assertive outreach team, Oxleas NHS trust

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Editor, David Kingdon's editorial (1) and Tiihonen et al study (2) raised doubts over the claimed superiority of atypical antipsychotic treatments in effectiveness and tolerability compared to the older typical treatments. Since the introduction of Clozapine as the first atypical antipsychotic treatment and the drug industry has been active producing many brands of this treatments that promised better outcome and safety.

Most of the evidence for the cost-effectiveness and tolerability of the atypical antipsychotic drugs came from randomised controlled trials funded, designed and published by the drug industry. The profit margin involved in the selling of these drugs caused the drug industry to look for fastest ways in the development and testing of these drugs (3). The two recent naturalistic studies (2 & 4) have produced less favourable outcomes of the atypical antipsychotic agents over the old typical treatments. These two studies came at a time when there is mounting evidence linking atypical anti-psychotic drugs with rapid weight gain and the metabolic syndrome (5, 6). This is particularly disturbing in view of the high cost to the NHS associated with the use of these drugs. In one month (February 2005) I have calculated that the atypical antipsychotic agents constituted 68% of the drug expenditure for the medium size mental health unit, where I work.

As the patent of some of these drugs is running out shortly, promising the availability of cheaper non proprietary atypical antipsychotic agents. The drug companies are resorting to new tactics to keep their high profit. One of these strategies is to advocate the use of the more expensive dispersable formulation of these drugs as the first line of treatment for psychosis claiming that it increases compliance though there is very little evidence that this is the case outside hospital setting. The other strategy used by these companies is to promote the practice of using the injectable long-acting atypical antipsychotic agents as the first line treatment in first episode psychosis (Emsley et al, 2006). The difficulty of establishing a valid diagnosis and the prevalence of drug induced psychosis in these cases raise many questions about the ethics of such practice. Also the acceptability and the long term safety of such a measure in young people with early episodes of psychosis are in doubt too.

I call upon The National Institute for Clinical Excellence (NICE) to have another review of the guidelines for the management of schizophrenia and other psychoses taking in consideration the emerging evidence.

References:

1. Kingdon D Psychological and social interventions for schizophrenia BMJ 2006;333:212-213.

2. Tiihonen J, Wahlbeck K, Lönnqvist J, Klaukka T, Ioannidis J, Volavka J, et al. Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: observational follow-up study. BMJ 2006;333: 224-7

3. Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 2005;353(12): 1209-23

4. Sramek, JJ, Cutler, NR, Kurtz, NM, Murphy, MF, Carta, A. Optimizing the development of antipsychotic drugs. John Wiley & Sons. Chichester, 1997, p195.

5. Koro, C, Fedder DO, L'Italien GJ, Weiss SS, Magder LS, Kreyenbuhl J, Revicki DA, and Buchanan RW Assessment of independent effect of olanzapine and risperidone on risk of diabetes among patients with schizophrenia: population based nested case-control study BMJ, Aug 2002; 325: 243.

6. Remington, G. Schizophrenia, Antipsychotics, and the Metabolic Syndrome: Is There a Silver Lining? Am J Psychiatry, Jul 2006; 163: 1132 - 1134.

7. Emsley, R, Oosthuizen, P, Koen, L, Niehaus, D, Medori, R. First Line Treatment with long-acting risperidone in patients with first episode psychosis: safety and efficacy results from a 6 months interim analysis. Poster number 27 at WWS, Davos, Switzerland 5-11 February 2006.

Competing interests: None declared

Competing interests: None declared

Walid K. Abdul-Hamid, Consultant Psychiatrist and Audit Lead

The Linden Centre, Woodlands Way, Broomfield, Chelmsford, Essex CM1 7LF.

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McKenna is consistent in his opposition to CBT for psychosis(1) but selectively quotes the Cochrane Review(2) which also concludes that ‘CBT is a promising but under evaluated intervention’. Since that review, further studies have demonstrated an effect on relapse(3;4) . Tarrier and Wykes actually ‘conclude cautiously that overall there is good evidence for the efficacy and effectiveness of CBTp in the treatment of schizophrenia’(5) and significant and enduring differences between CBT and non-specific effects have been shown, e.g.(6). Nonetheless CBT is certainly not the only psychosocial intervention of value and further evaluation of this and other interventions is occurring and more is needed. My optimism is based on seeing the major effects on patients and carers where these interventions are implemented within a broadly-based mental health service which includes acute inpatient beds.

