A literature review in chronological order from past 5 years
The blanket term Psychotherapy covers a multifaceted pluralistic enterprise in which a range of therapies is required to meet a patient’s various needs (Holmes J 2002). The National Service Framework cites cognitive behaviour therapy as being the psychotherapeutic method of choice for conditions that include “depression, eating disorders, panic disorder, obsessive-compulsive disorder, and deliberate self harm.” (Rouse et al. 2001)
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The first article we shall consider is a letter to the editor of the BMJ by Van Meer (R 2003). It is comparatively unusual since it is a clinician referring to clinical matters which are both intuitive and experience based. The author refers to the fact that many psychiatrists and related healthcare professionals actually avoid talking about the content of psychotic symptoms. The generally accepted rationale being that these are diagnostically of no significance and therefore therapeutically irrelevant. Van Meer contrasts this view with the basic concepts of cognitive behaviour therapy. He suggests that in his experience, the patient actually often will want to talk about issues that are central to their experience and are distressed when they are kept out of the conversation. He suggests that this is one of the reasons why cognitive behaviour therapy is popular with psychotic patients is that they have the opportunity to discuss with sympathetic professionals the significance of their experiences and this is capable of giving them a mechanism of dealing with what may be otherwise unexplainable to them. This publication is selected because of its counterintuitive thrust to support cognitive behaviour therapy against the “mainstream” of current clinical psychiatric practice and is written by an experienced practising clinician.
This area of consideration is given a further twist with a different insight from Moorhead (S 2003). He agrees that psychiatric professionals tend to try to avoid engagement with psychotic patients on the subject of their psychosis and “thereby unwittingly add to the prejudice that blights the lives of people who live with psychosis” . He points, very succinctly, to the fact (and cites Brabban A et al. 2000) that the central tenet of cognitive behaviour therapy is that the therapist should endeavour to show a clear linkage between “personal experience, core beliefs (schemas), and emergence of psychotic symptoms”. The significance of this publication is that it is unusual insofar as it outlines the benefit of cognitive behaviour therapy for the staff as much as the benefit for the patient, by suggesting that staff trained in the techniques of cognitive behaviour therapy are able to empathise on a much deeper level with the patient and this, in itself, has a “remarkable remoralising effect of developing a meaningful understanding of the psychotic phenomenon with a patient”. This point is echoed in the discussion of the Craig paper.
The Craig paper (Craig T K J et al. 2004) is a carefully constructed, but badly reported, randomised controlled trail of the current efficacy of specialised care modalities for cases of early psychosis. (Vickers, A. J et al. 2001). It is presented here as a case study in critical analysis. The interventions were delivered in two groups. The entry cohort was allocated to a standard care group (the control) or the intervention group (specialised care group). Both sets of treatment were delivered by the community mental health teams. The outcomes for both groups were rates of relapse or readmission to hospital. (Friedman GD. 1994)
We present this paper to illustrate a common problem with this type of trial. On first appreciation, it demonstrates the fact that the intervention group did better than the control group. The difficulty in critical analysis comes in trying to decide which of the treatment modalities actually produced this beneficial effect. (Mohammed, D et al. 2003)
The entry cohort was quite impressive for a study of this type with 319 presenting with psychotic illness over an 18 month period and 144 of these meeting the inclusion criteria. 94% of these were remained in the trial over the 18 months of follow up.
