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Mayer SF, Corcoran C, Kennedy L, Leucht S, Bighelli I. Cognitive behavioural therapy added to standard care for first-episode and recent-onset psychosis. Cochrane Database Syst Rev 2024; 3:CD015331. [PMID: 38470162 PMCID: PMC10929366 DOI: 10.1002/14651858.cd015331.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: 03/13/2024]
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) can be effective in the general population of people with schizophrenia. It is still unclear whether CBT can be effectively used in the population of people with a first-episode or recent-onset psychosis. OBJECTIVES To assess the effects of adding cognitive behavioural therapy to standard care for people with a first-episode or recent-onset psychosis. 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, ISRCTN, and WHO ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing CBT added to standard care vs standard care in first-episode or recent-onset psychosis, in patients of any age. DATA COLLECTION AND ANALYSIS Two review authors (amongst SFM, CC, LK and IB) independently screened references for inclusion, extracted data from eligible studies and assessed the risk of bias using RoB2. Study authors were contacted for missing data and additional information. Our primary outcome was general mental state measured on a validated rating scale. Secondary outcomes included other specific measures of mental state, global state, relapse, admission to hospital, functioning, leaving the study early, cognition, quality of life, satisfaction with care, self-injurious or aggressive behaviour, adverse events, and mortality. MAIN RESULTS We included 28 studies, of which 26 provided data on 2407 participants (average age 24 years). The mean sample size in the included studies was 92 participants (ranging from 19 to 444) and duration ranged between 26 and 52 weeks. When looking at the results at combined time points (mainly up to one year after start of the intervention), CBT added to standard care was associated with a greater reduction in overall symptoms of schizophrenia (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.47 to -0.08, 20 RCTs, n = 1508, I2 = 68%, substantial heterogeneity, low certainty of the evidence), and also with a greater reduction in positive (SMD -0.22, 95% CI -0.38 to -0.06, 22 RCTs, n = 1565, I² = 52%, moderate heterogeneity), negative (SMD -0.20, 95% CI -0.30 to -0.11, 22 RCTs, n = 1651, I² = 0%) and depressive symptoms (SMD -0.13, 95% CI -0.24 to -0.01, 18 RCTs, n = 1182, I² = 0%) than control. CBT added to standard care was also associated with a greater improvement in the global state (SMD -0.34, 95% CI -0.67 to -0.01, 4 RCTs, n = 329, I² = 47%, moderate heterogeneity) and in functioning (SMD -0.23, 95% CI -0.42 to -0.05, 18 RCTs, n = 1241, I² = 53%, moderate heterogeneity, moderate certainty of the evidence) than control. We did not find a difference between CBT added to standard care and control in terms of number of participants with relapse (relative risk (RR) 0.82, 95% CI 0.57 to 1.18, 7 RCTs, n = 693, I² = 48%, low certainty of the evidence), leaving the study early for any reason (RR 0.87, 95% CI 0.72 to 1.05, 25 RCTs, n = 2242, I² = 12%, moderate certainty of the evidence), adverse events (RR 1.29, 95% CI 0.85 to 1.97, 1 RCT, n = 43, very low certainty of the evidence) and the other investigated outcomes. AUTHORS' CONCLUSIONS This review synthesised the latest evidence on CBT added to standard care for people with a first-episode or recent-onset psychosis. The evidence identified by this review suggests that people with a first-episode or recent-onset psychosis may benefit from CBT additionally to standard care for multiple outcomes (overall, positive, negative and depressive symptoms of schizophrenia, global state and functioning). Future studies should better define this population, for which often heterogeneous definitions are used.
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Affiliation(s)
- Susanna Franziska Mayer
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, TUM School of Medicine and Health, Technical University of Munich, München, Germany
| | | | - Liam Kennedy
- Department of Old Age Psychiatry, Carew House, St Vincent's Hospital, Dublin, Ireland
| | - Stefan Leucht
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, TUM School of Medicine and Health, Technical University of Munich, München, Germany
- German Center for Mental Health (DZPG), Munich, Germany
| | - Irene Bighelli
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, TUM School of Medicine and Health, Technical University of Munich, München, Germany
- German Center for Mental Health (DZPG), Munich, Germany
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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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Dudley R, Turkington D, Coulthard N, Pyle M, Gumley A, Schwannauer M, Kingdon D, Morrison AP. Childhood Trauma in Clozapine-Resistant Schizophrenia: Prevalence, and Relationship With Symptoms. SCHIZOPHRENIA BULLETIN OPEN 2023; 4:sgad030. [PMID: 39145330 PMCID: PMC11207680 DOI: 10.1093/schizbullopen/sgad030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
Background and Hypothesis The role of early adversity and trauma is increasingly recognized in psychosis but treatments for trauma and its consequences are lacking. Psychological treatments need to understand the prevalence of these experiences, the relationship with specific symptoms and identify potentially tractable processes that may be targeted in therapy. It was hypothesized that greater adversity, and specifically abuse rather than neglect, would be associated with positive symptoms and specifically hallucinations. In addition, negative beliefs would mediate the relationship with positive symptoms. Study Design 292 Patients with treatment resistant psychosis completed measures of early adversity as well as current symptoms of psychosis. Study Results Early adversity in the form of abuse and neglect were common in one-third of the sample. Adversity was associated with higher levels of psychotic symptoms generally, and more so with positive rather than negative symptoms. Abuse rather than neglect was associated with positive but not with negative symptoms. Abuse rather than neglect was associated with hallucinations but not delusions. Abuse and neglect were related to negative beliefs about the self and negative beliefs about others. Mediation demonstrated a general relationship with adversity, negative-self, and other views and overall psychotic symptoms but not in relation to the specific experience of abuse and hallucinations. Females were more likely to be abused, but not neglected, than males. Conclusions Whilst most relationships were modest, they supported previous work indicating that adversity contributes to people with psychosis experiencing distressing symptoms especially hallucinations. Treatments need to address and target adversity.
