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Targeting Relapse Prevention and Positive Symptom in First-Episode Psychiatry Research 272 (2019) 275–283 Contents lists available at ScienceDirect Psychiatry Research journal homepage: www.elsevier.com/locate/psychres Targeting relapse prevention and positive symptom in first-episode schizophrenia using brief cognitive behavioral therapy: A pilot randomized T controlled study ⁎ Yan Liua,b, Xiaojie Yanga,b, Amy Gillespiec, Zhihua Guoa,b, Yun Maa,b, Runsen Chena,b,c, , ⁎ Zhanjiang Lia,b, a The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China b Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China c Department of Psychiatry, University of Oxford, UK ARTICLE INFO ABSTRACT Keywords: The present study aimed to provide preliminary evaluation of the effectiveness of a brief CBT intervention First-episode focusing on relapse prevention and positive symptom in a Chinese first episode schizophrenia (FES) population. CBT This randomized controlled trial recruited eighty outpatients with FES (as determined using the DSM-IV), aged Chinese population 16–45 years, and on a current atypical antipsychotic. Patients were randomized to either 10 sessions of in- One year follow up dividual CBT (intervention group) adjunctive to treatment as usual (TAU) or TAU alone (control group). Outcome assessment of symptoms, relapse, hospitalization, insight and social functioning were administered at baseline and then post treatment (10 weeks), and at 6-month and 12-month follow ups. At 12 months, patients in the intervention group had significantly greater improvements in positive symptoms, general psychopathology and social functioning, as well as significantly lower rates of relapse, compared to the control group. Although patients in both groups demonstrated significantly improved negative symptom and insight scores from baseline, no group differences were found. This RCT demonstrates that FES patient can greatly benefit from CBT designed to target relapse prevention and positive symptom, with improvements sustained for 1 year following treatment. 1. Introduction treatment, relapse rates are 70–80% over the 5 years following first onset and 33% of patients experience relapse at one year follow up Schizophrenia has become the eighth leading cause of disability (Robinson et al., 2005; Üçok et al., 2006). Relapse prevention is im- world-wide for people aged between 15–44 years (World Health portant in FES, as each relapse increases the risk of positive symptoms Organization, 2001). It is of vital important that individuals having becoming persistent (Wiersma et al., 1998). Thus, previous studies have their first episode of schizophrenia receive adequate treatment suggested combining antipsychotic treatment with psychosocial inter- (Zhu et al., 2017), as meta-analyses suggest that a long duration of ventions such as CBT for people with early psychosis and schizophrenia untreated psychosis is associated with worse clinical treatment out- (Alvarez-Jiménez et al., 2009; Penn et al., 2005). comes, such as more severe symptoms, worse social functioning, and Several meta-analyses and reviews have concluded that CBT is an failure to achieve remission (Perkins et al., 2005; Perkins et al., 2004). effective intervention for positive, negative and general symptoms, in- Although patients with first episode schizophrenia (FES) usually re- sight, relapse and social functioning in chronic psychosis patients spond well to antipsychotic treatment – potentially due to lower fre- (Wykes et al., 2008; Zimmermann et al., 2005); however, the picture is quency of negative symptoms and better cognition function compared less clear for first-episode schizophrenia patients. Of the controlled to patients with chronic schizophrenia - they may still experience dif- studies that exist, many report inconsistent findings (Drury et al., 1996, ficulties with social interaction and stigma, may discontinue treatment 2000; Garety et al., 2008; Grawe et al., 2006; Haddock et al., 1999b; (Ohlsen et al., 2004), and may relapse. Even with antipsychotic Jackson et al., 1998, 2008; Jolley et al., 2003; Lewis et al., 2002), with ⁎ Corresponding authors. E-mail addresses: [email protected] (R. Chen), [email protected] (Z. Li). https://doi.org/10.1016/j.psychres.2018.12.130 Received 9 July 2018; Received in revised form 15 November 2018; Accepted 23 December 2018 Available online 25 December 2018 0165-1781/ © 2018 Elsevier B.V. All rights reserved. Y. Liu et al. Psychiatry Research 272 (2019) 275–283 issues regarding small sample size (Haddock et al., 1999b; Jackson 2. Methods et al., 1998; Jolley et al., 2003), variable additional treatment, and highly heterogeneous samples (Drury et al., 1996, 2000; Lewis et al., 2.1. Sampling and study design 