Cognitive Therapy and Schizophrenia
by Rakesh Jain
"In view of the specific structural and neuroendocrine changes now known to occur in schizophrenia, is there any role for therapy—such as cognitive therapy or cognitive enhancement therapy?"
Rakesh Jain, MD, MPH:
Your excellent question immediately reveals two issues. First, and you are correct, we now have a tremendous amount of information that establishes schizophrenia’s structural and neuroendocrine impact on the patient’s brain and body. 1-6 The body’s inflammatory chemokine system is also dysregulated, raising concerns about the long-term impact on morbidity and mortality in these patients.
The second issue is that, unintentionally, you are revealing a bias many of us suffer from—that if a disorder has a biological “signature” (such as structural and neuroendocrine changes), then a mere “psychological” intervention such as cognitive therapy would have no or diminished role in helping patients.
This bias, which truly is widely held, deserves to be debunked. It is incumbent upon us clinicians to not see cognitive therapy as merely a psychological intervention that could not possibly have an impact on predominantly biological disorders such as schizophrenia. To dispel this bias, we must first closely examine the data at hand regarding cognitive therapy and cognitive enhancement therapy in patients afflicted with schizophrenia.
Let’s start this conversation by first acknowledging two salient and well established facts. Schizophrenia does indeed have a well-known, and often replicated, evidence base for structural changes in various parts of the brain, as well as neuroendocrine changes that adversely affect them. Secondly, tremendous strides have been made in the development of antipsychotics, and multiple atypical antipsychotics have recently been introduced thereby bringing an ever-improving balance between efficacy and tolerability. However, despite these advances, the lives of patients with schizophrenia remain significantly impaired and bio-psycho-social (all three) interventions are needed for optimized recovery.
Now, let’s turn our attention to the evidence at hand regarding cognitive therapy’s impact on patients with schizophrenia.
Quite impressively, a recent study found that cognitive enhancement therapy offered gray matter neuroprotection in patients with schizophrenia. In a two-year randomized study, patients participating in cognitive enhancement therapy showed significantly greater preservation of gray matter volume in the left hippocampus, parahippocampal gyrus, and fusiform gyrus, as well as significantly greater gray matter increases in the left amygdala ( P <0.04) compared with patients participating in enriched supportive therapy. “Less gray matter loss in the left parahippocampal and fusiform gyrus and greater gray matter increases in the left amygdala were significantly related to improved cognition and mediated the beneficial cognitive effects of cognitive enhancement therapy,” concluded the study authors.
Now you see why I worry that ignoring nonpharmacologic therapies may be detrimental to our patients’ long-term outcomes?
Here’s another question we must ask ourselves: Does cognitive therapy offer help with the positive or the negative symptoms of schizophrenia? The answer appears to be— both , with data supporting this therapy’s salutary effects both the damaging effects of positive and negative symptoms of schizophrenia.
Another question to ask: Do cognitive-based therapies help with acute reduction of symptoms or do they help with relapse prevention? The answer appears to be both . A recent study revealed that cognitive behaviorally based therapy did indeed significantly reduce relapse rates as compared to treatment as usual. This is one more feather in the cap for add-on cognitive therapy to antipsychotic medications!
Is the combination of antipsychotics with cognitive therapies superior to just antipsychotics alone? The answer, based on empirical studies, appears to be yes, thereby adding another weapon to our armamentarium against this savage disease.
Does cognitive therapy have to be individual or could it be effective in a cost-effective group setting? Evidence does show that group-based cognitive therapy was effective. There is even evidence for home-delivered cognitive-based therapies being effective.
A survey of clinical practices reveals that clinicians in the United States appear to have a greater bias against cognitive therapy’s usefulness in schizophrenia than our European colleagues. This bias is damaging to our patients, and we must confront it. I encourage you to further read on the issue of nonpharmacologic augmentation of medication treatment in schizophrenia, and I recommend the following review articles for a more detailed examination of cognitive therapies in schizophrenia.
In closing, I would like to make the following points:
- Schizophrenia is indeed a heavily biologically-based disorder, with overwhelming evidence for adverse structural, neuroendocrine, and inflammatory cytokine changes;
- Antipsychotics, particularly the atypicals, are the standard of care for these patients;
- Cognitive-based therapies, even though “psychological,” demonstrate both psychological and biological improvements in patients with schizophrenia;
- We North American clinicians appear to be more biased against cognitive-based therapies than our European colleagues; this is an issue we must proactively address; and
- Cognitive-based therapies appear to be effective in combination therapy with antipsychotics for acute treatment of both positive and negative symptoms, for both acute episodes and relapse prevention, and appear to improve patient quality of life in multiple ways.
I close this Q&A by thanking you for your question, and inviting comments from our readers of the Community Forum.
—Rakesh Jain, MD, MPH