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Cognitive behavioral therapy (CBT) for schizophrenia/psychosis

Adult Mental Health: Serious Mental Illness
Benefit-cost methods last updated December 2024.  Literature review updated December 2014.
This program was archived December 2024.
Cognitive behavioral therapy for psychosis (CBTp) includes the application of cognitive strategies focused on changing thoughts to improve feelings and behaviors as well as behavioral techniques most often used to address negative symptoms. CBTp involves teaching patients methods of coping with their symptoms and training in problem solving, social skills and strategies to reduce risk of relapse. In this collection of studies, CBTp was provided in addition to antipsychotic medication.
 
ALL
BENEFIT-COST
META-ANALYSIS
CITATIONS
For an overview of WSIPP's Benefit-Cost Model, please see this guide. The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2022).  The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our 2023 Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $9,566 Benefits minus costs $14,930
Participants $1,395 Benefit to cost ratio $9.70
Others $2,012 Chance the program will produce
Indirect $3,671 benefits greater than the costs 60%
Total benefits $16,645
Net program cost ($1,715)
Benefits minus cost $14,930

^WSIPP’s benefit-cost model does not monetize this outcome.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the program impacts measured in the research literature (for example, impacts on crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases. See Estimating Program Effects Using Effect Sizes for additional information on how we estimate effect sizes.

The effect size may be adjusted from the unadjusted effect size estimated in the meta-analysis. Historically, WSIPP adjusted effect sizes to some programs based on the methodological characteristics of the study. For programs reviewed in 2024 or later, we do not make additional adjustments, and we use the unadjusted effect size whenever we run a benefit-cost analysis.

Research shows the magnitude of effects may change over time. For those effect sizes, we estimate outcome-based adjustments, which we apply between the first time ES is estimated and the second time ES is estimated. More details about these adjustments can be found in our 2023 Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N Effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Major depressive disorder
Clinical diagnosis of major depression or symptoms measured on a validated scale.
 36 15 727 -0.123 0.070 37 -0.091 0.096 38 -0.123 0.078
Anxiety disorder
Clinical diagnosis of an anxiety disorder (e.g., general anxiety, panic, social anxiety, obsessive compulsive disorder) or symptoms measured on a validated scale.
 36 7 267 0.017 0.103 37 0.013 0.097 38 0.017 0.866
Global functioning^
How well individuals (typically those who are developmentally disabled or seriously mentally ill) have adapted to activities of daily living.
 36 18 721 0.231 0.069 37 n/a n/a n/a 0.232 0.001
Hospitalization (psychiatric)
Admission to a psychiatric ward or hospital.
 36 16 832 -0.124 0.106 37 -0.092 0.122 38 -0.124 0.241
Psychiatric symptoms^
Mental health symptoms (such as symptoms of psychosis) in individuals with serious mental illness, measured on a validated scale.
 36 25 1172 -0.148 0.101 37 n/a n/a n/a -0.148 0.144
Suicidal ideation^
Thinking about and/or planning death by suicide.
 36 2 115 -0.174 0.331 37 n/a n/a n/a -0.174 0.599
Psychosis symptoms (positive)^
Symptoms of psychosis that are experienced in addition to normal function (e.g., delusions, hallucinations, or agitation) measured on a validated scale, for individuals with serious mental illness.
 36 33 1477 -0.178 0.059 37 n/a n/a n/a -0.178 0.003
Psychosis symptoms (negative)^
Symptoms of psychosis that reflect a decrease or loss of normal function (e.g., diminished emotional expression, lack of motivation) measured on a validated scale, for individuals with serious mental illness.
 36 25 1143 -0.170 0.069 37 n/a n/a n/a -0.170 0.014
Medication adherence^
Adherence to a specific prescribed medication regimen.
36 2 75 -0.011 0.195 37 n/a n/a n/a -0.011 0.956
Hope^
A positive motivational state, as measure on a validated scale such as the Kadzin Hopelessness Scale for Children.
 36 3 92 0.300 0.249 37 n/a n/a n/a 0.300 0.299
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Affected outcome: Resulting benefits:1 Benefits accrue to:
Taxpayers Participants Others2 Indirect3 Total
Major depressive disorder Labor market earnings associated with major depression $926 $2,182 $0 $0 $3,109
Mortality associated with depression $1 $2 $0 $17 $20
Anxiety disorder Labor market earnings associated with anxiety disorder ($384) ($904) $0 $0 ($1,288)
Health care associated with anxiety disorder ($26) ($7) ($26) ($13) ($72)
Hospitalization (psychiatric) Health care associated with psychiatric hospitalization $9,049 $123 $2,038 $4,524 $15,734
Program cost Adjustment for deadweight cost of program $0 $0 $0 ($858) ($858)
Totals $9,566 $1,395 $2,012 $3,671 $16,645
Click here to see populations selected
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $1,436 2014 Present value of net program costs (in 2022 dollars) ($1,715)
Comparison costs $0 2014 Cost range (+ or -) 10%
Per-participant cost of treatment by modality (group/individual) was weighted by treatment Ns reported in the studies. Cost per-session per-person was $37.91/session for group and $120.90 for individual therapy (2014 dollars), based on actuarial tables reported for disabled adults in Mercer (2013) Behavioral Health Data Book for the State of Washington For Rates Effective January 1, 2014.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our 2023 Technical Documentation.
Benefits Minus Costs
Benefits by Perspective
Taxpayer Benefits by Source of Value
Benefits Minus Costs Over Time (Cumulative Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in discounted dollars. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Citations Used in the Meta-Analysis

Bach, P., & Hayes, S.C. (2002). The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 70(5), 1129-39.

