The role of CBT in the early treatment of psychosis and in at risk mental states

Tony Morrison

School of Psychological Sciences,

University of Manchester & Psychosis Research Unit, GMWMHFT

Acknowledgements: www.psychosisresearch.com

Overview

• Rationale, EBM and service user opinion • Evidence base: quantitative and qualitative • Cognitive model and therapy • Recent trial results • NICE guidance, implications and directions

Aripriprazole 10mg/day or 30mg/day Versus Placebo: PANSS Change in acute psychosis

Choices • “The literature makes it abundantly clear that service

users want to be offered more than just medication” (Warner, Mariathasan, Lawton-Smith, & Samele, 2006)

• Greater partnership and shared decision making with service users – valuing their experiences and making their preferences central to a recovery focused approach adopted by all services (Schizophrenia commission, 2012)

Results- Defining recovery Item % of 381

1 Recovery is the achievement of a personally acceptable quality of life 91 (89)

2 Recovery is feeling better about yourself 91 (90)

3 Recovery is a return to a state of wellness 89 (87)

4 Recovery is the process of regaining active control over one's life 88 (86)

5 Recovery is being happy with who you are as a person 87 (86)

6 Recovery is a way of living a satisfying, hopeful and contributing life, even with the limitations caused by symptoms/experiences of psychosis

87 (85)

7 Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems

86 (84)

8 Recovery is knowing that you can help yourself become better 86 (82)

9 Recovery is the unique journey of an individual living with mental health problems to build a life for themselves beyond illness

85 (82)

10 Recovery is learning how to live well in the context of continued mental health problems 84 (82)

11 Recovery is understanding how to control the symptoms of psychosis 83 (83)

12 Recovery is when there is meaning and purpose to life 83 (82)

13 Recovery is a process of changing one's orientation and behaviour from a negative focus on a troubling event, condition or circumstance to the positive restoration, rebuilding, reclaiming or taking control of one's life

83 (82)

14 Recovery is believing that you can meet your current personal goals 82 (81)

Principles of Cognitive Therapy • A cognitive model is required from which to empirically derive effective

treatments: FORMULATE USING MODEL • What are you concerned about? SHARE A GOAL • You are not mad, your difficulties are understandable: NORMALISING MESSAGES AND LANGUAGE • How you appraise events contributes to distress: EVENT – HOW MAKE SENSE – HOW I FEEL – WHAT I DO • Either it is real or you believe it to be real: SIT ON A COLLABORATIVE FENCE • Test it out – drop your safety-seeking responses: EXPERIMENT IN & OUT OF SESSION

Intervention - Process

• establish trust and therapeutic relationship • assessment • establish shared problem list • translate into shared goals • formulation • interventions derived from formulation • emphasis on tasks between sessions

(including for therapists)

Some Common Strategies • Advantages and disadvantages

• Normalisation (including formulation) • Evaluate appraisals using evidential

analysis and alternative explanations • Evaluate beliefs about self and others • Evaluate helpfulness of responses • Test beliefs using behavioural

experiments

“I don’t think it’s [CBT] used to eliminate them altogether its knowing why you get the voices erm… how to deal with them basically”

“We could test out our predictions, and like look

for other explanations like, there was some exercises in the CBT that I could do...so eventually I’d feel, like I’d get a de-escalating feeling of anxiety”

ACTION: Assessing Cognitive Therapy Instead Of Neuroleptics

(formerly North Of Britain Treatment Without Antipsychotics Trial)

• Two site single blind RCT with two conditions (CT plus TAU vs. TAU) for people with psychosis not taking antipsychotic medication (due to refusal or discontinuation)

• Assessments are 3 monthly following the initial baseline assessment (i.e. at baseline, 3, 6, and 9 months)

• Follow-up assessments are at 12, 15 and 18 months

• Recruitment target of n=80 – final n = 74

PANSS Total

30

40

50

60

70

80

0 3 6 9 12 15 18

Cognitive Therapy

TAU

ES = -0.46

>50% PANSS Change At 9 months • 7/22 CBT = 32% • 3/23 TAU = 13%

At 18 months • 7/17 CBT = 41% • 3/17 TAU = 18%

NB: 1 deterioration in CBT at 9 &18 months 2 deteriorations in TAU at 18 months

CT plus TAU TAU

N participants admitted

Mean no. days in hospital

(SD)

N participants admitted

Mean no. days in hospital

(SD)

Voluntary admission 4 12.25 (9.54)

1 27.00 (0.00)

Compulsory admission

0 0.00 (0.00)

3 42.00 (22.65)

DMC reporting • Total number of withdrawals = 10

– 5 in Newcastle, of which 2 were in TAU and 3 were in CBT arm) – 5 in Manchester, of which 3 were in TAU and 2 were in CBT arm)

• Loss to follow-up (inc. withdrawn and deceased participants) – 3 month: 28.4% – 6 month: 39.2% – 9 month: 29.7% – 12 month: 41.2% – 15 month: 40% – 18 month: 29.4%

• Blind breaks – 13 in total, 4 of which were in TAU and 9 were in CBT – Most common method of break was via a mental health professional

disclosing (n = 5) and by the participant disclosing (n = 4) • Potential serious adverse events

– 8 in total – 2 in CBT arm both of which occurred post therapy (O/D = 1; risk to others = 1) – 6 in the TAU arm (death = 2; section 3 = 3; O/D = 1) – None considered related to trial participation or CBT

Differential effects for EI population?

