Beyond Antipsychotics: Using Cognitive Behavioral Therapy for Psychosis

Kate Johnson

September 27, 2010

September 27, 2010 (Toronto, Ontario) — Individualized single-session interventions and group cognitive behavioral therapy (CBT) are legitimate considerations for psychotic patients who do not respond adequately to antipsychotic therapy, according to 2 studies presented here at the Canadian Psychiatric Association (CPA) 60th Annual Conference.

Traditionally, schizophrenic spectrum disorders (SSDs) were believed to be amenable to medication only, noted Ian Weinroth, MD, a clinical fellow in psychotherapy at Mount Sinai Hospital in Toronto, Ontario, Canada.

However, up to 50% of patients do not respond or respond poorly to antipsychotics — leaving a treatment gap that CBT can sometimes fill.

Single-session drop-in therapy delivered by a multidisciplinary team of psychologists, nurses, social workers, and family therapists can provide effective therapy and ease the burden on psychiatric services, 2 nurse therapists reported at the meeting.

"Single-session therapy is not assessment or triage — we are actually doing an intervention," explained Maureen Osis, RN, MN, a marriage and family therapist at the South Calgary Health Center, a community mental health walk-in Clinic in Alberta, Canada.

"We don't diagnose. We have people coming in with diagnoses, and we help them identify internal and external resources that have helped them in the past," said Pat Carruthers, RPN, PhD, a clinical nurse specialist at the clinic.

The clinic opened 6 years ago and now receives 800 visits per year, with 77% of clients waiting less than 20 minutes to be seen, the group reported. "We divert patients from other services and provide an alternative to the use of hospital emergency departments [EDs]," said Dr. Carruthers.

During a 3-year period, of 2550 clients responding to a survey, 69% said they would have sought services elsewhere if the clinic had not been an option, and 11% would have gone to a hospital, she reported.

Roughly three-quarters of the clinic's clientele fall between the ages of 18 and 54 years, and 60% are female.

Anxiety, Depression Common

Forty percent of their presenting problems involve anxiety, depression, or relationship issues. In total, 31% of clients return for a follow-up visit, 6% of these within 3 months of their initial visit.

Forty percent of clients indicate some risk for self-harm or harm to others, 22% are concerned about violence at home, and 8% report heavy use of street drugs or alcohol, she said.

The mean self-rated distress score at admission to the clinic is 7.7 of 10, decreasing to a mean of 5.3 at discharge, she said.

The team outlined 1 case of a 40-year-old bipolar patient who was being followed up by a psychiatrist but who had also visited the walk-in clinic 30 times during the past 6 years.

During the preceding decade, she had frequented hospital EDs several times per year and had been hospitalized several times.

Through her regular visits to the clinic the patient has been linked to urgent care mental health services and her psychiatrist when necessary but has avoided all hospital visits and admissions for 6 years.

Often, a visit to the clinic was enough to tide her over until her next appointment with her psychiatrist, said Ms. Osis. "She usually comes with a specific concern — she is very goal oriented — and the therapist and team help her to make a plan of action."

Single Sessions Can Be a Turning Point

"I'd certainly be endorsing a multidisciplinary service that includes nurses and psychologists," commented Dr. Weinroth after the presentation. "From a cost perspective and a flow perspective I'd support any diversion of patients from tertiary centers that are already swarming. If psychiatrists are so protective of their turf to think they're the only ones who can do this, it's just self-serving and arrogant."

Single-session interventions often lend themselves well to psychiatric crises, he added. "I've had experiences in my own practice where I've seen patients in consultation and done single, meaningful therapeutic interventions. It is about being able to identify, within that first visit, the core issues that the patient may not even be aware of," he said.

"For some people that's all they need — to help make sense of their experience, to reorganize, to boost their ability to cope and to go out the door with a plan of action. A patient won't get that kind of therapy in the ED," Dr. Weinroth added.

Even suicidality runs from passive thoughts of wanting to die to having a firm plan to do it, he added. "For some people, depending on severity, a single session can be enough to turn things around."

In recognition of this approach, guidelines from the CPA endorse individualized CBT in treatment-resistant patients with psychosis, said Dr. Weinroth. Building on this, his group is currently researching the effectiveness of CBT in a group setting for patients with SSDs.

Preliminary Data for Paranoid Symptoms Encouraging

Paranoid symptoms make recruitment difficult in this patient population, and his study is currently underpowered to show clear benefits of the group approach, he explained.

However, preliminary indications are positive. "We're encouraged that we're heading in the right direction based on positive feedback from the clients."

The Positive and Negative Symptom Scale and Suicide Intervention Response Inventory are being used to measure primary outcomes, such as delusions, hallucinations, and negative symptoms (apathy and withdrawal), as well as depression and anxiety.

"Even if we don't see a drop in scores, it may not necessarily reveal the whole picture. Although they may still hear voices throughout the day, they may respond to them differently, they may cope with them better — but a rating scale won't capture that," he said.

CBT represents a relatively new approach to managing patients who hear voices and have hallucinations and delusions, he said.

"How do you challenge people's view of the world if they are so very paranoid and so very sensitive and could take that as being a confrontation on their version of reality? The evidence more recently has suggested that while these ideas may not be completely broken and eliminated, they can be massaged and weakened. People can at least question their thoughts. Even if they don't challenge their delusions they can at least appreciate the idea and that's a start."

The investigators have disclosed no relevant financial relationships.

Canadian Psychiatric Association (CPA) 60th Annual Meeting: Abstracts PS4d and PS4a. Presented September 23, 2010.


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