Taalman HC; Goldberg DM; Ayub M; Munshi T; Rathod S; Farooq S; Naeem F

Research Article

J Schizophr Res. 2015; 2(3): 1019..

Effect of Cognitive Behaviour Therapy for Psychosis (CBTp) on Depressive Symptoms: A Review of Literature

Taalman HC¹, Goldberg DM1, Ayub M¹, Munshi T¹, Rathod S², Farooq S³ and Naeem F¹*

¹Queens University, Kingston, Canada

²Southampton University, Southampton, UK

³Staffordshire University, Staffordshire, UK

*Corresponding author: Naeem F, Queens University, Kingston, Canada

Received: November 09, 2015; Accepted: November 27, 2015; Published: November 30, 2015

Abstract

Objective: There is evidence from the literature that Cognitive Behavioral Therapy for psychosis (CBTp) might have a positive effect on depressive symptoms. The aim of this paper is to examine how treatment using CBTp for patients experiencing psychosis effects depressive symptoms associated with schizophrenia.

Methods: 17 trials of CBTp that reported depressive symptoms were selected for this literature review.

Results: Six out of 17 trials reported benefits for the depressive symptoms. In 3 of these trials CBT for anxiety and low self esteem was used that did not target psychotic symptoms as primary targets. In two trials effects on depression became statistically significant at followup only.

Conclusion: CBTp can reduce depressive symptoms in patients with schizophrenia. However, there is a need for improving reporting of these symptoms in future studies

Keywords: Cognitive behavioral therapy for psychosis; Schizophrenia; Depressive symptoms; Psychosis; Depression

Background

Approximately one third of those diagnosed with schizophrenia have concurrent depression, with these prevalence rates remaining highly consistent over time, study population, phase of the illness, and measures of depression. Comorbid depression has a considerable impact on the diagnosis, progression, and treatment of schizophrenia [1,2]. Depressive symptoms are associated with considerable longterm hindrance on the treatment of schizophrenia; those with depressive symptoms are more likely to use relapse-related mental health services, have poor social and family relationships, pose a greater danger to self and others, and have a lower quality of life, motivation, mental and physical health, lower level of functioning, and lower level of medication adherence [1,2].

Since the 1980s, Cognitive Behavioural Therapy (CBT) has been used as a method of treatment for affective disorders and has been integrated into common practice [3]. CBT was initially developed based on Beck’s priniciples of cognitive therapy for depression [4]. Although, Beck described use of CBT for psychosis [5], the first controlled studies on Cognitive Behaviour Therapy For Psychosis (CBTp) emerged in the early 1990s in the United Kingdom, and this treatment has developed and included some of the theoretical underpinnings of CBT from other disorders. The first controlled studies on Cognitive Behaviour Therapy For Psychosis (CBTp) emerged in the early 1990s in the United Kingdom, and this treatment has developed and included some of the theoretical underpinnings of CBT from other disorders.

Reviews of studies of CBTp have suggested that they are useful for the treatment of schizophrenia, and CBT for psychosis is now recognised as an intervention for schizophrenia in clinical guidelines in the UK and the United States [6-8]. There is evidence from meta analyses too, that it is effective; for example [3]. This review reported overall beneficial effects of the target symptom 0.40 (95% CI= 0.252, 0.548) from 33 studies. The same meta analysis reported an effect size of 0.363 [95% CI=0.079, 0.647] for its effect on depressive symptoms, on the basis of 15 studies. This latter finding has an intuitive appeal, in that CBT was originally developed for depressive symptoms, and both CBT for anxiety and depression and the CBT for psychosis use broadly similar principles. It is therefore important to examine this effect of CBTp on depressive symptoms.

The aim of the current article is to investigate the number of studies that include or address changes in depressive symptoms in the course of CBT treatment for psychosis.

Methods

Searched source

On March, 10, 2015, we searched the Embase, Medline, Current Contents, Web of Science, PsychInfo, and the Cochrane Collaborative Register of Trials. Additionally we hand searched grey literature, and cotacted leaders in the field.

Search strategy

We performed our search using the following search terms either as key terms or as key words:

(SCHIZO* or SCHIZOPHRENIA or SCHIZOAFFECTIVE DISORDER) AND (COGNITIVE

THERAPY or COGNITIVE BEHAVIOUR THERAPY or COGNITIVE BEHAVIOR THERAPY) AND (RANDOM or RANDOMISED CONTROL TRIAL or CLINICAL TRIAL).