CBT • EIP plus CBT = 20 • CMHT/ AOT plus CBT = 17

TAU • EIP plus TAU = 22 • CMHT/ AOT plus TAU = 15

CBT and SERVICE interaction ------------------------------------------------------------------------------- pansst | Coef. Std. Err. z P>|z| [95% Conf. Interval] --------------+---------------------------------------------------------------- pansstb | .6429226 .0824517 7.80 0.000 .4813203 .804525 SITE | 4.608801 2.446894 1.88 0.060 -.1870229 9.404625 GENDER | -4.899004 2.160813 -2.27 0.023 -9.134119 -.6638889 AGE | .1683638 .1234336 1.36 0.173 -.0735616 .4102893 time_2 | -3.106416 1.806712 -1.72 0.086 -6.647506 .4346748 time_3 | -5.069466 1.778694 -2.85 0.004 -8.555642 -1.58329 time_4 | -3.426503 1.85222 -1.85 0.064 -7.056788 .2037825 time_5 | -2.997222 1.922149 -1.56 0.119 -6.764566 .7701212 time_6 | -2.53159 1.941013 -1.30 0.192 -6.335905 1.272726 CBT | -10.9736 2.77681 -3.95 0.000 -16.41604 -5.531149 SERVICE | .4479191 3.631797 0.12 0.902 -6.670272 7.56611 CBT X SERVICE | 9.917511 4.217249 2.35 0.019 1.651854 18.18317 _cons | 19.69904 7.123947 2.77 0.006 5.736359 33.66172 --------------+---------------------------------------------------------------- sigma_u | 6.6067574 sigma_e | 8.2900007 rho | .38843054 (fraction of variance due to u_i) -------------------------------------------------------------------------------

EIS vs CMHTs

30

40

50

60

70

80

90

CT - EIP

CT - CMHT

TAU - EIP

TAU - CMHT

Psychosis ‘prodrome’

• A period of months to years prior to the onset of Psychosis (assessed retrospectively)

• Progressive symptoms/signs • Mood • Thinking • Behaviour • Cognitive functions

• Reduction in ability to function

Onset of psychosis

Prodrome

First psychotic symptom

Build up

Emergence of

psychosis

Why is early detection important?

• If psychosis is detected early, many problems can be prevented and functioning can be restored.

• The earlier the problems are treated, the greater the chance of a successful recovery.

• Onset is often in a critical stage of a young person’s life. Adolescents and young adults are just starting to develop their own identity, form lasting relationships, and make plans for the future.

• People are help seeking and distressed.

Ultra High Risk Criteria Original PACE criteria (Yung et al. 1996) Age between 14 and 30 years

AND Family history of DSM-IV psychotic disorder and reduction on

GAF scale of ≥ 30 AND/OR

Attenuated symptoms, occurring several times during the week for at least one week AND/OR

Brief, limited or intermittent psychotic symptoms (BLIPS) for less than one week and resolving spontaneously

Modified criteria now assessed using CAARMS

AXIS 1 Disorders • 91 young people referred to PACE met ARMS criteria:

– A total of 76 (83.5%) had a current/past Axis 1 disorder – Twenty-three (23.3%) had more than one current disorder

(Leicester et al., 2004)

05

101520253035404550

Percentage

No diagnosispast diagnosis1 current1 current and past2 current and past2 current3 current4 current

Common themes in EDIE 1 problem lists (French and Morrison, 2003)

• Anxiety – I’m going mad / identity – Social anxiety – Worry & metacognition – PTSD

• Mood & activity – Boredom / depression / hopelessness / self-esteem – College/job/money

• Social Networks – Relationships – friends, family, partners – Loneliness / lack of confidant – I’m different / odd one out / “square peg in a round hole”

Identification Study at PACE Yung et al 1998 British Journal of Psychiatry

0

5

10

15

20

25

0 1 2 3 4 5 6Months of assessment

Number not psychotic

40% made transition at six months, 50% at one year

Intervention Study at PACE: The prevention of psychosis

McGorry et al 2002 Archives of General Psychiatry

0%

5%

10%

15%

20%

25%

30%

35%

40%

6 12

Needs based Tx

Specificinterventions

Months

% making transition to psychosis

PRIME Study: Olanzapine versus placebo McGlashan et al. 2006 American Journal of Psychiatry

19

102468

101214161820

AverageWeight Gain lb

Olanzapine

Placebo

16.1

37.9

05

10152025303540

Transition %

*

Early Detection: Problems • Ethics of interventions in pre-psychotic phase

• Solution:

– employ interventions with minimal risks / side effects – employ interventions that will be useful to those who

will never become psychotic – informed choice

• Balancing the costs and benefits of treatment must be

weighted in some way according to the ratio of people actually helped to those unnecessarily treated

Our Approach

• To increase awareness in primary care services, secondary care services, voluntary sector, further education and the community

• Increase referrals through – Training for potential referrers – Rapid response – Flexible approach to clients – Positive, user friendly service

• Use of cognitive therapy

• Why CT? – Effective for psychotic symptoms (AS) – Effective for relapse prevention (BLIPS) – Effective for mood disorders

very frequent in prodrome (Birchwood, 1996) DSM IV outcomes of at-risk population

– Session structure, problem list and goals useful for other difficulties

Does it work for transition?