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Affiliation(s)
- Robert Dudley
- Early Intervention in Psychosis Service, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Gosforth, Newcastle Upon Tyne, NE3 3XT, UK
- Department of Psychology, University of York, York, YO10 5DDUK
| | - Douglas Turkington
- Early Intervention in Psychosis Service, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Gosforth, Newcastle Upon Tyne, NE3 3XT, UK
| | - Naomi Coulthard
- Early Intervention in Psychosis Service, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Gosforth, Newcastle Upon Tyne, NE3 3XT, UK
| | - Melissa Pyle
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, M25 3BL, UK
| | - Andrew Gumley
- School of Health & Wellbeing, University of, Glasgow Clarice Pears Building, 90 Byres Road, Glasgow G12 8TBUK
| | - Matthias Schwannauer
- Department of Clinical Psychology, School of Health in Social Science, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - David Kingdon
- University Department of Psychiatry, University of Southampton, Academic Centre, CollegeKeep 4-12 Terminus Terrace Southampton SO14 3DT, UK
| | - Anthony P Morrison
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, M25 3BL, UK
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Multicentre randomised controlled trial of a group psychological intervention for postnatal depression in British mothers of South Asian origin (ROSHNI-2): study protocol. BJPsych Open 2021. [PMCID: PMC8693900 DOI: 10.1192/bjo.2021.1032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BackgroundIn the UK, postnatal depression is more common in British South Asian women than White Caucasion women. Cognitive–behavioural therapy (CBT) is recommended as a first-line treatment, but there is little evidence for the adaptation of CBT for postnatal depression to ensure its applicability to different ethnic groups.AimsTo evaluate the clinical and cost-effectiveness of a CBT-based positive health programme group intervention in British South Asian women with postnatal depression.MethodWe have designed a multicentre, two-arm, partially nested, randomised controlled trial with 4- and 12-month follow-up, comparing a 12-session group CBT-based intervention (positive health programme) plus treatment as usual with treatment as usual alone, for British South Asian women with postnatal depression. Participants will be recruited from primary care and appropriate community venues in areas of high South Asian density across the UK. It has been estimated that randomising 720 participants (360 into each group) will be sufficient to detect a clinically important difference between a 55% recovery rate in the intervention group and a 40% recovery rate in the treatment-as-usual group. An economic analysis will estimate the cost-effectiveness of the positive health programme. A qualitative process evaluation will explore barriers and enablers to study participation and examine the acceptability and impact of the programme from the perspective of British South Asian women and other key stakeholders.
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Saini P, Hunt A, Taylor P, Mills C, Clements C, Mulholland H, Kullu C, Hann M, Duarte R, Mattocks F, Guthrie E, Gabbay M. Community Outpatient Psychotherapy Engagement Service for Self-harm (COPESS): a feasibility trial protocol. Pilot Feasibility Stud 2021; 7:165. [PMID: 34452642 PMCID: PMC8390538 DOI: 10.1186/s40814-021-00902-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 08/20/2021] [Indexed: 11/16/2022] Open
Abstract
Background People who self-harm are at high risk for future suicide and often suffer considerable emotional distress. Depression is common among people who self-harm and may be an underlying driver of self-harm behaviour. Self-harm is often repeated, and risk of repetition is highest immediately after an act of self-harm. Readily accessible brief talking therapies show promise in helping people who self-harm, but further evaluation of these approaches is needed. A brief talking therapy intervention for depression and self-harm has been designed for use in a community setting. This mixed methods feasibility study with repeated measures will examine the feasibility and acceptability of the Community Outpatient Psychological Engagement Service for Self-Harm (COPESS) for people with self-harm and depression in the community, compared to routine care. Methods Sixty participants with a history of self-harm within the last six months, who are also currently depressed, will be recruited to take part in a feasibility single-blind randomised controlled trial (RCT). Participants will be randomised 1:1 to receive COPESS plus treatment as usual (TAU) or TAU alone. Recruitment will be via General Practitioners (GP) and self-referral. Assessment of feasibility and acceptability will be assessed via quantitative and qualitative methods including measures of recruitment and retention to the feasibility trial, participants’ experience of therapy, completion/completeness of outcome measures at relevant time-points and completion of a service use questionnaire. Discussion The results will indicate whether it is feasible to conduct a definitive full trial to determine whether COPESS is a clinically and cost effective intervention for people who self-harm in the community. Qualitative and quantitative data will in addition help identify potential strengths and/or challenges of implementing brief community-based interventions for people who self-harm. Trial registration NCT04191122 registered 9th December 2019.
