CCOORRESRRESPPOONNDEDENNCCEE
                                                    companiescompanies toto attendattend educationaleducational meetings.meetings.                                                                                                                                                                                            ofof               CBTCBT withwith aa brieferbriefer intervention.intervention.                                                                                                                                          NorNor                                           criterioncriterion forfor aa goodgood clinicalclinical outcome.outcome. TheThe
                                                    M.T.M.T. hashas receivedreceived feesfees forfor makingmaking educa-educa-                                                                                                                                                                                                diddid theythey testtest thethe efficacyefficacy ofof twotwo differentdifferent                                                                                                                                                                                           differencedifference                                        inin            thethe numbersnumbers neededneeded toto treattreat
                                                    tionaltional contributionscontributions toto meetingsmeetings sponsoredsponsored                                                                                                                                                                                          kindskinds ofof CBT.CBT.                                                                                                                                                                                                                                                  isis          solelysolely                         duedue toto anan improvedimproved performanceperformance
                                                    byby pharmaceuticalpharmaceutical companies.companies.                                                                                                                                                                                                                                         WeWe believebelieve thatthat itit isis misleadingmisleading toto claimclaim                                                                                                                                                                          inin ourour treatmenttreatment asas usualusual groupgroup comparedcompared
                                                                                                                                                                                                                                                                                                                              comparabilitycomparability ofof trialstrials betweenbetween ‘expert’‘expert’ andand                                                                                                                                                                                       withwith standardstandard care.care.
                                                    BBiiancanchethettti,i, AA..,, FrFriisosonni,i, GG.. B.B.,, GGhhiissllaa,, K.K. MM..,, etet aall                                                                                                                                                                           ‘non-expert’‘non-expert’ therapists,therapists, andand betweenbetween resultsresults                                                                                                                                                                                                           ItIt          isis          certainlycertainly                                   correctcorrect toto statestate thatthat thethe
                                                    (1(199 99 88)) CClliinniiccaall pprredediictctoorsrs ooff tthhee iinnddiirrectect ccosoststs ooff                                                                                                                                                                         fromfrom 66 sessionssessions andand 2020 sessions.sessions. EvidenceEvidence                                                                                                                                                                                              twotwo studystudy                                                 populationspopulations                                                  werewere                          differentdifferent                                    byby
                                                    AAllzzhheeiimmeerrss ddiisseaeassee.. AArrcchhiivveess ofof NNeeuurroollogogyy,, 5555,,1130^30^113311..
                                                                                                                                                                                                                                                                                                                              forfor thethe efficacyefficacy ofof CBTCBT forfor psychosispsychosis isis atat                                                                                                                                                                                            definition.definition.                                         However,However, considerationconsideration ofof thethe
                                                           «
                                                    JoJonsnssosonn,, LL..,, LLiindndgrgrenen,, PP..,,WWiimmo,o, AA..,, etet aall (1(199999 9)) TheThe                                                                                                                                                                         anan earlyearly andand promisingpromising stage;stage; wewe thinkthink itit                                                                                                                                                                                               demographicsdemographics asas reportedreported inin thethe twotwo paperspapers
                                                    ccoosstt--eeffffeeccttiviveenneessss ooff ddoneoneppeezziill inin SSwweeddiisshh ppaattiieentntss wwitithh                                                                                                                                                                isis unhelpfulunhelpful toto makemake unsubstantiatedunsubstantiated com-com-                                                                                                                                                                                             showsshows                               thatthat                      therethere                         waswas                       littlelittle                    differencedifference                                          inin
                                                    AAllzhzheeiimemerrss ddiisseeaassee:: aa MarMarkkoovv momoddeell.. CCllinicalinical
                                                    TTheherrapapeueuttiiccss,, 2121,1, 1223300^1^1224400..                                                                                                                                                                                                                    parisonsparisons acrossacross trials,trials, andand hopehope thatthat thesethese                                                                                                                                                                                          thosethose whowho actuallyactually endedended upup beingbeing enrolledenrolled
