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Cognitive-behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: Randomised controlled trial

  • Philippa A. Garety (a1), David G. Fowler (a2), Daniel Freeman (a3), Paul Bebbington (a4), Graham Dunn (a5) and Elizabeth Kuipers (a3)...
Abstract
Background

Family intervention reduces relapse rates in psychosis. Cognitive-behavioural therapy (CBT) improves positive symptoms but effects on relapse rates are not established.

Aims

To test the effectiveness of CBT and family intervention in reducing relapse, and in improving symptoms and functioning in patients who had recently relapsed with non-affective psychosis.

Method

A multicentre randomised controlled trial (ISRCTN83557988) with two pathways: those without carers were allocated to treatment as usual or CBT plus treatment as usual, those with carers to treatment as usual, CBT plus treatment as usual or family intervention plus treatment as usual. The CBT and family intervention were focused on relapse prevention for 20 sessions over 9 months.

Results

A total of 301 patients and 83 carers participated. Primary outcome data were available on 96% of the total sample. The CBT and family intervention had no effects on rates of remission and relapse or on days in hospital at 12 or 24 months. For secondary outcomes, CBT showed a beneficial effect on depression at 24 months and there were no effects for family intervention. In people with carers, CBT significantly improved delusional distress and social functioning. Therapy did not change key psychological processes.

Conclusions

Generic CBT for psychosis is not indicated for routine relapse prevention in people recovering from a recent relapse of psychosis and should currently be reserved for those with distressing medication-unresponsive positive symptoms. Any CBT targeted at this acute population requires development. The lack of effect of family intervention on relapse may be attributable to the low overall relapse rate in those with carers.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial licence (http://creativecommons.org/licenses/by-nc/4.0/), which permits noncommercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work.
Corresponding author
Professor Philippa Garety, Department of Psychology, PO77, Institute of Psychiatry, De Crespigny Park, London, SE5 8AF, UK. Email: p.garety@iop.kcl.ac.uk
Footnotes
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See editorial, pp. 401-403, this issue.

Declaration of interest

None.

Funding detailed in Acknowledgements.

