Psychosocial and psychological interventions for relapse prevention in schizophrenia: a systematic review and network meta-analysis

The polygenic basis of relapse after a first episode of schizophrenia

Little is known about genetic predisposition to relapse. Previous studies have linked cognitive and psychopathological (mainly schizophrenia and bipolar disorder) polygenic risk scores (PRS) with clinical manifestations of the disease. This study aims to explore the potential role of PRS from major mental disorders and cognition on schizophrenia relapse. 114 patients recruited in the 2EPs Project were included (56 patients who had not experienced relapse after 3 years of enrollment and 58 patients who relapsed during the 3-year follow-up). PRS for schizophrenia (PRS-SZ), bipolar disorder (PRS-BD), education attainment (PRS-EA) and cognitive performance (PRS-CP) were used to assess the genetic risk of schizophrenia relapse.Patients with higher PRS-EA, showed both a lower risk (OR=0.29, 95% CI [0.11-0.73]) and a later onset of relapse (30.96± 1.74 vs. 23.12± 1.14 months, p=0.007. Our study provides evidence that the genetic burden of neurocognitive function is a potentially predictors of relapse that could be incorporated into future risk prediction models. Moreover, appropriate treatments for cognitive symptoms appear to be important for improving the long-term clinical outcome of relapse.

Randomised controlled trial on the effect of video-conference cognitive behavioural therapy for patients with schizophrenia: a study protocol

INTRODUCTION

Cognitive behavioural therapy for psychosis (CBTp) has demonstrated effectiveness in reducing positive symptoms, improving depression, enhancing coping skills and increasing awareness of illness. However, compared with cognitive behavioural therapy for depression and anxiety, the spread of CBTp in clinical practice is minimal. The present study designed a randomised controlled trial (RCT) research protocol to evaluate whether real-time remote video-conference CBTp (vCBTp) could facilitate access to psychosocial interventions and effectively improve symptoms compared with usual care (UC) for patients with schizophrenia.

METHODS AND ANALYSIS

This exploratory RCT will consist of two parallel groups (vCBTp+UC and UC alone) of 12 participants (n=24) diagnosed with schizophrenia, schizoaffective disorder or paranoid disorder, who remain symptomatic following pharmacotherapy. Seven 50-min weekly vCBTp interventions will be administered to test efficacy. The primary outcome will be the positive and negative syndrome scale score at week 8. The secondary outcome will be the Beck Cognitive Insight Scale to assess insight, the Patient Health Questionnaire-9 to assess depression, the Generalised Anxiety Disorder-7 to assess anxiety, the 5-level EuroQol 5-dimensional questionnaire to assess quality of life and the Impact of Event Scale-Revised to assess subjective distress about a specific stressful life event. We will take all measurements at 0 weeks (baseline) and at 8 weeks (post-intervention), and apply intention-to-treat analysis.

ETHICS AND DISSEMINATION

We will conduct this study in the outpatient department of Cognitive Behavioral Therapy Center at Chiba University Hospital. Further, all participants will be informed of the study and will be asked to sign consent forms. We will report according to the Consolidated Standards of Reporting Trials.

TRIAL REGISTRATION NUMBER

UMIN000043396.

The Efficacy of Psychoeducational Family Intervention for Major Depression: Study Protocol of a Randomized Controlled Trial

This study aims to assess the efficacy of a psychoeducational family intervention (PFI) to reduce the severity of depressive symptoms and to improve psychosocial functioning and to increase social contacts in a sample of patients with major depressive disorder (MDD). The degree to which PFI will reduce patients' relapses, hospitalizations, and self-stigmatization and will improve their quality of life will also be assessed. Other secondary outcomes include the improvement of relatives' coping strategies, family burden, expressed emotions and quality of life. This non-profit, unfunded, national, multicentric randomized controlled trial with blinded outcome assessments will be carried out in 24 Italian university outpatient units. Families will be assessed at baseline and at 6, 12, and 24 months post-randomization. Our working hypothesis is that the PFIs will reduce the patients' severity of depressive symptoms, their relapses, and their hospitalizations, and that they will improve their psychosocial functioning and quality of life. We expect these results to be maintained after 12 and 24 months, albeit with a reduction in magnitude. The sample will consist of 384 patients randomized at a 1:1 ratio and stratified according to center, age, gender, and educational level.

The application of cognitive behavioral therapy in patients with schizophrenia: A review

The aim of this review is to explore the clinical nursing application of cognitive behavioral therapy (CBT) in patients with schizophrenia. A literature search was conducted using the CINAHL and MEDLINE databases. The database search occurred during the month of December 2022. This article comprehensively summarizes the theoretical basis of CBT in improving schizophrenia in clinical nursing, its application in managing symptoms and improving social function, as well as research progress in this field. There are still inconsistencies in the research results on CBT, but overall, psychological intervention combined with drug treatment is more effective than conventional treatment alone. If social function training can be added at the same time, it is believed that it will have better effects on clinical treatment and can maintain long-lasting effectiveness. Only in this way can patients truly understand and recognize the disease, improve treatment compliance, and ultimately achieve the goal of improving prognosis and quality of life.

Characterization of an extreme phenotype of schizophrenia among women with homelessness

Background

Studies of schizophrenia and homelessness are often confounded by comorbid substance use. Women with schizophrenia and homelessness in India have very low rates of substance use and provide a unique opportunity to disentangle the effects of illness from that of substance use. We examined the clinical characteristics of women with schizophrenia and homelessness and compared it to an age-matched group of women with schizophrenia living with their family.

Methods

36 women with schizophrenia and homelessness, and 32 women with schizophrenia who were illness living with family were evaluated for psychopathology using Scale for Assessment of Positive Symptoms (SAPS)/ Scale for assessment of negative symptoms (SANS) scales, cognitive difficulties using Montreal Cognitive Assessment (MOCA)/Rowland Universal Dementia Scale (RUDAS), and Frontal Assessment Battery(FAB), disability using World Health Organization - Disability assessment Scale (WHO-DAS) and psychosocial factors using a semi-structured proforma. The groups were compared using t-tests and chi-square for continuous and categorical variables respectively.

Results

Women with schizophrenia and homelessness were found to have significantly higher scores on measures of psychopathology, significantly lower cognitive functioning, and much higher disability, and were also on higher doses of antipsychotics. The mean scores on measures of psychopathology, cognition and disability for women with schizophrenia and homelessness differed by 2-3 standard deviations with the mean for women living with family (i.e. z scores) suggesting that they represented an extreme phenotype. Rates of past employment were higher among women with schizophrenia and homelessness. Hence these differences were not accounted for by premorbid functioning.

Conclusions

The study raises the possibility of an extreme phenotype of schizophrenia with severe and persistent psychopathology non-responsive to dopamine blocking drugs, cognitive impairment, and disability, which needs further exploration.

Hopefulness among individuals living with schizophrenia and their caregivers in Tanzania: an actor-partner interdependence model

BACKGROUND

Hopefulness is a positive orientation or state of mind that can aid in the recovery and treatment of mental illness, as it can have significant impacts on clinical and psychosocial outcomes. As resource-constrained settings work to implement recovery-oriented care, there is a need to better understand hopefulness among people living with schizophrenia (PLWS) and caregivers in their extended family networks. This study seeks to examine the dyadic relationship of hopefulness and its associated correlates among PLWS attending outpatient psychiatric clinics and their caregivers in Tanzania.

METHODS

This study utilized baseline and immediate post-intervention data collected as part of a randomized controlled trial testing a culturally tailored model of Family Psychoeducation, KUPAA, in Tanzania. The Herth Hope Index was used to measure hopefulness among PLWS (n = 33) and their caregivers (n = 33) at baseline and immediate post-intervention. Univariable and multivariable regression models were conducted to determine correlates of hopefulness at baseline, while the Actor-Partner Interdependence Model (APIM) was employed to examine the longitudinal, dyadic relationship of hopefulness among and between PLWS and their caregivers.