Selection of studies

We included any published or unpublished randomized or quasi-randomized controlled trials using CBT for schizophrenia or schizophrenia-like illnesses that reported the effect of therapy on depressive symptoms. We therefore included “ studies providing outcome on depressive symptoms, either on a primary scale (such as the Hospital Anxiety and Depression Rating Scale) or a subscale or an item of another scale (such as Positive And Negative Symptoms Scale), provided the data on these subscales is clearly given”. Initial search returned 296 abstracts, of which 96 were clearly irrelevant. All abstracts were then inspected. If there was a doubt from the abstract alone, the full paper was obtained for clarification. Two authors (FN & TM) independently identified studies that had reported changes in mood. Conflicts were resolved through an independent review by MA or SF. Data were entered into an electronic database. In addition, we also inspected published meta-analyses and relevant Cochrane reviews. After removal of duplicates, abstracts and protocols we selected 36 studies for full text.

Results

We found 17 studies involving 1,396 individuals, that reported mood as a target. Information on these 17 studies was compiled and is outlined in (Table 1).

Table 1: Characteristics of included studies that reported the effect of CBT for psychosis with depressive symptoms.




  
    Study
    Sample Number and Type of    Patients
    Diagnosis & population
    Trial interventions
    Measures of depression
    Difference in scores^a
      Mean (SD)
    Comments
  
  
    Tarrier et al. [21]
    N =41, CSE=15
      PS=12, WP=14
    Treatment resistant symptoms of schizophrenia
    CSE (Coping strategy enhancement) vs. PS (Problem solving) WP (waiting period)
    PAS (Psychiatry assessment scale, depression items
    NA
    No improvement in depression
  
  
    Kuipers et al. [17]
    N=60, CBT+ TAU=28, TAU=32
    Positive symptoms, Schizophrenia, Schizoaffective,    delusional disorder
    CBT+TAU vs. TAU
    BDI (Beck Depression Inventory)
    NA
    No improvement in depression
  
  
    Wykes et al. [24]
    N =21,
      Individual =11
      Group=12
    Treatment    resistant schizophrenia
    CBT, Individual vs. Group
    BDI (Beck Depression inventory)
    NA
    No    improvement in depression
  
  
    Halperin et al. [14]
    N = 20, CBT=10, WL=10
    Schizophrenia (with comorbid social anxiety)
    CBT (Group) vs. WL    (Wait List)
    CDSS (Calgary Depression Scale for Schizophrenia)
    CBT=4.57 (3.26), TAU= 9.33    (2.70), (p < 0.001) 
    CBT for social anxiety**
  
  
    Sensky et al. [20]
    N= 90, CBT =46, BF-44
    Schizophrenia, positive symptoms
    CBT vs. (BF) Befriending
    MADRS (Montgomery-Asburg depression rating scale)
    CBT=4.8(4.0), BF=6.0(4.4)
    Improvement in CBT group at 9 months follow up (not end of    therapy)#
  
  
    Turkington et al. [23]
    N=422,CBT=257, TAU= 165
    Schizophrenia and related disorders
    CBT vs.TAU
    MADRS (Montgomery-Asburg depression rating scale)
    MD=0.87(P=0.003)
    Brief CBT delivered by nurses
  
  
    Hall et al. [13] 
    N= 25, CBT=12, TAU=13
    Positive    symptoms
    CBT +TAU vs. TAU
    HADS (Hospital Anxiety & depression scale)
    NA
    CBT for self-esteem** (No improvement in depression)
  
  
    Rector et al. [19]
    N=42, CBT+ETAU =24, ETAU= 18
    Treatment resistant schizophrenia 
    CBT +ETAU (enriched treatment as usual) vs. ETAU
    BDI(Beck Depression Inventory)
    NA
    Improvement in both groups, but no difference between    groups
  
  
    Jolley et al. [15]
    N= 21.CBT=12, TAU=9
    Schizophrenia spectrum disorder    (early psychosis) 
    CBT + TAU vs. TAU
     
    NA
    No improvement in depression
  
  
    Kingsep et al. [16] 
    N= 33,
      CBT= 16, TAU=17
    Schizophrenia with comorbid social    anxiety 
    CBT (Group) vs. TAU 
    CDSS (Calgary Depression Scale for Schizophrenia)
    CBT=4.06 (2.89) TAUl= 9.29 (2.87),    ES(1.82) 
    CBT for social anxiety**
  
  
    Trower et al. [22]
    N=38, CTCH=18
      TAU=20
    Schizophrenia    with command hallucinations
    CTCH (CT for command hallucinations) vs. TAU
    CDSS (Calgary depression scale for schizophrenia)
    No change at end of therapy. At 12    months follow up CBT= 8.1 (7.4). TAU= 12.6 (6.7) (P=0.012) 
    No    change in depression at end of therapy. By 12 months, depression had risen in    TAU# 
  
