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Cognitive Behavioural Therapy for refractory symptoms in schizophrenia
- Mahesh Jayaram, Prakash Hosalli, Leeds Mental Health Teaching NHS trust, Leeds (21 April 2005)
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Mahesh Jayaram Leeds Mental Health Teaching NHS trust, Leeds, Prakash Hosalli, Leeds Mental Health Teaching NHS trust, Leeds
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Mahesh.Jayaram{at}leedsmh.nhs.uk Mahesh Jayaram, et al.
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Valmaggia et al (2005) report an interesting randomised control trial evaluating 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 be available 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 at follow 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 ¡Þ and 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 the fact 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) Cognitive behaviour 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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