Cochrane Database Syst Rev. Author manuscript; available in PMC 2014 Sep 15. Published in final edited form as: PMCID: PMC4163968 EMSID: EMS58366 Cognitive behavioural therapy (CBT) is now a recommended treatment for people with schizophrenia.
This approach helps to link the person’s distress and problem behaviours to underlying patterns of thinking. To review the effects of CBT for people with schizophrenia when compared with other psychological therapies. We searched the Cochrane Schizophrenia Group Trials Register (March 2010) which is based on regular searches of CINAHL, EMBASE, MEDLINE and
PsycINFO. We inspected all references of the selected articles for further relevant trials, and, where appropriate, contacted authors. All relevant randomised controlled trials (RCTs) of CBT for people with schizophrenia-like illnesses. Studies were reliably selected and assessed for methodological quality. Two review authors, working
independently, extracted data. We analysed dichotomous data on an intention-to-treat basis and continuous data with 65% completion rate are presented. Where possible, for dichotomous outcomes, we estimated a risk ratio (RR) with the 95% confidence interval (CI) along with the number needed to treat/harm. Thirty one papers described 20 trials. Trials were often small and of limited quality. When CBT was compared with other
psychosocial therapies, no difference was found for outcomes relevant to adverse effect/events (2 RCTs, n = 202, RR death 0.57 CI 0.12 to 2.60). Relapse was not reduced over any time period (5 RCTs, n = 183, RR long-term 0.91 CI 0.63 to 1.32) nor was rehospitalisation (5 RCTs, n = 294, RR in longer term 0.86 CI 0.62 to 1.21). Various global mental state measures failed to show difference (4 RCTs, n = 244, RR no important change in mental state 0.84 CI 0.64 to 1.09). More specific measures of
mental state failed to show differential effects on positive or negative symptoms of schizophrenia but there may be some longer term effect for affective symptoms (2 RCTs, n = 105, mean difference (MD) Beck Depression Inventory (BDI) −6.21 CI −10.81 to −1.61). Few trials report on social functioning or quality of life. Findings do not convincingly favour either of the interventions (2 RCTs, n = 103, MD Social Functioning Scale(SFS) 1.32 CI −4.90 to 7.54; n = 37, MD EuroQOL −1.86 CI
−19.20 to 15.48). For the outcome of leaving the study early, we found no significant advantage when CBT was compared with either non-active control therapies (4 RCTs, n = 433, RR 0.88 CI 0.63 to 1.23) or active therapies (6 RCTs, n = 339, RR 0.75 CI 0.40 to 1.43) Trial-based evidence suggests no clear and convincing advantage for cognitive behavioural therapy over other - and sometime much less sophisticated - therapies
for people with schizophrenia. Medical Subject Headings (MeSH) Cognitive Therapy [*methods], Schizophrenia [*therapy] MeSH check words: Adult, Humans, Middle Aged Schizophrenia is a serious mental illness affecting one per cent of the population, irrespective of culture, class or race.
The illness varies in its severity and in the variety of its symptoms. Every year one person per 10,000 begins to fall ill with schizophrenia, making it about twice as common as epilepsy (APA 1995). The first episode of schizophrenia often occurs when a person is in their early twenties (WHO 1973)
and the course of the illness is variable. Many people experience considerable disability and there is a substantial increase in mortality (Drake 1986). Some people have difficulties with their thoughts, making illogical associations and developing false and sometimes bizarre explanations (i.e., delusions) for their experiences or symptoms. Problems with false perceptions may occur, for example,
hearing voices or seeing visions (hallucinations). Difficulties with concentration, attention and motivation may also lead to poor social and occupational functioning. The range of emotional expression, capacity to think and act may be reduced, together with an inability to experience pleasure. It is customary to view the symptoms of schizophrenia as falling into two broad categories: (i) ‘positive’ symptoms, which are unusual by their presence (for example, hearing voices); and (ii) ‘negative’
symptoms, which are unusual by their absence (for example, restricted range and intensity of emotional expression). Medication is the mainstay of treatment for schizophrenia but 5% to 25% of people continue to experience symptoms in spite of medication (Christison 1991;
Davis 1977; Meltzer 1992) and may experience side effects that are unwanted and unpleasant. Talking therapies may also be used in addition to medication. In cognitive behaviour therapy (CBT), links are made between the person’s feelings and patterns of thinking which underpin their
distress. The participant is encouraged to take an active part by using the following techniques. Challenging the habitual patterns of thinking. Examining the evidence for and against the distressing beliefs. Using reasoning abilities and personal experience to develop rational and personally acceptable alternative explanations and interpretations
(Alford 1994) and to test these alternative explanations in real world situations. Tarrier 1993 has stressed the beneficial effects of enhancing coping strategies and general problem-solving skills. At present, a variety of interventions have been labelled as CBT and it is difficult to provide a
single, unambiguous definition. In recognition, the review authors have constructed criteria that are felt to be both workable and to capture the elements of good practice in CBT. Cognitive behavioural therapy is becoming increasingly available for people with schizophrenia, with recent recommendations of national treatment guidelines suggesting that CBT should be more widely available for people with schizophrenia
(NICE 2009). This 2009 update of NICE 2002 is more directive in its support of the use of CBT for people with schizophrenia than the earlier version. In addition, many of the trials of CBT for psychosis have incorporated additional active therapeutic elements (e.g., psychoeducation and relapse prevention, etc) that would be considered adjunctive to techniques which are specifically targeted at
eliciting belief change (e.g., guided discovery or behavioural experiments). Cognitive behavioural therapy aims to remediate distressing emotional experiences or dysfunctional behaviour by changing the way in which the individual interprets and evaluates the experience or cognates on its consequence and meaning. Cognitive behavioural therapy encourages the person to identify and challenge biased
interpretations of experiences that may be maintaining symptoms. Many of the CBT programmes (e.g. Garety 2008) are based upon a stress-vulnerability model of symptom onset and relapse. The empirical evidence for the stress-vulnerability model has been questioned (McKenna 2007). In a
recent theoretical review of the potential change processes that CBT for psychosis might possess, Birchwood 2006 distinguishes between “quasi-neuroleptic” effects of CBT upon psychotic symptoms (e.g., hallucination) and the emotional and behavioural consequences of such experiences or their treatment. Accordingly,
Birchwood 2006 distinguishes between emotional/behavioural distress and psychotic symptomatology and advocates the former as an appropriate target for CBT interventions. Specifically, Birchwood 2006 suggests that CBT might focus upon the following. Distress reduction or the
reduction of depression and problem behaviour associated with beliefs about psychotic symptomatology. The emotional and interpersonal difficulty in individuals at high risk of developing psychosis. Relapse prodromes to prevent relapse in psychosis. ‘Comorbid’ depression and social anxiety, including the patient’s appraisal of the diagnosis and its stigmatising consequences. General stress reactivity, thereby increasing resilience to
life stress and preventing psychotic relapse. Increasing self-esteem and social confidence in people with psychosis. However, many of the current trials of CBT for psychosis have defined their outcomes in terms of psychotic symptomatology (e.g., hallucinatory and delusional experience) rather than distress, problem behaviour or stigma and self esteem. Despite
national treatment guidelines recommending CBT as an adjunct therapy for serious mental illness (NICE 2009), it is still not as widely available for people with schizophrenia as it is for people with other disorders (for example, depression and panic disorder). The first case report of CBT for delusional beliefs in 1952, reported by
Beck 2005, did not lead to widespread development of CBT for schizophrenia or its symptoms. Psychological interventions have become more widely accepted over the past two decades and are now seen as part of a comprehensive set of routine interventions in the treatment and management of schizophrenia
(NICE 2009; Turkington 2004). However, the availability of CBT and other evidence-based therapies on the NHS is extremely limited, despite government efforts to improve access. Waiting times of more than a year are commonplace
(Bird 2006). The delivery of CBT to people with schizophrenia also depends upon having a commitment from health service managers to support and facilitate training and supervision (Turkington 2004). Since the publication of the original Cochrane review of ‘Cognitive behavioural
therapy for schizophrenia’ (Jones 2004) there has been a substantial increase in the number of published and relevant clinical trials, and a refinement in the definition and working models of CBT. In addition, there has also been a diversification of research, with trials not only assessing overall effectiveness but investigating more specific aspects of CBT. Updating and splitting the original
review of CBT to create a family of CBT reviews (see Jones 2009a and Jones 2009b) to incorporate and address this new more diverse data is necessary. This particular review will provide information about CBT’s relative effectiveness compared with other similar adjunct psychosocial therapies. OBJECTIVESTo assess the effectiveness of adjunct CBT for people with schizophrenia compared with other adjunct psychosocial interventions. METHODSCriteria for considering studies for this reviewTypes of studiesAll relevant randomised controlled trials (RCTs). We excluded quasi-randomised trials, such as those where allocation is undertaken on surname. If a trial was described as double-blind, but it was implied it had been randomised, we included these trials in a sensitivity analysis. We included randomised cross-over studies but only data up to the point of first cross-over because of the instability of the problem behaviours and the likely carry-over effects of all treatments. As CBT requires the person to actively engage and participate in the therapy, it may not be possible to blind the participant to condition (that is, it may not be possible to provide a placebo control condition to reduce the effects of anticipated outcome on behalf of the participant). However, it is possible and desirable to blind the trialist to condition (that is, the trialist collecting outcome data is unaware of the allocation of the individual participant). Accordingly, single-blind trials are considered of appropriate methodological quality for the assessment of this type of intervention. We compared the outcomes of trials that described a single-blind procedure with trials that did not describe any blinding procedure. If there was no substantive difference within primary outcomes (see Types of outcome measures) when these non-blinded studies were added, then we did not include them in the final analysis. If there was a substantive difference, we only used only singleblinded randomised trials and the results of the sensitivity analysis are described in the text. Types of participantsPeople with a current diagnosis of schizophrenia, diagnosed by any criteria, irrespective of gender or race. We did not include participants who had very late onset of illness (onset after the age of 60 years) or those with other psychotic disorders such as bipolar affective disorder, substance-induced psychosis, significant physical or sensory difficulties or people with coexisting developmental disorders and/or learning disabilities. If studies randomised people with schizophrenia and those with the above disorders, we only included trials where more than 50% of the participants had a diagnosis of schizophrenia. This review did not include trials that report outcomes from participants deemed to be “at-risk” of developing schizophrenia in the future. Types of interventions1. Cognitive behavioural therapy (CBT)The label cognitive behavioural therapy has been applied to a variety of interventions, accordingly, is difficult to provide a single, unambiguous definition. Recognising this, the review authors constructed criteria that were felt to be both workable and to capture the elements of good practice in CBT. In order to be classified as ‘well-defined’ the intervention must clearly demonstrate the following components:
All therapies that did not meet these criteria (or that provided insufficient information) but were labelled as ‘CBT’ or ‘Cognitive Therapy’ were included as ‘less-well-defined CBT’. We conducted a sensitivity analysis on the primary outcomes of this review (see Types of outcome measures) in order to investigate whether a ‘well-defined’ implementation of this therapy presents with differential outcomes. In addition, we undertook a sensitivity analysis between studies that employed qualified CBT therapists compared with relatively unqualified CBT therapists. Qualified CBT therapists may be defined as:
Unqualified CBT therapists may be defined as persons not possessing appropriate professional qualifications or no report of training and adherence protocols. 2. Other psychosocial interventionsWhere standard care has been supplemented by additional psychological or social interventions, or both, such as supportive therapy, psycho-education, family therapy and other ‘talking therapies’. This review distinguishes between trials that described ‘active’ psychosocial interventions (e.g., family therapy) aimed at a meaningful symptom reduction and those trials which have used ‘non-active’ psychosocial interventions (e.g., unstructured conversations) which act as merely a control for the non-specific effects of therapy (e.g., time spent with therapist). Outcomes are presented separately for active and non-active psychosocial interventions and the pooled effect of these trials is also presented. Types of outcome measuresOutcomes can be categorised as being of short-, medium- or long-duration. A short-term outcome is defined as occurring within the period typically associated with active treatment. The National Institute for Clinical Excellence (NICE) asserts that “for it to make a difference, [the patient] should have CBT treatment for more than 6 months, meeting for more than ten treatment sessions” (NICE 2009). Accordingly, in this review, we have grouped outcomes into those measured in the short-term (within 24 weeks of the onset of therapy), medium-term (within 24 to 52 weeks of the onset of therapy) and long-term (over 52 weeks since the onset of therapy). Outcomes can also be grouped into broad areas (Table 1). Table 1Outcome categories
Primary outcomes1. Death1.1 Any cause and sudden, unexpected death or suicide. 2. Mental state2.1 No clinically important response as defined by the individual studies (for example global impression less than much improved, or less than 50% reduction on a specified rating scale) - short-, medium- and long-term. Secondary outcomes2. Mental state
