Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor

Til Wykes, Craig Steel, Brian Everitt, Nicholas Tarrier, Til Wykes, Craig Steel, Brian Everitt, Nicholas Tarrier

Abstract

Background: Guidance in the United States and United Kingdom has included cognitive behavior therapy for psychosis (CBTp) as a preferred therapy. But recent advances have widened the CBTp targets to other symptoms and have different methods of provision, eg, in groups.

Aim: To explore the effect sizes of current CBTp trials including targeted and nontargeted symptoms, modes of action, and effect of methodological rigor.

Method: Thirty-four CBTp trials with data in the public domain were used as source data for a meta-analysis and investigation of the effects of trial methodology using the Clinical Trial Assessment Measure (CTAM).

Results: There were overall beneficial effects for the target symptom (33 studies; effect size = 0.400 [95% confidence interval [CI] = 0.252, 0.548]) as well as significant effects for positive symptoms (32 studies), negative symptoms (23 studies), functioning (15 studies), mood (13 studies), and social anxiety (2 studies) with effects ranging from 0.35 to 0.44. However, there was no effect on hopelessness. Improvements in one domain were correlated with improvements in others. Trials in which raters were aware of group allocation had an inflated effect size of approximately 50%-100%. But rigorous CBTp studies showed benefit (estimated effect size = 0.223; 95% CI = 0.017, 0.428) although the lower end of the CI should be noted. Secondary outcomes (eg, negative symptoms) were also affected such that in the group of methodologically adequate studies the effect sizes were not significant.

Conclusions: As in other meta-analyses, CBTp had beneficial effect on positive symptoms. However, psychological treatment trials that make no attempt to mask the group allocation are likely to have inflated effect sizes. Evidence considered for psychological treatment guidance should take into account specific methodological detail.

Figures

Fig. 1.
Fig. 1.
Forest Plot of the Effect Sizes for the Trials Shown in Table 2.
Fig. 2.
Fig. 2.
A Bubbleplot of Effect Size Against Clinical Trial Assessment Measure (CTAM) Score (Radii of the Circles Represent the SE of the Effect Size).
Fig. 3.
Fig. 3.
Funnel Plot.

