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Cognitive behavioural therapy (brief versus standard duration) for

schizophrenia (Review)

Naeem F, Farooq S, Kingdon D

Naeem F, Farooq S, Kingdon D.

Cognitive behavioural therapy (brief versus standard duration) for schizophrenia.
Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD010646.
DOI: 10.1002/14651858.CD010646.pub3.

www.cochranelibrary.com

Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review)
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TABLE OF CONTENTS
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 3
BACKGROUND.............................................................................................................................................................................................. 4
OBJECTIVES.................................................................................................................................................................................................. 4
METHODS..................................................................................................................................................................................................... 4
RESULTS........................................................................................................................................................................................................ 10
Figure 1.................................................................................................................................................................................................. 11
DISCUSSION.................................................................................................................................................................................................. 12
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 13
ACKNOWLEDGEMENTS................................................................................................................................................................................ 14
REFERENCES................................................................................................................................................................................................ 15
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 17
ADDITIONAL TABLES.................................................................................................................................................................................... 18
APPENDICES................................................................................................................................................................................................. 19
WHAT'S NEW................................................................................................................................................................................................. 19
Figure 2.................................................................................................................................................................................................. 20
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 20
DECLARATIONS OF INTEREST..................................................................................................................................................................... 20
SOURCES OF SUPPORT............................................................................................................................................................................... 21
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 21
INDEX TERMS............................................................................................................................................................................................... 21

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[Intervention Review]

Cognitive behavioural therapy (brief versus standard duration) for

schizophrenia

Farooq Naeem1, Saeed Farooq2, David Kingdon3

1Department of Psychiatry, Queen's University, Kingston, Canada. 2Centre for Ageing and Mental Health, Staffordshire University &
Black Country Social Partnership NHS Foundation Trust, Wolverhampton, UK. 3Mental Health Group, University of Southampton,
Southampton, UK

Contact: Farooq Naeem, Department of Psychiatry, Queen's University, Kingston, ON, Canada. farooqnaeem@yahoo.com.

Editorial group: Cochrane Schizophrenia Group.

Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 10, 2015.

Citation: Naeem F, Farooq S, Kingdon D. Cognitive behavioural therapy (brief versus standard duration) for schizophrenia. Cochrane
Database of Systematic Reviews 2015, Issue 10. Art. No.: CD010646. DOI: 10.1002/14651858.CD010646.pub3.

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

Background
Cognitive behavioural therapy for people with schizophrenia is a psychotherapeutic approach that establishes links between thoughts,
emotions and behaviours and challenges dysfunctional thoughts. There is some evidence to suggest that cognitive behavioural therapy for
people with psychosis (CBTp) might be an effective treatment for people with schizophrenia. There are however, limitations in its provision
due to available resource and training issues. One way to tackle this issue might be to offer a brief version of CBTp.

Objectives
To review the effects of brief CBTp (6 to 10 regular sessions given in less than 4 months and using a manual) for people with schizophrenia
compared with standard CBTp (12 to 20 regular sessions given in 4 to 6 months and using a manual).

Search methods
We searched the Cochrane Schizophrenia Group’s Trials Register (August 21, 2013 and August 26, 2015) which is based on regular searches
of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO and registries of Clinical Trials. There are no language, date, document
type, or publication status limitations for inclusion of records in the register. We inspected all references of the selected articles for further
relevant trials. We also contacted experts in the field regarding brief CBTp studies.

Selection criteria
Randomised controlled trials involving adults with schizophrenia or related disorders, comparing brief cognitive behavioural therapy for
people with psychosis versus standard CBTp.

Data collection and analysis

Two review authors independently screened and assessed studies for inclusion using pre-specified inclusion criteria.

Main results
We found only seven studies which used a brief version of CBTp, but no study compared brief CBTp with CBTp of standard duration. No
studies could be included.

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Authors' conclusions
Currently there is no literature available to compare brief with standard CBTp for people with schizophrenia. We cannot, therefore, conclude
whether brief CBTp is as effective, less effective or even more effective than standard courses of the same therapy. This lack of evidence
for brief CBTp has serious implications for research and practice. Well planned, conducted and reported randomised trials are indicated.

PLAIN LANGUAGE SUMMARY

Brief versus standard cognitive behavioural therapy for schizophrenia

People with schizophrenia often hear voices or see things (hallucinations) and have strange beliefs (delusions). Characteristics of the illness
are disordered thoughts, feelings, beliefs and perceptions. People with schizophrenia may also find it difficult to find employment, make
friends and socialise with other people.

Cognitive behavioural therapy (CBT) works by focusing on people’s thoughts, emotions and behaviours and by challenging strange or
dysfunctional thoughts. CBT was originally developed to help people with psychological disorders such as Obsessive Compulsive Disorder.
More recently it has been used to help people with psychosis (CBTp). Working with a therapist, people establish links between their
thoughts, feelings or actions. They are encouraged to re-evaluate their beliefs, perceptions and reasoning as well as to monitor their own
thoughts, feelings, behaviours and symptoms. CBTp is suggested to provide alternative ways of coping with strange thoughts and the
symptoms of schizophrenia, which should reduce distress and improve people’s functioning.

Standard CBTp tends to involve around 16 sessions (12 to 20 sessions) over 4 to 6 months, while brief CBTp involves around 6 to 10 sessions,
in less than 4 months.

The aim of this review was to compare two types of CBTp, brief CBTp and standard CBTp for people with schizophrenia. A search was run
for relevant randomised studies in 2013. Only seven potentially-relevant studies were found. However, although all of them randomised
people with schizophrenia, none of these studies compared brief CBTp with standard CBTp. In the main they compared brief CBTp with
standard care or other therapies. There is, therefore, no information or literature available to compare brief with standard CBTp for
schizophrenia and psychosis.

There is a need for large scale research and trials that compare brief CBTp with standard CBTp. This research needs to evaluate costs, have
clear definitions of standard and brief CBTp and focus on the time period or number of sessions, i.e. the ‘effective dose’ of CBTp.

This plain language summary has been written by a consumer, Ben Gray, Service User Expert, Rethink Mental Illness.

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review)
SUMMARY OF FINDINGS

Summary of findings for the main comparison. BRIEF CBT compared to STANDARD DURATION CBT for schizophrenia

Library
Cochrane
BRIEF CBT compared to STANDARD DURATION CBT for schizophrenia

Patient or population: Patients with schizophrenia

Settings:
Intervention: Brief CBT

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Comparison: Standard duration CBT

Outcomes Illustrative comparative risks* Relative effect No of partici- Quality of the Comments
(95% CI) (95% CI) pants evidence
(studies) (GRADE)
Assumed risk Corresponding
risk

STANDARD DU- BRIEF CBT

RATION CBT

Global state: Improved to any extent See comment Not estimable 0 See comment We identified no
(0) trials comparing
Leaving the study early brief versus stan-
dard duration
Mental state: Improved to any extent CBT.