3. Adverse effects
4. Engagement with services
5. Global state
6. Quality of life
7. Satisfaction with treatment
8. Economic
Search methods for identification of studiesElectronic searches1. Electronic searches1.1 The Cochrane Schizophrenia Group’s Register (March 2010)This was searched by the Trial Search Co-ordinator of the Cochrane Schizophrenia Group, Samantha Roberts, using the phrase: {[(*cogniti* AND (*behavio* or therap*)) OR (*cogniti* and (*technique* or *restructur* or *challeng*)) OR (*self* and (*instruct* or *management* or *attribution*)) OR (*rational* and *emotiv*) in title, abstract, index terms of REFERENCE] or [Cognitive* in interventions of STUDY]} This register is compiled by systematic searches of major databases, handsearches and conference proceedings (see group module). 2. Details of previous searches for previous CBT reviewFor search details used in Jones 2004 Please see Appendix 1. Searching other resources1. Reference listsWe searched all references of included articles for further relevant trials. 2. AuthorsWhen appropriate, we contacted the first author of each of the included papers and requested additional published and unpublished materials. Data collection and analysisSelection of studiesThree review authors (AM, DH & CAJ) independently inspected all identified citations. When disputes arose as to which category a citation should be allocated, resolution was attempted by discussion. When this was not possible, we acquired the full article. Two review authors (DH, CAJ) independently inspected all articles identified in this way. When disputes arose as to whether an article was indeed relevant to this review, we attempted resolution by discussion. When this was not possible, we asked another review authors (CI) to read the article and decide. IR, AM and CI reviewed 30% of the citations and articles, included and excluded by DH and CAJ, to check the use of inclusion criteria. Data extraction and management1. ExtractionReview authors DH and CAJ extracted data from all included studies. In addition, to ensure reliability, CI independently extracted data from a random sample of these studies, comprising 10% of the total. We resolved disputes by discussion and adjudication from the other review authors (AM, CI and IC) if necessary. When it was not possible to extract data or if further information was needed, we attempted to contact the authors. We extracted data presented only in graphs and figures whenever possible, but the data were included only if two review authors independently had the same result. We attempted to contact authors through an open-ended request in order to obtain missing information or for clarification whenever necessary. Where possible, we extracted data relevant to each component centre of multi-centre studies separately. 2. Management2.1 FormsWe extracted data onto standard, simple forms. 2.2 Scale-derived dataWe included continuous data from rating scales only if: a. the psychometric properties of the measuring instrument had been described in a peer-reviewed journal (Marshall 2000); and b. the measuring instrument was not written or modified by one of the trialists for that particular trial; and c. the measuring instrument was either i. a self-report or ii. completed by an independent rater or relative (not the therapist). 2.3 Endpoint versus change dataThere are advantages of both endpoint and change data. Change data can remove a component of between-person variability from the analysis. On the other hand, calculation of change needs two assessments (baseline and endpoint) which can be difficult in unstable and difficult to measure conditions such as schizophrenia. We decided to primarily use endpoint data and only use change data if the former were not available. We combined endpoint and change data in the analysis as we used mean differences rather than standardised mean differences throughout (Higgins 2009). 2.4 Skewed dataContinuous data on clinical and social outcomes are often not normally distributed. To avoid the pitfall of applying parametric tests to non-parametric data, we aimed to apply the following standards to all data before inclusion: a) standard deviations and means are reported in the paper or obtainable from the authors; b) when a scale starts from the finite number zero, the standard deviation (SD), when multiplied by two, is less than the mean (as otherwise the mean is unlikely to be an appropriate measure of the centre of the distribution, (Altman 1996); c) if a scale started from a positive value (such as Positive and Negative Syndrome Scale (PANSS) which can have values from 30 to 210), the calculation described above was modified to take the scale starting point into account. In these cases skew is present if 2 SD > (S-S min), where S is the mean score and S min is the minimum score. Endpoint scores on scales often have a finite start and end point and these rules can be applied. When continuous data are presented on a scale that includes a possibility of negative values (such as change data), it is difficult to tell whether data are skewed or not. We planned to enter skewed data from studies of less than 200 participants in additional tables rather than into an analysis. Skewed data pose less of a problem when looking at means if the sample size is large and such data were entered into syntheses. 2.5 Common measureTo facilitate comparison between trials, we intended to convert variables that can be reported in different metrics, such as days in hospital (mean days per year, per week or per month) to a common metric (e.g. mean days per month). 2.6 Conversion of continuous to binaryWhere possible, efforts were made to convert outcome measures to dichotomous data. This could be done by identifying cut-off points on rating scales and dividing participants accordingly into ‘clinically improved’ or ‘not clinically improved’. It was generally assumed that if there had been a 50% reduction in a scale-derived score such as the Brief Psychiatric Rating Scale (BPRS, Overall 1962) or the PANSS (Kay 1987), this could be considered as a clinically significant response (Leucht 2005a; Leucht 2005b). If data based on these thresholds were not available, we used the primary cut-off presented by the original authors. 2.7 Direction of graphsWhere possible, we entered data in such a way that the area to the left of the line of no effect indicates a favourable outcome for CBT. 2.8 Summary of findings tableWe anticipated including the following short- or medium-term outcomes in a ‘Summary of findings’ table. 1. Global state
2. Mental state
3. Adverse effect
4. Social functioning
5. Quality of life
Assessment of risk of bias in included studiesTwo review authors (DH and CAJ) assessed risk of bias using the tool described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2009). This tool encourages consideration of how the randomisation sequence was generated, how allocation was concealed, the integrity of blinding at outcome measurement, the completeness of outcome data, selective reporting and other biases. We excluded studies where sequence generation was at a high risk of bias or where allocation was clearly not concealed. If disputes arose as to the correct category for a trial, this was resolved through discussion and adjudication by the other review authors (AM, CI and IC) if necessary. If this was not possible because further information was necessary, we intended not to enter the data but to allocate the trial to the list of those awaiting assessment. Review authors were not blinded to the names of the authors, institutions, journal of publication, or results of the trials. Measures of treatment effectWe adopted P = 0.05 as the conventional level of statistical significance but we were especially cautious where results were only slightly below this, and we reported 95% confidence intervals (CI) in preference to P values. 1. Binary dataFor binary outcomes, we calculated a standard estimation of the risk ratio (RR) and its 95% CI. It has been shown that RR is more intuitive (Boissel 1999) than odds ratios (OR) and that (OR) tend to be interpreted as RR by clinicians (Deeks 2000). For statistically significant results, we had planned to calculate the number needed to treat to provide benefit/to induce harm statistic (NNTB/H), and its 95% CI using Visual Rx (http://www.nntonline.net/) taking account of the event rate in the control group, but this has been superseded by the Summary of findings for the main comparison. 2. Continuous dataFor continuous outcomes, we estimated mean difference (MD) between groups. We preferred not to calculate effect size measures (standardised mean difference SMD). However, had scales of very considerable similarity been used, we would have presumed there was a small difference in measurement, and we would have calculated effect size and transformed the effect back to the units of one or more of the specific instruments. Unit of analysis issues1. Cluster trialsStudies increasingly employ ‘cluster randomisation’ (such as randomisation by clinician or practice) but analysis and pooling of clustered data poses problems. Firstly, authors often fail to account for intra-class correlation in clustered studies, leading to a ‘unit of analysis’ error (Divine 1992) whereby P values are spuriously low, CIs unduly narrow and statistical significance overestimated. This causes type I errors (Bland 1997; Gulliford 1999). Where clustering was not accounted for in primary studies, we had planned to present data in a table, with a (*) symbol to indicate the presence of a probable unit of analysis error. In subsequent versions of this review we will seek to contact first authors of studies to obtain intra-class correlation coefficients for their clustered data and to adjust for this by using accepted methods (Gulliford 1999). Where clustering has been incorporated into the analysis of primary studies, we will present these data as if from a non-cluster randomised study, but adjust for the clustering effect. We have sought statistical advice and been advised that the binary data presented in a report should be divided by a ‘design effect’. This is calculated using the mean number of participants per cluster (m) and the intra-class correlation coefficient (ICC) [Design effect = 1+(m-1)*ICC] (Donner 2002). If the ICC is not reported it is assumed to be 0.1 (Ukoumunne 1999). If cluster studies had been appropriately analysed taking into account ICCs and relevant data documented in the report, synthesis with other studies would have been possible using the generic inverse variance technique. 2. Cross-over trialsA major concern of cross-over trials is the carry-over effect. It occurs if an effect (e.g. pharmacological, physiological or psychological) of the treatment in the first phase is carried over to the second phase. As a consequence, on entry to the second phase, the participants can differ systematically from their initial state despite a wash-out phase. For the same reason cross-over trials are not appropriate if the condition of interest is unstable (Elbourne 2002). As both effects are very likely in severe mental illness, had we found any cross-over trials, we planned to use only the data from the first phase of the study. 3. Studies with multiple treatment groupsWhere a study involved more than two treatment arms, if relevant, we presented the additional treatment arms in the comparisons. Where the additional treatment arms were not relevant, we did not report these data. Dealing with missing data1. Overall loss of credibilityAt some degree of loss of follow-up, the findings of a trial must lose credibility (Xia 2009). We were forced to make a judgment where this was for the very short-term trials likely to be included in this review. We decided that if more than 40% of data were unaccounted for at eight weeks, we would not reproduce these data or use them within analyses. 2. BinaryIf attrition for a binary outcome was between 0% and 40% and outcomes of these people were described, we included these data as reported. Where these data were not clearly described for the primary outcome, we assumed the worst for each person who was lost, and for adverse effects, we assumed rates similar to those among patients who did continue to have their data recorded. 3. Continuous3.1 AttritionIn the case where attrition for a continuous outcome was between 0% and 40% and completer-only data were reported, we have reproduced these. 3.2 Standard deviationsWe first tried to obtain the missing values from the authors. If not available, where there were missing measures of variance for continuous data but an exact standard error (SE) and CI were available for group means, and either ‘P’ value or ‘t’ value were available for differences in mean, we noted these, and in future versions of this review we will calculate them according to the rules described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2009): When only the SE is reported, standard deviations (SDs) can be calculated by the formula SD = SE * square root (n). Chapters 7.7.3 and 16.1.3 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2009) present detailed formula for estimating SDs from P values, t or F values, CIs, ranges or other statistics. If these formula do not apply, we, in the future will calculate SDs according to a validated imputation method which is based on the SDs of the other included studies (Furukawa 2006). Some of these imputation strategies can introduce error. The alternative would be to exclude a given study’s outcome and thus to lose information. We will examine the validity of the imputations in a sensitivity analysis excluding imputed values. 3.3 Last observation carried forwardWe anticipated that in some studies the method of Last Observation Carried Forward (LOCF) would be employed within the study report. As with all methods of imputation to deal with missing data, LOCF introduces uncertainty about the reliability of the results. Therefore, where LOCF data have been used in the trial, if less than 40% of the data had been assumed, we reproduced these data and indicated that they are the product of LOCF assumptions. Assessment of heterogeneity1. Clinical heterogeneityWe considered all included studies initially, without seeing comparison data, to judge clinical heterogeneity. We simply inspected all studies for clearly outlying situations or people which we had not predicted would arise. When such situations or participant groups arose, these were fully discussed. 2. Methodological heterogeneityWe considered all included studies initially, without seeing comparison data, to judge methodological heterogeneity. We simply inspected all studies for clearly outlying methods which we had not predicted would arise. When such methodological outliers arose these were fully discussed. 3. Statistical heterogeneity3.1 Visual inspectionWe visually inspected graphs to investigate the possibility of statistical heterogeneity. 