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

Since publication of the original Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations in 1998, considerable scientific advances have occurred in our knowledge about how to help persons with schizophrenia. Today an even stronger body of research supports the scientific basis of treatment. This evidence, taken in its entirety, points to the value of treatment approaches combining medications with psychosocial treatments, including psychological interventions, family interventions, supported employment, assertive community treatment, and skills training. The most significant advances lie in the increased options for pharmacotherapy, with the introduction of second generation antipsychotic medications, and greater confidence and specificity in the application of psychosocial interventions. Currently available treatment technologies, when appropriately applied and accessible, should provide most patients with significant relief from psychotic symptoms and improved opportunities to lead more fulfilling lives in the community. Nonetheless, major challenges remain, including the need for (1) better knowledge about the underlying etiologies of the neurocognitive impairments and deficit symptoms that account for much of the disability still associated with schizophrenia; (2) treatments that more directly address functional impairments and that promote recovery; and (3) approaches that facilitate access to scientifically based treatments for patients, the vast majority of whom currently do not have such access.

The Schizophrenia Patient Outcomes Research Team (PORT): Updated Treatment Recommendations 2003

The Schizophrenia Patient Outcomes Research Team (PORT) project has played a significant role in the development and dissemination of evidence-based practices for schizophrenia. In contrast to other clinical guidelines, the Schizophrenia PORT Treatment Recommendations, initially published in 1998 and first revised in 2003, are based primarily on empirical data. Over the last 5 years, research on psychopharmacologic and psychosocial treatments for schizophrenia has continued to evolve, warranting an update of the PORT recommendations. In consultation with expert advisors, 2 Evidence Review Groups (ERGs) identified 41 treatment areas for review and conducted electronic literature searches to identify all clinical studies published since the last PORT literature review. The ERGs also reviewed studies preceding 2002 in areas not covered by previous PORT reviews, including smoking cessation, substance abuse, and weight loss. The ERGs reviewed over 600 studies and synthesized the research evidence, producing recommendations for those treatments for which the evidence was sufficiently strong to merit recommendation status. For those treatments lacking empirical support, the ERGs produced parallel summary statements. An Expert Panel consisting of 39 schizophrenia researchers, clinicians, and consumers attended a conference in November 2008 in which consensus was reached on the state of the evidence for each of the treatment areas reviewed. The methods and outcomes of the update process are presented here and resulted in recommendations for 16 psychopharmacologic and 8 psychosocial treatments for schizophrenia. Another 13 psychopharmacologic and 4 psychosocial treatments had insufficient evidence to support a recommendation, representing significant unmet needs in important treatment domains.

/pdf/the-schizophrenia-patient-outcomes-research-team-port-5d6rvp1l1s.pdf

The Schizophrenia Patient Outcomes Research Team (PORT): Updated Treatment Recommendations 2009

Background Cognitive–behavioural therapy (CBT) is considered to be effective for the symptoms of schizophrenia. However, this view is based mainly on meta-analysis, whose findings can be influenced by failure to consider sources of bias. Aims To conduct a systematic review and meta-analysis of the effectiveness of CBT for schizophrenic symptoms that includes an examination of potential sources of bias. Method Data were pooled from randomised trials providing end-ofstudy data on overall, positive and negative symptoms. The moderating effects of randomisation, masking of outcome assessments, incompleteness of outcome data and use of a control intervention were examined. Publication bias was also investigated. Results Pooled effect sizes were 70.33 (95% CI 70.47 to 70.19) in 34 studies of overall symptoms, 70.25 (95% CI 70.37 to

/pdf/cognitive-behavioural-therapy-for-the-symptoms-of-10wgnpo7a8.pdf

Cognitive-behavioural therapy for the symptoms of schizophrenia : systematic review and meta-analysis with examination of potential bias

Positive Clinical Psychology: a new vision and strategy for integrated research and practice

