A recent study published by psychologist Anthony Morrison and colleagues in the British medical journal, The Lancet, is stirring up a long-standing debate about the treatment of schizophrenia. The article describes a randomized controlled trial involving people diagnosed with schizophrenia who refused to take psychiatric medications called “antipsychotics.” The researchers tested whether these patients could be treated with a form of talk therapy called cognitive-behavioral therapy (CBT) in lieu of medications. In the study, patients received one-on-one counseling sessions in which the therapist normalized their experiences and taught them psychological coping strategies to reduce stress and manage their illness. After 18 months of treatment, 41% of patients receiving CBT achieved a “good clinical response” compared to only 18% of patients receiving standard care.
Some people are understandably skeptical of the results of the study. One reason is that schizophrenia is seen as a chronic, debilitating disorder in which the sufferer experiences hallucinations (hearing voices or seeing things that aren’t there), delusions (false beliefs that the person is convinced are true), and other thinking disturbances that can severely interfere with normal functioning. Although schizophrenia only affects about 1% of the general population, it is estimated that 5% of the public experiences psychotic symptoms, such as hallucinations or delusions, at least to some degree. Antipsychotic medications are thought to work by affecting neurotransmitters such as dopamine in the brain, thereby reducing the severity of hallucinations and delusions.
Despite their ability to help many people, the limitations of antipsychotic medications have become increasingly clear over the years. These medications aren’t effective for everyone and often produce problematic side effects that range from excessive drowsiness to potentially life-threatening complications, requiring careful clinical monitoring. Not surprisingly, about 50% of patients don’t adhere to their antipsychotic medication regimens. Research shows that antipsychotics can negatively affect a person’s health over time, leading to shrinkage of brain tissue and other cognitive impairments. Current treatment guidelines recommend that antipsychotics be continued even after the psychotic episode has remitted to prevent future relapse. Given emerging concerns over the long-term effects of antipsychotics on the brain, some have suggested that these medications are better used as short-term treatment and that alternatives should be considered in the longer-term.
Another recent study appears to affirm the wisdom of reducing unnecessary long-term antipsychotic usage when clinically possible. Wunderink and his colleagues randomized 128 patients in a first episode of psychosis, asking them to either continue their antipsychotic medication or withdraw the medication under a doctor’s supervision following remission of their symptoms. After a 2-year follow-up, those who discontinued the medications showed no differences in the severity of their symptoms compared to patients who stayed on antipsychotics. Even more surprisingly, those who were taken off the antipsychotic after being initially stabilized had over twice the rates of recovery from schizophrenia compared with those whose antipsychotic treatment was continued (40% vs 18%). It appeared that patients who safely discontinued the medications were less functionally impaired over time compared to those who remained on antipsychotics, resulting in higher recovery rates. Many are surprised to learn that recovery from schizophrenia is even possible. But prominent cases like that of the late John Nash, a Nobel-prize winning mathematician and subject of the book and film entitled A Beautiful Mind, provide public examples of this process.
So if antipsychotics can offer diminishing returns over time for many patients, what else can be done? There are now a large number of studies conducted with thousands of patients in different countries showing that adding psychotherapy, such as CBT, to a person’s treatment produces better clinical outcomes compared with medications alone. Therapy for psychosis continues to evolve. In recent years, researchers have begun incorporating mindfulness techniques into the treatment to provide further benefits. Put simply, mindfulness means bringing nonjudgmental awareness and acceptance to our moment-to-moment experiences, including thoughts and feelings. Being more mindful has been shown to produce many benefits to a person’s psychological and even physical health. Today’s CBT treatments for psychosis are increasingly combining mindfulness, acceptance, and self-compassion to help patients manage psychotic symptoms and to promote social and occupational functioning.
It is important for service users and their family members to know that current guidelines recommend combining cognitive-behavioral therapy with antipsychotic medication to achieve the best results when treating psychosis. But the Lancet study, showing that CBT can be beneficial even when patients are not taking antipsychotics, is challenging this conventional wisdom. Although potentially exciting, we must tread cautiously here. Further studies are needed to confirm the appropriateness of CBT for psychosis in the absence of ongoing antipsychotic treatment. Even if CBT alone can be shown to be useful for at least a subgroup of patients with schizophrenia, it is not likely to be an option for everyone. But recent research reminds us that we have a lot more to learn about how to help people cope with their psychosis. In the end, we must carefully weigh the benefits as well as costs of medications or psychotherapy for psychosis to better understand how they should be used, either alone or in combination, to promote optimal recovery from a very debilitating illness like schizophrenia.
I suspect it’s a sleeping disorder in which the brain is frequently falling in and out of sleep, and thus the hallucinations.
Dear Dr Gaudiano
I would make a few observations on your post about the Morrison et al trial.
You say “After 18 months of treatment, 41% of patients receiving CBT achieved a “good clinical response” compared to only 18% of patients receiving standard care”
This misrepresents the findings somewhat. This percentage is based on who achieved 50%+ improvement in symptoms at the end of the follow-up to the trial (i.e. 7/17 show improvement).
First, the number who participated was 37, so the reported percentage is not based on the total sample, but a sub-sample (less than half ultimately – see below)
Second, of the 7 who did improve, 2 had gone onto medication – so, at best it would be 5/17 i.e. 29% and not 41%.