We note that, although the programme of interventions did include cognitive behaviour therapy, it also included other treatment options such as low dose atypical antipsychotic regimens, cognitive behaviour therapy based on manualised protocols, and family counselling and vocational strategies based on established protocols (Jackson H et al. 1998). From the point of view of our considerations here, on the one hand the results appeared to be good insofar as the study showed that the intervention group had fewer readmissions to hospital in the study period and also they had fewer psychotic relapses (although this was of low statistical significance). On the other hand the paper tells us that all patients had medication and the ultimate choice of treatment pathway was decided by the intervention clinician, so although cognitive behaviour therapy was used, we have no absolute idea of its effectiveness from this trial. (Green J et al. 1998). All we can say with confidence is that, as part of a total package, cognitive behaviour therapy appeared to have helped to contribute to a beneficial outcome for a significant number of psychotic patients. A completely analytical and minimalist approach to this particular trial could suggest that it is indeed possible that cognitive behaviour therapy is actually ineffective per se. other than it served to keep the patient in closer contact with the clinicians. (Piantadosi S. 1997)
In this respect this is an instance of a trial which is seemingly supportive but does not contribute greatly to the evidence base
On first sight this particular view might be considered pedantic, but it is echoed by Yates (DH 2005) in a letter in the BMJ, where he specifically takes up this very point. He points to the fact that there is very little description of the regimes of cognitive behaviour therapy and the degree that it’s impact can be isolated from the overall effect. He also refers to the fact that a breakdown of the various therapies offered and the degree that each was helpful would have improved the paper tremendously. We have to agree.
We will next consider a high profile paper by Morrison (A P et al. 2004) which has been widely cited. This paper took the pioneering work of Yung (et al. 1996) who identified a high risk group of patients who would develop psychosis and studied the effect of cognitive behaviour therapy on the prevention of the development of the clinical state. Morrison et al. identified the fact that other studies (McGorry, P. D et al. 2002) had demonstrated that it was possible to reduce the incidence of psychosis development with a multifaceted approach, like that of Craig, which included elements of cognitive behaviour therapy. Morrison however, elected to carry out a study that used cognitive behaviour therapy as a single strand approach in this high risk population. (Leaverton P E. 1995)
The results from this study convincingly demonstrated that cognitive behaviour therapy alone “significantly reduced the likelihood of making progression to psychosis as defined on the Positive and Negative Syndrome Scale over 12 months.” (Kay, S. R et al. 1987) The authors were also able to demonstrate that cognitive behaviour therapy also reduced the likelihood of a patient being prescribes antipsychotic medication. Other criteria of analysis demonstrated that cognitive behaviour therapy “significantly improved the positive symptoms of psychosis “ in the target population.
This is an important study as it is one of the first to provide a reasonably secure evidence base that cognitive behaviour therapy works in the psychotic patient. It also shows that it works in the high risk group and has the possibility of a prophylactic effect by minimising the likelihood of psychotic relapse.
A critical analysis would observe that the intervention cohort was comparatively small and a disproportionately small number were entered in the control group (37 and 23 respectively). High risk psychotic patients are comparatively rare and therefore one has to appreciate the practical difficulties involved in accumulating a sufficiently large sample to study. (Grimes D A et al. 2002),
The last publication that we shall consider is that by Trower (P et al. 2004). It was published at the same time as the Morrison paper and is notable for the fact that, like the Morrison paper it recognises the shortfalls of the previous multi-modality studies and isolates cognitive behaviour therapy in its analysis. It also specifically targets a notoriously treatment-resistant group of psychotics, those who suffer from command hallucinations. (Haddock, G et al. 1999)
This was a single blind randomised trial with 38 patients. The trial was complex in structure but, in essence, it was able to show, with convincing statistical significance that cognitive behaviour therapy interventions alone was able to reduce the patient’s compliance rate with the psychotic commands. The authors noted that this reduction in compliance was associated with a reduction in levels of both anxiety and depression.
In conclusion we would like to commend the book by Eisenman (R 2004) “The Case Study Guide to Cognitive Behaviour Therapy of Psychosis” as a particularly authoritative and clinically useful overview. It cites a number of clinical case studies and analyses them in depth. It supports the view that cognitive behaviour therapy, by attempting to confront the patient’s distorted thinking and allowing them to appreciate their thoughts in a more rational and realistic way, can have beneficial results and it places cognitive behaviour therapy in a clinical context amongst the other, generally accepted modes of psychotherapy. It is not a peer reviewed publication so we shall not consider it further than that.
