A trial of combining cognitive remediation and CBT for first episode psychosis

What is it about?

There is good evidence from clinical trials for two psychological treatments for schizophrenia: Cognitive Behavioural Therapy for psychosis (CBTp) and Cognitive Remediation (CR). CR aims to improve neurocognitive problems, like poor concentration, memory and planning skills that are common schizophrenia symptoms. CBTp aims to treat delusions, hallucinations and other symptoms that those with schizophrenia can talk over with a therapist to find better ways of dealing with them. There is evidence that problems like poor memory interfere with CBTp. We hypothesised that giving CR to those on waiting lists for CBTp would improve people's neurocognition and help them take part in the CBTp better. We predicted greater improvement in symptoms, or perhaps shorter therapy. We focused on people who had just had their first episode of illness, because those who had been unwell for longer might have worse neurocognitive problems, and symptoms that responded more poorly to CBTp; so getting treatment started early on could avoid some of this deterioration. We divided 61 people randomly into two groups. One had CR before CBTp, lasting three months and delivered using a computer programme that set people tasks in a virtual world that gradually required more and more concentration, memory planning and so on to complete. Thye were helped by support workers to complete the weekly sessions of CR. The other group saw support workers for the same amount of time but had no CR. Both groups then had CBTp from therapists who did not know which group they were in, like the researchers who assessed their symptoms. We found that there was no difference between the two groups in the effect of CBTp on symptoms. However, the group who had CR improved on complicated tasks requiring flexible thinking. They also had more insight into their problems by the end of CBTp than the other group. Finally, as we thought might happen, the CR group had much shorter courses of CBTp - most needed 7 sessions or less, while in the other group most needed 13 sessions or less.

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Why is it important?

Most treatments are, like CR and CBTp, usually studied in isolation. Yet clinicians often combine treatments and some combinations might work better than others. NHS services are currently responding to recommendations that everybody receives psychological treatments early in the course of their illness, but this study suggests that CR first might enhance CBTp. It is always difficult to find well trained therapists and something that allows them to see more people (in a shorter time) with the same benefit for each person has to be an advantage for real-world clinical services. The same might be true for people who have been ill longer; we just don't know yet. Also, in our study CR was delivered relatively cheaply, though the support workers we recruited were better qualified than support workers often are. It is important to study how far this makes a difference to CR, which some studies (mostly in well organised rehabilitation in the US) show to be of substantial benefit. There are now studies examining how well different forms of CR work in the NHS, which might reveal novel ways to improve outcomes of an illness that the NHS often struggles to treat with the resources available.

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