Cognitive therapy might be beneficial for people with schizophrenia not taking antipsychotic drugs

For people with schizophrenia who can't or won't take antipsychotic drug treatment, cognitive therapy could be a viable therapeutic alternative, according to a groundbreaking randomised trial published in The Lancet.

The research, involving scientists from Durham University, suggests that cognitive therapy could be safe and effective in reducing psychotic symptoms and improving personal and social functioning compared with treatment as usual.

Although cognitive therapy has helped people with schizophrenia when given in combination with antipsychotic drugs, until now its feasibility and effectiveness in individuals not taking medication was unknown.

Study co-author, Dr Alison Brabban is a Fellow of the Wolfson Research Institute for Health and Wellbeing at Durham University and National Adviser for Severe Mental Illness within the Improving Access to Psychological Therapy programme.

She said: ''Our results show that cognitive therapy is an acceptable intervention for people who are usually considered to be very challenging to engage in mental health services.

''Anti-psychotic medication, while beneficial for many people, can have very severe side effects, such as sudden cardiac death, serious weight gain, and various metabolic disorders. Alternatives, which have been tested, should be available to those who choose not to take these drugs. For many, cognitive therapy might prove to be the preferred form of treatment although we do need to do further large-scale trials to confirm the clinical implications of this pilot study.''

The current study assessed whether cognitive therapy could reduce psychiatric symptoms in 74 individuals aged 16 to 65 years with schizophrenia spectrum disorders who had decided not to take or had stopped taking antipsychotics for at least 6 months.

Cognitive therapy involved a therapist working collaboratively with a patient to reappraise psychotic experiences and modify unhelpful thought patterns and behaviours.

Participants were randomly assigned to cognitive therapy (26 sessions over 9 months) plus treatment as usual (37 participants) or to treatment as usual alone (37). Change in symptoms was rated at regular intervals over 18 months on the Positive and Negative Syndrome Scale (PANSS)*. The lower the rating, the better the function.

Average PANSS scores were consistently lower in the cognitive therapy group than in the usual care group. After 18 months, seven (41 per cent) of 17 participants receiving cognitive therapy had an improvement of more than 50% in the PANSS total score compared with three (18 per cent) of 17 receiving treatment as usual. Cognitive therapy was also well tolerated, with low rates of drop-out and withdrawal.

Although the results of their study show that cognitive therapy could be a viable therapeutic alternative, the researchers stress that if someone is on anti-psychotics they should not just suddenly stop taking them as there is a major risk of relapse. Medical advice should always be sought if you are considering stopping your medication.

Writing in a linked comment in The Lancet, Oliver Howes from the Clinical Sciences Centres and Institute of Psychiatry, London, says, ''Morrison and colleagues' findings provide proof of concept that cognitive therapy is an alternative to antipsychotic treatment.

''Clearly this outcome will need further testing, but, if further work supports the relative effectiveness of cognitive therapy, a comparison between such therapy and anti-psychotic treatment will be needed to inform patient choice. If positive, findings from such a comparison would be a step change in the treatment of schizophrenia, providing patients with a viable alternative to antipsychotic treatment for the first time, something that is sorely needed.''

The research team will soon start a study in Manchester to compare cognitive therapy alone with antipsychotic medication alone and with a combined treatment in people with schizophrenia spectrum disorders.

Lead researcher, Professor Anthony Morrison from the University of Manchester, says, ''Anti-psychotic drugs are the mainstay of treatment for schizophrenia, but as many as half of all individuals with schizophrenia choose not to take drugs because of common, potentially severe side-effects, because the treatment is not felt to be effective, or because they do not perceive that they have an illness. Currently no evidence-based safe and effective treatment alternative exists.''

This study was funded by the National Institute for Health Research Research for Patient Benefit Programme.