2002). Importantly, two systematic reviews (Morrison, 2009; Penn et al., 2005) of CBT for first episode psychosis (FEP) concluded that Participants were recruited from Beijing Anding Hospital affiliated there was limited evidence of significant improvements in symptoms Capital Medical University between June 2012 and March 2014. (auditory hallucinations and hopelessness), recovery and functioning, Outpatients were referred to this program by psychiatrists. Inclusion as well as reducing rates of relapse or hospital readmission for first- criteria were: (1) A diagnosis of schizophrenia as assessed by experi- episode patients given CBT intervention. enced research psychiatrists using the Structured Clinical Interview for Few previous FEP studies have specifically looked at using CBT to DSM-IV Axis I Disorders-Clinician Version; (2) Age between 16–45 target relapse prevention, while studies in chronic patients have de- years; (3) The current illness episode was their first episode of schizo- monstrated that CBT focused on relapse prevention is effective in re- phrenia, and any continuous treatment had been for less than 1 month ducing relapse rates. For example, Gumley et al. (2003) found that or was inadequate treatment of less than 3 months verified through relapse prevention focused CBT greatly reduced hospital admission and clinical interview and medical chart review; (4) Use of a single atypical relapse rates in patients with chronic schizophrenia, as well as sig- antipsychotic drug for at least two weeks; (5) A score of 4 or more on nificantly improving symptoms, global psychopathology and social the delusion (P1) or hallucination (P3) symptom scales of the Positive functioning. This study emphasized the importance of early relapse and Negative Syndrome Scale (PANSS); (6) Their first psychotic indicators, which can trigger negative beliefs about relapse and hospi- symptoms had occured less than 3 years ago. Exclusion criteria were: talization. However, a study of relapse prevention therapy (combing (1) Co-morbid diagnosis of mental disability or primary substance de- individual and family CBT therapy) in early psychosis patients pendence; (2) Inability to communicate, or lack of spontaneity and flow (Gleeson et al., 2009) found that while this was indeed effective in of conversation (5 or above on PANSS in conceptual disorganization); reducing relapse rates over 7 months follow up, this did not generalize (3) Electroconvulsive therapy within the 1 month prior to entry into the to other outcomes, with no improvement in medication adherence, study; (4) Serious or unstable physical health condition; (5) Currently psychosocial functioning or quality of life. Thus, the authors suggested receiving any other form of systematic psychotherapy. that focusing on relapse prevention alone was not enough, and further Eighty patients met the criteria and were included in the trial. Fig. 1 consideration of the relevant targets for early CBT interventions is re- provides a CONSORT diagram illustrating the flow of participants quired. through the study. Positive symptoms, such as paranoia, hallucinations and delusions, This study was approved by the Human Research and Ethics are stronger predictors of relapse than negative symptom (Lavretsky, Committee of Beijing Anding Hospital, Capital Medicine University. 2008; Patel et al., 2014). A recent study in which CBT primarily tar- Informed consent was obtained from the patients and guardians. This geted negative symptoms in schizophrenia patients found that this ap- clinical trial is registered with the Chinese Clinical Trial Registry proach effectively reduced negative symptoms, but nearly 30% patients (ChiCTR-TRC-13003929). in the CBT group and 35.1% patients in the cognitive remediation group were readmitted to hospital within 1 year following treatment 2.2. Assessment (Klingberg et al., 2011). Similarly, Jackson et al. (1998) found that while CBT significantly improved negative symptoms in FEP, no group Face-to-face assessments of all participants were performed by three differences were found for rates of relapse and hospitalization. There- clinicians who were blind to the treatment condition, during treatment fore, the CBT model may need to be modified to provide effective as usual sessions. The clinicians were trained once every two months treatment for reducing both positive symptoms and preventing relapse and reviewed the standards of the scales, to ensure assessment accuracy in first episode psychosis. and consistency. At baseline and weeks 10, 36 and 62, severity of There is a great need for research investigating CBT for FES across psychopathology, relapse, number of hospital admissions, insight, and diverse ethnic backgrounds, especially
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