RESULTS

Better family functioning was associated with higher levels of hopefulness in PLWS and their caregivers. Lower levels of stigma, lower symptom severity, and lower disability were associated with higher levels of hopefulness in PLWS. For PLWS and their caregivers, actor effects from the APIM model were less than one (PLWS, [Formula: see text]; caregivers, [Formula: see text]), indicating stability (within each person) in hopefulness over time. Regarding partner effects, a caregiver's baseline hopefulness had a positive effect on the hopefulness of their PLWS at follow-up ([Formula: see text]). This indicates that higher caregiver hope at time 0 is associated with higher levels of hope in PLWS at time 1. Baseline hopefulness levels for PLWS had a negative effect on caregivers' hopefulness at follow-up ([Formula: see text]). This suggests that higher hopefulness among PLWS at baseline is associated with lower levels of hope in caregivers at follow-up.

CONCLUSION

Hopefulness is important to consider in family or caregiver-based treatments for PLWS because caregiver hopefulness may influence improvements in hopefulness among PLWS over time. Future studies should further explore the longitudinal dyadic relationship of hopefulness for these populations, as hope is a non-pharmacological and modifiable mechanism of change that is underutilized in care and treatment plans for PLWS globally.

TRIAL REGISTRATION

Clinical Trials #NCT04013932, July 10, 2019.

Sustained specialized and family treatment in first-episode schizophrenia or related disorders: a 5-year randomized controlled trial

BACKGROUND

The long-term outcome of first-episode schizophrenia needs improvement. Here, we evaluate the effectiveness of 5 years sustained specialist treatment (ST), ST including Parent groups (ST + P) or treatment as usual (TAU) on psychotic relapse and social functioning.

METHODS

A three condition randomized, parallel assigned, single-blind efficacy trial, in which 198 first-episode psychosis (FEP) patients aged 15-28 years were included. The effect on time to first relapse, first relapse rates, mean number of relapses per patient, and time to the improvement of social functioning were analyzed using Cox regression or ANOVA.

RESULTS

We found no significant differences between treatment conditions in the ITT analysis concerning time to first relapse, nor first relapse rate. Mean number of relapses per patient differed at a trend level between ST, ST + P or TAU conditions, respectively: 0.72; 0.62 or 1.02 (p = 0.069). No evidence was found for differential effect of treatment conditions on social functioning.

CONCLUSION

Five years sustained ST of FEP nor addition of parent groups increased time to first relapse or reduced first relapse rate, compared to sustained TAU. Indications for favorable effects of parent groups were found on relapses per patient.

Comparative efficacy and acceptability of non-pharmacological interventions for depression among people living with HIV: A protocol for a systematic review and network meta-analysis

BACKGROUND

Improving depression is critical to the success of HIV treatment. Concerns about the adverse effects of pharmacotherapy have led to non-pharmacological treatments for depression in people living with HIV (PLWH) becoming increasingly popular. However, the most effective and acceptable non-pharmacological treatments for depression in PLWH have not yet been determined. This protocol for a systematic review and network meta-analysis aims to compare and rank all available non-pharmacological treatments for depression in PLWH in the global network of countries as well as in the network of low-income and middle-income countries (LMICs) only.

METHODS

We will include all randomized controlled trials of any non-pharmacological treatments for depression in PLWH. The primary outcomes will consider efficacy (the overall mean change scores in depression) and acceptability (all-cause discontinuation). Published and unpublished studies will be systematically searched through the relevant databases (PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL, ProQuest, and OpenGrey), international trial registers, and websites. There is no restriction by language and publication year. All study selection, quality evaluation, and data extraction will be independently conducted by at least two investigators. We will perform a random-effects network meta-analysis to synthesize all available evidence for each outcome and obtain a comprehensive ranking of all treatments for the global network of countries as well as for the network of LMICs only. We will employ validated global and local approaches to evaluate inconsistency. We will use OpenBUGS (version 3.2.3) software to fit our model within a Bayesian framework. We will evaluate the strength of evidence using the Confidence in Network Meta-Analysis (CINeMA) tool, a web application based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

ETHICS AND DISSEMINATION

This study will use secondary data and therefore does not require ethical approval. The results of this study will be disseminated through peer-reviewed publication.

TRIAL REGISTRATION

PROSPERO registration number: CRD42021244230.

Delphi panel to obtain clinical consensus about using long-acting injectable antipsychotics to treat first-episode and early-phase schizophrenia: treatment goals and approaches to functional recovery

BACKGROUND

Schizophrenia is mostly a chronic disorder whose symptoms include psychosis, negative symptoms and cognitive dysfunction. Poor adherence is common and related relapse can impair outcomes. Long-acting injectable antipsychotics (LAIs) may promote treatment adherence and decrease the likelihood of relapse and rehospitalization. Using LAIs in first-episode psychosis (FEP) and early-phase (EP) schizophrenia patients could benefit them, yet LAIs have traditionally been reserved for chronic patients.

METHODS

A three-step modified Delphi panel process was used to obtain expert consensus on using LAIs with FEP and EP schizophrenia patients. A literature review and input from a steering committee of five experts in psychiatry were used to develop statements about patient population, adverse event management, and functional recovery. Recruited Delphi process psychiatrists rated the extent of their agreement with the statements over three rounds (Round 1: paper survey, 1:1 interview; Rounds 2-3: email survey). Analysis rules determined whether a statement progressed to the next round and the level of agreement deemed consensus. Measures of central tendency (mode, mean) and variability (interquartile range) were reported back to help panelists assess their previous responses in the context of those of the overall group.

RESULTS

The Delphi panelists were 17 psychiatrists experienced in treating schizophrenia with LAIs, practicing in seven countries (France, Italy, US, Germany, Spain, Denmark, UK). Panelists were presented with 73 statements spanning three categories: patient population; medication dosage, management, and adverse events; and functional recovery domains and assessment. Fifty-five statements achieved ≥ 80% agreement (considered consensus). Statements with low agreement (40-79%) or very low agreement (< 39%) concerned initiating dosage in FEP and EP patients, and managing loss of efficacy and breakthrough episodes, reflecting current evidence gaps. The panel emphasized benefits of LAIs in FEP and EP patients, with consensus that LAIs can decrease the risk of relapse, rehospitalization, and functional dysfunction. The panel supported links between these benefits and multidimensional longer-term functional recovery beyond symptomatic remission.

CONCLUSIONS

Findings from this Delphi panel support the use of LAIs in FEP and EP schizophrenia patients regardless of disease severity, number of relapses, or social support status. Gaps in clinician knowledge make generating evidence on using LAIs in FEP and EP patients critical.

Culturally adapted psychosocial interventions (CaPSI) for early psychosis in a low-resource setting: study protocol for a large multi-center RCT

BACKGROUND

Psychosis treatment guidelines recommend cognitive behaviour therapy (CBT) and family intervention (FI), for all patients with first episode psychosis (FEP), though guidance borrows heavily from literature in adults from high income countries. To our knowledge, there are few randomized controlled trials (RCTs) examining the comparative effect of these commonly endorsed psychosocial interventions in individuals with early psychosis from high-income countries and no such trials from low and middle-income countries (LMICs). The present study aims to confirm the clinical-efficacy and cost-effectiveness of delivering culturally adapted CBT (CaCBT) and culturally adapted FI (CulFI) to individuals with FEP in Pakistan.

METHOD

A multi-centre, three-arm RCT of CaCBT, CulFI, and treatment as usual (TAU) for individuals with FEP (n = 390), recruited from major centres across Pakistan. Reducing overall symptoms of FEP will be the primary outcome. Additional aims will include improving patient and carer outcomes and estimating the economic impact of delivering culturally appropriate psychosocial interventions in low-resource settings. This trial will assess the clinical-efficacy and cost-effectiveness of CaCBT and CulFI compared with TAU in improving patient (positive and negative symptoms of psychosis, general psychopathology, depressive symptoms, quality of life, cognition, general functioning, and insight) and carer related outcomes (carer experience, wellbeing, illness attitudes and symptoms of depression and anxiety).

