A retrospective evaluation of the impact of total smoking cessation on psychiatric inpatients taking clozapine.

OBJECTIVE: To investigate the effect of a complete smoking ban on a group of psychiatric inpatients maintained on the antipsychotic medication clozapine. METHOD: Retrospective data on clozapine dose and plasma levels were collected from a three month period before and a six month period after the introduction of the smoking ban. RESULTS: Before the ban only 4.2% of patients who smoked had a plasma clozapine level > or =1000 microg/l but after the ban this increased to 41.7% of the sample within the six month period following the ban despite dose reductions. CONCLUSION: Abrupt cessation of smoking is associated with a potentially serious risk of toxicity in patients taking clozapine. Plasma clozapine levels must be monitored closely and adjustments made in dosage, if necessary, for at least six months after cessation.

Cognitive behaviour therapy 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 standard care, specific medication, other therapies and no intervention. SEARCH STRATEGY: This 2004 update built on past work by searching the Cochrane Schizophrenia Groups' Register of Trials (January 2004). We inspected all references of the selected articles for further relevant trials. 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 (CI) along with the number needed to treat/harm (NNT/H). MAIN RESULTS: 30 papers described 19 trials. CBT plus standard care did not reduce relapse and readmission compared with standard care (long term 4 RCTs, n=357, RR 0.8 CI 0.5 to 1.5), but did decrease the risk of staying in hospital (1 RCT, n=62, RR 0.5 CI 0.3 to 0.9, NNT 4 CI 3 to 15). CBT helped mental state over the medium term (2 RCTs, n=123, RR No meaningful improvement 0.7 CI 0.6 to 0.9, NNT 4 CI 3 to 9) but after one year the difference was gone (3 RCTs, n=211, RR 0.95 CI 0.6 to 1.5). Continuous measures of mental state (BDI, BPRS, CPRS, MADRS, PAS) do not demonstrate a consistent effect. When compared with supportive psychotherapy, CBT had no effect on relapse (1 RCT, n=59, RR medium term 0.6 CI 0.2 to 2; 2 RCTs, n=83, RR long term 1.1 CI 0.5 to 2.4). This also applies to the outcome of 'No clinically meaningful improvements in mental state' over the same time periods (1 RCT, n=59, RR medium term 0.8 CI 0.6 to 1.1; 2 RCT, n=100, RR long term 0.9 CI 0.8 to 1.1). When CBT was combined with a psychoeducational approach there was no significant reduction of readmission rates relative to standard care alone (1 RCT, n=91, RR 0.9 CI 0.6 to 1.4). REVIEWERS' CONCLUSIONS: CBT is a promising but under evaluated intervention. Currently, trial-based data supporting the wide use of CBT for people with schizophrenia or other psychotic illnesses are far from conclusive. More trials are justified, especially in comparison with a lower grade supportive approach. These trials should be designed to be both clinically meaningful and widely applicable.

Cognitive behaviour therapy for schizophrenia.

