Has cognitive behavioural therapy for psychosis been oversold?

CBT is a recommended treatment for schizophrenia in the UK, but how strong is the evidence that it works? Keith Laws suggests it’s not as strong as we might hope.

The evidence for cognitive behavioural therapy to treat psychosis is not as strong as guidelines might make you think, according to Keith Laws. Photograph: Alamy

In 1952, the same year that chlorpromazine was introduced as the first effective drug treatment for schizophrenia, Aaron Beck first employed a form of cognitive-based talk therapy to treat delusional thinking. While chlorpromazine inaugurated the era of drug treatments in psychiatry, Beck’s psychological alternative was a slow-burner. Cognitive Therapy or Cognitive Behavioural Therapy (CBT), as we now know it, became part of the mainstream treatment for psychosis in the UK in 2002 when the National Institute of Clinical Excellence (NICE) endorsed it; and again in 2009, they further recommended that CBT be offered “to all people with psychosis or schizophrenia.” Despite repeated endorsements by this Government agency, is it possible that CBT for psychosis has been oversold?

NICE, along with almost everyone else nowadays, ‘takes stock’ of the results of clinical trials by using the quantitative technique of meta-analysis. This allows findings of different trials to be mathematically summed, giving more weight to larger (and usually methodologically more rigorous) trials. Notably the dozen meta-analyses of trials investigating CBT for schizophrenia document the shrinking evidence for its effectiveness on symptoms. Although initial meta-analyses optimistically suggested that around 50% of patients showed significant symptom reduction following CBT, more recent meta-analyses estimate that just 5% benefit significantly when compared to controls…

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