Cognitive behavioural therapy (CBT) is a promising option for patients with schizophrenia who refuse to take antipsychotics, show the findings of a pilot randomised trial.“We have showed that cognitive therapy is an acceptable intervention for a population who are usually considered to be very challenging to engage in mental health services,” said lead study author Anthony Morrison (University of Manchester, UK) in a press statement.The trial, which appears in The Lancet, involved 74 outpatients who were diagnosed with schizophrenia, schizoaffective disorder or delusional disorder but did not wish to take antipsychotics. A further three patients deemed eligible declined to take part in the trial.Co-author Douglas Turkington (Newcastle University, UK) commented: “One of our most interesting findings was that when given the option, most patients were agreeable to trying cognitive therapy.”Patients assigned to undergo CBT were offered 26 sessions over a maximum of 9 months, of which they received an average of 13, plus up to four booster sessions over the following 9 months. During this period, their average Positive And Negative Syndrome Scale (PANSS) score fell from 70.2 to 56.5, whereas the average score among patients who received treatment as usual changed little, from 73.3 to 71.2. Their scores were consistently lower across the whole period, to give a significant estimated between-group difference of 6.52 points and an effect size of 0.46.CBT had a significant effect on patients’ PANSS positive scores, but not negative scores. It also had positive effects on Psychotic Symptom Rating Scales scores, although not all were statistically significant. At the 9-month follow-up, 32% of patients in the CBT group had achieved a greater than 50% improvement in PANSS scores, compared with 13% of those receiving usual treatment.Two patients in each group had a greater than 50% deterioration in PANSS scores and there were eight serious adverse events. Two of these occurred in the CBT group, with one patient attempting a drug overdose and one becoming a risk to others.In an accompanying commentary, Oliver Howes (Institute of Psychiatry, London, UK) cautions that a placebo effect could have contributed to the positive findings, as there was no placebo intervention.“The potential effect of this limitation should not be underestimated because placebo effects can be large in schizophrenia trials, and have contributed to failed studies of new drug treatments for schizophrenia,” he says.Howes also cautions against overgeneralisation, especially regarding inpatients and patients who avoid contact with clinical services.He says that a direct comparison of CBT and antipsychotic treatment is needed; if positive, this would be “a step change in the treatment of schizophrenia, providing patients with a viable alternative to antipsychotic treatment for the first time, something that is sorely needed.”
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