The effectiveness of Cognitive Behavioural Therapy (CBT) in the management of schizophrenia

Mental Health Nursing Research Project

1.1.   Summary table of study characteristics

1.2.   Emerging Themes

1.2.1.      CBT against antipsychotics

Morrison et al. (2018) noted that antipsychotics can be administered to patients with schizophrenia. As such, there is a need to examine the effectiveness of CBT when compared to antipsychotics. Clinicians could also use other drugs such as antidepressants, anxiolytics, and hypnotics for participants. While comparing antipsychotics, CBT, and antipsychotics plus CBT; Morrison et al. (2018) found out that antipsychotics used together with CBT are more effective than CBT alone. However, the difference between antipsychotics together with CBT compared to antipsychotics alone was not statically significant. Moreover, effectiveness does not differ between groups, and significant differences should be examined with care. This means that the use of antipsychotics together with CBT does not prove to be more effective when antipsychotics are used alone. Further results showed that there were few side effects within the CBT group when compared to the antipsychotic group which had more side effects. The combined intervention group also had high levels of side effects compared to the CBT group alone. The low levels of side effects in the CBT group could be attributed to the existence of the symptoms of the psychotic disorder such as sleep problems, memory, and attention, loss of libido, loss of energy, and automatic symptoms. The implication is that the duration of CBT sessions is necessary for patients that receive CBT with the need to focus on the use of antipsychotic medication. Overall, a key insight emerging is that CBT is effective in reducing the negative symptoms of schizophrenia. Besides, CBT plus the use of antipsychotic medication could be more effective when managing symptoms of schizophrenia. However, there are concerns about the side effects of antipsychotic medications used.

1.2.2.      Depressive symptoms and low self-esteem

Pomerleau et al. (2022) also noted that after 90 weeks of treatment with CBT, patients in the CBT group have fewer negative symptoms than those treated with TAU. Sønmez et al. (2020) noted that CBT is not superior to Treatment as Usual (TAU) in the treatment of depressive symptoms and low self-esteem among patients in the early stages of psychosis. Both CBT and TAU groups contributed to significant improvements in depressive symptoms and self-esteem and other symptoms and function domains. These outcomes were assessed during treatment as a follow-up. A key conclusion is that CBT did not have additional benefits over TAU, either with regards to primary outcomes such as depression or self-esteem as a secondary measure.  The key aspects of TAU include the use of medication, use of regular psychiatric review, as well as regular follow-ups by case management. Lincoln et al. (2012) noted that CBT for treating depression was effective since it contributed to significant improvements over the waitlist group in the total PANSS score post-treatment or post waiting. Moreover, CBT is also more effective than the wait list group concerning secondary outcomes and positive symptoms, especially depression, psychopathology, and functioning.   Kim et al. (2017) found out that CBT is effective in achieving subjective well-being, positive attitude towards treatment, perceived stress, and suspiciousness in young Korean patients with early psychosis.

1.2.3.      Culturally-adapted CBT

Habib, Dawood, Kingdon, and Naeem (2015) outlined the need to adopt a culturally-adapted CBT that is not based on western cultures. This is based on the assumption that CBT has majorly been used in the western world to examine its effectiveness in treating psychosis. However, there is a need to focus on adopting culturally-adapted CBT for non-western cultures, especially in the case of patients with schizophrenia in Pakistan. Habib, Dawood, Kingdon, and Naeem (2015) found out that patients who receive a culturally-adapted CBT for psychosis showed significant improvements in measures of positive outcomes (PANSS) measures, negative outcomes, and overall psychotic symptoms, hallucinations, delusions, and insights at the end of therapy. The implication is that when adopting the use of CBT to manage the symptoms of schizophrenia, there is a need for clinicians to consider the culture of the patient so that the avoidance of the use of CBT measures tends to be effective in the western world within other cultures. A culturally-adapted CBT for treating psychosis should be considered and developed so that it can contribute to reduced symptoms of psychosis.