CONCLUSIONS

A successful trial may inform the rapid scale up of these interventions not only in Pakistan but other low-resource settings, to improve clinical outcomes, social and occupational functioning, and quality of life in South Asian and other minority groups with FEP.

TRIAL REGISTRATION

NCT05814913.

Built environment and schizophrenia re-hospitalization risk in China: A cohort study

BACKGROUND

Built environment exposure, characterized by ubiquity and changeability, has the potential to be the prospective target of public health policy. However, little research has been conducted to explore its impact on schizophrenia. This study aimed to investigate the association between built environmentand and schizophrenia rehospitalization by simultaneously considering substantial built environmental exposures.

METHODS

We recruited eligible schizophrenia patients from Hefei, Anhui Province, China between 2017 and 2019. The main outcome for this study was the time interval until the first recurrent hospital admission occurred within one year after discharge. For each included subject, we estimated the built environment exposures, including population density, walkability, land use mix, green and blue space, public transportation accessibility and road traffic indicator. Lasso (Least Absolute Shrinkage and Selection Operator) analysis was used to select the key variables. Multivariable Cox regression model was applied to obtain hazard ratio (HR) and its corresponding 95% confidence intervals (CI). Further, we also evaluated the joint effects of built environment characteristics on rehospitalization for schizophrenia by Quantile g-computation model.

RESULTS

A total of 1564 hospitalized schizophrenia patients were enrolled, with 347 patients (22.2%) had a rehospitalization within one-year after discharge. Multivariable Cox regression analysis indicated that the re-hospitalization rate for schizophrenia would be higher in areas with a high population density (HR: 1.10, 95%CI: 1.04-1.16). Nonetheless, compared to the reference (Q1), participants who lived in a neighborhood with the highest walkability and NDVI (Normalized Difference Vegetation Index) (Q4) had a 76% and 47% lower risk of re-hospitalization within one year (HR:0.24, 95%CI: 0.13-0.45; and 0.53, 95%CI:0.32-0.85), respectively. Moreover, quantile-based g-computation analyses revealed that increased walkability and green space significantly eliminated the adverse effects of population density increases on schizophrenia patients, with a HR ratio of 0.61 (95%CI:0.48,0.79) per one quartile change at the same time.

CONCLUSION

Our study provides scientific evidence for the significant role of built environment in schizophrenia rehospitalization, suggesting that optimizing the built environment is required in designing and building a healthy city.

A Patient-Clinician Discussion of Current Challenges in Schizophrenia Part 1: Addressing Daily Functioning and Cognitive Impairments Associated with Schizophrenia [Podcast]

Dr John M. Kane discusses cognitive impairments in schizophrenia with fellow expert Dr Philip D. Harvey and patient advocate and mental health clinician, Mr Carlos A. Larrauri, who was diagnosed with schizophrenia. The podcast aims to raise awareness of the unmet need to address cognitive impairments associated with schizophrenia (CIAS) as well as the challenges/opportunities faced by patients and clinicians regarding assessments and treatments. The authors emphasize the importance of a treatment focus on daily functioning, in parallel with cognitive symptoms, to mitigate impairments and improve overall outcomes. Mr Larrauri presents the patient perspective and shares his experiences of how psychosocial support and cognitive training can benefit recovery and help patients achieve their goals.

Clinicians' perceptions of family involvement in the treatment of persons with psychotic disorders: a nested qualitative study

Background

Family involvement in mental health care ranges from basic practices to complex interventions such as Family psychoeducation, the latter being a well-documented treatment for psychotic disorders. The aim of this study was to explore clinicians' perceptions of the benefits and disadvantages of family involvement, including possible mediating factors and processes.

Methods

Nested in a randomised trial, which purpose was to implement Basic family involvement and support and Family psychoeducation in Norwegian community mental health centres during 2019-2020, this qualitative study is based on eight focus groups with implementation teams and five focus groups with ordinary clinicians. Using a purposive sampling strategy and semi-structured interview guides, focus groups were audio-recorded, transcribed verbatim, and analysed with reflexive thematic analysis.

Results

Four main themes were identified as perceived benefits: (1) Family psychoeducation-a concrete framework, (2) Reducing conflict and stress, (3) A triadic understanding, and (4) Being on the same team. Themes 2-4 formed an interconnected triad of mutually reinforcing elements and were further linked to three important clinician-facilitated sub-themes: a space for relatives' experiences, emotions and needs; a space for patients and relatives to discuss sensitive topics and an open line of communication between clinician and relative. Although far less frequent, three main themes were identified as perceived disadvantages or challenges: (1) Family psychoeducation-occasional poor model fit or difficulties following the framework, (2) Getting more involved than usual, and (3) Relatives as a potentially negative influence-important nonetheless.

Conclusions

The findings contribute to the understanding of the beneficial processes and outcomes of family involvement, as well as the critical role of the clinician in achieving these and possible challenges. They could also be used to inform future quantitative research on mediating factors and implementation efforts.

The Patient Journey of Schizophrenia in Mental Health Services: Results from a Co-Designed Survey by Clinicians, Expert Patients and Caregivers

BACKGROUND

The Patient Journey Project aims to collect real-world experiences on schizophrenia management in clinical practice throughout all the phases of the disorder, highlighting virtuous paths, challenges and unmet needs.

METHODS

A 60-item survey was co-designed with all the stakeholders (clinicians, expert patients and caregivers) involved in the patient's journey, focusing on three areas: early detection and management, acute phase management and long-term management/continuity of care. For each statement, the respondents expressed their consensus on the importance and the degree of implementation in clinical practice. The respondents included heads of the Mental Health Services (MHSs) in the Lombardy region, Italy.

RESULTS

For early diagnosis and management, a strong consensus was found; however, the implementation degree was moderate-to-good. For acute phase management, a strong consensus and a good level of implementation were found. For long-term management/continuity of care, a strong consensus was found, but the implementation level was slightly above the cut-off, with 44.4% of the statements being rated as only moderately implemented. Overall, the survey showed a strong consensus and a good level of implementation.

CONCLUSIONS

The survey offered an updated evaluation of the priority intervention areas for MHSs and highlighted the current limitations. Particularly, early phases and chronicity management should be further implemented to improve the patient journey of schizophrenia patients.

Neurological Soft Signs in Schizophrenia, a Picture of the Knowledge in the Last Decade: A Scoping Review

(1) Background: Neurological Soft Signs (NSS) are subtle neurological abnormalities that are more common in schizophrenia patients than in healthy individuals and have been regularly observed in neuroleptic-naive first-episode patients, supporting the hypothesis that they are an intrinsic component of schizophrenia. (2) Methods: a review of articles published in the last ten years (from January 2013 to January 2023) was carried out on articles published in ScienceDirect and PubMed, by following the PRISMA Statement extension for scoping reviews (PRISMA-ScR), which evaluated the impact of NSS in correlation with the symptomatology, neuroleptic treatment, and the cerebral structural changes of patients with schizophrenia. (3) Results: thirty articles were included, among them twelve included MRI structural evaluation and four studies with a longitudinal design. (4) Conclusions: interest in researching NSS has increased in recent years, but questions remain about their origin and relationship to schizophrenia symptoms, thus this study aims to fill in information gaps in the hope that future research will help provide individualized treatment. It is suggested that NSS in schizophrenia might have an inherited genetic relationship pattern, thus being in line with a trait viewpoint. Most of the research revealed that schizophrenia patients had higher NSS scores than healthy controls, however, they were rather similar to their first-degree relatives, thus, also arguing in favor of a trait perspective. The greatest improvement in scores is seen in those with a remitting course, as shown by declining NSS ratings concurrent with symptomatology.

