1 Does Cognitive Behavioural Therapy Reduce the Symptoms of Psychosis?

Abstract Background: The aim of this review was to analyse and critically appraise current journals evaluating the efficacy of cognitive behavioural therapy in the treatment of psychosis. Method: A literary search was conducted in order to gather three journals studying the effects of CBT on psychosis. Results: All three studies indicated that CBT was beneficial to patients suffering psychosis. Conclusion: The recommendation from this review was that future investigations might include the use of CBT in cross cultural studies, studies involving gender differences and studies involving CBT with populations of individuals under 18 (non adults) or a geriatric population. Introduction Approximately 30 people per 100,000 over the age of 15 will develop a psychotic illness each year1. The population of the UK is approximately 60 million, which equates to approximately 18,000 new cases of psychotic illness per year. The annual prevalence of schizophrenia (or similar disorders) is estimated at 0.34% (based on 18 studies) of the population2. Despite the prevalence of psychosis in diagnosed cases of serious mental illness, only within the last fifteen years there has been a major turnaround in the attitudes of psychiatrists and healthcare professionals toward the psychological treatment of psychosis. Prior to this, it was thought that the only beneficial treatment was with antipsychotic medication. Cognitive Behavioural Therapy (CBT) is a relatively new form of psychological treatment, developed partly from theory developed out of a knowledge of psychological processes that positively influence symptoms, and partly from experimentation (randomized controlled trials) on patients who consent to the use of this as a treatement.3 Cognitive Behavioural Therapy involves altering a patients cognitions (thoughts) and as a result their actions (behaviour). A person can think and then behave in a way which is not helpful in their everyday life and can cause them great distress; CBT attempts to let a person understand their though processes and then to modify these cognitions in order to change their behaviour. CBT is a form of psychotherapy, and therefore involves patient contact with a therapist, usually for 20 sessions, weekly, and about an hour each.

2 The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) refers to the term psychotic as the presence of certain symptoms4. The reason for this not-well-defined condition is because psychosis has had a multiplicity of definitions in the past; some of these definitions have included many symptoms, and some have included only a few symptoms. The DSM-IV chose this definition most recently because the symptoms of psychosis vary with each psychotic disorder. For example, patients with a substance induced psychotic disorder will suffer from psychosis, as will patients with schizophrenia, but one may hear voices, and the other may not. The DSM-IV lists nine conditions that exhibit psychotic symptoms, schizophrenia is one of these conditions; the symptoms are described below. Schizophrenia lasts at least 6 months, and includes at least 1 month of active-phase symptoms. The condition must display at least two of the following symptoms: delusions, hallucinations, catatonic behaviour, disorganised speech, and negative symptoms. Another recent approach that is controversial amongst some psychiatrists is early intervention schemes. Early intervention in psychosis aims to minimise the DUP (Duration of Untreated Psychosis) as much as possible; significant evidence has shown that the longer the DUP, the greater the chance of relapse5-7. Early intervention teams most often deal with young adults, and aim to provide a range of services, including antipsychotic medication, and various forms of therapy8

Psychosis can be precipitated as a result of a number of factors; some people have a genetic pre-disposition9, some people may acquire a vulnerability to developing psychosis, e.g. from a traumatic experience. Medication for psychosis consists of typical or atypical antipsychotics (neuroleptics). The typical antipsychotics have been prescribed in the treatment of psychosis for many years, and have been shown to produce far worse side effects than when the newer atypical antipsychotics are prescribed. However both types of medication produce side effects. Clozapine, an atypical antipsychotic (one of the first) can cause agranulocytosis, increase in heart rate and a lower seizure threshold. The elderly are at more serious risk, and side effects may include: incontinence, reduced appetite, change in heart rate and rhythm, cognitive deficit, blurred vision and dry mouth10.

