Applying CBT for Psychosis in Schizophrenia Care: Strategies for Expanding Access

Announcer:
You’re listening to NeuroFrontiers on ReachMD, and this episode is sponsored by Bristol Myers Squibb. Here’s your host, Dr. Charles Turck.

Dr. Turck: 
This is NeuroFrontiers on ReachMD, and I’m Dr. Charles Turck. Joining me to discuss cognitive behavioral therapy, or CBT, for psychosis and how we can expand access and continuity of care for patients with schizophrenia is Dr. David Kimhy. He’s an Associate Professor, the Director of the Experimental Psychopathology Laboratory, and the Program Leader for New Interventions in Schizophrenia at the Department of Psychiatry at the Icahn School of Medicine at Mount Sinai. Dr. Kimhy, welcome to the program.

Dr. Kimhy: 
Thank you for having me.

Dr. Turck:
Well, why don’t we start with some background, Dr. Kimhy. What does the evidence tell us about cognitive behavioral therapy, or CBT, for psychosis—both its effectiveness across different symptom domains and what a typical course of therapy looks like in practice?

Dr. Kimhy:
So CBT for psychosis has been around for about 30 years now. Our first randomized clinical trials came in the 1990s, and at this point, there are more than 40 randomized clinical trials that have been published along with a number of meta-analyses. And the evidence is showing that there’s benefits for positive symptoms—these are delusions and hallucinations—as well as for depression and anxiety. There’s some moderate evidence for negative symptoms and functioning.

Dr. Turck:
Now, despite that strong evidence supporting CBT for psychosis, very few patients actually receive it in the U.S. So from your vantage point, what are the biggest systemic factors driving this gap in schizophrenia care?

Dr. Kimhy:
This is one of our biggest challenges. Despite the fact that we have a strong evidence base for CBT for psychosis and it’s included as part of the treatment guidelines for patients with schizophrenia by the American Psychiatric Association, very, very few patients actually get this treatment. The biggest bottleneck is a lack of trained clinicians. We don’t have enough trained clinicians to offer it, and as a result, you have major parts of the country—sometimes entire states—that don’t have even one provider. So that’s a big barrier there.

Another barrier is lack of awareness among mental health practitioners that are not aware of this or not aware of the evidence base and also among families. They don’t hear about it or know about it. When it comes to treatment of schizophrenia, everybody knows about it—there’s commercials on TV for antipsychotics. There’s no commercials for CBT for psychosis. So a lot of families and practitioners are not familiar with the fact that this is something that is available, helpful, and efficacious.

Dr. Turck:
And if we zero in on a common barrier, fragmented care transitions are one of the biggest risks, as many patients are discharged with prescriptions for antipsychotic medications but with little else and minimal follow-up plans. Would you tell us about the challenges those circumstances create for continuity of care and the changes we need to better support our patients?

Dr. Kimhy:
Yes, this is one of our biggest problems because when patients develop a psychotic episode, they go to the hospital, they stay there 2 to 3 weeks, and they get stabilized. But we know that about 60 percent of patients are still experiencing symptoms—they’re partial responders. And as a result, when they discharge, they’re still experiencing symptoms; they still have difficulties functioning. And I see it very often with families—they have a kid or a loved one that gets hospitalized and then they get discharged, and if you want anything beyond medication, it’s really a challenge to find somebody that is qualified to offer CBT for psychosis that is trained in that.

And as a result, patients either see other clinicians that are not trained in this or not trained in treatment of schizophrenia or psychosis, or they get referrals to community mental health centers. Often, clinicians there are burdened and don’t have enough resources, so they may see somebody once every 2 or 3 weeks—sometimes even less with a case manager. It’s a major issue; how do we help patients get continuity of care once they discharge from the hospital?

Dr. Turck:
For those just tuning in, you’re listening to NeuroFrontiers on ReachMD. I’m Dr. Charles Turck, and I’m speaking with Dr. David Kimhy about overcoming systemic barriers in schizophrenia care.

So, Dr. Kimhy, shared decision-making is often emphasized, but it really only works if it’s paired with culturally considerate care. With that being said, how can we build trust with patients who may have different beliefs or past experiences with mental health care?

Dr. Kimhy:
Yes, I think this is one of the issues that I often see in my practice. I think for many patients, based on past experiences, they have learned that if they talk about psychotic symptoms in detail or they talk about suicidal ideation if they experience that, the response from clinicians is to either increase the medication or sometimes even hospitalize them. And of course, this is not something that you want as a patient.

As part of CBT for psychosis, we take the opposite approach. We examine and talk about these experiences and belief in detail. We encourage patients to talk about what’s going on inside of them because this is part of the information that provides us the ability to move treatment forward. If you don’t know that somebody is experiencing something, it’s hard to develop treatments or focus on that. So that’s a key aspect of our treatment in CBT for psychosis, and it often takes some time to help patients to recognize that. So absolutely, that’s an important factor.

Dr. Turck:
Now, technology is starting to play a bigger role here. So how can tools like telepsychiatry, automated reminders, and smartphone apps change the way we support continuity of care?

Dr. Kimhy:
This is actually something that gives me a little bit of hope about the relatively dire state of CBT for psychosis in the U.S. The introduction of Zoom, telepsychiatry, and other similar technologies actually make accessibility much greater to clinicians and other providers. This is also in combination with, in recent years, the enactment of the PSYPACT agreements that allow clinicians in PSYPACT states to see patients from other PSYPACT states. So again, it’s increasing accessibility. For example, I’m located in New York and New Jersey, but I can see and treat patients that are located in other PSYPACT states. And at this point, there’s over 40 states that are approved as PSYPACT, so it’s covering most of the U.S.

I think in terms of automated reminders and smartphone apps, again, there’s a proliferation of those, and they’re not necessarily dedicated for people with psychosis; this is for mental health in general. But some of them can be quite beneficial, especially dealing more with the logistics of therapy and making sure that patients are connected with their providers.

Dr. Turck:
And before we close, Dr. Kimhy, if you had the ear of, say, a state mental health commissioner, what one policy change would you recommend to increase access to CBT for psychosis across the public behavioral health system?

Dr. Kimhy:
So as I mentioned, I think PSYPACT and telehealth are going to change the field quite a bit. But I think in terms of state and federal mental health commissioners, I think the biggest roadblock that we have is still not having enough clinicians. So I think that the best thing we can do at this point is to fund dedicated CBT for psychosis training. Primarily in academic programs, there’s a handful of programs that do that, but the numbers are still low—we’re talking about a handful of new clinicians every year. In order to actually make these treatment guidelines available—and not just at the present as a bit of a dead letter for CBT for psychosis—we need more clinicians, and we need more funding to train more clinicians that’ll know how to do this in an efficacious way.

Dr. Turck:
Well, as those comments bring us to the end of today’s program, I want to thank my guest, Dr. David Kimhy, for joining me to share strategies for promoting access, continuity, and equity in schizophrenia care. Dr. Kimhy, it’s great having you on the program.

Dr. Kimhy:
Thank you for having me. Good to talk to you.

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You’ve been listening to NeuroFrontiers, and this episode was sponsored by Bristol Myers Squibb. To access this and other episodes in our series, visit NeuroFrontiers on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!