                                                    TTrabrabuucccchhii,, MM.. ((1199999)9) AAnn eecconomonomiicc ppeerrssppeeccttiivvee onon                                                                                                                                                                                  commentscomments provideprovide somesome clarification.clarification.                                                                                                                                                                                                     inin             thethe                 twotwo studies.studies.                                                    TheThe meanmean numbernumber ofof
                                                    AAllzzhheeiimmeerrss ddiisseaeassee.. JJouourrnanall ooff GeGerriiatatrriicc PPssyycchhiiatatryry aandnd                                                                                                                                                                                                                                                                                                                                                                                                                                          admissionsadmissions inin KuipersKuipers etet alal (1997)(1997) waswas 5.25.2
                                                    NeNeuurroollooggyy,, 1212,2, 299^^3838..                                                                                                                                                                                                                                  KKuuiippeers,rs, E.E.,, GaGarretyety,, PP..,, FoFowwlleerr,, DD..,, etet alal (1(199 9977))                                                                                                                                                                               forfor                 thethe                 CBTCBT groupgroup andand 4.34.3 forfor standardstandard
                                                                                                                                                                                                                                                                                                                              LLondonondon^^EEaasstt AAnngglliiaa rrandoandommiisesedd ccononttrroolllleedd ttrriiaall ooff                                                                                                                                                                             carecare                     andand inin ourour studystudy 4.714.71 forfor CBTCBT andand
                                                     __            ,, GGhhiissllaa,, MM.. KK.. && BBiiancanchethettti,i, AA.. ((11999966)) COCODDEEMM::                                                                                                                                                                       ccogognniittiivvee^^bbeehahavviiouourarall tthheerarappyy ffoorr pspsyycchohossiiss.. II.. EEffffectsects ooff
                                                    lloongngiittududiinnaall ssttududyy oonn AAllzzhheeiimmeerr ddiisseeaassee ccoossttss..                                                                                                                                                                                   ththee ttrereatatmmeenntt pphhaassee.. BBrriittiishsh JJouourrnanall ooff PPssyycchhiiatatryry,, 171711,,                                                                                                                                                                 5.185.18 forfor treatmenttreatment asas usual.usual. WeWe endedended upup
                                                    InIn AAllzzhheeiimmeerr DDiisseeasasee::TThheerarapeupeuttiicc SSttraratteeggiieess                                                                                                                                                                                       313199^^332277..                                                                                                                                                                                                                                                          enrollingenrolling aa moremore treatment-resistanttreatment-resistant groupgroup
                                                    ((eeddss EE.. GGiiaaccoobbiinnii && RR.. BBeecckkerer),), pppp.. 556161^5^56655.. BBoossttoonn,,
                                                    MAMA:: BBiirrkkhhaaus« userer..                                                                                                                                                                                                                                           __             ,F,  Foowwlleerr,, DD..,, GGaarreetyty,, PP..,, etet aall (1(199 99 88)) LLondondonon ^^ EEaasstt                                                                                                                                                          becausebecause                                      ofof                 thethe                     factfact                      thatthat                       patientspatients                                     withwith
                                                                                                                                                                                                                                                                                                                              AAnngglliiaa rraanndomdomiisseedd ccoonnttrroolllleedd ttrriiaall ooff ccooggnniittiivvee^^                                                                                                                                                                               schizophreniaschizophrenia whosewhose symptomssymptoms werewere wellwell
                                                    WWoollsstetenhnhoollmmee,, JJ..,, FennFenn,, PP..,, GGrarayy,, A.A.,, etet aall (2(2000022))                                                                                                                                                                              bbeehahavviiouourarall tthheerraappyy ffoorr pspsyycchhososiiss.. IIIIII.. FFoolllloow-uw-upp anandd                                                                                                                                                                      controlledcontrolled                                           withwith                       medicationmedication                                                oftenoften                         diddid                  notnot
                                                    EEsstimtimaattiinngg tthhee rreellaatitioonnsshiphip bbeettwweeeenn didisseeaassee pprrooggrreessssiioonn                                                                                                                                                                 eeccoonomnomiicc eevvaalluauattiionon aatt 1188 mmonontthshs.. BrBriittisishh JJoouurrnnaall ofof
                                                    aannddccoossttooffccarareeiinnddememenenttiiaa..BBrriittiishsh JJouourrnanall ooff PPssyycchhiiatatryry,,                                                                                                                                                                 PPssyycchhiiatatryry,, 171733,, 6611^6^688..                                                                                                                                                                                                                              seesee                 thethe                   needneed                        toto               enterenter                        thethe                   studystudy                           whenwhen itit
                                                    181811,, 336^46^422..                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               waswas offeredoffered toto them.them.