Brabban A, Turkington D. 2000 The search for meaning: detecting congruence between life-events, underlying schema and psychotic symptoms. Formulation-driven and schema focussed CBT for a neuroleptic-resistant schizophrenic patient with a delusional memory. In: Morrison T, ed. A casebook of cognitive therapy for psychosis. Brighton : Psychology Press, 2000.
Craig T K L, Philippa Garety, Paddy Power, Nikola Rahaman, Susannah Colbert, Miriam Fornells-Ambrojo, and Graham Dunn 2004 The Lambeth Early Onset (LEO) Team : randomised controlled trial of the effectiveness of specialised care for early psychosis BMJ, Nov 2004 ; 329 : 1067 ;
Eisenman R 2004 The Case Study Guide to Cognitive Behaviour Therapy of Psychosis Am J Psychiatry, Jul 2004 ; 161 : 1318.
Friedman G D. 1994 Primer of Epidemiology. 4th ed. New York : Mc-Graw-Hill, 1994.
Green J, Britten N. 1998 Qualitative research and evidence based medicine. BMJ 1998 ; 316 : 1230-1233
Grimes D A, Schulz K F.2002 Cohort studies: marching towards outcomes. Lancet 2002 ; 359 : 341-5
Haddock, G., McCarron, J., Tarrier, N., et al (1999) Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS). Psychological Medicine, 39, 879 –889.
Holmes J 2002 All you need is cognitive behaviour therapy? BMJ, Feb 2002 ; 324 : 288 – 294 ;
Jackson H, McGorry P, Edwards J, Hulbert C, Henry L, Francey S, et al. 1998
Cognitively orientated psychotherapy for early psychosis (COPE). Br J Psychiatry 1998 ; 172 (Suppl 33) : 93-100. Kay, S. R. & Opler, L. A. (1987)
The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13, 507 -518.
Leaverton PE. 1995 A Review of Biostatistics. 5th ed. Boston: Little, Brown, 1995
McGorry, P. D., Yung, A. R., Phillips, L. J., et al (2002) Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis first-episode in a clinical sample with subthreshold symptoms. Archives of General Psychiatry, 59, 921 -928.
Mohammed, D Braunholtz, and T P Hofer 2003 The measurement of active errors: methodological issues Qual. Saf. Health Care, Dec 2003 ; 12: 8 – 12.
Moorhead S 2003 Cognitive behaviour therapy can help end alienation of psychosis BMJ 2003 ; 326 : 549
Morrison A P , Paul French, Lara Walford, Shôn W. Lewis, Aoiffe Kilcommons, Joanne Green, Sophie Parker, and Richard P. Bentall 2004 Cognitive therapy for the prevention of psychosis in people at ultra-high risk: Randomised controlled trial Br. J. Psychiatry, Oct 2004 ; 185 : 291 – 297.
Piantadosi S. 1997 Clinical Trials: A Methodologic Perspective. New York: John Wiley, 1997.
Rouse, Jolley, and Read 2001 National service frameworks BMJ, Dec 2001 ; 323 : 1429.
Rower P, MAX BIRCHWOOD, ALAN MEADEN, SARAH BYRNE, ANGELA NELSON, and KERRY ROSS 2004 Cognitive therapy for command hallucinations: randomised controlled trial Br. J. Psychiatry, Apr 2004; 184: 312 – 320.
van Meer R 2003 To listen or not to listen BMJ 2003 ; 326 : 549
Vickers, A. J. & Altman, D. G. (2001) Analysing controlled trials with baseline and follow up measurements. BMJ, 323, 1123–1124
Yates D H 2005 Specialised care for early psychosis: More detail is needed BMJ, Jan 2005 ; 330 : 197
Yung, A., McGorry, P. D., McFarlane, C. A., et al (1996) Monitoring and care of young people at incipient risk of psychosis. Schizophrenia Bulletin, 22, 283 -303.
5.5.06 PDG Word count 2,313
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