(1) McKenna PJ. "Cognitive-behavioural therapy for psychosis": Reply. [References]. British Journal of Psychiatry 2004;184(1).

(2) Jones C, Cormac I, Silveira da Mota Neto JI, Campbell C. Cognitive behaviour therapy for schizophrenia.[update of Cochrane Database Syst Rev. 2002;(1):CD000524; PMID: 11869579]. [Review] [104 refs]. Cochrane Database of Systematic Reviews (4):CD000524, 2004.

(3) Gumley A, O'Grady M, McNay L, Reilly J, Power K, Norrie J. Early intervention for relapse in schizophrenia: Results of a 12-month randomized controlled trial of cognitive behavioural therapy.. Psychological Medicine 2003;33(3):-431.

(4) Turkington D, Kingdon D, Rathod S, Hammond K, Pelton J, Mehta R. Outcomes of an effectiveness trial of cognitive-behavioural intervention by mental health nurses in schizophrenia. Br J Psychiatry 2006 Jul 1;189(1):36-40.

(5) Tarrier N, Wykes T. Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? A cautious or cautionary tale?. Behaviour Research and Therapy 2004;42(12)(1377-1401).

(6) Sensky T, Turkington D, Kingdon D, Scott JL, Scott J, Siddle R, et al. A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry 57(2):165-72, 2000.

Competing interests: None declared

Competing interests: None declared

David Kingdon, Professor

SO14 0YG

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The year 2006 AD started with Fonagy and Bateman [1] delivering a bombshell: 'in the vast majority of cases, borderline personality disorder naturally resolves within 6 years [...] some psychosocial treatments practised currently and perhaps even more commonly in the past, have impeded the borderline patient's capacity to recover following the natural course of the disorder and prevented them harnessing advantageous changes in social circumstances'.

Professor Scott [2] concluded in April that: 'People with bipolar disorder and comparatively fewer previous mood episodes may benefit from CBT. However, such cases form the minority of those receiving mental healthcare.'

Now, Professor McKeena [3] throws yet another challenge: 'Behind all the recent publicity surrounding CBT for schizophrenia lies a dirty little secret: it only works in poorly controlled trials and not in well- controlled ones.'

Quo vadis, Domine?

References

1 PETER FONAGY and ANTHONY BATEMAN Progress in the treatment of borderline personality disorder Br. J. Psychiatry, Jan 2006; 188: 1 - 3.

2 JAN SCOTT, EUGENE PAYKEL, RICHARD MORRISS, RICHARD BENTALL, PETER KINDERMAN, TONY JOHNSON, ROSEMARY ABBOTT, and HAZEL HAYHURST Cognitive–behavioural therapy for severe and recurrent bipolar disorders: Randomised controlled trial Br. J. Psychiatry, Apr 2006; 188: 313 - 320.

3 One psychological intervention is not effective in schizophrenia Peter J McKenna eletter bmj (2 August 2006)

Competing interests: None declared

Competing interests: None declared

Adrian Blaj, SpR General Adult Psychiatry

Luton

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"Over the past two decades few disorders have been subject to such big changes in management as schizophrenia. Yet these have gone unnoticed by the general medical and popular press—possibly because these changes have not arisen from breakthroughs in research on genetics, receptors, anatomy, or neuropharmacology......." I had not noticed that such big changes had occurred. The introduction of ever newer and better antipsychotics has done little to change the picture of schizophrenia, in my country, no significant social or psychological interventions have changed outcomes, the schizophrenic's lot remains one of stigma and the constant nagging over medication compliance.

Over five decades ago, a Canadian psychiatrist and biochemist found a treatment for schizophrenia that has proved effective in a significant percentage of sufferers. This simple, albeit very unorthodox treatment has stood the test of time, it has remained one of the pillars of the movement called Orthomolecular Medicine.