                                                                                                                                                                                                                                                                                                                              TTuurrkkiinnggttoonn,D, D..,, KKiinngdgdoonn,D, D..,,TTuurrnnerer,,TT..,, etet aall (2(2000022))
                                                                                                                                                                                                                                                                                                                              EEffffectectiivveennessess ooff aa bbrriieeff ccogognniittiivvee^^bbeehahavviiouourarall tthheerarappyy                                                                                                                                                                                        ItIt          isis         certainlycertainly truetrue thatthat thethe CBTCBT deliv-deliv-
                                                    AA.. BBiiancanchhetettti,i, FF.. CastCasteelllletettti,i, MM..                                                                                                                                                                                                            inteinterrvveentintioonn inin tthhee ttrreeaattmmeentnt ooff sscchihizzoopphhrreeniniaa.. BBrritisitishh                                                                                                                                                                  eredered byby KuipersKuipers andand colleaguescolleagues waswas ofof 2020
                                                    TTrrabua b u ccc c hh ii                                        GGeerriiaattrriicc RReseseaearrcchh GGrrououpp,,VViiaa                                                                                                                                                    JJouourrnanall ooff PPssyycchhiiatatryry,, 181800,,552233^^527527..                                                                                                                                                                                                       sessions’sessions’                                    durationduration                                        withwith                        aa            moremore                             sophisti-sophisti-
                                                    RoRommaanniinnoo 11 ^^ 2255112222 BBreresscciaia,, IIttaallyy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       catedcated                          treatmenttreatment                                           manual.manual.                                      ThisThis                       makesmakes                                thethe
                                                                                                                                                                                                                                                                                                                              E.E. KKuuiippeersrs                                               DDeeppaarrttmmenentt ooff PPsysycchhoollooggyy,, IInnsstitutitutete ooff                                                                                                                                resultresult                           ofof               ourour                     briefbrief                        CBTCBT interventionintervention                                                                              asas
                                                                                                                                                                                                                                                                                                                              PPssyycchhiiatatrryy,, DDee CCrerespigspignnyy PaParrkk,, DDeennmmaarrkk HHiillll,,                                                                                                                                                                                       delivereddelivered byby psychiatricpsychiatric nursesnurses allall thethe moremore
                                                    CBCBTT ffoorr ppssyycchhoossiiss                                                                                                                                                                                                                                          LLonondodonn SSEE55 88AAFF,,UUKK                                                                                                                                                                                                                                          impressive.impressive.                                             WeWe awaitawait thethe analysisanalysis ofof ourour
                                                    II        amam writingwriting toto replyreply toto TurkingtonTurkington etet alal                                                                                                                                                                                         P.P.       GGaarree tt yy                                    SStt ThThomomaass HHoossppiittaall,, LLoondndoonn,,UUKK                                                                                                                                                    short-termshort-term follow-upfollow-up resultsresults toto seesee whetherwhether
                                                    (2002:(2002: p.p. 525),525), whowho claimclaim inin theirtheir interest-interest-                                                                                                                                                                                         GG.. DuDunnnn                                           UUnniivveerrssiityty ooff MManancchhesestteerr,, MManancchhesestteerr,,                                                                                                                                           thethe                  impressiveimpressive                                             durabilitydurability                                         resultsresults                             reportedreported
                                                    inging                       andand                           recentlyrecently                                       publishedpublished                                               paperpaper                                  onon                                    UKUK                                                                                                                                                                                                                                                                      aboveabove cancan bebe equalled.equalled. IfIf CBTCBT isis toto makemake
                                                    cognitive–behaviouralcognitive–behavioural                                                                                        therapytherapy                                     (CBT)(CBT)                                 forfor                                    P.P.       BB ee bb bb ii nn gg tt oo nn                                             UUnniivveerrssiittyy CCoollllegegee LLonondodonn,,UUKK                                                                                                                               aa realreal impactimpact inin termsterms ofof thethe managementmanagement
                                                    psychosis,psychosis, thatthat ‘The‘The NNTNNT [numbers[numbers neededneeded                                                                                                                                                                                               D.D. FFoowwlleerr                                              UUnniivveersrsiityty ooff EEaastst AAnngglliia,a, NNoorwrwiicchh,,UUKK                                                                                                                                     ofof schizophrenia,schizophrenia, itit willwill needneed toto bebe deliv-deliv-
                                                    toto treat]treat] ofof 1313 forfor improvementimprovement inin overalloverall                                                                                                                                                                                             D.D. FFrreeeemmaann                                                       IInstnstiittuuttee ooff PPssyychchiiaattrryy,, LLoondndoonn,,UUKK                                                                                                                               eredered byby non-expertnon-expert therapiststherapists inin communitycommunity