3 Method To provide an evaluation of the question, Does Cognitive Behavioural Therapy Reduce the Symptoms of Psychosis? three separate journals were selected for evaluation. Before starting the process of selecting the individual journals, the criteria for selection was drawn up, and these criteria are listed below. 1. All patients involved must have a diagnosis of schizophrenia (according to the DSM-IV) as reported in each of the journals. 2. The journals should compare Cognitive Behavioural Therapy (CBT) against another treatment, preferably using Randomised Controlled Trials (RCTs) Various sources on the Internet were used for the literary search; websites such as MedLine, PubMed, IngentaConnect and the Cochrane Library were selected for use. IngentaConnect (Athens) did not provide sufficient choices, and many of the articles were not subscribed to by the University of Liverpool, and therefore were not accessible. The Cochrane Collaboration provided similar results to PubMed, and when MeSH was used, even fewer results were obtained. PubMed was chosen simply because I used it before the Cochrane Library. The search terms used and the number of results produced by these searches are shown below. My aim was to get the number of results under 150 to make reading through their summaries easier and faster. Search Term Mental Health Psychosis Cognitive therapy psychosis CBT schizophrenia 73258 38544 220 89 Number of Results

This is a screenshot of the PubMed search, which yielded the best results.

The journals chosen were: 1. Cognitive therapy for schizophrenia: a preliminary randomized controlled trial11 (Number 56 in the search) 2. Cognitive therapy for persistent psychosis in schizophrenia: a case-controlled clinical trial12 (Number 42 in the search) 3. Two-Year Follow-Up of CognitiveBehavioral Therapy and Supportive Counseling in the Treatment of Persistent Symptoms in Chronic Schizophrenia13 (Number 76 in the search)

5 Results Study 1 showed that the patients who were treated with CBT and regular treatment showed a greater improvement than those who were treated with regular treatment11. On the PANSS-Negative scale, 67% of those treated with CBT showed improvement between posttreatment and the follow up session; whereas only 31% of those receiving regular treatment showed improvement. However, near equal numbers receiving CBT (65%) and regular treatment (62%) showed improvement on the PANSS-Positive scale11. Study 2 showed statistically significant improvements in those treated with CBT, compared to those treated as usual. The general trend (similar to study 1) was that negative symptoms were greatly reduced. The results also showed that those receiving CBT treatment showed improvement of positive symptoms12. Study 3 showed that CBT and supportive counselling (separately) provide significant improvements in both positive and negative symptoms in comparison to routine care (usual treatment). The study also revealed that there was no significant difference between the effects of CBT and supportive counselling13. Discussion The results obtained appear to show that cognitive behavioural therapy provides better relief of symptoms than the usual treatment methods; however study 3 appeared to show that supportive counselling also provided outcomes comparable with the use of CBT13. It is important not to come to any conclusion based merely on the results of each study, because the methodologies used may be flawed leading to the conclusion that the results obtained were not consistent with a fair trial. These considerations are discussed below. Before trials begin, researchers must insure that the inclusion criteria are applied when admitting a patient into the trial, and more importantly, that the inclusion criteria themselves have scientific validation.

6 This is a table of the inclusion criteria from each of the studies11-13. Study 1 The patient must have a DSM-IV diagnosis of schizophrenia or schizoaffective disorder. Study 2 The patient must have a DSM-IV diagnosis of schizophrenia or schizoaffective disorder. Study 3 The patient must have a diagnosis of schizophrenia, schizoaffective psychosis, or delusional disorder according to the DSM-III. The patients records must show the presence of persistent positive and negative psychotic symptoms in the past 6 months. The patient must be on stable treatment with antipsychotic medications. The patients records must show severe and persistent psychotic symptoms, despite at least 3 months of continuous antipsychotic medication. It is inferred from the exclusion criteria that the patient must be on stable medication. The patient should be aged No indication of age 18-65. requirement. The patient must be aged between 18 and 65 years. The patients records must show that they have suffered persistent hallucinations and/or delusions for a minimum of 6 months. The patient must be on stable medication.

This is a table of the exclusion criteria from each study11-13.

7 Study 1 The patient has suspected organic brain pathology. The patient suffers from substance dependence or abuses substances. The patient suffers from substance dependence, is acutely suicidal or poorly stabilized. The patient has had previous treatment with CBT or similar therapies. The patient has received psychological or family intervention. Study 2 Study 3 The patient shows evidence of organic brain disease. The patient suffers from substance dependence or abuses substances.