"The most important thing is that those closest to you, understand you": a nested qualitative study of persons with psychotic disorders' experiences with family involvement

Introduction

Family interventions constitute effective treatment for persons with psychotic disorders. However, the active ingredients and beneficial processes of these interventions are insufficiently examined, and qualitative explorations of patients` experiences are lacking. This study was nested in a cluster randomised trial that implemented national guidelines on family involvement in Norwegian community mental health centres, including family psychoeducation and basic family involvement and support. The aim of this sub-study was to explore how patients with psychotic disorders experience systematic family involvement, and its significance.

Methods

We conducted semi-structured, individual interviews with 13 persons with a psychotic disorder after systematic family involvement. The participants were recruited through purposive sampling. Qualitative content analysis guided the analysis.

Results

Participants reported overall positive experiences with systematic family involvement. It was significant that the relatives increasingly understood more about psychosis and their situation, while they themselves also gained more insight into the relatives` situation. The participants emphasised the need to enable both patients and relatives to safely share experiences in a containing space, led by professionals. Shared understanding and awareness of each other's situation further improved communication, coping with the illness, reduced stress, and stimulated a more caring family environment. The therapist seemed crucial to facilitate these beneficial communication processes, and also to provide continuous support to the relatives. Reported challenges included that the participants felt vulnerable in the initial phase, a need for tailored approaches, and too late start-up.

Conclusion

Findings from this study suggest that persons with psychotic disorders may benefit greatly from participating in systematic family involvement. This study also gives new insight into possible mediators of positive outcomes both for the patients and the relatives. Systematic family involvement should be implemented a standard approach in the early phase of the disease, using a step-wise and tailored process.

Implementation of Guidelines on Family Involvement for Persons with Psychotic Disorders (IFIP): A Cluster Randomised Controlled Trial

Family involvement is part of the evidence-based treatment for persons with psychotic disorders, yet is under-implemented despite guideline recommendations. This study assessed whether an implementation support programme increased the adherence to guidelines on family involvement, compared to guideline/manual only. In a cluster randomised design, community mental health centre units in South-East Norway went through stratified allocation to the experimental (n = 7) or control (n = 7) arm. Experimental clusters received an implementation support programme including clinical training and supervision, appointing a family coordinator and an implementation team, a toolkit, and fidelity measurements at baseline, 12, 18, and 24 months with on-site feedback and supervision. Control clusters received no such support and had fidelity measurements at baseline and 24 months without feedback. During fidelity measurements, adherence to the guidelines was measured with the basic family involvement and support scale, the general organizational index, and the family psychoeducation fidelity scale, the latter being the primary outcome. The scales consist of 12-14 items rated from 1 to 5. Data was analysed with an independent samples t-test, linear mixed models, and a tobit regression model. At 24 months, the mean scores were 4.00 or higher on all scales in the experimental arm, and the increase in adherence to the guidelines was significantly greater than in the control arm with p-values < 0.001. Large-scale implementation of guidelines on family involvement for persons with psychotic disorders in community mental health centres may be accomplished, with substantial implementation support.Trial Registration: ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

Dementia among older people with schizophrenia: an update on recent studies

PURPOSE OF REVIEW

This narrative review examines recently published research that examines the prevalence, underlying causes, and treatments for dementia among people with schizophrenia.

RECENT FINDINGS

People with schizophrenia have high rates of dementia, compared with the general population, and cognitive decline has been observed 14 years prior to onset of psychosis with accelerated decline in middle age. Underlying mechanisms of cognitive decline in schizophrenia include low cognitive reserve, accelerated cognitive aging, cerebrovascular disease and medication exposure. Although pharmacologic, psychosocial and lifestyle interventions show early promise for preventing and mitigating cognitive decline, few studies have been conducted in older people with schizophrenia.

SUMMARY

Recent evidence supports accelerated cognitive decline and brain changes in middle-aged and older people with schizophrenia, relative to the general population. More research in older people with schizophrenia is needed to tailor existing cognitive interventions and develop novel approaches for this vulnerable and high-risk group.

Clinical Recovery and Long-Term Association of Specialized Early Intervention Services vs Treatment as Usual Among Individuals With First-Episode Schizophrenia Spectrum Disorder: 20-Year Follow-up of the OPUS Trial

Importance

The OPUS 20-year follow-up is the longest follow-up of a randomized clinical trial testing early intervention services (EIS) among individuals with first-episode schizophrenia spectrum disorder.

Objective

To report on long-term associations of EIS compared with treatment as usual (TAU) for first-episode schizophrenia spectrum disorder.

Design, Setting, and Participants

A total of 547 individuals were included in this Danish multicenter randomized clinical trial between January 1998 and December 2000 and allocated to early intervention program group (OPUS) or TAU. Raters who were blinded to the original treatment performed the 20-year follow-up. A population-based sample aged 18 to 45 years with first-episode schizophrenia spectrum disorder were included. Individuals were excluded if they were treated with antipsychotics (>12 weeks prior to randomization), had substance-induced psychosis, had mental disability, or had organic mental disorders. Analysis took place between December 2021 and August 2022.

Interventions

EIS (OPUS) consisted of 2 years of assertive community treatment including social skill training, psychoeducation, and family involvement by a multidisciplinary team. TAU consisted of the available community mental health treatment.

Main Outcomes and Measures

Psychopathological and functional outcomes, mortality, days of psychiatric hospitalizations, number of psychiatric outpatient contacts, use of supported housing/homeless shelters, symptom remission, and clinical recovery.

Results

Of 547 participants, 164 (30%) were interviewed at 20-year follow-up (mean [SD] age, 45.9 [5.6] years; 85 [51.8%] female). No significant differences were found between the OPUS group compared with the TAU group on global functional levels (estimated mean difference, -3.72 [95% CI, -7.67 to 0.22]; P = .06), psychotic symptom dimensions (estimated mean difference, 0.14 [95% CI, -0.25 to 0.52]; P = .48), and negative symptom dimensions (estimated mean difference, 0.13 [95% CI, -0.18 to 0.44]; P = .41). The mortality rate was 13.1% (n = 36) in the OPUS group and 15.1% (n = 41) in the TAU group. Likewise, no differences were found 10 to 20 years after randomization between the OPUS and TAU groups on days of psychiatric hospitalizations (incidence rate ratio, 1.20 [95% CI, 0.73-1.20]; P = .46) or number of outpatient contacts (incidence rate ratio, 1.20 [95% CI, 0.89-1.61]; P = .24). Of the entire sample, 53 participants (40%) were in symptom remission and 23 (18%) were in clinical recovery.

Conclusions and Relevance

In this follow-up study of a randomized clinical trial, no differences between 2 years of EIS vs TAU among individuals with diagnosed schizophrenia spectrum disorders at 20 years were found. New initiatives are needed to maintain the positive outcomes achieved after 2 years of EIS and furthermore improve very long-term outcomes. While registry data was without attrition, interpretation of clinical assessments are limited by high attrition rate. However, this attrition bias most likely confirms the lack of an observed long-term association of OPUS with outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT00157313.

Approach to schizophrenia

Schizophrenia is the most common of a group of psychotic disorders that occur in approximately 3% of the population over the lifespan. It has clear genetic antecedents, which are shared across the spectrum of psychotic disorders; however, a range of other biological and social factors influence the onset and treatment of the disorder. Schizophrenia is diagnosed by a characteristic set of symptoms (positive, negative, disorganisation, cognitive and affective) accompanied by a functional decline. Investigations are used to exclude other organic causes of psychosis and to provide a baseline for the negative effects of pharmacological treatments. Treatment requires a combination of pharmacological and psychosocial interventions. Physical health is poor in this group of people and this is not helped by inconsistent care from health services. Although earlier intervention has improved the immediate outcomes, the longer-term outcome has not significantly shifted.