Barrowclough, C., Haddock, G., Lobban, F., Jones, S., Siddle, R., Roberts, C., & Gregg, L. (2006). Group cognitive-behavioural therapy for schizophrenia: Randomised controlled trial. The British Journal of Psychiatry, 189, 6, 527-532.

Bateman, K., Hansen, L., Turkington, D., & Kingdon, D. (2007). Cognitive Behavioral Therapy reduces suicidal ideation in schizophrenia: Results from a randomized controlled trial. Suicide and Life-Threatening Behavior, 37(3), 284-290.

Bechdolf, A.,Knost, B.,Kuntermann, C.,Schiller, S, Klosterkötter, J., Hambrecht, M., & Pukrop, R. (2004). A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in patients with schizophrenia. Acta Psychiatica Scandivica, 110, 21-28.

Bradshaw, W. (2000). Integrating cognitive-behavioral psychotherapy for persons with schizophrenia into a psychiatric rehabilitation program: results of a three year trial. Community Mental Health Journal, 36(5), 491-500.

Cather, C., Penn, D., Otto, M.W., Yovel, I., Mueser, K.T., & Goff, D.C. (2005). A pilot study of functional Cognitive Behavioral Therapy (fCBT) for schizophrenia. Schizophrenia Research, 74, 2-3.

Daniels, L. (1998). A group cognitive-behavioral and process-oriented approach to treating the social impairment and negative symptoms associated with chronic mental illness. The Journal of Psychotherapy Practice and Research, 7(2), 167-76.

Durham, R.C., Guthrie, M., Morton, R.V., Reid, D.A., Treliving, L.R., Fowler, D., & Macdonald, R.R. (2003). Tayside-Fife clinical trial of cognitive-behavioural therapy for medication-resistant psychotic symptoms. Results to 3-month follow-up. The British Journal of Psychiatry : the Journal of Mental Science, 182, 303-11.

Edwards, J., Cocks, J., Burnett, P., Maud, D., Wong, L., Yuen, H.P., Harrigan, S.M., ... McGorry, P D. (2011). Randomized controlled trial of clozapine and CBT for first-episode psychosis with enduring positive symptoms: A pilot study. Schizophrenia Research and Treatment.

Farhall, J., Freeman, N.C., Shawyer, F., & Trauer, T. (2009). An effectiveness trial of cognitive behaviour therapy in a representative sample of outpatients with psychosis. The British Journal of Clinical Psychology / the British Psychological Society, 48, 47-62.

Fowler, D., Hodgekins, J., Painter, M., Reilly, T., Crane, C., Macmillan, I., Mugford, M., ... Jones, P.B. (2009). Cognitive behaviour therapy for improving social recovery in psychosis: a report from the ISREP MRC Trial Platform Study (Improving Social Recovery in Early Psychosis). Psychological Medicine, 39(10), 1627-36.

Garety, P.A., Fowler, D.G., Freeman, D., Bebbinton, P., Dunn, G., & Kuipers, E. (2008). Cognitive-behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: randomised controlled trial. The British Journal of Psychiatry, 192(6), 412-423.

Gaudiano, B.A., & Herbert, J.D. (2006). Acute treatment of inpatients with psychotic symptoms using Acceptance and Commitment Therapy: Pilot results. Behaviour Research and Therapy, 44 (3), 415-437.

Granholm, E., McQuaid, J.R., McClure, F.S., Link, P.C., Perivoliotis, D., Gottlieb, J.D., Patterson, T.L., ... Jeste, D. V. (2007). Randomized controlled trial of cognitive behavioral social skills training for older people with schizophrenia: 12-month follow-up. The Journal of Clinical Psychiatry, 68(5), 730-7.

Granholm, E., Holden, J., Link, P.C., McQuaid, J.R., & Jeste, D.V. (2013). Randomized controlled trial of cognitive behavioral social skills training for older consumers with schizophrenia: Defeatist performance attitudes and functional outcome. American Journal of Geriatric Psychiatry, 21 (3), 251-262.

Gumley, A.I., O'Grady, M., Mcnay, L., Reilly, J., Power, K.G., & Norrie, J. (2003). Early intervention for relapse in schizophrenia: results of a 12-month randomized controlled trial of cognitive behavioural therapy. Psychological Medicine, 33(3),419-431.

Haddock, G., Tarrier, N., Morrison, A.P., Hopkins, R., Drake, R., & Lewis, S. (1999). A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis. Social Psychiatry and Psychiatric Epidemiology, 34(5), 254-8.

