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.