BACKGROUND: Guidance in the United States and United Kingdom has included cognitive behavior therapy for psychosis (CBTp) as a preferred therapy. But recent advances have widened the CBTp targets to other symptoms and have different methods of provision, eg, in groups. AIM: To explore the effect sizes of current CBTp trials including targeted and nontargeted symptoms, modes of action, and effect of methodological rigor. METHOD: Thirty-four CBTp trials with data in the public domain were used as source data for a meta-analysis and investigation of the effects of trial methodology using the Clinical Trial Assessment Measure (CTAM). RESULTS: There were overall beneficial effects for the target symptom (33 studies; effect size = 0.400 [95% confidence interval [CI] = 0.252, 0.548]) as well as significant effects for positive symptoms (32 studies), negative symptoms (23 studies), functioning (15 studies), mood (13 studies), and social anxiety (2 studies) with effects ranging from 0.35 to 0.44. However, there was no effect on hopelessness. Improvements in one domain were correlated with improvements in others. Trials in which raters were aware of group allocation had an inflated effect size of approximately 50%-100%. But rigorous CBTp studies showed benefit (estimated effect size = 0.223; 95% CI = 0.017, 0.428) although the lower end of the CI should be noted. Secondary outcomes (eg, negative symptoms) were also affected such that in the group of methodologically adequate studies the effect sizes were not significant. CONCLUSIONS: As in other meta-analyses, CBTp had beneficial effect on positive symptoms. However, psychological treatment trials that make no attempt to mask the group allocation are likely to have inflated effect sizes. Evidence considered for psychological treatment guidance should take into account specific methodological detail.

http://www.reading.ac.uk/web/files/psychology/paper_4.pdf

Cognitive Behavior Therapy for Schizophrenia: Effect Sizes, Clinical Models, and Methodological Rigor

SummaryIn this report, recommendations for the pharmacological treatment of anxiety and obsessive-compulsive disorders are presented, based on available randomized, placebo-or comparator-controlled

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World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders – First Revision

The basic framework of the cognitive theory of psychopathology and cognitive therapy of specific psychiatric disorders was developed more than 40 years ago. Since that time, there has been continuing progress in the development of cognitive theory and therapy and in the empirical testing of both. A substantial body of research supports the cognitive model of depression and, to a somewhat lesser extent, the various anxiety disorders. Cognitive therapy (CT), often labeled as the generic term cognitive behavior therapy , has been shown to be effective in reducing symptoms and relapse rates, with or without medication, in a wide variety of psychiatric disorders. Suggestions for future research and applications are presented.

https://jamanetwork.com/journals/PSYCH/articlepdf/1108411/yps40003.pdf

The current state of cognitive therapy: a 40-year retrospective.

To date, few studies have been published on the doseresponse relationship, but there is general consensus that between 13 and 18 sessions of therapy are required for 50% of patients to improve. Reviewing the clinical trials literature reveals that in carefully controlled and implemented treatments, between 57.6% and 67.2% of patients improve within an average of 12.7 sessions. Using naturalistic data, however, revealed that the average number of sessions received in a national database of over 6,000 patients was less than five. The rate of improvement in this sample was only about 20%. These results suggest that patients, on average, do not get adequate exposure to psychotherapy, nor do they recover from illness at rates observed in clinical trials research.

http://dunx1.irt.drexel.edu/~emf27/Lab%20Group/Publications%20and%20Presentations_files/Hansen%20Lambert%20and%20Forman%202002.pdf

The Psychotherapy Dose‐Response Effect and Its Implications for Treatment Delivery Services

The Schizophrenia Patient Outcomes Research Team (PORT) psychosocial treatment recommendations provide a comprehensive summary of current evidence-based psychosocial treatment interventions for persons with schizophrenia. There have been 2 previous sets of psychosocial treatment recommendations (Lehman AF, Steinwachs DM. Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophr Bull. 1998;24:1-10 and Lehman AF, Kreyenbuhl J, Buchanan RW, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophr Bull. 2004;30:193-217). This article reports the third set of PORT recommendations that includes updated reviews in 7 areas as well as adding 5 new areas of review. Members of the psychosocial Evidence Review Group conducted reviews of the literature in each intervention area and drafted the recommendation or summary statement with supporting discussion. A Psychosocial Advisory Committee was consulted in all aspects of the review, and an expert panel commented on draft recommendations and summary statements. Our review process produced 8 treatment recommendations in the following areas: assertive community treatment, supported employment, cognitive behavioral therapy, family-based services, token economy, skills training, psychosocial interventions for alcohol and substance use disorders, and psychosocial interventions for weight management. Reviews of treatments focused on medication adherence, cognitive remediation, psychosocial treatments for recent onset schizophrenia, and peer support and peer-delivered services indicated that none of these treatment areas yet have enough evidence to merit a treatment recommendation, though each is an emerging area of interest. This update of PORT psychosocial treatment recommendations underscores both the expansion of knowledge regarding psychosocial treatments for persons with schizophrenia at the same time as the limitations in their implementation in clinical practice settings.

