The Cochrane Corner in this issue addresses the important issue of psychological ineterventions for common psychiatric disorders. The cognitive behaviour therapy for schizophrenia, combined psychotherapy plus antidepressants for panic disorder and counseling in primary care are undoubtedly are most important psychotherapeutic avenues in psychiatric practice. While pharmaceutical industry vigorously promotes and produces evidence for pharmacological interventions, the evidence for psychotherapeutic interventions is neither produced nor disseminated widely. For similar reasons the practitioners in developing countries are less likely to be aware of this evidence. We have therefore focused on this area in the present feature.

1. This systematic review discusses the role of different non pharmacological interventions, especially the cognitive behavior therapy (CBT) in the management of schizophrenia. CBT plus standard care did not reduce relapse and readmission compared with standard care but did decrease the risk of staying in hospital. Importantly when compared with supportive psychotherapy, CBT had no effect on relapse showing perhaps non specific effect of psychological interventions which is a common finding in research in psychotherapy.

2. Panic disorder is a serious psychiatric condition leading to social and occupational impairment. Early intervention in this disorder can prevent functional impairment and disability. It was found that in the acute phase treatment, the combined therapy was superior to antidepressant pharmacotherapy. After the acute phase treatment, as long as the drug was continued, the superiority of the combination over either monotherapy appeared to persist. In view of chronic disabling nature of the disorder it is important that the most effective interventions are provided. In the light of the evidence produced by this review the most effective intervention is a combination of cognitive behavior therapy and pharmacotherapy. . This poses a real challenge to provide these psychological interventions at much wider scale than is currently practiced.

3. Many epidemiological studies report very high prevalence of common mental disorders, such as mild to moderate depression, and anxiety disorders in primary care settings. Besides routine care, the most common psychological intervention in primary care population is structured counseling only. It is disappointing to note that only eight trials could be found evaluating the effectiveness of counseling in primary care. The analysis of these trials found significantly greater clinical effectiveness in the counseling group compared with usual care in the short-term but not the long-term. However, short term improvement in these common disorders in primary care is not a mean achievement considering the disability caused by these disorders..There was some evidence that the overall costs of counseling and usual care were similar. More importantly levels of satisfaction with counseling were high. Considering the high prevalence of common mental disorders in primary care there is clearly need for more evidence in this important area.

Edited by: Dr. Javed Akhtar, MCPS, FCPS, Senior Registrar, Department of Psychiatry, Lady Reading Hospital, Peshawar.

1. COGNITIVE BEHAVIOUR THERAPY FOR SCHIZOPHRENIA

Jones C, Cormac I, Silveira da Mota Neto JI, Campbell C

ABSTRACT

Background: Cognitive behavioural therapy (CBT) is now a recommended treatment for people with schizophrenia. This approach helps to link the person’s feelings and patterns of thinking which underpin distress.

Objectives: To review the effects of CBT for people with schizophrenia when compared to standard care, specific medication, other therapies and no intervention.

Search strategy: This 2004 update built on past work by searching the Cochrane Schizophrenia Groups’ Register of Trials (January 2004). We inspected all references of the selected articles for further relevant trials.

Selection criteria: All relevant clinical randomised trials of cognitive behaviour therapy for people with schizophrenia-like illnesses.

Data collection and analysis

Studies were reliably selected and assessed for methodological quality. Two reviewers, working independently, extracted data. We analysed dichotomous data on an intention-to-treat basis and continuous data with 65% completion rate are presented. Where possible, for dichotomous outcomes, we estimated a relative risk (RR) with the 95% confidence interval (CI) along with the number needed to treat/harm (NNT/H).

Main results

30 papers described 19 trials. CBT plus standard care did not reduce relapse and readmission compared with standard care (long term 4 RCTs, n=357, RR 0.8 CI 0.5 to 1.5), but did decrease the risk of staying in hospital (1 RCT, n=62, RR 0.5 CI 0.3 to 0.9, NNT 4 CI 3 to 15). CBT helped mental state over the medium term (2 RCTs, n=123, RR No meaningful improvement 0.7 CI 0.6 to 0.9, NNT 4 CI 3 to 9) but after one year the difference was gone (3 RCTs, n=211, RR 0.95 CI 0.6 to 1.5). Continuous measures of mental state (BDI, BPRS, CPRS, MADRS, PAS) do not demonstrate a consistent effect.