3.2 Employing the I2 statisticHeterogeneity between studies was investigated by considering the I2 method alongside the Chi2 ‘P’ value. The I2 provides an estimate of the percentage of inconsistency thought to be due to chance (Higgins 2003). The importance of the observed value of I2 depends on i. magnitude and direction of effects and ii. strength of evidence for heterogeneity (e.g. ‘P’ value from Chi2 test, or a CI for I2). We interpreted an I2 estimate greater than or equal to 75% accompanied by a statistically significant Chi2 statistic as evidence of substantial levels of heterogeneity (Higgins 2009). When substantial levels of heterogeneity were found in the primary outcome, we explored reasons for heterogeneity (Subgroup analysis and investigation of heterogeneity). Assessment of reporting biasesReporting biases arise when the dissemination of research findings is influenced by the nature and direction of results (Egger 1997). These are described in section 10.1 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2009). We are aware that funnel plots may be useful in investigating reporting biases but are of limited power to detect small-study effects. We did not use funnel plots for outcomes where there were 10 or fewer studies, or where all studies were of similar sizes. In other cases, where funnel plots were possible, we sought statistical advice in their interpretation. Data synthesisWe understand that there is no closed argument for preference for use of fixed-effect or random-effects models. The random-effects method incorporates an assumption that the different studies are estimating different, yet related, intervention effects. The random-effects model takes into account differences between studies, even if there is no statistically significant heterogeneity. There is, however, a disadvantage to the random-effects model. It puts added weight onto small studies which often are the most biased ones. Depending on the direction of effect, these studies can either inflate or deflate the effect size. Subgroup analysis and investigation of heterogeneity1. Subgroup analysesWe anticipated sub-group analyses to test the hypothesis that CBT may be highlighted to have different effects when compared with: 1.1 Active versus non-active control therapiesActive psychological treatments as opposed to inactive ones. 1.2 Rigorous criteria for diagnosing schizophrenia as opposed to more loose criteriaWe defined ‘rigorous’ as involving operational criteria. 1.3 Rigorous criteria for describing CBT as opposed to a more loose descriptionWe defined ‘rigorous’ as outlined this in Types of interventions. 1.4 People in first episode of illness versus those at a later stage of illnessFor each of the above subgroups, we aimed to undertake the analysis for only the primary outcomes of this review or the nearest we could find to them (see Types of outcome measures) and if data were available discussed the findings in the Effects of interventions.. 2. Investigation of heterogeneityIf inconsistency was high, this was reported. First, we investigated whether data had been entered correctly. Second, if data were correct, we visually inspected the graph and studies outside of the company of the rest were successively removed to see if heterogeneity was restored. When this occurred with no more than 10% of the data being excluded, we presented the data. If not, we did not pool data and discussed the issues. Where unanticipated clinical or methodological heterogeneity were obvious, we simply stated hypotheses regarding these for future reviews or versions of this review. We did not anticipate undertaking analyses relating to these. Sensitivity analysis1. Implication of randomisationWe aimed to include trials in a sensitivity analysis if they were described in some way as to imply randomisation. For the primary outcomes, we included these studies and if there was no substantive difference when the implied randomised studies were added to those with better description of randomisation, then we used all the data from these studies. 2. BlindingWe aimed to include trials in a sensitivity analysis if they were described in some way that suggested they blinded for assessment of outcome as opposed to not blinding at all. For the primary outcomes, we compared findings of blinded and non-blinded studies. 3. Well-defined CBT versus less-well-defined CBTWe aimed to include trials in a sensitivity analysis if they meet the criteria for ‘well-defined’ CBT as opposed to those studies that labelled the therapy as CBT but either did not contain the ‘inferential’ and ‘evaluative’ component or who did not provide enough information for this discrimination to be made (see Types of interventions). For the primary outcomes, we compared findings of well-defined CBT and less-well-defined CBT. RESULTSDescription of studiesResults of the searchElectronic searched identified 2279 references (Figure 1). Two hundred and ninety papers were relevant and all were obtained and scrutinised. Seventy-four of these reports (62 studies) did not meet the inclusion criteria (see Characteristics of excluded studies). One reference was not printed in English and is awaiting translation (Wu Ningqiang 2008) and one reference (NCT00980252) related to an early report of a trial for which we are awaiting outcome data.  Included studiesThirty one references describing 20 RCTs met the inclusion criteria for this review (see Characteristics of included studies). Lewis 2002 involved three different centres (Lewis 2002 - Liverpool; Lewis 2002 - Manchester; Lewis 2002 - Nottingham). 2. ParticipantsPeople in these studies were aged between 18 and 65. Participants were selected from in-patient and out-patient populations, at varying phases of illness (from acute phase to relatively stable but with treatment resistant symptoms), and with a range of typical co-morbidities. However, many trials excluded people with co-morbid substance misuse, evidence of organic brain disorder, learning disability or marked thought disorder and/or conceptual disorganisation. All 20 trials focused on people with psychosis, whether schizophrenia, delusional disorder or schizoaffective disorder, and all employed operational criteria for diagnoses (DSM III-R, DSM IV, DSM-IV TR or ICD-10). Many people were reported to have comorbid mental disorders, such as depression or anxiety disorder. The 20 trials included participants with a representative range of duration of illness. For example, Jackson 2008 reports outcomes from participants with approximately two years length of illness whereas Durham 2003 and Cather 2005 included participants with an average duration of illness in excess of 10 years. All participants received standard care in addition to CBT or other adjunctive therapies. Standard care would typically include antipsychotic medication. For example, Cather 2005 only included participants treated with olanzapine for at least six months, whereas Pinto 1999 intentionally selected people with medication-resistant symptoms. 3. Interventions3.1 Cognitive behavioural therapy armIn addition to cognitive restructuring, hypothesis testing and behavioural experiments, most CBT interventions commonly included other therapeutic activities such as psychoeducation, relapse prevention, coping strategy enhancement, problem-solving strategies or relaxation training. Some CBT interventions were administered on a group basis (Bechdolf 2004; Levine 1998; Penn 2009) whereas others utilised individual therapy (Lewis 2002; Jackson 2008; Valmaggia 2005). Drury 2000 employed a combination of both group and individual therapy. The CBT interventions varied with regard to both the target of the therapy and the degree of specificity of the focus of the intervention. For example, Kemp 1998 and O’Donnell 2003 used a CBT intervention focused specifically on medication compliance, whereas the CBT intervention described by Bechdolf 2004 had a wider focus incorporating auditory hallucinations and delusions, anxiety, depression, relapse prevention and enhancing medication compliance. Most trials targeted positive symptoms of psychosis, some with an explicit focus on auditory hallucinations (Bechdolf 2004; Haddock 2009; Jackson 2008; Penn 2009; Valmaggia 2005) and/or delusions (Garety 2008 a; Haddock 2009; Jackson 2008; Valmaggia 2005). It was less common for the CBT intervention to target negative symptoms of psychosis (Klingberg 2009). Strategies for relapse prevention were a common component in the CBT intervention and a specific focus in some trials (e.g., Garety 2008 a). Emotional distress (Bechdolf 2004; Sensky 2000) and self-esteem (Bechdolf 2004; Penn 2009), either in general or specifically related to the experience of psychosis, was a target in some trials that also targeted other symptoms. Finally, one trial, Haddock 2009, focused specifically on psychotic symptoms and anger relating to aggression and violence. 3.1.1 CBT arm does not include other active therapiesIn 17 trials (85%), the CBT arm was not ‘contaminated’ by other contemporaneous active psychological therapies which would not normally be a standard component of CBT for psychosis. However, Buchkremer 1997 reported a CBT intervention which variously included medication management training or key-person counselling, or both. The differential effects of the CBT and the medication management training or key-person counselling were not evaluated. Drury 2000 reported a CBT intervention that consisted of both individual and group cognitive therapy as well as family engagement (aimed at developing familial coping strategies). In addition, it included a structured activity programme (cooking, creative therapy and discussion groups) for an average of five hours per week. Thus, in Drury 2000 the intervention incorporates CBT within a broader rehabilitation framework. The differential effects of the CBT and the rehabilitation were not evaluated. Finally, Pinto 1999 includes social skills training in the CBT arm of the trial and also includes psychoeducation in the control arm of the trial. Accordingly, the differential effects of these interventions cannot be evaluated. 3.1.2 Well-defined CBTAll studies employed a cognitive behavioural intervention in addition to standard care. In order to be classified as ‘well-defined’ the intervention had to clearly demonstrate the components outlined above (Types of interventions). Only 11 trials (55%) met our criteria for ‘well-defined CBT’ (Bechdolf 2004; Cather 2005; Drury 2000; Garety 2008 a; Haddock 1999; Haddock 2009; Lewis 2002; Pinto 1999; Turkington 2000; Valmaggia 2005) in that they clearly reported a therapeutic focus on belief change or re-evaluating the subjective meaning of symptoms. Durham 2003 and Buchkremer 1997 describe their intervention as CBT and for this reason are included in this review. However, the therapeutic focus appears to be on problem-solving skills and the development of coping strategies rather than the re-evaluation of the subjective symptoms. Klingberg 2009 was unique in having a specific focus on negative symptoms, however, reflecting this focus, the intervention incorporated goal setting, initiation, planning and increasing activity levels. Accordingly, the re-evaluation of the subjective symptoms was not clearly a focus in this intervention. Penn 2009 focused on CBT for auditory hallucinations based on Wykes 2004 treatment protocol. The authors, however, acknowledge that their intervention in the CBT arm emphasised the development of coping skills and de-emphasised cognitive restructuring. 3.1.3 CBT provided by qualified therapistsWe defined qualified CBT therapists as:
According to these criteria 13 trials (65%) met the criteria for qualified CBT therapists, with the remaining studies not providing sufficient information to assess this. There was wide variation in the way in which trials fulfilled this criterion with some having a clearly specified a priori protocol to which adherence was assessed in a structured fashion, whilst others appear to have only a broad CBT-based agenda and to assess compliance by audio-taping samples of sessions (Turkington 2000) or by ensuring regular supervision. 3.2 Comparison therapy armIn all trials the non-CBT arm of the trial was in addition to treatment as usual or standard care. The comparison arm of the trials employed a variety of interventions. Interventions aimed at meaningful symptom or distress reduction were characterised as ‘active’ comparison therapy whereas psychosocial interventions which act as merely a control for the non-specific effects of therapy (for example, time spent with therapist) were characterised as ‘non-active’ comparison therapy. Some interventions such as supportive psychotherapy or counselling varied in the degree to which they were used as an active and structured therapy. In such cases, allocation to the active or non-active conditions was dependent upon whether the authors had made reference to the intervention as a control for the non-specific effects of therapy. Table 2 describes the interventions in each trial in more detail than is possible in Characteristics of included studies. Table 2More detailed description of interventions in the included studies
Nine trials compared CBT with non-active control therapies (Drury 2000; Haddock 2009; Jackson 2008; Kemp 1998; Lewis 2002; O’Donnell 2003; Sensky 2000; Turkington 2000; Valmaggia 2005). Eleven trials described active comparison therapies (Bechdolf 2004; Buchkremer 1997; Cather 2005; Durham 2003; Garety 2008 a; Haddock 1999; Klingberg 2009; Levine 1998; Penn 2009; Pinto 1999; Tarrier 1999 a), the most common being psychoeducation and supportive therapy or counselling. Notably, two trials used particularly well-defined non-CBT interventions. Garety 2008 a reported outcomes compared with family therapy and Klingberg 2009 reported outcomes compared with cognitive remediation therapy. 4. OutcomesAll studies, with the exception of Kemp 1998 and O’Donnell 2003, evaluated the effects of CBT on symptoms of psychosis. Kemp 1998 and O’Donnell 2003, however, reported trials in which CBT was focused on improving compliance with medication. 4.2 Global outcomesRelapse data were reported in six trials (Bechdolf 2004; Drury 2000, Garety 2008 a, Haddock 1999, Lewis 2002, Tarrier 1999 a). However, different studies used varied criteria for relapse. For example, Garety 2008 a defined relapse as “the re-emergence of, or significant deterioration in, positive psychotic symptoms of at least moderate degree persisting for at least 2 weeks” whereas Bechdolf 2004 defined relapse as “a rating of at least 5 and a 2-point increase compared with the previous assessment in at least one of the items of the Positive Syndrome Subscale of the PANSS”. Five trials reported data relating to re-hospitalisation (Bechdolf 2004; Buchkremer 1997; Drury 2000; Jackson 2008; Penn 2009). Two continuous measure of global state were reported. The Global Assessment of Functioning (GAF) scale is used by mental health professionals to rate social, occupational, and psychological functioning. Three trials used this scale (Durham 2003; Haddock 2009; Kemp 1998). The Global Assessment Scale (GAS) (Endicott 1976) rates people from zero to 100 on a continuum from psychological or psychiatric sickness to health (high = good). Outcomes on this scale were reported by Durham 2003. 4.3 Mental state outcomesSeven trials reported important or reliable change in mental health (Bechdolf 2004; Cather 2005; Drury 2000; Durham 2003; Garety 2008 a; Sensky 2000; Tarrier 1999 a). The definitions of important or reliable change varied between the trials. For example, Bechdolf 2004 defined clinically significant change as greater than two standard deviations on PANSS global score and a statistically significant Reliable Change Index, Cather 2005 defined important or reliable change as a clinically significant reduction of positive symptoms which is a 20% reduction in PANSS positive factor score, and Garety 2008 a defined important or reliable change as partial or full remission of symptoms without further episode. Sensky 2000 defined reliable change as greater than 50% improvement and reported outcomes at 18 months from the CPRS (CBT 29/46, Befreinding 17/44), MADRS (CBT 31/46, Befriending 22/44) and the SANS (CBT 23/46, Befriending 23/44) .For the purpose of this review the frequency of reliable change was averaged across these three outcome measures. It was common for trialists to report continuous measure of mental health outcomes. 