認知治療對於精神分裂症是可行的單一療法?


  【24drs.com】新研究認為,對於無法或不願意服用抗精神病藥物的精神分裂症患者,認知治療可能是可以取代抗精神病藥物的治療方法。
  
  在首度探討將認知治療作為精神分裂症單一療法的隨機試驗中,研究者發現,認知治療可顯著降低精神病症狀嚴重度,改善個人功能和社會功能,和部分妄想信念以及語音聽力。
  
  這篇研究線上登載於2月6日的Lancet期刊。
  
  英國曼徹斯特大學臨床心理學教授Anthony Morrison博士等人在文獻中指出,抗精神病藥物是精神分裂症的主要療法,但是,多達半數精神分裂症患者選擇不要服藥、或者因為擔心可能會有嚴重副作用而停止服用。
  
  認知治療已被證實可有效輔助抗精神病藥物,但是,迄今尚未暸解將它作為單一療法的可行性和有效性。Morrison博士等人在之前的實驗性研究指出,它對沒有使用抗精神病藥物的20名精神分裂症患者有顯著效益。
  
  他們這次報告的是74名16-65歲精神分裂症患者的研究結果,這些患者決定不要服用抗精神病藥物或者已經停用至少6個月;其中半數被隨機指定進行認知治療(9個月間進行26堂課)加上原本的治療,另外半數則是只有原來的療法。
  
  認知治療是一種結構式療法,在歷時數月的每週課程中,由治療師和病人一起合作,以重新評估精神病患者的經驗和修改無益的思維模式和行為;在18個月間,定期根據「正性與負性症狀量表(PANSS)」對症狀上的改變進行評比紀錄。
  
  研究者表示,認知治療已被證實可相當有效地減少精神病症狀和改善功能。認知治療組的平均PANSS總分優於一般組,兩組之間的差異為6.52 (95%信心區間[CI]為 -10.79至 -2.25)。
  
  18個月之後,認知治療組17名病患中7人(41%)的PANSS總分改善超過50%,一般組的17人只有3人(18%)如此;認知治療耐受度也比較好,退出與停止比率也比較低。
  
  一篇評論的作者在Lancet期刊中寫道,這些研究結果令人印象深刻,不過,還是需要注意。
  
  英國倫敦精神科研究院的Oliver Howes博士寫道,首先,這篇研究沒有使用安慰劑,這造成的可能影響不容小覷,因為精神分裂症試驗中的安慰劑效應很大;不過,作者們有使用屏蔽評估,並顯示出屏蔽程度很大。
  
  他表示,研究對象的特徵也需考量,例如,他們開始時的症狀嚴重度是相對中度,可能比一般納入急性藥物試驗的病患輕微,而僅相當於其他精神分裂症門診治療試驗的情況;另外值得一提的是,所有病患,包括一般組的結果都是相對好的。
  
  Howes博士建議,這篇研究的結果無法被一般化到所有精神分裂症患者,特別是住院病患或者沒有臨床團隊照護的患者。
  
  Howes博士寫道,藉由這篇研究,研究者提供了認知治療可以替代抗精神病藥物治療這個觀念的證據。
  
  Howes博士結論指出,這些結果顯然需要後續研究,但是,如果後續研究支持認知治療相對有效,應比較這類治療和抗精神病藥物治療,以告知病患選擇。如果是正面的,這類比較的結果將為精神分裂症治療帶來改變,首度為病患提供抗精神病藥物之外的可行替代方法,這是相當重要的。
  
  Morrison博士同意需要更多研究。他表示,我們仍需要明確的試驗,以強化對效果的信心,我們也需要直接比較認知治療和抗精神病藥物,我們預計4月於曼徹斯特進行這項試驗。
  
  資料來源: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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