Study or SubgroupADDINGTON2011AMORRISON2004MORRISON2011PHILLIPS2009VAN DER GAAG2012

Total (95% CI)Total eventsHeterogeneity: Tau² = 0.00; Chi² = 2.77, df = 4 (P = 0.60); I² = 0%Test for overall effect: Z = 2.57 (P = 0.01)

Events02779

25

Total1626952975

241

Events35

106

20

44

Total1516931986

229

Weight2.5%9.0%

24.4%24.3%39.7%

100.0%

M-H, Random, 95% CI0.13 [0.01, 2.40]0.25 [0.05, 1.12]0.69 [0.27, 1.72]0.76 [0.30, 1.93]0.52 [0.25, 1.06]

0.55 [0.35, 0.87]

CBT SC Risk Ratio Risk RatioM-H, Random, 95% CI

0.5 0.7 1 1.5 2Favours CBT Favours SC

Does it work for transition?

Study or SubgroupMCGORRY2002PHILLIPS2009

Total (95% CI)Total eventsHeterogeneity: Tau² = 0.02; Chi² = 1.13, df = 1 (P = 0.29); I² = 11%Test for overall effect: Z = 1.73 (P = 0.08)

Events67

13

Total2427

51

Events106

16

Total1719

36

Weight56.2%43.8%

100.0%

M-H, Random, 95% CI0.42 [0.19, 0.94]0.82 [0.33, 2.06]

0.57 [0.30, 1.08]

CBT + risperidone SC Risk Ratio Risk RatioM-H, Random, 95% CI

0.5 0.7 1 1.5 2Favours CBT + risperidone Favours SC

Does it work for symptoms?

Study or SubgroupPHILLIPS2009ADDINGTON2011AMORRISON2004MORRISON2011

Total (95% CI)Heterogeneity: Tau² = 0.00; Chi² = 0.94, df = 3 (P = 0.82); I² = 0%Test for overall effect: Z = 2.48 (P = 0.01)

Mean2.85.2

10.541714.88

SD2.95.6

3.0500115.54

Total27273595

184

Mean3.16.6

10.928620.84

SD3

4.72.99908

17.75

Total18242393

158

Weight12.9%15.1%16.6%55.4%

100.0%

IV, Random, 95% CI-0.10 [-0.70, 0.50]-0.27 [-0.82, 0.29]-0.13 [-0.65, 0.40]

-0.36 [-0.64, -0.07]

-0.27 [-0.49, -0.06]

CBT SC Std. Mean Difference Std. Mean DifferenceIV, Random, 95% CI

-1 -0.5 0 0.5 1Favours CBT Favours SC

NICE guidelines 2014 Preventing psychosis • If a person is considered to be at increased

risk of developing psychosis (as described in recommendation 1.2.1.1): – offer individual cognitive behavioural therapy

(CBT) with or without family intervention (delivered as described in section 1.3.7) and

– offer interventions recommended in NICE guidance for people with any of the anxiety disorders, depression, emerging personality disorder or substance misuse. [new 2014]

NICE guidelines 2014 Preventing psychosis • Do not offer antipsychotic medication:

– to people considered to be at increased risk of developing psychosis (as described in recommendation 1.2.1.1) or

– with the aim of decreasing the risk of or preventing psychosis. [new 2014]

• Antipsychotics help some people, but not all, and are often associated with severe side effects

• Service users want choice and access to evidence based talking therapies that promote recovery, help with symptoms and functioning

• Overall, there is evidence to support CT for people with psychosis combined with APs (both end of treatment and follow-up): recommended by NICE, PORT etc.

• CT is deliverable, safe and acceptable to people with psychosis not taking APs

• CT reduced severity of symptoms and improves social and personal functioning in people not taking medication

• Evidence-based alternatives should be

available to people who choose not to take antipsychotics and those who do not benefit from antipsychotics

• Need an evidence base comparing these treatments to facilitate informed choice

• Definitive research required: adequately powered RCTs

• Can identify people at risk of FEP • CBT can prevent transition to psychosis over

12 months • Need more research on feasibility of family

intervention in people at risk of FEP

Future Questions

• Who it helps and who it doesn’t • Active ingredients • Unwanted effects • Availability / access • Peer delivery • EBM combined with choice & involvement of

users and carers • Development of measures and methods