Clinical. The ABCs of cognitive-behavioral therapy for schizophrenia

Cognitive-behavioral therapy (CBT) in schizophrenia was originally developed to provide additional treatment for residual symptoms, drawing on the principles and intervention strategies previously developed for anxiety and depression. In the 1950s, Aaron Beck1 had already treated a psychotic patient with a cognitive approach, but thereafter the research in this specific area lay dormant for decades. Only after cognitive therapy had been firmly established for depression and anxiety, in the 1990s, did the research into psychological treatments for psychotic conditions gather force—again, with Beck in the forefront.Pharmacologic therapy can leave as many as 60% of psychotic patients with persistent positive and negative symptoms, even when the patients are compliant with their medication instructions.2 Furthermore, medication compliance remains a major problem despite the introduction of modern atypical antipsychotics. Studies have shown treatment discontinuation in an estimated 74% of patients in both outpatient and inpatient settings.3The evidence for the efficacy of CBT in treating patients with persistent symptoms of schizophrenia has progressed from case studies, case series, and uncontrolled trials to methodologically rigorous, randomized, controlled trials that include patients from both the acute4 and the chronic end of the schizophrenia spectrum.5-7 Subsequent meta-analysis8 and systematic reviews have further strengthened the evidence base.CBT is now recognized as an effective intervention for schizophrenia in clinical guidelines developed in the United States9 and in Europe.10 In spite of the evidence base and absence of side effects, however, the general availability of this treatment approach within community settings is still low.11 This article will examine the procedure of CBT for psychosis, the evidence for its use, and the implications for practicing psychiatrists