Conference Coverage

More evidence shows value of CBT for schizophrenia



ORLANDO – Cognitive-behavioral therapy (CBT) should be more widely offered to patients with psychosis, and a growing body of evidence is demonstrating why, an expert said at the annual congress of the Schizophrenia International Research Society.

Dr. Tony Morrison of the University of  Manchester, England

Dr. Tony Morrison

Tony Morrison, ClinPsyD, said that, while antipsychotic medications are appropriate for many patients with disorders such as schizophrenia, they are not offered cognitive therapy nearly often enough.

“What I am against is the sole reliance on antipsychotics,” said Dr. Morrison, professor of clinical psychology at the University of Manchester (England). “Putting all of our eggs in that basket is not particularly sensible.” That’s because so many patients who are started on antipsychotic medications discontinue them, either because they are ineffective or because they conclude that the risk of side effects – weight gain, cardiovascular problems, and sexual dysfunction among them – are not worth it.

In a trial published last year, 75 patients with psychosis who were not taking antipsychotic medication were randomized to receive up to 26 sessions of CBT over 6 months, antipsychotic medication, or both. After a year, no difference was found in Positive and Negative Symptom Scale (PANSS) scores between the three groups, researchers found, although the combination group saw an improvement in PANSS scores at 24 weeks before later falling in line with the other groups (Lancet Psychiatry. 2018 May;5[5]:411-23).

Patients in the medical treatment arm mostly received aripiprazole, olanzapine, or quetiapine. Patients received an average of 14 sessions of CBT, with 80% attending at least 6 sessions. Researchers did not see any significant level adverse events in the CBT group.

The findings show that this is fertile ground to explore further, Dr. Morrison said. “It is safe to conduct trials in which people with psychosis are not taking antipsychotics,” he said. “It is clear that people significantly improve across all measures of symptoms and recovery [and] function regardless of intervention.”

A larger, more definitive trial is needed in this area.

Treatment of patients for whom antipsychotic medication has already been shown not to work is a bigger challenge, but a recent study Dr. Morrison led shows that CBT could work in these patients as well (Health Technol Assess. 2019 Feb;23[7]:1-144).

In that study, 487 patients with schizophrenia who were resistant to treatment with clozapine were randomized to CBT – up to 30 sessions over 9 months – or treatment as usual, without CBT. Researchers saw a slight benefit in PANSS scores for CBT at 9 months (P = .049). But this benefit was not maintained after patients stopped their cognitive therapy, and no difference in PANSS scores was seen at 21 months, the study’s primary endpoint.

Nonetheless, the findings were encouraging, Dr. Morrison said, showing that CBT “compares favorably with augmenting treatment with a second antipsychotic.” Researchers, however, were not able to determine which patients were likely to benefit most from CBT, despite “lots of subanalyses” in an effort to do so.

Patients resistant to initial medical therapy will need their illness tackled from a variety of fronts – subsequent antipsychotic therapy, psychological therapy, social-activity based therapy, and peer support.

“I think we probably need lots of things in combination – a much more rich package of care,” Dr. Morrison said.

Dr. Morrison reported no disclosures.

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