Cognitive Therapy a Viable Monotherapy for Schizophrenia?

Megan Brooks

February 06, 2014

Cognitive therapy may be a viable alternative to antipsychotic drugs in patients with schizophrenia who cannot or will not take an antipsychotic, new research suggests.

In the first randomized trial of cognitive therapy as a stand-alone therapy for schizophrenia, researchers found that it significantly reduced the severity of psychiatric symptoms and improved personal and social functioning and some dimensions of delusional beliefs and voice hearing.

The study was published online February 6 in the Lancet.

Alternative Treatments Needed

Antipsychotic drugs are the mainstay of treatment for schizophrenia, but as many as half of all people with schizophrenia choose not to take drugs or discontinue them due to troubling and potentially serious side effects, Anthony Morrison, DClinPsy, professor of clinical psychology at the University of Manchester, United Kingdom, and colleagues note in their article.

Cognitive therapy has proven to be effective as an adjunct to antipsychotic drugs, but until now, its feasibility and effectiveness as a stand-alone treatment was unknown. In an earlier exploratory study, Dr. Morrison and colleagues noted significant benefit in 20 patients with schizophrenia who were not on antipsychotic drugs.

They now report results of a study of 74 individuals aged 16 to 65 years with schizophrenia spectrum disorders who had decided not to take or had stopped taking antipsychotics for at least 6 months. Half were randomly assigned to cognitive therapy (26 sessions during a 9-month period) plus treatment as usual and half to treatment as usual alone.

Cognitive therapy is a structured treatment that involves the therapist working collaboratively with the patient in weekly sessions during several months to reappraise psychotic experiences and modify unhelpful thought patterns and behaviors.

Change in symptoms was rated at regular intervals during 18 months on the Positive and Negative Syndrome Scale (PANSS).

Cognitive therapy proved to be highly effective in reducing psychotic symptoms and in improving function, the investigators say. Mean PANSS total scores were consistently lower (better) in the cognitive therapy group than in the treatment as usual group, with an estimated between-group difference of -6.52 (95% confidence interval [CI], -10.79 to -2.25).

After 18 months, 7 (41%) of 17 participants receiving cognitive therapy had an improvement of more than 50% in the PANSS total score compared with 3 (18%) of 17 receiving treatment as usual. Cognitive therapy was also well tolerated, with low rates of drop out and withdrawal.

"Impressive" Results, but Caution Warranted

"These findings are impressive; however, some caution is needed," writes the author of a comment in the Lancet.

"First, the study did not have a placebo intervention. The potential effect of this limitation should not be underestimated because placebo effects can be large in schizophrenia trials," writes Oliver Howes, MRCPsych, DM, PhD, of the Institute of Psychiatry in London, United Kingdom. However, the authors did use masked assessments and showed that masking was largely achieved, he added.

The characteristics of the patients in the study also need consideration, he says. Their baseline symptom severity was "relatively moderate, somewhat lower than that noted in patients typically entering acute drug trials, for example, but nevertheless similar to levels noted in other outpatient treatment trials of schizophrenia. Also notable is that outcomes in the patient group as a whole, including those in the treatment as usual group, were relatively good."

"The findings in this study should not be generalized to all patients with schizophrenia, particularly inpatients or patients not engaged with a clinical team," Dr. Howes advises.

With this study, the investigators "provide proof of concept that cognitive therapy is an alternative to antipsychotic treatment," writes Dr. Howes.

"Clearly this outcome will need further testing, but, if further work supports the relative effectiveness of cognitive therapy, a comparison between such therapy and antipsychotic treatment will be needed to inform patient choice. If positive, findings from such a comparison would be a step change in the treatment of schizophrenia, providing patients with a viable alternative to antipsychotic treatment for the first time, something that is sorely needed," Dr. Howes concludes.

Dr. Morrison agrees that more study is needed.

"We still need a definitive trial in order to be confident regarding efficacy," he told Medscape Medical News. "We also need a direct, head-to-head comparison of cognitive therapy with antipsychotics, and we are about to start a trial doing just that in April in Manchester," he said.

The study was funded by the UK National Institute for Health Research. Dr. Morrison and several coauthors are practitioners of cognitive therapy and deliver this intervention within the UK National Health Service; receive royalties from texts or books they have published on cognitive therapy; and have received fees for delivering workshops on cognitive therapy. One author has received lecture fees from pharmaceutical companies. Dr. Howes has received investigator-initiated research funding from or participated in advisory or speaker meetings organized by several manufacturers of antipsychotics: AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, Lyden-Delta, Servier, and Roche. In addition, he has provided cognitive therapy to patients as part of UK National Health Service treatment.

Lancet. Published online February 6, 2014. Abstract, Comment

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