CBT for Ultra-High-Risk Patients Lowers Incidence of Psychosis

The use of cognitive-behavioral therapy (CBT) in patients identified as being at ultra-high risk (UHR) for psychosis appears to effectively lower the incidence of conversion to psychosis after four years, according to a report in the August Schizophrenia Bulletin.

William Carpenter, M.D.

Moreover, significantly more patients receiving CBT remitted from their UHR status compared with patients receiving treatment as usual, suggesting that CBT may prevent psychosis and improve long-term trajectory.

The report looks at four-year outcomes comparing CBT specifically adapted for patients at ultra-high risk of psychosis and treatment as usual in patients enrolled in the Dutch Early Detection Intervention and Evaluation (EDIE). In a previous publication, researchers at the Parnassia Psychiatric Institute in the Hague, the Netherlands, demonstrated that CBT halved the incidence of psychosis over an 18-month period.

The longer follow-up results in the new study, including the higher rates of remission, add to a body of literature from programs serving UHR patients on the effectiveness of CBT.

“Delay of the onset of a first psychotic episode might prove to be more than postponement of transition to psychosis alone and might be regarded as real prevention, since very few participants made the transition from UHR to psychosis after the first 12 (and 18) months,” the researchers stated.

“Ultra-high risk” has come to define a group of patients with either a family history of psychosis and/or significant impairments in cognition and social and occupational functioning that do not yet rise to the level of clinical psychosis. In the Dutch study, criteria for inclusion included a family history of psychosis or scores on the Comprehensive Assessment of At-Risk Mental States (CAARMS) in the range of the “at-risk mental state,” and a score on the Social and Occupational Functioning Assessment Scale (SOFAS) of 54 or less and/or a reduction of 30 percent on the SOFAS for the duration of at least one month in the past year.

The Dutch EDIE study was a randomized, controlled trial with 196 patients at ultra-high risk of psychosis in secondary mental health care at six sites in the Netherlands. Patients in both conditions received treatment as usual (TAU)—that is, routine care provided for the nonpsychotic disorders (mainly depressive and anxiety disorders) for which the patients initially sought treatment. The experimental group received TAU plus CBT, with a maximum of 26 sessions in the first six months after inclusion.

In the four-year follow-up, 56 patients in the CBT group and 57 patients in the TAU group were evaluated.

The number of participants converting to psychosis in the CBT group increased from 10 at 18 months to 12 at four-year follow-up. In the TAU group, the number of participants who transitioned to psychosis at four-year follow-up remained at 22, the same number that had transitioned at 18 months.

The researchers noted that this rate of conversion continues to represent a significantly better outcome for the CBT group over four years. Moreover, the number of days to transition to psychosis was significantly higher in the CBT group (1,322.45 days) compared with the TAU group (1,188.91).

Especially important is the fact that remission from subthreshold psychotic symptoms was significantly higher in the CBT group—with 76.3 percent of the participants who received CBT and 58.7 percent of the participants receiving TAU having remitted from UHR status by four years. Remission from UHR status is clinically relevant, as most transitions from UHR to psychosis occur within the first 12 months after clinical presentation, the authors noted.

“This trial shows that CBT for patients at ultra-high risk of psychosis was successful in reducing the risk of a first psychosis by 50 percent and that these favorable effects were sustained over four years,” the researchers stated. “In addition, the CBT intervention achieved higher remission rates in UHR symptomatology.”

The researchers noted, however, that social functioning is still affected in most participants (even in participants who remitted from UHR status), and many still suffer from positive, negative, and cognitive symptoms; behavioral change symptoms; and anxiety.

“Much is gained by preventing a first psychotic episode, since patients who made a transition showed more severe psychopathology and worse social functioning compared with those who did not transition,” they stated. “The prognosis of the UHR status is much more favorable than the prognosis after a transition to a first psychotic episode.”

William Carpenter, M.D., editor of Schizophrenia Bulletin, told Psychiatric News that the advantage of CBT has been consistently shown in trials of patients at clinical high risk of psychosis, despite the fact that treatment as usual in studies like the Dutch EDIE is likely to be very good.

“This suggests to me that the effect of treatment versus no treatment is very robust both for secondary prevention of full psychosis and for symptoms and probably function. Our field should make early detection/therapeutic intervention a major priority because it is our best opportunity to improve the life course in persons vulnerable to psychotic disorders. The current emphasis on first psychotic episode intervention attempts to shorten the duration of untreated psychosis. Targeting high-risk patients seems certain to reduce the duration of untreated psychopathology and the duration of untreated psychosis.”

Carpenter also said he believes the diagnosis of attenuated psychosis syndrome in Section 3 of DSM-5 should be moved to the main text to help clinicians, including primary care physicians, translate evidence-based care developed in expert centers to sites where patients routinely seek care.

He added, “Integrated care is essential and needs to include CBT. This is a severe challenge in the U.S. medical system with an inadequate workforce of trained therapists and inadequate support of integration across disciplines.” ■