Service use: Admitted

Quality of life: Improved to any extent

Satisfaction with treatment: Improved to any ex-

tent

Cochrane Database of Systematic Reviews

Economic outcomes

GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
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BACKGROUND
Description of the condition
Schizophrenia is a group of syndromes, with variable course
and prognosis. Schizophrenia is characterised by disorders of
perceptions and of form and content of thought (APA 1994).
Schizophrenia is accompanied by significant social or occupational
dysfunction (McGrath 2008). The onset of symptoms typically
occurs in young adulthood. There are wide variations in reported
incidence, psychopathology and course of the illness. A systematic
review of epidemiological data indicates that, if the diagnostic
category of schizophrenia is considered in isolation, the lifetime
prevalence and incidence are 0.30 to 0.66% and 10 to 22 per 100,000
person-years, respectively (McGrath 2008).
Although the precise societal burden of schizophrenia is difficult
to estimate, because of the wide diversity of accumulated
data and methods employed, cost-of-illness indications uniformly
point to disquieting human and financial costs (Mueser 2004).
Schizophrenia does not just affect mental health; people with a
diagnosis of schizophrenia die 12 to 15 years before the average
population, with this mortality difference increasing in recent
decades (Saha 2007).
Description of the intervention
Several different psychotherapeutic approaches for schizophrenia
have been developed and studied.
Cognitive behavioural therapy (CBT) is defined as a discrete
psychological intervention where: i. recipients establish links
between their thoughts, feelings or actions with respect to current
or past symptoms, and/or functioning; and ii. the re-evaluation
of their perceptions, beliefs or reasoning relate to the target
symptoms (Jones 2012).
In addition a further component of the intervention involves
recipients monitoring their own thoughts, feelings or behaviours
with respect to the symptom or recurrence of symptoms; and/or the
promotion of alternative ways of coping with the target symptom;
and/or the reduction of distress; and/or the improvement of
functioning (Jones 2012). CBT for treating psychosis (CBTp) can be
standard duration and tends to involve around 16 sessions (12 to 20
sessions) over 4 to 6 months, while brief CBTp involves around 6 to
10 sessions, in less than 4 months.
How the intervention might work
CBT for psychosis focuses on establishing links between thoughts,
emotions and behaviours and by challenging dysfunctional
thoughts. It challenges delusions using Socratic dialogue
and dealing with hallucinations and beliefs underlying the
hallucinations. It also uses normalisation techniques as well
as behavioural techniques to reduce distress and improve
functioning. The key elements of CBTp include: engaging the
patient, collaboratively developing a problem list, and deciding on
a clear goal for the therapy session. Once the goal had been decided
on, a CBTp technique would be used (e.g., guided discovery and
Socratic questioning) to identify distortions in thinking style. This
would be followed by an agreed task (homework) for the patient
to complete by themselves before the following appointment (e.g.,
attempting to identify these distortions over the next week and
Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review)
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trying to correct them). Regular feedback and asking the patient
to provide a capsule summary (i.e. personal understanding) of
the session are also crucial elements. A formulation (narrative of
the person's history) is jointly generated to make sense of the
emergence and maintenance of the problem at hand.
Brief CBTp uses the same principles, though therapy is provided
within a shorter period of time, focusing on assessment,
formulation, working with psychotic symptoms, normalising
techniques and relapse prevention.
Why it is important to do this review
CBT is now recognised as an intervention for schizophrenia in
clinical guidelines in the United States (American Psychiatric
Association; APA 1994) and in the United Kingdom (National
Institute for Health and Clinical Excellence; NICE 2009). NICE
guidelines suggest that "cognitive behavioural therapy (CBT) is
offered to people with schizophrenia. This can be started either
during the acute phase or later, including inpatient settings". There
is some evidence to suggest that it is effective (Wykes 2008).
There is also some evidence to suggest that brief CBTp has some
effect in treating symptoms of schizophrenia (Turkington 2002).
If conclusive evidence is found that suggests that brief CBTp is
as effective as standard CBTp, it has enormous implications for
service delivery, reduction of distress and disability in patients with
schizophrenia, and above all, in terms of costs. Finding evidence for
therapy that is cost effective is especially important in the current
economic climate (Turkington 2002).
This review will also add to the findings of other similar Cochrane
reviews assessing the effectiveness of CBT for people with
schizophrenia. See Table 1.
OBJECTIVES
To compare the effects of brief cognitive behavioural therapy for
people with schizophrenia against standard cognitive behavioural
therapy for schizophrenia.
METHODS
Criteria for considering studies for this review
Types of studies
All relevant randomised controlled trials. If a trial was described as
'double blind' but implies randomisation, we planned to include
such trials in a sensitivity analysis (see Sensitivity analysis). If
their inclusion did not result in a substantive difference, they
were to remain in the analyses. If their inclusion did result in
important, clinically-significant but not necessarily statistically-
significant differences, we were not going to add the data from
these lower quality studies to the results of the better trials,
but would have presented such data within a subcategory. We
also decided to exclude quasi-randomised studies, such as those
allocating by alternate days of the week.
Where people were given additional treatments within brief CBTp,
we planned to include data if the adjunct treatment was evenly
distributed between groups and it was only the brief CBTp that was
randomised.
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Types of participants
Adults, however defined, with schizophrenia or related disorders,
including schizophreniform disorder, schizoaffective disorder and
delusional disorder, by any means of diagnosis.
We were interested in making sure that information is as relevant
to the current care of people with schizophrenia as possible, so
proposed to highlight the participants' current clinical state (acute,
early post-acute, partial remission, remission) as well as the stage
(prodromal, first episode, early illness, persistent) and whether the
studies primarily focused on people with particular problems (for
example, negative symptoms, treatment-resistant illnesses).
Types of interventions
Brief cognitive behavioural therapy for psychosis (CBTp) versus
standard CBTp .
Standard CBTp
The Jones 2012 Cochrane review defined standard CBTp as a
discrete psychological intervention in which:
• Recipients establish links between their thoughts, feelings or
actions with respect to the current or past symptoms, and/or
functioning; and
• The re-evaluation of their perceptions, beliefs or reasoning
relate to the target symptoms.
In addition, a further component of the intervention should involve
the following:
• Recipients monitor their own thoughts, feelings or behaviours
with respect to the symptom or recurrence of symptoms; and/or
• The promotion of alternative ways of coping with the target
symptom; and/or
• The reduction of distress; and/or
• The improvement of functioning.
According to NICE guidelines (NICE 2009) CBTp should be provided
on a one-to-one basis, in around 16 sessions (between 12 to 20
sessions), and using a manual over 4 to 6 months.
Brief CBTp
We define brief CBTp as the same as standard CBTp except that
treatment is delivered within 6 to 10 regular sessions given in less
than 4 months and using a manual.
Types of outcome measures
All outcomes were to be divided into short-term (within 6 months
of the onset of therapy), medium-term (within 6 to 12 months of the
onset of therapy) and long-term (over 12 months since the onset of
therapy).
Primary outcomes
1. Global state
1.1 Clinically-important response as defined by the individual
studies (for example global impression less than much improved,
or less than 50% reduction on a specified rating scale).
1.2 Relapse