4.3.1 Mental state scales used in this reviewa. Brief Psychiatric Rating Scale - BPRS (Overall 1962) The Brief Psychiatric Rating Scale is a brief rating scale used to assess the severity of a range of psychiatric symptoms, including psychotic symptoms. The most commonly used version of the scale has 18 items which are rated from one if not present to seven with high scores indicating poorer functioning, Each item can be defined on a seven-point scale varying from ‘not present’ to ‘extremely severe’. There was variation between trials in the manner in which BPRS scores were reported. Haddock 1999, Jackson 2008, Kemp 1998 and Pinto 1999 provided data for the BPRS. Unfortunately, Jackson 2008 reported only the positive symptoms subscale of the BPRS and these data could not be combined with the data reported in the other studies. b.Comprehensive Psychiatric Rating Scale - CPRS (Asberg 1978) The Comprehensive Psychiatric Rating Scale is a general psychiatric rating scale. Sensky 2000 reported outcomes for this measure. c. Psychotic Symptom Rating Scale - PSYRATS (Haddock 1999b) This scale is used to assess dimensions of hallucinations and delusions. PSYRATS consists of two scales designed to rate auditory hallucinations and delusions. The items are rated on a five-point ordinal scale (zero to four). The auditory hallucinations are on an 11-item scale. Items include frequency, duration, severity and intensity of distress, controllability, loudness, location, beliefs about origin of voices. This scale was used by Cather 2005, Durham 2003, Haddock 2009, Lewis 2002, Penn 2009 and Valmaggia 2005. The delusions subscale is a six-item scale which assesses dimensions of delusions. The items include preoccupation, distress, duration, conviction, intensity of distress and disruption. This scale was used by Cather 2005, Durham 2003, Haddock 2009, Lewis 2002, Penn 2009 and Valmaggia 2005. d. Positive and Negative Syndrome Scale (PANSS) (Kay 1987) This scale is designed to assess the positive symptoms (i.e., delusions, conceptual disorganisation, hallucinations, hyperactivity, grandiosity, suspiciousness/persecution and hostility), negative symptoms (i.e., blunted affect, emotional withdrawal, poor rapport, passive/apathetic social withdrawal, difficulty in abstract thinking, lack of spontaneity and flow of conversation, stereotyped thinking) and general psychopathology (i.e., somatic concern, anxiety, depression, guilt, tension, mannerisms and posture, motor retardation, uncooperativeness, unusual thought content, disorientation, attentional problems, lack of judgement and insight, disturbance of volition, poor impulse control, preoccupation and active social avoidance). This scale was used by Bechdolf 2004, Cather 2005, Haddock 2009, Levine 1998, Lewis 2002, Penn 2009, Valmaggia 2005 and Garety 2008 a. e. Beliefs about Voices Questionnaire - Revised (Chadwick 2000) This scale measures beliefs about voices including rating benevolence, malevolence, and omnipotence (i.e., power). It also measures the negative affective response to voices as well as attempts to resist the voice (resistance) and the positive affective response to voices as well as willing engagement or compliance with the voice (engagement). Penn 2009 reported outcomes relating to this scale. f. Scale for the Assessment of Negative Symptoms (SANS) (Andreasen 1984) The Scale for the Assessment of Negative Symptoms is designed to assess the negative symptoms of schizophrenia. This six-point scale gives a global rating of the following negative symptoms: alogia, affective blunting, avolition-apathy, anhedonia-asociality and attention impairment. Higher scores indicate more symptoms. Jackson 2008, Pinto 1999, Sensky 2000 and Tarrier 1999 a provide outcomes on this scale. g. Montgomery-Asberg Depression Rating Scale (MADRS) (Montgomery 1979) This depression rating scale is designed to be sensitive to change. It was developed using a 65-item comprehensive psychopathology scale to identify the 17 most commonly occurring symptoms in primary depressive illness. Ratings on 10 items, with higher score indicating poor outcome. Maximum score is 30. Sensky 2000 reported data from this scale. h. Beck Depression Inventory (BDI) (Beck 1961) This is a 21-item, self-report questionnaire which measures the intensity of depressive symptoms. Garety 2008 a and Penn 2009 used this scale. i. Beck Anxiety Inventory (BDI) (Beck 1988) This is a 21-item, self-report questionnaire which measures the intensity of depressive symptoms. Garety 2008 a and Penn 2009 used this scale. j. Beck Cognitive Insight Scale (Beck 2004) This is a 15-item, self-report measure of self-reflectiveness and over confidence in the interpretation of experiences. Penn 2009 reported outcomes on this scale. k. Rosenberg Self-Esteem Scale (Rosenberg 1965) This is a 10-item, self-rated measure of self-esteem. Penn 2009 reported outcomes on this scale. l. Novaco Anger Scale (Novaco 2003) This is a 48-item, self-report questionnaire measuring cognitive, behaviour and arousal aspects of anger. Haddock 2009 reported outcomes from this scale. m. Novaco Provocation Inventory (Novaco 2003) This is a 25-item, self-report questionnaire measuring triggers or provocations to anger. Haddock 2009 reported outcomes from this scale. n. Ward Anger Rating Scale (Haddock 2009) Part A consists of 18 dichotomous, weekly ratings regarding verbal and physical behaviours associated with anger and aggression. Part B consists of seven items regarding affective-behavioural attributes related to anger. Haddock 2009 reported outcomes from this scale. o. Historical Clinical Risk Management-20 ( Webster 1997 ) This 20-item, clinician-rated scale consists of three subscales (i.e., historical factors; clinical factors; and risk factors in relation to the future) relating to risk of violence. Haddock 2009 reported outcomes from this scale. 4.4 Social functioning outcomeThese important outcomes were not reported in binary form (able to look after self, able to hold employment). Scales were employed by a few trials. 4.4.1 Social functioning scales used in this reviewa. Social Functioning Scale (SFS) (Birchwood 1990) This scale measures social role and behavioural functioning across seven basic areas of community functioning: social engagement, interpersonal behaviour, prosocial activities, recreation, independence, employment. Penn 2009 reported outcomes on this scale. b. Social and Occupational Functioning Assessment Scale (Brambilla 2000). This is a clinician-rated measure of social and occupational functioning on a continuum from excellent to grossly impaired functioning. Jackson 2008 and Garety 2008 a reported outcomes on this measure. 4.5 Quality of life outcomesOnly Garety 2008 a reported on this important outcome. 4.5.1 Quality of life scales used in this reviewa. European Quality of Life Questionnaire (Brazier 1993). This is also known as the EuroQoL or the EQ-5D. This is a self-rated measure of five dimension of health relate quality of life (mobility, self care, usual activities, pain/discomfort, anxiety/depression). Excluded studiesWe excluded 62 studies (74 reports) from this review. 2. Issues relating to participantsTwo studies reported outcome on individuals at-risk of psychosis (McGorry 2002; Morrison 2002) and were therefore excluded as they do not apply directly to people with a diagnosis of schizophrenia. 4. Issues relating to interventionSeveral studies reported CBT interventions as part of a broader treatment package where is was not possible to identify the effect of the CBT elements (Edwards 2003; Evins 2001; Haldun 2002; Hayward 1995; Hertz 2000). In particular, Anzai 2002 reported comparisons of different types of services (community reentry model versus occupational rehabilitation) in which CBT had greater or lesser involvement. Several studies employed therapeutic strategies which did not meet our criteria for CBT (Bach 2002; Bellucci 2002; Bradshaw 1993; Claghorn 1974; Drake 1993; Fritze 1988; Gaudiano 2006; Hogarty 1997; Hogarty 2004; MacPherson 1996; Olbrich 1990; Roder 2002; Tarrier 1993 b; Van Der Gaag 2003; Velligan 2002; Wykes 2002). Notably, Tarrier 1993 b employed coping strategy enhancement which, although a commonly used component of CBT, would not in itself meet our criteria for CBT. The same applied to acceptance and commitment therapy (Bach 2002; Gaudiano 2006), which, like CBT, has a focus on cognitions. It, however, aims to help patients respond differently to their thoughts rather than directly challenge or test out their validity. Patients are encouraged to accept and experience their internal events non-judgmentally. Accordingly, this treatment would not meet our criteria for CBT. Personal therapy (Hogarty 1997), like CBT, aims to prevent relapse and promote personal and social adjustment. However, personal therapy differs from CBT in that it consists of psychoeducation awareness of early signs, supportive therapy techniques, social skills training, the teaching of coping strategies, without an explicit focus on beliefs and cognitive restructuring. Accordingly, this treatment would not meet our criteria for CBT. Several papers (Bellucci 2002; Fritze 1988; Hogarty 2004; Olbrich 1990; Van Der Gaag 2003; Velligan 2002; Wykes 2002) report the use of therapeutic strategies designed to on overcoming intellectual and memory deficits associated with schizophrenia rather than psychotic symptoms, beliefs or cognitive distortions. Risk of bias in included studiesFor graphical representation please see Figure 2 and Figure 3. Risk of bias summary: review authors’ judgements about each risk of bias item for each included study Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies AllocationAll of the 20 included trials reported some form of randomisation. Ten trials reported adequate sequence generation, whist the remaining trial provided insufficient information to rate this particular bias. Allocation was concealed in 11 studies, with the remaining studies not providing enough information to rate this bias. Incomplete outcome dataOverall, data were adequately reported. Some data were lost due to studies failing to report appropriate measures of central tendency and deviation; presenting findings in graphs; presenting outcomes in aggregated statistical form; or by inexact P values. Buchkremer 1997 did not report standard deviations, rendering these data unusable. We were unable to use the PAS used by Drury 2000 as the data were only reported in graphical form. Finally, the measure of compliance reported in Kemp 1998 was not peer reviewed and therefore could not be included. Selective reportingTurkington 2000 reported many continuous outcomes without standard deviations and it was therefore problematic to analyse these particular data. Klingberg 2009 is an ongoing trial that has yet to publish outcomes with respect to negative symptoms which is the main focus of their therapeutic intervention. Buchkremer 1997 failed to report a large number, but not all, of their outcomes by individual group and data were aggregated in a manner which rendered it unsuitable for meta-analysis. Other potential sources of biasHaddock 2009 is one of the few trials to report outcome data with regard to problem behaviours. However, a potential source of bias in these data may result from the inclusion of a mixed sample of in-patients and out-patients, with a greater opportunity to observe and record aggressive behaviour in the in-patient sample. Levine 1998 contained only six participants in each of the two arms of the trial. Such a small trial could not guarantee that randomisation would be adequate to control for idiosyncratic participant characteristics. Effects of interventionsSee: Summary of findings for the main comparison Cognitive behavioural therapy compared with other psychosocial therapies for schizophrenia 1. Comparison 1: CBT versus all other psychological therapies1.1 Adverse effect/event1.1.1 DeathDurham 2003 and Lewis 2002 reported six deaths during the trials, with Lewis 2002 specifically reporting suicides. There were two deaths in the CBT intervention group and four in the other psychological therapies (2 RCTs, n = 202, risk ratio (RR) 0.57 confidence interval (CI) 0.12 to 2.60; Analysis 1.1). Lewis 2002 employed supportive counselling as the non-active control therapy and Durham 2003 employed a more active procedure of supportive counselling. 1.1.2 Adverse EffectsKlingberg 2009 reported the presence or absence of adverse outcomes. There were no significant differences in adverse outcome between CBT and Cognitive Remediation Training in the long-term (n = 198, RR any adverse effect 2.00 CI 0.71 to 5.64; Analysis 1.2). 1.2 Mental state1.2.1 General symptomsFour outcomes were reported as indicators of general mental state; no important or reliable change, the British Psychiatric Rating Scale, the Total Score of the Positive and Negative Symptom Scale (PANSS), and the General Symptom Score of the PANSS. 1.2.1.1 No important or reliable changeNo advantage was observed for CBT in the short-term (2 RCTs, n = 99, RR 0.84 CI 0.40 to 1.75), medium-term (3 RCTs n = 162 RR 0.78 CI 0.61 to 1.00) or long-term (4 RCTs, n = 244, RR 0.91 CI 0.77 to 1.08) (Analysis 1.3). 1.2.1.2 Total score on the Brief Psychiatric Rating Scale (BPRS), the Positive and Negative Symptoms Scale (PANSS) and the Comprehensive Psychiartic Rating Scale (CPRS)Three trials reported endpoint data on the BPRS in the short- and medium-term. No advantage was observed in the short-term (2 RCTs, n = 94, MD 0.07 CI 1.15 −2.83 to 5.14). However, a small advantage, favouring CBT, was observed in the medium-term (1 RCT, n = 37, MD −7.60 CI −14.30 to −0.90; Analysis 1.4). This effect was observed from a single small trial (Pinto 1999) which compared CBT to an active therapy (supportive counselling). Six trials reported endpoint data on the Total Score of the PANSS in the short-, medium- and long-term (Analysis 1.4). A significant advantage favouring CBT was observed in the short-term (4 RCTs, n = 303, MD −11.26 CI −13.83 to −8.69) and medium-term (2 RCTs, n = 110, MD −8.09 CI −10.66 to −5.52). However, these data showed significant heterogeneity for short-term outcomes (Chi2 = 105.73, df = 3 (P < 0.001) I2 = 97%). In addition, this positive result appears to be largely attributable to one small trial (Levine 1998). When this trial is removed homogeneity is restored and the effect is no longer statistically significant (3 RCTs, n = 291, MD −2.27 CI −5.37 to 0.84; Chi2 = 2.63, df = 2 (P = 0.27); I2 = 24%). There was no clear effect was observed for CBT in the longer term (5 RCTs, n = 378, MD −2.58 CI −5.26 to 0.10). One trial (Sensky 2000) reported outcomes on the CPRS. No significant effect was observed in either the medium term (1 RCT, n = 90, MD −4.30 CI −9.26 to 0.66) or the longer term (1 RCT, n = 59, MD −4.60 CI −11.22 to 2.02). 1.2.2 Specific symptomsStudies reported specific symptoms relating positive symptom (e.g., hallucinations and delusions), negative symptoms, psychological distress (e.g., depression, anxiety, self esteem and anger) and problem behaviours.
