Is Cognitive Behaviour Therapy Effective in Managing Schizophrenia - Literature review Example

number: of study: Sheffield Hallam Faculty of Health and Well-Being Module Using and Evaluating Evidence to Inform Practice Assignment: Critical review Is Cognitive Behaviour Therapy Effective in Managing Schizophrenia? If data from the http://www.cureresearch.com/s/schizophrenia/stats-country.htm are reliable, the United Kingdom is one of the countries of Europe with the highest prevalence of schizophrenia. Schizophrenia is a debilitating condition of the mind. The incidence of schizophrenia worldwide is high worldwide at 1% of the world population, according to figures of the http://www.health.am/psy/schizophrenia/. According to the http://www.schizophrenia.com/szfacts.htm, there is no cure for schizophrenia so all talk of "treatment" or "therapy" may pertain to “management” and not actual “treatment” of the condition. In this work, we review three articles that I consider important in how cognitive behaviour therapy can be useful in the management and treatment of schizophrenia. We review three studies: Barrowclough et al. (2006), Turkington et al. (2006a) and Turkington et al. (2006b). Barrowclough et al. (2006) sought to evaluate the effectiveness of group cognitive behavioural therapy for schizophrenia. To do so, 113 people with chronic schizophrenia, the Barrowclough et al. study assigned each of the 113 people to receive either the group cognitive-behavioural therapy or the usual treatment. The primary measure employed to assess the efficacy of treatment were the positive symptom improvement on the positive and negative syndrome scales while the secondary measures were “secondary outcome measures” like symptoms, functioning, relapses, hopelessness and self-esteem (Barrowclough et al. 2006, p. 527). The finding of Barrowclough et al. (2006) is that there was no significant difference between the two methods of treatment. However, the individuals subjected to group cognitive-behavioural therapy have a reduction in “feelings of hopelessness and in low self-esteem.” Thus, the conclusion of the Barrowclough et al. (2006) study is that “although the group cognitive-behavioural therapy may not be the optimum treatment for reducing hallucinations and delusions, it may have important benefits, including feeling less negative about oneself and less hopeless” (p. 527). The Barrowclough et al. (2006) study exhibited adequate adherence to professional and research ethics. Perhaps, an important indication of this is that the study sought an ethical agreement with the local research ethics committee. The inclusion criteria for the study are very clear in Barrowclough et al. (2006, p. 527). One of the inclusion criteria is that informed consent from the patient was required although the study does not discuss whether the informed consent is merely verbal or written or whether the relatives or the guardians of the patients were made co-signatories in the informed consent mechanism. I believe that concurrence of relatives or guardians may be necessary because schizophrenic patients may be considered legally incompetent to respond to requests for consent (even if symptoms have not exacerbated six months prior to the study). In building cognitive behavioural therapy groups, the study built groups from the 113 individuals who were the subject of research. Those who administered the group cognitive-behavioural therapy composed another group who operated a program independent of the Barrowclough et al. research team. In the opinion of this researcher, the Barrowclough made due consideration for the welfare of patients by putting in their inclusion criteria the requirement that the patient had one month of stabilisation if they had experienced a symptom exacerbation in the last six months (Barrowclough et al. 2006, p. 527). At the same time, however, the inclusion criterion implies that the results of the study should be qualified or that the positive benefits of the group cognitive behavioural therapy for schizophrenia, if any, apply only to that population who have stabilized six months prior to therapy. The group cognitive-behavioural therapy itself to which a part of the 113 individuals were subjected ran for six months with 18 sessions (Barrowclough et al. 2006, p. 528). For me, this indicate a limitation: the result that group cognitive behavioural therapy would work only in the area of creating hope and improving self-esteem MAY only be true if the therapy is only for six months; but what if the therapy period is longer? Meanwhile, the Turkington et al. (2006a) study worked on the assumption that “little is known about the medium-term durability of cognitive-behavioural therapy (CBT) in a community of people with schizophrenia” (p. 36). Recall that the Barrowclough et al. (2006) study covered therapy sessions of only six months for the “treatment” or management of schizophrenia. Figure 1. Study participants’ flow through in Turkington et al. (2006a) Source: Turkington et al. (2006, p. 37) The Turkington