Background: Recent research indicates that cognitive-behaviour therapy (CBT) can be effective in ameliorating persistent positive symptoms in chronic psychotic patients. The effectiveness of CBT in acute and recent-onset psychosis has been little explored, although a recent pilot study indicated that CBT could significantly improve recovery in acutely psychotic inpatients. Method: Short-term individual CBT was compared to supportive counselling/psychoeducation (SC) as an adjunct to standard inpatient hospital care and medication in 21 inpatients experiencing a recent-onset acute schizophrenic episode. Results: Both groups showed significant reductions in Brief Psychiatric Rating Scale (BPRS) scores following treatment, although there were no group differences. Time to discharge did not differ significantly between the groups, although there was a greater variance for the SC patients. Two-year follow-up showed no significant differences between the groups, although the number of patients who relapsed, the number of relapses and the time to recurrence of psychotic symptoms was lower in the CBT group than the SC group. Interestingly, the time to readmission was shorter in the CBT group. Conclusions: CBT and SC are acceptable treatments for recent-onset acutely psychotic inpatients. A larger randomised controlled trial over multiple hospital sites is warranted.

A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis.

BACKGROUND: Cognitive-behavioural treatments have previously been explored in the treatment of chronic psychotic problems, but recently, the effectiveness of these treatments has been investigated with regard to recent onset and acute psychosis. METHOD: The literature relating to cognitive-behavioural treatments in psychosis is explored and the application of the approach to recent onset psychosis is described in detail. RESULTS: There appears to be a growing body of evidence that the advances made in the treatment of people with chronic treatment resistant psychosis can be similarly applied to people with recent onset and acute psychosis. CONCLUSIONS: Cognitive-behavioural treatments are feasible with recent onset psychotic patients although further evaluation of their effectiveness is necessary.

Individual cognitive-behavioural interventions in early psychosis

Two year follow-up of cognitive-behaviour therapy and supportive counselling in the treatment of persistent positive symptoms in chronic schizophrenia

Cognitive-Behavioural Treatments of Psychosis: Clinical Trials and Methodological Issues in Clinical Psychology

Background Theinitialphaseofatrialofcognitive^behaviouraltherapy(CBT)foracutelyillpatientswithschizophreniaofrecentonsetshowedthatitspeededrrececoovveeryry..Aims To test the hypothesis that CBTinadditiontotreatmentasusual(TAU)duringthefirstorsecondacuteepisodeofschizophreniawillconferclinicalbenefitoverafollow-upperiod.MMetethodhod Thiswasan18-monthfollow-upofamulticentreprospectivetrialofup ofamulticentreprospectivetrialofCBTor supportive counsellingadministeredasanadjuncttoTAU,comparedwithTAUalone,forpatientshospitalisedforanacuteepisodeofschizophreniaofrecentonset.Primaryoutcomesweretotalandpositivesymptomscales, timetorelapse andsymptomscales,timetorelapseandre-hospitalisation.RReesusulltsts ThereweresignificantTherewere significantadvantagesforCBTandsupportivecounsellingoverTAUaloneonsymptommeasuresat18 monthsbutnogroupdifferencewasseenforrelapseorre-hospitalisation.Therewasasignificantcentre^treatmentinteraction,reflectingcentredifferencesintheeffectofintroducingeither treatment, butnotinthecomparisonofCBTandsupportivecounselling.Medicationdosageandcompliancedidnotexplaingroupdifferences.Conclusions Adjunctivepsychologicaltreatmentscanhaveabeneficiallong-termeffectonsymptomreduction.Declarationof interest NNoneone..

N. Tarrier

Papers

A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis.

Individual cognitive-behavioural interventions in early psychosis

Two year follow-up of cognitive-behaviour therapy and supportive counselling in the treatment of persistent positive symptoms in chronic schizophrenia

Cognitive-Behavioural Treatments of Psychosis: Clinical Trials and Methodological Issues in Clinical Psychology

Cognitive ^ behavioural therapy in first-episode Cognitive ^ behavioural therapy in first-episode