Skip to main content Accessibility help
×
Home

Cognitive–behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias

  • S. Jauhar (a1), P. J. McKenna (a2), J. Radua (a2), E. Fung (a3), R. Salvador (a2) and K. R. Laws (a4)...

Abstract

Background

Cognitive–behavioural therapy (CBT) is considered to be effective for the symptoms of schizophrenia. However, this view is based mainly on meta-analysis, whose findings can be influenced by failure to consider sources of bias.

Aims

To conduct a systematic review and meta-analysis of the effectiveness of CBT for schizophrenic symptoms that includes an examination of potential sources of bias.

Method

Data were pooled from randomised trials providing end-of-study data on overall, positive and negative symptoms. The moderating effects of randomisation, masking of outcome assessments, incompleteness of outcome data and use of a control intervention were examined. Publication bias was also investigated.

Results

Pooled effect sizes were −0.33 (95% CI −0.47 to −0.19) in 34 studies of overall symptoms, −0.25 (95% CI −0.37 to −0.13) in 33 studies of positive symptoms and −0.13 (95% CI −0.25 to −0.01) in 34 studies of negative symptoms. Masking significantly moderated effect size in the meta-analyses of overall symptoms (effect sizes −0.62 (95% CI −0.88 to −0.35) v. −0.15 (95% CI −0.27 to −0.03), P = 0.001) and positive symptoms (effect sizes −0.57 (95% CI −0.76 to −0.39) v. −0.08 (95% CI −0.18 to 0.03), P<0.001). Use of a control intervention did not moderate effect size in any of the analyses. There was no consistent evidence of publication bias across different analyses.

Conclusions

Cognitive–behavioural therapy has a therapeutic effect on schizophrenic symptoms in the ‘small’ range. This reduces further when sources of bias, particularly masking, are controlled for.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Cognitive–behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Cognitive–behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Cognitive–behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias
      Available formats
      ×

Copyright

Corresponding author

P. J. McKenna, Benito Menni CASM. Germanes Hospitalàries del Sagrat Cor de Jesús, C/Doctor Antoni Pujades 38-C, 08830 - Sant Boi de Llobregat (BARCELONA), Spain. Email: mckennapeter1@googlemail.com

Footnotes

Hide All

Declaration of interest

None.