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2. Leaving the study early
3. Mental state
3.1 Clinically-important change in general mental state
3.2 Any change in general mental state
3.3 Average endpoint general mental state score
3.4 Average change in general mental state scores
3.5 Clinically-important change in specific symptoms
3.6 Any change in specific symptoms
3.7 Average endpoint specific symptom score
3.8 Average change in specific symptom scores
4. Service use
4.1 Clinically-important engagement with services
4.2 Any engagement with services
4.3 Average endpoint engagement score
4.4 Average change in engagement scores
4.5 Compliance with medication/treatment
4.6 Number of hospitalisations
4.7 Number of days in hospital
5. Quality of life
5.1 Clinically-important change in quality of life
5.2 Any change in quality of life
5.3 Average endpoint quality of life score
5.4 Average change in quality of life scores
5.5 Clinically-important change in specific aspects of quality of life
5.6 Any change in specific aspects of quality of life
5.7 Average endpoint specific aspects of quality of life
5.8 Average change in specific aspects of quality of life
Secondary outcomes
1. Death
1.1 Any cause (except suicide)
1.2 Sudden unexpected suicide
2. General functioning
2.1 Average endpoint general functioning score
2.2 Average change in general functioning scores
2.3 Clinically-important change in specific aspects of functioning,
such as social or life skills
2.4 Any change in specific aspects of functioning, such as social or
life skills
2.5 Average endpoint specific aspects of functioning, such as social
or life skills
2.6 Average change in specific aspects of functioning, such as social
or life skills
3. Satisfaction with treatment
3.1 Leaving the study early: specific reason
3.2 Recipient of care satisfied with treatment
3.3 Recipient of care average satisfaction score
3.4 Recipient of care average change in satisfaction scores
3.5 Carer satisfied with treatment
3.6 Carer average satisfaction score
3.7 Carer average change in satisfaction scores
4. Adverse effects
4.1 Any general adverse effects
4.2 Average endpoint general adverse effect score
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4.3 Average change in general adverse effect scores
4.4 Clinically-important change in specific adverse effects
4.5 Any change in specific adverse effects
4.6 Average endpoint specific adverse effects
4.7 Average change in specific adverse effects
5. Economic costs
We planned to carry out economic appraisal.
Main outcomes for 'Summary of findings' table
We planned to use the GRADE approach to interpret findings
(Schünemann 2008) and use GRADE profiler (GRADE PRO) to
import data from RevMan 5.2 (Review Manager) to create
'Summary of findings' tables. These tables provide outcome-
specific information concerning the overall quality of evidence
from each included study in the comparison, the magnitude of
effect of the interventions examined, and the sum of available
data on all outcomes we rate as important to patient care and
decision making. We aimed to select the following main outcomes
for inclusion in the 'Summary of findings' table:
1. Global state
2. Leaving the study early
3. Mental state
4. Service use
5. Quality of life
6. Satisfaction with treatment
7. Economic outcomes
Where possible, we planned to use binary outcomes of clear clinical
utility.
Search methods for identification of studies
Electronic searches
Cochrane Schizophrenia Group’s Trials Register
On August 26, 2015, the Trials Search Co-ordinator (TSC) searched
the Cochrane Schizophrenia Group’s Study-Based Register of Trials
using the following search strategy:
(*Cogn* AND *Brief*) in Title OR Abstract Fields of REFERENCE OR
in Intervention Field of Study
In such study-based register, searching the major concept retrieves
all the synonym keywords and relevant studies because all the
studies have already been organised based on their interventions
and linked to the relevant topics.
The Cochrane Schizophrenia Group’s Register of Trials is compiled
by systematic searches of major resources (including AMED, BIOSIS,
CINAHL, EMBASE, MEDLINE, PsycINFO, PubMed, and registries of
clinical trials) and their monthly updates, hand-searches, grey
literature, and conference proceedings (see Group Module). There
are no language, date, document type, or publication status
limitations for inclusion of records into the register.
For previous searches, please see Appendix 1.
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Searching other resources
1. Reference searching
We inspected the references of all identified included studies for
further relevant studies.
2. Personal contact
We also planned to contact the first author of each included study
for information regarding unpublished trials.
Data collection and analysis
Selection of studies
Two authors (FN and SF) independently inspected citations from
the searches and identified relevant abstracts. A random 20%
sample was independently re-inspected by DK to ensure reliability.
Full reports of the abstracts meeting the review criteria or
references/abstracts authors disagreed on, were obtained and
inspected by FN and SF. Again, a random sample of 20% of reports
were re-inspected by DK in order to ensure reliable selection.
Where it was not possible to resolve disagreement by discussion,
we planned to contact the authors of the study for clarification.
However, this did not happen. Review authors were not blinded
to the name(s) of the study author(s), their institution(s) or
publication sources at any stage of the review.
Data extraction and management
1. Extraction
One author (FN) extracted data from all included (or excluded in this
case) studies. In addition, to ensure reliability, SF independently
extracted data from a random sample of these studies, comprising
three of the total. Again, any disagreement was to be discussed,
decisions documented and, if necessary, authors of studies were to
be contacted for clarification. With remaining problems DK was to
help clarify issues and these final decisions were to be documented.
Data presented only in graphs and figures were planned to be
extracted whenever possible, but would have be included only if
two review authors independently had the same result. We planned
to contact authors through an open-ended request in order to
obtain missing information or for clarification whenever necessary.
If studies were multi-centre, where possible, we had planned
to extract data relevant to each component centre separately.
However, we did not undertake these steps as none of the studies
fulfilled the review's inclusion criteria.
2. Management
2.1 Forms
Data would have been extracted onto standard, simple forms.
2.2 Scale-derived data
We planned to include continuous data from rating scales only if:
a. the psychometric properties of the measuring instrument had
been described in a peer-reviewed journal (Marshall 2000); and
b. the measuring instrument had not been written or modified by
one of the trialists for that particular trial.
Ideally the measuring instrument should have been either i. a self-
report or ii. completed by an independent rater or relative (not
the therapist). We realise that this is not often reported clearly; in
Description of studies we planned to note if this was the case or not.
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2.3 Endpoint versus change data
There are advantages of both endpoint and change data. Change
data can remove a component of between-person variability from
the analysis. On the other hand calculation of change needs two
assessments (baseline and endpoint) which can be difficult in
unstable and difficult to measure conditions such as schizophrenia.
We decided to primarily use endpoint data, and only use change
data if the former were not available. Endpoint and change data
were to be combined in the analysis as we were going to use mean
differences (MD) rather than standardised mean differences (SMDs)
throughout (Higgins 2011).
2.4 Skewed data
Continuous data on clinical and social outcomes are often not
normally distributed. To avoid the pitfall of applying parametric
tests to non-parametric data, we aimed to apply the following
standards to all data before inclusion: a) standard deviations and
means are reported in the paper or obtainable from the authors;
b) when a scale starts from the finite number zero, the standard
deviation, when multiplied by two, is less than the mean (as
otherwise the mean is unlikely to be an appropriate measure of
the centre of the distribution (Altman 1996); c) if a scale started
from a positive value (such as the Positive and Negative Syndrome
