cognitive therapy for people with a schizophrenia spectrum diagnosis not taking antipsychotic...

Cognitive Therapy for People with a Schizophrenia Spectrum Diagnosis not Taking Antipsychotic Medication: Results From an Open Trial

Thomas Christodoulides, Clinical Psychologist Early Intervention in Psychosis Service, South of Tyne and Wear

Acknowledgments

Tony Morrison Douglas Turkington

Melissa Wardle, Helen Spencer, Laura Drage, Paul French

Rory Byrne

Robert Dudley, Paul Hutton, Victoria Lumley, Alison Brabban, Pauline Callcott, Nicola Chapman, Sara Tai

Background

NICE (2009): Antipsychotic medication is recommended as first line of treatment

But many service users choose not to take, or discontinue pharmacological treatment:– Lieberman et al (2005) 74% discontinued

their medication within 18 months– Lacro et al (2002) Estimated rate of

medication non-compliance in Schizophrenia: 40%-50%

Reasons for discontinuing Moncrieff et al (2009): service users

opposed to taking antipsychotic medication. Why?

Lack of insight Stigma Concerns about side effects

– weight gain – Extra pyramidal– Cardiovascular problems (Tandon et al, 2008) – Increased risk of sudden cardiac death (Ray et al,

2009)– Cerebral abnormalities (Ho et al, 2011)

Response to medication Leucht et al (2009):

– meta analysis – atypicals > placebos on the

PANSS by only 10 pts (about 5%)

Choice and Empowerment

Owens et al (2008)– many inpatients retain treatment decision

making capacity Warner et al (2006)

– Literature review on choice and decision making

– Service users want to be offered more than just medication

NICE guidelines for Schizophrenia (2009) – Recommended treatment choice for the

individual– All patients with Schizophrenia should have

access to CBT and family interventions.

CBT with antipsychotic medication Pilling et al (2002); Wykes,

Steel & Tarrier (2008)– Meta analyses – CBT effective in combination

with antipsychotic medication

CBT in the absence of antipsychotic medication?

Morrison (1994) - Single case: CBT achieved

significant reduction in auditory hallucinations.

Morrison (2001) - Case series: Reported significant

reduction in conviction, frequency, and distress associated with auditory hallucinations.

CBT in the absence of antipsychotic medication?

Christodoulides et al (2008) Wellcome and Insight trials

– Small number reported as antipsychotic medication free

– Showed significant improvement on a wide range of psychometric assessment measures

– Case series: Reduction in positive and negative symptoms of schizophrenia.

Design

Aim– To assess the feasibility and effectiveness of CBT

for patients not taking antipsychotics Dual Site

– North East (Professor Douglas Turkington) – Manchester (Professor Tony Morrison)

Experienced therapists offering 9 months CBT - 25 sessions.

Manualized therapy – Turkington et al (2009); Morrison et al (2008)

Recruiting from EIP, CMHT, CAMHS 20 participants

Inclusion Criteria: Exclusion Criteria:

ICD-10 diagnosis of schizophrenia, schizo-affective disorder or delusional disorder

Organic brain disease including dementia, epileptic psychosis, head injury (impaired cognitive functioning and with subsequent inability to engage in CBT) Use of antipsychotic medication in previous 6 months.

Or 4+ score on the PANSS on hallucinations or delusions, or 5 on conceptual disorganization, grandiosity, or suspiciousness

Primary diagnosis of drug or alcohol misuse

Age 16-65 years

Impaired intellect severe enough to interfere with ratings

Receiving acute psychiatric inpatient care at baseline, (patients must be stable enough to engage in CBT, and to justify continued absence of antipsychotic medication).

Previous manualised CBT for psychosis and/or previous manualised CBT for anxiety/depression within the last 2 years (those previously exposed to CBT may be habituated to the model).

