Letters to the Editor
Combined Use of Atypical Antipsychotics and Cognitive-Behavioural Therapy in Schizophrenia
There are few reports of cognitive-behavioural therapy (CBT) combined with atypical antipsychotic drugs (AAs) in cases of treatment-resistant schizophrenia, especially from North America (1,2). Given that AAs improve cognitive function (3), it would be interesting to explore whether AAs complement CBT and whether they can potentiate the effect of CBT. I discuss these issues in the case of a patient with treatment-resistant schizophrenia who was given clozapine and risperidone along with CBT.
Mr C, aged 29 years, was diagnosed with paranoid schizophrenia of 9 years’ duration. He suffered from auditory hallucinations, somatic passivity, and delusions of persecution, reference, and control. As formally tested, he had poor attention span and impaired verbal working memory. His baseline score on the Positive and Negative Syndrome Scale (PANSS) was 129. Having failed conventional AAs, Mr C was started on clozapine, titrated to 400 mg daily. His PANSS score dropped to 83. However, following generalized tonic-clonic seizures at clozapine 450 mg daily, the drug was reduced to 200 mg daily. Valproate was added and titrated to 1000 mg daily. After a normal EEG, his clozapine was increased, but owing to marked sedation, the drug was again reduced to 200 mg daily. Because the patient’s psychopathology had worsened (his PANSS score increased to 102), risperidone was subsequently added and titrated to 6 mg daily. Simultaneously, Mr C underwent CBT with 2 procedures: 1) belief modification by way of verbal challenge and reality testing for delusions (4) and 2) normalizing his rationale for auditory hallucinations and somatic passivity (5). Sessions were weekly and lasted 20 to 40 minutes.
Two months of this combined therapy saw Mr C’s PANSS score dropping to 59 (reduced by 54% from intake). His cognitive functioning, including attention, memory, and judgement, also improved. Notably, after starting CBT, his conviction regarding his delusions decreased, as did his preoccupation with somatic passivity and auditory hallucinations. The CBT was then shifted to once-monthly sessions, and the patient maintained this improvement at his last follow-up, 6 months later.
This report underscores the effectiveness of combined pharmacotherapy and psychotherapy in managing treatment-resistant schizophrenia, especially for patients in whom an initial good response to clozapine is curtailed by subsequent clozapine-induced seizures. Although it might be difficult to segregate the individual effects of AAs and CBT, these 2 modalities may be complementary, especially because they both bring about cognitive rehabilitation in patients with schizophrenia. The realm of cognitive rehabilitation includes 2 general components (6). First, specific deficits in attention, cognitive flexibility, and vigilance must be treated. These deficits are improved by AAs (3). Second, specific thought-content difficulties, such as hallucinations, delusions, and medication compliance, must be dealt with. These difficulties are addressed by CBT (2). Interestingly, clozapine and risperidone may in turn be complementary in improving cognitive deficits: clozapine improves attention and reaction time, while risperidone improves memory and concept formation (3).
It may also be speculated that AAs potentiate CBT. CBT in part reduces symptomatology by decreasing the salience of old learning and involving new, alternative appraisals, which requires intact learning processes; risperidone and olanazpine improve memory function, including new learning (3,7). Further validation of these observations in a systematic study comparing combined treatment with AAs alone is encouraged.
1. Rector NA, Beck AT. Cognitive therapy of schizophrenia: from conceptualization to intervention. Can J Psychiatry 2002;47:39–48.
2. Norman RMG, Townsend LA. Cognitive-behavioural therapy for psychosis: a status report. Can J Psychiatry 1999;44:245–52.
3. Goldman RS. Cognitve effects of typical and atypical antipsychotic medications in schizophrenia. In: Kane JM, editor. Managing the side effects of drug therapy in schizophrenia. London (UK): Science Press; 1999. p 15–25.
4. Chadwick PDJ, Lowe CF. Measurement and modification of delusional beliefs. J Consult Clin Psychol 1990;58:225–32.
5. Kingdon DG, Turkington D. Cognitive-behavioural therapy of schizophrenia. New York: Guilford; 1994.
6. MacEwan GW. Psychosocial rehabilitation. In: Lieberman JA, editor. Re-integration of the schizophrenic patient. London (UK): Science Press; 1998. p 35–44.
7. Westra HA, Stewart SH. Cognitive behavioural therapy and pharmacotherapy: complementary or contradictory approaches to the treatment of anxiety? Clin Psychol Rev 1998;18:307–40.
Harpreet S Duggal, MD