July 09, 2007

Cognitive Therapy May Prevent High Risk Populations From Developing Psychosis

A 3-year follow up study on the ability of Cognitive Therapy (CT or CBT) to prevent psychosis in ultra high-risk populations was completed and the article featured in Schizophrenia Bulletin. The study utilized 58 participants considered ultra high risk of having an initial psychotic episode, and administered CT over a 6-month period. The participants were monitored monthly, and followed up over the 3 years.

This is a study of interest because its one of the first studies showing a possibility of preventing psychosis over several years using a psychotherapeutic method. It is also noteworthy that they found a psychological therapy alone to have an effect that seems to be:

as efficacious and enduring as that found in the study of combined pharmacological therapy and psychotherapy and that of a double blind placebo-controlled trial of pharmacotherapy alone (it is worth noting that all of these studies had very similar sample sizes).

The studies of medications alone only found differences at the end of the study, but not on any follow-ups; showing that the psychotherapeutic therapy (CT) might be the most long term, in helping maintain stability.

After controlling for age, gender, baseline PANSS scores, and family history, they found CT to significantly reduce the likelihood of being prescribed antipsychotic medications during the time of the study. CT did not however have an effect on transitioning to psychosis, which they measured using the Positive and Negative Syndrome Scale (PANSS) or probable Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis.

"There appear to be enduring benefits of CT over the long term, suggesting that it is an efficacious intervention for people at high risk of developing psychosis."

Some criticisms of this study are within the structure and the way in which they measured progression to psychosis. Although they did not find CT to help with the transition when measured by PANSS, PANSS may not have been a good measure based on the fact that it relays on clinical interviewing, and assumes a person has crossed a "somewhat arbitrary" threshold from non-psychotic to psychotic.

However, CT did significantly reduce the likelihood of transition to psychosis defined using the PANSS over the 3-year period, after controlling for beliefs that are targeted during therapy and baseline PANSS scores. The numbers in the analysis are small, however.) But measuring progress based on antipsychotic medication prescribing may also have limitations. "Prescription of antipsychotic medication cannot be considered a definitive indicator of transition because it is increasingly used in clinical practice for other disorders."

How can this be helpful to people or families at risk or with genetic vulnerabilities?

The researchers suggest that CT be encouraged as the initial treatment (prior to the use of anti-psychotic medications) of those from ultra high risk populations for psychosis, in the hopes that it help prevent progression to mental illness. They argue this since research is finding possibly equal benefit from CT as with medications (without the potential drug side-effects), and that CT's benefits seem to be long lasting. This appears to be a safer and possibly more acceptable option for those young children, adolescents, or adults who meet criteria for high risk. It needs to be highlighted that this is NOT suggesting people with already psychotic symptoms, or a diagnosis of a psychotic disorder can discontinue meds and only utilize CT. The researchers are focusing on those that are high risk for eventually developing the disorder, and that CT is a safer alternative than medications in preventing psychosis.

Three-Year Follow-up of a Randomized Controlled Trial of Cognitive Therapy
for the Prevention of Psychosis in People at Ultrahigh Risk
Schizophrenia Bulletin 2007 33(3):682-687


This news blog says that the CT might be a more acceptable option for young children. I'll see if I can get hold of information about this being done in young children with psychotic prodrome.

In young children, there is much overlap with autistic spectrum, Sensory integration disorder, etc. and they are usually already in multiple types of therapies, so if this is better than the others, that is quite important. These young children usually are already stressed with school and therapy for their learning disabilities, and occupational-therapy and therapy for emotions and sensory integration... eeek!!!

I agree that therapy is a more acceptable alternative than medications at a young age, and if this type of therapy turns out to be more effective than the other available types of therapies, that would be very important to know, since, as I said, they usually already are in at least one - if not more - types of therapies since they usually have multiple disorders at once (comorbid).

I know that when my child was young I was told that a therapy based on talking would not be worthwhile. Of course, the one she DID have did NOT stop the progression of her illness, although it did help her cope with it.


Posted by: Naomi at July 9, 2007 08:36 PM


CT, which is cognitive therapy is often used interchangeably with CBT, cognitive behavioral therapy. They are the psychotherapies that have the most research backing up their effectiveness. CT is solution focused, problem solving, and deals with issues in the here and now (which may be why its so helpful).

Young children need to be given CT in a different modality, that means most therapists will utilize play therapy, art, clay, sand box, and even equine (horse assisted therapy mainly for autistic kids) with kids to deliver CT.

"talk" therapy is almost never sufficient for children under 12. But CT can be done with play or art techniques. For this reason children should be seen by someone who specializes in therapy for children.

I'm glad to hear that although your child's therapy didn't prevent, it was able to help them cope.

Posted by: Michelle at July 10, 2007 09:56 AM

Sounds like all the therapy for kids, then, already ARE "cognitive therapy". In Europe, (from what I have read) the "acceptable alternative" to medication at least to begin with, is testing for sleep disorders and treating problems for that. In the United States, seems like rather than run tests, the FIRST line of "intervention" is medications, but usually, IF the person can afford it, therapy is begun as well. Also, ADHD meds are given when the underlying problem is actually sleep problems (which is what they found in Europe, which might be a reason they don't use so much ADHD medication) -- and the ADHD medication can potentially make matters worse.

I guess bottom line is that proper testing needs to be done, and a more "holistic" approach should be taken. Diagnostic testing, nutrition, allergies, need for therapy for child and family -- all need to be taken into account.

For the kids who medically have a problem in the brain -- taking a "holistic approach" (which includes therapies) can help on multiple levels, but not "cure" the underlying medical problems, which, if treated incorrectly (wrong meds, wrong type of therapy, not treating underlying disorders), or only partially (such as with medication and no CT or through CT alone when there is more to it than psychological and developmental problems) can progress.

Now -- if we can only get the doctors and the insurance companies in the U.S.A. on board with that.


Posted by: Naomi at July 11, 2007 07:17 AM

At what point should CT be initiated in a child who is at high risk of mental illness? - Deb

Posted by: Deb at August 17, 2007 11:34 AM

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