1.2.2.1 Positive symptoms (outcomes 1.7 through 1.11)Eight trials reported endpoint outcomes on the positive symptom subscale of the PANSS (Analysis 1.5). No significant advantage was observed in the short-term (7 RCTs, n = 477, MD −0.67 CI −1.46 to 0.13) or medium-term (4 RCTs, n = 239, MD −0.99 CI −2.09 to 0.11). However, a small advantage favouring CBT was observed in the long-term (7 RCTs, n = 380, MD −0.90 CI −1.74 to −0.06). Only Penn 2009 evidenced a significant effect and this employed a variant of CBT which was explicitly focused on the management of auditory hallucinations. Five trials reported outcomes of the hallucinations subscale of the PSRS (Analysis 1.6). No effect was observed in the short-term (4 RCTs, n = 258, MD −0.92 CI −3.33 to 1.49), medium-term (2 RCTs, n = 105, MD −0.57 CI −3.95 to 2.80) or the long-term (6 RCTs, n = 267, MD −1.30 CI −4.01 to 1.41). Five trials reported outcomes on the delusions subscale of the PSRS (Analysis 1.7). There was a significant advantage favouring CBT in the short-term (4 RCTS, n = 311, MD −1.62 CI −3.16 to −0.07) which was not maintained at medium-term (2 RCTs, n = 106, MD −0.59 CI −3.03 to 1.86) or long-term (6 RCTs, n = 329, MD −0.89 CI −2.34 to 0.55). Only Haddock 2009 evidenced a significant effect in the short-term and it should be noted that this study’s intervention was targeted at anger and aggression rather than delusional beliefs. When Haddock 2009 was removed from these data the effect in the short-term was no longer statistically significant (3 RCTs, n = 233, MD −0.09 CI −1.73 to 1.91). 1.2.2.2 Negative symptoms (outcomes 1.12 through 1.13)Eight trials reported outcomes on the Negative Symptom subscale of the PANSS. No significant advantage was observed in the short-term (6 RCTs, n = 328, MD −0.25 CI −1.09 to 0.59), medium-term (4 RCTs, n = 239, MD −0.27 CI −1.28 to 0.74) or long-term (7 RCTs, n = 380, MD −0.43 CI −1.38 to 0.51; Analysis 1.10). Four trials (Jackson 2008; Pinto 1999; Sensky 2000; Tarrier 1999 a) reported outcomes on the Scale for the Assessment of Negative Symptoms (SANS). No significant advantage was observed in the short-term (3 RCTs, n = 195, MD −0.92 CI −3.42 to 1.59), medium-term (3 RCTs, n = 171, MD −0.68 CI −3.13 to 1.76) or long-term (3 RCTs, n = 161, MD 0.95 CI −1.56 to 3.46; Analysis 1.11). 1.2.2.3 Psychological distress (outcomes 1.14 through 1.20)Seven trials reported outcomes on the General Symptom Score of the PANSS. They observed no clear effect in the short-term (4 RCTs, n = 288, MD −0.06 CI −1.61 to 1.50), medium-term (5 RCTs, n = 280, MD −1.01 −2.66 to 0.63) or long-term (8 RCTs, n = 549, MD −1.03 −2.36 to 0.29; Analysis 1.12). Two trials reported outcomes on the Beck Depression Scale (BDI) when CBT was compared with family therapy (Garety 2008 a) and enhanced supportive therapy (Penn 2009). No significant advantage was observed in the short-term (1 RCT, n = 65, MD −1.20 CI −5.56 to 3.16) and medium-term (2 RCTs, n = 108, MD −3.09 CI −7.18 to 0.99) although all studies report outcomes favouring the CBT condition. However, in the long-term there was a statistically significant effect (2 RCTs, n = 105, MD −6.21 CI −10.81 to −1.61) with Garety 2008 a and Penn 2009 both reporting significant advantages for CBT (Chi2 = 0.01, df = 1 (P = 0.91); I2 = 0%; Analysis 1.13). Similarly, when depressive symptomatology was measured using the Montgomery-Asberg Depression Rating Scale (MADRS), and was compared against a non-active control therapy (Sensky 2000), there was no significant advantage in the medium-term (1 RCT, n = 90, MD −-2.50 CI −4.19 to −0.81). However, a no significant effect was observed in the long-term (1 RCT, n = 90, MD −1.50 CI −3.78 to 0.78; Analysis 1.18). No significant advantage was observed for a series of other scores - Rosenberg Self Esteem Scale (RSES) (Analysis 1.15), the Beck Anxiety Inventory (BAI) (Analysis 1.16), the Beck Cognitive Insight Scale (Analysis 1.17) or the Novaco Anger Scale (Analysis 1.14). 1.2.2.4 Problem behavioursNo significant advantage was observed in a series of rating scale scores: the Novaco Provocation Inventory in the short-term (1 RCT, n = 77, MD 4.12 CI −3.93 to 12.17) or long-term (1 RCT, n = 77, MD 3.33 CI −3.70 to 10.36; Analysis 1.19); Ward Anger Rating Scale (WARS) in the short-term (1 RCT, n = 77, MD −2.33 CI −4.84 to 0.18) or long-term (1 RCT, n = 77, MD −2.10 CI −5.01 to 0.81; Analysis 1.20); Historical Clinical Risk Management-20 scale (HCR-20) Risk Management subscale (1 RCT, n = 77, MD −0.23 CI −1.77 to 1.31; Analysis 1.21) or the Clinical subscale (1 RCT, n = 77, MD −0.46 CI −1.62 to 0.70; Analysis 1.22). 1.3 Global stateFour outcomes were reported as indicators of global state; relapse, re-hospitalisation, the Global Assessment of Functioning (GAF) Scale, and the Global Assessment Scale (GAS). 1.3.1 Relapse and rehospitalisationSix trials reported data relating to relapse in the short-term (Bechdolf 2004), medium-term (Tarrier 1999 a) and the long-term (Drury 2000; Garety 2008 a; Haddock 1999; Lewis 2002; Tarrier 1999 a). No significant reduction in relapse was reported in either the short-term (1 RCT, n = 71, RR 0.65 CI 0.21 to 1.95), medium-term (1 RCT, n = 59, RR 0.63 CI 0.19 to 2.11) or the long-term (5 RCTs, n = 350, RR 0.91 CI 0.63 to 1.32; Analysis 1.23). Only one of the six trials reported a significant reduction in relapse favouring CBT. This study, Lewis 2002, employed a non-active control therapy and was targeted at “positive symptoms of delusions and hallucinations, identifying precipitating and alleviating factors and reducing associated distress” (Lewis 2002, p92). This study, contributing 28% of weight to the final result also was responsible for the high heterogeneity (Tau2 = 0.10; Chi2 = 10.71, df = 4 (P = 0.03); I2 = 63%). Five trials reported data relating to re-hospitalisation in the shortterm (Bechdolf 2004; Penn 2009), medium-term (Buchkremer 1997; Penn 2009) and long-term (Bechdolf 2004; Buchkremer 1997; Drury 2000; Jackson 2008; Penn 2009). No significant reduction in re-hospitalisation was reported in either the shortterm (2 RCTs, n = 136, RR 0.36 CI 0.11 to 1.13), mediumterm (2 RCTs, n = 132, RR 0.59 CI 0.27 to 1.30) or the long-term (5 RCTs, n = 294, RR 0.86 CI 0.62 to 1.21; Analysis 1.24). None of the individual trials evidenced a significant reduction in re-hospitalisation (Chi2 = 2.36, df = 4 (P = 0.67); I2 = 0%). 1.3.2 Global Assessment of Function (GAF) and Global Assessment Scale (GAS)One trial (Durham 2003), employing an active control therapy of supportive counselling, reported outcomes on the GAS. No significant differences in treatments were observed in the mediumterm (1 RCT, n = 38, MD −0.60 CI −4.93 to 3.73) or the long-term (3 RCT, n = 155, mean difference (MD) 4.20 CI −0.63 to 9.03; Analysis 1.24). Durham 2003, Haddock 2009 and Kemp 1998 reported outcomes on the GAFscale. A consistent positive effect favouring CBT was observed in the short-term (2 RCTs, n = 147, MD 9.02 CI 4.29 to 13.75; Chi2 = 0.04, df = 1 (P = 0.84); I2 = 0%). The trials contributing to this effect employed both active (Haddock 2009) and non-active (Kemp 1998) control therapies. However, this effect was not statistically significant in the long-term (3 RCTs, n = 155, MD 4.20 CI −0.63 to 9.03; Analysis 1.24). 1.3.3 Social Functioning Scale (SFS) and Social and Occupational Functioning Assessment Scale (SOFAS)No significant advantage was observed on the SFS when CBT was compared with enhanced supportive therapy (Penn 2009) in the short-term (n = 65, MD 5.40 CI −5.18 to 15.98), medium-term (n = 65, MD 7.20 CI −3.46 to 17.86) or the long-term (n = 65, MD 8.80 CI −4.07 to 21.67; Analysis 1.25). Garety 2008 a and Jackson 2008 reported outcomes on the SOFAS. An advantage favouring CBT was observed in the short-term (1 RCT, n = 62, MD 9.09 CI 2.79 to 15.39) when compared with a non-active control therapy (befriending). This advantage was not observed in the medium-term (1 RCT, n = 45, MD 5.33 CI −2.57 to 13.23) and the long-term (2 RCTs, n = 103, MD 1.32 CI −4.90 to 7.54; Analysis 1.26). 1.4 Quality of life1.4.1 EuroQolOnly Garety 2008 a reported outcomes with regard to changes in quality of life. There was no significant differences in EuroQOL scores between CBT and family therapy in the long-term (n = 37, MD −1.86 CI −19.20 to 15.48; Analysis 1.27). 1.5 Satisfaction with treatment1.5.1 Attitude to medicationOne study rated attitude to medication and, using two measures, found significantly in favour of the CBT groups (Analysis 1.28). 1.5.2 Leaving the study earlyTen trials reported data on participants leaving the trial early (Analysis 1.29). There was no significant advantage when CBT was compared with either non-active control therapies (4 RCTs, n = 433, RR 0.88 CI 0.63 to 1.23; Analysis 2.22) or active therapies (6 RCTs, n = 339, RR 0.75 CI 0.40 to 1.43; Analysis 3.23). 2. Missing outcomesWe found no usable data on direct or indirect costs. 3. Sensitivity analyses3.1 Adverse eventOnly two studies reported outcomes relating to death (Durham 2003; Lewis 2002). Accordingly, no sensitivity analysis could be performed 3.2 Mental state: No important or reliable changeNo advantage was observed for CBT in the short-term, mediumterm or long-term across seven trial (Bechdolf 2004; Cather 2005; Durham 2003; Drury 2000; Garety 2008 a; Sensky 2000; Tarrier 1999 a). When trials showing inadequate or suspect blinding (Drury 2000; Sensky 2000) were removed then was no advantage for CBT in the medium-term (Z = 1.57, P = 0.12) or long-term (Z = 0.67, P = 0.50). When trials showing inadequate or suspect randomisation (Drury 2000; Sensky 2000) were removed then no advantage for CBT was observed in the medium-term (Z = 1.57, P = 0.12) or long-term (Z = 0.67, P = 0.50). When only well-defined CBT trials were considered there was a significant advantage for CBT in the medium term (2 RCTs, n = 121, MD 0.70 CI 0.53 to 0.93). However, this advantage was not evident in the three well-defined CBT trials contributing long-term outcomes (3 RCTs, n = 154, MD 0.94 CI 0.79 to 1.13). 3.3 Global state3.3.1 RelapseOf the six trials reported data relating to relapse in the short-term (Bechdolf 2004), medium-term (Tarrier 1999 a) and the long-term (Drury 2000; Garety 2008 a; Haddock 1999; Lewis 2002; Tarrier 1999 a). When trials showing inadequate or suspect blinding (Drury 2000) were removed from the long-term data then no advantage for CBT was observed (Test for overall effect: Z = 0.53, P = 0.60). Similarly, when trials showing inadequate or suspect randomisation (Drury 2000; Haddock 1999) were removed from the long-term data then no advantage for CBT was observed (Test for overall effect: Z = 0.10, P = 0.92). When only well-defined CBT trials (Drury 2000; Garety 2008 a; Haddock 1999; Lewis 2002) were considered there was no advantage for CBT in the long-term (4 RCTs, n = 350, MD 0.91 CI 0.63 to 1.32). 3.3.2 HospitalisationFive trials reported data relating to re-hospitalisation in the short-term (Bechdolf 2004; Penn 2009), medium-term (Buchkremer 1997; Penn 2009) and long-term (Bechdolf 2004; Buchkremer 1997; Drury 2000; Jackson 2008; Penn 2009). When trials showing inadequate or suspect blinding (Drury 2000) were removed from the long-term data then no advantage for CBT was observed (Test for overall effect: Z = 0.53, P = 0.60). Similarly, when trials showing inadequate or suspect randomisation (Penn 2009, Drury 2000,) were removed from the long-term data then no advantage for CBT was observed (Test for overall effect: Z = 0.62, P = 0.54). When only well-defined CBT trials (Buchkremer 1997, Drury 2000) were considered there was no advantage for CBT in the long-term (2 RCTs, n = 129, MD 0.86 CI 0.51 to 1.44). DISCUSSIONSummary of main results1. Comparison 1. CBT versus all other psychological therapies1.1 Adverse effect/eventOverall numbers were very small (3%), but CBT did not show an advantage with respect to avoidance of death by natural causes or suicide. For ‘general adverse effects’ no advantage was found for cognitive therapy. One trial (Klingberg 2009), reported no difference in adverse outcomes between CBT and Cognitive Remediation Training in the long-term. Many of these studies do not report adverse effects of this theoretically potent talking therapy. If such treatment is potentially to be recommended for wide adoption routine recording and reporting of adverse effects should be expected within evaluative studies. 1.2 Mental stateWe found no consistent advantage for CBT over other therapies with respect to clinically reliable or important changes in general psychiatric symptoms. Of the seven trials, only Drury 2000 and Sensky 2000 showed a positive effect for CBT and this was in comparison to non-active therapies designed to control for non-specific aspects of therapy. With respect to global psychiatric symptoms based on the BPRS, no effect was found in the short- or long-term but a small advantage for CBT was found in the medium-term. This was observed in only a single small trial (Pinto 1999) which compared CBT to an active therapy (supportive counselling). Global psychiatric symptoms as measured by the Total Score of the PANSS showed a significant advantage for CBT in the short- and medium-term, but not over longer periods. There was significant variation in the trial results in the short-term and the positive result was entirely attributable to Levine 1998 which targeted medication compliance. We found no effect in the short-, medium- or long-term on the general symptom scale of the PANSS. Much of the CBT-based interventions for psychosis focus on specific symptoms. With respect to positive symptoms on the PANSS, no significant advantage was found for CBT in the short- or medium-term. There was a small effect in the long-term in favour of CBT, but this seems to be accounted for by a single trial (Penn 2009) which employed a variant of CBT explicitly focused on the management of auditory hallucinations. When a more specific measure of dimensions of voice hearing (the PSRS or Beliefs About Voices Questionnaire) was used, no advantage was found for CBT at any duration of treatment outcome. With respect to delusions as measured by the Delusions subscale of the PSRS across five trials, a significant advantage was found for CBT in the short-term which was not maintained at longer durations, and the effect in the short-term is attributable to the impact of one trial that was not targeted at treatment of delusions (Haddock 2009). No effect was found for the differential impact of CBT on negative symptoms at any treatment duration. A significant advantage was found for CBT in comparison to both Family Therapy (Garety 2008 a) and Enhanced Supportive Therapy (Penn 2009) in terms of reducing depressive symptoms as measured by the BDI but only in longer term outcomes. At shorter durations there was a consistent but non-significant trend in favour of CBT. This pattern of longer-term benefits was demonstrated on a second measure of depression in a further trial (Sensky 2000). This finding supports the Birchwood 2006 assertion that CBT targets the emotional/behavioural distress rather than psychotic symptomatology. No advantage for CBT was found at any duration of outcome for anxiety, self-esteem, insight, anger or problem behaviours in the form of violence. 