Footnotes

References

Hide All
1 Kuipers, E Garety, P Fowler, D Dunn, G Bebbington, P Freeman, D et al. London–East Anglia randomised controlled trial of cognitive–behavioural therapy for psychosis. I: effects of the treatment phase. Br J Psychiatry 1997; 171: 319327.
2 National Collaborating Centre for Mental Health. Schizophrenia. Full National Clinical Guideline on Core Interventions in Primary and Secondary Care. Royal College of Psychiatrists and the British Psychological Society, 2003.
3 National Institute of Health and Clinical Excellence. Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care (Update). NICE, 2009.
4 Lehman, A Lieberman, JA Dixon, LB McGlashan, TH Miller, AL Perkins, DO et al. American Psychiatric Association Practice Guideline for the Treatment of Patients with Schizophrenia (2nd edn). American Psychiatric Association, 2004.
5 Kreyenbuhl, J Buchanan, RW Dickerson, FB Dixon, LB The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull 2010; 36: 94103.
6 Dixon, LB Dickerson, F Bellack, AS Bennett, M Dickinson, D Goldberg, RW et al. The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophr Bull 2010; 36: 4870.
7 Rathod, S Phiri, P Kingdon, D Cognitive behavioral therapy for schizophrenia. Psychiatr Clin North Am 2010; 33: 527536.
8 Sensky, T Turkington, D Kingdon, D Scott, JL Scott, J Siddle, R et al. A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Arch Gen Psychiatry 2000; 57: 165172.
9 Lewis, S Tarrier, N Haddock, G Bentall, R Kinderman, P Kingdon, D et al. Randomised controlled trial of cognitive–behavioural therapy in early schizophrenia: acute-phase outcomes. Br J Psychiatry 2002; 181 (suppl 43): s91s97.
10 Bechdolf, A Knost, B Kuntermann, C Schiller, S Klosterkotter, J Hambrecht, M et al. A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in patients with schizophrenia. Acta Psychiatr Scand 2004; 110: 2128.
11 Garety, PA 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 Psychiatry 2008; 192: 412423.
12 Klingberg, S Wolwer, W Engel, C Wittorf, A Herrlich, J Meisner, C et al. Negative symptoms of schizophrenia as primary target of cognitive behavioral therapy: results of the randomized clinical TONES study. Schizophr Bull 2011; 37 (suppl 2): S98110.
13 Turkington, D Kingdon, D Turner, T Effectiveness of a brief cognitive–behavioural therapy intervention in the treatment of schizophrenia. Br J Psychiatry 2002; 180: 523527.
14 van der Gaag, M Stant, AD Wolters, KJK Buskens, E Wiersma, D Cognitive–behavioural therapy for persistent and recurrent psychosis in people with schizophrenia-spectrum disorder: cost-effectiveness analysis. Br J Psychiatry 2011; 198: 5965.
15 Jones, C Cormac, I Silveira da Mota Neto, J Campbell, C Cognitive behaviour therapy for schizophrenia. Cochrane Database Syst Rev 2004; 4: CD000524.
16 Pilling, S Bebbington, P Kuipers, E Garety, P Geddes, J Orbach, G et al. Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychol Med 2002; 32: 763782.
17 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.
18 Lincoln, TM Suttner, C Nestoriuc, Y Effects of cognitive interventions for schizophrenia: a meta-analysis [Wirksamkeit kognitiver interventionen für schizophrenie: eine meta-analyse]. Psychol Rundsch 2008; 59: 217232.
19 Wykes, T Steel, C Everitt, B Tarrier, N Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophr Bull 2008; 34: 523537.
20 Lau, J Antman, EM Jimenez-Silva, J Kupelnick, B Mosteller, F Chalmers, TC Cumulative meta-analysis of therapeutic trials for myocardial infarction. N Engl J Med 1992; 327: 248254.
21 Green, BB Taplin, SH. Breast cancer screening controversies. J Am Board Fam Pract 2003; 16: 233241.
22 Streiner, DL. I have the answer, now what's the question?: Why metaanalyses do not provide definitive solutions. Can J Psychiatry 2005; 50: 829831.
23 Egger, M Smith, GD. Misleading meta-analysis. BMJ 1995; 310: 752754.
24 LeLorier, J Gregoire, G Benhaddad, A Lapierre, J Derderian, F Discrepancies between meta-analyses and subsequent large randomized, controlled trials. N Engl J Med 1997; 337: 536542.
25 Jüni, P Altman, DG Egger, M Systematic reviews in health care: assessing the quality of controlled clinical trials. BMJ 2001; 323: 4246.
26 Herbison, P Hay-Smith, J Gillespie, WJ Adjustment of meta-analyses on the basis of quality scores should be abandoned. J Clin Epidemiol 2006; 59: 12491256.
27 Higgins, JPT Altman, DG. Assessing risk of bias in included studies. In Cochrane Handbook for Systematic Reviews of Interventions, Version 5.0.1 (eds JPT Higgins, S Green). The Cochrane Collaboration, 2008.
28 Chambless, DL Hollon, SD. Defining empirically supported therapies. J Consult Clin Psychol 1998; 66: 718.
29 Jensen, PS Weersing, R Hoagwood, KE Goldman, E What is the evidence for evidence-based treatments? A hard look at our soft underbelly. Ment Health Serv Res 2005; 7: 5374.
30 Kirsch, I. Placebo psychotherapy: synonym or oxymoron? J Clin Psychol 2005; 61: 791803.
31 Bentall, R. Doctoring the Mind: Why Psychiatric Treatments Fail. Allen Lane, 2009.
32 Jones, C Hacker, D Cormac, I Meaden, A Irving, CB Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia. Cochrane Database Syst Rev 2012; 4: CD008712.
33 Penn, DL Meyer, PS Evans, E Wirth, RJ Cai, K Burchinal, M A randomized controlled trial of group cognitive-behavioral therapy vs. enhanced supportive therapy for auditory hallucinations. Schizophr Res 2009; 109: 5259.
34 Farhall, J Freeman, NC Shawyer, F Trauer, T An effectiveness trial of cognitive behaviour therapy in a representative sample of outpatients with psychosis. Br J Clin Psychol 2009; 48: 4762.
35 Fowler, D Hodgekins, J Painter, M Reilly, T Crane, C Macmillan, I et al. Cognitive behaviour therapy for improving social recovery in psychosis: a report from the ISREP MRC Trial Platform Study (Improving Social Recovery in Early Psychosis). Psychol Med 2009; 39: 16271636.
36 Haddock, G Barrowclough, C Shaw, JJ Dunn, G Novaco, RW Tarrier, N Cognitive–behavioural therapy v. social activity therapy for people with psychosis and a history of violence: randomised controlled trial. Br J Psychiatry 2009; 194: 152157.
37 Pinninti, NR Rissmiller, DJ Steer, RA Cognitive-behavioral therapy as an adjunct to second-generation antipsychotics in the treatment of schizophrenia. Psychiatr Serv 2010; 61: 940943.
38 Lincoln, TM Ziegler, M Mehl, S Kesting, ML Lullmann, E Westermann, S et al. Moving from efficacy to effectiveness in cognitive behavioral therapy for psychosis: a randomized clinical practice trial. J Consult Clin Psychol 2012; 80: 674686.
39 Edwards, J Cocks, J Burnett, P Maud, D Wong, L Yuen, HP et al. Randomized controlled trial of clozapine and CBT for first-episode psychosis with enduring positive symptoms: a pilot study. Schizophr Res Treatment 2011; March 30 (Epub ahead of print).
40 Grant, PM Huh, GA Perivoliotis, D Stolar, NM Beck, AT Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Arch Gen Psychiatry 2012; 69: 121127.
41 White, R Gumley, A McTaggart, J Rattrie, L McConville, D Cleare, S et al. A feasibility study of acceptance and commitment therapy for emotional dysfunction following psychosis. Behav Res Ther 2011; 49: 901907.
42 Granholm, E Holden, J Link, PC McQuaid, JR Jeste, DV Randomized controlled trial of cognitive behavioral social skills training for older consumers with schizophrenia: defeatist performance attitudes and functional outcome. Am J Geriatr Psychiatry 2013; 21: 251262.
43 Shawyer, F Farhall, J Mackinnon, A Trauer, T Sims, E Ratcliff, K et al. A randomised controlled trial of acceptance-based cognitive behavioural therapy for command hallucinations in psychotic disorders. Behav Res Ther 2012; 50: 110121.
44 Liberati, A Altman, DG Tetzlaff, J Mulrow, C Gotzsche, PC Ioannidis, JP et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6: e1000100.
45 Schulz, KF Grimes, DA. Generation of allocation sequences in randomised trials: chance, not choice. Lancet 2002; 359: 515519.
46 Hall, PL Tarrier, N. The cognitive-behavioural treatment of low self-esteem in psychotic patients: a pilot study. Behav Res Ther 2003; 41: 317332.
47 Tundo, A Salvati, L Di Spigno, D Cieri, L Parena, A Necci, R et al. Cognitive-behavioral therapy for obsessive-compulsive disorder as a comorbidity with schizophrenia or schizoaffective disorder. Psychother Psychosom 2012; 81: 5860.
48 Jackson, C Trower, P Reid, I Smith, J Hall, M Townend, M et al. Improving psychological adjustment following a first episode of psychosis: a randomised controlled trial of cognitive therapy to reduce post psychotic trauma symptoms. Behav Res Ther 2009; 47: 454462.
49 Halperin, S Nathan, P Drummond, P Castle, D A cognitive-behavioural, group-based intervention for social anxiety in schizophrenia. Aust N Z J Psychiatry 2000; 34: 809813.
50 Kingsep, P Nathan, P Castle, D Cognitive behavioural group treatment for social anxiety in schizophrenia. Schizophr Res 2003; 63: 121129.
51 Power, PJ Bell, RJ Mills, R Herrman-Doig, T Davern, M Henry, L et al. Suicide prevention in first episode psychosis: the development of a randomised controlled trial of cognitive therapy for acutely suicidal patients with early psychosis. Aust N Z J Psychiatry 2003; 37: 414420.
52 Drury, V Birchwood, M Cochrane, R Macmillan, F Cognitive therapy and recovery from acute psychosis: a controlled trial. I. Impact on psychotic symptoms. Br J Psychiatry 1996; 169: 593601.
