Cognitive behavioural therapy in clozapine-resistant schizophrenia (FOCUS)

an assessor-blinded, randomised controlled trial

Anthony P Morrison, Melissa Pyle, Andrew Gumley, Matthias Schwannauer, Douglas Turkington, Graeme MacLennan, John Norrie, Jemma Hudson, Samantha E Bowe, Paul French, Rory Byrne, Suzy Syrett, Robert Dudley, Hamish J McLeod, Helen Griffiths, Thomas R E Barnes, Linda Davies, David Kingdon, FOCUS trial group

Research output: Contribution to journalArticle

14 Citations (Scopus)
4 Downloads (Pure)

Abstract

BACKGROUND: Although clozapine is the treatment of choice for treatment-refractory schizophrenia, 30-40% of patients have an insufficient response, and others are unable to tolerate it. Evidence for any augmentation strategies is scarce. We aimed to determine whether cognitive behavioural therapy (CBT) is an effective treatment for clozapine-resistant schizophrenia.

METHODS: We did a pragmatic, parallel group, assessor-blinded, randomised controlled trial in community-based and inpatient mental health services in five sites in the UK. Patients with schizophrenia who were unable to tolerate clozapine, or whose symptoms did not respond to the drug, were randomly assigned 1:1 by use of randomised-permuted blocks of size four or six, stratified by centre, to either CBT plus treatment as usual or treatment as usual alone. Research assistants were masked to allocation to protect against rater bias and allegiance bias. The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months, which provides a continuous measure of symptoms of schizophrenia; PANSS total was also assessed at the end of treatment (9 months). The primary analysis was by randomised treatment based on intention to treat, for all patients for whom data were available. This study was prospectively registered, number ISRCTN99672552. The trial is closed to accrual.

FINDINGS: From Jan 1, 2013, to May 31, 2015, we randomly assigned 487 participants to either CBT and treatment as usual (n=242) or treatment as usual alone (n=245). Analysis included 209 in the CBT group and 216 in the treatment as usual group. No difference occurred in the primary outcome (PANSS total at 21 months, mean difference -0·89, 95% CI -3·32 to 1·55; p=0·48), although the CBT group improved at the end of treatment (PANSS total at 9 months, mean difference -2·40, -4·79 to -0·02; p=0·049). During the trial, 107 (44%) of 242 participants in the CBT arm and 104 (42%) of 245 in the treatment as usual arm had at least one adverse event (odds ratio 1·09, 95% CI 0·81 to 1·46; p=0·58). Only two (1%) of 242 participants in the CBT arm and one (<1%) of 245 in the treatment as usual arm had a trial-related serious adverse event.

INTERPRETATION: At 21-month follow-up, CBT did not have a lasting effect on total symptoms of schizophrenia compared with treatment as usual; however, CBT produced statistically, though not clinically, significant improvements on total symptoms by the end of treatment. There was no indication that the addition of CBT to treatment as usual caused adverse effects. The results of this trial do not support a recommendation to routinely offer CBT to all people who meet criteria for clozapine-resistant schizophrenia; however, a pragmatic individual trial might be indicated for some.

FUNDING: National Institute for Health Research Technology Assessment programme.

Original languageEnglish
Pages (from-to)633-643
Number of pages11
JournalThe lancet. Psychiatry
Volume5
Issue number8
Early online date11 Jul 2018
DOIs
Publication statusPublished - Aug 2018

Fingerprint

Clozapine
Cognitive Therapy
Schizophrenia
Randomized Controlled Trials
Therapeutics
Pragmatic Clinical Trials
Biomedical Technology Assessment
National Institutes of Health (U.S.)
Mental Health Services
Research

Keywords

  • Journal Article

Cite this

Cognitive behavioural therapy in clozapine-resistant schizophrenia (FOCUS) : an assessor-blinded, randomised controlled trial. / Morrison, Anthony P; Pyle, Melissa; Gumley, Andrew; Schwannauer, Matthias; Turkington, Douglas; MacLennan, Graeme; Norrie, John; Hudson, Jemma; Bowe, Samantha E; French, Paul; Byrne, Rory; Syrett, Suzy; Dudley, Robert; McLeod, Hamish J; Griffiths, Helen; Barnes, Thomas R E; Davies, Linda; Kingdon, David; FOCUS trial group.

