Outcomes of an effectiveness trial of cognitive-behavioural intervention by mental health nurses in schizophrenia
Turkington D, Kingdon D, Rathod S, Hammond K, Pelton J, Mehta R;
Commented by , 25 Jul 2006
Aim of the study
There is a surprising high number of randomized controlled studies on the effects of cognitive behaviour therapy (CBT) for schizophrenia. Most of these studies suggested that CBT has positive effects on symptoms, insight and compliance. Nevertheless, these studies have almost exclusively been carried out in research settings.
It has therefore been argued that a major limitation of CBT is that highly trained expert therapists are needed for its delivery. Another argument has been made about the mid- to long-term effects of CBT which has been provided in the form of only a few sessions.
The aim of the current study therefore was to examine whether CBT can be administered to people with schizophrenia by nurses working in a routine setting and whether it leads to a significant reduction of clinically important outcomes in terms of recovery, symptom burden and readmission to hospital at mid-term (1-year) follow-up.
Method
442 People with schizophrenia from 6 sites in the United Kingdom were randomised to 6 sessions over 2-3 months of CBT or usual care. Mental health nurses received a relatively short training of only 10 days. Outcomes were measured with rating scales (Comprehensive Psychopathological Rating Scale, Insight Rating Scale, Montgomery-Åsberg Depression Rating Scale, Psychotic Symptom Rating Scales, Negative Symptom Rating scale).
Working status and readmissions to hospital were also recorded. Raters were masked to treatment allocation and 336 of 422 patients were included in the one-year follow-up.
Results
A number of significant advantages of CBT were found at 1-year follow-up. CBT was associated with significantly more insight (P=0.021) and fewer negative symptoms (P= 0.002). Brief CBT also protected against depression that may be induced by increased insight. Time to rehospitalisation and time spent in hospital for those who did relapse was also shorter in the CBT group. There were no significant effects on psychotic symptoms, working status and overall psychopathology.
Dr Leucht's comments
CBT for schizophrenia has been the focus of numerous randomised controlled studies in the last two decades. Many of these studies have found beneficial effects of this intervention and two meta-analyses supported its effectiveness (ref. 1, ref. 2). Nevertheless, a number of open questions concerning the current and other studies in this area remain.
Blinding is an almost impossible problem to solve in psychotherapy research. Although raters can be blinded to treatment, the patients cannot be blinded. Therefore, the control group in such a study may play a crucial role. Instead of routine care the patients could for example receive psychoeducation, an even simpler but also highly effective psychotherapy (ref. 3).
The authors also highlight the problem that the nurses used were not selected "randomly" from the community, but were funded by the study group and had liaised with community mental health teams limiting the generalisability of the findings.
Nevertheless, it is remarkable how well CBT for schizophrenia has been developed and tested in randomized controlled trials, the quality of which often exceeded that of antipsychotic drug trials. I hope that future studies will show that the prevailing scepticism is not warranted.
References
1. 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. Psychological Medicine 2002; 32 (5); 763-782
2. National Institute for Clinical Excellence 2002, Clinical Guideline 1. Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care. London: NICE
3. Pitschel-Walz G, Leucht S, Bauml J, Kissling W, Engel RR. The effect of family interventions on relapse and rehospitalization in schizophrenia - a meta-analysis. Schizophrenia Bulletin 2001; 27 (1); 73-92