Haddock, G., Barrowclough, C., Shaw, J.J., Dunn, G., Novaco, R.W., & Tarrier, N. (2009). Cognitive-behavioural therapy v. social activity therapy for people with psychosis and a history of violence: randomised controlled trial. The British Journal of Psychiatry : the Journal of Mental Science, 194(2), 152-7.

Jackson, H., McGorry, P., Edwards, J., Hulbert, C., Henry, L., Harrigan, S., Dudgeon, P., ... Power, P. (2005). A controlled trial of cognitively oriented psychotherapy for early psychosis (COPE) with four-year follow-up readmission data. Psychological Medicine, 35(9), 1295-306.

Jackson, H.J., McGorry, P.D., Killackey, E., Bendall, S., Allott, K., Dudgeon, P., Gleeson, J., ... Harrigan, S. (2008). Acute-phase and 1-year follow-up results of a randomized controlled trial of CBT versus Befriending for first-episode psychosis: the ACE project. Psychological Medicine, 38(5), 725-35.

Jolley, S., Garety, P., Craig, T., Dunn, G., White, J., & Aitken, M. (2003). Cognitive therapy in early psychosis: A pilot randomized controlled trial. Behavioural and Cognitive Psychotherapy, 31(4), 473-478.

Kuipers, E., Garety, P., Fowler, D., & Dunn, G. (1997). London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. I: Effects of the treatment phase. The British Journal of Psychiatry, 171, 319.

Lecomte, T., Leclerc, C., Corbière, M., Wykes, T., Wallace, C. J., & Spidel, A. (2008). Group cognitive behavior therapy or social skills training for individuals with a recent onset of psychosis? Results of a randomized controlled trial. The Journal of Nervous and Mental Disease, 196(12), 866-75.

Levine, J., Barak, Y., & Granek, L. (1998). Cognitive Group Therapy for Paranoid Schizophrenics: Applying Cognitive Dissonance. Journal of Cognitive Psychotherapy, 12(1), 3.

Lewis, D., Tarrier, N., Haddock, G., Bentall, R.,Kinderman, P., Kingdon, D., Siddle, R., Drake, R., Everitt, J., . . . Leadley K., (2002). Randomised controlled trial of cognitive-behavioural therapy in early schizophrenia: acute-phase outcomes. British Journal of Psychiatry, 181(Supplement), s91-s97.

Lincoln, T.M., Ziegler, M., Mehl, S., Kesting, M.L., Lüllmann, E., Westermann, S., & Rief, W. (2012). Moving from efficacy to effectiveness in cognitive behavioral therapy for psychosis: a randomized clinical practice trial. Journal of Consulting and Clinical Psychology, 80(4), 674-86.

Moritz, S., Veckenstedt, R., Bohn, F., Hottenrott, B., Scheu, F., Randjbar, S., Aghotor, J., ... Roesch-Ely, D. (2013). Complementary group Metacognitive Training (MCT) reduces delusional ideation in schizophrenia. Schizophrenia Research, 151, 1-3.

Peters, E., Landau, S., McCrone, P., Cooke, M., Evans, R., Carswell, K., . . . Kuipers, E. (2010). A randomised controlled trial of cognitive behaviour therapy for psychosis in a routine clinical service. Acta Psychiatrica Scandinavica, 122 (4), 302-318.

Pinninti, N.R., Rissmiller, D.J., & Steer, R.A. (2010). Cognitive-behavioral therapy as an adjunct to second-generation antipsychotics in the treatment of schizophrenia. Psychiatric Services (Washington, D.C.), 61(9), 940-3.

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Rector, N.A., Seeman, M.V., & Segal, Z.V. (2003). Cognitive therapy for schizophrenia: a preliminary randomized controlled trial. Schizophrenia Research, 63, 1-2.

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Tarrier, N., Wittkowski, A., Kinney, C., McCarthy, E., Morris, J., & Humphreys, L. (1999). Durability of the effects of cognitive-behavioural therapy in the treatment of chronic schizophrenia: 12-month follow-up. The British Journal of Psychiatry, 174(6), 500-504.

Tarrier, N., Haddock, G., Lewis, S., Drake, R., & Gregg, L. (2006). Suicide behaviour over 18 months in recent onset schizophrenic patients: The effects of CBT. Schizophrenia Research, 83(1), 15-27.

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Turkington, D., & Kingdon, D. (2000). Cognitive-behavioural techniques for general psychiatrists in the management of patients with psychoses. The British Journal of Psychiatry : the Journal of Mental Science, 177, 101-6.

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Turkington, D., Kingdon, D., Rathod, S., Hammond, K., Pelton, J., & Mehta, R. (2006). Outcomes of an effectiveness trial of cognitive-behavioural intervention by mental health nurses in schizophrenia. The British Journal of Psychiatry, 189(1), 36-40.

Valmaggia, L.R., van der Gaag. M., Tarrier, N., Pijnenborg, M., & Slooff, C.J. (2005). Cognitive-behavioural therapy for refractory psychotic symptoms of schizophrenia resistant to atypical antipsychotic medication: Randomised controlled trial. The British Journal of Psychiatry, 186(4), 324-330.

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