In: The lancet. Psychiatry, Vol. 5, No. 8, 08.2018, p. 633-643.

Research output: Contribution to journalArticle

Morrison, AP, Pyle, M, Gumley, A, Schwannauer, M, Turkington, D, MacLennan, G, Norrie, J, Hudson, J, Bowe, SE, French, P, Byrne, R, Syrett, S, Dudley, R, McLeod, HJ, Griffiths, H, Barnes, TRE, Davies, L, Kingdon, D & FOCUS trial group 2018, 'Cognitive behavioural therapy in clozapine-resistant schizophrenia (FOCUS): an assessor-blinded, randomised controlled trial', The lancet. Psychiatry, vol. 5, no. 8, pp. 633-643. https://doi.org/10.1016/S2215-0366(18)30184-6
Morrison, Anthony P ; Pyle, Melissa ; Gumley, Andrew ; Schwannauer, Matthias ; Turkington, Douglas ; MacLennan, Graeme ; Norrie, John ; Hudson, Jemma ; Bowe, Samantha E ; French, Paul ; Byrne, Rory ; Syrett, Suzy ; Dudley, Robert ; McLeod, Hamish J ; Griffiths, Helen ; Barnes, Thomas R E ; Davies, Linda ; Kingdon, David ; FOCUS trial group. / Cognitive behavioural therapy in clozapine-resistant schizophrenia (FOCUS) : an assessor-blinded, randomised controlled trial. In: The lancet. Psychiatry. 2018 ; Vol. 5, No. 8. pp. 633-643.
@article{46621aed10ca4fa18372686185b1dfde,
title = "Cognitive behavioural therapy in clozapine-resistant schizophrenia (FOCUS): an assessor-blinded, randomised controlled trial",
abstract = "BACKGROUND: Although clozapine is the treatment of choice for treatment-refractory schizophrenia, 30-40{\%} of patients have an insufficient response, and others are unable to tolerate it. Evidence for any augmentation strategies is scarce. We aimed to determine whether cognitive behavioural therapy (CBT) is an effective treatment for clozapine-resistant schizophrenia.METHODS: We did a pragmatic, parallel group, assessor-blinded, randomised controlled trial in community-based and inpatient mental health services in five sites in the UK. Patients with schizophrenia who were unable to tolerate clozapine, or whose symptoms did not respond to the drug, were randomly assigned 1:1 by use of randomised-permuted blocks of size four or six, stratified by centre, to either CBT plus treatment as usual or treatment as usual alone. Research assistants were masked to allocation to protect against rater bias and allegiance bias. The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months, which provides a continuous measure of symptoms of schizophrenia; PANSS total was also assessed at the end of treatment (9 months). The primary analysis was by randomised treatment based on intention to treat, for all patients for whom data were available. This study was prospectively registered, number ISRCTN99672552. The trial is closed to accrual.FINDINGS: From Jan 1, 2013, to May 31, 2015, we randomly assigned 487 participants to either CBT and treatment as usual (n=242) or treatment as usual alone (n=245). Analysis included 209 in the CBT group and 216 in the treatment as usual group. No difference occurred in the primary outcome (PANSS total at 21 months, mean difference -0·89, 95{\%} CI -3·32 to 1·55; p=0·48), although the CBT group improved at the end of treatment (PANSS total at 9 months, mean difference -2·40, -4·79 to -0·02; p=0·049). During the trial, 107 (44{\%}) of 242 participants in the CBT arm and 104 (42{\%}) of 245 in the treatment as usual arm had at least one adverse event (odds ratio 1·09, 95{\%} CI 0·81 to 1·46; p=0·58). Only two (1{\%}) of 242 participants in the CBT arm and one (<1{\%}) of 245 in the treatment as usual arm had a trial-related serious adverse event.INTERPRETATION: At 21-month follow-up, CBT did not have a lasting effect on total symptoms of schizophrenia compared with treatment as usual; however, CBT produced statistically, though not clinically, significant improvements on total symptoms by the end of treatment. There was no indication that the addition of CBT to treatment as usual caused adverse effects. The results of this trial do not support a recommendation to routinely offer CBT to all people who meet criteria for clozapine-resistant schizophrenia; however, a pragmatic individual trial might be indicated for some.FUNDING: National Institute for Health Research Technology Assessment programme.",
keywords = "Journal Article",
author = "Morrison, {Anthony P} and Melissa Pyle and Andrew Gumley and Matthias Schwannauer and Douglas Turkington and Graeme MacLennan and John Norrie and Jemma Hudson and Bowe, {Samantha E} and Paul French and Rory Byrne and Suzy Syrett and Robert Dudley and McLeod, {Hamish J} and Helen Griffiths and Barnes, {Thomas R E} and Linda Davies and David Kingdon and {FOCUS trial group}",
note = "National Institute for Health Research Technology Assessment programme.",
year = "2018",
month = "8",
doi = "10.1016/S2215-0366(18)30184-6",
language = "English",
volume = "5",
pages = "633--643",
journal = "The lancet. Psychiatry",
issn = "2215-0366",
publisher = "Elsevier Limited",
number = "8",