Scale (PANSS) which can have values from 30 to 210) the calculation
described above was modified to take the scale starting point into
account. In these cases skew is present if 2SD>(S-S min), where S is
the mean score and S min is the minimum score. Endpoint scores
on scales often have a finite start and end point and these rules
can be applied. Skewed endpoint data from studies of less than 200
participants were to be entered as 'Other data' within the 'Data and
analyses' section of the review, rather than into statistical analysis.
Skewed endpoint data pose less of a problem when looking at
means if the sample size is large and data from trials with over 200
participants are entered into syntheses.
When continuous data are presented on a scale that includes a
possibility of negative values (such as change data), it is difficult to
tell whether data are skewed or not. Skewed change data were to
be entered into statistical analysis.
2.5 Common measure
To facilitate comparison between trials, we intended to convert
variables that can be reported in different metrics, such as days in
hospital (mean days per year, per week or per month) to a common
metric (e.g. mean days per month).
2.6 Conversion of continuous to binary
Where possible, we planned to convert outcome measures to
dichotomous data. This can be done by identifying cut-off points
on rating scales and dividing participants accordingly into 'clinically
improved' or 'not clinically improved'. It is generally assumed that
if there is a 50% reduction in a scale-derived score such as the Brief
Psychiatric Rating Scale (BPRS, Overall 1962) or the PANSS (Kay
1986), this could be considered as a clinically-significant response
(Leucht 2005a; Leucht 2005b). If data based on these thresholds
were not available, we planned to use the primary cut-off presented
by the original authors.
2.7 Direction of graphs
Where possible, we planned to enter data in such a way that
the area to the left of the line of no effect indicates a favourable
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outcome for brief CBTp compared with standard CBTp. Where
keeping to this made it impossible to avoid outcome titles with
clumsy double-negatives (e.g. 'Not un-improved') we planned to
report data where the left of the line indicates an unfavourable
outcome. This was to be noted in the relevant graphs.
2.8 Economic data
No studies were included in this review.
Assessment of risk of bias in included studies
No trials were included, if trials had been included FN was to
assess risk of bias by using criteria described in the Cochrane
Handbook (Higgins 2011). The set of criteria is based on evidence
of associations between overestimate of effect and high risk of
bias in study domains such as sequence generation, allocation
concealment, blinding, incomplete outcome data and selective
reporting. If trials had been included SF would have indpendently
assessed a random sample of included trials for risk of bias, to
ensure reliability.
Again, if the raters had included trials, where there was
disagreement, the final rating was to be made by consensus, with
the involvement of DK. Where inadequate details of randomisation
and other characteristics of trials were provided, we planned
to contact authors of the studies in order to obtain further
information. Non-concurrence in 'Risk of bias' assessment was to
be reported, but if disputes arose as to which rating a domain was
to be allocated, resolution was to be made by discussion.
The level of risk of bias was to be noted in both the text of the review
and in the 'Summary of findings' table, and reported in 'Risk of bias'
tables.
Measures of treatment effect
1. Binary data
For binary outcomes we planned to calculate a standard estimation
of the risk ratio (RR) and its 95% confidence interval (CI). It has been
shown that RRs are more intuitive (Boissel 1999) than odds ratios
and that odds ratios tend to be interpreted as RRs by clinicians
(Deeks 2000). The number needed to treat for an additional harmful
outcome (NNTH) statistic with its CIs is intuitively attractive to
clinicians but is problematic, both in its accurate calculation in
meta-analyses and interpretation (Hutton 2009). For binary data
presented in the 'Summary of findings' table/s, where possible, we
planned to calculate illustrative comparative risks.
2. Continuous data
For continuous outcomes we planned to estimate mean difference
(MD) between groups. We preferred not to calculate effect size
measures (standardised mean difference (SMD)). However, if scales
of considerable similarity were used, we were going to presume
there was a small difference in measurement, and we were going
to calculate effect size and transform the effect back to the units of
one or more of the specific instruments.
Unit of analysis issues
1. Cluster trials
Studies increasingly employ 'cluster randomisation' (such as
randomisation by clinician or practice) but analysis and pooling of
clustered data poses problems. Firstly, authors often fail to account
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for intra-class correlation in clustered studies, leading to a 'unit
of analysis' error (Divine 1992) whereby P values are spuriously
low, confidence intervals unduly narrow and statistical significance
overestimated. This causes type I errors (Bland 1997; Gulliford
1999).
Where clustering is not accounted for in primary studies, we
planned to present data in a table, with a (*) symbol to indicate
the presence of a probable unit of analysis error. In subsequent
versions of this review we planned to seek to contact first authors of
such studies to obtain intra-class correlation coefficients (ICCs) for
their clustered data and to adjust for this using accepted methods
(Gulliford 1999).
Where clustering was incorporated into the analysis of primary
studies, we planned to present these data as if from a non-cluster
randomised study, but adjust for the clustering effect.
Statistical advice suggested the binary data as presented in a report
should be divided by a 'design effect'. This is calculated using the
mean number of participants per cluster (m) and the ICC [Design
effect = 1+(m-1)*ICC] (Donner 2002). If the ICC is not reported it will
be assumed to be 0.1 (Ukoumunne 1999).
If cluster studies were been appropriately analysed taking into
account ICCs and relevant data documented in the report, synthesis
with other studies would be possible using the generic inverse
variance technique.
2. Cross-over trials
A major concern of cross-over trials is the carry-over effect. It occurs
if an effect (e.g. pharmacological, physiological or psychological) of
the treatment in the first phase is carried over to the second phase.
As a consequence, on entry to the second phase the participants
can differ systematically from their initial state despite a wash-out
phase. For the same reason, cross-over trials are not appropriate if
the condition of interest is unstable (Elbourne 2002). As both effects
are very likely in severe mental illness, we would only have used
data from the first phase of cross-over studies.
3. Studies with multiple treatment groups
Where a study involved more than two treatment arms, if
relevant, the additional treatment arms were to be presented in
comparisons. If data were binary these were to be simply added and
combined within the two-by-two table. If data were continuous we
planned to combine data following the formula in section 7.7.3.8
of the Cochrane Handbook (Higgins 2011). Where the additional
treatment arms were not relevant, these data were not to be
reproduced.
Dealing with missing data
1. Overall loss of credibility
At some degree of loss of follow-up, data must lose credibility (Xia
2009). If, for any particular outcome, more than 50% of data were
unaccounted for, we planned not to reproduce these data or use
them within analyses. If, however, more than 50% of those in one
arm of a study were lost, but the total loss was less than 50%, we
were going to address this within the 'Summary of findings' table/
s by downgrading quality. We also planned to downgrade quality
within the 'Summary of findings' table/s should the loss be 25% to
50% in total.
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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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2. Binary
In the case where attrition for a binary outcome was between 0%
and 50% and where these data were not clearly described, we
planned to present data on an intention-to-treat (ITT) basis. Those
leaving the study early were all assumed to have the same rates
of negative outcome as those who completed, with the exception
of the outcome of death and adverse effects. For these outcomes
