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Cognitive–behavioural therapy for refractory psychotic symptoms of schizophrenia resistant to atypical antipsychotic medication: Randomised controlled trial

  • Lucia R. Valmaggia (a1), Mark van der Gaag (a2), Nicholas Tarrier (a3), Marieke Pijnenborg (a4) and Cees J. Slooff (a4)...
Abstract
Background

There is increasing evidence that cognitive–behavioural therapy can be an effective intervention for patients experiencing drug-refractory positive symptoms of schizophrenia.

Aims

To investigate the effects of cognitive–behavioural therapy on in-patients with treatment-refractory psychotic symptoms.

Method

Manualised therapy was compared with supportive counselling in a randomised controlled study. Both interventions were delivered by experienced psychologists over 16 sessions of treatment. Therapy fidelity was assessed by two independent raters. Participants underwent masked assessment at baseline, after treatment and at 6 months' follow-up. Main outcome measures were the Positive and Negative Syndrome Scale and the Psychotic Symptoms Rating Scale. The analysis was by intention to treat.

Results

Participants receiving cognitive–behavioural therapy had improved with regard to auditory hallucinations and illness insight at the post-treatment assessment, but these findings were not maintained at follow-up.

Conclusions

Cognitive–behavioural therapy showed modest short-term benefits over supportive counselling for treatment-refractory positive symptoms of schizophrenia.

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Copyright
Corresponding author
Lucia R. Valmaggia, Department of Psychological Medicine, PO 67, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. Tel/fax: +44 (0)20 7848 0952; e-mail: L.Valmaggia@iop.kcl.ac.uk
Footnotes
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Declaration of interest

None. Funding detailed in Acknowledgements.

Footnotes
References
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Cognitive–behavioural therapy for refractory psychotic symptoms of schizophrenia resistant to atypical antipsychotic medication: Randomised controlled trial

  • Lucia R. Valmaggia (a1), Mark van der Gaag (a2), Nicholas Tarrier (a3), Marieke Pijnenborg (a4) and Cees J. Slooff (a4)...
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eLetters

Cognitive Behavioural Therapy for refractory symptoms in schizophrenia

Mahesh Jayaram
21 April 2005

Valmaggia et al (2005) report an interesting randomised control trialevaluating Cognitive-behavioural therapy (CBT) for refractory psychotic symptoms of schizophrenia resistant to atypical antipsychotic medication. The authors conclude that patients should not be excluded from psychological help on the grounds that they were too ill to benefit from therapy and cognitive behavioural therapy for psychotic symptoms should beavailable in in-patient facilities.

We feel the conclusions drawn by the authors do not truly reflect their results. The authors report that their primary hypothesis was that CBT would be more effective than supportive counselling in reducing auditory hallucinations and delusional beliefs. They have used the Positive and Negative syndrome scale (PANSS) and Psychotic symptom rating scale (PSYRATS) to measure the outcomes. From their own results, the post-treatment score on the PANSS positive subscale was not significantly different from the control group. On PSYRATS no significant effect was found on the delusions. CBT did benefit the physical characteristics of the auditory hallucination and cognitive interpretation but not on emotional characteristics. Even the benefits noticed were not sustained atfollow up. It would have been helpful if the authors had used an a priori definition of what constitutes a clinically meaningful improvement and provided the actual figures for the dichotomous outcome.

Also if one were to look at the NNT calculations, the authors have accurately reported the lack of statistical significance (PANSS positive symptom scale NNT 8, 95% CI 3 to ¡Þ, PSYRATS factor 2 NNT is 6, CI 2 to ¡Þand delusion scale factor 1, NNT is 4, CI 2 to ¡Þ and factor 2 NNT is 12, CI 3 to ¡Þ). The only finding with reasonable confidence intervals seems to be cognitive interpretation on the auditory hallucination scale of PSYRATS. (NNT 3, 95% CI 2-13). The authors also draw our attention to thefact that clozapine is effective in 32% of cases in producing a clinical improvement NNT 5, 95% CI 4 to 7 (Wahlbeck et al 1999). The authors seem to suggest that the figures from the current study are comparable to the effects of clozapine. However it has to be noted that this figure reported by Wahlbeck et al is for global improvement whereas in the current report the authors do not give any figures for global improvement and hence in our opinion these are not comparable. To conclude from these results that CBT could induce a change in psychotic symptoms seems to be overestimating the beneficial effects.

Patients with schizophrenia who are resistant to clozapine form one of the most difficult to treat client group. Cochrane review (Jones et al 2004) conclude that trial-based data supporting the wide use of CBT for people with schizophrenia or other psychotic illnesses are far from conclusive. This study evaluating interventions aimed at this population in a randomised control design is a welcome measure.

References:

Jones C, Cormac I, Silveira da Mota Neto JI., et al (2004) Cognitivebehaviour therapy for schizophrenia. The Cochrane Database of Systematic Reviews 2004, Issue 4.

Valmaggia, L.R., Gaag, Van der M., Tarrier, N., et al (2005) Cognitive¨Cbehavioural therapy for refractory psychotic symptoms of schizophrenia resistant to atypical antipsychotic medication: Randomised controlled trial Br J Psychiatry 2005; 186: 324-330

Wahlbeck K, Cheine M, Essali MA. (1999) Clozapine versus typical neuroleptic medication for schizophrenia. The Cochrane Database of Systematic Reviews 1999, Issue 4.
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Conflict of interest: None Declared

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