Intensive cognitive behaviour therapy for chronic schizophrenia

Editor—Tarrier et al’s randomised controlled trial of intensive cognitive behaviour therapy for patients with chronic schizophrenia seems to show that cognitive behaviour therapy offers advantages over routine care alone. It is not clear, however, that the patients receiving cognitive behaviour therapy did better than a third group, which received non-specific supportive counselling. The outcomes in this group were intermediate between those for the cognitive behaviour therapy and routine care groups and apparently did not differ significantly from either, although the paper is not as clear as it could be on this point.

This study provides some evidence that the course of schizophrenia can be improved by psychological support, but we cannot conclude that cognitive behaviour therapy exerts any specific effect. This is important for two reasons. Firstly, understanding what interventions affect the course of the illness may help us to understand the pathological mechanisms involved. Secondly, cognitive behaviour therapy is likely to be substantially more expensive than supportive counselling. Many schizophrenic patients already receive supportive counselling as part of their routine care, perhaps as part of sessions with a key worker at a day centre or in their supported accommodation. Finally, the authors did not mention the fact that of the patients available for follow up, 8 of 32 receiving cognitive behaviour therapy dropped out or refused follow up while only 3 of 24 receiving supportive counselling did so. This difference is not significant, but it is as noteworthy as several of the results that the authors do draw attention to.