53 Bradshaw, W. Integrating cognitive-behavioral psychotherapy for persons with schizophrenia into a psychiatric rehabilitation program: results of a three year trial. Community Ment Health J 2000; 36: 491500.
54 Granholm, E McQuaid, JR McClure, FS Auslander, LA Perivoliotis, D Pedrelli, P et al. A randomized, controlled trial of cognitive behavioral social skills training for middle-aged and older outpatients with chronic schizophrenia. Am J Psychiatry 2005; 162: 520529.
55 Jenner, JA Nienhuis, FJ Wiersma, D van de Willige G. Hallucination focused integrative treatment: a randomized controlled trial. Schizophr Bull 2004; 30: 133145.
56 Kuipers, E Holloway, F Rabe-Hesketh, S Tennakoon, L An RCT of early intervention in psychosis: Croydon Outreach and Assertive Support Team (COAST). Soc Psychiatry Psychiatr Epidemiol 2004; 39: 358363.
57 Garety, PA Craig, TKJ Dunn, G Fornells–Ambrojo, M Colbert, S Rahaman, N et al. Specialised care for early psychosis: symptoms, social functioning and patient satisfaction. Randomised controlled trial. Br J Psychiatry 2006; 188: 3745.
58 Grawe, RW Falloon, IR Widen, JH Skogvoll, E Two years of continued early treatment for recent-onset schizophrenia: a randomised controlled study. Acta Psychiatr Scand 2006; 114: 328336.
59 Guo, X Zhai, J Liu, Z Fang, M Wang, B Wang, C et al. Effect of antipsychotic medication alone vs combined with psychosocial intervention on outcomes of early-stage schizophrenia: a randomized, 1-year study. Arch Gen Psychiatry 2010; 67: 895904.
60 Gleeson, JF Cotton, SM Alvarez-Jimenez, M Wade, D Gee, D Crisp, K et al. A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients. J Clin Psychiatry 2009; 70: 477486.
61 Moritz, S Veckenstedt, R Randjbar, S Vitzthum, F Woodward, TS Antipsychotic treatment beyond antipsychotics: metacognitive intervention for schizophrenia patients improves delusional symptoms. Psychol Med 2011; 41: 18231832.
62 Gaudiano, BA Herbert, JD. Acute treatment of inpatients with psychotic symptoms using acceptance and commitment therapy: pilot results. Behav Res Ther 2006; 44: 415437.
63 Leclerc, C Lesage, AD Ricard, N Lecomte, T Cyr, M Assessment of a new rehabilitative coping skills module for persons with schizophrenia. Am J Orthopsychiatry 2000; 70: 380388.
64 Peralta, V Cuesta, MJ. Psychometric properties of the positive and negative syndrome scale (PANSS) in schizophrenia. Psychiatry Res 1994; 53: 3140.
65 Smith, DA Mar, CM Turoff, BK The structure of schizophrenic symptoms: a meta-analytic confirmatory factor analysis. Schizophr Res 1998; 31: 5770.
66 Sayers, SL Curran, PJ Mueser, KT Factor structure and construct validity of the Scale for the Assessment of Negative Symptoms. Psychol Assess 1996; 8: 269280.
67 Steel, C Garety, PA Freeman, D Craig, E Kuipers, E Bebbington, P et al. The multidimensional measurement of the positive symptoms of psychosis. Int J Methods Psychiatr Res 2007; 16: 8896.
68 Higgins, JPT Green, S (eds). Cochrane Handbook for Systematic Reviews of Interventions, version 5.1.0. The Cochrane Collaboration, 2011.
69 Lecomte, T Leclerc, C Corbiere, M Wykes, T Wallace, CJ Spidel, A Group cognitive behavior therapy or social skills training for individuals with a recent onset of psychosis? Results of a randomized controlled trial. J Nerv Ment Dis 2008; 196: 866875.
70 Jolley, S Garety, P Craig, T Dunn, G White, J Aitken, M Cognitive therapy in early psychosis: a pilot randomized controlled trial. Behav Cogn Psychother 2003; 31: 473478.
71 Jackson, HJ McGorry, PD Killackey, E Bendall, S Allott, K Dudgeon, P et al. Acute-phase and 1-year follow-up results of a randomized controlled trial of CBT versus Befriending for first-episode psychosis: the ACE project. Psychol Med 2008; 38: 725735.
72 Tarrier, N Wittkowski, A Kinney, C McCarthy, E Morris, J Humphreys, L Durability of the effects of cognitive–behavioural therapy in the treatment of chronic schizophrenia: 12-month follow-up. Br J Psychiatry 1999; 174: 500504.
73 Durham, RC Guthrie, M Morton, RV Reid, DA Treliving, LR Fowler, D et al. Tayside–Fife clinical trial of cognitive–behavioural therapy for medication-resistant psychotic symptoms. Results to 3-month follow-up. Br J Psychiatry 2003; 182: 303311.
74 Duval, S Tweedie, R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56: 455463.
75 Begg, CB Mazumdar, M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994; 50: 10881101.
76 Egger, M Davey Smith, G Schneider, M Minder, C Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629634.
77 Daniels, L. A group cognitive-behavioral and process-oriented approach to treating the social impairment and negative symptoms associated with chronic mental illness. J Psychother Pract Res 1998; 7: 167176.
78 Levine, J Barak, Y Granek, I Cognitive group therapy for paranoid schizophrenics: applying cognitive dissonance. J Cogn Psychother 1998; 12: 312.
79 Haddock, G Tarrier, N Morrison, AP Hopkins, R Drake, R Lewis, S A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis. Soc Psychiatry Psychiatr Epidemiol 1999; 34: 254258.
80 Pinto, A La Pia, S Mennella, R Giorgio, D DeSimone, L Cognitive-behavioral therapy and clozapine for clients with treatment-refractory schizophrenia. Psychiatr Serv 1999; 50: 901904.
81 Turkington, D Kingdon, D. Cognitive–behavioural techniques for general psychiatrists in the management of patients with psychoses. Br J Psychiatry 2000; 177: 101106.
82 Granholm, E McQuaid, JR McClure, FS Pedrelli, P Jeste, DV A randomized controlled pilot study of cognitive behavioral social skills training for older patients with schizophrenia. Schizophr Res 2002; 53: 167169.
83 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: 419431.
84 Rector, NA Seeman, MV Segal, ZV Cognitive therapy for schizophrenia: a preliminary randomized controlled trial. Schizophr Res 2003; 63: 111.
85 Wang, C Li, Y Zhao, Z Controlled study on long-term effect of cognitive behavior intervention on first episode schizophrenia. Chin Ment Health J 2003; 17: 200202.
86 Startup, M Jackson, MC Bendix, S North Wales randomized controlled trial of cognitive behaviour therapy for acute schizophrenia spectrum disorders: outcomes at 6 and 12 months. Psychol Med 2004; 34: 413422.
87 Trower, P Birchwood, M Meaden, A Byrne, S Nelson, A Ross, K Cognitive therapy for command hallucinations: randomised controlled trial. Br J Psychiatry 2004; 184: 312320.
88 Cather, C Penn, D Otto, MW Yovel, I Mueser, KT Goff, DC A pilot study of functional cognitive behavioral therapy (fCBT) for schizophrenia. Schizophr Res 2005; 74: 201209.
89 Valmaggia, LR van der Gaag, M Tarrier, N Pijnenborg, M Slooff, CJ Cognitive–behavioural therapy for refractory psychotic symptoms of schizophrenia resistant to atypical antipsychotic medication. Randomised controlled trial. Br J Psychiatry 2005; 186: 324330.
90 Wykes, T Hayward, P Thomas, N Green, N Surguladze, S Fannon, D et al. What are the effects of group cognitive behaviour therapy for voices? A randomised control trial. Schizophr Res 2005; 77: 201210.
91 Barrowclough, C Haddock, G Lobban, F Jones, S Siddle, R Roberts, C et al. Group cognitive–behavioural therapy for schizophrenia. Randomised controlled trial. Br J Psychiatry 2006; 189: 527532.
92 Penadés, R Catalan, R Salamero, M Boget, T Puig, O Guarch, J et al. Cognitive remediation therapy for outpatients with chronic schizophrenia: a controlled and randomized study. Schizophr Res 2006; 87: 323331.
93 McLeod, T Morris, M Birchwood, M Dovey, A Cognitive behavioural therapy group work with voice hearers. Part 2. Br J Nurs 2007; 16: 292295.
94 Deng, L-H Li, Y-D Song, Z-W Controlled trial of cognitive behavioral therapy for slowly-episode schizophrenia [in Chinese]. Med J Chin People's Health 2008; 15: 17021707.
95 England, M. Significance of cognitive intervention for voice hearers. Perspect Psychiatr Care 2008; 44: 4047.
96 Wu, N Wang, Q Kong, L A controlled study of cognitive behaviour therapy in chronic schizophrenia [in Chinese]. J Clin Psychosom Dis 2008; 14: 206207.
97 Rathod, S Phiri, P Harris, S Underwood, C Thagadur, M Padmanabi, U et al. Cognitive behaviour therapy for psychosis can be adapted for minority ethnic groups: a randomised controlled trial. Schizophr Res 2013; 143: 319326.
98 Hunt, N. How Science takes Stock: The Story of Meta-Analysis. Sage, 1997.
99 Schulz, KF Chalmers, I Hayes, RJ Altman, DG Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995; 273: 408412.
100 Wood, L Egger, M Gluud, LL Schulz, KF Juni, P Altman, DG et al. Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study. BMJ 2008; 336: 601605.
101 Hrobjartsson, A Thomsen, AS Emanuelsson, F Tendal, B Hilden, J Boutron, I et al. Observer bias in randomised clinical trials with binary outcomes: systematic review of trials with both blinded and non-blinded outcome assessors. BMJ 2012; 344: e1119.
102 Gillespie, R. Manufacturing Knowledge: A History of the Hawthorne Experiments. Cambridge University Press, 1991.
103 Niemeyer, H Musch, J Pietrowsky, R Publication bias in meta-analyses of the efficacy of psychotherapeutic interventions for schizophrenia. Schizophr Res 2012; 138: 103112.
104 Cuijpers, P Smit, F Bohlmeijer, E Hollon, SD Andersson, G Efficacy of cognitive–behavioural therapy and other psychological treatments for adult depression: meta-analytic study of publication bias. Br J Psychiatry 2010; 196: 173178.
105 The All Party Parliamentary Group on Mental Health. Implementation of NICE Guideline on Schizophrenia. Department of Health, 2010.
Type Description Title
PDF
Supplementary materials