Intersectoral and multisectoral approaches to enable recovery for people with severe mental illness in low- and middle-income countries: A scoping review

The needs of people with severe mental illness are complex and require a range of services embedded in well-coordinated systems of care to enable recovery, promote well-being and optimise social integration. The concept of recovery is strongly rooted in the centrality of multi and intersectoral systems of care, and, while multi and -intersectoral dimensions of mental health systems have been highlighted in analyses focusing on high-income regions, little has been elaborated in terms of these approaches in the recovery of people with severe mental illness (SMI) in low- and middle-income countries (LMICs). The aim of this review was to identify and describe multi and intersectoral approaches underpinning community-based SMI recovery interventions in LMICs. A scoping review was carried out following the following steps: (1) Objectives for the review were developed and refined; (2) A systematic search of databases (EbscoHost, PubMed, Google Scholar) and previous reviews were undertaken from 2012 to 2022, where relevant papers were identified; (3) Papers with a focus on SMI and recovery, a specific description of an intervention, located in LMICs, with explicit linkages between sectors, and published in English, were selected for inclusion; (4) Data were extracted and charted and (5) Findings were analysed and reported thematically. Thirty-six papers were included for analysis, from 18 countries, including qualitative studies, trials, desktop and secondary data reviews and case studies. Examples of multi- and intersectoral action included collaboration between healthcare and community support systems, collaboration in providing supported housing and supportive community spaces for recovery, and linkages between biomedical and social spheres of care. Barriers included the dominance of mental health professions in delivering care, community-based stigmatising attitudes towards SMI. Multi- and intersectoral collaboration for SMI recovery requires investments in financing, education and coordination by a governing body.

Psychotic disorders as a framework for precision psychiatry

People with psychotic disorders can show marked interindividual variations in the onset of illness, responses to treatment and relapse, but they receive broadly similar clinical care. Precision psychiatry is an approach that aims to stratify people with a given disorder according to different clinical outcomes and tailor treatment to their individual needs. At present, interindividual differences in outcomes of psychotic disorders are difficult to predict on the basis of clinical assessment alone. Therefore, current research in psychosis seeks to build models that predict outcomes by integrating clinical information with a range of biological measures. Here, we review recent progress in the application of precision psychiatry to psychotic disorders and consider the challenges associated with implementing this approach in clinical practice.

Real-world calibration and transportability of the Disease Recovery Evaluation and Modification (DREaM) randomized clinical trial in adult Medicaid beneficiaries with recent-onset schizophrenia

BACKGROUND: The Disease Recovery Evaluation and Modification study (DREaM; NCT02431702) assessed the benefit of initiating paliperidone palmitate (PP), a long-acting injectable antipsychotic, in patients with recent-onset schizophrenia or schizophreniform disorder. OBJECTIVE: To determine whether reductions in psychiatric hospitalizations with early initiation of PP vs oral antipsychotic (OAP) therapy observed in a DREaM post hoc analysis are transportable to a real-world population of patients with recent-onset schizophrenia. METHODS: Patients enrolled in DREaM were randomized to receive OAP or PP for 9 months, after which OAP recipients were re-randomized to receive OAP or PP for another 9 months. We used this design to form treatment arms: OAP-OAP, OAP-PP, and PP-PP. Inclusion/exclusion criteria were used to identify a Medicaid Managed Care (MMC) OAP-treated cohort of 1,000 patients diagnosed with schizophrenia using IBM Truven databases from 2015 to 2019. The MMC cohort was combined with the subset of patients diagnosed with schizophrenia enrolled in DREaM from US sites (N = 45, 43, and 44 for OAP-OAP, OAP-PP, and PP-PP, respectively). Propensity scores for the MMC cohort were estimated using baseline variables identified via double-lasso regression. Estimated propensity scores were used to weight psychiatric hospitalizations in the DREaM OAP-OAP group and compared with observed MMC OAP cohort psychiatric hospitalizations. After the successful calibration of the DREaM OAP-OAP group, similar approaches were taken for the OAP-PP and PP-PP groups to transport DREaM effects to MMC data. RESULTS: Standardized mean differences in baseline covariates between DREaM treatment arms and MMC groups were substantially reduced after calibration. The 18-month cumulative numbers of psychiatric hospitalizations per patient (SE) were 0.83 (0.14) for the MMC cohort, 0.43 (0.14) for the unweighted OAP-OAP, and 0.80 (0.37) for the calibrated OAP-OAP. The difference between the calibrated OAP-OAP and MMC was not statistically significant (difference, 0.03 [95% CI = -0.67 to 0.81]), indicating successful calibration. The mean difference in 18-month cumulative psychiatric hospitalizations relative to the MMC cohort was -0.77 (95% CI = -1.08 to -0.47) for OAP-PP and -0.83 (95% CI = -1.15 to -0.60) for PP-PP. CONCLUSIONS: Our study demonstrates that results from the DREaM OAP-OAP group reflect psychiatric hospitalizations in a real-world population when calibrated using specific baseline characteristics. Transporting the DREaM effects, we find that using OAP-PP and PP-PP treatment strategies for patients with recent-onset schizophrenia in the MMC population could reduce psychiatric hospitalizations compared with the use of OAP. These findings, along with the potential reduction in associated costs, should be considered when assessing the value of PP formulations. DISCLOSURES: Dr Basu reports consulting fees through Salutis Consulting LLC related to this work. Dr Mavros is a former employee of the Janssen Pharmaceutical Companies of Johnson & Johnson, Inc, and holds stock in the company. Ms Benson, Dr Fu, Ms Patel, and Dr Brown are employees of Janssen Scientific Affairs, LLC, and hold stock in Johnson & Johnson. This research was funded by Janssen Scientific Affairs, LLC. The sponsor was involved in the study design; collection, analysis, and interpretation of data; and development and review of the manuscript. All authors had full access to the study data and take responsibility for data integrity and the accuracy of the analyses. All authors provided direction and comments on the manuscript, reviewed and approved the final version prior to submission, made the final decision about where to publish these data, and approved submission to this journal.

[Current evidence for various inpatient psychotherapy programs in the treatment of psychoses-A narrative review article]

BACKGROUND

The analysis of the efficacy of evidence-based psychotherapy for patients with psychotic disorders has mostly been carried out in the outpatient field. In the inpatient field the efficacy is sometimes difficult to assess due to different healthcare systems.

OBJECTIVE

The aim of this narrative review is to summarize international guidelines and meta-analyses on the efficacy of inpatient psychotherapeutic treatment strategies for patients with psychotic disorders. Based on this, recommendations for disorder-specific ward concepts for acute and postacute fields are formulated.

METHODS

The German S3 guidelines, international guidelines, current meta-analyses and primary studies on psychological interventions in the treatment of psychotic disorders were included. Based on the results, recommendations for the inpatient psychotherapeutic treatment in various phases of treatment were formulated (acute phase and postacute phase).

RESULTS

In the acute phase a combination of cognitive behavioral therapy (CBTp) in the individual setting and family interventions in the group setting as well as metacognitive training (MCT acute) is effective and recommended. In the postacute phase, in addition to individual and group CBTp and family interventions, psychoeducation, social skills training and cognitive remediation have been shown to be effective and are recommended.

DISCUSSION

The suggested recommendations for concrete interventions in various treatment phases and the evidence base are critically discussed and recommendations for the structure of wards are presented.

Comparative efficacy and acceptability of non-pharmacological interventions for depression in people living with HIV: A systematic review and network meta-analysis

BACKGROUND

Treatment for depression in people living with HIV has increasingly turned to non-pharmacological treatments due to the adverse reactions of pharmacotherapy. However, it remains unclear which non-pharmacological treatment is the most effective and acceptable for depression in people living with HIV.

OBJECTIVE

To compare and rank the efficacy and acceptability of different non-pharmacological treatments for depression in people living with HIV.

DESIGN

A systematic review and Bayesian network meta-analysis.