1.3 Global stateThere was no consistent advantage for CBT over other therapies with respect to rate of relapse or rehospitalisation. No differential effect of CBT was observed on global functioning as measured by the Global Assessment Scale. In contrast, there was a consistent positive effect on global functioning (as measured by the DSM-IV GAF measure) which favoured CBT; this effect, however, was only observed in the short-term and was not present over longer periods and may be a chance finding. However, notably, the studies contributing to this short-term effect involved a focus on anger and psychotic symptoms relating to problem behaviour (Haddock 2009) and medication compliance (Kemp 1998). The findings with respect to social functioning were equivocal and dependent on the measure used. No significant advantage was observed on the SFS when CBT was compared with Enhance supportive therapy (Penn 2009) at any duration of outcome. In contrast, using the SOFAS, Garety 2008 a and Jackson 2008 reported an advantage favouring CBT in the short-term when compared with a non-active control therapy (befriending) but this was not maintained at subsequent follow-up. This important outcome is not often measured but there is no indication that the addition of CBT to standard care has any convincing generalised effect. 1.4 Quality of lifeIt is surprising that only one trial of less than 40 participants (Garety 2008 a) reported a measure of quality of life. No differential effect of CBT was found at any duration of outcome. 1.5 Satisfaction with careCognitive behavioural therapy did not seem to keep people in care any more than other therapies. About 20% of both groups left the studies. However, this rate of attrition this is better than is seen in many drug trials. Overall completeness and applicability of evidence1. CompletenessThis review contains data on the primary outcomes (adverse event, mental state - no clinically important response, relapse, hospitalisation). Even the most replete of the outcomes contains less than 300 participants,. Trials are small, often undertaken by pioneers of CBT, and numbers of events in any one group are few. There is a poverty of measurement of some outcomes and none on others. For example, there are few studies that attempt to report on adverse effects, and none that measures engagement with services, 2. Applicability2.1 ParticipantsThe included studies involved people with serious mental illnesses (as derived from recognised diagnostic criteria) from a wide range of settings, including both in-patients and out-patients. The results of this review could be said to be valid for people with a diagnosis of a psychotic disorder whose illness has taken a chronic course whether treated on an in-patient or out-patient basis. The exclusion criteria were such that this review is of less relevance to persons with other psychotic disorders such as bipolar disorder, substance-induced psychosis, significant physical or sensory difficulties or people with acquired brain injury or coexisting developmental learning disabilities. 2.2 InterventionsEleven trials meet our criteria for ‘well-defined CBT’. The period of active therapy varied between studies. Bechdolf 2004 provided up to eight weeks of individual CBT, whilst Drury 2000 gave both individual and group cognitive therapy over the course of recovery (which did not exceed nine months) as well as family engagement, aimed at developing familial coping strategies and a structured activity programme (for an average of five hours per week) including cooking, creative therapy and discussion groups. On the other hand, Kemp 1998, reported that their intervention consisted of four to six sessions of therapy aimed at increasing medication compliance. The CBT interventions varied with regard to both the target of the therapy and the degree of specificity of the focus of the intervention. For example, Kemp 1998 and O’Donnell 2003 used a CBT intervention focused specifically on medication compliance, whereas the CBT intervention described by Bechdolf 2004 had a wider focus incorporating auditory hallucinations and delusions, anxiety, depression, relapse prevention and enhancing medication compliance. Most trials targeted positive symptoms of psychosis, some with an explicit focus on auditory hallucinations (Bechdolf 2004; Haddock 2009; Jackson 2008; Penn 2009; Valmaggia 2005) and/or delusions (Garety 2008 a; Haddock 2009; Jackson 2008; Valmaggia 2005). It was less common for the CBT intervention to target negative symptoms of psychosis (Klingberg 2009). Strategies for relapse prevention were a common component in the CBT intervention and a specific focus in some trials (e.g., Garety 2008 a). Emotional distress (Bechdolf 2004; Sensky 2000) and self-esteem (Bechdolf 2004; Penn 2009), either in general or specifically related to the experience of psychosis, was a target in some trials that also targeted other symptoms. Finally, Haddock 2009 focused specifically on psychotic symptoms and anger relating to aggression and violence. The present review differed from previous reviews in that we adopted a tiered definition of CBT. Cognitive behavioural therapy in clinical practice typically includes a number of components: cognitive restructuring, hypothesis testing, behavioural experiments, psychoeducation, relapse prevention, coping strategy enhancement, problem-solving strategies, with or without, relaxation training. In this respect, many of the current trials reflect common clinical practice. However, this multi-component approach is not necessarily helpful in identifying the active components of CBT as control arms to the trials are often not balanced in terms of component therapies. Trials generally include a range of interventions in the same treatment arm and in many the intervention is described as “CBT” without a clear and explicit indication that the active element of therapy involves explicit manipulation of belief. In addition, cognitive therapy for psychosis, as reflected in current trials, has become increasingly distanced from its basis in CBT for non-psychotic mood disorders where the focus is on the emotional and behavioural consequences of dysfunctional thinking patterns and the intervention is clearly designed to address cognitions and beliefs. This point has been identified by Birchwood 2006 who has noted that CBT for psychosis has often been treated as if it were a ‘quasi-neuroleptic’ where the focus of outcome measurement has been on global symptoms with the expectation that CBT should reduce psychotic symptoms directly as opposed to eliciting emotional and behavioural changes. More recent trials of CBT in relation to treatment as usual are more clearly based on theoretical models of psychotic symptoms (e.g. Trower 2004). Such trials have a clear focus on the specificity of the beliefs addressed (e.g. power beliefs about voices) and outcome measures which are sensitive to belief change as the mediator of emotional and behavioural change. Overall, interventions did vary considerably but findings were consistent. When well-implemented CBT is given, for long or short periods, with various foci of treatment, there is no convincing difference between CBT and other psychosocial interventions in relation to psychotic symptomatology and broad measures of functioning (Summary of findings for the main comparison). However, there are some promising preliminary findings with respect to the effect of CBT on symptoms of depression. At present, it remains unclear but it is interesting to speculate as to the relative benefits for CBT for psychosis compared with CBT which is specifically focused upon depression in this group of patients. Quality of the evidenceThis is an attempt to quantitatively summarise the effects of cognitive behavioural therapy for schizophrenia. This has not been an easy task and the review authors will be pleased to hear from readers in order to improve this work for future issues of The Cochrane Library. The methodological quality of the included studies is summarised in Figure 2. There still are too few trials. Studies are too small. Outcomes are often reported in such a way that leaves presentation in a systematic review, difficult or impossible. In addition, scales are often used to measure outcomes that are not directly relevant to psychological therapy. There has, however, been a general improvement in methodological rigor of the more recent trials. Several trials had relatively large sample sizes (Buchkremer 1997; Garety 2008 a; Klingberg 2009; Lewis 2002 all exceeded 100 people). All 20 included studies report some form of randomisation, with 10 describing adequate sequence generation. Allocation was concealed in 11 studies and 16 of the 20 trials (80%) employed raters blinded to the treatment condition. One of the key issues which is a limiting factor in interpreting current trial data is the wide variation in the targets of treatment and there is little agreement on how these targets and key outcomes should be operationalised. Studies frequently measure different outcomes or measure the same outcome using different measures. The differences in the psychometric properties of these measures make it difficult to interpret the variability of the outcomes reported in the trials. It would be invaluable to future trialists to receive direction regarding a common consensus on the most reliable, valid and clinically relevant outcome measures for CBT for psychosis. In the view of the authors this is likely to require the design and validation of new outcome measures both for specific aspects of positive symptoms (e.g. beliefs, preoccupation and conviction) as well as key emotional and behavioural outcomes including anxiety, depression and more specific symptom-related distress. For example, current state-of-the-art measures of these dimensions are not fully adequate to assess the efficacy of CBT. The PSYRATS, for example, includes only a single four-point measure of delusional or voice-related distress and the Beliefs About Voices Questionnaire includes measures of emotional response to voices which are not clearly delineated from other variables, such as the person’s behaviour in relation to the voice. In addition, the ultimate aim of clinical intervention is to improve functioning and trials should include primary outcomes relating to this including, return to work, social functioning and quality of life. It would seem important to also report on some economic outcomes. Finally, a welcome addition to some of the newer trials is the introduction of protocols to assess adherence to CBT methods, though there remains a lack of consensus across trials as to how this is implemented. In addition, a recent government focus in the UK on making psychological therapies more widely available is likely to mean that a broader range of expertise is employed in the delivery of CBT for psychosis. At present the experience of therapists in trials is not always clearly described and this renders it difficult to undertake a sensitivity analysis of the effect of therapist expertise. Potential biases in the review processOne of the review authors (AM) is actively engaged in the evaluation of the efficacy of CBT for psychosis. Agreements and disagreements with other studies or reviewsThere are few reviews of CBT compared with other psychological therapies. However, in a meta-analysis of eight trials with 528 patients, Pilling 2002 reported that CBT did not show an advantage over other active therapies (i.e., supportive counselling, and a problem solving group) although positive effects of CBT were reported relative to standard care. AUTHORS’ CONCLUSIONSImplications for practice1. For people with schizophreniaThe use of CBT has been associated with some reduction in symptoms, especially the positive symptoms of schizophrenia. However, there is considerable variability in the findings of the various studies and, at present, it is not possible to assert any substantial benefit for cognitive behavioural therapy over other psychological therapies. 2. For cliniciansPresently, CBT is a scarce commodity, often provided by highly skilled and experienced therapists. These data are not convincing of clear benefit over other - and sometimes less sophisticated - therapies for people with schizophrenia. There is some indication that CBT may help the affective problems associated with having such a serious illness as schizophrenia. 3. For policy makersCognitive behavioural therapy held promise of providing a useful adjunct to traditional treatment of people with psychotic disturbance. The Included randomised controlled trials of CBT and their small sample sizes demand caution until such time as data from larger, more methodologically coherent randomised controlled trials are available to supplement these initial findings. A cost/benefit analysis would enable clinicians and purchasers to manage service provision and make best use of resources. 4. For funders of researchMore, large, generally applicable, clinically meaningful trials are needed. More comparisons of CBT with supportive approaches would seem of particular interest. Further research should address the issue of the use of CBT in specific settings and contexts (e.g., tertiary psychiatric services, long-stay institutions, day hospitals). The present data provides little indication of how effective CBT procedures might be when they are applied by less experienced practitioners. It would be useful to know whether the effects of CBT are sustained after the therapy course has finished, whether booster sessions are beneficial, or whether continued (long-term) therapy is required to sustain the treatment effect. Implications for research1.General1.1 Presentation of dataIf all of the trials within this review had conformed to the suggestions within the CONSORT statement on trials reporting (Begg 1996; Moher 2001) much more may be known on the effect of CBT for people with schizophrenia. Cognitive behavioural therapy trials are difficult to undertake so data should not be wasted. Unfortunately, trialists often did not present clear measures of association between intervention and outcome, for example, risk ratios, odds ratios, risk or means difference, as well as the raw data. Wherever possible, binary outcomes should be reported in preference to continuous scale derived data as they are easier to interpret and clinically relevant. If P values are used, the exact value should be reported. 1.2 RandomisationAllocation concealment is a fundamental part of trial methodology. If readers are to be reassured that selection bias was minimised then the randomisation process should be clearly described. 1.3 BlindingDouble-blind evaluation of the outcomes of a psychosocial intervention is extremely difficult, and probably impossible. Trialists should, however, take every precaution to minimise the effect of biases by using blinded or independent raters (quoting inter-rater reliability and measuring their blindness) and, probably more importantly, using ‘harder’ outcomes such as relapse, self-harm, and relapse or admission rather than scale data. 1.4 WithdrawalsIntention-to-treat analysis is preferable. If possible, trialists should describe from which groups withdrawals came, why they occurred and what was their outcome. 2. Specific to cognitive behavioural therapy trials2.1 The issue of practitionersCognitive behavioural therapy holds the promise of providing a valuable adjunct to traditional treatments for people with psychotic disturbances. Despite the fact that it may be an effective therapy, it is currently inaccessible to most of those with schizophrenia even within well-resourced care services. This situation will remain until either i. the basic skills of cognitive behavioural therapy can be generalised to other healthcare professionals; or ii. there can be increased availability of specialists specifically practising CBT for those with schizophrenia. 