Founded by Linus Pauling and this Canadian named Abram Hoffer, MD, PhD, O.M., which has long been called "megavitamin therapy" by its critics, is something that seems to have been bypassed by conventional psychiatry and medicine. OM uses substances that normally occur in the human body in an attempt to restore a balance of essential nutrients. Hoffer et al unveiled a big secret underlying schizophrenia, the adrenochrome connection. Nutrients in high doses are administered in order to overcome the dysperception and dysfunction and the results are impressive to those who dare to look.

Behaviour therapy, talk therapy per se has no such results, its track record is often wishful thinking crowned by the apparent success through the comfort of one on one personal communication.

Before more time and effort is expended in that direction, a closer look into what OM is doing would seem the proper thing to do.

Competing interests: None declared

Competing interests: None declared

Dr. Herbert H. Nehrlich, Private Practice

Bribie Island, Australia 4507

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Kingdon’s1 statement that ‘More than 20 randomised controlled trials and five meta-analyses have shown cognitive behaviour therapy to be beneficial in schizophrenia’ gives an oversimplified picture of both the randomised controlled trials and the meta-analyses.

Reviewing the randomised controlled trials, Tarrier and Wykes2, two supporters of cognitive behaviour therapy (CBT) in schizophrenia, noted that five included groups who received befriending, supportive counselling or problem solving in order to control for the nonspecific effects of intervention, in other words as a psychological placebo. They stated that ‘not one study has shown clear and significant overall differences between CBT and the non-specific control groups’.

The conclusion of the Cochrane Collaboration’s3 meta-analysis of CBT for schizophrenia was: ‘Currently, trial-based data supporting the wide use of CBT for people with schizophrenia or other psychotic illnesses are far from conclusive.’ Compared to standard care, CBT was found not to reduce relapse and readmission, helped mental state over the medium term but after one year the difference was gone, and did not demonstrate a consistent effect on continuous measures of mental state. When compared to supportive psychotherapy, CBT had no effect on relapse or on the outcome of 'no clinically meaningful improvements in mental state' over the same time periods.

Behind all the recent publicity surrounding CBT for schizophrenia lies a dirty little secret: it only works in poorly controlled trials and not in well-controlled ones.

1. Kingdon C. Psychological and social interventions for schizophrenia. BMJ 2006;333:212-3.

2. Tarrier N, Wykes T. Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? A cautious or cautionary tale? Behav Res Ther 2004;42:1377-401

3. Jones C, Cormac I, Silveira da Mota Neto JI, Campbell C. Cognitive behaviour therapy for schizophrenia. Cochrane Database of Systematic Reviews 2004, Issue 4.

Competing interests: None declared

Competing interests: None declared

Peter J McKenna, Professor of Psychiatry

University of Glasgow G12 0XH

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Kingdon brings a welcome air of optimism to the management of schizophrenia (1). Advances in psychosocial management have been made but have not been implemented due to funding restrictions. Kingdon highlights new models of service delivery such as home treatment and early intervention teams in reducing admissions. These may be best suited to those patients with a relapsing and remitting illness who only require brief admissions. Such services are expensive and in order to fund them commissioners and providers will need to divert resources from existing services, including longer stay rehabilitation units. Kingdon himself states that "the programme to close mental hospitals is near completion in the United Kinngdom."

The calls for an end to stigma and a greater emphasis on social inclusion and recovery are laudable. However, when it comes to service provision, an exclusively recovery based model is flawed. Trusts with limited access to longer stay in patient beds have high rates of "new long stay patients" on acute admission wards. Up to 80% of these have diagnoses of schizophrenia or schizoaffective disorder (2). These patients do not fulfil services' expectations of recovery. As a result they and the teams that care for them are likely to experience increased stigma, made manifest by the use of perjorative terms such as "bed blockers". The abscence of local beds is leading to the growing phenomenon of reinstitutionalisation in private sector units. These units are costly and of uncertain quality. They are also usually far removed from family and friends, which arguably compounds an already profound sense of alienation which is characteristic of the illness itself.

Kingdon concludes that a more optimistic outlook for schizophrenia is warranted based on a more benign course in some patients. Such optimism is welcome, but we would urge commissioners and providers at a local level not to forget those with more severe and chronic illnesses who do not fit neatly into the recovery model.

