Talk Therapy of Limited Use for Psychosis
Adding cognitive therapy to regular patient monitoring was no better at preventing the emergence of psychotic symptoms than monitoring alone, researchers found.
It does, however, appear to lessen the severity of psychotic disorders in at-risk patients, Anthony Morrison, MD, of the University of Manchester in England, and colleagues, reported online in BMJ.
“A reduction in severity of psychotic symptoms is clearly desirable in young people at risk,” they wrote. “The lack of an effect on transition to psychosis is, however, disappointing.”
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To test whether cognitive therapy could prevent a transition to psychosis in at-risk patients - those with transient psychotic symptoms or family history of illness, for example - Morrison and colleagues enrolled 288 patients, ages 14 to 35, at five U.K. centers.
About 67% of patients had at least one DSM-IV diagnosis at study entry, particularly major depressive disorder.
Half were assigned to cognitive therapy plus monitoring, the other half to monitoring only. Monitoring, however, was an “enhancement” over routine care, the researchers said, because it ensured patients had a general practitioner whom they could regularly contact.
People with long-lasting depression may benefit from talk therapy when other treatment methods such as antidepressant drugs alone aren’t working, suggests a new study. But the topic needs more research, the authors say - and they also point out that talk therapy isn’t accessible or affordable for everyone.
About 15 million adults in America suffer from major depressive disorder - serious cases of depression that last more than two weeks - in any given year, according to the National Institute of Mental Health. Most people who are diagnosed with major depressive disorder get prescribed an antidepressant rather than going straight into talk therapy, explained Dr. Ranak Trivedi, the lead author on the current study from the University of Washington School of Public Health.
But up to half of those people might not feel any better after they start taking the medication, she said.
Guidelines point doctors to a few different options for treating patients who don’t respond to their first antidepressant drug. The doctor can add a new antidepressant to the first one, or switch drugs completely. Sometimes it takes several attempts to find the drug or drugs that will help the patient feel better. They can also refer the patient to talk therapy, either in addition to medication or instead of medication.
Patients were followed for at least 12 months; those in the intervention group had mean of about 9 sessions over six months, each lasting about an hour.
Schizophrenia Ireland has published a new document outlining the benefits of psychological or talk therapies in the treatment of psychosis as part of Lucia Week, the national schizophrenia awareness week.
“The need for greater access to psychological or talk therapies has been clearly articulated by many groups. The demand for psychological and social therapies and the evidence for their effectiveness has been growing in recent years,” said John Saunders, director of Schizophrenia Ireland.
The document, Talking about Talking Therapies: Psychotherapy and Psychosis, is published in conjunction with the present government mental health policy, which emphasises the need to provide a range of drug, psychological and social therapies to aid people in their recovery from mental illness.
Psychological therapies should be regarded as a routine component of basic mental healthcare services, rather than being viewed as additional options that are not consistently available, Mr Saunders added.
This is the consensus among users and service providers alike, he said.
Morrison and colleagues found that the overall rate of transition to psychosis was lower than expected at 8% (proportional odds ratio 0.73, 95% CI 0.32 to 1.68), which potentially contributed to the study being underpowered to detect a difference between groups, they wrote.
Fewer patients who had cognitive therapy made the defined transition to psychosis, but there was no significant difference between groups (6.9% versus 9%).
In regression analyses, they found that distress from psychotic symptoms didn’t differ between groups at 12 months (estimated difference -3, 95% CI -6.95 to 0.94), but those who had cognitive therapy had significantly reduced symptom severity at 12 months (estimated between group effect size -3.67, 95% CI -6.71 to -0.64, P=0.018).
There were no differences between groups, however, in terms of functioning, depression, social anxiety, or quality of life, the researchers reported.
They said the findings are similar to those of other trials of at-risk patients, which found that symptom severity could be reduced, but not transition to psychosis during a similar intervention period.
Still, it’s possible that the therapeutic effects of monitoring were more beneficial because it “provided regular contact with nonjudgmental, warm, empathic, and accepting individuals,” they wrote.
Dr Terry Lynch, psychotherapist and GP, explains that traditionally, psychosis has been interpreted as evidence of total loss of contact with reality, utterly irrational, beyond comprehension; but a more expansive understanding of psychosis is now being called for.
“The psychotic experience is far from meaningless, purposeless and nonsensical. Frequently, vital clues and statements towards understanding the person and their distress are contained within the experience,” he says.
Dr Lynch believes that therapy is a safe place for that psychotic experience to be revealed and explored, and stresses that the obvious benefits of medication, particularly in the acute stages, do not negate the role of talking therapies.
Recognising this, Schizophrenia Ireland, the national organisation dedicated to upholding the rights and addressing the needs of all those affected by enduring mental illness, provides a confidential, safe and professional counselling service. It is available free of charge in Dublin, Cork, Kilkenny, and Tullamore.
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According to Schizophrenia Ireland, an analysis of over 100 studies found that programmes which included both psychological and drug therapy yielded a 60% success rate. They also found that the relapse rate after 17 months for service users with schizophrenia who received psychotherapy as well as medication was 20% lower than those who received medication only.
In line with international guidelines, Talking about Talking Therapies concludes that people with schizophrenia should be offered multi-faceted treatment, which includes both psychological and drug therapy.
These treatments include family therapy to promote family support, medication adherence to prevent relapse, cognitive behaviour therapy to help clients manage symptoms, social skills training to enhance confidence and reduce isolation, cognitive rehabilitation, and supported employment or individual placement.
The study had some limitations including missing data. Also, 29 potential participants were excluded because they may have under-reported their risk level at baseline, but showed psychotic experiences consistent with transition at the second baseline assessment.
“We may have excluded those participants at highest risk of immediate transition, which would adversely affect the statistical power of the trial,” the authors explained.