Something’s burning?

Ella Rhodes reports on perspectives on psychosis and schizophrenia at the University of Bath.

Opening this event, organised in response to the Understanding Psychosis and Schizophrenia report from the British Psychological Society’s Division of Clinical Psychology, Professor Paul Salkovskis expressed a hope that the event would ‘generate light rather than heat during the discussion’. However, he admitted to being ‘perturbed’ by the report because he and others had not been consulted about it. The debate was needed, he urged, to consider other professions’ views and to explore recent science and theory in the area.

Professor David Clark, from the University of Oxford and the Clinical Lead behind the Government’s Improving Access to Psychological Therapies programme (which he developed along with Lord Layard), gave an overview of its successes in treating anxiety and depression. He also gave suggestions to the gathered psychologists and psychiatrists about ways a similar model may be used in helping people with psychosis and schizophrenia, outlining key principles such as a national outcome monitoring system, a national training programme in NICE recommended CBT treatments, and ambitious and clear access targets. ‘I hope that the principles of IAPT will now be extended to people with bipolar schizophrenia and personality disorders,’ he concluded. ‘To some extent it’s up to you to ensure it happens.’ Clinicians need to ‘step up to the plate’, embrace outcome monitoring and be transparent about their data so patients could see if a certain service was likely to help. It was critically important, he said, to have a well-argued economic case; in IAPT they could tell the government it would save more money than it cost.

The results of a trial of an IAPT-type approach in helping those with psychosis and schizophrenia was outlined next by Philippa Garety (King’s College London). Professor Garety spoke two demonstration sites in South London and Maudsley Trust, which have been the centre of data collection for a new approach for treating psychosis and schizophrenia. The project, which started in 2012 and collected data until December last year, included a trust which covers four London boroughs with ‘exceptionally high’ levels of psychosis. In this new treatment people were offered CBT to NICE recommendations, a course which lasts six to nine months with weekly or fortnightly one-hour sessions. People using the service showed improvement in wellbeing, distress and social functioning. Although not everyone presented at the clinic with a current hallucination or delusion, those who did showed a reduction in such symptoms.

Finally Garety pointed to preliminary data from an economic analysis by Paul McCrone which looked into the costs to the NHS. He compared costs before and after therapy and found crisis team usage and bed costs were reduced. She concluded there was clear evidence of demand for CBT in psychosis, good completion rates and evidence of improvement on a number of measures.

Daniel Freeman (University of Oxford) spoke next, about some new work targeting the severe paranoid thoughts often seen in people who experience psychosis. He said among the psychological factors which maintain such thoughts is worry – rates of worry between people with schizophrenia and those with anxiety disorders are near-identical. As a result of this and other work, Freeman worked with a clinical group of 150, all of whom had persistent persecutory delusions, to target these feelings of worry. All of them had at least 50 per cent conviction in their delusions and had worry levels similar to those in general anxiety disorder. Some were given a six-week worry-intervention CBT using six booklets of exercises, while others continued their normal treatment. Worry was reduced by eight weeks and remained at the same level at the 42-week follow-up. The intervention also caused a reduction in delusions, which also persisted after 24 weeks.

The debate over the potential genetic basis for schizophrenia and psychosis has raged for many decades, and Robin Murray, Professor of Psychiatric Research (King’s College London) spoke about the interaction between genes, the environment, cannabis and social adversity. He began by explaining that people who experience psychosis have an over-reactive dopamine system which can be triggered by stress, and social factors can make it worse: ‘It’s dopamine that grabs your attention and it’s dopamine that leads to you thinking all sorts of things around you are significant when they’re not,’ he said. Other risk factors for psychosis and schizophrenia include drug abuse, being a migrant, being abused as a child, and being in an ethnic minority. Murray ran through some evidence showing that those who had experienced childhood abuse or had a disrupted childhood, but had not suffered psychosis, also had dopamine dysregulation problems in times of stress. Is the answer in the genes? Murray concluded with a new study which looked into 37,000 cases of schizophrenia and found there were at least 108 regions of the genome where there are genes associated with schizophrenia. ‘Individual risk genes are neither necessary nor sufficient to cause schizophrenia… rather, they increase the risk.’

A new video which aims to normalise opinions of psychosis among the general public, and to inform them about compassionate relating treatment, was shown by Dr Charles Heriot-Maitland (King’s College London). The video (compassionforvoices.com) tells the fictional story of Stuart who experiences voices and seeks help from a therapist. Developed with Dr Eleanor Longden and Dr Rufus May, psychologists who have both had personal experience of psychosis, it outlines three emotional systems – threat, drive and soothing – and how these can be regulated with compassion training.

