Letters to the Editor
Re: The Combined Use of Atypical Antipsychotics and Cognitive-Behavioural Therapy in Schizophrenia
Dear Editor:
We read with interest Dr Duggal’s letter on the combined use of atypical antipsychotics (AAs) and cognitive- behavioural therapy (CBT) in schizophrenia (1). Dr Duggal reports that his patient showed a reduction of 54% in symptom severity as indexed by the Positive and Negative Syndrome Scale (PANSS). His baseline score when unmedicated was 129 and varied from 83 to 102 with medication; when medication was combined with CBT, his PANSS score was 59.
Dr Duggal’s finding is consistent with, and adds to, the existing literature on the combined use of second-generation antipsychotics (SGAs) and CBT. Our Symptom-Specific Group Treatment Program (conducted at Bronx Psychiatric Center) was designed to match the 5 symptom dimensions of the PANSS: positive, negative, activation, dysphoria, and autistic preoccupation (2). We found that patients attending symptom-specific groups in addition to receiving standard medications showed an additional 22% decrease in symptom severity when compared with a group of patients receiving standard medications alone (3).
We question only Dr Duggal’s speculation that “AAs potentiate CBT.” CBT has been found to be useful in patients who receive standard neuroleptics, including those in our sample, as well as in patients receiving SGAs. Further, it may well be that SGAs and CBT do not potentiate one another but that their effects are additive. The 2 treatment modalities may be targeting different facets of schizophrenia. For example, CBT may teach or remediate coping skills, cognitive functions, and social adeptness impaired during acute psychosis; standard neuroleptics target positive symptoms, and SGAs target positive, negative, activation, dysphoria, and autistic preoccupation symptoms.
More work is needed to better understand whether the interaction between antipsychotics and CBT is additive or synergistic, as well as how CBT works with different antipsychotics.
References
1. Duggal HS. Combined use of atypical antipsychotics and cognitive-behavioural therapy in schizophrenia [letter]. Can J Psychiatry ;47:887–8.
2. White L, Harvey PD, Opler LA, Lindenmayer J-P, Bell M, Caton CLM, and others. Empirical assessment of the factorial structure of clinical symptoms in schizophrenia: a multisite multimodel evaluation of the factorial structure of the Positive and Negative Syndrome Scale (PANSS). Psychopathology 1997;30:263–74.
3. Shelley AM, Battaglia J, Lucey J, Ellis A, Opler L. Symptom-specific group therapy for inpatients with schizophrenia. Einstein Quarterly:Journal of Biology and Medicine, 2001;18(1):21–8.
Anne-Marie Shelley, PhD
Lewis A Opler, MD, PhD
Joseph Battaglia, MD
Jeffrey Lucey, MD
Mount Vernon, New York
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