the rate of those who stayed in the study - in that particular
arm of the trial - was to be used for those who did not. We
planned to undertake a sensitivity analysis testing how prone the
primary outcomes were to change when data only from people who
complete the study to that point were compared to the ITT analysis
using the above assumptions.
3. Continuous
3.1 Attrition
In the case where attrition for a continuous outcome was between
0% and 50%, and data only from people who complete the study to
that point were reported, we planned to reproduce these.
3.2 Standard deviations
If standard deviations (SDs) were not reported, we planned to
first try to obtain the missing values from the study authors. If
not available, where there were missing measures of variance for
continuous data, but an exact standard error (SE) and CIs available
for group means, and either P value or 't' value available for
differences in mean, we planned to calculate them according to the
rules described in the Cochrane Handbook for Systematic Reviews
of Interventions (Higgins 2011). When only the SE was reported, SDs
were to be calculated by the formula SD = SE * square root (n).
Chapters 7.7.3 and 16.1.3 of the Cochrane Handbook for Systematic
Reviews of Interventions (Higgins 2011) present detailed formula
for estimating SDs from P values, t or F values, CIs, ranges or
other statistics. If these formula did not apply, we were going
to calculate the SDs according to a validated imputation method
which is based on the SDs of the other included studies (Furukawa
2006). Although some of these imputation strategies can introduce
error, the alternative would be to exclude a given study’s outcome
and thus to lose information. We nevertheless planned to examine
the validity of the imputations in a sensitivity analysis excluding
imputed values.
3.3 Last observation carried forward
We anticipated that in some studies the method of last observation
carried forward (LOCF) would be employed. As with all methods of
imputation to deal with missing data, LOCF introduces uncertainty
about the reliability of the results (Leucht 2007). Therefore, where
LOCF data were reported, if less than 50% of the data had been
assumed, we planned to present and use these data and indicate
that they were the product of LOCF assumptions.
Assessment of heterogeneity
1. Clinical heterogeneity
We planned to consider all included studies initially, without seeing
comparison data, to judge clinical heterogeneity. We were to simply
inspect all studies for clearly outlying people or situations which we
had not predicted would arise. When such situations or participant
groups arose, these were to be fully discussed.
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2. Methodological heterogeneity
We planned to consider all included studies initially, without seeing
comparison data, to judge methodological heterogeneity. We
planned to inspect all studies for clearly outlying methods which we
had not predicted would arise. When such methodological outliers
arose, these were to be fully discussed.
3. Statistical heterogeneity
3.1 Visual inspection
We planned to visually inspect graphs to investigate the possibility
of statistical heterogeneity.
3.2 Employing the I2 statistic
We planned to investigate heterogeneity between studies by
considering the I2 method alongside the Chi2 P value. The I2
provides an estimate of the percentage of inconsistency thought to
be due to chance (Higgins 2003). The importance of the observed
value of I2 depends on (1) magnitude and direction of effects, and
(2) strength of evidence for heterogeneity (e.g. P value from Chi2
test, or a confidence interval for I2). An I2 estimate greater than
or equal to around 50% accompanied by a statistically-significant
Chi2 result, were to be interpreted as evidence of substantial levels
of heterogeneity (Section 9.5.2, Higgins 2011). When substantial
levels of heterogeneity were found in the primary outcome, we
planned to explore reasons for heterogeneity (Subgroup analysis
and investigation of heterogeneity).
Assessment of reporting biases
1. Protocol versus full study
Reporting biases arise when the dissemination of research findings
is influenced by the nature and direction of results (Egger 1997).
These are described in section 10.1 of the Cochrane Handbook
(Higgins 2011). We planned to locate protocols of included
randomised trials. If the protocol was available, outcomes in the
protocol and in the published report were to be compared. If the
protocol was not available, outcomes listed in the methods section
of the trial report was to be compared with the reported results.
2. Funnel plot
Funnel plots may be useful in investigating reporting biases, but are
of limited power to detect small-study effects. We decided not to
use funnel plots for outcomes where there were 10 or fewer studies,
or where all studies were of similar size. In other cases, where funnel
plots were possible, we planned to seek statistical advice in their
interpretation.
Data synthesis
We understand that there is no closed argument for preference for
use of fixed-effect or random-effects models. The random-effects
method incorporates an assumption that the different studies
are estimating different, yet related, intervention effects, while
the random-effects model takes into account differences between
studies even if there is no statistically-significant heterogeneity.
There is, however, a disadvantage of the random-effects model. It
puts added weight onto small studies which often are the most
biased. Depending on the direction of effect these studies can
either inflate or deflate the effect size. We planned to apply a
Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Database of Systematic Reviews
random-effects model for all analyses because of the heterogeneity
of the data available.
Subgroup analysis and investigation of heterogeneity
1. Subgroup analyses - only primary outcomes
We proposed to assess the effects of brief CBTp for people with
schizophrenia in general. In addition, we decided to try to report
data on subgroups of people in the same clinical state, stage and
with similar problems.
2. Investigation of heterogeneity
If inconsistency was high, this was to be reported. First we were
going to investigate whether data were entered correctly. Second,
if data were correct, the graph was to be visually inspected and
outliers were to be successively removed to see if homogeneity was
restored. For this review we decided that should this occur with
data contributing to the summary finding of no more than around
10% of the total weighting, data would be presented. If not, data
would not be pooled and issues would be discussed. We know of no
supporting research for this 10% cut off, but are investigating use of
prediction intervals as an alternative to this unsatisfactory state.
When unanticipated clinical or methodological heterogeneity were
obvious, we were going to state hypotheses regarding these for
future reviews or updates of this review.
Sensitivity analysis
1. Implication of randomisation
We aimed to include trials in a sensitivity analysis if they were
described in some way as to imply randomisation. For the primary
outcomes we planned to include these studies and if there was no
substantive difference when the implied randomised studies were
added to those with a better description of randomisation, then all
data were to be employed from these studies.
2. Assumptions for lost binary data
Where assumptions had to be made regarding people lost to follow-
up, or missing SDs (see Dealing with missing data), we planned
to compare the findings of the primary outcomes when we used
our assumption compared with completer data only. If there was
a substantial difference, we planned to report results and discuss
them but continue to employ our assumption.
3. Risk of bias
We planned to analyse the effects of excluding trials that were
judged to be at high risk of bias across one or more of the
domains of randomisation (implied as randomised with no further
details available), allocation concealment, blinding and outcome
reporting for the meta-analysis of the primary outcome. If the
exclusion of trials at high risk of bias did not substantially alter the
direction of effect or the precision of the effect estimates, then data
from these trials were to be included in the analysis.
4. Imputed values
We also planned to undertake a sensitivity analysis to assess the
effects of including data from trials where we used imputed values
for ICC in calculating the design effect in cluster randomised trials.
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If substantial differences were noted in the direction or precision RESULTS