Footnotes
References
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1 Craig, TK, Garety, P, Power, P, Rahaman, N, Colbert, S, Fornells-Ambrojo, M, Dunn, G. The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. BMJ 2004; 329: 1067–70.
2 Thornicroft, G, Tansella, M, Becker, T, Knapp, M, Leese, M, Schene, A, Vasquez-Barquero JL on behalf of the EPSILON study group. The personal impact of schizophrenia in Europe. Schizophr Res 2004; 69: 125–32.
3 Lieberman, JA, Stroup, TS, McEvoy, JP, Swartz, MS, Rosenheck, RA, Perkins, DO, Keefe, RS, Davis, SM, Davis, CE, Lebowitz, BD, Severe, J, Hsiao JK on behalf of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 2005; 353: 1209–23.
4 Grawe, RW, Falloon, I, Widen, JH, Skogvoll, E. Two years of continued early treatment for recent-onset schizophrenia: a randomised controlled study. Acta Psych Scand 2006; 114: 328–36.
5 Jones, PB, Barnes, TR, Davies, L, Dunn, G, Lloyd, H, Hayhurst, KP, Murray, RM, Markwick, A, Lewis, SW. Randomized controlled trial of the effect on quality of life of second- vs first-generation antipsychotic drugs in schizophrenia: Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS1). Arch Gen Psychiatry 2006; 63: 1079–87.
6 Pilling, S, Bebbington, P, Kuipers, E, Garety, P, Geddes, J, Orbach, G, Morgan, C. Psychological treatments in schizophrenia. I: Meta-analysis of family intervention and cognitive behaviour therapy. Psycho Med 2002; 32: 763–82.
7 Jones, C, Cormac, I, Silveira Da Mota Neto, JI, Campbell, C. Cognitive behaviour therapy for schizophrenia. Cochrane Database Syst Rev 2004; 18 (4): CD000524.
8 Zimmermann, G, Favrod, J, Trieu, VH, Pomini, V. The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophr Res 2005; 77: 19.
9 Pfammatter, M, Junghan, UM, Brenner, HD. Efficacy of psychological therapy in schizophrenia: conclusions from meta-analyses. Schizophr Bu 2006; 32 (suppl 1): S6480.
10 Pitschel-Walz, G, Leucht, S, Bauml, J, Kissling, W, Engel, RR. The effect of family interventions on relapse and rehospitalization in schizophrenia: a meta-analysis. Schizophr Bull 2001; 27: 7392.
11 Pharoah, F, Mari, J, Rathbone, J, Wong, W. Family intervention for schizophrenia. Cochrane Database Syst Rev 2006; 18 (4): CD000088.
12 Bustillo, JR, Lauriello, J, Horan, WP, Keith, SJ. The psychosocial treatment of schizophrenia: an update. Am J Psychiatry 2001; 158: 163–75.
13 Gumley, A, O'Grady, M, McNay, L, Reilly, J, Power, K, Norrie, J. Early intervention for relapse in schizophrenia: results of a 12-month randomized controlled trial of cognitive behavioural therapy. Psychol Med 2003; 33: 419–31.
14 Trower, P, Birchwood, M, Meaden, A, Byrne, S, Nelson, A, Ross, K. Cognitive therapy for command hallucinations: randomised controlled trial. Br J Psych 2008 2004; 184: 312–20.
15 Tarrier, N, Wykes, T. Is there evidence that CBT is an effective treatment for schizophrenia? A cautious or cautionary tale. Behav Res Ther 2004; 42: 1371–401.
16 National Institute for Health and Clinical Excellence. Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care (Full Guideline). Gaskell & British Psychological Society, 2003.
17 Kay, RS. Positive and Negative Syndromes in Schizophrenia: Assessment and Research. Brunner/Mazel, 1991.
18 Fowler, D, Garety, PA, Kuipers, L. Cognitive Behaviour Therapy for Psychosis: Theory and Practice. Wiley, 1995.
19 Garety, PA, Kuipers, E, Fowler, D, Freeman, D, Bebbington, PE. A cognitive model of the positive symptoms of psychosis. Psychol Med 2001; 31: 189–95.
20 Freeman, D, Garety, PA, Fowler, D, Kuipers, E, Bebbington, PE, Dunn, G. Why do people with delusions fail to choose more realistic explanations for their experiences? An empirical investigation. J Consult Clin Psychol 2004; 72: 671–80.
21 Kuipers, E, Leff, JP, Lam, D. Family Work for Schizophrenia: A Practical Guide (2nd edn). Gaskell, 2002.
22 Young, JE, Beck, AT. Cognitive Therapy Scale: Rating Manual. Center for Cognitive Therapy, Philadelphia, USA, 1980.
23 Startup, M, Jackson, M, Pearce, E. Assessing therapist adherence to cognitive-behaviour therapy for psychosis. Behav Cogn Psychother 2002; 30: 329–39.
24 Bebbington, PE, Craig, T, Garety, P, Fowler, D, Dunn, G, Colbert, S, Fornells-Ambrojo, M, Kuipers, E. Remission and relapse in psychosis: operational definitions based on case-note data. Psychol Med 2006; 36: 1551–62.
25 World Health Organization. SCAN Schedules for Clinical Assessment in Neuropsychiatry. World Health Organization, 1992.
26 Haddock, G, McCarron, J, Tarrier, N, Faragher, EB. Scales to measure dimensions of hallucinations and delusions: the Psychotic Symptom Rating Scales (PSYRATS). Psychol Med 1999; 29: 879–89.
27 Beck, AT, Steer, RA, Brown, GK. BDI-II Manual. Psychological Corporation, 1996.
28 Beck, AT, Epstein, N, Brown, G, Steer, RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 1988; 56: 893–7.
29 Jolley, S, Garety, PA, Ellett, L, Kuipers, E, Freeman, D, Bebbington, PE, Fowler, DG, Dunn, G. A validation of a new measure of activity in psychosis. Schizophr Res 2006; 85: 288–95.