2.2 PowerEstimates of statistical power based on data obtained from this review indicates that using data from within this review for the outcome of ‘no important improvement’, estimates of statistical power indicate that about 70 people per group are required to show a statistically significant difference in the outcome over a period of at least six months (alpha 0.05, beta 0.8). This computation assumes that the difference in proportions is −0.29 (specifically, 0.58 versus 0.87). Given an attrition rate of approximately 30%, researchers should aim for a minimal sample size of 100 persons per intervention. 2.3 Outcomes measuredOutcomes should be clear and clinically useful but if authors are to persist in using continuous scale-derived data these tools should be standardised, and peer reviewed (Marshall 2000). Concrete outcomes of disturbance such as ‘disturbed episode’, ‘use of detention order’, ‘use of special nursing observation’ or, for those in the community, ‘avoiding hospitalisation’ would be of interest. Data on quality of life, social functioning, occupational status, general impression of carer/other, unwanted effects, such as anxiety, depression and dependence on the relationship with the therapist, staff fatigue and economic outcomes would be very welcome. PLAIN LANGUAGE SUMMARYCognitive behaviour therapy versus other psychosocial treatments for schizophreniaCognitive behavioural therapy (CBT) is a talking therapy first mentioned in 1952 but only became recommended as a routine treatment in 2002. CBT encourages people to openly discuss their beliefs, emotions and experiences with a therapist (individually or in a group), as well as participate in assessing their symptoms, emotional distress and behaviour. Such discussion is thought to help develop ways of challenging, coping and managing unhelpful thoughts and problem behaviour. People with schizophrenia may have difficulties with concentration, attention and motivation. The capacity to think, feel pleasure, talk openly and act also may be reduced. All of which can mean making friends, living independently and finding employment are sometimes hard. The idea of CBT is to help with these problems by coming up with ‘real world’ coping strategies and problem solving skills. Relatively little is known about the effects of CBT when compared with other psychological or talking therapies (such as supportive therapy, psycho-education, group, relaxation and family therapy) in helping people with schizophrenia. This review found that research in this area was often small scale and of limited quality. The majority of therapists (65%) met the review’s standard of being qualified (but this was not a complete finding as most studies did not take into account appropriate training and the qualification of therapists). In the main, no difference in overall effectiveness was found between CBT and other talking therapies. Relapses (people with schizophrenia becoming unwell again) and re-hospitalisation (the need to go back into hospital) were not reduced. CBT was not any better at improving mental state compared to other talking therapies and CBT was no better or worse in managing the symptoms of schizophrenia, both in terms of managing positive symptoms (such as hearing voices or seeing things) and negative symptoms (not feeling emotions, inactivity which leads to weight gain). No difference was found for leaving the study early or continuing treatment for CBT compared with other therapies, although the overall number of people who left the study early was relatively low compared to drug trials meaning that CBT and other talking therapies may better at retaining and keeping people with schizophrenia in treatment. No advantage for CBT was recorded with regard to death by natural causes or suicide, coping with anxiety, building self-esteem, developing insight or helping with anger or problem behaviours such as violence. Few studies reported the effect CBT had on quality of life and in developing better social or work skills. The review, however, suggests that there might be some longer term advantage in CBT for dealing with emotions and distressing feelings. Some initial findings indicated that CBT may be of greater benefit to people with depression and managing its symptoms. This Plain Language Summary was written by a consumer Benjamin Gray, Service User and Service User Expert, Rethink Mental Illness. ACKNOWLEDGEMENTSClive Adams, for invaluable editorial support and encouragement. SOURCES OF SUPPORT Internal sources
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CHARACTERISTICS OF STUDIESCharacteristics of included studies [ordered by study ID]Bechdolf 2004
Buchkremer 1997
Cather 2005
Drury 2000
Durham 2003
Garety 2008 a
Haddock 1999
Haddock 2009
Jackson 2008
Kemp 1998
Klingberg 2009
Levine 1998
Lewis 2002
Lewis 2002 - Liverpool
Lewis 2002 - Manchester
Lewis 2002 - Nottingham
O’Donnell 2003
Penn 2009
Pinto 1999
Sensky 2000
Tarrier 1999 a
Turkington 2000
Valmaggia 2005
BAI: Beck Anxiety Inventory; BDI: Beck Depression Inventory; BPRS: Brief Psychiatric Rating Scale; CBT: Cognitive behavioural therapy; GAF: Global Assessment of Functioning; GAS: Global Assessment Scale; KC: Key-person counselling; MADRS:Montgomery-Asberg Depression Rating Scale; PANSS: Positive and Negative Syndrome Scale; PAS: Psychiatric Assessment Scale; PMT:Psychoeducational medication training; PSRS: Psychotic Symptom Rating Scale; RSES: Rosenberg Self-Esteem Scale; SANS: Scale for the Assessment of Negative Symptoms; SFS: Social Functioning Scale; SOFAS: Social and occupational functioning; WARS: Ward Anger Rating Scale. Characteristics of excluded studies [ordered by study ID]
BPRS: Brief Psychiatric Rating Scale; CBT: Cognitive behavioural therapy; PAS: Premorbid Adjustment Scale; PRP: program for relapse prevention; SANS: Scale for the Assessment of Negative Symptoms; TAU: treatment as usual. Characteristics of studies awaiting assessment [ordered by study ID]NCT00980252
Wu Ningqiang 2008
CBT: Cognitive behavioural therapy DATA AND ANALYSESComparison 1CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES
Comparison 2SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES
Comparison 3SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES
Analysis 1.1Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 1 Adverse effect/event: 1. Death Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 1 Adverse effect/event: 1. Death Analysis 1.2Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 2 Adverse effect/event: 2. Adverse effects - any - medium-term only Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 2 Adverse effect/event: 2. Adverse effects - any - medium-term only Analysis 1.3Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 3 Mental state: 1. General - no important or reliable change Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 3 Mental state: 1. General - no important or reliable change Analysis 1.4Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 4 Mental state: 2. Average scale score - total Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 4 Mental state: 2. Average scale score - total Analysis 1.5Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 5 Mental state: 3a. Specific - average score - positive symptoms - overall (PANSS, endpoint data, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 5 Mental state: 3a. Specific - average score - positive symptoms - overall (PANSS, endpoint data, high = poor) Analysis 1.6Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 6 Mental state: 3b. Specific - average score - positive symptoms - hallucinations (Psychotic Symptom Rating Scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 6 Mental state: 3b. Specific - average score - positive symptoms - hallucinations (Psychotic Symptom Rating Scale, high = poor) Analysis 1.7Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 7 Mental state: 3c. Specific - average score - positive symptoms - delusions (Psychotic Symptom Rating Scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 7 Mental state: 3c. Specific - average score - positive symptoms - delusions (Psychotic Symptom Rating Scale, high = poor) Analysis 1.8Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 8 Mental state: 3d. Specific - average score - positive symptoms - delusions cognitive characteristics (psychotic symptom rating scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 8 Mental state: 3d. Specific - average score - positive symptoms - delusions cognitive characteristics (psychotic symptom rating scale, high = poor) Analysis 1.9Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 9 Mental state: 3e. Specific - average score - positive symptoms - delusions emotional characteristics (psychotic symptom rating scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 9 Mental state: 3e. Specific - average score - positive symptoms - delusions emotional characteristics (psychotic symptom rating scale, high = poor) Analysis 1.10Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 10 Mental state: 4a. Specific - average score - negative symptoms - overall (PANSS, endpoint data, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 10 Mental state: 4a. Specific - average score - negative symptoms - overall (PANSS, endpoint data, high = poor) Analysis 1.11Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 11 Mental state: 4b. Specific - average score - negative symptoms - overall (SANS, high = good) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 11 Mental state: 4b. Specific - average score - negative symptoms - overall (SANS, high = good) Analysis 1.12Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 12 Mental state: 5a. Specific - average score - affective symptoms (PANSS General symptoms, endpoint data, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 12 Mental state: 5a. Specific - average score - affective symptoms (PANSS General symptoms, endpoint data, high = poor) Analysis 1.13Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 13 Mental state: 5b. Specific - average score - affective symptoms - depression (Beck Depression Inventory, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 13 Mental state: 5b. Specific - average score - affective symptoms - depression (Beck Depression Inventory, high = poor) Analysis 1.14Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 14 Mental state: 5g. Specific - average score - affective symptoms - Anger/aggression (Novaco Anger Scale (high = poor)) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 14 Mental state: 5g. Specific - average score - affective symptoms - Anger/aggression (Novaco Anger Scale (high = poor)) Analysis 1.15Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 15 Mental state: 5d. Specific - average score - affective symptoms - self esteem (Rosenberg Self Esteem Scale (high = good)) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 15 Mental state: 5d. Specific - average score - affective symptoms - self esteem (Rosenberg Self Esteem Scale (high = good)) Analysis 1.16Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 16 Mental state: 5e. Specific - average score - affective symptoms - anxiety (Beck anxiety Inventory (high = poor)) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 16 Mental state: 5e. Specific - average score - affective symptoms - anxiety (Beck anxiety Inventory (high = poor)) Analysis 1.17Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 17 Mental state: 5f. Specific - average score - affective symptoms - insight (Beck Cognitive Insight Scale (high = good)) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 17 Mental state: 5f. Specific - average score - affective symptoms - insight (Beck Cognitive Insight Scale (high = good)) Analysis 1.18Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 18 Mental state: 5c. Specific - average score - affective symptoms - depression (Montgomery-Asberg Depression Rating Scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 18 Mental state: 5c. Specific - average score - affective symptoms - depression (Montgomery-Asberg Depression Rating Scale, high = poor) Analysis 1.19Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 19 Mental state: 6a. Specific - average score - problem behaviours (Novaco Provocation Inventory, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 19 Mental state: 6a. Specific - average score - problem behaviours (Novaco Provocation Inventory, high = poor) Analysis 1.20Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 20 Mental state: 6b. Specific - average score - problem behaviours (Ward Anger Rating Scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 20 Mental state: 6b. Specific - average score - problem behaviours (Ward Anger Rating Scale, high = poor) Analysis 1.21Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 21 Mental state: 6c. Specific - average score - problem behaviours (HCR-20 risk management, high poor) - long-term only Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 21 Mental state: 6c. Specific - average score - problem behaviours (HCR-20 risk management, high poor) - long-term only Analysis 1.22Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 22 Mental state: 6d. Specific - average score - problem behaviour (HCR - 20 clinical scale, high = poor) - long-term only Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 22 Mental state: 6d. Specific - average score - problem behaviour (HCR - 20 clinical scale, high = poor) - long-term only Analysis 1.23Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 23 Global state: 1. Relapse/rehospitalisation Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 23 Global state: 1. Relapse/rehospitalisation Analysis 1.24Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 24 Global state: 2. Various outcomes Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 24 Global state: 2. Various outcomes Analysis 1.25Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 25 Global state: 3a. Social functioning - average scores (Social Functioning Scale, high = good) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 25 Global state: 3a. Social functioning - average scores (Social Functioning Scale, high = good) Analysis 1.26Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 26 Global state: 3b. Social functioning - average scores (Social and Occupational Functioning Assessment Scale, high = good) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 26 Global state: 3b. Social functioning - average scores (Social and Occupational Functioning Assessment Scale, high = good) Analysis 1.27Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 27 Quality of life: Average score (EuroQOL, high = good) - long-term only Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 27 Quality of life: Average score (EuroQOL, high = good) - long-term only Analysis 1.28Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 28 Satisfaction with treatment: 1. Attitude to medication - average score - short-term Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 28 Satisfaction with treatment: 1. Attitude to medication - average score - short-term Analysis 1.29Comparison 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES, Outcome 29 Satisfaction with treatment: 2. Leaving the study early Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 1 CBT versus ALL OTHER PSYCHOLOGICAL THERAPIES Outcome: 29 Satisfaction with treatment: 2. Leaving the study early Analysis 2.1Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 1 Adverse effect/event: Death Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 1 Adverse effect/event: Death Analysis 2.2Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 2 Mental state: 1. General - no important or reliable change Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 2 Mental state: 1. General - no important or reliable change Analysis 2.3Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 