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Cognitive behavioral therapy (CBT) is now a recommended treatment for people with schizophrenia. In CBT, links are made between the person’s feelings and patterns of thinking that underpin their distress. At present, a variety of interventions have been labeled as CBT and it is difficult to provide a single, unambiguous definition. In recognition, the review authors have constructed criteria that are felt to be both workable and to capture the elements of good practice in CBT.
Cognitive behavioral therapy is becoming increasingly available for people with schizophrenia, with recent recommendations of treatment guidelines in, for example, the United Kingdom suggesting that CBT should be more widely available for people with schizophrenia.
It should be noted that many of the trials of CBT for psychosis have incorporated additional active therapeutic elements (eg, psychoeducation and relapse prevention) that would be considered adjunctive to techniques that are specifically targeted at eliciting belief change (eg, guided discovery or behavioral experiments).
The comparison arm of the trials reported other psychosocial therapies, such as supportive therapy, psychoeducation, family therapy, and other “talking therapies.” The full review distinguishes between trials that described “active” psychosocial interventions (eg, family therapy) aimed at a meaningful symptom reduction and those trials that have used “nonactive” psychosocial interventions (eg, supportive therapy), which act as merely a control for the nonspecific effects of therapy (eg, time spent with therapist). Outcomes are presented separately for active and nonactive psychosocial interventions and the pooled effect of these trials is also presented.
We searched the Cochrane Schizophrenia Group Trials Register (March 2010) that is based on regular searches of CINAHL, EMBASE, MEDLINE, and PsycINFO. We inspected all references of the selected articles for further relevant trials, and, where appropriate, contacted authors.
All relevant randomized controlled trials of CBT for people with schizophrenia-like illnesses.
Studies were reliably selected and assessed for methodological quality. Two review authors, working independently, extracted data. We analyzed dichotomous data on an intention-to-treat basis and continuous data with 65% completion rate are presented. Where possible, for dichotomous outcomes, we estimated a risk ratio (RR) with the 95% confidence interval (CI) along with the number needed to treat/harm.
Thirty articles described 20 trials. Trials were often small and of limited quality. In figure 1 the various risks of bias are presented as percentages across all included studies.
The main findings of this review are summarized in table 1. When CBT was compared with other psychosocial therapies, no difference was found for outcomes relevant to adverse effect/events (2 RCTs, n = 202, RR death 0.57 CI 0.12–2.60). Relapse was not either reduced over any time period (5 RCTs, n = 183, RR long term 0.91 CI 0.63–1.32) nor was rehospitalization (5 RCTs, n = 294, RR in longer term 0.86 CI 0.62–1.21). Various global mental state measures failed to show difference (4 RCTs, n = 244, RR no important change in mental state 0.84 CI 0.64–1.09). More specific measures of mental state failed to show differential effects on positive or negative symptoms of schizophrenia, but there may be some long-term effect for affective symptoms (2 RCTs, n = 105, mean difference (MD) Beck Depression Inventory (BDI) −6.21 CI −10.81 to −1.61). Few trials report on social functioning or quality of life. Findings do not convincingly favor either of the interventions (2 RCTs, n = 103, MD Social Functioning Scale (SFS) 1.32 CI −4.90 to 7.54; n = 37, MD EuroQOL −1.86 CI −19.20 to 15.48). For the outcome of leaving the study early, we found no significant advantage when CBT was compared with either nonactive control therapies (4 RCTs, n = 433, RR 0.88 CI 0.63–1.23) or active therapies (6 RCTs, n = 339, RR 0.75 CI 0.40–1.43).
The use of CBT has been associated with some reduction in symptoms, particularly affective problems associated with having such a serious illness. However, there is considerable variability in the findings of the various studies and, at present, it is not possible to assert any substantial benefit for cognitive behavioral therapy over other psychological therapies. Full details are published in the Cochrane Review (Jones, 2012).