From these tables it is clear that the researchers involved do know how to identify patients to be included in their trials. All of the studies identify that a DSM-IV (or DSM-III) diagnosis for schizophrenia is needed (as its definition is generally accepted worldwide), and they all specify that the patient must have had persistent symptoms over a defined period of time. They ensure that the patient has a history of stable treatment with medication prior to inclusion in the trial (this reduces the risk of the patient dropping out of the study). Study 1 and 3 imposed an age limit of 18 65, but study 2 made no note of this. I believe the decision to impose an age limit is because anyone under the age of 18 is not legally an adult, and they may also not have the maturity to participate in the trial, and as a result they may not fully understand what is involved. An increase in mortality, according to the age for subjects over 65 years, may be a reason to not include this group in the study - which may last for more than 2 years. It would be unfortunate to choose candidates who have a greater chance of not completing the study11-13. In study 1 and 3, the researchers exclude the patient if there is evidence of organic brain disease. This is because psychosis resulting from organic brain disease presents with similar symptoms to schizophrenia, but would not respond to CBT as its origins are organic-biological and not psychological, and so not amenable to psychological treatments11,13. In all of the studies, the patient was excluded if they had substance abuse disorders, as

8 this may interfere with the treatment and the study outcomes11-13. Finally, the patient was excluded (in study 1 and 3 only) if they had or were currently having, CBT or similar therapy. This is because alternate therapies in the past or present could interfere with the results; the patient may know what to expect and take the wrong approach to the treatment, or they may have benefited from the treatment already, and therefore show no improvement11-13. Study 1 enrolled 50 patients who completed the initial assessment phase, however 8 patients dropped out before treatment was completed. 42 patients remained, 24 completed the CBT treatment and 18 people completed treatment as usual. All 42 completed the post treatment assessment. Study 2 enrolled 19 patients; 10 began CBT treatment and 9 began treatment as usual. All patients partaking in the treatment as usual completed the study; only 8 of the 10 patients completed the CBT. Study 3 enrolled 87 patients; all of them completed the pre-treatment assessment. 79 were then reassessed post-treatment. Of these 79 people, 61 were available at 2 years (27 months after pre-treatment assessment) to follow-up11,12. Study 3 had the greatest number of people enrolled into treatment, and also the highest number of people who completed the treatment. However, study 3 had three separate groups, therefore the number of patients per group would be less than that of study 111,13. Study 1: 24 patients completed CBT treatment11 Study 2: 8 patients completed CBT treatment12 Study 3: 20 patients completed CBT treatment13 Study 1 had the greatest number of patients in the trial receiving cognitive behavioural therapy, which would be consistent with providing the most reliable results.

Accurate testing methods for the severity of the condition are needed in order to produce results that show if the treatment has been effective or not. For diagnosing schizophrenia, schizoaffective disorder or delusional disorder, each study used a different technique.

9 Study 1 used the Structured Clinical Interview for DSM-IV axis I disorders (SCID-I interview) to determine if the patient had been suffering from persistent positive and negative psychotic symptoms in the past 6 months. In order to measure the effect of treatment, this study used the PANSS10 scale (Positive and Negative Syndrome Scale), which is a 7-point observer based scale, which assesses 30 items rated on a 7-point scale11. Study 2 diagnosed the severity of the psychotic symptoms using structured psychiatric interviews which included the Comprehensive Assessment of Symptoms and History (CASH)14 and PSYCH (Psychosocial Status You Currently Have). The positive and negative symptoms were evaluated using The Scale for the Assessment of Negative Symptoms (SANS)15 and The Scale for the Assessment of Positive Symptoms (SAPS)16. Study 3 identified positive psychotic symptoms by using the Present State Examination (PSE)17 and rated these symptoms on the Brief Psychiatric Rating Scale15 (a 7-point scale). Negative symptoms were assessed by the Scale for Assessment of Negative Symptoms (SANS)18. Study 1 maintained the blind by hiring assessors that were not staff within the hospital, and therefore had no contact with the treatment services. Also, the patients were informed that they were not to discuss their care with the assessor. All of the patients enrolled were randomly allocated into either CBT or normal treatment programmes. Study 2 did not blind the assessors and the patients were not randomized into groups. Study 3, like study 1, hired assessors who were not staff within the hospital. Patients were randomly allocated into CBT, supportive counselling or normal treatment groups11-13. Study 1 and study 3 both used blinding to reduce the possibility of assessors producing biased results. Study 2 did not use blinds, and therefore the assessor knew if the patient was being treated with CBT or not, and therefore may (subconsciously on not) interpret a greater success of the treatment. Study 1 and 3 also used randomisation, study 2 did not. Randomisation is important as people are spread amongst the groups equally. If the patients were hand picked for the groups, the researchers may choose patients for certain groups based on their opinion regarding whether or not these individuals chosen would produce the best outcomes11-13. Study 1 was carried out in Toronto and Ontario (15 miles apart) with a population of

