Other treatments
Cognitive remediation therapyMany people with schizophrenia have memory problems, find it hard to concentrate, organise themselves or make plans. Mental health professionals call this ‘cognitive impairment’ and these difficulties can make it harder for people to work and live independently. Cognitive remediation therapy aims to help people improve their thinking skills and attention, and to find ways of remembering important information. Researchers continue to investigate the use of cognitive remediation therapy – or CRT – in the treatment of people with a diagnosis of psychosis. A number of research studies in the USA have shown that when CRT is offered at the same time as vocational support, it can help people to get a job. The National Institute for Health and Clinical Excellence Guideline on Schizophrenia, published in 2009, does not currently recommend CRT be offered to be people with schizophrenia as part of a routine package of treatment. This is because there hasn’t yet been enough research carried out to show how best CRT on its own it can help people, and whether there are long term benefits. There are, however, a number of research studies that are currently investigating how effective CRT is. Electroconvulsive therapy (ECT)For electroconvulsive therapy, an electric current is passed briefly to the brain through electrodes put on the head. The electric current causes a seizure or ‘fit’. ECT is given under a general anaesthetic and people are also given a muscle relaxant to stop body spasms. Many people report short-term or long-term memory loss after the treatment. Electroconvulsive therapy (ECT) should not be used as a treatment for schizophrenia. Sometimes it may be offered to people with bipolar disorder if they are very unwell, or to people who have psychotic depression. The National Institute of Health and Clinical Excellence (NICE) issued guidance on the use of ECT in 2003, stating electroconvulsive therapy (ECT) should only be used for:
This guidance says ECT should only be used to gain fast improvement of severe symptoms when all other treatment options have failed, or when the situation is thought to be life-threatening. Unless it is an emergency, the Mental Health Act says that patients who have the capacity to consent cannot be given ECT unless they agree. The NICE guidance says people must be given information about potential risks and benefits of ECT in order to make an informed decision about whether to have the treatment. Doctors must not put pressure on a patient to have the treatment, and an independent person – a family member or advocate – should be involved in the decision if possible. The guidance is called The clinical effectiveness and cost effectiveness of electroconvulsive therapy (ECT) for depressive illness, schizophrenia, catatonia and mania. You can read a summary of the guidance on ECT at the NICE website. The recommendations on the use of ECT specifically for depression have been updated in an October 2009 NICE guidance on The treatment and management of depression in adults. This says that ECT should be considered for severe depression that is life-threatening and when urgent treatment is needed, or for moderate or severe depression when other treatments have failed. You can read a summary of the guidance about depression at the NICE website. Cognitive behaviour therapy for specific problems or symptomsCognitive behaviour therapy (CBT) is designed to help solve problems by changing the way people think and the way they behave and react to a problem. Different types of cognitive behaviour therapy targeting specific symptoms of psychosis are being developed and tested. So, for example, a new version of cognitive behaviour therapy has been designed to challenge the power of voices that tell people to do harmful or dangerous things. Most people try to resist aggressive commands but often feel they must obey because they fear what will happen if they don’t. This kind of CBT has been developed by mental health professionals and academics in Birmingham. It aims to help people understand that the voices are not themselves powerful and so reduce the urge to obey them, and help people feel more in control. It is now being tested in a large research study called COMMAND. Another cognitive behaviour style therapy has been developed by a research team at Manchester University to help young people who have had experiences resembling the symptoms of psychosis and who may be at risk from becoming unwell. This therapy aims to stop people from going on to develop a first episode of psychosis. At the Institute of Psychiatry, King’s College London, researchers are developing a computerised cognitive behaviour therapy that helps people make decisions more slowly so that they come to less hasty conclusions. This is designed to help improve people’s ability to develop alternative explanations for their strongly held views of delusions, and to help them begin to doubt these views. Mindfulness-based cognitive therapy (MBCT)This type of psychological therapy is recommended by NICE (National Institute for Health and Clinical Excellence) guidance on the treatment of depression. There is now some research being undertaken to find out if MBCT could help people with psychosis. The group therapy is designed to help people recognise negative thoughts and feelings that are warning signs of a relapse, and might contribute to them becoming unwell again, and then to help them cope better and be more accepting of those experiences, and to react to them in a more positive way. Research has shown that MBCT is effective in treating depression, and NICE recommends it as a psychological treatment for depression. Studies are continuing to find out whether the therapy is as good as, or less effective than, antidepressants. Counselling and supportive therapyThere is no evidence to show that counselling or supportive therapy such as befriending helps improve the symptoms of psychosis in the long term, or stops people from relapsing. However, people with psychosis and their families sometimes really appreciate counselling and supportive therapies because it means there is someone who will listen to them and offer advice or re-assurance. The NICE Guidance on Schizophrenia recommends mental health professionals take account of people’s preferences and refer them for counselling or supportive therapy if they so wish, especially if cognitive behaviour therapy for psychosis or family therapy is not available in their neighbourhood. Psychoanalysis and psychodynamic therapyPsychoanalysis is based on the belief that we all have an unconscious mind where feelings that are too painful to deal with are kept hidden. Psychoanalysis – or psychodynamic therapy – aims to bring those feelings into people’s conscious mind in a bid to help someone understand and have more control over their life. There is no research to show that this sort of therapy helps the symptoms of psychosis, helps prevent relapse or reduces time spent in hospital. The NICE (National Institute for Health and Clinical Excellence) Guidance on Schizophrenia, however, recommends mental health professionals may consider using psychoanalysis or psychodynamic therapy ideas to help them understand more about the experiences of people with schizophrenia. Psychoeducation‘Psychoeducation’ is a term mental health professionals use to describe packages of information given to people who have mental health problems and their families. This may include information about the diagnosis, planned treatment and strategies for coping with a mental health problem. This sort of information should be offered routinely as part of good quality care. You should also be able to ask for information from your mental health team or GP. There are elements of psychoeducation included in most family therapy for psychosis programmes. There are also stand-alone psychoeducation packages that can be offered to groups of people with mental health problems, or to groups of people who are unwell and their family members. Transcranial magnetic stimulationTranscranial magnetic stimulation involves putting an electromagnet on the scalp that produces magnetic pulses. These pass through the skull and stimulate a small part of the brain. Low frequency (one pulse per second) transcranial magnetic stimulation can reduce the activity of the area that is stimulated. People are conscious throughout the procedure and no anaesthetic is needed as there is no pain. You may see the procedure referred to as rTMS – the ‘r’ stands for repetitive. Studies are being carried out to investigate whether rTMS is an effective treatment for people with severe depression, but NICE (National Institute for Health and Clinical Excellence) does not recommend rTMS for the treatment of depression because there is not yet sufficient evidence. Research is also being undertaken to see if low frequency rTMS can reduce the voices heard by people with psychosis by inhibiting the activity in the brain area where the voices are generated, and whether high frequency rTMS can help with the negative symptoms of schizophrenia. Motivational interviewingMotivational interviewing (MI) is a psychological therapy that can help people change the way they behave. Research has shown that MI can help people who have an addiction – to alcohol, drugs, or gambling, for example. It is also being trialled as a treatment for people with eating disorders. Researchers are investigating whether MI, when offered with vocational support, can help people with psychosis secure and keep employment. Some studies have looked at whether MI could encourage people with psychosis to regularly take their medication, but the results have not shown it to be effective for everyone. A team of researchers in Manchester and some based at the Institute of Psychiatry, King’s College London, have carried out a project to find out whether combining MI with cognitive behaviour therapy can help people with psychosis who also misuse drugs or alcohol. This page was updated on 22/9/10
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