Cognitive behavioural therapy plus standard care versus standard care plus other psychosocial treatments for people with schizophrenia.

BACKGROUND: Cognitive behavioural therapy (CBT) is a psychosocial treatment that aims to help individuals re-evaluate their appraisals of their experiences that can affect their level of distress and problematic behaviour. CBT is now recommended by the National Institute for Health and Care Excellence (NICE) as an add-on treatment for people with a diagnosis of schizophrenia. Other psychosocial therapies that are often less expensive are also available as an add-on treatment for people with schizophrenia. This review is also part of a family of Cochrane Reviews on CBT for people with schizophrenia. OBJECTIVES: To assess the effects of CBT compared with other psychosocial therapies as add-on treatments for people with schizophrenia. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Study Based Register of Trials (latest 6 March, 2017). This register is compiled by systematic searches of major resources (including AMED, BIOSIS CINAHL, Embase, MEDLINE, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) involving people with schizophrenia who were randomly allocated to receive, in addition to their standard care, either CBT or any other psychosocial therapy. Outcomes of interest included relapse, global state, mental state, adverse events, social functioning, quality of life and satisfaction with treatment. We included trials meeting our inclusion criteria and reporting useable data. DATA COLLECTION AND ANALYSIS: We reliably screened references and selected trials. Review authors, working independently, assessed trials for methodological quality and extracted data from included studies. We analysed dichotomous data on an intention-to-treat basis and continuous data with 60% completion rate. Where possible, for binary data we calculated risk ratio (RR), for continuous data we calculated mean difference (MD), all with 95% confidence intervals (CIs). We used a fixed-effect model for analyses unless there was unexplained high heterogeneity. We assessed risk of bias for the included studies and used the GRADE approach to produce a 'Summary of findings' table for our main outcomes of interest. MAIN RESULTS: The review now includes 36 trials with 3542 participants, comparing CBT with a range of other psychosocial therapies that we classified as either active (A) (n = 14) or non active (NA) (n = 14). Trials were often small and at high or unclear risk of bias. When CBT was compared with other psychosocial therapies, no difference in long-term relapse was observed (RR 1.05, 95% CI 0.85 to 1.29; participants = 375; studies = 5, low-quality evidence). Clinically important change in global state data were not available but data for rehospitalisation were reported. Results showed no clear difference in long term rehospitalisation (RR 0.96, 95% CI 0.82 to 1.14; participants = 943; studies = 8, low-quality evidence) nor in long term mental state (RR 0.82, 95% CI 0.67 to 1.01; participants = 249; studies = 4, low-quality evidence). No long-term differences were observed for death (RR 1.57, 95% CI 0.62 to 3.98; participants = 627; studies = 6, low-quality evidence). Only average endpoint scale scores were available for social functioning and quality of life. Social functioning scores were similar between groups (long term Social Functioning Scale (SFS): MD 8.80, 95% CI -4.07 to 21.67; participants = 65; studies = 1, very low-quality evidence), and quality of life scores were also similar (medium term Modular System for Quality of Life (MSQOL): MD -4.50, 95% CI -15.66 to 6.66; participants = 64; studies = 1, very low-quality evidence). There was a modest but clear difference favouring CBT for satisfaction with treatment - measured as leaving the study early (RR 0.86, 95% CI 0.75 to 0.99; participants = 2392; studies = 26, low quality evidence). AUTHORS' CONCLUSIONS: Evidence based on data from randomised controlled trials indicates there is no clear and convincing advantage for cognitive behavioural therapy over other - and sometimes much less sophisticated and expensive - psychosocial therapies for people with schizophrenia. It should be noted that although much research has been carried out in this area, the quality of evidence available is mostly low or of very low quality. Good quality research is needed before firm conclusions can be made.

Eight decades of mortality in an English high-security hospital.

BACKGROUND: Psychiatric patients are known to have poorer physical health than the general population and to have premature mortality, but the impact of institutional care on the physical health of patients is less clear. AIMS: This study aimed to compare mortality rates and causes of death between a high-security psychiatric hospital cohort and the general population in England for the periods 1920-1961 and 1972-2000. METHOD: Data were obtained from various clinical and non-clinical archives and death certificates. Standardised mortality ratios were calculated for all causes of patient death for each International Classification of Diseases, 10th Edition category. RESULTS: Mortality rates of men ever resident in Rampton Hospital were similar to those of men in the general population, but women in Rampton Hospital had nearly twice the national death rate. Younger men in the latest time period (1972-2000), however, had a higher mortality rate. Higher mortality rates in the hospital than in the general population were accounted for by infectious and parasitic diseases as well as diseases of the nervous system; rates of neoplasms and diseases of the blood and of circulatory or respiratory diseases were lower among the patients. CLINICAL IMPLICATIONS: Specific-cause mortality rates were compatible with our working hypothesis that the hospital could in some ways pose risks and in other ways be protective. Morbidity and causes of premature death may be environment-specific, so recognition of the types of illness linked to premature death among high-security hospital patients could inform improvements in the physical health of long-stay patients. Further longitudinal studies should be undertaken to monitor trends and inform changes needed to reduce premature mortality. Copyright © 2015 John Wiley & Sons, Ltd.

Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia.

BACKGROUND: Cognitive behavioural therapy (CBT) is now a recommended treatment for people with schizophrenia. This approach helps to link the person's distress and problem behaviours to underlying patterns of thinking. OBJECTIVES: To review the effects of CBT for people with schizophrenia when compared with other psychological therapies. SEARCH METHODS: We searched the Cochrane Schizophrenia Group Trials Register (March 2010) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. We inspected all references of the selected articles for further relevant trials, and, where appropriate, contacted authors. SELECTION CRITERIA: All relevant randomised controlled trials (RCTs) of CBT for people with schizophrenia-like illnesses. DATA COLLECTION AND ANALYSIS: Studies were reliably selected and assessed for methodological quality. Two review authors, working independently, extracted data. We analysed dichotomous data on an intention-to-treat basis and continuous data with 65% completion rate are presented. Where possible, for dichotomous outcomes, we estimated a risk ratio (RR) with the 95% confidence interval (CI) along with the number needed to treat/harm. MAIN RESULTS: Thirty papers described 20 trials. Trials were often small and of limited quality. When CBT was compared with other psychosocial therapies, no difference was found for outcomes relevant to adverse effect/events (2 RCTs, n = 202, RR death 0.57 CI 0.12 to 2.60). Relapse was not reduced over any time period (5 RCTs, n = 183, RR long-term 0.91 CI 0.63 to 1.32) nor was rehospitalisation (5 RCTs, n = 294, RR in longer term 0.86 CI 0.62 to 1.21). Various global mental state measures failed to show difference (4 RCTs, n = 244, RR no important change in mental state 0.84 CI 0.64 to 1.09). More specific measures of mental state failed to show differential effects on positive or negative symptoms of schizophrenia but there may be some longer term effect for affective symptoms (2 RCTs, n = 105, mean difference (MD) Beck Depression Inventory (BDI) -6.21 CI -10.81 to -1.61). Few trials report on social functioning or quality of life. Findings do not convincingly favour either of the interventions (2 RCTs, n = 103, MD Social Functioning Scale (SFS) 1.32 CI -4.90 to 7.54; n = 37, MD EuroQOL -1.86 CI -19.20 to 15.48). For the outcome of leaving the study early, we found no significant advantage when CBT was compared with either non-active control therapies (4 RCTs, n = 433, RR 0.88 CI 0.63 to 1.23) or active therapies (6 RCTs, n = 339, RR 0.75 CI 0.40 to 1.43) AUTHORS' CONCLUSIONS: Trial-based evidence suggests no clear and convincing advantage for cognitive behavioural therapy over other - and sometime much less sophisticated - therapies for people with schizophrenia.

WITHDRAWN: Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia.

BACKGROUND: Cognitive behavioural therapy (CBT) is now a recommended treatment for people with schizophrenia. This approach helps to link the person's feelings and patterns of thinking which underpin distress. OBJECTIVES: To review the effects of CBT for people with schizophrenia when compared to other psychological therapies. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group Trials Register (March 2010) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. We inspected all references of the selected articles for further relevant trials, and, where appropriate, contacted authors. SELECTION CRITERIA: All relevant clinical randomised trials of cognitive behaviour therapy for people with schizophrenia-like illnesses. DATA COLLECTION AND ANALYSIS: Studies were reliably selected and assessed for methodological quality. Two reviewers, working independently, extracted data. We analysed dichotomous data on an intention-to-treat basis and continuous data with 65% completion rate are presented. Where possible, for dichotomous outcomes, we estimated a relative risk (RR) with the 95% confidence interval along with the number needed to treat/harm. MAIN RESULTS: Twenty-nine papers described 20 trials. Trials were often small and of limited quality. When CBT was compared with other psychosocial therapies no difference was found for outcomes relevant to adverse effect/events (2 RCTs, n=202, RR death 0.57 CI 0.12 to 2.60). Relapse was not reduced over any time period (5 RCTs, n=183, RR in long term 0.91 CI 0.63 to 1.32) nor was rehospitalisation (5 RCTs, n=294, RR in longer term 0.86 CI 0.62 to 1.21). Various global mental state measures failed to show difference (4 RCTs, n=244, RR no important change in mental state 0.84 CI 0.64 to 1.09). More specific measures of mental state failed to show differential effects on positive or negative symptoms of schizophrenia but there may be some longer term effect for affective symptoms (2 RCTs, n=105, MD BDI -6.21 CI -10.81 to -1.61). Few trials report on social functioning or quality of life. Findings do not convincingly favour either interventions (2 RCT, n=103, MD SFS 1.32 CI -4.90 to 7.54; n=37, MD EuroQOL -1.86 CI -19.20 to 15.48). For the outcome of leaving the study early we found no significant advantage when CBT was compared with either non-active control therapies (4 RCTs, n=433, RR 0.88 CI 0.63 to 1.23) or active therapies (6 RCTs, n=339, RR 0.75 CI 0.40 to 1.43) AUTHORS' CONCLUSIONS: Trail-based evidence suggests no clear and convincing advantage for cognitive behavioural therapy over other and sometime much less sophisticated therapies for people with schizophrenia.