10 approximately 4.5million. Study 2 was carried out in Iowa and study 3 was carried out in the UK with a catchment area of approximately half a million people. None of the studies were carried out in multiple locations, and even with a large population size (e.g. study 1) the results were all collected from the same location, and may not be valid in different parts of the country or world11-13.

The main reasons for these discrepancies in the results are down to the factors of time and cost. The studies took place over many months, the longer the time period of the study, and the greater the number of patients participating contribute to a greater overall cost. Therefore it is reasonable to consider that the researchers could only carry out the study on a limited number of people to reduce overall cost. Secondly, a shorter time span means that the research paper can be published more quickly, and many scientists are eager to gain recognition as quickly as possible. Future Studies Future studies should have adequate selection criteria (e.g. selection according to diagnosis of schizophrenia from DSM-IV). A study should test the effectiveness of CBT on patients affected with only one condition (e.g. schizophrenia) to prevent the introduction of complications as a result of the influence of other conditions (e.g. substance abuse). Those undertaking the research should check for pathological brain disorders (and exclude the patient if found present). In the studies discussed, the minimum patient age was set at 18 years old, however this would not provide any evaluation the efficacy of CBT in patients under the age of 18. A study regarding the use of CBT in age-defined population(s) of under 18s would provide useful research information on the use of CBT in a non-adult population. Informed consent from the patient, and parents or carers, would however be needed. Differences in effectiveness of CBT according to age may also be studied by selecting elderly population groups. The study should include as many patients as possible (e.g. 1000), collected from a large catchment area (> 2 million) and should carry out identical studies in multiple locations to reduce bias. Treatment that may prove to be effective in certain regions may not be universally effective, and cultural and ethnic considerations would be an

11 important area for further study, (e.g. CBT may prove effective for white Europeans, but may not in other cultural or racial populations). In addition, consideration could be given to research on the effectiveness of CBT across gender differences by specifically selecting groups according to gender.

Studies should compare CBT to at least one other treatment (e.g. routine care) and be blinded at all times to avoid bias from the assessor; this should be done by involving a 3rd party assessor who would have no interest in the results, and can therefore produce raw data without bias. The assessor should be highly qualified, and separate assessors should evaluate each patient on the same day (without the assessors knowledge). This would show if the assessors agree on the patient (and if they dont an average score could be calculated). Patients enrolled into the study should be randomly selected into a group through some suitable method of random allocation. All studies should be carried out over a specified time frame, preferably with data collected as regularly as possible. This would potentially show if the effects of CBT wear off over time, and if so, the relationship between time and the effect the CBT had. From this data, it could be calculated when another treatment of CBT is necessary. The study should use the most accurate method for determining the severity of positive and negative symptoms of schizophrenia; each study should use the same scale, (e.g. PANSS scale). This reduces complications in comparing scoring from different scales, and therefore produces more consistent results. Future studies could also assess the effect of CBT associated with different doses of antipsychotic medication. This may provide evidence to what degree CBT is effective in conjunction with the lowest dosage of ant-psychotic medication.

References 1. Proctor SE, Mitford E, Paxton R. First episode psychosis: a novel methodology