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Affiliation(s)
- Pooja Saini
- School of Psychology, Liverpool John Moores University, Byrom Street, Liverpool, L3 3AF, UK
| | - Anna Hunt
- School of Psychology, Liverpool John Moores University, Byrom Street, Liverpool, L3 3AF, UK
| | - Peter Taylor
- Division of Psychology & Mental Health, Academic Health Sciences Centre, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Catherine Mills
- Mersey Care NHS Foundation Trust, V7 Building, Kings Business Park, Prescot, L34 1PJ, UK
| | - Caroline Clements
- Division of Psychology & Mental Health, Academic Health Sciences Centre, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Helen Mulholland
- Department of Primary Care and Mental Health, The University of Liverpool, Waterhouse Building Block B, Liverpool, L69 3GF, UK
| | - Cecil Kullu
- Mersey Care NHS Foundation Trust, V7 Building, Kings Business Park, Prescot, L34 1PJ, UK
| | - Mark Hann
- Biostatistics, Division of Population Health, Health Services Research & Primary Care, Manchester, UK
| | - Rui Duarte
- Department of Primary Care and Mental Health, The University of Liverpool, Waterhouse Building Block B, Liverpool, L69 3GF, UK
| | | | - Else Guthrie
- School of Medicine, The University of Leeds, Woodhouse, Leeds, LS2 9JT, UK
| | - Mark Gabbay
- Department of Primary Care and Mental Health, The University of Liverpool, Waterhouse Building Block B, Liverpool, L69 3GF, UK.
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Morrison AP, Pyle M, Byrne R, Broome M, Freeman D, Johns L, James A, Husain N, Whale R, MacLennan G, Norrie J, Hudson J, Peters S, Davies L, Bowe S, Smith J, Shiers D, Joyce E, Jones W, Hollis C, Maughan D. Psychological intervention, antipsychotic medication or a combined treatment for adolescents with a first episode of psychosis: the MAPS feasibility three-arm RCT. Health Technol Assess 2021; 25:1-124. [PMID: 33496261 PMCID: PMC7869006 DOI: 10.3310/hta25040] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND When psychosis emerges in young people there is a risk of poorer outcomes, and access to evidence-based treatments is paramount. The current evidence base is limited. Antipsychotic medications show only a small benefit over placebo, but young people experience more side effects than adults. There is sparse evidence for psychological intervention. Research is needed to determine the clinical effectiveness and cost-effectiveness of psychological intervention versus antipsychotic medication versus a combined treatment for adolescents with psychosis. OBJECTIVES The objective of Managing Adolescent first-episode Psychosis: a feasibility Study (MAPS) was to determine the feasibility of conducting a definitive trial to answer the question of clinical effectiveness and cost-effectiveness of these three treatment options. DESIGN This was a prospective, randomised, open-blinded, evaluation feasibility trial with a single blind. Participants were allocated 1 : 1 : 1 to receive antipsychotic medication, psychological intervention or a combination of both. A thematic qualitative study explored the acceptability and feasibility of the trial. SETTING Early intervention in psychosis services and child and adolescent mental health services in Manchester, Oxford, Lancashire, Sussex, Birmingham, Norfolk and Suffolk, and Northumberland, Tyne and Wear. PARTICIPANTS People aged 14-18 years experiencing a first episode of psychosis either with an International Classification of Diseases, Tenth Revision, schizophrenia spectrum diagnosis or meeting the entry criteria for early intervention in psychosis who had not received antipsychotic medication or psychological intervention within the last 3 months. INTERVENTIONS Psychological intervention involved up to 26 hours of cognitive-behavioural therapy and six family intervention sessions over 6 months, with up to four booster sessions. Antipsychotic medication was prescribed by the participant's psychiatrist in line with usual practice. Combined treatment was a combination of psychological intervention and antipsychotic medication. MAIN OUTCOME MEASURES The primary outcome was feasibility (recruitment, treatment adherence and retention). We used a three-stage progression criterion to determine feasibility. Secondary outcomes were psychosis symptoms, recovery, anxiety and depression, social and educational/occupational functioning, drug and alcohol use, health economics, adverse/metabolic side effects and adverse/serious adverse events. RESULTS We recruited 61 out of 90 (67.8%; amber zone) potential participants (psychological intervention, n = 18; antipsychotic medication, n = 22; combined treatment, n = 21). Retention to follow-up was 51 out of 61 participants (83.6%; green zone). In the psychological intervention arm and the combined treatment arm, 32 out of 39 (82.1%) participants received six or more sessions of cognitive-behavioural therapy (green zone). In the combined treatment arm and the antipsychotic medication arm, 28 out of 43 (65.1%) participants received antipsychotic medication for 6 consecutive weeks (amber zone). There were no serious adverse events related to the trial and one related adverse event. Overall, the number of completed secondary outcome measures, including health economics, was small. LIMITATIONS Medication adherence was determined by clinician report, which can be biased. The response to secondary outcomes was low, including health economics. The small sample size obtained means that the study lacked statistical power and there will be considerable uncertainty regarding estimates of treatment effects. CONCLUSIONS It is feasible to conduct a trial comparing psychological intervention with antipsychotic medication and a combination treatment in young people with psychosis with some adaptations to the design, including adaptations to collection of health economic data to determine cost-effectiveness. FUTURE WORK An adequately powered definitive trial is required to provide robust evidence. TRIAL REGISTRATION Current Controlled Trials ISRCTN80567433. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Anthony P Morrison
