Has cognitive behavioural therapy for psychosis been oversold?
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2295 (Published 25 March 2014) Cite this as: BMJ 2014;348:g2295
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Delusions and auditory hallucinations are the core positive symptoms of schizophrenia.All the antipsychotics have only modest anti-hallucinatory and anti-delusional effects. Clozapine has the maximum anti-hallucinatory effect. Yet, 30% of patients treated with clozapine remain super-refractory. Cognitive behavioural therapy (CBT) has met with partial success when applied to various aspects of cognitive dysfunction noted in auditory verbal hallucinations ( AVH) which can linger on even after other positive symptoms have been ameliorated. Specific techniques have been designed to modify the frequency of AHVs and restore a sense of control over them: a primary aim being to change the belief that they are omnipotent and uncontrollable and to suppress the associated attributes of false identity, wrong intentions, and urges to harm oneself and others. CBT encourage patients to challenge irrational interpretations and modify maladaptive behaviour, diverting attention from voices with distraction techniques. Reality testing and behavioural experiments are one form of intervention. Behavioural change may be the most effective. Attention switching can be used to challenge the belief that hallucinations are uncontrollable.
CBT practitioners suggest that AVH may be interpreted as incorrectly identified internal speech or thought, postulating malfunction of the brain’s ability to identify thoughts. Several experiments to convince voice sufferers about the irrationality of their experience have been devised. 1 Trower et al. observed weakening of conviction and significant reduction in compliance behaviour following cognitive therapy in a group of 38 forensic patients, 2 which indicates scope for CBT in these patients. C.BT is not iatrogenic. CBT works better with intelligent and insightful patients. Otherwise, it would be like pouring water into a shut bottle. Therapists have to be highly skilful. The cost effectiveness of psychological interventions is poorly studied although information on cost effectiveness is highly relevant for policy decisions in health care.
Antipsychotics are found to have more quality life indicators such as general wellbeing, ability to work and rewarding relationships. As psychotic symptoms are many-sided, treatment should be individualistic and clinicians should be prepared to apply several clinical and non clinical approaches concurrently to challenge them.3 The conventional belief that treatment of schizophrenia is effective only for as long as the treatments are active is true of CBT and it should be sold and bought with realistic expectations. From the patient’s perspective, the calming and relaxing effects of pharmacological therapies are a priority for relief from the distress due to positive symptoms. Antipsychotics have protected the dignity of patients and prevented suicides and homicides. Medical research should focus on discovering a derivative of clozapine that has not got the haematological side effects of the drug. In such a future scenario, clozapine would become the first line of treatment and most of the positive symptoms can be nipped in the bud.
1.Hoffmann G. Stefan., Tompson C. Martha. Treating Chronic and Severe Mental Diorders.2002; London: Guildford Press.
2..Trower P, Birchwood M, Meaten A, Byrn S, and Nelson A, Kerry R. Cognitive therapy for command hallucinations: randomised controlled trial. BJP 2004; 184:312-30.
3.Laroi Frank, Alman Andre.(2010) Hallucinations, a guide to Treatment and Management, Oxford: Oxford University Press.
Dr. James Paul Pandarakalam,
Consultant Psychiatrist
5 Boroughs Partnership NHS Foundation Trust.
Hollins Park Hospital, Hollins Lane, Warrington WA2 8WA
jpandarak@hotmail.co.uk
Competing interests: No competing interests
I would have dearly loved to attend the live debate but have to see patients with this condition. I have enjoyed the debate in the journal so far and wanted to comment.
I previously have mentioned concerns about the effects of exclusion in meta-analyses and pleaded for more detailed consideration of these effects (1). I therefore have some sympathy with David Kingdon’s view about the justification for study exclusion. Peter McKenna is right to question the scientific rigour of studies and blindness, but I have some misgivings about studies claiming to be blinded, again this depends how rigorously this is assessed and what successful blinding looks like. Unless, I did not read it, the potential risk of “invisible trials” i.e. unpublished (and probably negative) studies are not discussed. This could apply to both camps. This becomes more relevant when one considers the size of the evidence base - and when one considers the exclusion criteria and drop-out rates that can occur in this difficult area of research, how “good” is a “good” study?
I am concerned that the debate mirrors a false dichotomy in view, between “psychological” and “physical (or psychiatric)” approaches to treatment. I am not convinced they can ever be separated, for example, to recruit patients into a drug RCT (even if NHS funded) will require considerable psychological skill and awareness. Conversely, recruitment into a psychological treatment study will need awareness of drug effects and compliance. In my experience, patient preference is for both treatment modalities, tailored in a flexible and personalised way. What does this mean in the real world if I have to summarise the message of this debate to a patient (and this does happen!) and what it means for them. The difficult answer might be not a lot, as a considerable proportion might be excluded from some of the RCTs mentioned in the debate.
Therein lies the rub, as I would love to have something akin to CATIE (2) to discuss with my patients, looking at the most effective drug and psychological therapy combination in the real world.
Lieberman J A et al (2005) Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia N Engl J Med 353:1209-12238
Lynch S (2014) Re: Evidence Based medicine – an oral history http://www.bmj.com/content/348/bmj.g371/rr/683518
Competing interests: No competing interests
Re: Has cognitive behavioural therapy for psychosis been oversold?
The verdict is out! Cognitive behaviour therapy for psychosis (CBTp) has not been oversold. The vote at the Maudsley debate on 2nd April 2014 was:
Vote before: For motion = 83; Against = 87; Undecided = 61
Vote after: For motion = 47; Against = 132; Undecided = 25
This is not just a victory for clinicians who believe in CBTp but also a victory for patients who suffer with psychosis. There is no doubt that medication has transformed the way we treat people who suffer with psychosis and the move to deinstitutionalise our patients and treat in the community has been possible due to the same. However we all know that antipsychotic medications have limitations and even if this is not the case concordance can be an issue 1). CBTp has demonstrated an impact on symptoms and has an evidence base for improving concordance and insight which of course complements medication management and recovery(2).
The meta-analyses, systematic reviews and RCTs will continue to be discussed but paramount is promoting recovery for our patients. Recovery is about enhancing treatment impact by promoting hope, agency and control, thereby destigmatising illness (3). CBTp does just that.
1. Lieberman J A et al (2005) Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia N Engl J Med 353:1209-12238.
2. Turkington, D., Kingdon, D., Rathod, S. et al. An effectiveness trial of a brief cognitive behavioural intervention by mental health nurses in schizophrenia: clinically important outcomes in the medium term. British Journal of Psychiatry, 2006; 189 (1); 31-35.
3. Boardman, J,, Friedli, L. (2008). Recovery, Public Mental Health and Wellbeing - Implementing recovery through organisational change. The Sainsbury Centre for Mental Health: London.
Competing interests: No competing interests