Diagnosis

All diagnosis established using – ICD-10 – Case notes – Review by a consultant psychiatrist

– Schizophrenia (n =15)– Schizo-affective disorder (n = 4)– Delusional disorder (n = 1)

Outcome measures

PANSS – 30 item (0-7) – semi-structured interview of +ve and –ve

symptoms and psychopathology PSYRATS

– clinician administered 11 item (0-4) questionnaire of hallucinations and delusions

Clinically significant change on PANSS – >50%, >25%, <25%

Outcome measures

PRP – user defined measure of recovery– 22 item questionnaire

PSP – Personal and Social Performance Scale – 100 point single item rating scale

Socially useful activities Personal and social relationships Self care Disturbing and aggressive behaviour

Baseline

Therapy (9 months >25 sessions)

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Psychometric Psychometric Assessment Schedule:Assessment Schedule:

Therapy Booster sessions>4 sessions (6 months post therapy)

3 months

Measures MeasuresMeasures

9 months15 months

(Follow-up: 6 months post therapy)

Measures

6 months

Measures

Intervention

Maximum 26 sessions 9 months Beckian CBT Manual based

– Morrison et al (2004b)– Kingdon & Turkington (2005)

Model– Morrison (2001b)– Normalize and de-catastrophize – generate and explore alternatives

Results 1

Variable

Pre-treatment Mean (S.D.)

Post- treatment mean (S.D.)

t/Wa P d 95% CI

PANSS total

69.55 (11.99) 59.20(19.52)

3.66 0.0002

0.85 0.32-1.35

PANSSPositive

18.75 (4.74) 14.65(7.37)

2.99 0.0003

0.87 0.45-1.53

PANSS Negative

14.60 (5.06) 12.40(5.58)

3.33 0.001 1.00 0.45-1.54

Results 1

Variable



t/Wa P d 95% CI

PANSS total

69.55 (11.99)

59.20(19.52)

3.66 0.0002

0.85 0.32-1.35

PANSSPositive

18.75 (4.74) 14.65(7.37)

2.99 0.0003

0.87 0.45-1.53

PANSS Negative

14.60 (5.06) 12.40(5.58)

3.33 0.001 1.00 0.45-1.54

Results 1

Variable



t/Wa P d 95% CI

PANSS total

69.55 (11.99) 59.20(19.52)

3.66 0.0002

0.85 0.32-1.35

PANSSPositive

18.75 (4.74) 14.65(7.37)

2.99 0.0003

0.87 0.45-1.53

PANSS Negative

14.60 (5.06) 12.40(5.58)

3.33 0.001 1.00 0.45-1.54

Results 2

Variable


Follow up (S.D.)

t/Wa P d 95% CI

PANSS total

69.55 (11.99) 54.30 (17.23) 5.63 0.000 1.26 0.66-1.84

PANSSPositive

18.75 (4.74) 13.35 (6.11) 3.31 0.0001

1.08 0.51-1.62

PANSS Negative

14.60 (5.06) 12.15 (5.41) 2.80 0.0005

0.79 0.27-1.28

Results 2

Variable


Follow up (S.D.)

t/Wa P d 95% CI

PANSS total

69.55 (11.99)

54.30 (17.23) 5.63 0.000 1.26 0.66-1.84

PANSSPositive

18.75 (4.74) 13.35 (6.11) 3.31 0.0001

1.08 0.51-1.62

PANSS Negative

14.60 (5.06) 12.15 (5.41) 2.80 0.0005

0.79 0.27-1.28

Results 2

Variable


Follow up (S.D.)

t/Wa P d 95% CI

PANSS total

69.55 (11.99) 54.30 (17.23)

5.63 0.000 1.26 0.66-1.84

PANSSPositive

18.75 (4.74) 13.35 (6.11) 3.31 0.0001

1.08 0.51-1.62

PANSS Negative

14.60 (5.06) 12.15 (5.41) 2.80 0.0005

0.79 0.27-1.28

Results 2

Variable


Follow up (S.D.)

t/Wa P d 95% CI

PANSS total

69.55 (11.99) 54.30 (17.23) 5.63 0.000 1.26 0.66-1.84

PANSSPositive

18.75 (4.74) 13.35 (6.11) 3.31 0.0001

1.08 0.51-1.62

PANSS Negative

14.60 (5.06) 12.15 (5.41) 2.80 0.0005

0.79 0.27-1.28

Results 3

Variable Pre-treatment Mean (S.D.)

