For a long time, psychotherapy has been seen as providing little benefit to patients with schizophrenia or other psychotic disorders. However, two recent studies, including one in unmedicated patients, have found cognitive therapy to be quite helpful.
In the first study, researchers in the United Kingdom tested cognitive therapy in patients with schizophrenia spectrum disorders who refused antipsychotic medication and had been off the drugs for six months. Twenty patients were provided with a maximum of 26 CT sessions over nine months, and then were followed for an additional six months.
In a paper published in Psychological Medicine, the U.K. researchers reported that 35% of the patients had at least a 50% reduction in their psychiatric symptoms at the end of nine months (as measured by the Positive and Negative Syndromes Scale), and that an even higher percentage of patients — 50% — had reached this level of improvement by the end of the followup period.
No patient significantly deteriorated during the study, and only one dropped out during the nine-month treatment period.
The researchers concluded that cognitive therapy for psychotic disorders “is an acceptable treatment and is associated with a clinically significant reduction in psychiatric symptoms at both end of treatment and follow-up, in a group that are assumed to deteriorate without total adherence to medication.” In addition, cognitive therapy was “associated with improved functioning and self-rated recovery, with significant increases shown at follow-up for both.”
An obvious question, but one unaddressed by the study, is how these results would compare with outcomes from drug treatment over a 15-month period. It also would be helpful to run a study in which unmedicated psychotic patients were randomized to CT or to a “placebo” form of psychotherapy, and thus determine if CT beat placebo.
The second CT study was led by Aaron Beck, the father of cognitive therapy in the United States, and his colleagues at the University of Pennsylvania. Their goal was to help low-functioning schizophenia patients with severe negative symptoms — a loss of motivation and emotional engagement — identify and pursue concrete goals for improving their quality of life and reintegrating into society.
In the study, 60 were randomized either to a combination of cognitive therapy and standard therapy (which included antipsychotic medication), or to standard therapy alone. Those in the cognitive therapy group got weekly outpatient CT sessions for 18 months, with each session typically lasting 50 minutes. At the end of 18 months, the CT patients had better functioning and greater improvement on their negative and positive symptoms relative to those who received standard treatment only. The researchers concluded:
“The [CT] treatment encourages the patients to set goals related to their everyday functioning, and they become motivated to engage in tasks (initially simple pleasurable, social, and constructive activities) that move them out of their withdrawn state. This increase in activity and motivation puts the patients more in touch with reality and reduces hallucinations, delusions, and disorganization. Reduced positive symptoms allow for further engagement in activity, leading to better functional outcomes and enhancement of motivation, which in turn facilitate a further amelioration of positive symptoms.”
In this case, one wonders what outcomes might have been if cognitive therapy had been paired with a medication tapering protocol, given that antipsychotics can induce emotional lethargy in patients. But together, the two studies tell of a non-drug therapy that needs to be further tested and explored.
In other news:
Antipsychotics and brain shrinkage
In February of 2011, Nancy Andreasen reported that the brain shrinkage seen in schizophrenia patients was associated with use of the older neuroleptics, the newer atypical antipsychotics and clozapine. In a recent follow-up paper, Andreasen provides new details about the nature of that shrinkage, but downplays her earlier findings that antipsychotics cause such shrinkage. Instead, she mostly attributes it to the disease, even while acknowledging that she previously found that “neuroleptic treatment” contributes “significantly and independently to the tissue volume reductions, while other possible confounders such as substance misuse do not.”
In this new article, Andreasen reports that tissue loss in schizophrenia patients is seen in multiple gray matter regions of the brain (total cerebral, frontal lobes, and thalamus), and in multiple white matter regions (total cerebral, frontal, temporal, and parietal.)This tissue loss appears to be most severe during the early stages of illness, and occurs “at severe levels” in only a subset of patients. The tissue loss is strongly associated with cognitive decline, and more weakly associated with an increase in symptoms (negative symptoms, psychotic symptoms, and disorganized thinking.)
However, it is unclear why Andreasen is confident that the shrinkage is due at least in part to a disease process, given the recent review of this topic by Joanna Moncrieff and Jonathan Leo. They scoured the literature for MRI studies of schizophrenia patients who had been ill for an extended period of time and had never been medicated, and they found three such studies. Yet, in all three, the researchers concluded that there were “no major differences” between the schizophrenia patients and normal controls “in global cerebral, grey-matter, ventricular, or CSF (cerebrospinal fluid) volumes.”