1.2.4.      Hallucinations

Gottlieb et al. (2013) found out that CBT for psychosis for treating patients with schizophrenia, especially self-directed web-based CBT contributed to reductions in measures of auditory hallucinations, especially severity and the perceptions of voices as ‘outside entity’ and intensity of ‘negative commentary’. Also, CBT was effective in reducing the severity of psychotic symptoms and psychopathology. Therefore, it is important to guarantee access to CBT by considering the use of web-based programs that can assist patients to cope and experience potential clinical benefits. Thus, CBT should be used within intensive care management teams to improve clinical outcomes in schizophrenia and severe and persistent mental illness. Shukla et al. (2021) also noted that CBT is effective for the treatment of auditory hallucination in schizophrenia. These therapeutic gains were also noted and maintained at follow-up which means that CBT can be used in the long-term based on its durable effectiveness. In particular, Shukla et al. (2021) affirmed that CBT together with pharmacotherapy is more effective in improving clinical symptoms of schizophrenia and global functioning. However, pharmacology alone is not more effective than CBT plus pharmacotherapy.

1.3.   A critical analysis (CASP)

Table 4: CASP summary table

Sønmez et al. (2020) obtained consent from the participants so that they agree to be part of the study. A randomized-controlled design was used which is a highly advanced method. In particular, the RCT method is relevant to the research objective of comparing CBT against TAU. As such, analysis has focused on the use of descriptive and inferential statistics.  The randomisation process is a key aspect of RCTs that guarantees rigour of the research method thereby affecting the trustworthiness of findings. Sønmez et al. (2020) ensured that they used a computerised random number generator that was administered by staff at Oslo University Hospital independently of the research team. This means that the researchers were not aware of the randomisation process. As a result, it can be said that the randomisation process was rigorous enough to avoid any bias that can affect the results. A total of 63 patients were included as randomised to CBT (n=32) and TAU (n=31). These are equal samples that guarantee a comparison of the results. Overall, the results can be applied in practice, especially the need to use CBT to reduce depressive symptoms among patients with schizophrenia as well as enhance their self-esteem.

Morrison et al. (2018) also used the RCT method. A single-blind pilot randomised controlled trial for patients with psychosis was used within NHS trusts in Greater Manchester UK. The participants were randomly assigned to antipsychotics, CBT, or antipsychotics plus CBT at a ratio of (1:1:1). The randomisation ensured that each group had an equal number of participants so that the findings can be compared. Unequal samples would not be ideal for achieving comparisons since results would mean that differences in number influenced the statistical measures. Morrison et al. (2018) also adopted blinded randomisation which means that the researchers were not aware of how the participants were grouped into the three groups. For instance, a web-based randomisation system or sealed envelope was used with permuted blocks of 4 and 6. The RCT method is relevant to the research aim of comparing the three treatment methods. Besides, the researchers managed to adopt quantitative data analysis to reveal the statistical relationship between the variables of concern. However, there is a need for a longitudinal study to ascertain whether these treatment methods would be effective in the long term. Since results showed that CBT combined with antipsychotics was effective in reducing the PANSS score, these findings can influence current practice whereby clinicians use CBT together with antipsychotics to manage psychotic symptoms among patients with schizophrenia. It should also be noted that among patients treated with CBT only, there were fewer side effects compared to patients treated with antipsychotics as well as antipsychotic and CBT groups. The results can be applied to current practice by exploring the need to examine whether the side effects can lead to avoidance of the use of antipsychotic drugs while focusing on the use of CBT alone. A current study has shown that when CBT is combined with antipsychotics, there are more positive outcomes.

