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Bighelli I, Çıray O, Salahuddin NH, Leucht S. Cognitive behavioural therapy without medication for schizophrenia. Cochrane Database Syst Rev 2024; 2:CD015332. [PMID: 38323679 PMCID: PMC10848293 DOI: 10.1002/14651858.cd015332.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) can be effective in people with schizophrenia when provided in combination with antipsychotic medication. It remains unclear whether CBT could be safely and effectively offered in the absence of concomitant antipsychotic therapy. OBJECTIVES To investigate the effects of CBT for schizophrenia when administered without concomitant pharmacological treatment with antipsychotics. SEARCH METHODS We conducted a systematic search on 6 March 2022 in the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, and WHO ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) in people with schizophrenia comparing CBT without antipsychotics to standard care, standard care without antipsychotics, or the combination of CBT and antipsychotics. DATA COLLECTION AND ANALYSIS Two review authors independently screened references for inclusion, extracted data from eligible studies, and assessed risk of bias using Cochrane's RoB 2 tool. We contacted study authors for missing data and additional information. Our primary outcome was general mental state measured with a validated rating scale. Key secondary outcomes were specific symptoms of schizophrenia, relapse, service use, number of participants leaving the study early, functioning, quality of life, and number of participants actually receiving antipsychotics during the trial. We also assessed behaviour, adverse effects, and mortality. MAIN RESULTS We included 4 studies providing data for 300 participants (average age 21.94 years). The mean sample size was 75 participants (range 61 to 90 participants). Study duration was between 26 and 39 weeks for the intervention period and 26 to 104 weeks for the follow-up period. Three studies employed a blind rater, while one study was triple-blind. All analyses included data from a maximum of three studies. The certainty of the evidence was low or very low for all outcomes. For the primary outcome overall symptoms of schizophrenia, results showed a difference favouring CBT without antipsychotics when compared to no specific treatment at long term (> 1 year mean difference measured with the Positive and Negative Syndrome Scale (PANSS MD) -14.77, 95% confidence interval (CI) -27.75 to -1.79, 1 RCT, n = 34). There was no difference between CBT without antipsychotics compared with antipsychotics (up to 12 months PANSS MD 3.38, 95% CI -2.38 to 9.14, 2 RCTs, n = 63) (very low-certainty evidence) or compared with CBT in combination with antipsychotics (up to 12 months standardised mean difference (SMD) 0.30, 95% CI -0.06 to 0.65, 3 RCTs, n = 125). Compared with no specific treatment, CBT without antipsychotics was associated with a reduction in overall symptoms (as described above) and negative symptoms (PANSS negative MD -4.06, 95% CI -7.50 to -0.62, 1 RCT, n = 34) at longer than 12 months. It was also associated with a lower duration of hospital stay (number of days in hospital MD -22.45, 95% CI -28.82 to -16.08, 1 RCT, n = 74) and better functioning (Personal and Social Performance Scale MD -12.42, 95% CI -22.75 to -2.09, 1 RCT, n = 40, low-certainty evidence) at up to 12 months. We did not find a difference between CBT and antipsychotics in any of the investigated outcomes, with the exception of adverse events measured with the Antipsychotic Non-Neurological Side-Effects Rating Scale (ANNSERS) at both 6 and 12 months (MD -4.94, 95% CI -8.60 to -1.28, 2 RCTs, n = 48; MD -6.96, 95% CI -11.55 to -2.37, 2 RCTs, n = 42). CBT without antipsychotics was less effective than CBT combined with antipsychotics in reducing positive symptoms at up to 12 months (SMD 0.40, 95% CI 0.05 to 0.76, 3 RCTs, n = 126). CBT without antipsychotics was associated with a lower number of participants experiencing at least one adverse event in comparison with CBT combined with antipsychotics at up to 12 months (risk ratio 0.36, 95% CI 0.17 to 0.80, 1 RCT, n = 39, low-certainty evidence). AUTHORS' CONCLUSIONS This review is the first attempt to systematically synthesise the evidence about CBT delivered without medication to people with schizophrenia. The limited number of studies and low to very low certainty of the evidence prevented any strong conclusions. An important limitation in the available studies was that participants in the CBT without medication group (about 35% on average) received antipsychotic treatment, highlighting the challenges of this approach. Further high-quality RCTs are needed to provide additional data on the feasibility and efficacy of CBT without antipsychotics.