When compared with supportive psychotherapy, CBT had no effect on relapse (1 RCT, n=59, RR medium term 0.6 CI 0.2 to 2; 2 RCTs, n=83, RR long term 1.1 CI 0.5 to 2.4). This also applies to the outcome of ‘No clinically meaningful improvements in mental state’ over the same time periods (1 RCT, n=59, RR medium term 0.8 CI 0.6 to 1.1; 2 RCT, n=100, RR long term 0.9 CI 0.8 to 1.1).

When CBT was combined with a psychoeducational approach there was no significant reduction of readmission rates relative to standard care alone (1 RCT, n=91, RR 0.9 CI 0.6 to 1.4).

Authors’ conclusions

CBT is a promising but under evaluated intervention. Currently, trial-based data supporting the wide use of CBT for people with schizophrenia or other psychotic illnesses are far from conclusive. More trials are justified, especially in comparison with a lower grade supportive approach. These trials should be designed to be both clinically meaningful and widely applicable. Cochrane Database of Systematic Reviews 2008 Issue 2.

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

2. COMBINED PSYCHOTHERAPY PLUS ANTIDEPRESSANTS FOR PANIC DISORDER WITH OR WITHOUT AGORAPHOBIA

Furukawa TA, Watanabe N, Churchill R

ABSTRACT

Background: Panic disorder can be treated with pharmacotherapy, psychotherapy or in combination, but the relative merits of combined therapy have not been well established.

Objectives:To review evidence concerning short- and long-term advantages and disadvantages of combined psychotherapy plus antidepressant treatment for panic disorder with or without agoraphobia, in comparison with

either therapy alone.

Search strategy: The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 11/10/2005, together with a complementary search of the Cochrane Central Register of Controlled Trials and MEDLINE, using the keywords antidepressant and panic. A reference search, SciSearch and personal contact with experts were carried out.

Selection criteria

Two independent review authors identified randomised controlled trials comparing the combined therapy against either of the monotherapies among adult patients with panic disorder with or without agoraphobia.

Data collection and analysis

Two independent review authors extracted data using predefined data formats, including study quality indicators. The primary outcome was relative risk (RR) of “response” i.e. substantial overall improvement from baseline as defined by the original investigators. Secondary outcomes included standardised weighted mean differences in global severity, panic attack frequency, phobic avoidance, general anxiety, depression and social functioning and relative risks of overall dropouts and dropouts due to side effects.

Main results

We identified 23 randomised comparisons (representing 21 trials, 1709 patients), 21 of which involved behaviour or cognitive-behaviour therapies. In the acute phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR 1.24, 95% confidence interval (CI) 1.02 to 1.52) or psychotherapy (RR 1.17, 95% CI 1.05 to 1.31). The combined therapy produced more dropouts due to side effects than psychotherapy (number needed to harm (NNH) around 26). After the acute phase treatment, as long as the drug was continued, the superiority of the combination over either monotherapy appeared to persist. After termination of the acute phase and continuation treatment, the combined therapy was more effective than pharmacotherapy alone (RR 1.61, 95% CI 1.23 to 2.11) and was as effective as psychotherapy (RR 0.96, 95% CI 0.79 to 1.16).

Authors’ conclusions

Either combined therapy or psychotherapy alone may be chosen as first line treatment for panic disorder with or without agoraphobia, depending on patient preference. Cochrane Database of Systematic Reviews 2008 Issue2.

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

3. EFFECTIVENESS AND COST EFFECTIVENESS OF COUNSELLING IN PRIMARY CARE

Bower P, Rowland N

ABSTRACT

Background: The prevalence of mental health and psychosocial problems in primary care is high. This review examines the clinical and cost-effectiveness of psychological therapies provided in primary care by counsellors.

Objectives:To assess the effectiveness and cost effectiveness of counselling in primary care by reviewing cost and outcome data in randomised controlled trials for patients with psychological and psychosocial problems considered suitable for counselling.

Search strategy: To update the review, the following electronic databases were searched on 25-10-2005: MEDLINE, EMBASE, PsycLIT, CINAHL, the Cochrane Controlled Trials register and the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers.

Selection criteria

All controlled trials comparing counselling in primary care with other treatments for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of June 2005 were included in the review.

Data collection and analysis

Data were extracted using a standardised data extraction sheet. Trials were rated for quality using CCDAN criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form.

Main results

Eight trials were included in the review. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials). Levels of satisfaction with counseling were high. There was some evidence that the overall costs of counselling and usual care were similar.

Authors’ conclusions

Counseling is associated with modest improvement in short-term outcome compared to usual care, but provides no additional advantages in the long-term. Patients are satisfied with counselling. Although some types of health care utilization may be reduced, counseling does not seem to reduce overall healthcare costs. Cochrane Database of Systematic Reviews 2008 Issue 2.

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.