Jauhar et al. supplementary material
Supplementary Material

 PDF (147 KB)
147 KB

Cognitive–behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias

  • S. Jauhar (a1), P. J. McKenna (a2), J. Radua (a2), E. Fung (a3), R. Salvador (a2) and K. R. Laws (a4)...

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Cognitive–behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias

  • S. Jauhar (a1), P. J. McKenna (a2), J. Radua (a2), E. Fung (a3), R. Salvador (a2) and K. R. Laws (a4)...
Submit a response

eLetters

RE: Dose and effect in CBT for schizophrenia

Christian Gold, Principal Researcher, Professor, Uni Research Health, Bergen, Norway
26 April 2015

Many thanks to Jauhar and colleagues for their interesting and throught-provoking review of CBT for schizophrenia (1), and especially for making their data publicly available. Previous discussants (Byrne; McKenna et al.) have commented on the lack of consideration given to ’dose’ (i.e. number of sessions) of CBT. The relation between dose and effect is almost a classic in psychotherapy research (2). It has more recently been shown to be of importance in reviews of other psychosocial therapies (e.g. 3). Together with the obvious plausibility of such a relationship, this seems to be enough reason to examine the dose-effect relation carefully. I used the effect sizes calculated by Jauhar et al. and extracted the number of sessions from the original papers (I was able to do this for 32 of the 52 studies). I then ran a meta-regression (functions metagen and metareg from R package meta) for each of the four outcomes (Figure 1). Most studies used between 10 and 20 sessions, with a few outliers in both directions. The regression lines show little support for an increase of effect with dose. On the contrary, there are tendencies in the opposite direction for all outcomes. The paradoxical observation is that effects seem to be strongest when few sessions were provided (significant for positive symptoms, p = .0005).

Obviously this analysis has a number of limitations: 1. As McKenna et al. noted in their response to the comment by Byrne, participants were not randomised to different doses. 2. Dose is likely confounded with duration (4) and may also be confounded with blindness and control interventions (1). 3. There may be differences between the scheduled and the received dose, and this was not reported consistently in the original papers. 4. Dose data were not independently extracted by two people.

However, I think one can conclude from these analyses that dose is unlikely to have masked a clearer effect in these data. A more detailed re-analysis of this data set may be warranted. In general, the dosage of psychotherapy should be considered carefully in future studies.

References

1.Jauhar S, McKenna PJ, Radua J, Fung E, Salvador R, Laws KR. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. Brit J Psychiat. 2014 Jan;204(1):20-9.

2.Howard KI, Kopta SM, Krause MS, Orlinsky DE. The dose-effect relationship in psychotherapy. Am Psychol. 1986;41(2):159-64.

3.Gold C, Solli HP, Krüger V, Lie SA. Dose-response relationship in music therapy for people with serious mental disorders: systematic review and meta-analysis. Clin Psychol Rev. 2009;29(3):193-207.

4.Gold C. Quantitative psychotherapy outcome research: Methodological issues. In: Gelo OCG, Pritz A, Rieken B, editors. Psychotherapy Research: Foundations, Process, and Outcome. Vienna: Springer; 2015. p. 537-58.
... More

Conflict of interest: None Declared

Write a reply

Author Response to Peters

Keith Laws, PhD
09 September 2014

One of the founding principles of meta-analysis is to pool data from as many studies as possible1. Among other benefits this prevents studies being preselected for consideration on arbitrary grounds. It is difficult to imagine anything more arbitrary than restricting a meta-analysis of CBTfor schizophrenia to studies that conform to some notional interpretation of the NICE guideline, as Peters seems to be suggesting, not to mention excluding any that were in Chinese.

Similarly, it would be wrong to exclude studies that used group CBT apriori. Here, though, it is entirely legitimate to examine this issue posthoc, ie to ask whether use of group vs individual CBT significantly moderates effect size. Carrying out this analysis on our data reveals thatthe pooled effect sizes for both types of intervention were closely similar in the meta-analysis of overall symptoms (ES in 7 group studies -0.24 vs -0.23 in 24 individual studies, Q=0.006, p=0.94); for positive symptoms, group CBT had a nonsignificantly smaller effect size than individual CBT (ES in 8 group studies -0.08 vs -0.25 in 23 individual studies, Q=1.73, p=0.19) (across both analyses one study employed both group and individual CBT and three were rated as 'unclear'). This may or may not be considered evidence that group CBT is less effective than individual CBT, but what it does not mean is that inclusion of group studies in our original meta-analyses somehow acted to dilute the pooled estimate - the effect sizes for studies using individual CBT are similar or lower to those we reported for all studies combined (ESs were -0.33 foroverall symptoms and -0.25 for positive symptoms).