Post-treatment Mean (S.D.)

t/Wa P d 95% CI

PSYRATS Hallucinations

19.35 (15.03)

10.80 (13.34)

2.17 0.030

0.56 0.84-1.03

PSRATSDelusions

14.70 (6.67)

6.45 (7.07) 4.41 0.000

0.99 0.44-1.52

QPR total 48.83 (15.69)

57.22 (18.59)

1.69 0.110

0.41 0.09-0.90

PSP total 47.4 (13.80)

56.45 (18.37)

2.44 0.025

0.54 0.07-1.01

Results 4

Variable Pre-treatment Mean (S.D.)

Follow upMean (S.D.)

t/Wa P d 95% CI

PSYRATS Hallucinations

19.35 (15.03)

9.65 (12.81)

2.70 0.008

0.70 0.20-1.19

PSRATSDelusions

14.70 (6.67)

6.40(6.69)

4.31 0.000

0.98 0.42-1.15

QPR total 48.83 (15.69)

60.96(18.80)

2.50 0.024

0.65 0.08-1.11

PSP total 47.4 (13.80)

66.05(18.31)

3.99 0.001

0.87 0.34-1.37

Discussion

CBTp without APM is acceptable Associated with clinically

significant reduction in symptoms post treatment

Maintained at follow up Associated with clinically

significant improvement in functioning

Methodological Limitations Small sample size Diagnostically heterogeneous sample Treatment fidelity not formally assessed Open trial

– No control – allegiance effects – Non-blind ratings

Inflated estimates of treatment effects? Need for RCT replication

Key reference

Morrison, A. P., Hutton, P., Wardle, M., Spencer, H., Barratt, S., Brabban, A., Callcott, P., Christodoulides, T., Dudley, R., French, P., Lumley, V., Tai, S.J. and Turkington, D. (2011). Cognitive therapy for people with a schizophrenia spectrum diagnosis not taking antipsychotic medication: an exploratory trial. Psychological Medicine, 1-8.

Email address for correspondence: [email protected]

References

Christodoulides, T., Dudley, R., Brown, S., Turkington, D., & Beck, A. (2008). Cognitive behaviour therapy in patients with schizophrenia who are not prescribed antipsychotic medication: a case series. Psychology and Psychotherapy: Theory Research and Practice, 81, 199-207.

Ho, B., Andreason, N., Ziebell, S., Pierson, R., Magnotta, V. (2011). Long term antipsychotic treatment and brain volumes: a long term longitudinal study of first episode schizophrenia. Archives of General Psychiatry, 68, 128-137.

Kingdon, D., & Turkington, D. (2005). Cognitive Therapy for Schizophrenia. Guilford Press: New York

Lacro, J., Dunn, L., Dolder, C. (2002). Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. Journal of Clinical Psychiatry, 63, 892-909.

References

Leucht, S., Corves, C., Arbter, D., Engel, R., Li, C., Davis, J. (2009). Second generation versus first generation antipsychotic drugs for schizophrenia: a meta analysis. Lancet, 373, 31-41.

Lieberman, J., Stroup, T., McEvoy, J., Swatz, m., Rosenheck, R., Perkins, D., Keefe, R., Davis, S., Davis, C., Lebowitz, B., Severe, J., & Hsiao, J. (2005). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. New England Journal of Medicine, 353, 1209 – 1223.

Moncrieff, J., Cohen, D., Mason, J. (2009). The subjective experience of taking antipsychotic medication: a content analysis of internet data. Acta Psychiatrica Scandinavica, 120, 102-111.

Morrison, A. (1994). Cognitive behaviour therapy for auditory hallucinations without concurrent medication: a single case. Behavioural and Cognitive Psychotherapy, 22, 259-264.