Next to speak was Co-ordinating Editor of the Cochrane Schizophrenia Group, Clive Adams (University of Nottingham). The group aims to identify all trials worldwide into schizophrenia, and reviews evidence from around the world on the prevention, treatment and rehabilitation of people with psychotic illnesses. Adams spoke about managing bias when reviewing studies, the history and future of investigations, and the importance of using real-world measures in trials.

Moving on to the controversial evidence around the use of CBT in treating psychosis, Adams outlined a review by Chris Jones in Birmingham, who had written: ‘Trial-based evidence shows no clear, convincing advantages over sometimes much less sophisticated therapies on average.’ On NICE guidelines, Adams quoted Udayanga Perera and Mark Taylor who wrote that the guidelines for using CBT seem to promote psychosocial interventions beyond the evidence and makes recommendations based on no evidence at all. Adams concluded: ‘Where does this leave us psychiatry, mental health, nursing? I think it leaves us in trouble. Ever so polite but sniping at each other, and that’s wholly unedifying, privately or publicly. The hopes of people with schizophrenia are raised and dashed at the same time, how dare we do that? Clinicians don’t know which way to turn and the researchers research. Careers blossom and fade and Rome burns while the services degrade – something’s wrong here.’

Finally, in a round table discussion Peter Kinderman (University of Liverpool), co-author of the DCP Report, began by promising to involve input from more people in future, apologising to those who did not get advance notice. However, he added that he did not expect to be consulted on every report in a relevant field. Professor Kinderman moved on to criticisms of the report’s content, saying that much of it had been from those who did not share the views of the authors, but that a report should not be criticised through misrepresenting its content. He added that although he expected to find the conference at variance with his world view, he had actually agreed with all that was presented and felt that it was compatible with the content of the report.

Next, psychiatrist and epidemiologist Dr James McCabe (King’s College London) shared his views on whether we should view psychosis as being on a continuum or in categories – a topic also included in the DCP report. Viewing psychosis on a continuum captures more information and can sometimes be helpful for those experiencing a first episode of psychosis, to know a large proportion of the normal population occasionally have psychotic symptoms. But when scientists are confronted by masses of confusing data, categorising it can be useful. McCabe concluded with some of his current work looking to develop new ways of describing groups of people that are likely to respond to particular treatments, rather than just their symptoms.

Dr Rachel Churchill, a Psychiatric Epidemiologist from the University of Bristol, gave a professional and personal perspective on how systematic reviews and high-quality evidence synthesis can be of immense value. She added that groups who make decisions that result in change to healthcare use evidence synthesis: ‘We need to produce evidence syntheses directed at these groups to make a difference for people who experience psychosis’. Churchill said it was also crucial to also consider the organisation of care between different providers, the patient’s circumstances and wishes, as well as the value of public education about psychosis. Reducing stigma would make people better understand psychosis as well as making the experience of psychosis in the first instance easier to speak about.

James Coyne (Universtity of Pennsylvania), who has voiced criticisms of the Understanding Psychosis and Schizophrenia report, put these in some context. He said in the 1980s while working as Director of Research at the Mental Research Institute in Palo Alto he witnessed what he described as the ‘horrible’ Soteria project. He explained that participants in the project had acute psychosis and were given just low doses of medication. ‘It’s important because it informs my perspective a lot of what we’re hearing about dealing with people with severe mental disorder, we’ve been there, tried it and it didn’t work… Some horrible chaos ensued, horrible exploitation of some patients by other patients, and when it finally collapsed, we tried to revive the project not to continue with this way of dealing with patients but to make sense of what had happened. We applied for NIMH funding to do follow-ups. It was soundly rejected, the reason being all the clinical data on these patients was very experiential not categorical.’

Coyne said this experience told him there was a necessity for precision of observation as well as categorisation. He also raised concerns that quotes in the DCP report were not from psychotic patients, adding ‘I think studies that simply involve checklist assessments of anomalous experience really don’t add to our understanding.’ He concluded: ‘I think the UK is committed to studies that are next-to worthless in looking at the effectiveness of cognitive behavioural therapy. They’re committed to studies that make comparisons of routine care that’s not adequately quantified or standardised. And I think, deliberately, the people who are doing CBT research avoid comparisons with minimal active treatment conditions like befriending.’

The final discussion involved several people with personal experience of psychosis / schizophrenia, and Professor Salkovskis told The Psychologist later that what he took from it, and from the day as a whole, was that there was ‘more agreement than disagreement, and a consensus to do better.’ So in sum, a day with plenty of light and perhaps a thawing of relations between various parties in the debate, but heat is likely to remain around this important and controversial topic.

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