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Melissa Pyle
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Rory Byrne
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Matthew Broome
- Institute for Mental Health, School of Psychology, University of Birmingham, Birmingham, UK
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, UK
- Centre for Human Brain Health, School of Psychology, University of Birmingham, Birmingham, UK
- Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Daniel Freeman
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, UK
- Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Louise Johns
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, UK
- Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Anthony James
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, UK
- Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Nusrat Husain
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Early Intervention in Psychosis Service, Lancashire and South Cumbria NHS Foundation Trust, Chorley, UK
| | - Richard Whale
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sarah Peters
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Linda Davies
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Samantha Bowe
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Jo Smith
- School of Allied Health and Community, University of Worcester, Worcester, UK
| | - David Shiers
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Emmeline Joyce
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Wendy Jones
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Chris Hollis
- National Institute for Health Research MindTech MedTech Co-operative, Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Daniel Maughan
- Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford, UK
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Dragoi AM, Radulescu I, Năsui BA, Pop AL, Varlas VN, Trifu S. Clozapine: An Updated Overview of Pharmacogenetic Biomarkers, Risks, and Safety-Particularities in the Context of COVID-19. Brain Sci 2020; 10:E840. [PMID: 33187329 PMCID: PMC7697202 DOI: 10.3390/brainsci10110840] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND clozapine (CLZ) use is precarious due to its neurological, cardiovascular, and hematological side effects; however, it is the gold standard in therapy-resistant schizophrenia (TRS) in adults and is underused. OBJECTIVE to examine the most recent CLZ data on (a) side effects concerning (b) recent pharmacological mechanisms, (c) therapy benefits, and (d) the particularities of the COVID-19 pandemic. DATA SOURCES a search was performed in two databases (PubMed and Web of Science) using the specific keywords "clozapine" and "schizophrenia", "side effects", "agranulocytosis", "TRS", or "bipolar affective disorder (BAF)" for the last ten years. STUDY ELIGIBILITY CRITERIA clinical trials on adults with acute symptoms of schizophrenia or related disorders. RESULTS we selected 37 studies, randomized controlled trials (RCTs), and clinical case series (CCS), centered on six main topics in the search area: (a) CLZ in schizophrenia, (b) CLZ in bipolar disorder, (c) side effects during the clozapine therapy, (d) CLZ in pregnancy, (e) CLZ in early-onset schizophrenia, and (f) CLZ therapy and COVID-19 infection. LIMITATIONS we considered RCTs and CCS from two databases, limited to the search topics. Conclusions and implications of key findings: (a) clozapine doses should be personalized for each patient based on pharmacogenetics testing when available; the genetic vulnerability postulates predictors of adverse reactions' severity; patients with a lower genetic risk could have less frequent hematological monitoring; (b) a CLZ-associated risk of pulmonary embolism imposes prophylactic measures for venous thromboembolism; (c) convulsive episodes are not an indication for stopping treatment; the plasma concentration of clozapine is a better side effect predictor than the dosage; (d) COVID-19 infection may enhance clozapine toxicity, generating an increased risk of pneumonia. Therapy must be continued with the proper monitoring of the white blood count, and the clozapine dose decreased by half until three days after the fever breaks; psychiatrists and healthcare providers must act together.
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Affiliation(s)
- Ana Miruna Dragoi
- Department of Psychiatry, “Alexandru Obregia” Clinical Hospital for Psychiatry, 10 Berceni St., 041914 Bucharest, Romania;
| | - Ioana Radulescu
- Department of General Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania; (I.R.); (V.N.V.)
| | - Bogdana Adriana Năsui
- Department of Community Health, “Iuliu Hațieganu” University of Medicine and Pharmacy, 6 Louis Pasteur St., 400349 Cluj-Napoca, Romania; or
| | - Anca Lucia Pop
- Department of Clinical Laboratory, Food Safety, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia St., 020945 Bucharest, Romania
| | - Valentin Nicolae Varlas
- Department of General Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania; (I.R.); (V.N.V.)