With regard to some of the other points raised by Peters, our diagnostic criteria were broad and similar to those used by NICE, Wykes etal and the Cochrane Collaboration. We recognized the possibility that Acceptance and Commitment Therapy might be different from regular CBT and presented an analysis in the article excluding two studies using this2, 3,and another where CBT took the form predominantly of coping skills enhancement4; this did not materially affect the results. She expresses surprise over our decision to exclude studies that specifically targeted hallucinations from the meta-analysis of positive symptoms. As it happens,only three studies of hallucination-directed CBT also reported outcomes for positive symptoms. Adding the data from two of them5, 6 (data cannot be extracted from one study7) to the positive symptoms dataset produces makes no difference to the pooled effect size (ES=-0.25, CI -0.36/-0.13).

Peters argues that there was too much heterogeneity among the resultsto obtain meaningful pooled estimates. In fact, the Cochrane Collaborationarticle she cites8, recommends (i) not pooling data using meta-analysis; or (ii) investigating heterogeneity using subgroup analysis or meta-regression; or (iii) using a random-effects model for meta-analysis as this includes consideration of heterogeneity in the effect size estimate. The authors also note that 'even though a random-effects model helps to consider heterogeneity, it does not remove it - heterogeneity still needs to be considered in interpreting the results'. We used a random effects model and examined heterogeneity.

Finally, we would like to re-iterate that for those who wish to examine for themselves other points of the type raised by Peters, a detailed database of the studies we included is available at (http://www.cbtinschizophrenia.com/).

P. J. McKenna, MB, ChB, MRCPsych and J. Radua, MD, PhD, FIDMAG Germanes Hospitalaries Research Foundation, Barcelona and CIBERSAM, Spain.

K. R. Laws, PhD, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK

S. Jauhar, MB, ChB, BSc(Hons), MRCPsych, Department of Psychosis Studies, Institute of Psychiatry, London, UK.References

1. Hunt N. How science takes stock: the story of meta-analysis. New York: Sage; 1997.2. White R, Gumley A, McTaggart J, et al. A feasibility study of Acceptance and Commitment Therapy for emotional dysfunction following psychosis. Behav Res Ther 2011; 49:901-7.3. Gaudiano BA, Herbert JD. Acute treatment of inpatients with psychotic symptoms using Acceptance and Commitment Therapy: pilot results. Behav ResTher 2006; 44:415-37.4. Leclerc C, Lesage AD, Ricard N, Lecomte T, Cyr M. Assessment of a new rehabilitative coping skills module for persons with schizophrenia. Am J Orthopsychiatry 2000; 70:380-8.5. Penn DL, Meyer PS, Evans E, Wirth RJ, Cai K, Burchinal M. A randomized controlled trial of group cognitive-behavioral therapy vs. enhanced supportive therapy for auditory hallucinations. Schizophr Res 2009; 109:52-9.6. Shawyer F, Farhall J, Mackinnon A, et al. A randomised controlled trialof acceptance-based cognitive behavioural therapy for command hallucinations in psychotic disorders. Behav Res Ther 2012; 50:110-21.7. Trower P, Birchwood M, Meaden A, Byrne S, Nelson A, Ross K. Cognitive therapy for command hallucinations: randomised controlled trial. Br J Psychiatry 2004; 184:312-20.8. Ryan R. Cochrane Consumers and Communication Review Group. Heterogeneity and subgroup analyses in Cochrane Consumers and Communication Review Group reviews: planning the analysis at protocol stage. http://cccrg.cochrane.org, February 2014.

... More

Conflict of interest: None declared

Write a reply

Citation Analysis Reveals Disproportionate Emphasis on Positive Claims in Study Abstracts

Marcus R Munafo, Professor of Biological Psychology
19 August 2014

Evidence-based medicine relies on evidence from high-quality randomized trials and observational studies (1). However, meta-analyses, the cornerstone of evidence-based medicine, may be at odds with the prevailing views of the relevant research community. One factor that may contribute to the distortion of an evidence base is selective citation of studies that support (or do not support) a particular treatment. Greenberg(2) showed that citation distortions (such as a bias against citing studies that refute or weaken a particular belief) create an unfounded impression of authority and consensus.

We used a recent meta-analysis of cognitive behavioural therapy in schizophrenia (3) to explore patterns of citations within this literature.Studies included in the meta-analysis (k = 50) were coded according to whether or not they provided support for the intervention (defined as P < 0.05 in the direction of therapeutic benefit). We also coded whether or not the study abstract reported that the study provided support for theintervention, given evidence that abstracts may over-state the findings ofa study (4). Finally, we coded which other studies within the literature (i.e., those included in the meta-analysis) were cited by each individual study. Independent coding was by two authors (DFH and NEJR), and discrepancies resolved by mutual consent.

Our results indicated that abstracts are more likely to report a favourable outcome (42 studies, 84%) compared with the data reported within the meta-analysis (20 studies, 40%). We also observed a clear pattern of citation distortion: studies that claimed support in the abstract received 138 citations (95%), while those that showed support forthe intervention on the basis of the data reported in the meta-analysis received 58 citations (40%). A binomial test indicated that the number of citations to studies with abstracts reporting a favourable outcome was greater than expected (95% of citations from 84% of abstracts, P < 0.001).

These findings could explain discrepancies between the evidence base as indicated by a meta-analysis, and the beliefs held by practitioners andclinicians within the field. While we used data from one specific literature, we have no particular reason to believe that our findings are unique to this literature. Claims from highly cited observational studies have been shown to persist even after strong contradictory evidence from randomized trials (5). Since citation distortions may be driven, in part, by inflated claims in study abstracts, readers should not rely solely on the abstract of an article.

Acknowledgements

MRM is a member of the United Kingdom Centre for Tobacco and Alcohol Studies, a UKCRC Public Health Research: Centre of Excellence. Funding from British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, and the National Institute forHealth Research, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged.

References

1. Greenhalgh T, Howick J, Maskrey N, Evidence Based Medicine Renaissance G. Evidence based medicine: a movement in crisis? BMJ. 2014; 348: g3725.

2. Greenberg SA. How citation distortions create unfounded authority:analysis of a citation network. BMJ. 2009; 339: b2680.

3. Jauhar S, McKenna PJ, Radua J, Fung E, Salvador R, Laws KR. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. British Journal of Psychiatry. 2014; 204(1): 20-9.

4. Park IU, Peacey MW, Munafo MR. Modelling the effects of subjectiveand objective decision making in scientific peer review. Nature. 2014; 506(7486): 93-6.

