Intended for healthcare professionals

Head To Head Maudsley Debate

Has cognitive behavioural therapy for psychosis been oversold?

BMJ 2014; 348 doi: (Published 25 March 2014) Cite this as: BMJ 2014;348:g2295
  1. Peter McKenna, research psychiatrist1,
  2. David Kingdon, professor of mental health care delivery2
  1. 1FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain
  2. 2University of Southampton, Southampton, UK
  1. Correspondence to: Peter McKenna mckennapeter1{at}, David Kingdon, D.Kingdon{at}

Peter McKenna—Yes

After the discovery of chlorpromazine in 1952 and the subsequent rise of biological psychiatry, the mainstream view of schizophrenia became that it was amenable only to drug treatment. But everything changed in 1997 when a pioneering trial found that drug resistant patients improved when given a form of cognitive therapy adapted to target delusions and hallucinations, two of the core “positive” symptoms of schizophrenia.1 Many other trials— more than 50 to date—have since followed.

Problems with the evidence

Promising results in early studies is one thing; demonstrating that a treatment is effective in large, well controlled trials is another. And it is here that cognitive behavioural therapy for schizophrenia has run into difficulties. There have been around nine moderately sized or large (35-257 participants in the cognitive therapy group), blind trials comparing cognitive behavioural therapy with usual treatment or a control psychological intervention (trials of psychotherapy are invariably carried out under single blind rather than double-blind conditions). Only two of these nine methodologically rigorous trials have had positive results on their primary outcomes of overall symptoms, positive symptoms, or relapse at the end of the treatment period,2 3 and in one of these the authors noted that the blinding became compromised as the trial went on.3

Notwithstanding the mixed signals from these and many other smaller or less rigorous studies, meta-analyses over the years have generally been supportive. The leading example here is unquestionably the meta-analysis, or rather series of meta-analyses, carried out for the 2009 National Institute for Health and Care Excellence’s schizophrenia guideline.4 On the basis of these, NICE concluded that cognitive therapy was effective in reducing rates of readmission to hospital and duration of admission. It was also judged to be effective in reducing overall symptom severity, both at the end of treatment and after up to …

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