30 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, (4th edn) (DSM-IV) APA, 1994.
31 Beecham, J, Knapp, M. Costing psychiatric interventions. In Measuring Mental Health Needs (eds Thornicroft, G, Brewin, CR, Wing, JK) Gaskell, 1992: 163–84.
32 Amador, XF, Strauss, DH, Yale, SA, Flaum, MM, Endicott, J, Gorman, JM. Assessment of insight in psychosis. Am J Psychiatry 1993; 150: 873–9.
33 Watson, PW, Garety, PA, Weinman, J, Dunn, G, Bebbington, PE, Fowler, D, Freeman, D, Kuipers, E. Emotional dysfunction in schizophrenia spectrum psychosis: the role of illness perceptions. Psychol Med 2006; 36: 761–70.
34 Weinman, J, Petrie, K, Moss-Morris, R, Horne, R. The Illness Perception Questionnaire: a new method for assessing the cognitive representation of illness. Psychol Health 1996; 11: 431–45.
35 Fowler, D, Freeman, D, Smith, B, Kuipers, E, Bebbington, P, Bashforth, H, Coker, S, Hodgekins, J, Gracie, A, Dunn, G, Garety, P. The Brief Core Schema Scales (BCSS): psychometric properties and associations with paranoia and grandiosity in non-clinical and psychosis samples. Psychol Med 2006; 36: 749–59.
36 Garety, PA, Freeman, D, Jolley, S, Dunn, G, Bebbington, PE, Fowler, DG, Kuipers, E, Dudley, R. Reasoning, emotions, and delusional conviction in psychosis. J Abnorm Psychol 2005; 114: 373–84.
37 Wessely, S, Buchanan, A, Reed, A, Cutting, J, Everitt, B, Garety, P, Taylor, PJ. Acting on delusions. (I): prevalence. Br J Psychiatry 1993; 163: 6976.
38 Ammons, RB, Ammons, CH. The Quick Test: Provisional Manual. Psychological Test Specialists, 1962.
39 Vaughn, CE, Leff, J. The measurement of expressed emotion in the families of psychiatric patients. Br J Soc Clin Psychol 1976; 15: 157–65.
40 Szmukler, GL, Burgess, P, Herrman, H. Caring for relatives with serious mental illness: the development of the Experience of Caregiving Inventory. Soc Psychiatry Psychiatr Epidemiol 1996; 31: 137–48.
41 Goldberg, DP, Hillier, VF. A scaled version of the General Health Questionnaire. Psychol Med, 1979; 9: 139–45.
42 Elashoff, JD. nQuery Advisor User's Guide. Dixon Associates, 1995.
43 StataCorp. Stata Statistical Software: Release 9.0. Stata Corporation, 2005.
44 Little, RJA, Rubin, DB. Statistical Analysis with Missing Data (2nd edn). John Wiley & Sons, 2002.
45 Everitt, BS, Pickles, A. Statistical Aspects of the Design and Analysis of Clinical Trials. Imperial College Press, 1999.
46 Heyting, A, Tolboom, JT, Essers, JG. Statistical handling of drop-outs in longitudinal clinical trials. Stats Med 1992; 11: 2043–61.
47 Brazier, J, Jones, N, Kind, P. Testing the validity of the EuroQol and comparing it with the SF-36 health survey questionnaire. Qual Life Res 1993; 2: 169–80.
48 Kuipers, E, Bebbington, P, Dunn, G, Fowler, D, Freeman, D, Watson, P, Hardy, A, Garety, P. Influence of carer expressed emotion and affect on relapse in non-affective psychosis. Br J Psychiatry 2006; 188: 173–9.
49 Hogarty, GE, Kornblith, SJ, Greenwald, D, DiBarry, AL, Cooley, S, Ulrich, RF, Carter, M, Flesher, S. Three years trials of personal therapy with schizophrenics living with or independent of family. I: Description of study and effects on relapse rates. Am J Psychiatry 1997; 154: 1504–13.
50 Hogarty, GE, Greenwald, D, Ulrich, RF, Kornblith, SJ, DiBarry, AL, Cooley, S, Carter, M, Flesher, S. Three years trials of personal therapy with schizophrenics living with or independent of family. II: Effects on adjustment of patients. Am J Psychiatry 1997; 154: 1514–24.
51 Garety, PA, Bebbington, P, Fowler, D, Freeman, D, Kuipers, E. Theoretical paper: implications for neurobiological research of cognitive models of psychosis. Psychol Med 2007; 37: 1377–91.
52 Bebbington, PE, Bhugra, D, Brugha, T, Singleton, N, Farrell, M, Jenkins, R, Lewis, G, Meltzer, H. Psychosis, victimisation and childhood disadvantage: evidence from the second British National Survey of Psychiatric Morbidity. Br J Psychiatry 2004; 185: 220–6.
53 Morgan, C, Kirkbride, J, Leff, J, Craig, T, Hutchinson, G, McKenzie, K, Morgan, K, Dazzan, P, Doody, GA, Jones, P, Murray, R, Fearon, P. Parental separation, loss and psychosis in different ethnic groups: a case-control study. Psychol Med 2007; 37: 495503.
54 Tait, L, Birchwood, M, Trower, P. Adapting to the challenge of psychosis: personal resilience and the use of sealing-over (avoidant) coping strategies. Br J Psychiatry 2004; 185: 410–5.
55 Rollinson, R, Haig, C, Warner, R, Garety, P, Kuipers, E, Freeman, D, Bebbington, P, Dunn, G, Fowler, D. The application of cognitive-behavioral therapy for psychosis in clinical and research settings. Psychiatr Serv 2007; 58: 1297–302.
56 Birchwood, M, Trower, P. The future of cognitive-behavioural therapy for psychosis: not a quasi-neuroleptic. Br J Psychiatry 2006; 188: 107–8.
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Cognitive-behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: Randomised controlled trial