References

    1. Beck AT. Successful out-patient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt. Psychiatry. 1952;15:205–212.
    1. Shapiro MB, Ravenette AT. A preliminary experiment on paranoid delusions. J Ment Sci. 1959;105:295–312.
    1. Liberman RP, Teigen J, Patterson R, Baker V. Reducing delusional speech in chronic paranoid schizophrenics. J Appl Behav Anal. 1973;6:57–64.
    1. Meichenbaum D, Cameron R. Training schizophrenics to talk to themselves: a means of developing attentional control. Behav Ther. 1973;4:515–534.
    1. Brown GW, Birley JLT, Wing JK. Influence of family life on course of schizophrenic disorders—replication. Br J Psychiatry. 1972;121:241–258.
    1. Butzlaff RL, Hooley JM. Expressed emotion and psychiatric relapse: a meta-analysis. Arch Gen Psychiatry. 1998;5:547–552.
    1. Mueser KT, Berenbaum H. Psychodynamic treatment of schizophrenia: is there a future? Psychol Med. 1990;20:253–262.
    1. Meltzer HY, Bobo WV. Interpreting the efficacy findings in the CATIE study: what clinicians should know. CNS Spectr. 2006;11:14–24.
    1. Jones PB, Barnes TR, Davies L, et al. Randomized controlled trial of the effect on quality of life of second- vs first-generation antipsychotic drugs in schizophrenia: Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS 1) Arch Gen Psychiatry. 2006;63:1079–1087.
    1. Tarrier N, Calam R. New developments in cognitive-behavioural case formulation. Epidemiological, systemic and social context: an integrative approach. Cogn Behav Psychother. 2002;30:311–328.
    1. Tarrier N. Case Formulation in Cognitive Behaviour Therapy: The Treatment of Challenging and Complex Clinical Cases. London, UK: Routledge; 2006.
    1. Cormac I, Jones C, Campbell C, Silveira da Mota Neto J. Cochrane Library. Issue 1. Oxford, UK: Update Software; 2003. Cognitive behaviour therapy for schizophrenia (Cochrane Review)
    1. Pilling S, Bebbington P, Kuipers E, Garety P, Orbach G, Morgan C. Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychol Med. 2002;32:763–782.
    1. Thornicroft G, Susser E. Evidence-based psychotherapeutic interventions in the community care of schizophrenia. Br J Psychiatry. 2001;178:2–4.
    1. NHS Centre for Reviews and Dissemination Psychosocial interventions for schizophrenia. Eff Health Care. 2000;6:1–8.
    1. Dickerson FB. Cognitive behavioral psychotherapy for schizophrenia: a review of recent empirical studies. Schizophr Res. 2000;43:71–90.
    1. Dickerson FB. Update on cognitive behavioural psychotherapy for schizophrenia: review of recent studies. J Cogn Psychother. 2004;18:189–205.
    1. Rector NA, Beck AT. Cognitive behavioral therapy for schizophrenia: an empirical review. J Nerv Ment Dis. 2001;189:278–287.
    1. Gould RA, Mueser KT, Bolton E, Mays V, Goff D. Cognitive therapy for psychosis in schizophrenia: an effect size analysis. Schizophr Res. 2001;48:335–342.
    1. Pfammatter M, Junghan U, Brenner H. Efficacy of psychological therapy in schizophrenia: conclusions from meta-analyses. Schizophr Bull. 2006;32:S64–S80.
    1. Zimmermann G, Favrod J, Trieu V, Pomini V. The effect of cognitive behavioural treatment on schizophrenia spectrum disorders: a meta-analysis. Schizophr Res. 2005;77:1–9.
    1. Sensky T. The effectiveness of cognitive therapy for schizophrenia: what can we learn from the meta-analyses. Psychother Psychosom. 2005;74:131–135.
    1. Gaudiano BA. Is symptomatic improvement in clinical trials of cognitive-behavioral therapy for psychosis clinically significant? J Psychiatr Pract. 2006;12:11–23.
    1. NICE. Schizophrenia: Core interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. 2003.
    1. Lehman AF, Kreyenbuhl J, Buchanan R, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophr Bull. 2004;30:193–217.
    1. Barrowclough C, Haddock G, Tarrier N, et al. Randomized controlled trial of motivational interviewing, cognitive behaviour therapy, and family intervention of patients with co-morbid schizophrenia and substance use disorder. Am J Psychiatry. 2001;158:1706–1713.
    1. Richardson A, Baker M, Burns T, Lilford RJ, Muijen M. Reflections on methodological issues in mental health research. J Ment Health. 2000;9:463–470.
    1. Slade M, Priebe S. Are randomised controlled trials the only gold that glitters? Br J Psychiatry. 2001;179:286–287.
    1. Pocock SJ. Clinical trials with multiple outcomes: a statistical perspective on their design, analysis, and interpretation. Control Clin Trials. 1997;18:530–545.
    1. Doll R. Controlled trials: the 1948 watershed. BMJ. 1998;317:1217–1220.
    1. Everitt BS, Wessely S. Clinical Trials in Psychiatry. Oxford, UK: Oxford University Press; 2003.
    1. Everitt BS, Pickles A. Statistical Aspects of the Design and Analysis of Clinical Trials. London, UK: Imperial College Press; 2000.
    1. Begg C, Cho M, Eastwood S, et al. Improving the quality of reporting of randomized controlled trials: the CONSORT statement. JAMA. 1996;276:637–639.
    1. Moher D, Schultz K, Altman D. The CONSORT statement: revised recommendations for improving the quality of reports of parallel group randomisation. JAMA. 2001;285:1987–1991.
    1. Thornley B, Adams C. Content and quality of 2000 controlled trials in schizophrenia over 50 years. BMJ. 1998;317:1181–1184.
