Alison Brabban

Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial

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. FUNDING National Institute for Health Research.

Predictors of Outcome in Brief Cognitive Behavior Therapy for Schizophrenia

Antipsychotic medications, while effective, often leave patients with ongoing positive and negative symptoms of schizophrenia. Guidelines recommend using cognitive behavior therapy (CBT) with this group. Clearly, mental health professionals require training and supervision to deliver CBT-based interventions. This study tested which antipsychotic-resistant patients were most likely to respond to brief CBT delivered by psychiatric nurses. Staff were trained over 10 consecutive days with ongoing weekly supervision. Training for carers in the basic principles of CBT was also provided. This article represents the secondary analyses of completer data from a previously published randomized controlled trial (Turkington D, Kingdon D, Turner T. Effectiveness of a brief cognitive-behavioural therapy intervention in the treatment of schizophrenia. Br J Psychiatry. 2002;180:523-527) (n = 354) to determine whether a number of a priori variables were predictive of a good outcome with CBT and treatment as usual. Logistic regression was employed to determine whether any of these variables were able to predict a 25% or greater improvement in overall symptoms and insight. In the CBT group only, female gender was found to strongly predict a reduction in overall symptoms (P = .004, odds ratio [OR] = 2.39, 95% confidence interval [CI] = 1.33, 4.30) and increase in insight (P = .04, OR = 1.84, 95% CI = 1.03, 3.29). In addition, for individuals with delusions, a lower level of conviction in these beliefs was associated with a good response to brief CBT (P = .02, OR = 0.70, 95% CI = 0.51, 0.95). Women with schizophrenia and patients with a low level of conviction in their delusions are most likely to respond to brief CBT and should be offered this routinely alongside antipsychotic medications and other psychosocial interventions.

Cognitive therapy for people with a schizophrenia spectrum diagnosis not taking antipsychotic medication: an exploratory trial

BACKGROUND Although antipsychotic medication is the first line of treatment for schizophrenia, many service users choose to refuse or discontinue their pharmacological treatment. Cognitive therapy (CT) has been shown to be effective when delivered in combination with antipsychotic medication, but has yet to be formally evaluated in its absence. This study evaluates CT for people with psychotic disorders who have not been taking antipsychotic medication for at least 6 months. METHOD Twenty participants with schizophrenia spectrum disorders received CT in an open trial. Our primary outcome was psychiatric symptoms measured using the Positive and Negative Syndromes Scale (PANSS), which was administered at baseline, 9 months (end of treatment) and 15 months (follow-up). Secondary outcomes were dimensions of hallucinations and delusions, self-rated recovery and social functioning. RESULTS T tests and Wilcoxons signed ranks tests revealed significant beneficial effects on all primary and secondary outcomes at end of treatment and follow-up, with the exception of self-rated recovery at end of treatment. Cohens d effect sizes were moderate to large [for PANSS total, d=0.85, 95% confidence interval (CI) 0.32-1.35 at end of treatment; d=1.26, 95% CI 0.66-1.84 at follow-up]. A response rate analysis found that 35% and 50% of participants achieved at least a 50% reduction in PANSS total scores by end of therapy and follow-up respectively. No patients deteriorated significantly. CONCLUSIONS This study provides preliminary evidence that CT is an acceptable and effective treatment for people with psychosis who choose not to take antipsychotic medication. An adequately powered randomized controlled trial is warranted.

Opportunities and challenges in Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI): Evaluating the first operational year of the South London and Maudsley (SLaM) demonstration site for psychosis

Despite its demonstrated clinical and economic effectiveness, access to Cognitive Behavioural Therapy for psychosis (CBTp) in routine practice remains low. The UK National Health Service (NHS England) Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI) initiative aims to address this problem. We report 14-month outcomes for our psychosis demonstration site. Primary and secondary care and self-referrals were screened to check the suitability of the service for the person. Psychotic symptoms, distress, service use, functioning and satisfaction were measured before and after therapy, by trained assessors. User-defined wellbeing and goal-attainment were rated sessionally. Access to CBTp increased almost threefold (2011/12 accepted referrals/year n = 106; 2012/13, n = 300). The IAPT-SMI assessment protocol proved feasible and acceptable to service users, with paired primary outcomes for 97% of closed cases. Therapy completion (≥5 sessions) was high (83%) irrespective of ethnicity, age and gender. Preliminary pre-post outcomes showed clinical improvement and reduced service use, with medium/high effect sizes. User-rated satisfaction was high. We conclude that individual psychological interventions for people with psychosis can be successfully delivered in routine services using an IAPT approach. High completion rates for paired outcomes demonstrate good user experience, clinical improvement, and potential future cost savings.

A preliminary exploration of predictors of outcome and cognitive mechanisms of change in cognitive behaviour therapy for psychosis in people not taking antipsychotic medication.

BACKGROUND Cognitive behaviour therapy (CBT) has been shown to be effective in an open trial for people with psychotic disorders who have not been taking antipsychotic medication. There is little known about predictors of outcome in CBT for psychosis and even less about hypothesised mechanisms of change. METHOD 20 participants with schizophrenia spectrum disorders received CBT in an exploratory trial. Our primary outcome was psychiatric symptoms measured using the PANSS. Secondary outcomes were dimensions of hallucinations and delusions, self-rated recovery and social functioning, and hypothesised mechanisms of change included appraisals of psychotic experiences, dysfunctional attitudes and cognitive insight. We also measured patient characteristics that may be associated with outcome. RESULTS T-tests revealed that several of the hypothesised mechanisms did significantly change over the treatment and follow-up periods. Correlational analyses showed that reductions in negative appraisals of psychotic experiences were related to improvements on outcome measures and that shorter duration of psychosis and younger age were associated with greater changes in symptoms. CONCLUSIONS CBT based on a specific cognitive model appears to change the hypothesised cognitive mechanisms, and these changes are associated with good outcomes. CBT may be more effective for those who are younger with shorter histories of psychosis.

