A multicentre, randomised controlled trial of cognitive therapy to reduce harmful compliance with command hallucinations

Lead Research Organisation: University of Birmingham
Department Name: School of Psychology

Abstract

Schizophrenia remains the most debilitating of the psychiatric disorders; and in spite of advances in drug treatment, over 50% of people with schizophrenia continue to experience distressing symptoms, including command hallucinations (CHs),60% of which stipulate harmful or dangerous actions. Most patients try to resist these commands but feel compelled to obey, fearing the consequences if they don t. Such individuals are of great concern to clinicians and consume exceptionally high levels of services. There are no accepted treatment for this high risk group.We recently completed a pilot trial funded by the DoH of an adapted form of cognitive therapy(a talking therapy) which sucessfuly reduced compliance with the voice by encouraging the patient to see that the voice is not as powerful as they believe. In this proposed trial we compare the treatment with treatment as usual in 3 centres in the UK , using the infrastructure of the Mental Health Research Network. Over a period of 18 months we will recruit 180 individuals;our primary aim is to reduce compliance and self harm which will be monitored over 18 months.NHS and other service consumption will also be monitored .
This study will provide a breakthrough , evidence based treatment for this high-need group and open the way for further important work to help similar patients.The applicant has considerable experience of public dissemination of results of this kind of research through radio and TV interviews. He is also patron to RETHINK a leading UK mental health charity that actively promotes this therapy to their members and families.

Technical Summary

In spite of advances in drug treatment, over 50% of people with schizophrenia continue to experience distressing psychotic symptoms;the most distressing, high-risk, yet treatment resistant, are command hallucinations(CHs). Harmful compliance with, or appeasement of CHs is evident in about 60% of those with commands that stipulate harmful or dangerous actions. Such individuals are of great concern to clinicians and consume exceptionally high levels of services. There are no evidence based treatments for this high risk group.Following phase I and II work we recently reported our DoH funded pilot trial of adapted cognitive therapy for CHs(CTCH). CTCH promises a treatment effect of major clinical significance, substantially reducing harmful compliance(effect size=1.2). In this proposed pragmatic trial we compare CTCH with treatment as usual(TAU) in 3 centres in the UK , using the infrastructure of the Mental Health Research Network. Over an inception period of 18 months we will recruit 180 individuals;our primary outcome will be compliance and self harm which will be monitored over a further 18 months.Service consumption will also be monitored .The main process measure will be patients appraisal of voices power, the main target of CTCH. This study will provide breakthrough, evidence based treatment for this high-risk group and open the way for further important work to help similar high risk groups to live in the community.

Publications

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Ellett L (2017) Distress, omnipotence, and responsibility beliefs in command hallucinations. in The British journal of clinical psychology

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Griffiths S (2012) Cognitive Theory and Therapy for Command Hallucinations in Journal of Experimental Psychopathology

 
Title Cognitive behavioural therapy for Command hallucinations 
Description A cognitive-behavioural therapy for command hallucinations is currently being evaluated in a large scale randomized controlled trial 
Type Therapeutic Intervention - Complementary
Current Stage Of Development Late clinical evaluation
Year Development Stage Completed 2006
Development Status Under active development/distribution
Impact A pilot study has already proven the effectiveness of this therapy in reducing risk in people with command hallucinations. The long term effect of this intervention is currently being tested within a large scale RCT 
 
Description European Congress of Psychiatry. Madrid 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact 100 plus professional
Year(s) Of Engagement Activity 2016
 
Description Presentation: Mental Health Innovation workshop - Hokkaido, Japan 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Presentation: "Does CBT for psychosis have a future?"
Year(s) Of Engagement Activity 2018
 
Description Two Presentations in:1) Quebec University and Mental Health Services, Canada; 2.) Montreal CHUM 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Two talks on: "The COMMAND trial of cognitive therapy for harmful compliance with command hallucinations: the therapy, trial outcome and predictors /mediators of change."
Year(s) Of Engagement Activity 2017
 
Description York University 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact A lecture on Psychological treatments
Year(s) Of Engagement Activity 2018
 
Description community mental health teams & inpatient wards - Birmingham, Manchester and London 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Health professionals
Results and Impact presentations have been and are still conducted in community mental health team during multidisciplinary meetings which health professionals attend (CPNs, psychiatrists, psychologists, social workers). Each of these meetings is attended by all the members of each clinical team. The presentations are conducted jointly by the trial manager and research associate.

There meetings have promoted recruitment to the trial, generated referrals and have served the purpose of advertising the trial and building relationshiops with community mental health teams and clinicians
Year(s) Of Engagement Activity 2007,2008,2009