et al. (2006a) study sought to “investigate whether the brief CBT produces clinically important outcomes in relation to recovery, symptoms burden and readmission to hospital in people with schizophrenia at 1-year follow-up.” Here, the objective or aim of the Turkington et al. (2006a) study does not appear to have been well-written. A closer reading of the Turkngton et al. (2006a) material, however, indicated that the whole point of the research was to find out whether patients on whom CBT were applied perform well compared with patients treated in the usual way. Turkington et al. (2006a) discussed the recruitment of the sample and how the study was implemented in a complicated manner but Turkington et al. had a diagram represented by Figure 1. It is clear from Figure 1 that the Turkington et al. (2006a) study had clear participation criteria and that the 422 patients were randomised into two groups. The first group were subjected to CBT intervention in which 225 patients completed the treatment but only 211 of the 225 completed the follow-up. The second group was given the usual treatment in which 128 patients wherein only 125 out of the 128 completed the follow-up. It is puzzling why out of the 694 referred for the study, a high 255 patients refused. This is interesting because the number 255 is too close to 40% of the potential patients in the sample with whom the CBT can be administered. The data itself presents serious questions. What is or what are the elements in the CBT that close to 40% of the patient does not like about? Will this prevalence apply to about 40% of the schizophrenic patients? Note that if close to 40% of patients would object at once to CBT, this might imply that CBT may not be useful to at least 40% of patients with schizophrenia. Of course, it is also possible that the CBT has not yet been recognized legitimate or valid therapy for schizophrenia. It is worth noting how the Turkington et al. (2006a) study sought and obtain their informed consent from patients. While the Barrowclough et al. (2006) study discussed earlier sought informed consent from the patients only, the Turgkington et al. (2006a) sought informed consents from the patients only AFTER consent has been given by the “responsible medical officer” and “community keyworker”. The Turkington et al. (2006a) approach appears to be better than the Barrowclough et al. (2006) approach. Nevertheless, it may be important to raise whether it would be better if the consent of the patients’ guardians or closest relatives or spouse should have been obtained as well for schizophrenic patients. The main finding of the Turkington et al. (2006a) study is that “durable, statistically significant improvements were seen at 12-month follow-up in insight and negative symptoms in the CBT group compared with the usual care group”. However, the “primary negative symptoms, including alogia and affective blunting, were not improved by intervention” (Turkington et al. 2006a, p. 38). In my opinion, these statements are ambivalent and have several interpretations. The Turkington et al. (2006a, p. 38) statement that is unambivalent or unequivocal, however, is the statement that “no significant difference was found between the two groups for positive symptoms, overall symptoms or depression.” In other words, the Turkington et al. (2006) study does not seem to provide evidence that CBT is better than the usual treatment when the point for comparison are the “primary negative symptoms” and “affective blunting”. In the Turkington et al. (2006a) study, a good clinical outcome of a treatment takes place when there is an improvement of 25% or more for the negative symptoms. Unfortunately, the CBT and the usual treatment for schizophrenia have no significant difference for positive symptoms, overall symptoms, depression (Turkington et al. 2006, p. 38). Although the Turkington et al. (2006a) study was able to see “encouraging” results form their study, it is unfortunate that the key concluding statement of the Turkington et al. (2006a, p. 36) is that “mental health nurses should be trained for brief CBT for schizophrenia to supplement case management, family intervention and experttherapy for treatment resistance”. In other words, the Turkington et al. (2006a) study did not unequivocally address the study objectives the researchers have declared for their study. In the opinion of this writer, the results of the Turkington et al. (2006a) study can be interpreted this way: although the difference in results are not statistically different, the generally better figures of the CBT group may be indicative of the better efficacy of the CBT over the usual treatment. Given that CBT is also safe, there is a case for supplementing current modes of therapy with CBT. One can also cite the Barrowclough (2006) study as indicative that the CBT may be providing other benefits that the usual treatment has been unable to provide: providing patients with a sense of hope and improving their self-esteem. The study of Turkington et al. (2006b, p. 365) declared