METHODS

We systematically searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, PsycArticles, CINAHL, ProQuest, OpenGrey, and international trial registers for published and unpublished studies from their inception to September 1, 2022, and searched key conference proceedings from January 1, 2020, to September 25, 2022. We searched for randomized controlled trials of any non-pharmacological treatments for depression in adults living with HIV (≥18 years old). Primary outcomes were efficacy (mean change scores in depression) and acceptability (all-cause discontinuation). We used a random-effects network meta-analysis model to synthesize all available evidence. The methodological quality of the included studies was assessed using the Cochrane Collaboration Risk of Bias Tool. We registered this study in PROSPERO, number CRD42021244230.

RESULTS

A total of 53 randomized controlled trials were included in this network meta-analysis involving seven non-pharmacological treatments for depression in people living with HIV. For efficacy, mind-body therapy, interpersonal psychotherapy, cognitive-behavioral therapy, supportive therapy, and education were significantly more effective than most control conditions (standardized mean differences ranged from -0.96 to -0.36). Rankings probabilities indicated that mind-body therapy (79%), interpersonal psychotherapy (71%), cognitive-behavioral therapy (62%), supportive therapy (57%), and education (57%) might be the top five most significantly effective treatments for depression in people living with HIV, in that order. For acceptability, only supportive therapy and interpersonal psychotherapy were significantly less acceptable than most control conditions (odds ratios ranged from 1.92 to 3.43). Rankings probabilities indicated that education might be the most acceptable treatment for people living with HIV (66%), while supportive therapy (26%) and interpersonal psychotherapy (10%) might rank the worst. The GRADE assessment results suggested that most results were rated as "moderate" to "very low" for the confidence of evidence.

CONCLUSIONS

Our study confirmed the efficacy and acceptability of several non-pharmacological treatments for depression in people living with HIV. These results should inform future guidelines and clinical decisions for depression treatment in people living with HIV.

The Structure of Temperament in Caregivers of Patients with Schizophrenia

The onset of schizophrenia symptoms usually occurs in early youth. As a result, the parents of these patients usually become their caregivers. The role of a caregiver for a person with schizophrenia is a considerable mental and physical burden. Therefore, an interesting issue is what motivates these people to take up this challenge. It is probable that, apart from the moral imperative or kinship, the factor determining this decision is the personality structure of the caregiver. The aim of our study was to compare the structure of temperament (according to the model of temperament as formal characteristics of behavior developed by Jan Strelau) in caregivers of young adults (age 18-25 years) with schizophrenia with the structure of temperament of parents of healthy young adults still living in the family home under their care. The study group consisted of 64 people (51 women), who were taking care of young adults (aged 18-25 years) with schizophrenia, while the control group (53 people, 42 women) consisted of parents of healthy adults still living in the family home. Both groups were asked to complete a questionnaire of the authors' own design on their demographic data as well as The Formal Characteristics of Behavior-Temperament Inventory to assess the temperament traits. The results were given in the number of points obtained on average in each dimension. Both groups did not differ in terms of size and age, with women predominating. Caregivers of young adults with schizophrenia had higher values of briskness (43.22 ± 4.45 vs. 42.90 ± 3.98, p = 0.032), emotional reactivity (46.02 ± 4.39 vs. 41.01 ± 3.12, p = 0.012) and activity level (44.01.89 ± 4.15 vs. 37.59 ± 4.77, p = 0.022) compared to the control group. The remaining dimensions of temperament: perseverance, sensory sensitivity, rhythmicity, and endurance did not differentiate between the two groups. The temperament structure of caregivers of young people with schizophrenia differs from the temperament structure of caregivers of healthy adults. Caregivers of sick people have higher values of briskness, emotional reactivity, and activity level compared to the control group.

Psychiatric rehabilitation patterns in Italy: Results from the Italian Society of Psychosocial Rehabilitation (SIRP) survey

INTRODUCTION

Psychiatric rehabilitation can be considered a bidirectional technique, designed to allow patients to achieve their personal target, focusing on the individuals' strengths and challenges related to these targets and also on the community organizations in which they will live them out. Unfortunately, psychiatric rehabilitation is too often not considered a first line treatment. Moreover, rehabilitation has been confused with a generic and rough practice, consisting of extemporary actions and aimless entertainments designed to fill "the time passing".

METHODS

The aim of this study was to increase the knowledge and awareness about the state of the art of different systems of management and funding of psychosocial rehabilitation in the Italian "real-world" rehabilitative settings, using a specifically developed questionnaire.

RESULTS

The data obtained are positive for some aspects of the rehabilitation interventions, in particular for the use of validated tools for the evaluation and revision of projects and for the trend to work on a team, even though the scarcity of evidence-based rehabilitation interventions applied in Italian psychiatric services is less encouraging.

CONCLUSION

This survey presents, at least partially, the "real-world" of rehabilitation in Italy so that we can lay the foundations for the definition of an updated, validated and shared network of what is implemented in the context of psychiatric rehabilitation.

Efficacy and acceptability of psychosocial interventions in schizophrenia: systematic overview and quality appraisal of the meta-analytic evidence

Psychosocial interventions are recommended in schizophrenia and first-episode psychosis/early psychosis (EP). Nevertheless, literature is heterogeneous and often contradictory. We conducted an umbrella review of (network) meta-analyses of randomized controlled trials (RCTs) comparing psychosocial interventions vs treatment as usual (TAU)/active interventions(ACTIVE)/MIXED controls. Primary outcome was total symptoms (TS); secondary outcomes were positive/negative/depressive symptoms (PS/NS/DS), cognition, functioning, relapse, hospitalization, quality of life (QoL), treatment discontinuation. Standardized mean difference (SMD)/odds ratio (OR)/risk ratio (RR) vs TAU/ACTIVE/MIXED were summarized at end-of-treatment (EoT)/follow-up (FU). Quality was rated as high/medium/low (AMSTAR-PLUS). Eighty-three meta-analyses were included (RCTs = 1246; n = 84,925). Against TAU, regarding TS, Early Intervention Services (EIS) were superior EoT/FU in EP (SMD = -0.32/-0.21), cognitive behavioral therapy (CBT) in schizophrenia EoT/FU (SMD = -0.38/-0.19). Regarding secondary outcomes, in EP, EIS were superior for all outcomes EoT except cognition, and at FU for PS/NS/QoL, specific family interventions (FI-s) prevented relapse EoT; in schizophrenia, superiority emerged EoT for CBT for PS/NS/relapse/functioning/QoL; psychoeducation (EDU)/any FI for relapse; cognitive remediation therapy (CRT) for cognition/functioning; and hallucination-focused integrative treatment for PS. Against ACTIVE, in EP, mixed family interventions (FI-m) were superior at FU regarding TS (SMD = -0.61) and for functioning/relapse among secondary outcomes. In schizophrenia, regarding TS, mindfulness and social skills training (SST) were superior EoT, CBT at FU; regarding secondary outcomes superiority emerged at EoT for computerized cognitive drill-and-practice training for PS/DS, CRT for cognition/functioning, EDU for relapse, individual placement and support (IPS) for employment; and at FU CBT for PS/NS. Against MIXED, in schizophrenia, CRT/EDU were superior for TS EoT (d = -0.14/SMD = -0.33), CRT regarding secondary outcomes EoT for DS/social functioning, both EoT/FU for NS/cognition/global functioning; compensatory cognitive interventions for PS/functioning EoT/FU and NS EoT; CBT for PS at FU, and EDU/SST for relapse EoT. In conclusion, mental health services should consider prioritizing EIS/any FI in EP and CBT/CRT/any FI/IPS for schizophrenia, but other interventions may be helpful for specific outcomes.