    1. Moher D, Pham B, Jones A, et al. Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? Lancet. 1998;352:609–613.
    1. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias: dimensions of methodological quality associated with estimates of treatment effect in controlled trials. JAMA. 1995;280:178–180.
    1. Marshall M, Lockwood A, Bradley C, Adams C, Joy C, Fenton M. Unpublished rating scales; a major source of bias in randomised controlled trials of schizophrenia. Br J Psychiatry. 2000;176:249–252.
    1. Moher D, Jadad AR, Nichol G, Penman M, Tugwell P, Walsh S. Assessing the quality of randomised controlled trials: an annotated bibliography of scales and checklists. Control Clin Trials. 1995;16:62–73.
    1. Barrowclough C, Haddock G, Lobban F, et al. Group cognitive-behavioural therapy for schizophrenia: randomised controlled trial. Br J Psychiatry. 2006;189:1–7.
    1. Kemp R, Kirov G, Everitt B, Hayward P, David A. Randomised controlled trial of compliance therapy. 18-month follow-up. Br J Psychiatry. 1998;17:413–419.
    1. Chalmers TC, Smith H, Blackburn B, et al. A method for assessing the quality of a randomized control trial. Control Clin Trials. 1981;2:31–49.
    1. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17:1–12.
    1. Juni P, Witschi A, Bloch R, Eggar M. The hazards of scoring the quality of clinical trials for meta-analysis. JAMA. 1999;282:1054–1060.
    1. Juni P, Altman G, Eggar M. Assessing the quality of controlled clinical trials. BMJ. 2001;323:42–46.
    1. Kazdin AE, Bass P. Power to detect differences between alternative treatments in comparative psychotherapy outcome research. J Consult Clin Psychol. 1989;57:138–147.
    1. Sterne JAC, Juni P, Schulz KF, Altman DG, Barlet C, Eggar M. Statistical methods for assessing the influence of study characteristics on treatment effects in meta-epidemiological research. Stat Med. 2002;21:1513–1524.
    1. Huwiler-Muntener K, Juni P, Junker C, Eggar M. Quality of reporting of randomised trials as a measure of methodologic quality. JAMA. 2002;287:2801–2804.
    1. Tarrier N, Wykes T. Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? A cautious or cautionary tale? Behav Res Ther. 2004;42:1377–1401.
    1. Schulz KF, Altman DG, Moher D. Allocation concealment in clinical trials. JAMA. 2002;288:2406–2407.
    1. Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomised trials: explanation and elaboration. Ann Intern Med. 2001;134:663–694.
    1. Brown SA. Measurement of quality of primary studies for meta-analysis. Nurs Res. 1991;40:352–355.
    1. Trower P, Birchwood M, Meaden A, Byrne S, Nelson A, Ross K. Cognitive therapy for command hallucinations: randomised controlled trial. Br J Psychiatry. 2004;184:312–320.
    1. Milton F, Patwa VK, Hafner RJ. Confrontation vs belief modification in persistently deluded patients. Br J Med Psychol. 1978;51:127–130.
    1. Tarrier N, Beckett R, Harwood S, Baker A, Yusupoff L, Ugarteburu I. A controlled trial of two cognitive behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients: I. Outcome. Br J Psychiatry. 1993;162:524–532.
    1. Garety PA, Kuipers L, Fowler D, Chamberlain F, Dunn G. Cognitive behavioural therapy for drug resistant psychosis. Br J Psychiatry. 1994;67:259–271.
    1. Bentall RP, Haddock G, Slade PD. Cognitive behaviour therapy for persistent auditory hallucinations: from theory to therapy. Behav Ther. 1994;25:51–66.
    1. Drury V, Birchwood M, Cochrane R, Manmillan F. Cognitive therapy and recovery from acute psychosis: a controlled trial. I. Impact on psychotic symptoms. Br J Psychiatry. 1996;169:593–601.
    1. Kuipers E, Garety P, Fowler D, et al. London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. I: effects of the treatment phase. Br J Psychiatry. 1997;171:319–327.
    1. Tarrier N, Yusupoff L, Kinney C, et al. A randomised controlled trial of intensive cognitive behaviour therapy for chronic schizophrenia. BMJ. 1998;317:303–307.
    1. Daniels L. A group cognitive-behavioral and process-oriented approach to treating the social impairment and negative symptoms associated with chronic mental illness. J Psychother Pract Res. 1998;7:167–176.
    1. Levine J, Barak Y, Granek I. Cognitive group therapy for paranoid schizophrenics: applying cognitive dissonance. J Cogn Psychother. 1998;12:3–12.
    1. Pinto A, La Pia S, Mennella R, Giorgio D, De Simone L. Cognitive-behavioural therapy and clozapine for clients with treatment-refractory schizophrenia. Psychiatr Serv. 1999;50:901–904.
    1. Haddock G, Tarrier M, Morrison AP, Hopkins R, Drake R, Lewis S. A pilot study evaluating the effectiveness of individual inpatient cognitive behavioural therapy in early psychosis. Soc Psychiatry Psychiatr Epidemiol. 1999;34:254–258.
    1. Halperin S, Nathan P, Drummond P, Castle D. A cognitive-behavioural, group-based intervention for social anxiety in schizophrenia. Aust N Z J Psychiatry. 2000;34:809–813.
    1. Sensky T, Turkington D, Kingdon D, et al. A randomised controlled trial of cognitive-behavioural therapy for persistent symptoms in schizophrenia resistant to medication. Arch Gen Psychiatry. 2000;57:165–172.
