To the Editor: The review article by Douglas Turkington, M.B.Ch.B., F.R.C.Psych., and colleagues (1) makes the assertion that cognitive behavior therapy for treating patients with schizophrenia has been accepted in the United Kingdom and that evidence supporting this treatment for schizophrenia validates a similar uptake in the United States. In the editorial accompanying the article by Turkington and colleagues (2), it is accepted that cognitive behavior therapy is a promising treatment but that there is a need to avoid overpromising. To this caution, two points must be made.
First, the evidence base of cognitive behavior therapy for schizophrenia consists of heterogeneous models of cognitive behavior therapy delivered to heterogeneous diagnostic cohorts, with some studies only having 60% of subjects with schizophrenia. This diagnostic heterogeneity leads to possible systematic bias, and the outcome variables can be clinically misleading (3). The aim of cognitive behavior therapy for treating schizophrenia is to decrease the distress associated with symptoms, but by denying the prognostic implications of diagnosis, the validity of this therapy becomes an oxymoron.
Second, the evidence base shows the greatest effect to be associated with the poorest methodology (4), and therefore the validity of the combination of the current reported trials for meta-analysis is doubtful. A recent United Kingdom National Health Service report on long-term follow-up trials of cognitive behavior therapy for treating psychosis found that there was generally a poor outcome with no superiority on clinically significant change and no economic advantage regardless of treatment modality (5).
As a cognitive behavior therapist, I feel that the lack of scientific rigor from the findings of the evidence base needs to be challenged but should not necessarily change the approach to treating patients with schizophrenia. Tarrier and Wykes (4) suggest that the component analysis of cognitive behavior therapy for schizophrenia may not be the way to settle the theoretical arguments, but it may be that an approach within the “spirit of cognitive behavior therapy” is more important, with an analogy being motivational interviewing. The debate in the United Kingdom over the effectiveness of cognitive behavior therapy for treating schizophrenia is far from over, but most psychiatrists would agreed that interacting with patients and enhancing collaboration is universal, good clinical practice.
1.Turkington D, Kingdon D, Weiden PJ: Cognitive behavior therapy for schizophrenia. Am J Psychiatry 2006; 163:365–373
2.Keith SJ: Are we still talking to our patients with schizophrenia. Am J Psychiatry 2006; 163:362–364
3.Marlowe K: Early interventions for psychosis. Br J Psychiatry 2005; 186:262–263
4.Tarrier N, Wykes T: Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? a cautious or cautionary tale? Behav Res Ther 2004; 42:1377–1401
5.Durham RC, Chambers JA, Power KG, Sharp DM, Macdonald RR, Major KA, Dow MGT, Gumley AL: Long-term outcome of cognitive behaviour therapy clinical trials in central Scotland. Health Technol Assess 2005; 9:1–174