of effect estimates in any of the sensitivity analyses listed above,
we planned to not pool data from the excluded trials with the other Description of studies
trials contributing to the outcome, but present them separately.
We did not find any studies that fulfilled the inclusion criteria.
5. Fixed-effect and random-effects
Results of the search
All data were to be synthesised using a random-effects model,
We found 576 records through electronic searching of the Cochrane
however we were going to synthesise data for the primary outcome
Schizophrenia Register 2013; 262 of these were duplicates leaving
using a fixed-effect model to evaluate whether the greater weights
173 records for screening (Figure 1). After screening, 53 full text
assigned to larger trials with greater event rates, altered the
articles were obtained for further assessment but only 7 were
significance of the results compared to the more evenly distributed
potentially relevant, these were closely assessed for inclusion but
weights in the random-effects model.
none of these could eventually be included in the review. Seven
studies therefore are in the Excluded studies section of the review.
Three records were found after 2015 update search, all 3 citations
not relevant and could be excluded at initial screening. No new
studies added to included or excluded studies tables.

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Figure 1. Study flow diagram. 2013 search

Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review) 11
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Included studies
There are no included studies in this review.
Excluded studies
We assessed seven studies carefully for inclusion but all were
excluded as none compared brief CBTp to standard CBTp. Four
excluded studies used interventions that were not brief CBTp, such
as compliance therapy (Kemp 1998, O’Donnell 2003) or group CBT
(Levine 1998). One study compared brief CBT for psychosis with
care as usual for in-patients with psychosis. This group used a five
week CBTp programme, with 15 to 20 hours of therapy but did not
specify the number of sessions and compared this to supportive
therapy (Lewis 2002). Turkington 2000 conducted a randomised
controlled trial of brief CBT for psychosis delivered by experts,
compared with befriending. Two trials compared brief CBTp to
standard care rather than standard CBTp (Turkington 2002; Wykes
2005).
Ongoing studies
There are no ongoing studies of which we are aware.
Awaiting assessment
There are no trials currently awaiting assessment.
Risk of bias in included studies
No studies could be included in this review, hence we were unable
to assess risk of bias.
Effects of interventions
See: Summary of findings for the main comparison BRIEF CBT
compared to STANDARD DURATION CBT for schizophrenia
Excluded studies demonstrate that trials of brief CBTp are possible,
but no trials comparing standard duration therapy have been
conducted. We had hoped to gather information on global and
mental state, issues around use of services, quality of life,
satisfaction with treatment and costs. Such data are not available
from randomised trials of care (Summary of findings for the main
comparison).
DISCUSSION
1. Definition of 'brief'
We defined brief CBTp as therapy comprising 6 to 10 sessions
delivered in less than 4 months. This cut-off was based on the
observation that current standard CBTp treatments typically span
12 to 20 sessions over 4 to 6 months (NICE 2009). We located
empirical studies of the efficacy of brief CBTp by asking experts
in a variety of areas about available research and by searches of
Psychological Abstracts. In the absence of a clear definition for
schizophrenia, we adopted our definition after a careful review of
the literature on brief CBT in depression. Currently there is more
literature on brief CBT for depression and anxiety disorders than for
schizophrenia. Although standard CBT for depression is considered
by most to be delivered between 10 and 20 sessions (for example,
Cully 2008; Hazlett-Stevens 2002), there is no agreement as to how
many sessions should be included in brief CBT for depression.
Churchill et al (Churchill 2001) described brief psychological
interventions for depression to be delivered in 20 or fewer sessions,
Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Database of Systematic Reviews
while Cully 2008 described brief CBT for depression to be delivered
in between 4 and 8 sessions. We think that the definition of 'brief
CBT' used in this review is reasonable and in broad agreement with
practitioners' views.
2. Dearth of evidence
We did not find any study which compared brief CBT for psychosis
(CBTp) with the standard form of CBTp. Seven studies had some
form of brief therapy used for schizophrenia and could be relevant
but none of these studies met the inclusion criteria. The literature
on brief CBTp is practically nonexistent, as even those studies
which employed brief therapy in one of the arms (but without
comparison to standard CBTp) did not clearly meet the criteria for
‘brief’ therapy’. We structured our review by diagnostic category,
as there has been no empirical investigation of the efficacy of brief
CBTp across different disorders (Bond 2002).
We found seven studies which used brief CBT for schizophrenia (6
to 10 sessions), but none compared brief CBTp with standard CBTp
- the simple 'dose-ranging' question of this review. Researchers
were more interested in the effects the brief CBTp versus other -
different - approaches. Two studies used other techniques (psycho-
education - Kemp 1998; O’Donnell 2003) or formats (group CBTp -
Levine 1998; Wykes 2005). One study compared CBT for psychosis
with care as usual in in-patients with psychosis (Lewis 2002). Lewis
2002 used a 5 week CBTp programme with 15 to 20 hours of therapy,
but did not specify the number of sessions. Turkington 2000 is a trial
of brief CBT for psychosis versus befriending and Turkington 2002
a randomised trial of brief CBTp delivered by trained nurses versus
treatment as usual. The Wykes 2005 study compared seven weeks
of group CBTp against care as usual for voices.
It is easy to surmise, but difficult to be sure as to why there is a
dearth of evidence for the comparison which is the focus of this
review. The firm evidence is that we did not find any studies. We
cannot know if brief CBTp is as effective, less effective or even more
effective than standard courses of the same therapy. This lack of
evidence for brief CBTp has serious implications for research and
practice.
Summary of main results
We did not find any study which compared brief CBTp with the
standard form of CBTp. Seven studies used some form of brief
therapy for schizophrenia and could be relevant, but none of these
studies met the review's inclusion criteria.
Potential biases in the review process
Although as authors we have interests in CBT for psychosis (FN
has published on CBT for psychosis and culturally-adapted CBT for
psychosis and DK has pioneered CBT for psychosis techniques.
Potential biases in the review process are limited by following
Cochrane methodology. The search for trials was thorough with no
language, date, document type, or publication status limitations.
We strictly followed the review protocol in the process of study
selection, data extraction and analysis.
Agreements and disagreements with other studies or
reviews
We know of no other reviews focusing on this comparison.
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AUTHORS' CONCLUSIONS
Implications for practice
For people with schizophrenia
Cognitive behavioural therapy (CBT) may have benefit for people
with schizophrenia but this has not been convincingly shown by fair
testing and review of trials (Buckley 2007; Jones 2012). If offered
the therapy, people with schizophrenia may wish to opt for the
standard course, a brief course or none at all. All would seem
reasonable choices given the dearth of evidence. If brief therapy