| | - Simona Trifu
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania;
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Morrison AP, Pyle M, Gumley A, Schwannauer M, Turkington D, MacLennan G, Norrie J, Hudson J, Bowe S, French P, Hutton P, Byrne R, Syrett S, Dudley R, McLeod HJ, Griffiths H, Barnes TR, Davies L, Shields G, Buck D, Tully S, Kingdon D. Cognitive-behavioural therapy for clozapine-resistant schizophrenia: the FOCUS RCT. Health Technol Assess 2020; 23:1-144. [PMID: 30806619 DOI: 10.3310/hta23070] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clozapine (clozaril, Mylan Products Ltd) is a first-choice treatment for people with schizophrenia who have a poor response to standard antipsychotic medication. However, a significant number of patients who trial clozapine have an inadequate response and experience persistent symptoms, called clozapine-resistant schizophrenia (CRS). There is little evidence regarding the clinical effectiveness of pharmacological or psychological interventions for this population. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of cognitive-behavioural therapy (CBT) for people with CRS and to identify factors predicting outcome. DESIGN The Focusing on Clozapine Unresponsive Symptoms (FOCUS) trial was a parallel-group, randomised, outcome-blinded evaluation trial. Randomisation was undertaken using permuted blocks of random size via a web-based platform. Data were analysed on an intention-to-treat (ITT) basis, using random-effects regression adjusted for site, age, sex and baseline symptoms. Cost-effectiveness analyses were carried out to determine whether or not CBT was associated with a greater number of quality-adjusted life-years (QALYs) and higher costs than treatment as usual (TAU). SETTING Secondary care mental health services in five cities in the UK. PARTICIPANTS People with CRS aged ≥ 16 years, with an International Classification of Diseases, Tenth Revision (ICD-10) schizophrenia spectrum diagnoses and who are experiencing psychotic symptoms. INTERVENTIONS Individual CBT included up to 30 hours of therapy delivered over 9 months. The comparator was TAU, which included care co-ordination from secondary care mental health services. MAIN OUTCOME MEASURES The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months and the primary secondary outcome was PANSS total score at the end of treatment (9 months post randomisation). The health benefit measure for the economic evaluation was the QALY, estimated from the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), health status measure. Service use was measured to estimate costs. RESULTS Participants were allocated to CBT (n = 242) or TAU (n = 245). There was no significant difference between groups on the prespecified primary outcome [PANSS total score at 21 months was 0.89 points lower in the CBT arm than in the TAU arm, 95% confidence interval (CI) -3.32 to 1.55 points; p = 0.475], although PANSS total score at the end of treatment (9 months) was significantly lower in the CBT arm (-2.40 points, 95% CI -4.79 to -0.02 points; p = 0.049). CBT was associated with a net cost of £5378 (95% CI -£13,010 to £23,766) and a net QALY gain of 0.052 (95% CI 0.003 to 0.103 QALYs) compared with TAU. The cost-effectiveness acceptability analysis indicated a low likelihood that CBT was cost-effective, in the primary and sensitivity analyses (probability < 50%). In the CBT arm, 107 participants reported at least one adverse event (AE), whereas 104 participants in the TAU arm reported at least one AE (odds ratio 1.09, 95% CI 0.81 to 1.46; p = 0.58). CONCLUSIONS Cognitive-behavioural therapy for CRS was not superior to TAU on the primary outcome of total PANSS symptoms at 21 months, but was superior on total PANSS symptoms at 9 months (end of treatment). CBT was not found to be cost-effective in comparison with TAU. There was no suggestion that the addition of CBT to TAU caused adverse effects. Future work could investigate whether or not specific therapeutic techniques of CBT have value for some CRS individuals, how to identify those who may benefit and how to ensure that effects on symptoms can be sustained. TRIAL REGISTRATION Current Controlled Trials ISRCTN99672552. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 7. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Anthony P Morrison
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Melissa Pyle
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Andrew Gumley
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Matthias Schwannauer
- Department of Clinical Psychology, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Douglas Turkington
- Academic Psychiatry, Northumberland, Tyne and Wear NHS Foundation Trust, Centre for Ageing and Vitality, Newcastle General Hospital, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Clinical Trials Unit, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Jemma Hudson
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Samantha Bowe
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK
| | - Paul French
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Paul Hutton
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Rory Byrne
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Suzy Syrett
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Robert Dudley
- School of Psychology, Newcastle University, Newcastle upon Tyne, UK
| | - Hamish J McLeod
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Helen Griffiths
- Department of Clinical Psychology, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | | | - Linda Davies
- Division of Population Health, University of Manchester, Manchester, UK
| | - Gemma Shields
- Division of Population Health, University of Manchester, Manchester, UK
| | - Deborah Buck
- Division of Population Health, University of Manchester, Manchester, UK
| | - Sarah Tully
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - David Kingdon
- Department of Psychiatry, University of Southampton, Academic Centre, Southampton, UK
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9
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iMAgery focused psychological therapy for persecutory delusions in PSychosis (iMAPS): a multiple baseline experimental case series. Behav Cogn Psychother 2020; 48:530-545. [DOI: 10.1017/s1352465820000168] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Many people with psychosis experience persecutory delusions and report negative schematic beliefs and intrusive mental images which may be maintaining factors for psychotic symptoms.Aims:This study examined the feasibility and acceptability of a new psychological therapy targeting schemas and images (iMAPS therapy).Method:The study used a randomised multiple baseline design. Participants with first episode psychosis were randomised using a multiple baseline design with 2–5 assessments. Six sessions of therapy, consisting of a combination of imagery techniques and imagery rescripting techniques, was used. In each session, participants completed a Mental Imagery in Psychosis Questionnaire (MIPQ) and imagery interview. Mood and delusional beliefs (PSYRATS) were also measured at each session.Results:Five participants with first episode psychosis completed the baseline visits and attended all therapy sessions. One participant declined the final assessment. Results demonstrated significant reductions in negative schematic beliefs, delusions, imagery distress and other measures of schema (YSQ, SMI). Although multiple baseline randomisation strengthens the study, it lacked a control arm and blind assessments.Conclusions:iMAPS appears a feasible and acceptable treatment for psychosis, and further evaluation is indicated.