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Affiliation(s)
- Irene Bighelli
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Germany
- German Center for Mental Health (DZPG), Munich, Germany
| | - Oğulcan Çıray
- Child and Adolescent Psychiatry Department, Mardin State Hospital Child and Adolescent Psychiatry Department, Mardin, Turkey
| | - Nurul Husna Salahuddin
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Stefan Leucht
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Germany
- German Center for Mental Health (DZPG), Munich, Germany
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Chakrabarti S. Clozapine resistant schizophrenia: Newer avenues of management. World J Psychiatry 2021; 11:429-448. [PMID: 34513606 PMCID: PMC8394694 DOI: 10.5498/wjp.v11.i8.429] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
About 40%-70% of the patients with treatment-resistant schizophrenia have a poor response to adequate treatment with clozapine. The impact of clozapine-resistant schizophrenia (CRS) is even greater than that of treatment resistance in terms of severe and persistent symptoms, relapses and hospitalizations, poorer quality of life, and healthcare costs. Such serious consequences often compel clinicians to try different augmentation strategies to enhance the inadequate clozapine response in CRS. Unfortunately, a large body of evidence has shown that antipsychotics, antidepressants, mood stabilizers, electroconvulsive therapy, and cognitive-behavioural therapy are mostly ineffective in augmenting clozapine response. When beneficial effects of augmentation have been found, they are usually small and of doubtful clinical significance or based on low-quality evidence. Therefore, newer treatment approaches that go beyond the evidence are needed. The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS. Secondly, newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered. Lastly, perhaps the most effective way to deal with CRS would be to optimize clozapine treatment, which might prevent clozapine resistance from developing. Personalized dosing, adequate treatment durations, management of side effects and non-adherence, collaboration with patients and caregivers, and addressing clinician barriers to clozapine use are the principal ways of ensuring optimal clozapine treatment. At present, these three options could the best way to manage CRS until research provides more firm directions about the effective options for augmenting clozapine response.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Tognin S, van Hell HH, Merritt K, Winter-van Rossum I, Bossong MG, Kempton MJ, Modinos G, Fusar-Poli P, Mechelli A, Dazzan P, Maat A, de Haan L, Crespo-Facorro B, Glenthøj B, Lawrie SM, McDonald C, Gruber O, van Amelsvoort T, Arango C, Kircher T, Nelson B, Galderisi S, Bressan R, Kwon JS, Weiser M, Mizrahi R, Sachs G, Maatz A, Kahn R, McGuire P. Towards Precision Medicine in Psychosis: Benefits and Challenges of Multimodal Multicenter Studies-PSYSCAN: Translating Neuroimaging Findings From Research into Clinical Practice. Schizophr Bull 2020; 46:432-441. [PMID: 31424555 PMCID: PMC7043057 DOI: 10.1093/schbul/sbz067] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
In the last 2 decades, several neuroimaging studies investigated brain abnormalities associated with the early stages of psychosis in the hope that these could aid the prediction of onset and clinical outcome. Despite advancements in the field, neuroimaging has yet to deliver. This is in part explained by the use of univariate analytical techniques, small samples and lack of statistical power, lack of external validation of potential biomarkers, and lack of integration of nonimaging measures (eg, genetic, clinical, cognitive data). PSYSCAN is an international, longitudinal, multicenter study on the early stages of psychosis which uses machine learning techniques to analyze imaging, clinical, cognitive, and biological data with the aim of facilitating the prediction of psychosis onset and outcome. In this article, we provide an overview of the PSYSCAN protocol and we discuss benefits and methodological challenges of large multicenter studies that employ neuroimaging measures.
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Affiliation(s)
- Stefania Tognin
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK,Outreach and Support in South London (OASIS), South London and Maudsley NHS Foundation Trust, London, UK
| | - Hendrika H van Hell
- Department of Psychiatry, University Medical Center Utrecht Brain Center, Utrecht, the Netherlands,To whom correspondence should be addressed; Clinical Trial Center, Department of Psychiatry, University Medical Center Utrecht Brain Center, PO Box 85500, 3508 GA Utrecht, The Netherlands; tel: +31 88 755 7247, e-mail:
| | - Kate Merritt
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Inge Winter-van Rossum
- Department of Psychiatry, University Medical Center Utrecht Brain Center, Utrecht, the Netherlands
| | - Matthijs G Bossong
- Department of Psychiatry, University Medical Center Utrecht Brain Center, Utrecht, the Netherlands
| | - Matthew J Kempton
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Gemma Modinos
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Paolo Fusar-Poli
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy,National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Andrea Mechelli
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Paola Dazzan
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Arija Maat
- Department of Psychiatry, University Medical Center Utrecht Brain Center, Utrecht, the Netherlands
| | - Lieuwe de Haan
- Department Early Psychosis, Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Benedicto Crespo-Facorro
- CIBERSAM, Department of Psychiatry, University Hospital Virgen del Rocío, Sevilla, Spain,IDIVAL, Marqués de Valdecilla University Hospital, Santander, Spain,School of Medicine, University of Cantabria, Santander, Spain
| | - Birte Glenthøj
- Centre for Neuropsychiatric Schizophrenia Research (CNSR), Mental Health Centre Glostrup, University of Copenhagen, Glostrup, Denmark,Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research (CINS), Mental Health Centre Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Stephen M Lawrie
- Division of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital, Edinburgh, UK
| | - Colm McDonald
- Centre for Neuroimaging & Cognitive Genomics (NICOG), NCBES Galway Neuroscience Centre, National University of Ireland Galway, Galway, Ireland
| | - Oliver Gruber
- Section for Experimental Psychopathology and Neuroimaging, Department of General Psychiatry, Heidelberg University, Heidelberg, Germany
| | - Therese van Amelsvoort
- Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañon, CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Tilo Kircher
- Department of Psychiatry, University of Marburg, Marburg, Germany
| | - Barnaby Nelson
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia,Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Silvana Galderisi
- Department of Psychiatry, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Rodrigo Bressan
- Interdisciplinary Lab for Clinical Neurosciences (LiNC), Department of Psychiatry, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Jun S Kwon
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
| | - Mark Weiser
- Department of Psychiatry, Sheba Medical Center, Tel Hashomer, Israel,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Romina Mizrahi
- Institute of Medical Science, University of Toronto, Toronto, Canada,Centre for Addiction and Mental Health, Toronto, Canada,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Gabriele Sachs
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Anke Maatz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - René Kahn
- Department of Psychiatry, University Medical Center Utrecht Brain Center, Utrecht, the Netherlands,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Phillip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK,Outreach and Support in South London (OASIS), South London and Maudsley NHS Foundation Trust, London, UK,National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
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