Third, it might be argued that the real comparison is at the end of the 9 month CBT intervention (as the authors have no control over what happened to the two groups between 9 and 18 months. At 9 months, the percentage of the CBT group showing 50% clinical improvement was 22% vs 13% in controls.
Fourth, we might argue that it is more interesting to look at the total numbers who improved regardless of the 50% rule – at 9 months 10/22 CBT group improved and 12/23 of the controls improved (after removing those who went on medication) – so, slightly fewer improved with CBT. At 18 months the numbers were: 11/17 in CBT improved and 8/17 in the control – Neither of these would show a significant benefit of CBT over what is essentially ‘doing nothing’ for these individuals
Finally, you refer to the problems with adherence to medication regimens – and interestingly, this Morrison et al study clearly shows the same to be true for CBT – the drop-out rate was 50% – in fact, there were more authors on the study than patients left in the CBT arm of the trial at the end – hardly a ringing endorsement for the acceptability of CBT (in those who have rejected medication). I also note that the one case of significant clinical *deterioration* occurred in the CBT group – should we also then not note the possibility that at least 5% of patients in receipt of CBT for psychosis might undergo a 50-100% symptom worsening? I say at least 5%, as we dont know what happened to the people who left the trial – it seems feasible that they gave up CBT because they perceived it to be ineffective or even possibly worsened their symptoms – not altogether unlikely given the recent meta analysis on negative symptoms by Velthorst et al http://www.ncbi.nlm.nih.gov/pubmed/24993642
Prof Laws’ comment is unfortunately beset with too much negative speculation to be of any help to any reader unsure of the scientific quality of the study described.
In the interest of transparency, I should declare I’m a junior author of the study, and have had numerous interactions with Keith online about this topic.
To cut a long story short, it may be of interest to eagle-eyed readers to see if they can spot how many times Keith uses words like ‘might’, ‘feasible’, ‘possibility’. If it ‘might’ be argued that the 9-month assessment point is the most important, why refer to the discontinuation rate seen at 18-months?
Criticism of important research is valuable, but Keith’s relentless negative spinning of this article verges on vandalism. Fascinating to see, but not helpful to anyone.
Readers can see the full – actual – study article here: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2813%2962246-1.pdf
I note that you fail to rebut any of my points…
Dear Dr. Laws,
Thank you for sharing your thoughts on the Morrison et al. study that I discussed in my blog post. I know that you have, in your previous work, pointed out many important limitations in the research to date on CBT for psychosis which deserve careful attention. I believe we should appreciate the complexity of these issues in order to understand the potential effectiveness of CBT for psychosis and to further improve non-medication treatments for psychosis in the future.
The Morrison et al. study is one important step in this direction, but certainly has several limitations, as you note. I agree that the magnitude of the benefits of CBT for psychosis reported in the Morrison et al. study vary based on the metric used to assess clinical improvement; although overall results still appear positive and supportive of the authors’ conclusions when weighed in totality in my opinion.
A few additional thoughts provoked by your comments:
1. My understanding is that CBT booster sessions were offered during the 9 month follow-up, so I think it is still important to consider the longer-term (18 month) impact of CBT and not just its more acute affects. Often in the CBT literature, research shows that the effects of CBT increase over time, even after the initial phase of treatment has ended. I think most people would see this as a positive and not a negative or weakness. In fact, only examining improvement at treatment termination would be a much greater weakness of the study, as we wouldn’t know how stable the effects were otherwise.
2. Clinical deterioration must be compared between randomized conditions not just within conditions. As clinical deterioration was no higher in the CBT condition relative to the comparison group, it is not appropriate to attribute any worsening within the CBT condition, specifically to CBT. In other words, similar deterioration was observed in non-CBT group receiving other early intervention services.
3. You are correct that some patients started antipsychotic medications during the study (about 27% overall I believe). I think most would see this as a positive development suggesting that engagement in psychosocial treatment (including early intervention services) encouraged those who may benefit from additional pharmacotherapy to receive it eventually. But it also is important to note that patients in both conditions started medication during the trial at similar rates, and this did not appear to account for the differences in outcomes when this issue was examined by the authors.
4. You note that there was about 50% drop out in this study and so do not consider this an improvement over medication nonadherence (also about 50% on average in the literature). Perhaps, but I think it would only be logical to consider that by definition, 100% of these patients were nonadherent to medications at the start of this study (as they refused to take them in the first place even though recommended). Many fully or partially adhered to psychotherapy in the study. So I would not be so quick to discount the importance of these patients’ willingness to engage (albeit imperfectly) in another treatment for their condition when offered.
5. I think the bottom line is that, for an initial study, the authors appeared to do a more than reasonable job conducting their clinical trial. At this time, I think it is more relevant for readers to appreciate that the results come from one particular study only. Thus, it will be important for additional studies to be conducted to replicate the results before we can determine the generalizability of the findings to the majority of patients in clinical practice. Morrison et al.’s sample size was only modest, and the study excluded some important groups (e.g., patients needing inpatient admission or rejecting early intervention services altogether). Also, it is important to note that we don’t know if the results are specific to CBT. Other types of psychotherapy may have produced similar benefits.
So in the end, I’m sure we can go around and again quibbling about exact percentages and exploring minute differences to support our respective positions. But at this point, only further studies (many of which I’m sure are already underway) will be able to provide substantive evidence to support or disconfirm the Morrison et al. findings. I agree that those interested in this debate would best be served by reading the full report in detail, and I thank Dr. Byrne for providing the link.
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