Clinical trial NCT04752449: Virtual Cognitive Behavioural Therapy for Psychosis
Official title: Virtual Cognitive Behavioural Therapy for Psychosis: A Randomized Controlled Trial
Study type: INTERVENTIONAL
Overall status: ACTIVE_NOT_RECRUITING
Phase: NA
Conditions: Psychotic Disorders
Schizophrenia
Keywords: cbt
psychosis
schizophrenia
cbtp
cognitive behavioural therapy
psychotherapy
virtual
Lead sponsor: University of Toronto
Sponsor class: OTHER
Collaborators: name: Ontario Shores Centre for Mental Health Sciences
First posted: 2021-02-12
Enrollment: 70
Sex: ALL
Minimum age (years): 18
Maximum age (years): 65
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: Participants will be randomized to receive either Virtual Cognitive Behavioural Therapy or to Treatment as Usual. All participants who receive Treatment as Usual will be offered CBT at the end of the study period.
Primary purpose: TREATMENT

Brief summary: Participants with schizophrenia-spectrum disorders who are experiencing active symptoms of psychosis will randomized to either receive 6 months of individual cognitive behavioural therapy for psychosis or to receive treatment as usual. Participants will be assessed at baseline, 6 months, and 12 months.

Detailed description: Schizophrenia-spectrum disorders are the most persistent, debilitating, and economically burdensome mental illnesses worldwide, and are associated with the greatest per-patient expense of all mental health conditions. Schizophrenia is associated with a 15-20 year decrease in life expectancy, 5-fold increase in likelihood of death by suicide, and a significant decrease in quality of life. Antipsychotic medications are the first line treatment for individuals with schizophrenia spectrum disorders and are prescribed to nearly every service-user. However, in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) trial (one of the largest antipsychotic trials in 1493 individuals with schizophrenia), medication effects on psychosocial functioning were small (d = 0.25). Thus, the primary treatment available to all individuals with schizophrenia does little to improve community functioning. This may partially be a result of the limited efficacy of antipsychotic medication to improve neurocognitive abilities, widely recognized as a core feature of schizophrenia, and one recommendation stemming from the CATIE trial was that "more intensive psychosocial rehabilitative services, including cognitive rehabilitation, may be needed to affect more substantial gains in functioning."

Cognitive behavioural therapy (CBT) is a psychological intervention originally developed to treat depression, and subsequently adapted to treat schizophrenia spectrum disorders. CBT has demonstrated moderate treatment effects (d = 0.36 - 0.44) in multiple meta-analyses and is widely recommended for the treatment of schizophrenia in international guidelines. CBT involves clients learning to evaluate their cognitive content in order to develop more accurate representations of the world. CBT has proven effective for improving hallucinations, delusions, negative symptoms, and personal recovery.

Despite the established efficacy of CBT delivered through in-person methods, most clinics have discontinued in-person treatments as a result of the COVID-19 pandemic and have moved to virtual delivery methods. While it has been assumed that virtual delivery of CBT is equivalent to in-person delivery, our recent systematic review demonstrated that there has never been a trial examining the efficacy of virtually delivered CBT for psychosis. Characteristics of schizophrenia such as paranoia, and disorganization already present challenges to psychological treatment and it is possible that this challenge will be further exacerbated by treatment delivery through virtual methods. Additionally, it is unclear the extent to which individuals with schizophrenia-spectrum disorders will be interested in receiving virtual CBT and capable of using the technology that is required.

Thus the goals of the current study are two-fold:

1. Examine the efficacy of virtually delivered CBT for schizophrenia-spectrum disorders to reduce symptoms and improve community functioning.
2. Examine the feasibility and acceptability of virtually-delivered CBT for individuals with schizophrenia-spectrum disorders.

CBT will be delivered according to an established manual that the PI has previously used successfully for in-person treatment. Treatment will consist of individual sessions with a therapist for 1-hour per week for 6-months. Therapists will be either a registered clinical psychologist or a graduate student in clinical psychology under the supervision of a registered clinical psychologist. All treatment will be delivered virtually in the participant's home using the online platform Zoom which is PHIPA/PIPEDA compliant. If participants do not have the technology required for virtual sessions then a tablet will be loaned to them for the duration of treatment. This treatment will be delivered in addition to usual care and no changes to usual care will be required.