Are continuum beliefs about psychotic symptoms associated with stereotypes about schizophrenia

Contact with people diagnosed with schizophrenia, and causal beliefs about the disorder, have both been shown to correlate with stigmatization. However, the associations are complex and heterogeneous. The effects of antistigma campaigns that have implemented personal contact have been limited and interventions promoting biological causal explanations have been found to increase stigmatization in some cases. Possibly a more suitable strategy for antistigma interventions could be to incorporate continuum beliefs, which propose that symptoms of schizophrenia lie on a continuum with normal experiences. The present study considers the potential for interventions focused on continuum beliefs by investigating the association between continuum beliefs and stigmatization. Within a sample of 120 participants of an online study, higher levels of continuum beliefs (assessed with the Continuum Beliefs Questionnaire, CBQ) were significantly correlated with lower stereotype scores. This association remained significant after controlling for known correlates of stereotypes (contact, causal beliefs, and educational level). We did not find an association between continuum beliefs and social distance. It is concluded that the promotion of continuum beliefs should be considered in the development of new antistigma campaigns.

Identifying specific interpretations and use of safety behaviours in people with distressing visual hallucinations: an exploratory study.

BACKGROUND Visual hallucinations (VH) are a common experience and can be distressing and disabling, particularly for people suffering from psychotic illness. However, not everyone with visual hallucinations reports the experience to be distressing. Models of VH propose that appraisals of VH as a threat to wellbeing and the use of safety seeking behaviours help maintain the distress. AIMS This study investigated whether people with distressing VH report threat appraisals and use safety behaviours. METHOD The study utilized a single group descriptive design, in which 15 participants with psychosis and VH were asked questions in order to assess the content, distress, appraisals, and behaviours associated with visual hallucinations. RESULTS People who found visual hallucinations distressing (n = 13) held negative appraisals about those hallucinations and specifically saw them as a threat to their physical or psychological wellbeing. They also engaged in safety seeking behaviours that were logically related to the appraisal and served to maintain the distress. CONCLUSIONS People with distressing VH regard them as a threat to their wellbeing and use safety seeking behaviours as a result of this perceived threat. These key processes are potential targets for treatments that will alleviate the distress associated with VH.

Associations of self-esteem, dysfunctional beliefs and coping style with depression in patients with schizophrenia: A preliminary survey

Psychological models of depression in schizophrenia have proposed that cognitive structures (e.g., self-esteem, dysfunctional beliefs) may have a role in the development and maintenance of depression. However, it has not been clear what the characteristics of these cognitive structures were in people with schizophrenia and whether they have an independent association with depression, especially in those from a Chinese cultural background. The present investigation examined 133 people with schizophrenia and 50 healthy controls and indicated that compared to the controls people with schizophrenia showed lower self-esteem, higher levels of dysfunctional beliefs and negative coping styles. Multiple linear regression analysis revealed that only low frustration tolerance, problem solving and self-blame were found to be the independent correlates of depression in schizophrenia. Results are discussed with the view of clinical implications of cognitive formulation and therapy for schizophrenia in China.

Assessing Cognitive Therapy Instead Of Neuroleptics: Rationale, study design and sample characteristics of the ACTION trial

Abstract Aims: Recent evidence regarding over-estimation of the efficacy of antipsychotics and under-estimation of their toxicity, as well as emerging data regarding alternative treatment options, suggest it may be time to introduce patient choice. However, only a small number of studies have reported on the efficacy of interventions for psychological interventions such as cognitive therapy. Early results suggest that cognitive therapy may be an effective, well-tolerated treatment for people who choose not to take antipsychotics. We report on the rationale and design for a multi-site randomised, controlled trial of cognitive therapy for people with a schizophrenia spectrum diagnosis who choose not to take antipsychotics. Methods: The study employs a single-blind design in which all participants receive treatment as usual, and half are randomised to up to 30 sessions of cognitive therapy for up to 9 months. Participants will be followed-up for a minimum of 9 months and to a maximum of 18 months. Results: We report the characteristics of the final sample at baseline (N = 74). Conclusions: Our study aims to expand the currently limited evidence base for best practice in interventions for individuals with psychosis who choose not to take antipsychotics.

The importance of human relationships, ethics and recovery-orientated values in the delivery of CBT for people with psychosis

Abstract Cognitive behavioural therapy for psychosis (CBTp) is, at times, perceived as a technical therapy that undervalues the importance of human relationships and the fundamental principles on which CBTp itself is based (such as collaboration, validation, optimism and recovery-orientated practice). As such, it can be dismissed by service users or practitioners as undesirable. It is also possible that delivering CBTp that does not adhere to these values can be unhelpful or harmful. We review the evidence regarding what service users want from mental health services and the ability of CBTp to meet these standards. Evidence from qualitative studies and randomised controlled trials suggests that CBTp should be delivered in a manner that is both acceptable to, and empowering of, service users. We suggest strategies that are likely to maximise the likelihood of successful implementation that is consistent with both values base and evidence base.