5. Tatsioni A, Bonitsis NG, Ioannidis JP. Persistence of contradictedclaims in the literature. Journal of the American Medical Association. 2007; 298(21): 2517-26.

... More

Conflict of interest: None declared

Write a reply

Author Response to Birchwood et al and Byrne

Peter J. McKenna, MB, ChB, MRCPsych
20 May 2014

We thank Birchwood et al and Byrne for their comments. Birchwood et al make two points that require clarification. First, their statement thatour findings from studies with high methodological rigour, particularly masking, imply that CBT has small but by no means negligible effects on positive and total symptoms 'broadly in line with the NICE review and particularly that of Wykes et al,' seems to us questionable. Wykes et al1 reported an effect size of 0.37 for positive symptoms, which reduced slightly to 0.31 in masked studies. This latter value was four times larger than the value of 0.08 we found for masked studies of positive symptoms. Ratings of bias were made for the studies included in the 2009 NICE guideline2,3; however, no analyses excluding low quality studies or otherwise examining methodological rigour were actually carried out.

Secondly, Birchwood et al's argument that a finding of significant heterogeneity among studies implies that CBT is effective in certain subgroups of patients is not formally correct. It could simply mean that there are systematic differences in effect size between studies at high and low risk of bias. Tending to support this latter interpretation, in our meta-analysis of positive symptoms there was no significant heterogeneity in either the masked (N=20, ES 0.08, I2 0%, Q=18, p=0.49) orunmasked studies (N= 8, ES 0.57, I2 23% , Q=9, p= 0.24) when they were considered separately. Heterogeneity was also not significant in the masked studies of overall symptoms (N=20, ES 0.15, I2=25%, Q=25, p=0.15), although it remained significant in the unmasked studies (N=10, ES 0.62, I2=71%, Q=31, p<0.001).

Byrne argues that our findings are limited by not considering follow-up data. We presume he is arguing here for a 'delayed action' effect of CBT, as found in the 2000 study of Sensky et al4 and an early meta-analysis by Pilling et al5. However, the meta-analyses carried out for the2009 NICE guideline2 provide only lukewarm support for such a view: the pooled effect sizes for overall symptoms were 0.27, 0.23, 0.40 and 0.19 atend of treatment, 6 months,12 months and 12-18 months follow-up, respectively, when CBT was compared to standard care; they were 0.13 at end of treatment and 0.18 at 12 months when CBT was compared to other active treatments.

Among the other issues raised, whether there is evidence for a dose effect for CBT seems to us essentially imponderable, since none of the 50+published RCTs to date has manipulated dose or duration of the intervention. Such an effect would also likely be difficult to detect using meta-analytic methods, given the many other sources of variation among the existing studies. With respect to whether or not CBT should be considered as a 'quasi-neuroleptic', we simply note that CBT was originally developed for and continues to be promoted as a treatment for positive symptoms.

P. J. McKenna, MB, ChB, MRCPsych and J. Radua, MD, PhD,FIDMAG Germanes Hospital?ries Research Foundation, Barcelona and CIBERSAM,Spain.

S. Jauhar, MB, ChB, BSc(Hons), MRCPsych, Department of Psychosis Studies, Institute of Psychiatry, London, UK.

K. R. Laws, PhD, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.

References

1. Wykes T, Steel C, Everitt B, Tarrier N. Cognitive behavior therapyfor schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophr Bull 2008; 34:523-37.

2. NICE. Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care (update). London: National Institute of Clinical Excellence; 2009.

3. NICE. Schizophrenia (update) Appendix 15c: Psychological therapiesand psychosocial interventions study characteristics tables. London: National Institute of Clinical Excellence; 2009.

4. Sensky T, Turkington D, Kingdon D, et al. A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Arch Gen Psychiatry 2000; 57:165-72.

5. Pilling S, Bebbington P, Kuipers E, et al. Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychol Med 2002; 32:763-82.

... More

Conflict of interest: None declared

Write a reply

Jauhar et al: An oversimplification of psychosis, its treatment, and its outcomes?

Emmanuelle Peters, Reader in Clinical Psychology
16 May 2014

This meta-analysis of randomised controlled trials in Cognitive Behaviour Therapy for psychosis (CBTp) is broadly consistent with previousresults(1) ie there is an overall significant but modest impact on psychotic symptoms, with blinded studies showing lower effect sizes than those that are not masked. However, there are a number of problems with this study and especially with its conclusions.

Jauhar et al conclude that they find the Government (including NICE)'s advocacy for CBTp "puzzling", bearing in mind the low effect sizesfound for psychotic symptoms. However I find it puzzling that the authors comment on NICE recommendations, since 1/3rd of the studies included for their overall symptoms analysis (12/34) were not based on therapies recommended by NICE in the first place (based on what we know is effectivefrom the literature so far) ie they were either group or brief CBT studies. Three further studies were in Chinese so their relevance to NICE recommendations is hard to tell.

It is a testament to the far-reaching effects of CBTp that the analyses revealed any effects at all, since the authors looked at outcomeswhich were not always targeted by the therapy. For instance, only a few ofthe 34 studies included for negative symptoms actually targeted such symptoms specifically. Furthermore, severity of positive symptoms/hallucinations was used as the outcome for studies that did not hypothesize changes in psychotic symptoms since the target was on compliance with command hallucinations(2), emotional dysfunction(3), or social functioning(4). In contrast, outcomes on depression, anxiety or distress as a result of psychotic symptoms, and trials targeting self-esteem, post-traumatic symptoms, suicidality, or substance abuse, which are all main and legitimate targets in CBTp, were all excluded.

The criteria for studies to be included in the final analyses were idiosyncratic. Perhaps the most surprising was the decision to exclude studies that targeted hallucinations specifically from their positive symptoms analyses. A separate 'supplementary' meta-analysis was carried out for those studies, with an effect size of .34, which is not reported in the abstract (where only the - lower - .25 effect on positive symptoms is reported). Clinicians familiar with clinical presentations of patients with psychosis may be surprised at their rationale for excluding trials because patients had a dual diagnosis, or had medication-resistant psychotic symptoms but with no further diagnosis specification. None of the follow-up data available was included, meaning that the Sensky et al(5) (non-significant) end of study results contribute to the findings, but the (significant) 9 months and 5 years follow-up results do not(6).

Meta-analyses can be highly informative, but they are highly prone tobias(7). Those with a "washing machine" approach, such as this one (ie amalgamating different populations - from acute inpatients to chronic outpatients, from young people with a first episode of psychosis to older adults; different therapies - from 3 sessions of Acceptance and CommitmentTherapy to 18 months of weekly cognitive therapy; different modalities - groups or individual; different targets - from compliance with command hallucinations to emotional dysfunction), tell us very little about what works for whom. Unsurprisingly the heterogeneity statistics were highly significant for all analyses, with I2 being at 50% or above (ie representing "substantial heterogeneity"), suggesting that there was too much heterogeneity to obtain meaningful pooled estimates, and that the necessary criteria for rendering a meta-analysis appropriate were not met(8).

