CBT Beneficial for Medication-Resistant Psychosis

Megan Brooks

July 09, 2014

Cognitive-behavioral therapy (CBT) for psychosis can help patients with schizophrenia who continue to exhibit symptoms despite adequate antipsychotic therapy, a new meta-analysis confirms.

Conducted by investigators at the University of British Columbia, Vancouver, Canada, the review included 12 randomized controlled trials of patients with medication-resistant psychosis that explicitly measured changes in these symptoms in response to CBT for psychosis.

The authors found a beneficial effect of CBT posttreatment, with a medium effect size for positive symptoms (Hedges g = 0.47) and general symptoms (Hedges g = 0.52).

These effects were maintained at follow-up for both positive and general symptoms (Hedges g = 0.41 and 0.40, respectively).

"For patients who continue to exhibit symptoms of psychosis despite adequate trials of medication, CBT for psychosis can confer beneficial effects above and beyond the effects of medication," the authors write.

The study was published in the July issue of Psychiatric Services.

Important Clinical Issue

CBT for psychosis was originally developed for outpatients with medication-resistant positive symptoms, and most studies have involved this subset of patients. However, prior meta-analyses have not provided an estimate of effect sizes of CBT specifically for these patients.

"Given that 20% to 50% of patients continue to experience psychotic symptoms that interfere with their functioning despite adequate trials of medication, it was important to examine the effects of CBT in the treatment of residual symptoms," study author Amy Burns, a PhD student in clinical psychology at the University of British Columbia, who worked on the study, told Medscape Medical News.

"The results from the current meta-analysis suggest that CBT is effective in the management of persistent psychotic symptoms above and beyond the effects of medication," she added.

The analysis included a total of 639 patients; 552 completed the posttreatment assessment (14% dropout rate). The duration of CBT ranged from 4 to 9 months, with follow-up out to 18 months.

However, the authors point out the analysis has its share of limitations.

"The most salient limitation was the aggregation of various methods and models of CBT within a common category for analysis. Aggregation across various adjunctive control therapies may also have undermined delineation between more or less effective alternate strategies," they write.

"Another important issue is the identification of the active ingredients," the authors write. CBT for psychosis has a range of components that vary in length and emphasis, they note. At least 4 treatment manuals for CBT for psychosis have been empirically validated in randomized controlled trials. "Thus this review — and the field as a whole — has not identified the active elements in CBT protocols," they add.

It is also important to note that in many of the studies, CBT was carried out by therapists trained in CBT for psychosis.

"In most cases, the supervising therapists wrote the treatment manuals. The results of the studies are thus limited to well-trained and experienced psychologists with expertise in CBT for psychosis and may not generalize to experienced general mental health clinicians," the authors note.

Meaningful Study

Despite these limitations, David Kingdon, MD, PhD, professor of mental health care delivery, University of Southampton, United Kingdom, told Medscape Medical News, "This is a very sensible and well-conducted meta-analysis which looks at a key group of people with psychosis ― those who have not fully responded to antipsychotics ― and who are then offered CBT. So it is also very clinically relevant and meaningful."

Dr. Kingdon, who was not involved in the analysis, also noted that "other meta-analyses have been too heterogeneous to be easily interpreted ― they have combined patients who are experiencing their first episode or have specific symptom targets or are not treatment resistant in addition to the group examined in this meta-analysis."

Furthermore, "the number of patients assessed is sufficient to be valid, although, as ever, larger samples would be beneficial. The findings are clear and supportive of the clinical guidelines which endorse CBT for psychosis internationally," Dr. Kingdon concludes.

The "consistent and long-lasting effect sizes" found in this new meta-analysis are noteworthy, Amanda Tinkelman, MD, associate director of psychiatric services at Zucker Hillside Hospital, Glen Oaks, New York, and from North Shore–LIJ Health System, told Medscape Medical News.

Dr. Tinkelman and colleagues are involved in a study at Zucker Hillside Hospital called Improving Care Reducing Costs (ICRC) that is aimed at patients with primary psychotic disorders who are at high risk for relapse by virtue of having been discharged within the last 30 days from an inpatient hospitalization.

The study, which is funded by the Centers for Medicare and Medicaid Services, will determine whether delivering increased services to these high-risk patients, including evidence-based treatments, helps to reduce the costs of their care during the next 6 months by reducing their readmission rates, said Dr. Tinkelman.

The study is also testing the value of online CBT for psychosis, which would increase access, she added.

"Primarily, CBT is used for anxiety disorders and for depression. And while there are a lot of therapists that are trained in CBT generally, there are many fewer therapists who have been trained in CBT for psychosis, so it's not commonly used at the moment, strictly because of a lack of available providers," she said.

The study was supported by the Social Sciences and Humanities Research Council of Canada. The authors, Dr. Kingdon, and Dr. Tinkelman report no relevant financial relationships.

Psychiatr Serv. 2014;65:874-880. Abstract

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