Eligibility criteria: Inclusion Criteria:

The inclusion criteria is anyone who meets the criteria of schizophrenia, schizoaffective disorder or any other psychotic disorder, are also 18-65 years of age, know how to use a computer, are not abusing drugs or alcohol and can read and speak English. Participants must be experiencing active symptoms of psychosis as indicated on the PANSS.

Exclusion Criteria:

Exclusion criteria include anyone who has received CBT in the past 6 months, or anyone with a neurological disease or neurological damage that would make it difficult to participate in a talk therapy.

Primary outcomes:
measure: Positive and Negative Syndrome Scale (PANSS) Total Score
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
Secondary outcomes:
measure: Personal and Social Performance Scale (PSP)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
measure: The Psychotic Symptom Rating Scales (PSYRATS)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
measure: Calgary Depression Scale for Schizophrenia (CDSS)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
measure: The Questionnaire About the Process of Recovery (QPR)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
measure: Beliefs About Paranoia Scale (BAPS)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
measure: Beliefs About Voices Questionnaire (BAVQ)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
measure: Experiences Questionnaire (EQ)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
measure: Brief Core Schema Scale (BCSS)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
measure: Dysfunctional Attitude Scale (DAS)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
measure: Davos Assessment of Cognitive Biases Scale (DACOBS)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
measure: Childhood Trauma Questionnaire (CTQ)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
measure: Working Alliance Inventory (WAI)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
measure: Psychological Distance Scaling Task (PDST)
timeFrame: Change from Baseline to Follow-up (6 months post treatment)
Other outcomes:
Locations:
city: Scarborough
country: Canada
facility: University of Toronto Scarborough
state: Ontario
Study officials:
affiliation: University of Toronto
name: Michael W Best, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Wu EQ, Birnbaum HG, Shi L, Ball DE, Kessler RC, Moulis M, Aggarwal J. The economic burden of schizophrenia in the United States in 2002. J Clin Psychiatry. 2005 Sep;66(9):1122-9. doi: 10.4088/jcp.v66n0906.
citation: Palmer BA, Pankratz VS, Bostwick JM. The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry. 2005 Mar;62(3):247-53. doi: 10.1001/archpsyc.62.3.247.
citation: Eack SM, Newhill CE. Psychiatric symptoms and quality of life in schizophrenia: a meta-analysis. Schizophr Bull. 2007 Sep;33(5):1225-37. doi: 10.1093/schbul/sbl071. Epub 2007 Jan 4.
citation: Swartz MS, Perkins DO, Stroup TS, Davis SM, Capuano G, Rosenheck RA, Reimherr F, McGee MF, Keefe RS, McEvoy JP, Hsiao JK, Lieberman JA; CATIE Investigators. Effects of antipsychotic medications on psychosocial functioning in patients with chronic schizophrenia: findings from the NIMH CATIE study. Am J Psychiatry. 2007 Mar;164(3):428-36. doi: 10.1176/ajp.2007.164.3.428.
citation: Chadwick P. Person-based cognitive therapy for distressing psychosis. (Wiley & Sons Ltd., 2006).
citation: Kingdon DG, Turkington D. Cognitive Therapy of Schizophrenia. The Guilford Press, 2005.
citation: Morrison AP, Renton JC, Dunn H, Williams S, Bentall RP. Cognitive Therapy for Psychosis: A Formulation-Based Approach. Routledge, 2004
citation: van der Gaag M, Valmaggia LR, Smit F. The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: a meta-analysis. Schizophr Res. 2014 Jun;156(1):30-7. doi: 10.1016/j.schres.2014.03.016. Epub 2014 Apr 14.
citation: Burns AM, Erickson DH, Brenner CA. Cognitive-behavioral therapy for medication-resistant psychosis: a meta-analytic review. Psychiatr Serv. 2014 Jul;65(7):874-80. doi: 10.1176/appi.ps.201300213.