Schizophrenia: One Name, Many Different Manifestations

Schizophrenia is a disabling condition impacting approximately 1% of the worldwide population. Symptoms include positive symptoms (eg, hallucinations, delusions), negative symptoms (eg, avolition, anhedonia), and cognitive impairment. There are likely many different environmental and pathophysiologic etiologies involving distinct neurotransmitters and neurocircuits. Pharmacologic treatment at present consists of dopamine receptor antagonists, which are reasonably effective at treating positive symptoms, but less effective at treating cognitive and negative symptoms. Nondopaminergic medications targeting alternative receptors are under investigation. Supportive psychosocial treatments can work in tandem with antipsychotic medications and optimize patient care.

Network Analysis of the Structure of the Core Symptoms and Clinical Correlates in Comorbid Schizophrenia and Gambling Disorder

Few studies have analyzed the clinical profile of treatment-seeking patients with the comorbid presence of schizophrenia (SCZ) and gambling disorder (GD), which warrants new research to assess the network structure of this complex mental condition. The aim of this study was to explore the organization of the symptoms and other clinical correlates of SCZ with GD. Network analysis was applied to a sample of N = 179 SCZ patients (age range: 19-70 years, mean=39.5, SD=9.9) who met clinical criteria for gambling disorder-related problems. Variables included in the network were the core GD symptoms according to the DSM-5, psychotic and paranoid ideation levels, global psychological distress, GD severity measures (debts and illegal behavior related with gambling), substances (tobacco, alcohol, and illegal drugs), and personality profile. The nodes with the highest authority in the network (variables of highest relevance) were personality traits and psychological distress. Four empirical modules/clusters were identified, and linkage analysis identified the nodes with the highest closeness (bridge nodes) to be novelty seeking and reward dependence (these traits facilitate the transition between the modules). Identification of the variables with the highest centrality/linkage can be particularly useful for developing precise management plans to prevent and treat SCZ with GD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11469-022-00983-y.

The duty of confidentiality during family involvement: ethical challenges and possible solutions in the treatment of persons with psychotic disorders

BACKGROUND

Family involvement during severe mental illness is still poorly implemented, contrary to evidence-based recommendations. Confidentiality issues are among the most prominent barriers, with mental health professionals facing complex ethical, legal, and practical challenges. However, research focusing on this barrier is very sparse. Nested within a cluster-randomised trial to implement guidelines on family involvement for persons with psychotic disorders in community mental health centres, the aim of this sub-study was to explore ethical challenges related to the duty of confidentiality as experienced by mental health professionals, and to explore key measures that might contribute to improving the handling of such challenges.

METHODS

In total 75 participants participated in 21 semi-structured focus groups, including implementation team members at the initial and late phase of the intervention period and clinicians who were not on the implementation teams, at late phase of implementation. We used purposive sampling and manifest content analysis to explore participants' experiences and change processes.

RESULTS

Ethical challenges related to the duty of confidentiality included 1) Uncertainty in how to apply the legislation, 2) Patient autonomy versus a less strict interpretation of the duty of confidentiality, 3) Patient alliance and beneficence versus a less strict interpretation of the duty of confidentiality, 4) How to deal with uncertainty regarding what relatives know about the patients' illness, and 5) Relatives' interests versus the duty of confidentiality. Measures to facilitate better handling of the duty of confidentiality included 1) Training and practice in family involvement, and 2) Standardisation of family involvement practices.

CONCLUSION

When health professionals gained competence in and positive experiences with family involvement, this led to vital changes in how they interpreted and practiced the duty of confidentiality in their ethical reasoning and in clinical practice. Especially, the need to provide sufficient information to the patients about family involvement became evident during the study. To improve the handling of confidentiality issues, professionals should receive training in family involvement and confidentiality statutes followed by practice. Furthermore, family involvement should be standardised, and confidentiality guidelines should be implemented in the mental health services.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

Effects of psychological treatments on functioning in people with Schizophrenia: a systematic review and meta-analysis of randomized controlled trials

Functioning is recognized as a key treatment goal in alleviating the burden of schizophrenia. Psychological interventions can play an important role in improving functioning in this population, but the evidence on their efficacy is limited. We therefore aimed to evaluate the effect of psychological interventions in functioning for patients with schizophrenia. To conduct this systematic review and meta-analysis, we searched for published and unpublished randomized controlled trials (RCTs) in EMBASE, MEDLINE, PsycINFO, BIOSIS, Cochrane Library, WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and the Study register of the Cochrane Schizophrenia Group. The outcome functioning was measured with validated scales. We performed random-effects pairwise meta-analysis to calculate standardized mean differences (SMDs) with 95% confidence intervals (CIs). We included 58 RCTs (5048 participants). Psychological interventions analyzed together (SMD =  - 0.37, 95% CI  - 0.49 to  - 0.25), cognitive behavioral therapy (30 RCTs, SMD =  - 0.26, 95% CI  - 0.39 to  - 0.12), and third wave cognitive-behavioral therapies (15 RCTs, SMD =  - 0.60, 95% CI  - 0.83 to  - 0.37) were superior to control in improving functioning, while creative therapies (8 RCTs, SMD = 0.01, 95% CI  - 0.38 to 0.39), integrated therapies (4 RCTs, SMD =  - 0.21, 95% CI  - 1.20 to 0.78) and other therapies (4 RCTs, SMD =  - 0.74, 95% CI  - 1.52 to 0.04) did not show a benefit. Psychological interventions, in particular cognitive behavioral therapy and third wave cognitive behavioral therapies, have shown a therapeutic effect on functioning. The confidence in the estimate was evaluated as very low due to risk of bias, heterogeneity and possible publication bias.

Research in eating disorders: the misunderstanding of supposing serious mental illnesses as a niche specialty

PURPOSE

Eating disorders (EDs) are mental illnesses with severe consequences and high mortality rates. Notwithstanding, EDs are considered a niche specialty making it often difficult for researchers to publish in high-impact journals. Subsequently, research on EDs receives less funding than other fields of psychiatry potentially slowing treatment progress. This study aimed to compare research vitality between EDs and schizophrenia focusing on: number and type of publications; top-cited articles; geographical distribution of top-ten publishing countries; journal distribution of scientific production as measured by bibliometric analysis; funded research and collaborations.

METHODS

We used the Scopus database, then we adopted the Bibliometrix R-package software with the web interface app Biblioshiny. We included in the analyses 1,916 papers on EDs and 6491 on schizophrenia.

RESULTS

The ED field published three times less than schizophrenia in top-ranking journals - with letters and notes particularly lacking-notwithstanding a comparable number of papers published per author. Only 50% of top-cited articles focused on EDs and a smaller pool of journals available for ED research (i.e., Zones 1 and 2 according to Bradford's law) emerged; journals publishing on EDs showed an overall lower rank compared to the schizophrenia field. Schizophrenia research was more geographically distributed and more funded; in contrast, a comparable collaboration index was found between the fields.

CONCLUSION

These data show that research on EDs is currently marginalized and top-rank journals are seldom achievable by researchers in EDs. Such difficulties in research dissemination entail potentially serious repercussions on clinical advancements.

LEVEL OF EVIDENCE

Level V: opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Chronic Use of Antipsychotics in Schizophrenia: Are We Asking the Right Question?

There is an ongoing debate about the potential risks and benefits of long-term antipsychotic treatment in schizophrenia. The data for and against the chronic use of these medicines is mostly indirect, either from observational studies potentially exposed to reverse causation bias or randomized controlled studies that do not cover beyond 2–3 years. We propose that perseverating on the question of what positive or negative outcomes are causally associated with chronic antipsychotic treatment may not lead to better answers than the limited ones that we have, given the limited feasibility of more conclusive studies. Rather, we argue that addressing the research question of the risks and benefits of antipsychotic discontinuation from a perspective of personalized medicine, can be more productive and meaningful to people living with schizophrenia. To this end, research that can quantify the risk of relapse after treatment continuation for a given individual should be prioritized. We make the case that clinically feasible neuroimaging biomarkers have demonstrated promise in related paradigms, and that could be offering a way past this long debate on the risks and benefits of chronic antipsychotic use.

