Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia
Abstract
Background
Cognitive behavioural therapy (CBT) is now a recommended treatment for people with schizophrenia. This approach helps to link the person's distress and problem behaviours to underlying patterns of thinking.
Objectives
To review the effects of CBT for people with schizophrenia when compared with other psychological therapies.
Search methods
We searched the Cochrane Schizophrenia Group Trials Register (March 2010) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. We inspected all references of the selected articles for further relevant trials, and, where appropriate, contacted authors.
Selection criteria
All relevant randomised controlled trials (RCTs) of CBT for people with schizophrenia‐like illnesses.
Data collection and analysis
Studies were reliably selected and assessed for methodological quality. Two review authors, working independently, extracted data. We analysed dichotomous data on an intention‐to‐treat basis and continuous data with 65% completion rate are presented. Where possible, for dichotomous outcomes, we estimated a risk ratio (RR) with the 95% confidence interval (CI) along with the number needed to treat/harm.
Main results
Thirty one papers described 20 trials. Trials were often small and of limited quality. When CBT was compared with other psychosocial therapies, no difference was found for outcomes relevant to adverse effect/events (2 RCTs, n = 202, RR death 0.57 CI 0.12 to 2.60). Relapse was not reduced over any time period (5 RCTs, n = 406, RR long‐term 1.03 CI 0.86 to 1.24) nor was rehospitalisation (6 RCTs, n = 670, RR in longer term 0.96 CI 0.81 to 1.14). Various global mental state measures failed to show difference (4 RCTs, n = 244, RR no important change in mental state 0.84 CI 0.64 to 1.09). More specific measures of mental state failed to show differential effects on positive or negative symptoms of schizophrenia but there may be some longer term effect for affective symptoms (2 RCTs, n = 105, mean difference (MD) Beck Depression Inventory (BDI) ‐6.21 CI ‐10.81 to ‐1.61). Few trials report on social functioning or quality of life. Findings do not convincingly favour either of the interventions (2 RCTs, n = 103, MD Social Functioning Scale(SFS) 1.32 CI ‐4.90 to 7.54; n = 37, MD EuroQOL ‐1.86 CI ‐19.20 to 15.48). For the outcome of leaving the study early, we found no significant advantage when CBT was compared with either non‐active control therapies (5 RCTs, n = 495, RR 0.90 CI 0.68 to 1.19) or active therapies (6 RCTs, n = 339, RR 0.75 CI 0.40 to 1.43)
Authors' conclusions
Trial‐based evidence suggests no clear and convincing advantage for cognitive behavioural therapy over other ‐ and sometime much less sophisticated ‐ therapies for people with schizophrenia.
PICOs
Plain language summary
Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia
Cognitive behavioural therapy (CBT) is a talking therapy first mentioned in 1952 but only became recommended as a routine treatment in 2002. CBT encourages people to openly discuss their beliefs, emotions and experiences with a therapist (individually or in a group), as well as participate in assessing their symptoms, emotional distress and behaviour. Such discussion is thought to help develop ways of challenging, coping and managing unhelpful thoughts and problem behaviour. People with schizophrenia may have difficulties with concentration, attention and motivation. The capacity to think, feel pleasure, talk openly and act also may be reduced. All of which can mean making friends, living independently and finding employment are sometimes hard. The idea of CBT is to help with these problems by coming up with ‘real world’ coping strategies and problem solving skills.
Relatively little is known about the effects of CBT when compared with other psychological or talking therapies (such as supportive therapy, psycho‐ education, group, relaxation and family therapy) in helping people with schizophrenia. This review found that research in this area was often small scale and of limited quality. The majority of therapists (65%) met the review’s standard of being qualified (but this was not a complete finding as most studies did not take into account appropriate training and the qualification of therapists).
In the main, no difference in overall effectiveness was found between CBT and other talking therapies. Relapses (people with schizophrenia becoming unwell again) and re‐hospitalisation (the need to go back into hospital) were not reduced. CBT was not any better at improving mental state compared to other talking therapies and CBT was no better or worse in managing the symptoms of schizophrenia, both in terms of managing positive symptoms (such as hearing voices or seeing things) and negative symptoms (not feeling emotions, inactivity which leads to weight gain).
No difference was found for leaving the study early or continuing treatment for CBT compared with other therapies, although the overall number of people who left the study early was relatively low compared to drug trials meaning that CBT and other talking therapies may better at retaining and keeping people with schizophrenia in treatment. No advantage for CBT was recorded with regard to death by natural causes or suicide, coping with anxiety, building self‐esteem, developing insight or helping with anger or problem behaviours such as violence. Few studies reported the effect CBT had on quality of life and in developing better social or work skills.
The review, however, suggests that there might be some longer term advantage in CBT for dealing with emotions and distressing feelings. Some initial findings indicated that CBT may be of greater benefit to people with depression and managing its symptoms.
This Plain Language Summary was written by a consumer Benjamin Gray, Service User and Service User Expert,
Rethink Mental Illness. Email: [email protected].
