Cognitive behaviour therapy and early intervention for treatment and relapse prevention in psychosis
Professor Philippa Garety, PhD FBPsS, Department of Psychology, Institute of Psychiatry, King’s College, London And South London and Maudsley NHS Foundation Trust
Introduction Since the 1960s, the primary treatment for people with psychosis has been anti-psychotic medication, which is of demonstrated effectiveness in treating symptoms and preventing relapse. However, it is now widely recognised that a substantial proportion of people show a suboptimal outcome, with persisting symptoms, symptomatic relapses and disabling side effects, and, as a consequence, many show poor adherence to medication (Jones et al, 2006). Recently, therefore, two new approaches to improving treatment response in psychosis have been proposed: cognitive behavioural therapy and early intervention.
Cognitive behavioural therapy Cognitive behavioural therapy (CBT) for psychosis has been applied, in combination with medication, for over a decade (Beck, 2005). Its development and application to psychosis will be described and the current evidence for it reviewed. It has now been evaluated in over 30 randomised controlled trials, which can be sub-divided into those targeted at acute psychosis and those directed at the treatment of persistent positive symptoms. While the evidence from meta-analyses for benefits of CBT for the treatment of persistent symptoms is now strong, with an effect size of 0.4 (Zimmerman et al, 2005; Wykes et al, 2007), the evidence in acute psychosis and for relapse prevention is less clear. A new trial of CBT for relapse prevention in the acute episode will be described and the results presented (Garety et al, in press).
Early intervention Early intervention for psychosis refers to the prevention, early recognition and assertive multi-modal treatment of psychotic disorders (McGorry et al, 2007). Only a handful of randomised controlled trials have been conducted of early intervention. A small number of trials has been directed at treatment before the onset of frank psychosis, in the ‘prodromal’ or ‘at risk’ phase (e.g. McGorry, et al, 2002; Morrison et al, 2004). These show promise, at least in the short-term, for reducing hospitalisation or delaying the onset of psychosis; however more studies are needed before any firm conclusions can be drawn (Phillips et al, 2007). Early intervention services, in which assertive treatment of psychosis in the early stages is undertaken, have also been developed in certain countries (e.g. Australia, Canada, UK). One trial, conducted in the UK, will be presented (Craig et al, 2004; Garety et al, 2006). This used a combination of interventions – medication, CBT, Family work, social support and vocational work – aimed at preventing relapse following a first episode of psychosis, treating symptoms and promoting social and vocational functioning. The results of this trial will be presented and discussed.
Conclusion Two recent approaches, CBT and early intervention, are valuable new developments for improving outcomes in the treatment of psychosis. The present evidence suggests that CBT is effective in treating persisting symptoms, and may have benefits for mood and social functioning, whereas early intervention may reduce relapse and improve functioning.