Young people with psychotic symptoms should be offered CBT before antipsychotics, according to new RCT

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Antipsychotic drugs are currently prescribed to a significant proportion of young people who are diagnosed with psychosis. Past research has estimated that up to half of people at risk of developing psychosis at a young age will progress to a full blown psychotic illness such as schizophrenia.

A new landmark randomised controlled trial has been published in the BMJ which challenges this view and suggests that a new approach is warranted for this group. The study aims to determine whether cognitive therapy is effective in preventing the worsening of emerging psychotic symptoms experienced by young people deemed to be at risk of schizophrenia.

288 patients (aged 14-35) were included in the study and randomised to one of two treatment arms:

  1. Cognitive therapy (up to 26 (mean 9.1) sessions over six months) plus monitoring of mental state
  2. Monitoring of mental state only

Patients were followed up for between 12 and 24 months and the main outcomes were psychosis symptoms and distress.

Here’s what they found:

  • Overall, only 8% of patients made the transition from initial psychotic symptoms to full psychotic illness
  • There was no significant difference in rates of transition between the two groups
  • The severity of psychotic symptoms was significantly lower in the cognitive therapy group (estimated between group effect size at 12 months −3.67, −6.71 to −0.64, P=0.018)

Professor Andrew Gumley, who led the research team at the University of Glasgow, said:

This study has very important implications for ensuring that young people who are at risk of developing psychosis are offered psychological therapy.

Our findings that there is a much lower transition rate than previously found means that clinicians have to be extremely careful about prescribing antipsychotics in this group since only one in 10 will actually develop psychosis.

Links

Morrison AP et al. Early detection and intervention evaluation for people at risk of psychosis: multisite randomised controlled trial. BMJ 2012;344:e2233

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