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Articles   |    
Cognitive-Behavioral Therapy for Medication-Resistant Psychosis: A Meta-Analytic Review
Amy M. N. Burns, M.Ed.; David H. Erickson, Ph.D.; Colleen A. Brenner, Ph.D.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300213
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Ms. Burns and Dr. Brenner are with the Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada (e-mail: aburns@psych.ubc.ca. Dr. Erickson is with the Psychology Department, Royal Columbian Hospital, New Westminster, British Columbia. The findings were presented at the annual convention of the Canadian Psychological Association, Quebec City, Quebec, Canada, June 13–15, 2013.

Copyright © 2014 by the American Psychiatric Association

Abstract

Objective  Support for cognitive-behavioral therapy (CBT) for psychosis has accumulated, with several reviews and meta-analyses indicating its effectiveness for various intended outcomes in a broad variety of clinical settings. Most of these studies, however, have evaluated CBT provided to the subset of people with schizophrenia who continue to experience positive symptoms despite adequate treatment with antipsychotics. Despite several reviews and meta-analyses, a specific estimate of the effects of CBT for patients with medication-resistant positive symptoms, for whom CBT is frequently used in outpatient clinical settings, is lacking. This meta-analysis examined CBT’s effectiveness among outpatients with medication-resistant psychosis, both on completion of treatment and at follow-up.

Methods  Systematic searches (until May 2012) of the Cochrane Collaborative Register of Trials, MEDLINE, PsycINFO, and PubMed were conducted. Sixteen published articles describing 12 randomized controlled trials were used as source data for the meta-analysis. Effect sizes were estimated using the standardized mean difference corrected for bias, Hedges’ g, for positive and general symptoms.

Results  The trials included a total of 639 individuals, 552 of whom completed the posttreatment assessment (dropout rate of 14%). Overall beneficial effects of CBT were found at posttreatment for positive symptoms (Hedges’ g=.47) and for general symptoms (Hedges’ g=.52). These effects were maintained at follow-up for both positive and general symptoms (Hedges’ g=.41 and .40, respectively).

Conclusions  For patients who continue to exhibit symptoms of psychosis despite adequate trials of medication, CBT for psychosis can confer beneficial effects above and beyond the effects of medication.

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Figure 1 Forest plot of the effect sizes for positive symptoms at posttreatment in trials of cognitive-behavioral therapya

a For the trials listed in Table 2. Hedge’s g with 95% confidence intervals (bars). The diamond is the average of the effect sizes.

Figure 2 Forest plot of the effect sizes for general symptoms at posttreatment in trials of cognitive-behavioral therapya

a For the trials listed in Table 2. Hedge’s g with 95% confidence intervals (bars). The diamond is the average of the effect sizes.

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Table 1Characteristics of randomized controlled trials of cognitive-behavioral therapy (CBT) for outpatients with medication-resistant psychosis included in the meta-analysis
Table Footer Note

a BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; BPRS, Brief Psychiatric Rating Scale; CPRS, Comprehensive Psychopathological Rating Scale; MADRS, Montgomery-Asburg Depression Rating Scale; MADS, Maudsley Assessment of Delusions Schedule; PANSS, Positive and Negative Syndrome Scale; PSE, Present State Examination; PSYRATS, Psychotic Symptoms Rating Scale; SANS, Scale for the Assessment of Negative Symptoms; SAPS, Scale for the Assessment of Positive Symptoms; VCS, Voice Compliance Scale

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Table 2Effect sizes for positive and general symptoms in trials of cognitive-behavioral therapy for outpatients with medication-resistant psychosisa
Table Footer Note

a Outcome at follow-up is from 3 to 18 months after treatment.

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