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Wednesday, March 7, 2012

Schizophrenia and CBT

A new study by Grant et al. (2012) indicates that for a fairly treatment resistant schizophrenia population hour long weekly cognitive behavioral therapy (CBT) might help.

The study assessed how low functioning patients with schizophrenia and prominent negative symptoms respond to the addition of weekly CBT to treatment as usual. And surprise: patients did get better! Why the surprise? As low functioning and negative symptoms when part of the clinical picture in schizophrenia are traditionally though of indicative of treatment-resistance. In other words, the consensus is that for this patient group nothing works. Typically, this are patients who don't spend much time with anyone - partly because they don't have an interest in socializing, partly because most people also have difficulties connecting with them.
fMRI study of working memory in schizophrenia
By Kim J, Matthews NL, Park S. via Wikimedia Commons

When it comes to psychotherapy the clinical encounters tend be brief and mostly supportive.

In a strange way, the social isolation that seems to be the crux of the problems, is not fought against but kind of reinforced by the brevity of the therapy sessions and other types of social intercourse, including support groups, ACT, day programs etc., where more times than not these patients are allowed to simply fade into the background.

Well, this study tells a slightly different story. We learn that treatment resistant patients, when socially engaged for about one hour on a weekly basis, contrary to all expectations, actually improved over time. This runs contrary to our current understanding of prognosis and treatment response. We don't expect this patients to respond to anything, yet they do. We don't expect them to benefit from social interactions, yet they do. And the catalyst of change, surprisingly, is not some other pill but time spend week after week, with someone who cares and keeps engaging the patient not for a few minutes but for almost a full hours.

The study has a number of limitations. There is no comparable control group, which makes it difficult to ascertain if the reported effect is due to the specificity of CBT or other non-specific study factors, related to the more intense social interactions in the active group.

Also, strangely enough, even if the subjects were randomized, somehow the CBT group gathered patient with a more favorable prognostic profile at baseline: the CBT patients were younger, had a shorter duration of illness, a higher rate of schizoaffective disorder (which carries a better prognosis than schizophrenia), and were treated with less cognitively impairing medications (higher rate of atypical) and lower doses (also presumably with less need for higher doses and cognitive side effects). This is a constellation of factors that unfortunately weakens the study conclusions as presumably the reported effect might in part be a result of more favorable risk profile.

Nevertheless this remains a thought provoking study. First and foremost  in that it offers a glimmer of hope for a group of patients whose sufferance has been commonly deemed as irredeemable. Secondly for pointing out that even when facing disarming levels of chronicity and severity, everything else being equal, doctors still have a duty to hold dear hope up rather than throwing in the towel. And last but not least, for reminding us all about the importance of human connection, that universal ingredient of any effective therapy, which sometimes gets forgotten in our approach to treating schizophrenia.

© Copyright Adrian Preda, M.D.

Further Reading:
Schizophrenia: Causes, Symptoms, Signs, Diagnosis and Treatments - Revised Edition - Illustrated by S. Smith

Surviving Schizophrenia: A Manual for Families, Patients, and Providers

The Center Cannot Hold: My Journey Through Madness

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