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10
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Taylor PJ, Perry A, Hutton P, Tan R, Fisher N, Focone C, Griffiths D, Seddon C. Cognitive Analytic Therapy for psychosis: A case series. Psychol Psychother 2019; 92:359-378. [PMID: 29719118 PMCID: PMC6766854 DOI: 10.1111/papt.12183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 03/23/2018] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Cognitive Analytic Therapy (CAT) is an effective psychological intervention for several different mental health conditions. However, whether it is acceptable, safe, and beneficial for people with psychosis remains unclear, as is the feasibility of providing and evaluating it within a research context. The aim of this study was to begin to address these questions and to obtain for the first time a rich and detailed understanding of the experience of receiving CAT for psychosis. DESIGN A mixed-methods case series design. METHOD Seven individuals who experienced non-affective psychosis received CAT. They completed assessments at the start of CAT, 16 weeks, and 28 weeks post-baseline. Qualitative interviews were completed with four individuals following completion of or withdrawal from therapy. RESULTS Six participants attended at least four sessions of therapy and four went on to complete therapy. There were no serious adverse events, and self-reported adverse experiences were minimal. Qualitative interviews suggested CAT is acceptable and provided a way to understand and work therapeutically with psychosis. There was limited evidence of change in psychotic symptoms, but improvement in perceived recovery and personality integration was observed. CONCLUSIONS The results suggest that CAT is a safe and acceptable intervention for psychosis. Personality integration, perceived recovery, and functioning are relevant outcomes for future evaluations of CAT for psychosis. PRACTITIONER POINTS It is feasible to conduct research evaluating CAT for people with psychosis. Within this case series, CAT appears acceptable and safe to individuals with psychosis. Within this case series, clients reported that CAT was a positive and helpful experience. There is a mixed picture with regard to secondary outcomes, but the design and aims of this case series limit conclusion that can be drawn from this data.
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Affiliation(s)
- Peter J. Taylor
- Division of Psychology and Mental HealthUniversity of ManchesterUK
| | | | - Paul Hutton
- School of Health and Social CareEdinburgh Napier UniversityUK
| | - Ranil Tan
- Leeds and York Partnerships NHS Foundation TrustWest YorkshireUK
| | - Naomi Fisher
- Spectrum Centre for Mental Health ResearchUniversity of LancasterUK
| | | | - Diane Griffiths
- Liverpool Early Intervention ServiceMersey Care NHS TrustLiverpoolUK
| | - Claire Seddon
- Liverpool Early Intervention ServiceMersey Care NHS TrustLiverpoolUK
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11
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Pyle M, Broome MR, Joyce E, MacLennan G, Norrie J, Freeman D, Fowler D, Haddad PM, Shiers D, Hollis C, Smith J, Liew A, Byrne RE, French P, Peters S, Hudson J, Davies L, Emsley R, Yung A, Birchwood M, Longden E, Morrison AP. Study protocol for a randomised controlled trial of CBT vs antipsychotics vs both in 14-18-year-olds: Managing Adolescent first episode Psychosis: a feasibility study (MAPS). Trials 2019; 20:395. [PMID: 31272477 PMCID: PMC6611021 DOI: 10.1186/s13063-019-3506-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 06/10/2019] [Indexed: 01/03/2023] Open
Abstract
Background Adolescent-onset psychosis is associated with more severe symptoms and poorer outcomes than adult-onset psychosis. The National Institute for Clinical Excellence (NICE) recommend that adolescents with first episode psychosis (FEP) should be offered a combination of antipsychotic medication (APs), cognitive behavioural therapy (CBT) and family intervention (FI). The evidence for APs in treating psychosis is limited in adolescents compared to adults. Nevertheless, it indicates that APs can reduce overall symptoms in adolescents but may cause more severe side effects, including cardiovascular and metabolic effects, than in adults. CBT and FI can improve outcomes in adults, but there are no studies of psychological interventions (PI) in patients under 18 years old. Given this limited evidence base, NICE made a specific research recommendation for determining the clinical and cost effectiveness of APs versus PI versus both treatments for adolescent FEP. Methods/design The current study aimed to establish the feasibility and acceptability of conducting such a trial by recruiting 14–18-year-olds with a first episode of psychosis into a feasibility prospective randomised open blinded evaluation (PROBE) design, three-arm, randomised controlled trial of APs alone versus PI alone versus a combination of both treatments. We aimed to recruit 90 participants from Early Intervention and Child and Adolescent Mental Health Teams in seven UK sites. APs were prescribed by participants’ usual psychiatrists. PI comprised standardised cognitive behavioural therapy and family intervention sessions. Discussion This is the first study to compare APs to PI in an adolescent population with FEP. Recruitment finished on 31 October 2018. The study faced difficulties with recruitment across most sites due to factors including clinician and service-user treatment preferences. Trial registration Current controlled trial with ISRCTN, ISRCTN80567433. Registered on 27 February 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3506-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Melissa Pyle
- The Psychosis Research Unit, Department of Psychology, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, M25 3BL, UK.,Division of Psychology and Mental Health, University of Manchester, Zochonis Building, Manchester, M13 9PL, UK
| | - Matthew R Broome
- Institute for Mental Health, School of Psychology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. .,Department of Psychiatry, Medical Sciences Division, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK. .,Centre for Human Brain Health, School of Psychology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. .,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX4 7JX, UK.
