older psychiatryCognitive behavioural therapy (CBT) could be a viable therapeutic alternative for people with schizophrenia who cannot, or will not, take antipsychotic drugs, according to new research.

Researchers from Newcastle and Manchester Universities suggest that cognitive therapy could be safe and effective in reducing psychotic symptoms and improving personal and social functioning compared with treatment as usual.

While CBT 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.

The study, published in The Lancet, assessed whether CBT could reduce psychiatric symptoms in 74 individuals aged 16-65 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.

Equal numbers of participants were randomly assigned to cognitive therapy (26 sessions over 9 months) plus treatment as usual or to treatment as usual alone. 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 CBT group than in the usual care group. After 18 months, 41% of 17 participants receiving cognitive therapy had an improvement of more than 50% in the PANSS total score compared with 18% of 17 receiving treatment as usual. CBT was also well tolerated, with low rates of drop-out and withdrawal. 

Douglas Turkington, professor of psychiatry at Newcastle University and joint lead author, said: “One of our most interesting findings was that when given the option, most patients were agreeable to trying cognitive therapy.” 

Professor Turkington also stressed that “if someone is on antipsychotics 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.”

Acceptable intervention

Co-lead author professor Anthony Morrison from the University of Manchester, added: “Antipsychotic drugs are the mainstay of treatment for schizophrenia, but as many as half of all people with schizophrenia choose not to take drugs because of side-effects that can include serious weight gain, development of metabolic disorders and an increased risk of sudden cardiac death, because the treatment is not felt to be effective, or because they do not perceive that they need treatment. Currently no evidence-based safe and effective treatment alternative exists.

“We have showed that cognitive therapy is an acceptable intervention for a population who are usually considered to be very challenging to engage in mental health services. Antipsychotic medication, while beneficial for many people, can have severe side effects. Evidence-based alternatives 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. However, a larger definitive trial is needed to confirm the clinical implications of our pilot study.”

Writing in a linked Comment in The Lancet, Oliver Howes from the Clinical Sciences Centres and Institute of Psychiatry, London, said that the research showed proof of concept, but would need further testing. “If further work supports the relative effectiveness of cognitive therapy, a comparison between such therapy and antipsychotic 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.” 

Professor Morrison and colleagues are about to commence such a study in Manchester to compare cognitive therapy alone with antipsychotic medication alone and with a combined treatment in people with schizophrenia spectrum disorders. 

Informed choices

Paul Jenkins, CEO of the charity Rethink Mental Illness, welcomed the report’s findings, saying that they reinforce what they charity’s members and supporters have been saying “for years.” 

“Patients should be able to make their own informed choices about what kind of treatment works for them, whether that's medication, talking therapies or a combination of the two,” he added. 

“However, because mental health services are chronically under-funded, just 1 in 10 people with schizophrenia have been offered cognitive therapy. There would be public outcry if cancer sufferers were only offered some of the treatments they're entitled to; people with schizophrenia should not be expected to put up with it either. We need the NHS to start putting mental illness on an equal footing to physical illness when it comes to funding treatments.”