is an option, and agreed upon, it may be that the person with
schizophrenia would want to help with generation of higher-grade
evidence than this review currently attains.
For clinicians
The conclusions of Jones 2012 (standard duration CBTp versus
psychological interventions for schizophrenia) state "trial-based
evidence suggests no clear and convincing advantage for cognitive
behavioural therapy over other - and sometime much less
sophisticated - therapies for people with schizophrenia." This
finding concurs with that of the review of supportive therapy for
schizophrenia (Buckley 2007), whose 2013 (in press) update states
"when we compared supportive therapy to cognitive behaviour
therapy, we again found no significant differences in primary
outcomes." Clinicians are, therefore, left in a difficult position -
being advised to provide around 16 sessions of CBT (NICE 2009) -
but often being unable to provide this duration of therapy (Kingdon
2006). If the therapy is available, there is no evidence that a brief
course is contraindicated. It seems likely that offer of the longer
course will result in more commitment of finite resources and,
therefore, less resources for other treatments.
For funders and managers
NICE guidelines recommend that CBT should be provided for
all patients with schizophrenia (NICE 2009), using a manual and
around 16 sessions. However, the same guidelines describe most
studies as delivering between 12 and 20 sessions. Current evidence
suggests that only about 50% of those suffering from schizophrenia
in the United Kingdom have access to CBT (Kingdon 2006).
One way to overcome this huge gap in the provision of CBTp
is to provide brief CBTp. This has the potential to reduce the
gap by almost half if the effectiveness of brief CBT can be
demonstrated against standard CBT. Increasingly CBTp is also being
provided using online tools or mobile phone-based applications
(for example clintouch.com). Brief CBTp will also be better suited
to this form of intervention delivery, especially through the use
of mobile phone applications ('apps'), but also through use of
guided self-help material. If, however, the effectiveness of brief
CBTp cannot be demonstrated against standard CBTp, and the
effectiveness of even the latter is open to interpretation and doubt
(Buckley 2007; Jones 2012), commissioners and funders of care
may, understandably, wish to consider if investment in this area is
a priority.
Implications for research
1. Reviews
Excluded studies suggest further reviews relevant to CBTp are
indicated (Table 2). We feel that the consideration of the brief versus
Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review)
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Cochrane Database of Systematic Reviews
standard duration of CBTp remains a legitimate comparison. It
may, however, be appropriate that an update of this review should
expand the review's scope to 'brief cognitive behavioural therapy
for people with schizophrenia' and so allow other comparisons
involving a brief therapy to be included.
2. Randomised trials
An important question to be addressed in future research is
whether brief CBT can be feasible in psychotic disorders. There
are studies which compare brief with standard CBT for non-
psychotic disorders (Bond 2002). Many CBT treatments for non-
psychotic disorders lead to significant clinical improvement and
symptom reduction, relative to other forms of psychotherapy,
when delivered in a brief format (Bond 2002). Some approaches
to increase the efficiency of CBT treatments include adapting
individual treatments to a group format, self-help materials, biblio-
therapy and eMedia-assisted therapy programs. The most common
approach for enhancing efficiency, however, is to abbreviate
existing CBT treatments by reducing the number of treatment
sessions.
Brevity has many clear advantages. Increased cost-effectiveness
could make treatment accessible to more individuals in need of
assistance. Patients enjoy rapid treatment gains, and this may
also improve the credibility of the treatment and increase the
motivation for further change (Hazlett-Stevens 2002). However,
this approach may be disadvantageous in some circumstances. An
abbreviated CBT approach assumes that the target for change is
clearly defined and circumscribed. Patients presenting with more
diffuse symptoms or with particular comorbid conditions that
interfere with directly targeted programs may need more lengthy
treatment. Brief CBT puts a greater burden on the patient to engage
actively in treatment both during and between sessions. It can be
argued that in psychotic disorders, especially with symptoms such
as severe auditory hallucinations, brief therapy may not work as
engaging patients and overcoming psychotic phenomenon need
a prolonged and intensive treatment approach. It is also possible
that brief therapy may leave patients more confused, and could
prove harmful. However, the literature on the use of brief CBT
for non-psychotic disorders does not seem to substantiate these
apprehensions.
There is some evidence to suggest that brief therapies work in
psychosis, but the research in this area needs to address the
fundamental issue of the dose-effect relationship in CBT. This
is especially important to provide information to the service
providers, funders, researchers, reviewers and the user groups.
The dose of therapy not only depends upon duration (brief versus
long) but also on number of sessions, time for each session (for
example number of hours), and intensity of therapy. Other factors
that should be taken into consideration in this regard should be
description of therapy (for example use of a manual), therapist’s
training, fidelity to CBT model (for example use of CBT Scale) and
expertise. In a recent Cochrane review (Jones 2012) which included
30 studies describing 20 trials, it was found that only 11 trials met
the criteria for well-defined CBT, and 13 trials met the criteria for
qualified therapists. In the future, trials of CBT for psychosis (or,
for that matter, any psychological treatment) need to include some
measure of the 'effective dose' of a specific therapy. This will add to
further standardisation of measures of effect and dose of therapy
required to bring about change.
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There is a need for randomised trials to compare brief CBTp with
standard CBTp. These trials should further focus on evaluating cost.
This comparison is very important as brief CBTp might provide a
solution for patients with schizophrenia in areas where resources
and training are limited. There is also a need for clearer definitions
of standard and brief CBTp. Finally, this review also highlights one
very important issue that needs further research, that of 'effective
dose of CBT', as currently there is no research on measurement of
'dose' (quantity of therapy and time period as well as therapy and
therapist factors) of CBTp and effect on psychotic symptoms.
We offer a draft design for a trial in this area, in Table 3
ACKNOWLEDGEMENTS
We thank the editorial staff of the Cochrane Schizophrenia Group
for their support in preparing this review.
We also thank Emily Beetschen for peer reviewing the protocol and
for her helpful comments and Chris Jones for peer reviewing the
finished review.
The Cochrane Schizophrenia Group Editorial Base in Nottingham
produces and maintains standard text for use in the Methods
section of their reviews. We have used this text as the basis of what
appears here and adapted it as required.

Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review) 14
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Informed decisions.
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CHARACTERISTICS OF STUDIES

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Kemp 1998 Allocation: randomised.

Participants: people who were inpatients (schizophrenia, schizoaffective disorder, delusional dis-
order).