| | - Emmeline Joyce
- The Psychosis Research Unit, Department of Psychology, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, M25 3BL, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, 3rd Floor Health Sciences Building, Aberdeen, AB25 2ZD, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Centre for Population Health Sciences, Usher Institute, Nine Edinburgh BioQuarter, 9 Little France Road, Edinburgh, EH16 4UX, UK
| | - Daniel Freeman
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK.,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX4 7JX, UK
| | - David Fowler
- School of Psychology, Pevensey Building, University of Sussex, Falmer, BN1 9QH, UK
| | - Peter M Haddad
- The Psychosis Research Unit, Department of Psychology, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, M25 3BL, UK.,Department of Psychiatry, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - David Shiers
- The Psychosis Research Unit, Department of Psychology, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, M25 3BL, UK.,Division of Psychology and Mental Health, University of Manchester, Zochonis Building, Manchester, M13 9PL, UK
| | - Chris Hollis
- NIHR MindTech MedTech Co-operative, Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham, Innovation Park, Triumph Road, Nottingham, NG7 2TU, UK
| | - Jo Smith
- School of Allied Health and Community, Bredon Building, University of Worcester, Worcester, WR2 6AJ, UK
| | - Ashley Liew
- Institute for Mental Health, School of Psychology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.,Centre for Educational Development, Appraisal and Research, University of Warwick, Coventry, CV4 7AL, UK.,Forward Thinking Birmingham, Birmingham Women's and Children's NHS Foundation Trust, Finch Road, Lozells, B19 1HS, UK
| | - Rory E Byrne
- The Psychosis Research Unit, Department of Psychology, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, M25 3BL, UK.,Division of Psychology and Mental Health, University of Manchester, Zochonis Building, Manchester, M13 9PL, UK
| | - Paul French
- The Psychosis Research Unit, Department of Psychology, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, M25 3BL, UK.,Institute of Psychology, Health and Society, University of Liverpool, Waterhouse Building, Liverpool, L69 3BX, UK
| | - Sarah Peters
- Division of Psychology and Mental Health, University of Manchester, Zochonis Building, Manchester, M13 9PL, UK
| | - Jemma Hudson
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, 3rd Floor Health Sciences Building, Aberdeen, AB25 2ZD, UK
| | - Linda Davies
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Jean MacFarlane Building, Manchester, M13 9PL, UK
| | - Richard Emsley
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, Denmark Hill, London, SE5 8AZ, UK
| | - Alison Yung
- The Psychosis Research Unit, Department of Psychology, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, M25 3BL, UK.,Division of Psychology and Mental Health, University of Manchester, Zochonis Building, Manchester, M13 9PL, UK.,Centre for Youth Mental Health, Faculty of Medicine, University of Melbourne, 35 Poplar Rd, Parkville, Melbourne, VIC, 3052, Australia
| | - Max Birchwood
- Warwick Medical School-Mental Health and Wellbeing, University of Warwick, Coventry, CV4 7AL, UK
| | - Eleanor Longden
- The Psychosis Research Unit, Department of Psychology, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, M25 3BL, UK.,Division of Psychology and Mental Health, University of Manchester, Zochonis Building, Manchester, M13 9PL, UK
| | - Anthony P Morrison
- The Psychosis Research Unit, Department of Psychology, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, M25 3BL, UK.,Division of Psychology and Mental Health, University of Manchester, Zochonis Building, Manchester, M13 9PL, UK
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12
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Cognitive therapy of psychosis: Research and implementation. Schizophr Res 2019; 203:62-65. [PMID: 29129504 DOI: 10.1016/j.schres.2017.09.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/10/2017] [Accepted: 09/19/2017] [Indexed: 12/31/2022]
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13
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Should people with psychosis be supported in choosing cognitive therapy as an alternative to antipsychotic medication: A commentary on a commentary. Schizophr Res 2018; 199:445-446. [PMID: 29631872 DOI: 10.1016/j.schres.2018.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 04/01/2018] [Indexed: 11/22/2022]
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14
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Morrison AP, Pyle M, Gumley A, Schwannauer M, Turkington D, MacLennan G, Norrie J, Hudson J, Bowe SE, French P, Byrne R, Syrett S, Dudley R, McLeod HJ, Griffiths H, Barnes TRE, Davies L, Kingdon D. Cognitive behavioural therapy in clozapine-resistant schizophrenia (FOCUS): an assessor-blinded, randomised controlled trial. Lancet Psychiatry 2018; 5:633-643. [PMID: 30001930 PMCID: PMC6063993 DOI: 10.1016/s2215-0366(18)30184-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although clozapine is the treatment of choice for treatment-refractory schizophrenia, 30-40% of patients have an insufficient response, and others are unable to tolerate it. Evidence for any augmentation strategies is scarce. We aimed to determine whether cognitive behavioural therapy (CBT) is an effective treatment for clozapine-resistant schizophrenia. METHODS We did a pragmatic, parallel group, assessor-blinded, randomised controlled trial in community-based and inpatient mental health services in five sites in the UK. Patients with schizophrenia who were unable to tolerate clozapine, or whose symptoms did not respond to the drug, were randomly assigned 1:1 by use of randomised-permuted blocks of size four or six, stratified by centre, to either CBT plus treatment as usual or treatment as usual alone. Research assistants were masked to allocation to protect against rater bias and allegiance bias. The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months, which provides a continuous measure of symptoms of schizophrenia; PANSS total was also assessed at the end of treatment (9 months). The primary analysis was by randomised treatment based on intention to treat, for all patients for whom data were available. This study was prospectively registered, number ISRCTN99672552. The trial is closed to accrual. FINDINGS From Jan 1, 2013, to May 31, 2015, we randomly assigned 487 participants to either CBT and treatment as usual (n=242) or treatment as usual alone (n=245). Analysis included 209 in the CBT group and 216 in the treatment as usual group. No difference occurred in the primary outcome (PANSS total at 21 months, mean difference -0·89, 95% CI -3·32 to 1·55; p=0·48), although the CBT group improved at the end of treatment (PANSS total at 9 months, mean difference -2·40, -4·79 to -0·02; p=0·049). During the trial, 107 (44%) of 242 participants in the CBT arm and 104 (42%) of 245 in the treatment as usual arm had at least one adverse event (odds ratio 1·09, 95% CI 0·81 to 1·46; p=0·58). Only two (1%) of 242 participants in the CBT arm and one (<1%) of 245 in the treatment as usual arm had a trial-related serious adverse event. INTERPRETATION At 21-month follow-up, CBT did not have a lasting effect on total symptoms of schizophrenia compared with treatment as usual; however, CBT produced statistically, though not clinically, significant improvements on total symptoms by the end of treatment. There was no indication that the addition of CBT to treatment as usual caused adverse effects. The results of this trial do not support a recommendation to routinely offer CBT to all people who meet criteria for clozapine-resistant schizophrenia; however, a pragmatic individual trial might be indicated for some. FUNDING National Institute for Health Research Technology Assessment programme.