References

Morrison, A. (2001b). The interpretations of intrusions in psychosis: an integrative cognitive approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy, 29, 257-276.

Morrison, A., Renton, J., Dunn, H., Williams, S., Bentall, R. (2004b). Cognitive Therapy for Psychosis: A formulation based Approach. Brunner-Routledge: London.

NICE (2009). Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary care. National Institute for Clinical Excellence: UK.

Owens, G., Richardson, G., David, a., Szmuckler, G., Hayward, P., & Hotopf, (2008). Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study. British Medical Journal, 337, 448.

Pilling, S., Bebbington, p., Kuipers, E., Garety, p., Geddes, J., Orbach, G., & Morgan, C. (2002). Psychological treatments in schizophrenia: I. meta analysis of family intervention and cognitive behaviour therapy. Psychological Medicine, 32, 763-782

References

Ray, W., Chung, C., Murray, K., Hall, K., & Stein, M. (2009). Atypical antipsychotic drugs and the risk of sudden cardiac death. New England Journal of Medicine, 360, 225-235.

Tandon, R., Belmaker, R., Gattaz, w., Lopez-Ibor Jr, J., Okasha, A., Singh, B., Stein D., Olie, J., Fleischhacker, W., & Moeller, H. (2008). World Psychiatric association Pharmacopsychiatry section statement on comparative effectiveness of antipsychotics in the treatment of schizophrenia. Schizophrenia Research, 100, 20 – 38.

Warner, L., Mariathasan, J., Lawton-Smith S., Samele, C. (2006). A review of the literature and consultation on choice and decision making for users and carers of mental health and social care services. King’s Fund/Sainsbury Centre for Mental Health: London

Wykes, T., Steel, C., & Tarrier, N. (2008). Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34, 523-537.

A brief case illustration: A brief case illustration: SandySandy An 18-year old man who had heard and seen an

invisible figure (‘John’) most of his life. Did not wish to take medication (and never had). Beginning to experience a lack of control (obeying

instructions). Distressed and seeking help. Cognitive therapy involved seeking continual

consent as the experience was valued by the client.

His initial goals were to increase control. Later goals were to reduce frequency/duration of visual and auditory hallucinations down to zero.

Formulation…

Causes

HOW DO I MAKE SENSE OF THIS?

Increases Increases

Leads to

Maintains

Leads to

WHAT I DOHOW I FEEL

TRIGGERS

Sandy:Intervention I have no control over this” (100% conviction)

– Advantages & disadvantages analysis of John– Thought suppression experiment (to examine

whether ‘pushing away’ was helpful)– Mindful detachment encouraged (just observe

rather than engage – let it come and go)– Examined whether shouting back was helpful– Spontaneously stopped obeying John, once the

appraisal of ‘having no control’ decreased.

Sandy:Intervention “It means I’m weird” (100% conviction)

– Normalising: Information detailing prevalence of this and other experiences was given to Sandy to keep and refer to.

“I don’t feel alone with it any more”– Distinction between different / acceptable, and

different / unacceptable discussed. “I’m a little bit different but that doesn’t mean

I’m not acceptable

Beliefs about John

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Week (session)

Co

nvi

ctio

n

I have no control

It means I'm weird

Mindful detachment

Normalising

Beliefs about John

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Week (session)

Co

nvi

ctio

n

People will reject me

It means I haven't grown up

Distinction made between different/acceptable & different/unacceptable

Frequency of John per week

0

5

10

15

20

25

30

Week (session)

Nu

mb

er

of

ap

pe

ara

nc

es

pe

r w

ee

k

Average duration of John per week

0

10

20

30

40

50

60

70

Week (session)

Min

ute

s

Sandy:Conclusion Wants to spread remaining 4 sessions out over the

next year. Pleased he can contact us if any problems in the meantime. – ‘I’m 99.1% confident I can sort it out on my own’ – ‘I’ll read the information and listen to the therapy tapes’

He perhaps still has some anxiety but encouraging a ‘so what’ approach to reappearance of experience.

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