  
    Granholm et al. [12]
    N= 76, CBSST=37, TAU=39
    Chronic    schizophrenia
    CBSST (CB Social skills training) + TAU vs. TAU
    HDRS (Hamilton Depression rating scale)
    NA
    No    improvement in depression, but increase in depression mid-therapy
  
  
    Cather et al. [10]
    N = 28,
      fCBT=15
      PE=13
    Schizophrenia,    schizoaffective disorder with depression
    FCBT (Functional cognitive behavioural therapy) vs. PE
    PANASS (Positive and negative symptoms scale) dysphoric mood 
    NA
    Improvement in both    groups, but no difference between groups 
  
  
    Barrowclough et al. [9]
    N =113, CBT =57, TAU=56
    Schizophrenia, schizoaffective 
    CBT (Group) vs. TAU
    Hospital anxiety & depression scale (HADS)
    NA
    No    improvement in depression
  
  
    Garety et al. [11]
    N= 301 No carer pathway
      n=218, Carer pathway
      n=83 
    Non-affective    psychosis
    CBT vs. Family intervention 
    BDI (Beck Depression Inventory)
    MD (95%CI) at 24 months= 73.07    (76.04 to 70.11) 
    CBT for relapse    prevention. CBT showed a beneficial
      effect on depression at 24    months (not at 12 months)
  
  
    Penn et al. [18]
    N=65, CBT=32
      SST=33
    Schizophrenia    with distressing voices
    CBT (Group) vs. SST (Social skills training)
    BDI (Beck Depression Inventory)
    NA
    CBT for hallucinations. No improvement in depression
  
  
    Rathod et al. [25]
    N=30, CaCBT=14
      TAU=16
    Schizophrenia    and related disorders
    CaCBT (Culturally adapted CBT) vs. TAU
    MADRS (Montgomery-Asburg depression rating scale)
    No change at end of therapy or at 6 months follow up 
    CBT was culturally adapted for ethnic minority clients



Table 1:  Characteristics of included studies that reported the effect of CBT for psychosis with depressive symptoms.

Out of 17 RCTs [9-25] only 6 [11,14,16,20,22,23] reported improvement in mood, the rest failed to find benefit in favour of CBT compared with the Control condition. In 3 RCTs the focus of CBT was not psychotic symptoms. Of these two focused on social anxiety [14,16], and another on self esteem [13]. Four studies reported use of CBT in group settings [9,14,16,18]. One trial reported effect of CBT to continue once the therapy had stopped [20], while another [22] reported an increase in depression scores in control group compared with the CBT group at follow up. Interestingly there was no statistically significant difference in mood in these two RCTs at the end of therapy. One RCT reported a brief version of CBT [23]. Most of the studies reported outcome on mood measures, without sufficient statistical details. One study [12] reported mid therapy deterioration in depression, that was possibly due to incrase in insght.

These studies focused on a variety of diagnoses, including; schizophrenia, schizoaffective disorder, delusional disorder, nonaffective psychosis, psychotic disorder, and schizophrenia spectrum disorder. These studies also used a number of assessment scales to measure depression. These studies reported a variety of scales to measure depressive symptoms, which have been included in (Table 1).

Discussion

CBT for schizophrenia has great potential to address both the schizophrenia and the associated symptoms given that this form of treatment is based on a stress vulnerability model [26]. The use of this model allows for emphasis on a number of factors and triggers, such as life events and predispositions, which may address not only schizophrenia but the depressive symptoms associated with such.

None of the studies directly addressed depressive symptoms in patients with schizophrenia. Change in depressive symptoms was recorded as a secondary outcome to effect of CBT for psychosis on schizophrenic symptoms. There were, however, three studies which focused on social anxiety (2 studies) or low self esteem (1 study), and possibly could have a direct effect on depressive symptoms. Another interesting finding is that, in two studies no benefits were found for CBT at the end of therapy, but the difference becamse statistically apparent at the follow up. It is possible that the effect of CBT continues to increase with time, as individuals learn and practice techniques. In another study CBT continued to reduce the symptoms of depression, while in the second study patients in the control group had an increase in symptoms. It is possible that CBT might have a protective effect on depressive symptoms in those with schizophrenia. The results are not consistent as most studies did not find an improvement in mood, as a secondary outcome, and therefore it is hard to draw any firm conclusions in this area. There were also problems with the reporting of the results.

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Citation: Taalman HC, Goldberg DM, Ayub M, Munshi T, Rathod S, et al. Effect of Cognitive Behaviour Therapy for Psychosis (CBTp) on Depressive Symptoms: A Review of Literature. J Schizophr Res. 2015; 2(3): 1019. ISSN : 2471-0148

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