3 Mental state: 2a. General - average score - total (BPRS, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 3 Mental state: 2a. General - average score - total (BPRS, high = poor) Analysis 2.4Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 4 Mental state: 2b. General - average score - total (PANSS, endpoint data, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 4 Mental state: 2b. General - average score - total (PANSS, endpoint data, high = poor) Analysis 2.5Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 5 Mental state: 3a. Specific - average score - positive symptoms - overall (PANSS, endpoint data, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 5 Mental state: 3a. Specific - average score - positive symptoms - overall (PANSS, endpoint data, high = poor) Analysis 2.6Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 6 Mental state: 3b. Specific - average score - positive symptoms - hallucinations (Psychotic Symptom Rating Scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 6 Mental state: 3b. Specific - average score - positive symptoms - hallucinations (Psychotic Symptom Rating Scale, high = poor) Analysis 2.7Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 7 Mental state: 3c. Specific - average score - positive symptoms - delusions (Psychotic Symptom Rating Scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 7 Mental state: 3c. Specific - average score - positive symptoms - delusions (Psychotic Symptom Rating Scale, high = poor) Analysis 2.8Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 8 Mental state: 4a. Specific - average score - negative symptoms - overall (PANSS, endpoint data, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 8 Mental state: 4a. Specific - average score - negative symptoms - overall (PANSS, endpoint data, high = poor) Analysis 2.9Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 9 Mental state: 4b. Specific - average score - negative symptoms - overall (SANS, high = good) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 9 Mental state: 4b. Specific - average score - negative symptoms - overall (SANS, high = good) Analysis 2.10Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 10 Mental state: 5a. Specific - average score - affective symptoms (PANSS General symptoms, endpoint data, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 10 Mental state: 5a. Specific - average score - affective symptoms (PANSS General symptoms, endpoint data, high = poor) Analysis 2.11Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 11 Mental state: 5b. Specific - average score - affective symptoms - depression (Montgomery-Asberg Depression Rating Scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 11 Mental state: 5b. Specific - average score - affective symptoms - depression (Montgomery-Asberg Depression Rating Scale, high = poor) Analysis 2.12Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 12 Mental state: 5c. Specific - average score - affective symptoms - Anger/aggression (Novaco Anger Scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 12 Mental state: 5c. Specific - average score - affective symptoms - Anger/aggression (Novaco Anger Scale, high = poor) Analysis 2.13Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 13 Mental state: 6a. Specific - average score - problem behaviours (Novaco Provocation Inventory, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 13 Mental state: 6a. Specific - average score - problem behaviours (Novaco Provocation Inventory, high = poor) Analysis 2.14Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 14 Mental state: 6c. Specific - average score - problem behaviours (Ward Anger Rating Scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 14 Mental state: 6c. Specific - average score - problem behaviours (Ward Anger Rating Scale, high = poor) Analysis 2.15Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 15 Mental state: 6d. Specific - average score - problem behaviour (HCR - 20 clinical scale, high = poor) - long-term only Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 15 Mental state: 6d. Specific - average score - problem behaviour (HCR - 20 clinical scale, high = poor) - long-term only Analysis 2.16Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 16 Mental state: 6e. Specific - average score - problem behaviours (HCR-20 risk management, high poor) - long-term only Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 16 Mental state: 6e. Specific - average score - problem behaviours (HCR-20 risk management, high poor) - long-term only Analysis 2.17Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 17 Global state: 1. Relapse - long-term only Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 17 Global state: 1. Relapse - long-term only Analysis 2.18Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 18 Global state: 2. Rehospitalisation - long-term only Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 18 Global state: 2. Rehospitalisation - long-term only Analysis 2.19Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 19 Global state: 3. Average score (GAF, high = good) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 19 Global state: 3. Average score (GAF, high = good) Analysis 2.20Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 20 Global state: 4. Social functioning - average scores (Social and Occupational Functioning Assessment Scale, high = good) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 20 Global state: 4. Social functioning - average scores (Social and Occupational Functioning Assessment Scale, high = good) Analysis 2.21Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 21 Satisfaction with treatment: 1. Attitude to medication - average score - short-term Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 21 Satisfaction with treatment: 1. Attitude to medication - average score - short-term Analysis 2.22Comparison 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES, Outcome 22 Satisfaction with treatment: 2. Leaving the study early Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 2 SUBGROUP 1: CBT versus “NON-ACTIVE” THERAPIES Outcome: 22 Satisfaction with treatment: 2. Leaving the study early Analysis 3.1Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 1 Adverse effect/event: 1. Death Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 1 Adverse effect/event: 1. Death Analysis 3.2Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 2 Adverse effect/event: 2. Adverse effects - any - medium-term only Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 2 Adverse effect/event: 2. Adverse effects - any - medium-term only Analysis 3.3Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 3 Mental state: 1. No important or reliable change Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 3 Mental state: 1. No important or reliable change Analysis 3.4Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 4 Mental state: 2a. General - average score - total (BPRS, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 4 Mental state: 2a. General - average score - total (BPRS, high = poor) Analysis 3.5Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 5 Mental state: 2b. General - average score - total (PANSS, endpoint data, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 5 Mental state: 2b. General - average score - total (PANSS, endpoint data, high = poor) Analysis 3.6Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 6 Mental state: 3a. Specific - average score - positive symptoms - overall (PANSS, endpoint data,high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 6 Mental state: 3a. Specific - average score - positive symptoms - overall (PANSS, endpoint data, high = poor) Analysis 3.7Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 7 Mental state: 3b. Specific - average score - positive symptoms - hallucinations (Psychotic Symptom Rating Scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 7 Mental state: 3b. Specific - average score - positive symptoms - hallucinations (Psychotic Symptom Rating Scale, high = poor) Analysis 3.8Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 8 Mental state: 3c. Specific - average acore - positive symptoms - delusions (Psychotic Symptom Rating Scale, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 8 Mental state: 3c. Specific - average acore - positive symptoms - delusions (Psychotic Symptom Rating Scale, high = poor) Analysis 3.9Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 9 Mental state: 4a. Specific - average score - negative symptoms - overall PANSS, endpoint data,high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 9 Mental state: 4a. Specific - average score - negative symptoms - overall (PANSS, endpoint data, high = poor) Analysis 3.10Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 10 Mental state: 4b. Specific - average score - negative symptoms - overall (SANS, high = good) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 10 Mental state: 4b. Specific - average score - negative symptoms - overall (SANS, high = good) Analysis 3.11Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 11 Mental state: 5a. Specific - average score - affective symptoms (PANSS General symptoms,endpoint data, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 11 Mental state: 5a. Specific - average score - affective symptoms (PANSS General symptoms, endpoint data, high = poor) Analysis 3.12Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 12 Mental state: 5b. Specific - average score - affective symptoms - depression (Beck Depression Inventory, high = poor) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 12 Mental state: 5b. Specific - average score - affective symptoms - depression (Beck Depression Inventory, high = poor) Analysis 3.13Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 13 Mental state: 5c. Specific - average score - affective symptoms - self esteem (Rosenberg Self Esteem Scale (high = good)) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 13 Mental state: 5c. Specific - average score - affective symptoms - self esteem (Rosenberg Self Esteem Scale (high = good)) Analysis 3.14Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 14 Mental state: 5d. Specific - average score - affective symptoms - anxiety (Beck anxiety Inventory (high = poor)) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 14 Mental state: 5d. Specific - average score - affective symptoms - anxiety (Beck anxiety Inventory (high = poor)) Analysis 3.15Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 15 Mental State: 5e. Specific - average score - affective symptoms - insight (Beck Cognitive Insight Scale (high = good)) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 15 Mental State: 5e. Specific - average score - affective symptoms - insight (Beck Cognitive Insight Scale (high = good)) Analysis 3.16Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 16 Global state: 1. Relapse Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 16 Global state: 1. Relapse Analysis 3.17Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 17 Global state: 2. Rehospitalisation Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 17 Global state: 2. Rehospitalisation Analysis 3.18Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 18 Global state: 3a. Average score (GAS, endpoint data, high = good) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 18 Global state: 3a. Average score (GAS, endpoint data, high = good) Analysis 3.19Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 19 Global state: 3b. Average score (GAF, high = good) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 19 Global state: 3b. Average score (GAF, high = good) Analysis 3.20Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 20 Global state: 4a. Social Functioning Scale (high = good) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 20 Global state: 4a. Social Functioning Scale (high = good) Analysis 3.21Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 21 Global state 4b. Social and Occupational Functioning Assessment Scale (high = good) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 21 Global state 4b. Social and Occupational Functioning Assessment Scale (high = good) Analysis 3.22Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 22 Quality of Life: EuroQOL (high = good) Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 22 Quality of Life: EuroQOL (high = good) Analysis 3.23Comparison 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES, Outcome 23 Satisfaction with treatment: 1. Leaving the study early Review: Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Comparison: 3 SUBGROUP 2: CBT versus “ACTIVE” PSYCHOLOGICAL THERAPIES Outcome: 23 Satisfaction with treatment: 1.Leaving study early FEEDBACKTwitter comment, 11 November 2012ReplyAuthors have amended review in response to this twitter. ContributorsTwitter comment: Paul Hutton. Author responding: Chris Jones. WHAT’S NEWLast assessed as up-to-date: 8 March 2010.
HISTORYProtocol first published: Issue 9, 2010 Review first published: Issue 4, 2012 DIFFERENCES BETWEEN PROTOCOL AND REVIEWThe original protocol has been substantially reformatted to make it more clear but the content has not been substantively changed. SUMMARY OF FINDINGS FOR THE MAIN COMPARISONCognitive behavioural therapy compared with other psychosocial therapies for schizophrenia Patient or population: patients with schizophrenia Settings: in either community or hospital settings Intervention: Cognitive behavioural therapy Comparison: other psychosocial therapies
FootnotesDECLARATIONS OF INTEREST Chris Jones is a Clinical Psychologist who specialises in neuropsychology. David Hacker is a Clinical Psychologist who specialises in neuropsychology. Alan Meaden is a Clinical Psychologist who works with persons with psychosis. Irene Cormac is a Forensic Psychiatrist - no declarations of interest. Claire Irving - no declarations of interest. References to studies included in this reviewBechdolf 2004 {published data only} . Bechdolf A, Knost B, Kuntermann C, Schiller S, Klosterkotter J, Hambrecht M, Pukrop R. A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in patients with schizophrenia. Acta Psychiatrica Scandinavica. 2004;110(1):21–8. [PubMed] [Google Scholar] Bechdolf A, Kohn D, Knost B, Pukrop R, Klosterkotter J. A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in acute patients with schizophrenia: outcome at 24 months. 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Some of the most important risk factors for heart disease involve behavior change, stress reduction, and learning to think about things differently. Cognitive Behavioral Therapy (CBT) has been well researched as the most effective psychological treatment for cardiac disease.
Which of the following statements is true of behavior therapy quizlet?Which of the following statements is true of behavior therapies? They strive to eliminate individuals' depressed symptoms or behaviors.
Which of the following is one criticism of behavior therapy?One criticism is it sterile or mechanical approach to human interaction, it can be disconcerting for many to have much of social-emotional interactions reduced to a mathematical type equation of antecedents, behaviors, and consequences.
What is the main idea of behavioral therapy quizlet?Behavior therapy is based on: applying the experimental method to the therapeutic process. The main goal of behavior therapy is: eliminating maladaptive learning and providing for more effective learning.
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Behavior therapy has undergone important changes and has expanded considerably.
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