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The 2009 Schizophrenia PORT Psychosocial Treatment Recommendations and Summary Statements

BACKGROUND We test the hypotheses that (a) cognitive therapy is of comparable efficacy to psychodynamic psychotherapy, (b) 8-10 sessions of therapy is as effective as 16-20 sessions, and (c) brief therapist training is as effective as intensive training.

METHOD Of 178 out-patients referred to a clinical trial of psychological treatment for generalised anxiety, 110 patients met DSM-III-R criteria for generalised anxiety disorder and were randomly assigned to three different forms of psychotherapy. The main comparison was between cognitive therapy and analytic psychotherapy, delivered by experienced therapists at weekly or fortnightly intervals over six months. A third treatment, anxiety management training, was delivered at fortnightly intervals by registrars in psychiatry after a brief period of training. Eighty patients completed treatment and were assessed before treatment, after treatment, and at six-month follow-up.

RESULTS Cognitive therapy was significantly more effective than analytic psychotherapy, with about 50% of patients considerably better at follow-up. Analytic psychotherapy gave significant improvement but to a lesser degree than cognitive therapy. There was no significant effect for level of contact. Patients receiving anxiety management training showed similar improvements to cognitive therapy after treatment, with rather lower proportions showing clinically significant change.

CONCLUSIONS Cognitive therapy is likely to be more effective than psychodynamic psychotherapy with chronically anxious patients. Significant improvements in symptoms can be achieved by trainee psychiatrists after only brief instruction in behaviourally based anxiety management. However, the superiority of cognitive therapy at follow-up suggests that the greater investment of resources required for this approach is likely to pay off in terms of more sustained improvement. There is no evidence that 16-20 sessions of treatment is more effective, on average, than 8-10 sessions.

Cognitive therapy, analytic psychotherapy and anxiety management training for generalised anxiety disorder.

Background Evidence for the efficacy of cognitive—behavioural therapy for schizophrenia is promising but evidence for clinical effectiveness is limited.

Aims To test the effectiveness of cognitive—behavioural therapy delivered by clinical nurse specialists in routine practice.

Method Of 274 referrals, 66 were allocated randomly to 9 months of treatment as usual (TAU), cognitive—behavioural therapy plus TAU (CBT) or supportive psychotherapy plus TAU (SPT) and followed up for 3 months.

Results Treatment effects were modest but the CBT condition gave significantly greater improvement in overall symptom severity than the SPT or TAU conditions combined ( F (1,53)=4.14; P =0.05). Both the CBT and SPT conditions combined gave significantly greater improvement in severity of delusions than did the TAU condition ( F (1,53)=4.83; P =0.03). Clinically significant improvements were achieved by 7/21 in the CBT condition (33%), 3/19 in the SPT condition (16%) and 2/17 in the TAU condition (12%).

Conclusions Cognitive—behavioural therapy delivered by clinical nurse specialists is a helpful adjunct to routine care for some people with chronic psychosis.

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Tayside-Fife clinical trial of cognitive-behavioural therapy for medication-resistant psychotic symptoms. Results to 3-month follow-up.

The Patient’s Brain: The Neuroscience Behind the Doctor–Patient Relationship By Fabrizio Benedetti. Oxford University Press. 2010. £34.95 (pb). 304pp. ISBN: 9780199579518 

Following on from his highly acclaimed book Placebo Effects , Benedetti has taken his understanding of the neuroscience

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The Patient’s Brain: The Neuroscience Behind the Doctor–Patient Relationship

At a time when males abused in childhood are coming increasingly to attention of clinical services, we review the literature, describe the process and report on clinical outcomes of a slow open long-term dynamically orientated group for abused adult males. Twenty-nine men referred to the local psychotherapy service for consideration for inclusion in the group are discussed along with some of the most prevailing themes, namely identification with the aggressor, self-esteem, guilt and sexuality. Symptoms were measured using the SCL 90-R and demonstrate relatively high levels of psychological distress in this group at initial assessment. There is significant improvement in global scores, interpersonal sensitivity, depression and psychoticism in the group of 13 men who engaged in therapy for at least six months compared with those who did not.



The authors conclude that symptom measurement provides evidence that group psychotherapy is a useful therapeutic approach in a group of men who might otherwise be considered unsuitable for psychotherapeutic interventions due to symptom severity and personality difficulties.

Evaluation of outcome in a dynamically orientated group for adult males who have been sexually abused in childhood

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The Neuroscience of Psychotherapy: Healing the Social Brain (3rd edn) By Louis Cozolino , W.W.Norton and Company, 2017, £30.80 (hb), 608 pp. ISBN: 978-0393712643

Linda R. Treliving

Papers

Cognitive therapy, analytic psychotherapy and anxiety management training for generalised anxiety disorder.

Tayside-Fife clinical trial of cognitive-behavioural therapy for medication-resistant psychotic symptoms. Results to 3-month follow-up.

The Patient’s Brain: The Neuroscience Behind the Doctor–Patient Relationship

Evaluation of outcome in a dynamically orientated group for adult males who have been sexually abused in childhood

The Neuroscience of Psychotherapy: Healing the Social Brain (3rd edn) By Louis Cozolino , W.W.Norton and Company, 2017, £30.80 (hb), 608 pp. ISBN: 978-0393712643