The field of CBTp has now progressed such that it is no longer appropriate to simply lump together psychosis patients assuming that clinical presentations are the same, that therapy is for the same problem,and that the type of CBT is the same. Other recent meta-analyses, which focus on treatment-resistant patients(9), or on individually tailored, formulation-based CBT for hallucinations and delusions(10), will be more informative to clinicians and researchers about the specific effects of CBTp.

To conclude, the reported analyses reflect an over-simplification of the complexities of psychosis and psychological interventions. The biggestchallenges in psychological therapies trial methodology (and in clinical practice) are the quality/adherence of the therapy delivered and the competence of the therapists, none of which was taken into account in thisstudy. A more meaningful reading of the existing research is that the next steps are to investigate which patients benefit on which outcomes at which stages with which types of therapy, and how to ensure therapist competence (and availability).

Emmanuelle Peters, Reader in Clinical PsychologyDepartment of Psychology, Institute of Psychiatry, Denmark Hill, London SE5 8AF

References

1.Wykes T, Steel C, Everitt B, Tarrier N. Cognitive behavior therapyfor schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin. 2008 May;34(3):523-37. PubMed PMID: ISI:000255156500016. English.2.Trower P, Birchwood M, Meaden A, Byrne S, Nelson A, Ross K. Cognitive therapy for command hallucinations: randomised controlled trial. British Journal of Psychiatry. 2004 Apr;184:312-20. PubMed PMID: ISI:000220754200007. English.3.White R, Gumley A, McTaggart J, Rattrie L, McConville D, Cleare S, et al. A feasibility study of Acceptance and Commitment Therapy for emotionaldysfunction following psychosis. Behaviour Research and Therapy. 2011 Dec;49(12):901-7. PubMed PMID: ISI:000297887500010. English.4.Granholm E, McQuaid JR, McClure FS, Auslander LA, Perivoliotis D, Pedrelli P, et al. A randomized, controlled trial of cognitive behavioral social skills training for middle-aged and older outpatients with chronic schizophrenia. Am J Psychiatry. 2005 Mar;162(3):520-9. PubMed PMID: 15741469. Epub 2005/03/03. eng.5.Sensky T, Turkington D, Kingdon D, Scott JL, Scott J, Siddle R, et al. A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry. 2000 Feb;57(2):165-72. PubMed PMID: ISI:000085086100008. English.6.Turkington D, Sensky T, Scott J, Barnes TRE, Nur U, Siddle R, et al. A randomized controlled trial of cognitive-behavior therapy for persistent symptoms in schizophrenia: A five-year follow-up. Schizophrenia Research. 2008 Jan;98(1-3):1-7. PubMed PMID: ISI:000252494100001. English.7.Murray RM. On collecting meta-analyses of schizophrenia and postage stamps. Psychological Medicine. 2014 21st March 2014.8.Cochrane Consumers and Communication Review Group; Ryan R. Heterogeneity and subgroup analyses in Cochrane Consumers and Communication Review Group reviews: planning the analysis at protocol stage. 2014 February 2014.9.Burns AM, Erickson DH, Brenner CA. Cognitive-Behavioral Therapy for Medication-Resistant Psychosis: A Meta-Analytic Review. Psychiatr Serv. 2014 Apr 1. PubMed PMID: 24686725. Epub 2014/04/02. Eng.10.van der Gaag M, Valmaggia LR, Smit F. The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: A meta-analysis. Schizophrenia Research. 2014 Jun;156(1):30-7. PubMed PMID: 24731619. Epub 2014/04/16. eng.

... More

Conflict of interest: EP is the Director of the Psychological Interventions Clinic for outpatients with Psychosis (PICuP), South London and Maudsley NHS Foundation Trust. She is a practising Cognitive Behaviour Therapist for psychosis (CBTp), and has conducted randomised controlled trials in CBTp.

Write a reply

Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias

Zarshed Khan, ST6
28 March 2014

I congratulate the authors on a very interesting and vigorously carried out study to address a very pertinent issue. The authors have rightly pointed out some inherent problems associated with Meta-analysis. NICE and some pressure groups have been advocating for CBT in schizophrenia but as such I have not come across any response from the government towards this issue. The authors have made a very strong statement that 'the claim that CBT is effective against psychotic symptomsis no longer tenable'. As is the case with most of the studies, a carefully thought through and robustly designed study rarely produced positive results. The same is true for this study as well. The author has put the onus on pro CBT researcher to prove its effectiveness which should be welcomed as more robust studies need to be carried out. Nevertheless, one should be cautious in applying findings from this study in day to day practice. This study does not take into account individual characteristicsof the patient group and the stage of their illness. The length and quality of CBT has not been considered before arriving to conclusion. The authors have shown stated that there was no consistent evidence of publication bias, but it is not clear whether concerted efforts were made to access non English language studies.

... More

Conflict of interest: none

Write a reply

RE: Cognitive-behavioural therapy for the symptoms of schizophrenia

Rory E. Byrne, User-researcher
07 February 2014

Jauhar and colleagues' review and meta-analysis of CBT for the reduction of particular symptoms associated with schizophrenia is interesting but incomplete. For example the review does not examine the clinical significance of dose or duration of CBT treatment. This limitation is considerable, as a recent analysis of effective elements of CBT for psychosis found that "consistent delivery of full therapy, including specific cognitive and behavioural techniques, was associated with clinically and statistically significant increases in months in remission, and decreases in psychotic and affective symptoms", while "delivery of partial therapy involving engagement and assessment was not effective." [1]

Jauhar et al. have also excluded measurement of long-term outcomes from their analysis, measuring only end-of-study data. This is another considerable limitation, as symptom reductions maintained at 9- or 18-month follow-up represent a substantial benefit of effective CBT. Further,while reduction of psychotic symptoms is an important treatment outcome tomeasure, CBT is particularly focused on reducing distress associated with such symptoms and improving an individual's ability to cope with them. Aspsychotic symptoms can continue even with administration of powerful antipsychotic medication, improvements in these areas may be clinically significant for many CBT recipients. Indeed, a comprehensive synthesis of qualitative research into service users' experiences of CBT for psychosis [2] found that the most commonly identified 'key ingredients' of CBT included increased understanding of psychosis and of coping strategies, reappraisal of distressing beliefs, and normalisation: "Participants did not necessarily experience an actual reduction in the frequency or distressing content of psychotic experiences, but instead gained an increased ability to cope and an increased perception of personal power." It is also important to consider that not all service users want their 'symptoms' eradicated: "I don't want to get rid of them, I don't feel likethey should ever really die or anything" (from Hayward and Fuller, 2010, p369). Similar personal appraisals are common in the wider literature intorecovery from psychosis or schizophrenia: "Learning to cope to accept thatyou hear voices or whatever your symptoms are. Recovery is... to be able to live with it" (from Pitt et al., 2007, p57). So, while analyses of CBT that focus only on psychotic symptom reduction are important, they are also incomplete; 'secondary' outcomes such as reduced distress or self-defined recovery may be valued more highly than symptom reduction alone bymany service users, and such outcomes are increasingly well-measured in CBT trials [3,4]. Future meta-analyses of CBT will contribute more meaningfully to our understanding of its effectiveness by examining thesewider outcome domains and acknowledging their value as long-term benefits.

