CBT for psychotic disorders: beyond meta-analyses and guidelines - it is time to implement!

Abstract

The treatment of psychotic disorders has considerably improved since the introduction of antipsychotic medication more than half a century ago, and there is no doubt that this medication can reduce psychotic symptoms and the risk of relapse 1. However, even though pharmacological treatment is significantly better than placebo, there are a number of patients who experience side effects which in some cases can be harmful, and a proportion of people who still experience psychotic symptoms in spite of antipsychotic treatment 2. There are also patients who refuse antipsychotics because of the risk of side effects, the belief that they are able to handle their difficulties without medication, or a fundamental disagreement with the clinician about the nature of their symptoms. In other words: there is room for improvement, and the use of approaches other than medication alone should be explored. There is clear evidence that cognitive behavior therapy (CBT) can reduce psychotic symptoms in schizophrenia when added to pharmacotherapy 1. Several meta-analyses have supported this conclusion, although many studies did not meet optimal standards for randomized controlled trials with regard to blinded measurement of outcome. The effect size in the most rigorously conducted trials is small 3, and evidence is lacking about the effectiveness of short versus long duration CBT 5. Few trials have directly compared CBT with other talking therapies 4, and it is possible, but not yet proven, that other therapies may also be effective. However, based on current evidence, it has not been established that psychodynamic therapy is better than treatment as usual 1. On this background, the American Schizophrenia Patient Outcomes Research Team (PORT) recommendations state that persons with schizophrenia who have persistent psychotic symptoms while receiving adequate pharmacotherapy should be offered adjunctive CBT to reduce the severity of symptoms 6, and the National Institute for Clinical Excellence (NICE) guidelines recommend to offer CBT to all people with psychosis or schizophrenia 7. In a recent paper, Morrison et al 8 presented data indicating that CBT can be effective even among patients who do not want to take antipsychotic medication. Whilst the sample size was small, this result is promising and warrants replication. Many CBT trials have focused on treatment resistant delusions, where the therapist and the patient will examine the basis and the likelihood of the delusional belief, exploring alternative explanations and identifying behavior that can reduce the stress related to the symptoms. Hallucinations can also be a target for CBT interventions. In a recently published multicenter trial, Birchwood et al 9 reported that CBT focusing on modifying conviction of beliefs linked to the construct of voice power, thereby challenging the omniscience and omnipotence of the voices, can successfully decrease compliance with command hallucinations. This finding is very important from a clinical point of view, as the patients were otherwise treatment resistant, and in many cases posed a significant danger to themselves or others. Hallucinations and delusions, however, are not the only symptoms in schizophrenia. For many patients, negative symptoms, depression, anxiety and low self-esteem are experienced as much more debilitating. CBT has been shown to be a promising intervention in reducing these phenomena. A more holistic approach to treatment, focusing not only on primary symptoms but also on the functional and psychological consequences of having a severe mental illness, is congruent with the current emphasis on factors that can facilitate recovery. In order to ensure that guidelines in different countries are actually rolled out, a carefully designed and closely monitored plan for implementation is required, including financial resources for educational material, training and supervision. Politicians and administrators should understand the need for a strong educational fundament. A continuing focus on intervention quality through skilled supervision is necessary to avoid “puppet on a string” therapists, who can only mechanically implement the intervention as taught in training courses without a clear understanding of what is needed in a specific clinical situation 10. The systematic evaluation of the implementation of CBT interventions in clinical settings can help build on the current evidence base and provide valuable information such as which subgroups may benefit from CBT, the acceptability of the intervention, the durability of treatment effects, and the meaningful outcomes which can be achieved.