CBT for schizophrenia: a critical viewpoint

Abstract

In England and Wales, cognitive behavioral therapy (cognitive therapy, CBT) has been part of official treatment guidelines for schizophrenia since 2002 (NICE, 2009, p. 212). The 2014 NICE guideline (NICE, 2014), which is based on the same meta-analytic evidence as its predecessor in 2009, recommends that it be offered to all people with schizophrenia, including first-episode patients and those with established illness, and to patients who are actively symptomatic and in remission. Similar recommendations are to be found in the Scottish SIGN guideline (SIGN, 2013) as well as those of several other countries (Rathod et al., 2010). In 2012, however, the Cochrane collaboration sounded a discordant note, concluding that '[t]rial-based evidence suggests no clear and convincing advantage for cognitive behavioural therapy over other-and sometimes much less sophisticated-therapies for people with schizophrenia' (Jones et al., 2012). A further challenge came from a 2014 meta-analysis carried out by ourselves (Jauhar et al., 2014), which found end of treatment effect sizes (ESs) that were uniformly in the small range [overall symptoms: 0.33 (95% CI 0.19-0.47), 34 studies; positive symptoms: 0.25 (95% CI 0.13-0.37), 33 studies; negative symptoms: 0.13 (95% CI 0.01-0.25), 34 studies] (note these and all further ESs are shown as a positive sign favoring CBT). A 2018 network meta-analysis of various psychological interventions to reduce positive symptoms in schizophrenia (Bighelli et al., 2018), carried out on a rather different dataset of 27 studies than us, again found pooled ESs for CBT in the small range, though this time at the upper end of this [v. treatment as usual (TAU): 0.30 (95% CI 0.14-0.45), 18 trials; v. inactive control interventions: 0.29 (95% CI 0.03-0.55), seven trials] (Bighelli et al., 2018). Most recently, a 2018 update of the 2012 Cochrane meta-analysis has continued to find no clear or convincing evidence of superiority on any measure apart from leaving the study early (Jones et al., 2018). In the wake of a 'viewpoint' article examining whether it is right to continue to regard CBT as a gold standard for depression and anxiety (Leichsenring and Steinert, 2017), we consider the current status of this form of therapy in schizophrenia and the related psychotic disorders that are typically included in trials (schizoaffective disorder, delusional disorder, and psychosis not otherwise specified). We draw on what can legitimately be regarded as the two best sources of evidence, namely meta-analyses and large, well-conducted individual trials.

The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta‐analytic evaluation of recent meta‐analyses

“…The largest meta‐analysis reported a small SMD in comparison with TAU (0.33, see Figure 2) 111 . Considering all meta‐analyses, small effect sizes compared to nonspecific controls were found for overall symptoms, positive and negative symptoms (SMDs: 0.32, 0.24 and 0.08, respectively) 138 . In comparison to TAU, psychotherapy achieved small to medium SMDs for negative symptoms (0.15‐0.58) 110,112 .…”

Effectiveness of mindfulness‐based intervention on psychotic symptoms for patients with schizophrenia: A meta‐analysis of randomized controlled trials

“…In addition to medication, cognitive behavioural therapy (CBT), a non‐pharmacological treatment, has been used to treat psychosis for patients with schizophrenia (NICE, 2014). However, a review study found limited effects of conventional CBT on reducing psychotic symptoms (Jauhar et al., 2019). In recent years, mindfulness‐based intervention, a novel branch of CBT, was developed for patients with schizophrenia (Cramer et al., 2016; Louise et al., 2018).…”

“…Previous studies found that conventional cognitive behavioural therapy (CBT) aiming to manage the cognitive distortions only led to small‐to‐moderate reductions in psychotic symptoms (Jauhar et al., 2019; Naeem et al., 2016). However, high dropout rates from conventional CBT suggest low clinical feasibility of this treatment modality (Bighelli et al., 2018).…”

Mindfulness-Based Interventions for People with Schizophrenia: A Systematic Review and Meta-Analysis

“…115–118). Although there is a certain amount of controversy regarding its effectiveness in the treatment of schizophrenia [ 21 ], on the whole, research yields positive results, especially in the decrease of positive symptoms [ 22 , 23 , 24 ]. A crucial difference between CBT and MBIs is that the latter do not focus the intervention on the psychotic symptoms per se but rather on the relationship patients establish with psychotic-like experiences.…”