Getting back on an even keel

Comparing people-based treatments for psychosis

Research comparing two different treatments for psychosis could have important implications for mental health services.

"When I started as a clinical psychologist 20 years ago," says Philippa Garety, "you didn't talk to psychotic patients about their symptoms, about what they were actually experiencing. The emphasis was all on helping them to get on with their lives, offering practical support and rehabilitation. Talking about psychosis was simply thought to make it worse. And even if we wanted to do it, we didn't have the therapeutic tools."

Psychotic disorders can be highly disabling (see box below). Antipsychotic drugs (also known as major tranquillisers or neuroleptics) have been the first-line treatment for psychosis for many years, and can be effective. However, 80 per cent of people who experience a first episode of psychosis will relapse within five years. People with such enduring mental health problems may often find medication of limited help, partly because of adverse effects such as weight gain, constant drowsiness, or shaking limbs. There is consequently an urgent need to improve treatment.

While mental health services are still heavily weighted towards drug treatments, psychological interventions for psychosis have gained increasing prominence in recent years. With funding from the Wellcome Trust, Philippa Garety, Professor of Clinical Psychology at Guy's, King's and St Thomas' School of Medicine, King's College London, and Elizabeth Kuipers, Professor of Clinical Psychology at the Institute of Psychiatry are jointly leading (see Research team below) the biggest ever trial of psychological treatments for psychosis.

"We're very excited to have the opportunity to do this," comments Professor Garety. "We will be studying 500 patients for five years. This is really sizeable for a study of this sort. Psychological treatments receive nothing like the funding given to drug treatment research, and so we have not been able so far to build up the evidence base on psychological treatments for psychosis."

Two treatments

The study will compare the two most effective psychological treatments for psychosis: cognitive behaviour therapy and family intervention. Both these 'talking treatments' have been shown to reduce symptoms or relapse when added to standard care and medication, but they have not been directly compared before.

Cognitive behaviour therapy was first introduced in the UK in the early 1980s, with US psychologist Aaron T Beck's studies on treatment for depression. The main assumption behind the treatment is that psychological difficulties depend on how people think about or interpret events (cognitions), how people respond to these events (behaviour), and how it makes them feel (emotions). It uses a collaborative format, with therapist and patient working together to identify thoughts and beliefs; review evidence for these beliefs; encourage self-monitoring of cognitions; relate thoughts to mood and behaviour, and identify thinking biases.

It is only very recently that cognitive behaviour therapy has been taken up as a treatment for psychosis. The UK is the leader in this field, and there is now substantial evidence that it is an effective treatment for psychosis, with 25 per cent reductions in symptom severity (similar to the effects of clozapine, one of the most commonly used antipsychotics).

Family intervention grew out of the work of George Brown and colleagues in the 1960s, who looked at how social factors influenced relapse in psychotic patients, and in particular what happened to people when they returned to the family environment. They found that high levels of criticism, tension and anxiety - so called expressed emotion - within the family were more likely to trigger relapse in the patient. Family intervention was developed to help families reduce levels of expressed emotion.

In the early 1980s, Elizabeth Kuipers and colleagues published the first outcome study of family intervention, showing a reduction in relapse for the patient and reduced stress in other family members. The evidence base for family intervention in psychosis is now the most substantial of all the psychological interventions.

The new research being carried out by Professor Garety and Professor Kuipers aims both to establish the relative effectiveness of family intervention and cognitive behaviour therapy, and also to answer some questions about how and why these therapies work. Professor Garety explains: "While cognitive behaviour therapy has been shown to reduce symptoms and improve mood, it has not been explicitly proven to reduce relapse. And while family intervention has been shown to reduce relapse, little is known, theoretically or empirically, about the link between social environment and the patient's thoughts and feelings. Why does it reduce relapse? We hope to unpack the social and cognitive processes affected by these two therapeutic interventions in order to improve our understanding of psychosis and its treatments."

The 500 patients will be contacted via acute psychiatric wards in inner London, outer London, Norwich and rural Norfolk. They will be people who have relapsed at least once, who will typically be in their twenties and thirties and trying to adjust to their difficulties.

They will all be receiving prescriptions for antipsychotic medication, though not all will be taking the drugs. The trial will use self report and observer report to assess drug treatment adherence. There are currently no grounds to suggest that medication compliance affects outcomes in either cognitive behaviour therapy or family intervention, and this is an area the group will be investigating further.

The actual therapies will be given by mental health practitioners - mainly clinical psychologists and nurse therapists. Training in both techniques will be carried out as part of the research programme - there is currently insufficient capacity within mental health services to administer the levels of therapy required for the trial. Professor Garety sees a possible twofold benefit for existing mental health services: "We will be negotiating with mental health services to train some of their staff in cognitive behaviour therapy and family intervention. We hope to see not only therapeutic benefits from the trials themselves, in terms of reduced demand on mental health and related services, but also to build up a workforce better trained in these techniques."

Understanding illness

As well as the two major trials comparing outcomes, the research programme will also involve explanatory studies about the cognitive and social processes that maintain psychosis. "Understanding the factors that cause relapse and that maintain the psychosis after onset is so important in treatment terms," explains Professor Garety. "The original causes of psychosis are of course very relevant for prevention - and we want to look at these too - but as far as the practical implications for mental health services are concerned we want to focus on relapse. We'll have a number of different studies, falling broadly speaking into four areas that we feel might maintain the psychosis: reasoning - the way the person thinks about themselves and their experience; self concept, which includes for example self esteem; current emotional states; and the person's understanding of the psychotic illness itself."

Professor Garety feels the study and its results could have some profound implications for the treatment of psychosis. "It is scandalous, really, that people can have a very serious mental illness and there hasn't been a serious attempt, using the evidence we already have, to talk to these people about what has happened to them. We hope to change this, and in doing so advance both our understanding of the illness itself, and how best to help people live with it."

Team of researchers

The complete research team is Professor Philippa Garety; Professor Elizabeth Kuipers; Paul Bebbington, Professor of Social and Community Psychiatry at University College London; Graham Dunn, Professor of Biomedical Statistics at the University of Manchester; David Fowler, Senior Lecturer in Clinical Psychology at the University of East Anglia; and Daniel Freeman, Research Coordinator.

The basis of psychosis

Psychosis is an umbrella term for unusual perceptions - for example, hearing voices, or holding unusual beliefs; patients may think they are being followed or monitored by unseen, often malign, forces. People experiencing psychosis are often diagnosed with schizophrenia or related disorders. About 300 000 people in the UK are likely to have been diagnosed with schizophrenia and related disorders. Psychosis causes great distress to the individual, puts great demands on carers, and has high social and healthcare costs.

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