citation: Velthorst E, Koeter M, van der Gaag M, Nieman DH, Fett AK, Smit F, Staring AB, Meijer C, de Haan L. Adapted cognitive-behavioural therapy required for targeting negative symptoms in schizophrenia: meta-analysis and meta-regression. Psychol Med. 2015 Feb;45(3):453-65. doi: 10.1017/S0033291714001147. Epub 2014 May 22.
citation: Psychosis and schizophrenia in adults: prevention and management. London: National Institute for Health and Care Excellence (NICE); 2014 Mar. Available from http://www.ncbi.nlm.nih.gov/books/NBK555203/
citation: Norman R, Lecomte T, Addington D, Anderson E. Canadian Treatment Guidelines on Psychosocial Treatment of Schizophrenia in Adults. Can J Psychiatry. 2017 Sep;62(9):617-623. doi: 10.1177/0706743717719894. Epub 2017 Jul 13.
citation: Grant PM, Huh GA, Perivoliotis D, Stolar NM, Beck AT. Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Arch Gen Psychiatry. 2012 Feb;69(2):121-7. doi: 10.1001/archgenpsychiatry.2011.129. Epub 2011 Oct 3.
citation: Morrison AP, Law H, Carter L, Sellers R, Emsley R, Pyle M, French P, Shiers D, Yung AR, Murphy EK, Holden N, Steele A, Bowe SE, Palmier-Claus J, Brooks V, Byrne R, Davies L, Haddad PM. Antipsychotic drugs versus cognitive behavioural therapy versus a combination of both in people with psychosis: a randomised controlled pilot and feasibility study. Lancet Psychiatry. 2018 May;5(5):411-423. doi: 10.1016/S2215-0366(18)30096-8. Epub 2018 Apr 5.
citation: Best MW, CIHR Knowledge Synthesis: Examining the Efficacy of Psychosocial Interventions for Schizophrenia-Spectrum disorders delivered through virtual care. 2020.
citation: Morrison AP, Renton JC, Dunn H, Williams S, Bentall RP. Cognitive therapy for psychosis: A formulation-based approach. Routledge, 2004.
citation: Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull. 1987;13(2):261-76. doi: 10.1093/schbul/13.2.261.
citation: Nasrallah H, Morosini P, Gagnon DD. Reliability, validity and ability to detect change of the Personal and Social Performance scale in patients with stable schizophrenia. Psychiatry Res. 2008 Nov 30;161(2):213-24. doi: 10.1016/j.psychres.2007.11.012. Epub 2008 Oct 11.
citation: Haddock G, McCarron J, Tarrier N, Faragher EB. Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS). Psychol Med. 1999 Jul;29(4):879-89. doi: 10.1017/s0033291799008661.
citation: Addington D, Addington J, Maticka-Tyndale E. Assessing depression in schizophrenia: the Calgary Depression Scale. Br J Psychiatry Suppl. 1993 Dec;(22):39-44.
citation: Beck AT, Weissman F. Dysfunctional Attitudes Scale (DAS). 1987.
citation: van der Gaag M, Schutz C, Ten Napel A, Landa Y, Delespaul P, Bak M, Tschacher W, de Hert M. Development of the Davos assessment of cognitive biases scale (DACOBS). Schizophr Res. 2013 Mar;144(1-3):63-71. doi: 10.1016/j.schres.2012.12.010. Epub 2013 Jan 15.
citation: Bernstein DP, Fink L, Handelsman L, Foote J. Childhood trauma questionnaire. Assessment of family violence: A handbook for researchers and practitioners. 1998.
citation: Horvath AO, Greenberg LS. Development and validation of the Working Alliance Inventory. Journal of Counselling Psychology. 1989; 36(2): 223.
citation: Ross RM, McKay R, Coltheart M, Langdon R. Jumping to Conclusions About the Beads Task? A Meta-analysis of Delusional Ideation and Data-Gathering. Schizophr Bull. 2015 Sep;41(5):1183-91. doi: 10.1093/schbul/sbu187. Epub 2015 Jan 22.
citation: Diehl C, Yin S, Markell H, Gallop R, Gibbons MBC, Crits-Christoph P. The Measurement of Cognitive Schemas: Validation of the Psychological Distance Scaling Task in a Community Mental Health Sample. Int J Cogn Ther. 2017;10(1):17-33. doi: 10.1521/ijct_2016_09_18.
citation: Best MW, Milanovic M, Iftene F, Bowie CR. A Randomized Controlled Trial of Executive Functioning Training Compared With Perceptual Training for Schizophrenia Spectrum Disorders: Effects on Neurophysiology, Neurocognition, and Functioning. Am J Psychiatry. 2019 Apr 1;176(4):297-306. doi: 10.1176/appi.ajp.2018.18070849. Epub 2019 Mar 8.
citation: Best MW, Gale D, Tran T, Haque MK, Bowie CR. Brief executive function training for individuals with severe mental illness: Effects on EEG synchronization and executive functioning. Schizophr Res. 2019 Jan;203:32-40. doi: 10.1016/j.schres.2017.08.052. Epub 2017 Sep 19.