Interventions: compliance therapy (4 to 6 sessions) compared with treatment as usual. Not brief
CBTp versus standard CBTp.

Levine 1998 Allocation: randomised.

Participants: people with paranoid schizophrenia.

Interventions: group CBT (6 weekly sessions) compared with supportive therapy. Not brief CBTp
versus standard CBTp.

Lewis 2002 Allocation: randomised.

Participants: schizophrenia or other psychotic disorders.

Interventions: inpatient CBT (15 to 20 hours in 5 weeks) compared with supportive counselling. Not
brief CBTp versus standard CBTp.

O’Donnell 2003 Allocation: randomised.

Participants: people with schizophrenia.

Interventions: compliance therapy (5 sessions) compared with non-specific counselling. Not brief
CBTp versus standard CBTp.

Turkington 2000 Allocation: randomised.

Participants: people with schizophrenia.

Interventions: CBT (6 sessions plus 1 to 2 for family) compared with befriending. Not brief CBTp ver-
sus standard CBTp.

Turkington 2002 Allocation: randomised.

Participants: people with schizophrenia.

Interventions: CBT delivered by nurses trained in CBT (6 sessions, plus 3 for carers), compared with
standard care. Not brief CBTp versus standard CBTp.

Wykes 2005 Allocation: randomised.

Participants: people with schizophrenia.

Interventions: group CBT for voices (7 sessions) compared with standard care. Not brief CBTp ver-
sus standard CBTp.

Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review) 17
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ADDITIONAL TABLES

Table 1. Other directly relevant Cochrane reviews

Review/Protocol title Reference

Cognitive behavioural therapy (group) for schizophrenia Guaiana 2012

Cognitive behavioural therapy versus specific pharmacological treatments for schizophrenia Jones 2009b

Cognitive behavioural therapy versus standard care for schizophrenia Jones 2009a

Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia Jones 2012

Supportive therapy for schizophrenia Buckley 2007*

* Major update imminent

Table 2. Reviews suggested by excluded studies

Comparison Excluded trial Relevant Cochrane re-
view

Befriending for schizophrenia Turkington 2000 -

Brief CBT versus standard care for schizophrenia Turkington 2002 Jones 2009a*

Brief CBT versus therapies other than standard duration CBT for Levine 1998 Lewis 2002 , Turkington Jones 2012*
schizophrenia 2000

Compliance therapy for schizophrenia Kemp 1998, O’Donnell 2003 McIntosh 2006

Group CBT for schizophrenia Levine 1998, Wykes 2005 Guaiana 2012

Supportive therapy versus CBT for schizophrenia Levine 1998 Lewis 2002 Buckley 2007**

* It is possible that these studies be included in this review but it may be justified to have a full new review on brief CBT.
** Update imminent

Table 3. Suggested design of study

Methods Allocation: randomised, fully explicit description of methods of randomisation and allocation con-
cealment.
Blinding: open.
Setting: anywhere.
Duration: 1 year.

Participants Diagnosis: schizophrenia (clinical diagnoses, operational for random sample).

N = 300.*
Age: adults.
Sex: both.

Interventions 1. Brief CBT: 4 to 6 sessions. N = 150.

2. Standard CBT: 15 to 20 sessions. N = 150.

Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review) 18
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Table 3. Suggested design of study (Continued)

Outcomes Global state: CGI.**

Leaving the study early.

Mental state: CGI.

Service use.

Quality of life: CGI.

Satisfaction with treatment: CGI.

Economic outcomes.

Notes * Powered to be able to identify a difference of ˜ 20% between groups for primary outcome with
adequate degree of certainty.

** This simple measure can be used to target specific aspects of functioning, symptoms or atti-
tudes.

APPENDICES

Appendix 1. Previous searches

Search in 2013
Electronic searches
Cochrane Schizophrenia Group’s Trials Register

The Trials Search Coordinator (TSC) searched the Cochrane Schizophrenia Group’s Registry of Trials using the following phrase (August
21, 2013):

(*Cognitive* or *Cognitive Behavioural Therapy*) in Interventions Field of STUDY

The Cochrane Schizophrenia Group’s Registry of Trials is compiled by systematic searches of major resources (including AMED, BIOSIS,
CINAHL, EMBASE, MEDLINE, PsycINFO, PubMed, and registries of Clinical Trials) and their monthly updates, handsearches, grey literature,
and conference proceedings (see Group Module). There are no language, date, document type, or publication status limitations of inclusion
of records in the register.

Searching other resources

1. Reference searching

We inspected the references of all identified studies for further relevant studies.

2. Personal contact

We also planned to contact the first author of each included study for information regarding unpublished trials.

WHAT'S NEW

Date Event Description

8 September 2015 New citation required but conclusions Results of 2015 update search screened. No new included or ex-
have not changed cluded studies. See also Figure 2. Conclusions unchanged.

26 August 2015 New search has been performed Search updated, 3 citations found.

Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review) 19
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Figure 2. Study flow diagram 2015 search

CONTRIBUTIONS OF AUTHORS
Farooq Naeem - completion of protocol, trial selection, data extraction of excluded studies, write up of report.

Saeed Farooq - completion of protocol, trial selection, data extraction of sample of excluded studies, write up of report.

David Kingdon - completion of protocol, help with trial selection, advice with completion of report

DECLARATIONS OF INTEREST
Farooq Naeem - has published on CBT for psychosis and other disorders and has developed a model of adaptation of CBT in non-Western
cultures, adapting CBT for psychosis and depression.

Saeed Farooq - has experience of conducting literature reviews on psychosis-related topics. SF has published a Cochrane systematic review
and also systematic reviews and meta-analyses in peer-reviewed scientific journals.

David Kingdon - has pioneered the use of CBT for psychosis and has published widely on this issue.

Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review) 20
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SOURCES OF SUPPORT

Internal sources
• Department of Psychiatry, Queens University, Kingston, ON, Canada, UK.

Employer of author
• Staffordshire University & Black Country Social Partnership NHS Foundation Trust, Wolverhampton, UK.

Employer of author
• University of Southampton, Southampton, UK.

Employer of author

External sources
• NIHR Grant 2011, Reference number: 10/4001/15, UK.

Funding provided by the NIHR to enable completion of this review.

DIFFERENCES BETWEEN PROTOCOL AND REVIEW

As a result of a literature review, we further clarified the difference between standard and brief CBT for psychosis, as "standard CBT for
psychosis tends to involve around 16 sessions (12 to 20 session) over 4 to 6 months, while brief CBT involves around 6 to 10 sessions, in
less than 4 months".

INDEX TERMS

Medical Subject Headings (MeSH)

*Psychotherapy, Brief; Cognitive Behavioral Therapy [*methods]; Schizophrenia [*therapy]; Time Factors

MeSH check words

Humans

Cognitive behavioural therapy (brief versus standard duration) for schizophrenia (Review) 21
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