References:

1. Dunn G, Fowler D, Rollinson R, Freeman D, Kuipers E, Smith B, Steel C, Onwumere J, Jolley S, Garety P, Bebbington P. Effective elements of cognitive behaviour therapy for psychosis: results of a novel type of subgroup analysis based on principal stratification. Psychological Medicine 2012, May;42(5):1057-68. doi: 10.1017/S0033291711001954. Epub 2011 Sep 23

2. Berry C. and Hayward M. What can qualitative research tell us about service user perspectives of CBT for psychosis? A synthesis of current evidence. Behavioural and Cognitive Psychotherapy 2011, 39, 487-494.

3. Neil ST, Kilbride M, Pitt L, Nothard S, Welford M, Sellwood W, Morrison AP. The questionnaire about the process of recovery (QPR): a measurement tool developed in collaboration with service users. Psychosis:Psychological, Social and Integrative Approaches 2009, 1, 145-155.

4. Greenwood KE, Sweeney A, Williams S, Garety P, Kuipers E, Scott J,Peters E. Choice of Outcome In Cbt for psychosEs (CHOICE): the developmentof a new service user-led outcome measure of CBT for psychosis. Schizophrenia Bulletin 2010, 36, 126-135.

... More

Conflict of interest: Declaration of interest: RB was a member of a National Institute for Health and Clinical Excellence guideline development group: Psychosis and Schizophrenia in Children and Young People, and is involved in NHS-funded CBT for psychosis research.

Write a reply

CBT for psychosis: not a quasi-neuroleptic.

Max J Birchwood, Professor of Youth Mental Health
27 January 2014

As members of the recent NICE clinical guideline update for schizophrenia (MB, DS), we read with interest the excellent meta-analysis of CBT for symptoms of schizophrenia by Jauhar et al (1).The results are broadly in line with the NICE review and particularly thatof Wykes et al (2), which showed that studies with high methodological rigour, including masking, have a small effect size for positive and totalsymptoms.Clearly CBT is no panacea; but neither is it ineffective.Meta analyses bring together all trials, with patients drawn from heterogeneous populations, including different phases of illness. The tests for heterogeneity not accounted for by chance (I2) in this meta-analysis were all high. The question therefore arises, 'for whom is CBT inpsychosis most effective and for what outcome? Likely groups are individuals at ultra high risk for psychosis (3), those in the early phaseof psychosis (4) and perhaps those with chronic stable symptoms, appearingto benefit the most; the PRP trial suggests that those beginning treatmentearly in the course of recovery from acute symptoms, do not benefit. Thesetrials focus on individuals in receipt of medication, with enduring symptoms. They therefore ask the question, 'does CBT offer added value compared to medication alone?'. We might also ask the converse, 'does anti-psychotic medication offer added value to CBT alone? It is known that up to 50% of individuals will not adhere to medication; a recent highquality trial of CBT in those not taking medication is soon to be published (5). Given that the low acceptability of anti-psychotic medication and their serious impact on health, this is an important question for further research (6).We note that our trial of CBT for commanding hallucinations is included in the analysis for hallucinations; however, this trial did not predict a reduction in hallucinations, but reported a 'high' effect size for harmfulcompliance (not reported), which has recently been the subject of a large multi-centre trial, soon to report (7). We argued some time ago that CBT for psychosis should not be conceived and evaluated as a 'quasi-neuroleptic'(8): the dimensions of delusions (power, distress) and generalaffective dysfunction are, we believe, among the most appropriate targets for CBT, with strong theoretical justification.Given the recent evidence from systematic reviews of antipsychotics (9) that the improvements claimed for antipsychotics, are of questionable clinical utility, with most trials failing to demonstrate minimal clinicalimprovement using the PANSS, with effect sizes smaller than for adverse side effects, there is clearly much work to be done to improve care, as the Schizophrenia Commission outlined in their 2012 review of current treatment and services (www.schizophreniacommission.org.uk ).

Max Birchwood, Professor of Youth Mental Health, Division of Health and Wellbeing, Warwick Medical School, University of Warwick, UK

David Shiers, GP Advisor to the National Audit of Schizophrenia (The Royal College of Psychiatrists) and Rethink Mental Illness Trustee.

Jo Smith, Visiting Professor in Early intervention and Psychosis, University of Worcester and Consultant Clinical Psychologist, Worcestershire Health and Care NHS Trust.

References

1. Jauhar, S. McKenna P. J., Radua J., Fung, E. Salvador R and Laws K. R. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. The British Journal of Psychiatry (2014) 204, 20-29.2. Wykes T, Steel C, Everitt B, Tarrier N. Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigour.Schizophr Bull 2008; 34: 523-37.3. Stafford MR ,Jackson H ,Mayo-Wilson E ,Morrison AP ,Kendall T. Early interventions to prevent psychosis: systematic review and meta-analysis. BMJ 2013;346:f185doi:10.1136/bmj.f1854. Bird V, Premkumar P, Kendall T, Whittington C, Mitchell J, Kuipers E. Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review. British Journal of Psychiatry 2010; 197(5): 350-356.5. Morrison, A.P., Wardle, M., Hutton, P., Davies, L., Dunn, G., Brabban, A., Byrne, R., Drage, L., Spencer, H. & Turkington, D. Assessing cognitive therapy instead of neuroleptics: rationale, study design and sample characteristics of the ACTION trial. Psychosis - Psychological Social and Integrative Processes. 2013;5:82-92.6. National Institute of Health and Clinical Excellence Psychosis and schizophrenia in adults: treatment and management, guideline update, February, 2014.7. Birchwood, M., Emmanuelle P, Tarrier,N., Dunn, G., Lewis, S., Wykes,T.,Davies,L.,Helen Lester, H., and Michail, M. "A Multi-Centre, Randomised Controlled Trial of Cognitive Therapy to Prevent Harmful Compliance with Command Hallucinations." BMC Psychiatry 11, (2011).8. Birchwood M, Trower P.The future of cognitive-behavioural therapy for psychosis: not a quasi-neuroleptic. . Br J Psychiatry. 2006 Feb;188:107-8.9. Lepping P, Sambhi RS, Whittington R, Lane S, Poole R. Clinical relevance of findings in trials of antipsychotics: systematic review. The British Journal of Psychiatry 2011;198(5):341-345.

... More

Conflict of interest: None declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *