认知治疗对于精神分裂症是可行的单一疗法?


  【24drs.com】新研究认为,对于无法或不愿意服用抗精神病药物的精神分裂症患者,认知治疗可能是可以取代抗精神病药物的治疗方法。
  
  在首度探讨将认知治疗作为精神分裂症单一疗法的随机试验中,研究者发现,认知治疗可显著降低精神病症状严重度,改善个人功能和社会功能,和部分妄想信念以及语音听力。
  
  这篇研究在线登载于2月6日的Lancet期刊。
  
  英国曼彻斯特大学临床心理学教授Anthony Morrison博士等人在文献中指出,抗精神病药物是精神分裂症的主要疗法,但是,多达半数精神分裂症患者选择不要服药、或者因为担心可能会有严重副作用而停止服用。
  
  认知治疗已被证实可有效辅助抗精神病药物,但是,迄今尚未了解将它作为单一疗法的可行性和有效性。Morrison博士等人在之前的实验性研究指出,它对没有使用抗精神病药物的20名精神分裂症患者有显著效益。
  
  他们这次报告的是74名16-65岁精神分裂症患者的研究结果,这些患者决定不要服用抗精神病药物或者已经停用至少6个月;其中半数被随机指定进行认知治疗(9个月间进行26堂课)加上原本的治疗,另外半数则是只有原来的疗法。
  
  认知治疗是一种结构式疗法,在历时数月的每周课程中,由治疗师和病人一起合作,以重新评估精神病患者的经验和修改无益的思维模式和行为;在18个月间,定期根据「正性与负性症状量表(PANSS)」对症状上的改变进行评比纪录。
  
  研究者表示,认知治疗已被证实可相当有效地减少精神病症状和改善功能。认知治疗组的平均PANSS总分优于一般组,两组之间的差异为6.52 (95%信心区间[CI]为 -10.79至 -2.25)。
  
  18个月之后,认知治疗组17名病患中7人(41%)的PANSS总分改善超过50%,一般组的17人只有3人(18%)如此;认知治疗耐受度也比较好,退出与停止比率也比较低。
  
  一篇评论的作者在Lancet期刊中写道,这些研究结果令人印象深刻,不过,还是需要注意。
  
  英国伦敦精神科研究院的Oliver Howes博士写道,首先,这篇研究没有使用安慰剂,这造成的可能影响不容小觑,因为精神分裂症试验中的安慰剂效应很大;不过,作者们有使用屏蔽评估,并显示出屏蔽程度很大。
  
  他表示,研究对象的特征也需考量,例如,他们开始时的症状严重度是相对中度,可能比一般纳入急性药物试验的病患轻微,而仅相当于其它精神分裂症门诊治疗试验的情况;另外值得一提的是,所有病患,包括一般组的结果都是相对好的。
  
  Howes博士建议,这篇研究的结果无法被一般化到所有精神分裂症患者,特别是住院病患或者没有临床团队照护的患者。
  
  Howes博士写道,藉由这篇研究,研究者提供了认知治疗可以替代抗精神病药物治疗这个观念的证据。
  
  Howes博士结论指出,这些结果显然需要后续研究,但是,如果后续研究支持认知治疗相对有效,应比较这类治疗和抗精神病药物治疗,以告知病患选择。如果是正面的,这类比较的结果将为精神分裂症治疗带来改变,首度为病患提供抗精神病药物之外的可行替代方法,这是相当重要的。
  
  Morrison博士同意需要更多研究。他表示,我们仍需要明确的试验,以强化对效果的信心,我们也需要直接比较认知治疗和抗精神病药物,我们预计4月于曼彻斯特进行这项试验。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=7052&x_classno=0&x_chkdelpoint=Y
  

Cognitive Therapy a Viable Monotherapy for Schizophrenia?

By Megan Brooks
Medscape Medical News

Cognitive therapy may be a viable alternative to antipsychotic drugs in patients with schizophrenia who cannot or will not take an antipsychotic, new research suggests.

In the first randomized trial of cognitive therapy as a stand-alone therapy for schizophrenia, researchers found that it significantly reduced the severity of psychiatric symptoms and improved personal and social functioning and some dimensions of delusional beliefs and voice hearing.

The study was published online February 6 in the Lancet.

Alternative Treatments Needed

Antipsychotic drugs are the mainstay of treatment for schizophrenia, but as many as half of all people with schizophrenia choose not to take drugs or discontinue them due to troubling and potentially serious side effects, Anthony Morrison, DClinPsy, professor of clinical psychology at the University of Manchester, United Kingdom, and colleagues note in their article.

Cognitive therapy has proven to be effective as an adjunct to antipsychotic drugs, but until now, its feasibility and effectiveness as a stand-alone treatment was unknown. In an earlier exploratory study, Dr. Morrison and colleagues noted significant benefit in 20 patients with schizophrenia who were not on antipsychotic drugs.

They now report results of a study of 74 individuals aged 16 to 65 years with schizophrenia spectrum disorders who had decided not to take or had stopped taking antipsychotics for at least 6 months. Half were randomly assigned to cognitive therapy (26 sessions during a 9-month period) plus treatment as usual and half to treatment as usual alone.

Cognitive therapy is a structured treatment that involves the therapist working collaboratively with the patient in weekly sessions during several months to reappraise psychotic experiences and modify unhelpful thought patterns and behaviors.

Change in symptoms was rated at regular intervals during 18 months on the Positive and Negative Syndrome Scale (PANSS).

Cognitive therapy proved to be highly effective in reducing psychotic symptoms and in improving function, the investigators say. Mean PANSS total scores were consistently lower (better) in the cognitive therapy group than in the treatment as usual group, with an estimated between-group difference of -6.52 (95% confidence interval [CI], -10.79 to -2.25).

After 18 months, 7 (41%) of 17 participants receiving cognitive therapy had an improvement of more than 50% in the PANSS total score compared with 3 (18%) of 17 receiving treatment as usual. Cognitive therapy was also well tolerated, with low rates of drop out and withdrawal.

"Impressive" Results, but Caution Warranted

"These findings are impressive; however, some caution is needed," writes the author of a comment in the Lancet.

"First, the study did not have a placebo intervention. The potential effect of this limitation should not be underestimated because placebo effects can be large in schizophrenia trials," writes Oliver Howes, MRCPsych, DM, PhD, of the Institute of Psychiatry in London, United Kingdom. However, the authors did use masked assessments and showed that masking was largely achieved, he added.

The characteristics of the patients in the study also need consideration, he says. Their baseline symptom severity was "relatively moderate, somewhat lower than that noted in patients typically entering acute drug trials, for example, but nevertheless similar to levels noted in other outpatient treatment trials of schizophrenia. Also notable is that outcomes in the patient group as a whole, including those in the treatment as usual group, were relatively good."

"The findings in this study should not be generalized to all patients with schizophrenia, particularly inpatients or patients not engaged with a clinical team," Dr. Howes advises.

With this study, the investigators "provide proof of concept that cognitive therapy is an alternative to antipsychotic treatment," writes Dr. Howes.

"Clearly this outcome will need further testing, but, if further work supports the relative effectiveness of cognitive therapy, a comparison between such therapy and antipsychotic treatment will be needed to inform patient choice. If positive, findings from such a comparison would be a step change in the treatment of schizophrenia, providing patients with a viable alternative to antipsychotic treatment for the first time, something that is sorely needed," Dr. Howes concludes.

Dr. Morrison agrees that more study is needed.

"We still need a definitive trial in order to be confident regarding efficacy," he told Medscape Medical News. "We also need a direct, head-to-head comparison of cognitive therapy with antipsychotics, and we are about to start a trial doing just that in April in Manchester," he said.

The study was funded by the UK National Institute for Health Research. Dr. Morrison and several coauthors are practitioners of cognitive therapy and deliver this intervention within the UK National Health Service; receive royalties from texts or books they have published on cognitive therapy; and have received fees for delivering workshops on cognitive therapy. One author has received lecture fees from pharmaceutical companies. Dr. Howes has received investigator-initiated research funding from or participated in advisory or speaker meetings organized by several manufacturers of antipsychotics: AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, Lyden-Delta, Servier, and Roche. In addition, he has provided cognitive therapy to patients as part of UK National Health Service treatment .

Lancet. Published online February 6, 2014.

    
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