  • Philippa A. Garety (a1), David G. Fowler (a2), Daniel Freeman (a3), Paul Bebbington (a4), Graham Dunn (a5) and Elizabeth Kuipers (a3)...
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eLetters

No risk of harm after psychological intervention for psychosis

Philippa A Garety, Professor of Clinical Psychology
01 August 2008

1st August 2008 PAG/JS/010808

Editor,British Journal of Psychiatry,Royal College of Psychiatrists,17 Belgrave Square,LONDONSW1X 8PG

Dear Editor,

Marlowe notes that the primary outcome of our trial was relapse and comments that it is surprising, therefore, that it was not analysed in more detail. He does not appear to understand the inferential problems raised by the lack of full or partial remission in a considerable proportion of the patients in this trial. The number with full or partialremission is itself an outcome of the trial (i.e. it is a post-randomisation measure). Those who have shown no recovery are excluded fromthe relapse data that Marlowe presents. In fact, twice as many people showno recovery in TAU as in CBT (18:9). The data reported by Marlowe are therefore not a causal effect of randomisation (i.e. not an intention-to-treat effect). Because of this problem, we used months in full or partial remission as our primary indicator of outcome, for which a formal intention-to-treat analysis is presented. This analysis and also a furtherexamination of total days in hospital and number of admissions very clearly demonstrate that CBT, FI and TAU do not differ. We also reported fully on deaths and other adverse events and found no differences (the only completed suicide was in TAU). We are therefore not at all convinced by the suggestion that psychological intervention might be detrimental. Indeed, we infer on the basis of the results of this trial and of numerousmeta-analyses (e.g. Pfammater et al 2006; Pilling et al 2002; Wykes et al 2008) that CBT and FI are beneficial for certain populations for a range of outcomes.

With respect to the effects of having a carer on a psychological intervention, we are of course, very aware of the Hogarty et al (1997a & 1997b) study, which we also discuss. It reported mixed findings. Ourpoint here concerned the apparently beneficial effect of having a carer onCBT, which has not been examined before, including in that study.

Yours sincerely

Philippa A Garety, David G Fowler, Daniel Freeman, Paul Bebbington, Graham Dunn & Elizabeth Kuipers

References:

Hogarty, G.E., Kornblith, S.J., Greenwald, P., et al (1997a). Three years trials of personal therapy with schizophrenics living with or independent of family. I: Description of study and effects on relapse rates. American Journal of Psychiatry, 154, 1504-1513

Hogarty, G.E., Greenwald, P., Ulrich, R.F., et al (1997b). Three years trials of personal therapy with schizophrenics living with or independent of family. II: Effects on adjustment of patients. American Journal of Psychiatry, 154, 1514-1524.

Pfammatter, M., Jungham, U.M., & Brenner, H.D. (2006). Efficacyof psychological therapy in schizophrenia: conclusions from meta-analyses.Schizophrenia Bulletin, 32 Suppl 1, S64-80.

Pilling, S., Bebbington, P., Kuipers, E., et al. (2002). Psychological treatments in schizophrenia. I: Meta-analysis of family intervention and cognitive behaviour therapy. Psychological Medicine, 32:763-782.

Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behaviour therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34: 523-537.

Declaration of interest

None.

Trial funded by Wellcome Trust.

Details for authors:

Corresponding author:Philippa Garety,Professor of Clinical Psychology,Department of Psychology, PO77,Institute of Psychiatry,King’s College London,De Crespigny Park,LONDONSE5 8AFTel: 020 7848 5046Fax: 020 7848 5006

David Fowler,Professor of Social Psychiatry,Department of Psychology and Psychiatry,School of Medicine,University of East Anglia,Earlham Road,NORWICHNR4 7TJ

Daniel Freeman,Senior Lecturer in Clinical Psychology,Department of Psychology, PO77,Institute of Psychiatry,King’s College London,De Crespigny Park,LONDONSE5 8AF

Paul Bebbington,Professor of Social and Community Psychiatry,Mental Health Sciences,Charles Bell House,University College London,67-73 Riding House Street,LONDONW1W 7EJ

Graham Dunn,Professor of Biomedical Statistics,Health Medical Research Group,Community Based Medicine,University of Manchester,University Place,Oxford Road,MANCHESTERM13 9PL

Elizabeth Kuipers,Professor of Clinical Psychology,Department of Psychology, PO77,Institute of Psychiatry,King’s College London,De Crespigny Park,LONDONSE5 8AF
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Conflict of interest: None Declared

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Risk of harm from increased relapse of psychosis after psychological intervention

Karl Marlowe, Consultant Psychiatrist
30 July 2008

Dear Sir,

The paper by Garety et al (1) was an extremely important and methodological robust examination of the impact of psychosocial interventions for schizophrenia. The editorial by Scott (2) in the same edition, suggested that there has been an over promise of CBT and the inclusion in the NICE (3) guideline might have been oversold as there was a lack of evidence of efficacy in schizophrenia. There are several points which need to be added to that discussed in the paper and in the editorial.

The hypothesis used to calculate power was based on the primary outcome of relapse from a non-affective psychosis (ICD-10 category F20-29,and not F2 as reported in the paper), using Treatment As Usual (TAU), CBT for Psychosis and Family Intervention (FI) as comparison interventions. Itis therefore important to focus on this outcome and it is surprising that this was not analysed in greater detail.

The published relapse rates after full remission and from full/partial remission, in the no-carer pathway, was 35.4% and 37% for TAU, 46.8% and 54.6% for CBT; in the carer pathways this was 21.4% and 25.9% for TAU, 27.3% and 28% for CBT, 22.2% and 20.8% for FI. It would have been important to analysis the pathways separately as the no-carer pathway shows a trend for an increase in relapse rates. This was indeed the statistical evaluation in the seminal Personal Therapy/Family Therapy 3-year study by Hogarty et al (4), where offering therapeutic interventionin a no-carer pathway led to significantly increased rates of psychotic relapse. The discussion in the published paper was thus incorrect in the assertion of the effect of having a carer during psychological intervention, had not been reported before.

The second table of results showed the number of relapses in the no-carer pathway was 0.79 for TAU, 1.17 for CBT; and for the carer pathway this was 0.31 for TAU, 0.63 for CBT and 0.96 for FI. The relapse rates point towards an increase in hypothesised outcome and the risk of harm or hazard (5) needs to have been discussed in greater detail, to give balanceto what has already been acknowledged to be an over sold intervention.

(word count =360)

Reference

1 Garety P, Fowler DG, Freeman D, Bebbington P, Dunn G, Kuipers E. Cognitive–behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: randomised controlled trial. Br J Psych 2008; 192: 412 -23.

2 Scott J. Cognitive-behavioural therapy for severe mental disorders: back to the future? Br J Psych 2008; 192: 401 -03.

3 National Institute for health and Clinical Excellence. Schizophrenia: Core interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. NICE, 2003

4 Hogarty GE, Kornblith SJ, Greenwald D, DiBarry AL, Cooley S, UlrichRF, Carter M, Flesher S. Three years trials of personal therapy with schizophrenics living with or independent of family. I: Description of study and effects on relapse rates. Am J Psychiatry 1997; 154: 1504 -13.

5 Marlowe K. Early interventions for psychosis. Br J Psych 2005; 186: 262 -3.
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Conflict of interest: None Declared

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