Academic journal article The International Journal of Behavioral Consultation and Therapy

The Cognitive-Behavioral Treatment of Schizophrenia: The State of the Art and the Evidence

Academic journal article The International Journal of Behavioral Consultation and Therapy

The Cognitive-Behavioral Treatment of Schizophrenia: The State of the Art and the Evidence

Article excerpt

Abstract

Schizophrenia and other psychotic disorders are associated with high degrees of impairment and often respond inadequately to pharmacotherapy alone. In recent years, numerous clinical trials have been published showing the benefits of adjunctive cognitive behavior therapy for treating psychosis. However, research in this area has been hampered by the inherent problems conducting psychotherapy research in severely mentally ill populations. This paper provides a brief overview of the cognitive-behavioral treatment of psychosis and discusses the state of the evidence in this area, including its many unresolved issues.

Keywords: Schizophrenia, psychosis, cognitive therapy, behavior therapy, cognitive behavior therapy, acceptance and commitment therapy, empirically supported treatments, randomized controlled trials, literature review

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Pharmacotherapy and the Need for Adjunctive Psychosocial Approaches In recent times, the treatment of severe mental disorders such as schizophrenia has been thought by many to be the almost exclusive territory of psychiatry and psychopharmacology. It is true that the emergence of neuroleptic medications in the 1950s permitted deinstitutionalization for many individuals. In fact, antipsychotic medications are in some ways the real success stories in psychopharmacology, especially when compared to the relatively unimpressive outcomes of drug treatments for anxiety and depressive disorders (Gaudiano & Herbert, 2005). Antipsychotic medications are primarily effective for treating the positive symptoms of schizophrenia, in contrast to the accompanying negative symptoms and other deficits in psychosocial functioning that are quite impairing to daily life. Nevertheless, many individuals suffering from schizophrenia fail to respond to medications as their sole or primary treatment. For example, some treated individuals seem to recover remarkably in certain domains, but nevertheless remain unable to function successfully in society. Many others who would benefit from the medications refuse to take them, either because of a lack of insight or due to intolerable side effects. Still others faithfully adhere to their medication regimens, but continue to experience distressing and impairing "residual" symptoms of the illness.

The atypical antipsychotic agents are assumed by many clinicians to be clearly superior in terms of efficacy and tolerability compared to their first generation counterparts, although research suggests otherwise. Perhaps some of the more informative findings in this area come from the recently published Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study (Lieberman et al., 2005), the largest and longest antipsychotic trial of its kind. In this double-blind effectiveness trial, 1,493 people with schizophrenia were randomly assigned to receive olanzapine, quetiapine, risperidone, perphenazine, or ziprasidone for 18 months. Even though noncompliance with antipsychotics is known to be high in this population, study results were nonetheless compelling. By 18 months, 74% of patients discontinued their initial medications. Overall, the atypical antipsychotics studied failed to show superior efficacy or compliance compared to the first generation drug perphenazine. The only exception was in the case of olanzapine, which showed a statistically superior 64% discontinuation rate. However, olanzapine also had the highest rate of discontinuation due to tolerability (18%), which largely resulted from increased weight and metabolic concerns. Olanzapine was associated with an average of 2 pounds per month weight gain. In fact, 30% of patients on olanzapine gained 7% or more of their baseline body weight. Not surprisingly given the high discontinuation rates, the improvement in symptoms observed with these drugs also was relatively poor in the study. The government-funded CATIE study provides the most comprehensive and extensive data on the effectiveness of antipsychotic agents to date, and clearly highlights a potential role for adjunctive interventions for patients with schizophrenia. …

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