Brett Daniel Kaylor, DO, MA

Can cognitive behavioral therapy (CBT) be used in a busy practice setting for psychosis? Farooq Naeem, MD, and colleagues set out to prove that it was feasible in a brief self-help form. He discussed the results in his 

 presentation, “New Directions in CBT for Psychosis (CBTp): CBTp in Busy Clinics Using a Guided Self-Help Approach.”

In settings with limited resources, it can often be challenging to implement psychosocial resources for patients in remission from psychosis who continue to have residual positive and negative symptoms despite medication.

Issues arise with respect to cost limitations in publicly funded or managed care systems, and poor access to services. Only a minority of practices are able to engage a small number of trained therapists-if such therapists are available at all.

Dr Naeem pointed out that self-help interventions have been used for many years in the treatment of depression and anxiety; however, 

 for use in schizophrenia has lagged behind.

 This is despite the effective use of these interventions in some practice settings for many years.

 that indicates brief, low-intensity CBT can be effectively used for psychosis.

 He believes a need exists and a gap in care can be filled by integrating a self-help or guided self-help CBT model for schizophrenia, one that can be delivered in community settings by providers at many levels.

In his study, Dr Naeem randomized 33 individuals to either treatment as usual (TAU) or a treatment group that consisted of 12 to 16 sessions with a provider. Sessions focused on creating a treatment alliance, providing psychoeducation, distributing worksheets and handouts, and conceptualizing between-session homework.

These sessions typically lasted 15 to 20 minutes and focused on guiding the CBT work for between-session practice. Assessment of feasibility was based on feedback from patients and the professionals.

Strictly self-help models use evidence-based psychological therapy. The material may be in any “non-human media,” such as books, CD-ROMs, and web or phone applications, and may include individual or group formats. The aim of the intervention is to relieve symptoms and distress and to improve overall functioning, but without contact with a therapist or another person to direct treatment.

Guided self-help includes the above materials; however, it also involves brief sessions with someone to facilitate self-help. The facilitator can be a layperson, case manager, nurse, or therapist (in the last case, the contact would be at a minimum, often less than 25% of normal therapy sessions). The guidance could be face-to-face contact, by telephone, by email, or by any other communication method, flexible to the circumstances of the individual in need.

Results indicated significant reductions compared with TAU in positive and negative symptoms, hallucinations, and delusions, and an improvement in overall function and level of disability, based on measurements on the Positive and Negative Symptom Scale, the Psychotic Symptom Rating Scale, and the World Health Organization Disability Assessment Schedule 2.0. However, Dr Naeem noted that the study is limited by its small scale and is predominantly focused on the feasibility of the intervention rather than on efficacy.

The participants were highly motivated, were already engaged in treatment, and had only moderate levels of psychopathology and disability. Furthermore, they were generally well educated (64% had a college degree), and the majority (76%) were employed.

With respect to feasibility, Dr Naeem found that feedback was very good, with high levels of recruitment and retention and of acceptability among patients. He noted that what patients found particularly beneficial was the effect of normalizing their psychopathology: that their thoughts, emotions, and behavioral reactions were understandable in the context of their delusions and hallucinations.

The participants at the outset were encouraged to watch 

 the movie based on the life of Nobel Laureate 

, who himself struggled with schizophrenia. Dr Naeem said that patients found it very uplifting and was a powerful way to destigmatize the illness.

Dr Naeem noted that the self-help approaches used may only be suitable for a selected group of patients, who have low severity of psychopathology, are motivated, and have the cognitive ability to engage the treatment, as self-help approaches require a good deal of autonomy. 

 include the possibility of using cognitive remediation therapy before intervention, which has been found to improve cognitive deficits independent of psychopathology.

Dr Naeem sees promise in the effective use of digital media, such as Internet and mobile phones, for providing psychotherapy to patients with many disorders in the future, “and this area is no exception.”

“Most important is to instill hope, especially those who do not see a lot of hope, if you connect and engage,” he said. Dr Naeem believes self-help CBT paradigms can be used effectively and can make a profound change in people’s lives, with the overall aim to instill hope, reduce stress, and improve well-being.

Dr Kaylor is Chief Resident in the department of psychiatry and health behavior at the Medical College of Georgia, Augusta University, and a Staff Psychiatrist at The Bluff Plantation - Rivermend Health, in Augusta, Georgia.

 Lewis G, Anderson L, Araya R, et al. Self-help interventions for mental health problems. Report to the Department of Health, 1140. 2003. 

http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4125794.pdf

Self-help and guided self-help interventions for schizophrenia and related disorders.

 Cochrane Database Syst Rev. 2015;5:CD011698. DOI: 10.1002/14651858.CD011698.
	

A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes

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How to make cognitive behavioral therapy for psychosis feasible in a busy practice with limited resources.

CBT for Psychosis

 presentation, “Early Detection and Intervention for Adolescents With Early Psychosis: Promising New Approaches,” Stephen Adelsheim, MD, Professor of Psychiatry at 

, began with this quote from an adolescent with prodromal psychosis:

“I’d say I started having paranoid feelings about a year ago. If I really think, things started to happen little by little, but they gradually got worse. I didn’t notice because I thought the way I felt was right. And my parents didn’t notice because it was so gradual.”