    1. Bailer J, Takats I, Westermeier C. Efficacy of individualized cognitive-behavioral therapy for schizophrenic patients with negative symptoms and social disabilities: a controlled trial. Z Klin Psychol Psychother. 2001;30:268–278.
    1. Lewis SW, Tarrier N, Haddock G, et al. Randomised controlled trial of cognitive-behaviour therapy in early schizophrenia: acute phase outcomes. Br J Psychiatry. 2002;181(suppl 43):91–97.
    1. Turkington D, Kingdom D, Turner T The Insight Group. Effectiveness of a brief cognitive behavioural therapy intervention in the treatment of schizophrenia. Br J Psychiatry. 2002;180:523–528.
    1. Durham RC, Guthrie M, Morton RV, et al. Tayside-Fife clinical trial of cognitive-behavioural therapy for medication-resistant psychotic symptoms: results to 3-month follow-up. Br J Psychiatry. 2003;182:303–311.
    1. Hall PL, Tarrier M. The cognitive-behavioural treatment of low self-esteem in psychotic patients: a pilot study. Behav Res Ther. 2003;41:317–332.
    1. Valmaggia L, van der Gaag M, Tarrier N, Pijnenborg GHM, Sloof CJ. A randomized controlled trial of cognitive behavior therapy with treatment refractory positive symptoms of schizophrenia. Br J Psychiatry. 2005;186:324–330.
    1. Granholm E, McQuaid JR, McClure FS, Pedrelli P, Jeste DV. A randomized controlled pilot study of cognitive behavioural social skills training for older patients with schizophrenia. Schizophr Res. 2002;53:167–169.
    1. Gumley A, O'Grady M, McNay L, Reilly J, Power KG, Norrie J. Early intervention for relapse in schizophrenia: results of a 12-month randomised controlled trial of cognitive behavioural therapy. Psychol Med. 2003;33:419–431.
    1. Rector N, Seeman MV, Segal ZV. Cognitive therapy for schizophrenia: a preliminary randomised controlled trial. Schizophr Res. 2003;63:1–11.
    1. Jolley S, Garety P, Craig T, Dunn G, White J, Aitken M. Cognitive therapy in early psychosis: a pilot randomized controlled trial. Behav Cogn Psychother. 2003;31:473–478.
    1. Kingsep P, Nathan P, Castle D. Cognitive behavioural group treatment for social anxiety in schizophrenia. Schizophr Res. 2003;63:121–129.
    1. Wiersma D, Jenner J, Nienhuis F, van de Willige G. Hallucination focused integrative treatment improves quality of life in schizophrenia patients. Acta Psychiatr Scand. 2004;109:194–201.
    1. Bechdolf A, Knost B, Kuntermann C, et al. A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in patients with schizophrenia. Psychiatr Scand. 2004;110:21–28.
    1. Startup M, Jackson M, Bendix S. North Wales randomized controlled trial of cognitive behaviour therapy for acute schizophrenia spectrum disorders: outcomes at 6 and 12 months. Psychol Med. 2004;34:413–422.
    1. Cather C, Penn D, Otto M, Yovel I, Mueser K, Goff D. A pilot study of functional Cognitive Behavioral Therapy (fCBT) for schizophrenia. Schizophr Res. 2005;74:201–209.
    1. Granholm E, McQuaid JR, McClure FS, et al. A randomized, controlled trial of cognitive behavioral social skills training for middle-aged and older outpatients with chronic schizophrenia. Am J Psychiatry. 2005;162:520–529.
    1. Wykes T, Hayward P, Thomas N, et al. What are the effects of group cognitive behaviour therapy for voices? A randomised control trial. Schizophr Res. 2005;77:201–210.
    1. Gaudiano B, Herbert J. Acute treatment of inpatients with psycholtic symptoms using acceptance and commitment therapy: pilot results. Behav Res Ther. 2006;44:415–437.
    1. Fleiss JL. Measures of effect size for categorical data. In: Cooper H, Hedges LV, editors. The Handbook of Research Synthesis. New York, NY: Russell Sage Foundation; 1993. pp. 245–281.
    1. Everitt BS. Modern Medical Statistics: A Practical Guide. London, UK: Arnold; 2002.
    1. Tarrier N, Taylor K, Gooding P. Cognitive behavioural interventions to reduce suicidal behaviour: a systematic review and meta-analysis. Behav Modif. In press.
    1. Gregg L, Tarrier N. Virtual reality in mental health: a review of the literature. Soc Psychiatry Psychiatr Epidemiol. 2007;42:343–354.
    1. Moja L, Telaro E, D'Amico R, Moschetti I, Coe L, Liberati A. Assessment of methodological quality of primary studies by systematic reviews: results of the metaquality cross sectional study. BMJ. 2005;330:1053.
    1. Balk E, Bonis P, Moskowitz H, et al. Correlation of quality measures with estimates of treatment effect in meta-analyses of randomized controlled trials. JAMA. 2002;287:2973–2982.
    1. Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbe KA. Incorporating variations in the trial quality of individual randomised trial into meta-analysis. J Clin Epidemiol. 1992;45:255–265.
    1. Gotzsche PC. Methodology and overt and hidden bias in reports of 196 double-blind trials of nonsteroidal anti-inflammatory drugs in rheumatoid arthritis. Control Clin Trials. 1989;10:31–56.
    1. Pildal J, Chan A-W, Hróbjartsson A, Forfang E, Altman D, Gøtzsche P. Comparison of descriptions of allocation concealment in trial protocols and the published reports: cohort study. BMJ. 2005;330:1049.
    1. Tarrier N, Barrowclough C, Haddock G, McGovern J. The dissemination of innovative cognitive-behavioural treatments for schizophrenia. J Ment Health. 1999;8:569–582.

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