}

TY - JOUR

T1 - Cognitive behavioural therapy in clozapine-resistant schizophrenia (FOCUS)

T2 - an assessor-blinded, randomised controlled trial

AU - Morrison, Anthony P

AU - Pyle, Melissa

AU - Gumley, Andrew

AU - Schwannauer, Matthias

AU - Turkington, Douglas

AU - MacLennan, Graeme

AU - Norrie, John

AU - Hudson, Jemma

AU - Bowe, Samantha E

AU - French, Paul

AU - Byrne, Rory

AU - Syrett, Suzy

AU - Dudley, Robert

AU - McLeod, Hamish J

AU - Griffiths, Helen

AU - Barnes, Thomas R E

AU - Davies, Linda

AU - Kingdon, David

AU - FOCUS trial group

N1 - National Institute for Health Research Technology Assessment programme.

PY - 2018/8

Y1 - 2018/8

N2 - BACKGROUND: Although clozapine is the treatment of choice for treatment-refractory schizophrenia, 30-40% of patients have an insufficient response, and others are unable to tolerate it. Evidence for any augmentation strategies is scarce. We aimed to determine whether cognitive behavioural therapy (CBT) is an effective treatment for clozapine-resistant schizophrenia.METHODS: We did a pragmatic, parallel group, assessor-blinded, randomised controlled trial in community-based and inpatient mental health services in five sites in the UK. Patients with schizophrenia who were unable to tolerate clozapine, or whose symptoms did not respond to the drug, were randomly assigned 1:1 by use of randomised-permuted blocks of size four or six, stratified by centre, to either CBT plus treatment as usual or treatment as usual alone. Research assistants were masked to allocation to protect against rater bias and allegiance bias. The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months, which provides a continuous measure of symptoms of schizophrenia; PANSS total was also assessed at the end of treatment (9 months). The primary analysis was by randomised treatment based on intention to treat, for all patients for whom data were available. This study was prospectively registered, number ISRCTN99672552. The trial is closed to accrual.FINDINGS: From Jan 1, 2013, to May 31, 2015, we randomly assigned 487 participants to either CBT and treatment as usual (n=242) or treatment as usual alone (n=245). Analysis included 209 in the CBT group and 216 in the treatment as usual group. No difference occurred in the primary outcome (PANSS total at 21 months, mean difference -0·89, 95% CI -3·32 to 1·55; p=0·48), although the CBT group improved at the end of treatment (PANSS total at 9 months, mean difference -2·40, -4·79 to -0·02; p=0·049). During the trial, 107 (44%) of 242 participants in the CBT arm and 104 (42%) of 245 in the treatment as usual arm had at least one adverse event (odds ratio 1·09, 95% CI 0·81 to 1·46; p=0·58). Only two (1%) of 242 participants in the CBT arm and one (<1%) of 245 in the treatment as usual arm had a trial-related serious adverse event.INTERPRETATION: At 21-month follow-up, CBT did not have a lasting effect on total symptoms of schizophrenia compared with treatment as usual; however, CBT produced statistically, though not clinically, significant improvements on total symptoms by the end of treatment. There was no indication that the addition of CBT to treatment as usual caused adverse effects. The results of this trial do not support a recommendation to routinely offer CBT to all people who meet criteria for clozapine-resistant schizophrenia; however, a pragmatic individual trial might be indicated for some.FUNDING: National Institute for Health Research Technology Assessment programme.