12 reveals higher than expected incidence; a reality-based population profile in Northumberland, UK. J Eval Clin Pract. 2004;10:539-547. 2. Johannessen JO. Review: lifetime prevalence of schizophrenia and related disorders is about 5.5 per 1000, but there is significant variation between regions. Evid Based Ment Health. 2003 6:74. 3. Morrison AP, Dunn H, Bentall R, Renton J, Williams S. Cognitive Therapy for Psychosis - A Formulation-based Approach. East Sussex: Brunner-Routledge. 2003. 4. Amador X, Arndt S, Berner P, Bitter I, Black DW, Borum R et al. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association. 2000. p. 297. 5. Clarke M, Whitty P, Browne S, McTigue O, Kamali M, Gervin M et al. Untreated illness and outcome of psychosis. Br J Psychiatry. 2006 Sep:189:235-40. 6. Drake RJ, Haley CJ, Akhtar S, Lewis SW. Causes and consequences of duration of untreated psychosis in schizophrenia. Br J Psychiatry. 2000 Dec;177:511-5. 7. Carbone S, Harrigan S, McGorry PD, Curry C, Elkins K. Duration of untreated psychosis and 12-month outcome in first-episode psychosis: the impact of treatment approach. Acta Psychiatr Scand. 1999 Aug;100(2):96-104. 8. Birchwood M, McGorry P, Jackson H. Early intervention in schizophrenia. Br J Psychiatry. 1997 Jan;170:2-5. 9. Kendler KS, Diehl SR. The genetics of schizophrenia: a current, geneticepidemiologic perspective. Schizophr Bull. 1993;19(2):261-85. 10. Saltz BL, Woerner MG, Robinson DG, Kane JM. Side effects of antipsychotic drugs. Avoiding and minimizing their impact in elderly patients. Postgrad Med. 2000;107:169-72, 175-8.

11. Rector NA, Seeman MV, Segal ZV. Cognitive therapy for schizophrenia: a preliminary randomized controlled trial. Schizophr Res. 2003 Sep 1;63(1-2):1-11.

13 12. Temple S, Ho BC. Cognitive therapy for persistent psychosis in schizophrenia: a case-controlled clinical trial. Schizophr Res. 2005 May 1;74(2-3):195-9. 13. Tarrier N, Kinney C, McCarthy E, Humphreys L, Wittkowski A, Morris J. TwoYear Follow-Up of CognitiveBehavioral Therapy and Supportive Counseling in the Treatment of Persistent Symptoms in Chronic Schizophrenia. 2000 Oct;68(5):917-22.

14. Andreasen NC, Flaum M, Arndt S. The Comprehensive Assessment of Symptoms and History (CASH). An instrument for assessing diagnosis and psychopathology. Arch Gen Psychiatry. 1992;49:615-623. 15. Andreasen NC. Scale for the Assessment of Negative Symptoms (SANS). University of Iowa, Iowa City, 1982. 16. Andreasen NC. The Scale for the Assessment of Positive Symptoms (SAPS). University of Iowa, Iowa, 1984. 17. Wing J, Cooper J, Sartorius N. Measurement and classification of psychiatric symptoms. Cambridge, England: Cambridge University Press. 1974. 18. Lukoff D, Liberman RP, Nuechterlein KH. Symptom monitoring in the rehabilitation of schizophrenic patients. Schizophr Bull. 1986;12:578-602.

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Appendix Timetable
Mon 21 Met convenor. Discussed SSM options. Initial choice of CBT was made 28 Checked if referencing was correct with convenor substitute 29 Reviewed intro, shortened it and rephrased. Searched PubMed 30 Chose criteria for literary search. Finished intro. Searched PubMed 31 Narrowed search to 89 results. Read through several summaries Chose articles 4 Unwell 5 Continued working. Emailed convenor to catch up on Monday 6 Summarised journals in Microsoft word 7 Wrote more on intro, added some sources. 8 2200 words, began thinking of conclusion. Read 9 Finished method. Changed intro, wrote conclus10 Checked spelling, grammar, changed some 1 Read all three journal articles. Highligting key parts 2 Began main section of write-up. Stopped due to headache 3 Unwell Tues 22 Wed 23 Thu 24 Visited MedLine, Athens, Cochrane Library, PubMed Fri 25 Wrote a brief into to psychosis and CBT. Read about delusions Sat 26 Searched for articles on CBT and psychosis Sun 27 Read how to reference and practiced DSM - IV

Researched Browsed psychosis and CBT Read DSM IV on psychotic illness internet on CBT, psychosis Wrote title of review

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and to see if I was on the right track 11 Met convenor Decided to change structure. 12 Removed most direct quotes. Put into own words 13 Finished writing abstract. Reviewed everything Wrote more of main article 14 Finalised everything. Handed in review. 15 over write up so far ion sentences