Other treatments

• Cognitive remediation therapy
• Electroconvulsive therapy (ECT)
• Cognitive behaviour therapy for specific problems or symptoms
• Mindfulness-based cognitive therapy (MBCT)
• Counselling and supportive therapy
• Psychoanalysis and psychodynamic therapy
• Psychoeducation
• Transcranial magnetic stimulation

Cognitive remediation therapy

Many 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 CRT can make a difference when used to help people 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 it can help people, and whether there are long term benefits. There are, however, a number of research studies that are investigating how effective CRT is.

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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.

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:
• the treatment of severe depressive illness;
• a prolonged or severe episode of mania;
• or catatonia. Catatonia is sometimes associated with schizophrenia or with mood disorders. Someone with catatonia may stop moving and remain rigid, may stop eating and drinking, or may become very excited for no apparent reason and move around excessively.

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.

The recommendations on the use of ECT for depression have been updated in an October 2009 NICE guidance on Depression. This says that ECT should be considered for severe depression that is life-threatening, and when a rapid response is required, or when other treatments have failed.

Read the NICE guidance on ECT. 

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Cognitive behaviour therapy for specific problems or symptoms

Cognitive behaviour therapy 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. The CBT has been designed to reduce the urge to obey the voices and help people feel more in control by mental health professionals and academics in Birmingham. 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 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, researchers are developing a style of cognitive behaviour 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 doubt strongly held views or delusions that are often among the symptoms of psychosis.

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Mindfulness-based cognitive therapy (MBCT)

‘Mindfulness’ is the ability to pay attention to, and accept without criticism, what is happening in the present, and to be more aware and accepting of thoughts, feelings and experiences. Mindfulness-based therapies are designed to help people learn skills to help them cope with mental and physical health problems by changing the way they process negative thinking. People who have depression may be offered mindfulness based cognitive therapy and different versions are being tested for people with psychosis.

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Counselling and supportive therapy

There 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.

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Psychoanalysis and psychodynamic therapy

Psychoanalysis 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 out of the unconsciousness 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 reduce time spent in hospital. The NICE Guidance on Schizophrenia, however, recommends mental health professionals may consider using psychoanalysis or psychodynamic therapy to help them understand more about the experiences of people with schizophrenia.

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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. Research shows psychoeducation can make carers feel more optimistic, and can make a difference to many mental health problems, including psychosis, helping to reduce symptoms and prevent relapse.

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 alone, or to people who are unwell and their families together.

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Transcranial magnetic stimulation

Transcranial 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, and research is 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 voices are generated.

The National Institute for Health and Clinical Excellence does not recommend rTMS for the treatment of depression because it is still not clear whether it is an effective treatment.