Andreasen doesn’t cite that finding in her new paper. Instead, she sums up the disease/medication question in this way: “While neuroprogression may be partially accounted for by a medication effect, it also reflects an intrinsic and progressive disease process.”
In other words, if her interpretation is correct, antipsychotics could be said to exacerbate a disease process that characterizes schizophrenia.
More Evidence of Harm To Children
Recently, there has been a steady stream of evidence detailing the increasing burden of mental illness in our society. The latest report, published in the December issue of Archives of General Psychiatry, tells of a sharp rise in the number of children and adolescents hospitalized for psychiatric problems between 1996 and 2007.
Joseph Blader, from Stony Brook University School of Medicine, found that the number of children ages five to 13 years old hospitalized for psychiatric reasons rose from 155 per 100,000 children in 1996 to 283 per 100,000 in 2007. Total inpatient days for children of this age soared from 1,845 days per 100,000 in 1996 to 4,370 per 100,000 children in 2007.
In adolescents ages 14 to 19, the number hospitalized for psychiatric reasons rose from 683 per 100,000 to 969 per 100,000 between 1996 and 2007. Total inpatient days for adolescents increased from 5,882 to 8,247 days per 100,000 population in that period.
As is well documented, the prescribing of psychiatric drugs to children and adolescents has increased notably in the past 15 years. Thus, once again, we see the same correlation: As the prescribing of psychiatric drugs to a population increases, there is an increase in psychiatric distress in that population. This data tells of that happening— and one might conclude tragically so — to our nation’s youngest population.
Please, no more STAR*D lies
When the NIMH announced the results of its STAR*D trial, it claimed that two-thirds of the patients who entered the trial remitted. The trial design was such that if a first antidepressant didn’t work, patients could be put on a second one, and so forth, through four tries, and this result suggested that if depressed people would just keep on trying one pill after another, they would likely eventually find a drug that would work.
Unfortunately, that 67% recovery rate is a made-up number. Ed Pigott has published a number of articles detailing all of the scientific chicanery that went on during that trial, all of which served to inflate the remission rate. As best as I can tell, fewer than 40% of the protocol-eligible patients ever remitted, even for a brief period. More to the point, only 3% of the 4,041 patients remitted and then stayed well and in the trial during the year-long followup.
However, go to a recent blog written by Thomas Insel, director of the NIMH. In a piece that discusses the long-term effectiveness of antidepressants, he points to the STAR*D trial as possible evidence of that sort. He writes that “65 percent” of the patients remitted at six months, which makes it seem as though two-thirds of the patients were depression free at the end of that longer period. So the public is being fed the spin, rather than the real results, and this is being used to promote the notion that antidepressants provide a long-term benefit.
One does wish that this sort of government propaganda would come to a stop.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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Robert Whitaker laments propaganda of the NIMH. He hopes they will stop. That is unlikely. The pharamaceutical industry with their false front organization NAMI promote drug treatment for the benefit of the stockholders of the corporations. For almost 100 years the public relations industry in American controls the information flow to the public. Walter Lippmann, Ivy Lee, Edward Bernays are some of the early proponents of controlling the population through public relations. Many people still believe that major media keeps people informed. They reveal only what benefits themselves and their corporate sponsors. The drug industry plays a major role in misleading the public about the benefits and harm of their products. See for example television and print advertisements about how wonderful their drugs are. Or the new radio ad produced by the Ad Council promoting NAMI. Without a relentless education program about propaganda the public will continue to be misled about and by the drug industry. Drug companies will continue to employ large public relations firms to counter any negative responses to their propaganda. Discrediting their critics is a major effort, rule number one of propaganda.
Two comments. Firstly, on the impact of cognitive therapy on non-medicated people with experience of psychosis. Since reading Anatomy of an Epidemic I’ve been wondering what the impact of cognitive therapy on depression might be in medicated versus non-medicated people, and whether medication might offset the beneficial impact of CBT in the medium to long-term. If so, it would explain a lot of my experience of multiple relapse despite regular use of CBT techniques.
Which brings me to my second point, which is that the lack of studies of long-term impact of types of therapies on depression is a real problem. Along with this is the issue of studies using ‘statistically significant change’ as the only benchmark, without reference to whether scores went into a normative range. This means a study can find a statistically significant improvement in depression when most of the people in the experimental condition were still depressed, especially if they were severely depressed to start with. This can give a misleading impression if it’s not spelt out (which is often the case).