CBT Beneficial for Depression and Anxiety in Schizophrenia

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Depression has been found to be predictive of increased hallucinations and delusions and influenced how patients coped with psychotic symptoms.
Depression has been found to be predictive of increased hallucinations and delusions and influenced how patients coped with psychotic symptoms.

Individuals with schizophrenia spectrum disorders often have comorbid depression and anxiety disorders, with prevalence rates as high as 50% and 38%, respectively.1 In addition to the direct burden of these disorders, negative affective states have also been implicated in the occurrence of psychotic symptoms.

Studies have shown that depression was a predictor of increased hallucinations and delusions and influenced how patients coped with psychotic symptoms.2 In other research, anxiety was found to mediate the increase in paranoia that patients with psychosis experienced during social exposure.3

"Hence, empirical evidence suggests that addressing depression and anxiety as a therapeutic target is relevant to psychosis and is likely to have a positive impact on positive symptoms," wrote the authors of a recent systematic review.1

Cognitive-behavioral therapy for psychosis (CBTp), which involves "developing and improving coping strategies for psychotic symptoms, and cognitive restructuring of delusional beliefs and dysfunctional beliefs about symptoms," is recommended in various professional guidelines for the management of psychosis and schizophrenia, according to the review.

However, the clinical application of this approach is limited by its complexity and the need for intensive training: "In contrast, interventions focusing on depression and anxiety are familiar to most therapists, are more broadly implemented, and are likely to be more acceptable to some patients," the review authors write.

In addition, some patients reject the label of schizophrenia, and this low insight has been linked to poor treatment adherence: "In contrast, affective problems present a more relevant treatment goal for many patients, who might thus be more willing to accept interventions targeting anxiety or depression," the authors noted.

To that end, they examined studies that focused on CBT for symptoms of depression and anxiety in patients with psychotic disorders. Their review included 6 studies on depression and 8 studies on anxiety; selected findings are summarized here.

  • One study found competitive memory training, which aims to strengthen memories linked to positive self-esteem, to improve depressive symptoms compared with treatment as usual.4
  • A pilot trial that compared acceptance-based depression and psychosis therapy — which includes the identification of values and goals, mindfulness and acceptance skills, and more — found a large controlled effect size for depressive symptoms.5
  • Online mindfulness training and progressive muscle relaxation were also associated with significant reductions in depressive symptoms.6
  • Progressive muscle relaxation has also been linked to reductions in state anxiety, and cognitive-behavioral interventions have demonstrated positive effects on social anxiety.7,8
  • Research assessing worry-focused CBT interventions reported reductions in anxiety and persecutory delusions.9
  • In other studies, prolonged exposure and eye movement desensitization and reprocessing were associated with large and medium to large effect sizes on posttraumatic symptoms compared with controls.10

Among other future directions, it might "be of importance to consider the right time for a certain intervention. Because many patients already display depression- or anxiety-related symptoms at a prodromal stage, it would be interesting to investigate whether an implementation of cognitive-behavioral interventions focusing on those target symptoms at such an early stage" might reduce the risk for transition to psychosis, the authors wrote.

Psychiatry Advisor checked in with review coauthor Sandra M. Opoka, MSc, a clinical psychology researcher at the University of Hamburg, Germany, to learn more about the implications of the findings.

Psychiatry Advisor: Overall, what were the main findings of your review?

Sandra M. Opoka, MSc: Symptoms of anxiety and depression, which are highly prevalent in patients with schizophrenia spectrum disorders and contribute to the formation and maintenance of psychotic symptoms, can be treated successfully in patients with psychosis. Results also indicate the possibility of a carryover effect from improvement of negative affect to improvement of psychotic symptoms

Psychiatry Advisor: For clinicians, what are the top takeaways of these findings?

Ms Opoka: Interventions focusing specifically on negative affect can be implemented successfully with patients with psychosis and might also contribute to a reduction in psychotic symptoms.

Psychiatry Advisor: What should be next steps in terms of research in this area? 

Opoka: Further research regarding a potential carryover effect to psychotic symptoms should be conducted. To date, there have been only a few studies with very heterogeneous designs. Specifically, large-scale randomized controlled trials would be helpful to get more insight regarding a carryover effect, comparing CBTp with CBT for negative affect in patients with psychosis using a comparable format and number of sessions, and conducting long-term follow-ups to examine the possibility of a delayed carryover effect.

In addition, it is important to note that it might be beneficial and possible to not focus on these prominent symptoms, but to aim at improving factors, such as negative affect, that contribute to the formation and maintenance of those prominent psychotic symptoms such as hallucinations and delusions.


  1. Opoka SMLincoln TM. The effect of cognitive behavioral interventions on depression and anxiety symptoms in patients with schizophrenia spectrum disorders: a systematic review. Psychiatr Clin North Am. 2017;40(4):641-659.
  2. Smith B, Fowler DG, Freeman D, et al. Emotion and psychosis: links between depression, self-esteem, negative schematic beliefs and delusions and hallucinations. Schizophr Res. 2006;86(1-3):181-188.
  3. Freeman D, Emsley R, Dunn G, et al. The stress of the street for patients with persecutory delusions: a test of the symptomatic and psychological effects of going outside into a busy urban area. Schizophr Bull. 2015;41(4):971-979.
  4. van der Gaag M, Van Oosterhout B, Daalman K, Sommer IE, Korrelboom K. Initial evaluation of the effects of competitive memory training (COMET) on depression in schizophrenia-spectrum patients with persistent auditory verbal hallucinations: a randomized controlled trial. Br J Clin Psychol. 2012;51(2):158-171.
  5. Gaudiano BA, Busch AM, Wenze SJ, Nowlan K, Epstein-Lubow G, Miller IW. http:Acceptance-based behavior therapy for depression with psychosis: results from a pilot feasibility randomized controlled trial. J Psychiatr Pract. 2015;21(5):320-333.
  6. Moritz S, Cludius B, Hottenrott B, et al. Mindfulness and relaxation treatment reduce depressive symptoms in individuals with psychosis. Eur Psychiatry. 2015;30(6):709-714.
  7. Vancampfort D, De Hert M, Knapen J, et al. Effects of progressive muscle relaxation on state anxiety and subjective well-being in people with schizophrenia: a randomized controlled trial. Clin Rehabil. 2011;25(6):567-575.
  8. Foster C, Startup H, Potts L, Freeman D. A randomised controlled trial of a worry intervention for individuals with persistent persecutory delusions. J Behav Ther Exp Psychiatry. 2010;41(1):45-51.
  9. Halperin S, Nathan P, Drummond P, Castle D. A cognitive-behavioural, group-based intervention for social anxiety in schizophrenia. Aust N Z J Psychiatry. 2000;34(5):809-813.
  10. van den Berg DPG, de Bont PAJM, van der Vleugel BM, et al. Prolonged exposure vs eye movement desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a psychotic disorder: a randomized clinical trial. JAMA Psychiatry. 2015;72(3):259-267.
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