                                                    symptomssymptoms waswas compacompatibletible withwith thethe resultsresults                                                                                                                                                                                                                                                                                                                                                                                                                                                                         mentalmental                                 healthhealth                             teams.teams.                               TheThe realreal                                         issuesissues                          forfor
                                                    achievedachieved                                          whenwhen                                 CBTCBT                              waswas                         delivereddelivered                                          byby                                                                                                                                                                                                                                                                                                              expertexpert cognitivecognitive therapiststherapists areare toto organiseorganise
                                                    expertexpert                               therapiststherapists                                          (Kuipers(Kuipers                                       etet              alal,,                1997)’.1997)’.                                                    AuAutthhoorrss rreeppllyy:: OurOur studystudy waswas designeddesigned spe-spe-                                                                                                                                                                                          trainingtraining                                  courses,courses,                                   provideprovide                                   supervisionsupervision                                               andand
                                                    WeWe dodo notnot thinkthink thisthis claimclaim isis justified.justified.                                                                                                                                                                                                 cificallycifically                               toto             answeranswer thethe questionquestion raisedraised byby                                                                                                                                                  toto               deliverdeliver                              moremore                            complexcomplex                                        CBTCBT forfor thosethose
                                                                         First,First,                        inin              ourour                    studystudy                           64%64% ofof thethe CBTCBT                                                                                                       JonesJones etet alal (1999)(1999) ofof whetherwhether thethe benefitsbenefits                                                                                                                                                                                             patientspatients withwith schizophreniaschizophrenia whowho areare moremore
                                                    groupgroup achievedachieved clinicalclinical improvementimprovement com-com-                                                                                                                                                                                              achievedachieved                                       byby expertexpert                                             therapiststherapists                                        inin             researchresearch                                                        psychologicallypsychologically                                                                   difficultdifficult                                      oror                    whowho                               havehave
                                                    paredpared withwith 47%47% ofof thethe controlscontrols (Kuipers(Kuipers                                                                                                                                                                                                  settingssettings                               couldcould bebe replicatedreplicated byby non-expertnon-expert                                                                                                                                                             comorbiditycomorbidity                                                    suchsuch asas post-traumaticpost-traumatic stressstress
                                                    etet alal,, 1997).1997). WeWe diddid notnot presentpresent thethe NNTNNT                                                                                                                                                                                                  therapiststherapists                                         workingworking                                       inin              communitycommunity                                                    mentalmental                                                    disorder,disorder,                                       alcoholalcohol                                   dependencedependence                                                     andand                       socialsocial
                                                    butbut theythey areare 66 atat thethe endend ofof treatmenttreatment andand                                                                                                                                                                                               healthhealth teams.teams. AnAn end-of-therapyend-of-therapy compari-compari-                                                                                                                                                                                              phobia.phobia. ThereThere isis thereforetherefore aa potentialpotential rolerole
                                                    33 atat thethe endend ofof follow-upfollow-up (Kuipers(Kuipers etet alal,,                                                                                                                                                                                                sonson                    waswas thereforetherefore                                                            necessarynecessary                                         withwith                       oneone                     ofof                                  forfor                bothboth expertexpert andand non-expertnon-expert therapiststherapists
                                                    1998).1998).                                                                                                                                                                                                                                                              thethe methodologicallymethodologically robustrobust studiesstudies quotedquoted                                                                                                                                                                                          inin             thethe                 managementmanagement ofof everyevery patientpatient withwith
                                                                         Second,Second, thethe twotwo studiesstudies addressaddress differ-differ-                                                                                                                                                                            inin thethe aboveabove review.review. KuipersKuipers etet alal (1997)(1997)                                                                                                                                                                                               schizophrenia.schizophrenia.