that their objective was to “offer a broad perspective on the subject of cognitive behaviour therapy for schizophrenia for the American reader”. To meet the objectives, the authors summarized “current practice and data supporting the use of cognitive behaviour therapy for schizophrenia” (Turkington et al. 2006, p. 365). Right away, it is easy to see a methodological defect in the methodology of Turkington et al. (2006b). I believe that there are several advantages if the Turkington et al. (2006b) also covered a review of studies that did not support CBT. One of such advantages is that we can see the CBT in a more objective light. Another advantage is that through a balance review of the studies that support CBT and also studies that did not support the claims of efficacy of the CBT, we can identify possible weaknesses in all studies on the CBT and work on improving earlier studies. One possibility is that the CBT works but that the CBT works under certain conditions. Thus, a balanced review of studies in which the CBT did not work and studies in which the CBT work will enable to us discover the specific situations in which the CBT may work and the specific situations in which CBT may not work. If the CBT does work, a balanced review may also allow us to see the specific situations in which the CBT does not work. Of course, these are only possibilities because another possibility is that the CBT does not really work and a balanced review would allow us to see and assess this possibility. In any case, according to Turkington et al. (2006b, p. 365), the studies providing evidence on the efficacy of CBT for schizophrenia also come from studies using randomised clinical trials. The use of CBT for treatment of schizophrenia has encouraged because the 1960s and the 1970s showed that psychoanalytically oriented psychotherapy “was ineffective, and at times even harmful, for patients with schizophrenia” (Turkington et al. 2006b, p. 365). The overall conclusion made by Turkington et al. (2006b) in their study is that CBT enjoys good evidence for its efficacy as therapy for schizophrenia and stressed that CBT should receive more attention in the United States. It must pointed out that Turkington et al. (2006b) was written for a United States academic journal while Turkington et al. 2006a was written for a journal based in the United Kingdom. Turkington et al. (2006b, p. 367) that CBT as treatment for schizophrenia enjoys a good following in the United Kingdom but not in the United States. Unlike in the United Kingdom, “there has been a dearth of controlled studies of the efficacy of cognitive behaviour therapy for schizophrenia in the United States”. In the United Kingdom, however, the problem lies more on uncertainties on how one would interpret the findings (Turkington 2006b, p. 367). In conclusion, I think not all studies are able to prove that the CBT works better than the usual treatment for schizophrenia. Yet, at the same time, the way many of the studies have concluded their research on the efficacy of CBT for schizophrenia suggests that CBT is just as good as the usual therapy for schizophrenia. In March 2009, the UK National Institute for Health and Clinical Excellence even included CBT as one of the possible core treatments for schizophrenia (p. 9). The real value of the CBT may lie more in producing desirable effects on schizophrenic patients in area of the provision of hope and improving their self-esteem, something that may be lacking in the usual mode of treatment for schizophrenia. Thus, research may be actually suggesting that CBT may a better mode of treatment because of the additional benefits. It is too early to make conclusions on the matter and research must continue despite the UK National Institute for Health and Clinical Excellence March 2009 material. Word Count: 2, 190 References Barrowclough, C., Haddock, G., Lobban, F., Jones, S., Siddle, R., Roberts, C., and Gregg, L., 2006. Group cognitive-behavioural therapy for schizophrenia: Randomised controlled trial. British Journal of Psychiatry, 189, 527-532. Turkington, D., Kingdon, D., and Chadick, P., 2003. Cognitive-behavioural therapy for schizophrenia: Filling the therapeutic vacuum. British Journal of Psychiatry, 183, 98-99. Turkington, D., Kingdon, D., Rathod, S., Hammond, K., Pelton, J., and Mehta, R., 2006a. Outcomes of an effectiveness trial of cognitive-behavioural intervention by mental health nurses in schizophrenia. British Journal of Psychiatry, 189, 36-40. Turkington, D., Kingdon, D., and Weiden, P., 2006b. Cogitive behavior therapy for schizophrenia. American Journal of Psychiatry, 163 (3), 365-373. Turkington, D., Dudley, R., Warman, D., and Beck, A., 2006c. Cognitive-Behavioral Therapy for Schizophrenia: A Review. Focus 4 (2), 223-233. UK National Institute for Health and Clinical Excellence, March 2009. Schizophrenia: Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. NICE clinical guideline 82 (Update of NICE clinical guideline 1). London: National Institute for Health and Clinical Excellence. Read More