Dr Adelsheim’s talk was a part of a symposium titled “Interventions for Early Psychosis in Children and Adolescents: New Advances in Community and Policy Approaches,” which captured the widespread problem in identifying youth and adolescents with emerging psychosis in many communities around the US. And, as many preventive and early intervention programs have been better integrated and finding success in Europe and Australia, Dr Adelsheim declares we have a lot of catching up to do.

[[{"type":"media","view_mode":"media_crop","fid":"42141","attributes":{"alt":"psychosis","class":"media-image media-image-right","height":"167","id":"media_crop_7499741800178","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4538","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©Lightspring/Shutterstock","typeof":"foaf:Image","width":"189"}}]]Data indicate that the incidence of mental health issues is highest in the 10- to 30-year-old age group, and furthermore that fully half of all lifetime cases of mental illness start by age 14 and 75% by age 24. During this period, 79% don’t access care. However, as the quote above depicts, symptoms of prodromal psychosis present a notable challenge, as they can be quite subtle, emerge gradually, and are often overlooked by adolescents, their families, and many primary providers.

 (Recovery After an Initial Schizophrenia Episode) Early Treatment Program study-the first to examine duration in untreated psychosis (DUP) in community mental health centers in the US-which showed that the median DUP was a full 74 weeks and that 68% of the 404 15- to 40-year-olds with first-episode psychosis had greater than 6 months’ duration without treatment.

Unfortunately, longer DUP and delay in initiating treatment have been shown to correlate with poorer outcomes in overall functioning, positive symptoms, and quality of life, in addition to diminished response to treatment and lower likelihood of remission.

 Early intervention is the key, as Dr Adelsheim notes, as a shorter DUP is associated with better response to antipsychotics, greater decrease in both positive and negative symptom severity, decreased frequency of relapse, more time at school or work, and overall improved treatment response over time (

There is a greater need for training of professionals to recognize the early signs of psychosis, which can present as nonspecific cognitive problems-such as memory complaints, confusion, and odd or distracting thoughts-which have been shown to correlate with longer delays in treatment.

 However, while increased provider education is needed, the early signs may be more likely to be recognized by those who have more immediate contact with children and adolescents, including teachers, school counselors, and community members.

Early Detection, Intervention and Prevention of Psychosis Program

 (EDIPPP), a 6-city multisite study that assessed the effectiveness of a community education and outreach program designed for prevention or intervention in young people at high risk for psychosis, or those at a very early point in their first episode of psychosis.

 It was modeled after a program developed by the Portland Identification and 

 in Portland, Maine, which educated more than 7000 professionals and found a 34% reduction in incidence of hospitalizations for first-episode psychosis.

EDIPPP’s model was geared toward rapid referrals for preventive treatment by creating networks of community personnel to identify signs of early psychosis and to direct young people into Coordinated Specialty Care (CSC), a recovery-based treatment program. CSC uses a team of specialists who make personalized treatment plans, including psychotherapy, medication management, and family education, support, and case management.

Targets for educational presentations on the early warning signs of psychosis included school counselors and nurses, community school mental health and school-based health center teams, focused student and parent education efforts, and ongoing stigma management.

Symptoms of prodromal psychosis present a notable challenge. They can be quite subtle, emerge gradually, and are often overlooked by adolescents, their families, and many primary providers.

Many of the presentations were geared toward culturally diverse audiences and systems that were previously inaccessible. After nearly 1000 formal and informal presentations to 34,000 attendees completed in a 3-year period, 1652 referrals were received to the program. Of these, 520 (31%) were offered in-person orientation, 392 were assessed for treatment, and 337 met criteria for directing into support.

The study, and Dr Adelsheim himself, raised many important questions: eg, how to make educational interventions culturally appropriate for diverse audiences; how to build effective and integrated coordinated specialty care models in those areas that sought referrals; and what it means to truly integrate into primary and secondary schools, such as with respect to creating accommodations and focused special education. He states that “we have a long way to go” to frame these support systems for young people, and he advocates for continuing to move our interventions earlier with further research on models of integrating care at all levels.

Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities,

 untreated mental health and substance use issues in this age group cause a significant burden on individuals, their families, and their communities, and can additionally carry over into adulthood without effective approaches at harm reduction. Increased interest has developed in finding evidence-based preventive practices. Dr Adelsheim’s and his colleagues’ work indicates momentum and success in community-based outreach approaches.

 Addington J, Heinssen RK, Robinson DG, et al. 

Duration of untreated psychosis in community treatment settings in the United States.

 Marshall M, Lewis S, Lockwood A, et al. 

Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review

Understanding delay in treatment for first-episode psychosis.

Strategies for effective recruitment of individuals at risk for developing psychosis

Early Detection, Intervention and Prevention of Psychosis Program: community outreach and early identification at six U.S. sites

 McFarlane WR, Susser E, McCleary R, et al. 

Reduction in incidence of hospitalizations for psychotic episodes through early identification and intervention

The key to identification of prodromal psychosis may lie in community-based outreach.

Author | Brett Daniel Kaylor, DO, MA

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