AB - BACKGROUND: Although clozapine is the treatment of choice for treatment-refractory schizophrenia, 30-40% of patients have an insufficient response, and others are unable to tolerate it. Evidence for any augmentation strategies is scarce. We aimed to determine whether cognitive behavioural therapy (CBT) is an effective treatment for clozapine-resistant schizophrenia.METHODS: We did a pragmatic, parallel group, assessor-blinded, randomised controlled trial in community-based and inpatient mental health services in five sites in the UK. Patients with schizophrenia who were unable to tolerate clozapine, or whose symptoms did not respond to the drug, were randomly assigned 1:1 by use of randomised-permuted blocks of size four or six, stratified by centre, to either CBT plus treatment as usual or treatment as usual alone. Research assistants were masked to allocation to protect against rater bias and allegiance bias. The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months, which provides a continuous measure of symptoms of schizophrenia; PANSS total was also assessed at the end of treatment (9 months). The primary analysis was by randomised treatment based on intention to treat, for all patients for whom data were available. This study was prospectively registered, number ISRCTN99672552. The trial is closed to accrual.FINDINGS: From Jan 1, 2013, to May 31, 2015, we randomly assigned 487 participants to either CBT and treatment as usual (n=242) or treatment as usual alone (n=245). Analysis included 209 in the CBT group and 216 in the treatment as usual group. No difference occurred in the primary outcome (PANSS total at 21 months, mean difference -0·89, 95% CI -3·32 to 1·55; p=0·48), although the CBT group improved at the end of treatment (PANSS total at 9 months, mean difference -2·40, -4·79 to -0·02; p=0·049). During the trial, 107 (44%) of 242 participants in the CBT arm and 104 (42%) of 245 in the treatment as usual arm had at least one adverse event (odds ratio 1·09, 95% CI 0·81 to 1·46; p=0·58). Only two (1%) of 242 participants in the CBT arm and one (<1%) of 245 in the treatment as usual arm had a trial-related serious adverse event.INTERPRETATION: At 21-month follow-up, CBT did not have a lasting effect on total symptoms of schizophrenia compared with treatment as usual; however, CBT produced statistically, though not clinically, significant improvements on total symptoms by the end of treatment. There was no indication that the addition of CBT to treatment as usual caused adverse effects. The results of this trial do not support a recommendation to routinely offer CBT to all people who meet criteria for clozapine-resistant schizophrenia; however, a pragmatic individual trial might be indicated for some.FUNDING: National Institute for Health Research Technology Assessment programme.

KW - Journal Article

U2 - 10.1016/S2215-0366(18)30184-6

DO - 10.1016/S2215-0366(18)30184-6

M3 - Article

VL - 5

SP - 633

EP - 643

JO - The lancet. Psychiatry

JF - The lancet. Psychiatry

SN - 2215-0366

IS - 8

ER -