1.) Kingdon, D. Psychological and social interventions for schizophrenia. BMJ 2006;333: 212-3

2.) Cowan C, Walker P,. New long stay patients in a psychiatric admission ward setting. Psychiatric Bulletin 2005; 29: 452-454

Competing interests: None declared

Competing interests: None declared

v Balasubramanian, staff grade psychiatrist

Rob Evans, Consultant Psychiatrist

Solihull Assertive Outreach Team, 15 Larch Croft, Chelmsley Wood, Solihull, B37 5TZ

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David Kingdom describes in his article that “revolutionising services” for people with schizophrenia is as a result of the closure of mental hospitals and treating people at home. Whilst I agree that many patients benefit from home treatment, this must not be regarded as a blanket solution for all. Early intervention teams can only be successful if they accept there are limitations to their role and that acutely psychotic patients who are unwilling to comply with treatment in the community need urgent admission. This is not only to benefit the patients own mental health but also to prevent a breakdown in their social, professional and personal relations. Relatives can not be expected to supervise the treatment of such patients in the community alone as these patients are often manipulative, lack insight and are difficult to control. Unfortunately, with dwindling resources for community programmes this is what often happens and only after months of delay, deterioration and distress do local crisis services bow out and patients gain definitive treatment in hospital.

Competing interests: None declared

Competing interests: None declared

Katharine E Nolan, foundation yr1 doctor

City hospital B17 EH

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Dear Editor,

Whilst agreeing with Prof. Kingdon .1. that psychological therapies are definitively helpful in the treatment of schizophrenia, especially CBT and family therapy, I would like to highlight that the prodromal state of schizophrenia remains ill-defined.

To begin with there are no defining criteria or boundaries for the prodrome. The existing definitions suggest subjective difficulties like difficulties with differential attention over the relevant versus irrelevant stimuli, perplexity, clarity of thought, withdrawal from social interactions, problems with sense of control and some perceptual abnormalities. These may initially manifest as affective symptoms- anxiety, depression and then develop into a state of delusional mood – a perplexed individual who presents worried, unsure and disturbed about something non-specific in the external world. Further on, the subject develops frank delusions and hallucinations.2.3.

The difficulties are however that increasing and robust evidence suggests that nearly one in twenty to one in five (5-20%) of the general population might experience psychotic symptoms at some point in their lives, especially adolescence.4.5. And considering this whilst the “prodomal symptoms” may be providing a sensitive screening tool, their specificity is not sufficient for clinical effectiveness. Authors have even described a psychosis continuum in general population.4. So, the experience and the zeal of the person(s) forwarding the diagnosis hence remain critical determinants.

Prof. Kingdon has highlighted with an evidence base that in the prodromal phase cognitive therapy may reduce the risk of developing psychosis and has also very correctly identified that in England considerable problems remain in implementing psycho-social interventions, even where services are available.1. The lesser manpower intensive alternative is of course, prescription of anti-psychotic medications; newer or older, with the prescription the natural history of the disease unfolds a new arm – adverse effects and their management. The dilemma for the clinician is ever increasing: when to diagnose, in whom, when to treat and how to treat?

References:

1. Professor David Kingdon. Psychological and social interventions in schizophrenia. BMJ 2006;333;212-3

2. Klosterkotter J, Hellmich M, Steinmeyer EM, Schultze-Lutter F 2001, Diagnosing schizophrenia in initial prodromal phase, Archieves of General Psychiatry 58:158-164

3. Miller P, Lawrie SM, Hodges A et al 2001 Preliminary findings from the Edinburgh study of people at high risk of schizophrenia . Social Psychiatry and Psychatric Epidemiology 36:338-342

4. Verdoux H, van Os J 2002 Psychotic symptoms in non-clinical populations and the continuum of psychosis. Schizophrenia Research 54:59-65

5. Wiles NJ, Zammit S, Bebbington P, Singleton N, Meltzer H and Lewis G Self reported psychotic symptoms in general population. British Journal of Psychiatry June 2006, 188, 519-526

Competing interests: None declared

Competing interests: None declared

Arnob Chakraborti, Senior House Officer

Dorothy Pattison Hospital, Walsall PCT, WS2 9XH

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