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Affiliation(s)
- Anthony P Morrison
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK; Zochonis Building, University of Manchester, Manchester, UK; Division of Psychology and Mental Health, Zochonis Building, University of Manchester, Manchester, UK.
| | - Melissa Pyle
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK; Zochonis Building, University of Manchester, Manchester, UK; Division of Psychology and Mental Health, Zochonis Building, University of Manchester, Manchester, UK
| | - Andrew Gumley
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - Matthias Schwannauer
- Department of Clinical Psychology, School of Health in Social Science, Old Medical School, The University of Edinburgh, Edinburgh, UK
| | - Douglas Turkington
- Academic Psychiatry, Northumberland, Tyne and Wear NHS Foundation Trust, Centre for Aging and Vitality, Newcastle General Hospital, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences & Informatics, Nine Edinburgh BioQuarter, The University of Edinburgh, Edinburgh, UK
| | - Jemma Hudson
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Samantha E Bowe
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK; Zochonis Building, University of Manchester, Manchester, UK
| | - Paul French
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK; Zochonis Building, University of Manchester, Manchester, UK; Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Rory Byrne
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK; Zochonis Building, University of Manchester, Manchester, UK; Division of Psychology and Mental Health, Zochonis Building, University of Manchester, Manchester, UK
| | - Suzy Syrett
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - Robert Dudley
- School of Psychology, Newcastle University, Newcastle Upon Tyne, UK; Early Intervention in Psychosis Service, Northumberland, Tyne and Wear NHS Foundation Trust, Tranwell Unit, Queen Elizabeth Hospital, Gateshead, UK
| | - Hamish J McLeod
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - Helen Griffiths
- Department of Clinical Psychology, School of Health in Social Science, Old Medical School, The University of Edinburgh, Edinburgh, UK
| | | | - Linda Davies
- Division of Population Health, Zochonis Building, University of Manchester, Manchester, UK
| | - David Kingdon
- University Department of Psychiatry, Academic Centre, University of Southampton, Southampton, UK
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15
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A (five-)level playing field for mental health conditions?: exploratory analysis of EQ-5D-5L-derived utility values. Qual Life Res 2017; 27:717-724. [PMID: 29248995 PMCID: PMC5845602 DOI: 10.1007/s11136-017-1768-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 10/29/2022]
Abstract
PURPOSE Economic evaluations of mental health interventions often measure health benefit in terms of utility values derived from the EQ-5D. For the five-level version of the EQ-5D, there are two methods of estimating utility [crosswalk and stated preference (5L-SP)]. This paper explores potential impacts for researchers and decision-makers when comparing utility values derived from either method in the specific context of mental health. METHODS Baseline EQ-5D-5L data from three large randomised controlled trials of interventions for mental health conditions were analysed. Utility values were generated using each method. Mean utility values were compared using a series of t tests on pooled data and subgroups. Scenario analyses explored potential impacts on cost-effectiveness decisions. RESULTS EQ-5D data were available for 1399 participants. The mean utility value for each trial was approximately 0.08 higher when estimated using the 5L-SP approach compared to crosswalk (p < 0.0001). The difference was greatest among people reporting extreme anxiety/depression (mean utility 5L-SP 0.309, crosswalk 0.084; difference = 0.225; p < 0.0001). Identical improvements in health status were associated with higher costs to gain one QALY with the 5L-SP approach; this is more pronounced when improvements are across all domains compared to improvements on the anxiety/depression domain only. CONCLUSIONS The two approaches produce significantly different utility values in people with mental health conditions. Resulting differences in cost per QALY estimates suggest that thresholds of cost-effectiveness may also need to be reviewed. Researchers and decision-makers should exercise caution when comparing or synthesising data from trials of mental health interventions using different utility estimation approaches.
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16
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Morrison AP. A manualised treatment protocol to guide delivery of evidence-based cognitive therapy for people with distressing psychosis: learning from clinical trials. PSYCHOSIS-PSYCHOLOGICAL SOCIAL AND INTEGRATIVE APPROACHES 2017. [DOI: 10.1080/17522439.2017.1295098] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Anthony P. Morrison
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK
- Psychosis Research Unit, Greater Manchester West NHS Trust, Manchester, UK
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