CBT for refractory psychotic symptoms

We read with interest the study of Valmaggia et al (2005), particularly noting that the interventions delivered were based on a comprehensive treatment manual and delivered by therapists specifically trained in the protocol.

By the authors’ admission, some aspects of the intervention showed only modest benefit over supportive counselling; indeed the only outcomes when examining the 95% CI that provide support for cognitive–behavioural therapy (CBT) are physical characteristics of hallucinations and cognitive interpretation of hallucinations. At the same time, the 95% CI for negative symptoms (Positive and Negative Syndrome Scale) suggest that supportive counselling is more effective than CBT. In addition, the effects of 16 sessions of highly structured CBT disappeared at follow-up. We were therefore very surprised at the authors’ conclusions that this therapy should be available within in-patient facilities. As experienced CBT clinicians and nurses, we are acutely aware that there is a serious shortage of CBT therapists and nursing staff available to provide therapist or ‘manualised’ CBT. Indeed, waiting lists of over 12 months are common for therapist-provided out-patient CBT. In turn, a very large number of in-patient wards rarely, if ever, see a psychologist, let alone have the capacity to train therapists and provide 16 h of therapy! Should we not be more prudent when making claims on such scant resources by first ensuring that we have adequate evidence to support such claims? Perhaps the editor should consider making obligatory a section in every paper relating to real-world implications.