                                                    entent                    questionsquestions                                           inin               differentdifferent                                      samples.samples.                                       OurOur                                           waswas chosenchosen becausebecause aa similar,similar, goodgood clinicalclinical
                                                    studystudy                            testedtested                            whetherwhether                                       CBTCBT forfor                                            psychosispsychosis                                                            outcomeoutcome analysisanalysis onon overalloverall symptomssymptoms hadhad                                                                                                                                                                                               JonJoneess,, CC..,, CCormormaacc,, II..,, MMototaa,, J.J.,, etet aall (1(199999 9)) CCoognitivgnitivee
                                                    couldcould                              improveimprove                                         outcomeoutcome                                          comparedcompared                                                withwith                                           beenbeen reportedreported atat endend ofof therapy.therapy. TheThe appro-appro-                                                                                                                                                                                           bbeehhaavviioouurr ttheherraappyy ffoorr sschchiizzophophrreenniiaa..IInn CoCochchrraannee LLiibbrraarryy,,
                                                    treatmenttreatment asas usual,usual, inin aa samplesample comprisingcomprising                                                                                                                                                                                            priatepriate end-of-therapyend-of-therapy comparisoncomparison isis 14/2814/28                                                                                                                                                                                            iissssuuee 44.. OOxxffoorrd:d: UUppdadattee SSooffttwwaarree..
                                                    subjectssubjects                                     deliberatelydeliberately                                                  chosenchosen                                   toto                havehave                           atat                                 (50%)(50%)                                  forfor                  cognitive–behaviouralcognitive–behavioural                                                                                        therapytherapy                                                      KKuuiippeersrs,, E.E.,, GaGarretyety,, PP..,, FoFowwlleerr,, DD..,, etet aall (1(199 9977))
                                                    leastleast                     oneone distressing,distressing, positive,positive, medication-medication-                                                                                                                                                                  (CBT)(CBT) asas measuredmeasured atat thethe levellevel ofof 20%20% im-im-                                                                                                                                                                                                LLondondonon ^^EaEasstt AAnngglliiaa rranandodommiisesedd ccononttrroolllleedd ttrriiaall ooff
                                                    resistantresistant                                  symptomsymptom ofof psychosispsychosis (not(not fromfrom                                                                                                                                                              provementprovement inin overalloverall symptomssymptoms inin thethe origi-origi-                                                                                                                                                                                          ccooggnniittiivvee ^^ bbeehhaavviioouurarall tthheerarappyy ffoorr pspsyycchhososiiss.. II.. EEffeffectscts ooff
                                                    ‘lists‘lists                  ofof patientspatients withwith schizophreniaschizophrenia receivreceiv--                                                                                                                                                                    nalnal                 KuipersKuipers etet alal (1997)(1997) paperpaper comparedcompared                                                                                                                                                                                  ththee ttrereatatmmeenntt pphhaasse.e. BBrriitistishh JoJouurrnanall ooff PPssyycchhiiatatryry,, 171711,,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        313199^^332277..
                                                    inging                    treatment’;treatment’;                                               TurkingtonTurkington                                                    etet               alal,,                2002:2002:                                                withwith                        112/257112/257                                       (44%)(44%) asas measuredmeasured atat thethe
                                                    p.p. 523).523).                                  WeWe werewere aimingaiming atat aa treatment-treatment-                                                                                                                                                                  levellevel ofof aa 25%25% improvementimprovement inin ourour study.study.                                                                                                                                                                                                 D.D. TTuurrkkiinnggttoonn                                                           DeDepaparrttmmeenntt ooff PPssyycchhiiaattryry,,
                                                    resistantresistant                                   group,group,                               aa ratherrather                                     differentdifferent                                   samplesample                                                     TheseThese resultsresults showshow aa comparablecomparable effecteffect sizesize                                                                                                                                                                                          UUnniivveersrsiityty ooff NNeewwccaassttllee uuppoonnTTyynnee,, RRooyyaall VViictctoorriiaa
                                                    fromfrom thatthat recruitedrecruited byby TurkingtonTurkington andand col-col-                                                                                                                                                                                            forfor CBTCBT inin thethe twotwo studies,studies, consideringconsidering thatthat                                                                                                                                                                                         IInnffiirrmmaaryry,,QQuueeeennVViictctoorriiaa RRoadoad,, NNeewwcacassttllee uuponpon
                                                    leagues.leagues. NeitherNeither studystudy comparedcompared 99 monthsmonths                                                                                                                                                                                               ourour studystudy hadhad toto satisfysatisfy aa moremore stringentstringent                                                                                                                                                                                               TyTy nn ee              NNEE11 44 LL PP,, UUKK
                                                    535344
            https://doi.org/10.1192/bjp.181.6.534 Published online by Cambridge University Press