CBT not anti-psychotics should be first-line treatment for people at risk of psychosis

Anti-psychotics should not be used as a first-line treatment for people at risk of psychosis, including schizophrenia, researchers have claimed.

Instead, “benign” active monitoring or cognitive behavioural therapy (CBT) should be the favoured first intervention, said researchers.

Their study had found that just 8% of people judged to be “at high risk” of developing psychosis and who were not prescribed medication actually went on to be diagnosed with the condition.

This was an “optimistic” finding, wrote the researchers yesterday in the British Medical Journal.

“This low rate of transition to psychosis…and recovery from psychosis and affective symptoms is clearly an important and optimistic message to convey,” they wrote

For the research, a total of 288 people aged 14-35 who had sought psychiatric help and were judged to be at high risk of psychosis were used.

Of these, 144 had 23 weekly cognitive therapy sessions over six months, and their mental state was monitored. The other 144 only had their mental state monitored.

Overall, just 8% (23 out of 288) of both groups went on to be diagnosed with psychosis – a figure that was “lower than expected”.

Although distress from psychotic symptoms did not differ for each group, symptom severity was significantly reduced for those who had cognitive therapy.

The researchers concluded that because of the known detrimental effects, such as brain damage, of anti-psychotics cognitive-behavioural therapy should instead be considered as a first-line intervention.

“Cognitive therapy reduces the severity of psychotic experiences without the use of anti-psychotic drugs, which should provide the benefits of symptom-based improvement without the associated risks of serious side-effects,” they wrote.

“On the basis of low transition rates, high responsiveness to simple interventions such as monitoring, a specific effect of cognitive therapy on the severity of psychotic symptoms, and the toxicity associated with antipsychotic drugs, we would suggest that anti-psychotics are not delivered as a first line treatment to people meeting the criteria for being in an at risk mental state.”

The researchers stated that the low rate of transition to psychosis should also encourage a “normalising, non-catastrophic” perspective on psychosis.

They concluded: “Any treatment should largely be needs-driven on the basis of what problems are presented and prioritised by service users.

“This is something that cognitive therapy is suited to, given its collaborative, problem-oriented nature.”

Reseachers also encouraged the use of “benign” active monitoring of people at risk of psychosis over a 12-month period, without therapeutic intervention, as it encouraged active patient engagement.

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