Lee (2019) also used the RCT method by recruiting 60 patients diagnosed with schizophrenia. They were randomly assigned to an MBI or treatment as usual group. However, there are no insights into whether the randomization was concealed or not known by the researchers. This means that the rigour of the research method can be questioned. Moreover, a sample of 60 patients diagnosed with schizophrenia can be said to be too less to achieve generalizations to the larger population. Larger sample size can be explored while using more rigorous studied procedures such as double-blinded randomisation processes through computer programs. Overall, the study managed to use RCT as a quantitative research method which is relevant to the aim of examining the effectiveness of CBT in reducing the severity of positive schizophrenia symptoms. Spencer et al. (2018) also used the RCT method with no clear insights on how randomization was conducted, whether blinded or block. Thus, it is difficult to ascertain the trustworthiness of the research methods and findings. However, the findings that those engaged in longitudinal CBT sessions had low levels of treatment side effects that those who were treated with neuroleptics as antipsychotic mediation. This means that the results can be applied to the current practice of making decisions on whether to use CBT or not.

Habib, Dawood, Kingdon, and Naeem (2015) also used the RCT method while noting that only 42 patients were randomised into two equal groups. This means that the two groups can be compared. Besides, the RCT method is relevant to the research aim of evaluating the efficacy of a culturally adapted CBT for psychosis. While there is information that the patients were randomised into two equal groups, there is no understanding of whether the researcher did not engage in the randomization process. Thus, the trustworthiness or rigour of the research process can be questioned in case the researcher was aware of how the participants were randomized to the two groups. The result that culturally-adapted CBT is effective in reducing symptoms of psychosis can be applied to current practice so that clinicians and mental health professionals focus on designing and using CBT that meets the needs of diverse groups without the need to adapt one CBT method for all patients from different cultures.

Lincoln et al. (2012) adopted a clear aim of testing the efficacy of CBT in reducing psychotic symptoms. Thus, the RCT method as part of quantitative research design is effective in determining the effectiveness of CBT through quantitative analysis. A total of 80 patients with schizophrenic spectrum disorders were randomised into two groups CBT=40 and waitlist n=40.  The equal samples mean that the results can be compared without the notion that one group was larger than the other thereby influencing the analysis negatively. Also, there is no understanding of whether the researchers did not participate in the randomization process to avoid bias.  The finding that the CBT group experienced significant improvements in the wait list group regarding PANSS score can influence current practice in the use of CBT to manage psychosis symptoms among patients diagnosed with schizophrenia.

Kim et al. (2017) adopted a quantitative research design that is relevant in testing the effectiveness of CBT as noted in statistical tests conducted. In the process of developing a model of group CBT for Korean patients, the researchers engaged in metacognitive training, cognitive restructuring, and lifestyle management. This means that this study is believable since these research methods can only be conducted by experts with knowledge and experience in clinical practice. However, a total of 34 patients included in the analysis contribute to concerns that the sample size might be too small to make conclusions on what affects the entire population or the effectiveness of CBT. More samples could be used.

Shukla et al. (2021) used a purposive sampling technique to group 40 patients with schizophrenia into 20 for the experimental group and another 20 for the control group. The effectiveness of this research method is that the focus was on a purposive sampling of patients with schizophrenia, especially those with symptoms such as hallucination and delusions. However, it is not clear how the patients were randomized to these two groups. This means that there could be bias in the process of randomization which might have affected the trustworthiness of the results. Moreover, a sample size of 40 patients is not sufficient to guarantee representativeness to the whole population.

Pomerleau et al. (2022) adopted the quality improvement method. This means that these are highly qualified and experienced professionals capable of implementing the Quality Improvement intervention. Thus, the study is believable since it was conducted by experts in the field. The CBT group had 40 patients while the TAU has 49 patients. While there is statistical analysis and comparison of these two groups, they are not equal which leads to the notion of biased results. Besides, it is not clear how the randomization was done, whether blinded or not.

Overall, the RCT method adopted in the studies selected for this review prevents high-quality evidence. However, a major limitation is that they present a quantitative analysis of data with no insight into the qualitative analysis. For instance, when CBT showed effectiveness in treating psychotic symptoms, there is a lack of information on the feelings or views of patients as well as clinicians who adopted these interventions. More research can be conducted to provide insights into the views and experiences of patients as well as clinicians who adopted the CBT and other interventions. There is also a need to consider double-blinded randomisation that is conducted by independent boards or computer programs rather than the researchers as part of measures to minimise bias and guarantee the trustworthiness of the RCT method.