BACKGROUND: Medication is the mainstay of treatment for schizophrenia. Many people with schizophrenia, however, continue to experience symptoms in spite of medication and may experience side effects that are unwanted and unpleasant. In addition to medication additional forms of treatment include talking therapies such as cognitive behavioural therapy. This approach helps to link the person's feelings and patterns of thinking which underpin distress. OBJECTIVES: To review the effectiveness of cognitive behavioural therapy for people with schizophrenia, when compared to standard care, specific medication, other therapies and non-intervention. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1980-1998), CINAHL (1982-1998), The Cochrane Library (Issue 2, 1998), The Cochrane Schizophrenia Groups' Register of Trials, which encompasses up to date searches of all listed databases (January 2001), EMBASE (1980-1998), MEDLINE (1966-1998), PsychLIT (1887-1997), SIGLE (1990-1998), Sociofile (1980-1998) were undertaken. All references of the articles selected were searched for further relevant trials. SELECTION CRITERIA: This review includes relevant randomised trials of cognitive behaviour therapy for people with a diagnosis of schizophrenia-like illnesses. Outcomes such as death, mental state, relapse, psychological well-being and acceptability of treatment were sought. DATA COLLECTION AND ANALYSIS: Studies were reliably selected and assessed for methodological quality. Data were extracted by two reviewers working independently. Dichotomous data were analysed on an intention-to-treat basis and continuous data with 65% completion rate are presented. Where possible, for dichotomous outcomes, a relative risk (RR) with the 95% confidence interval (CI) was estimated along with the number needed to treat statistic (NNT). MAIN RESULTS: Twenty-two relevant papers describing thirteen trials were identified. Cognitive behavioural therapy in addition to standard care did not significantly reduce the rate of relapse and readmission to hospital when compared with standard care alone (medium term 1 RCT, N=61, RR 0.1 CI 0.01 to 1.7; long term 2 RCTs, N=123, RR 1.1 CI 0.8 to 1.5). A significant difference was observed, however, favouring cognitive behavioural therapy over standard care alone, in terms of being able to be discharged from hospital (1 RCT, N=62, RR 0.5 CI 0.3 to 0.9, NNT 3 CI 2 to 12). For 'no important improvement in mental state' data showed a significant difference favouring the cognitive behavioural therapy group over standard care alone when measured at 13 to 26 weeks (2 RCTs, N=123, RR 0.7 CI 0.6 to 0.9, NNT 4 CI 2 to 8). After one year the difference was no longer significant (3 RCTs, N=211, RR 0.95 CI 0.6 to 1.5). On continuous measures (BPRS, CPRS, Psychiatric Assessment Scale) data are not convincing of an effect. A cognitive behavioural therapy approach focusing on compliance may have some effects on insight and attitudes to medication, but the clinical meaning of these data is unclear. When compared with supportive psychotherapy, cognitive behavioural therapy had no effects on relapse rate and clinically meaningful improvements in mental state. Cognitive behavioural therapy combined with other psycho-social/educational interventions may decrease the numbers of people able to tolerate the intervention, at least under study conditions. REVIEWER'S CONCLUSIONS: Cognitive behavioural therapy is a promising but under evaluated intervention. Currently, trial-based data supporting the wide use of cognitive behavioural therapy for people with schizophrenia or other psychotic illnesses are far from conclusive. More trials are justified, especially in comparison with a lower grade supportive approach. These trials should be designed to be both clinically meaningful and widely applicable.

Cognitive behaviour therapy for schizophrenia.

BACKGROUND: Although medication is the mainstay of treatment for schizophrenia, always, some sort of informal or formal talking therapy is indicated. In cognitive behavioural therapy (CBT) links are made between the person's feelings and patterns of thinking which underpin their distress. OBJECTIVES: To review the effects of cognitive behaviour therapy (CBT) for those with schizophrenia compared to standard care, specific medication and non-intervention; also to review the effects of CBT for those with schizophrenia who are concurrently receiving standard care compared to no additional intervention to standard care, specific medication, additional drug interventions to standard care and other additional psychosocial interventions to standard care. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1980-1998), CINAHL (1982-1998), The Cochrane Library (Issue 2, 1998), The Cochrane Schizophrenia Group's Register of Trials (August 1998), EMBASE (1980-1998), MEDLINE (1966-1998), PsycLIT (1887-1998), SIGLE (1990-1998), and Sociofile (1980-1998) were undertaken. All references of articles selected were searched for further relevant trials. SELECTION CRITERIA: Randomised trials of cognitive behaviour therapy for people with a diagnosis of schizophrenia, possible schizophrenia or mental illnesses where specific diagnoses have not been employed. Outcomes such as death, metal state, relapse, psychological well-being and acceptability of treatment were sought. DATA COLLECTION AND ANALYSIS: Studies were reliably selected and assessed for methodological quality. Data were extracted by two reviewers working independently. Dichotomous data were analysed on an intention-to-treat basis and continuous data with 70% completion rate are presented. MAIN RESULTS: Four small trials were identified. All presented data suggested that there was a difference favouring CBT plus standard care over standard care alone in terms of reducing relapse rates (short term OR 0.31 CI 0.1-0.98; medium term OR 0.38 CI 0.17-0.83; long term OR 0.46 CI 0.26-0.83, NNT 6 CI 3-30). These findings were supported within the trials by scale-derived data. CBT, however, did not keep more people in care than a standard approach and there is no data relating to the effect of CBT on compliance with medication. One study also presented data on the effects of CBT when compared to supportive psychotherapy. No effect statistically significantly favoured either group but all were suggestive that the trial may have been underpowered to find an effect in favour of CBT. REVIEWER'S CONCLUSIONS: The results of well conducted and reported ongoing trials are eagerly awaited. Currently, for those with schizophrenia willing to receive CBT, access to this treatment approach is associated with a substantially reduced risk of relapse. However, at present CBT is a fairly scarce commodity, often provided by highly skilled and experienced therapists. Therefore, its application in day to day practice may be restricted by the availability of suitable practitioners. Similarly, the present data provides little indication of how effective CBT procedures might be when they are applied by less experienced practitioners.