Art therapy as an adjuvant treatment for schizophrenia: A protocol for an updated systematic review and subgroup meta-analysis of randomized clinical trials following the PRISMA guidelines

BACKGROUND

The efficacy of art therapy as an adjuvant treatment for schizophrenia remains inconclusive, and variation in the effects of art therapy on schizophrenia by the type of schizophrenia, severity of schizophrenia, type of art therapy, follow-up duration, or different populations has never been systematically assessed. The objective of this study is to systematically evaluate the effects of art therapy on schizophrenia and to determine whether there are some potential influencing factors affecting the effects of art therapy.

METHODS

Seven online databases will be searched from their inception until June 30, 2022. All the relevant randomized clinical trials (RCTs) comparing art therapy plus standardized treatment versus standardized treatment alone for schizophrenia will be selected and assessed for inclusion. The Cochrane risk-of-bias tool will be used to evaluate the methodological quality of the included RCTs. Review Manager 5.4 will be used to analyze all the data obtained. Mental health symptoms are defined as the primary outcome, and the secondary outcomes include the Global Assessment of Functioning score, quality of life, functional remission, and the level of self-esteem. Subgroup analyses will be performed based on the type of schizophrenia, severity of schizophrenia, type of art therapy, follow-up duration, or different populations.

RESULTS

The results will be published in a peer-reviewed journal.

CONCLUSIONS

This updated systematic review and subgroup meta-analysis will evaluate the effects of art therapy as adjunctive treatment to standardized treatment in patients with schizophrenia and determine whether there are some potential confounding variables affecting the effects of art therapy on the outcomes of schizophrenia patients, thus strengthening the evidence base for the clinical application of this combination therapy for schizophrenia.

Barriers and facilitators when implementing family involvement for persons with psychotic disorders in community mental health centres - a nested qualitative study

Background

The uptake of family involvement in health care services for patients with psychotic disorders is poor, despite a clear evidence base, socio-economic and moral justifications, policy, and guideline recommendations. To respond to this knowledge-practice gap, we established the cluster randomised controlled trial: Implementation of guidelines on Family Involvement for persons with Psychotic disorders in community mental health centres (IFIP). Nested in the IFIP trial, this sub-study aims to explore what organisational and clinical barriers and facilitators local implementation teams and clinicians experience when implementing family involvement in mental health care for persons with psychotic disorders.

Methods

We performed 21 semi-structured focus groups, including 75 participants in total. Implementation team members were interviewed at the initial and middle phases of the intervention period, while clinicians who were not in the implementation team were interviewed in the late phase. A purposive sampling approach was used to recruit participants with various engagement in the implementation process. Data were analysed using manifest content analysis.

Results

Organisational barriers to involvement included: 1) Lack of shared knowledge, perceptions, and practice 2) Lack of routines 3) Lack of resources and logistics. Clinical barriers included: 4) Patient-related factors 5) Relative-related factors 6) Provider-related factors. Organisational facilitators for involvement included: 1) Whole-ward approach 2) Appointed and dedicated roles 3) Standardisation and routines. Clinical facilitators included: 4) External implementation support 5) Understanding, skills, and self-efficacy among mental health professionals 6) Awareness and attitudes among mental health professionals.

Conclusions

Implementing family involvement in health care services for persons with psychotic disorders is possible through a whole-ward and multi-level approach, ensured by organisational- and leadership commitment. Providing training in family psychoeducation to all staff, establishing routines to offer a basic level of family involvement to all patients, and ensuring that clinicians get experience with family involvement, reduce or dissolve core barriers. Having access to external implementation support appears decisive to initiate, promote and evaluate implementation. Our findings also point to future policy, practice and implementation developments to offer adequate treatment and support to all patients with severe mental illness and their families.

Trial registration

ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08489-y.

Factors associated with health-related quality of life in long-stay inpatients with chronic schizophrenia

Aim

Few studies have investigated the health-related quality of life (HRQoL) in long-stay inpatients with chronic schizophrenia in Japan. This study aimed to clarify the factors associated with HRQoL among these patients.

Methods

Out of 238 patients with chronic schizophrenia admitted to three hospitals, 101 inpatients provided informed consent to participate in the study. The patients' HRQoL was assessed using two instruments: the EuroQol 5 dimensions (EQ-5D) as a generic index and the Subjective Well-being Under Neuroleptic Treatment Scale, Japanese Version (SWNS-J) as a disease-specific index. We examined the factors associated with these HRQoL indices using multiple linear regression models.

Results

The patients' mean age was 62.9 years, and 51.5% were female. The mean (standard deviation) EQ-5D score and SWNS-J total score were 0.776 (0.177) and 83.5 (16.5), respectively. Multiple linear regression analysis indicated that the EQ-5D score was significantly and negatively associated with the female sex, benzodiazepine use, and Drug-Induced Extrapyramidal Symptoms Scale scores. In contrast, the SWNS-J total score was significantly and negatively associated with first-generation antipsychotics use, Brief Psychiatric Rating Scale scores, Drug-Induced Extrapyramidal Symptoms Scale scores, and Global Assessment of Functioning scale scores.

Conclusion

This study identified the factors associated with two HRQoL indices among long-stay inpatients with chronic schizophrenia in Japan. Although the analyses showed differences in the associated factors between the generic EQ-5D and the disease-specific SWNS-J, extrapyramidal symptoms as adverse effects of antipsychotic treatment were found to be associated with both indices.

Further validation of the Cognitive Biases Questionnaire for psychosis

BACKGROUND

Cognitive biases are recognized as important treatment targets for reducing symptoms associated with severe mental disorders. Although cognitive biases have been linked to symptoms in most studies, few studies have looked at such biases transdiagnostically. The Cognitive Bias Questionnaire for psychosis (CBQp) is a self-reported questionnaire that assesses cognitive biases amongst individuals with a psychotic disorder, as well as individuals with other severe mental disorders. The current study aims to validate a French version of the CBQp and to explore transdiagnostic cognitive biases in individuals with psychotic disorders, individuals with depression, and in healthy controls.

METHODS

The CBQp was translated into French following a protocol based on international standards. Discriminant validity and internal consistency were determined for total score and each subscale score. Confirmatory factor analyses were performed to test construct validity. Finally, cluster analyses were conducted to investigate cognitive biases across diagnostic groups.

RESULTS

Our results were similar to those of the original authors, with the one-factor solution (assessment of a general thinking bias) being the strongest, but the two-factor solution (assessing biases within two themes relating to psychosis) and the five-factor solution (assessment of multiple distinct biases) being clinically more interesting. A six-cluster solution emerged, suggesting that individuals with similar diagnoses score differently on all cognitive biases, and that individuals with different diagnoses might have similar cognitive biases.

CONCLUSIONS

The current findings support the validity of the French translation of the CBQp. Our cluster analyses overall support the transdiagnostic presence of cognitive biases.

Association between psychiatric hospitalizations of patients with schizophrenia and polygenic risk scores based on genes with altered expression by antipsychotics

OBJECTIVE

To test whether a schizophrenia polygenic risk score (PRS) based on the subset of polymorphisms that affect brain expression of genes with altered expression by antipsychotics (exprAP PRS) is associated with psychiatric readmission of patients with schizophrenia.

METHODS

The study involved 427 patients with schizophrenia. Genes with altered expression by antipsychotics were extracted from the Comparative Toxigenomics Database. ExprAP PRS was estimated using the clumping and thresholding (p < 0.05) method. Two additional PRS were tested based on subsets of exprAP polymorphisms whose schizophrenia risk allele has the same (unrestored PRS) or opposite (restored PRS) direction of effect on gene expression than antipsychotics. A general SCZ PRS was tested for comparison. Logistic and ordinal regression were used to test for association of each PRS with ever readmission and admission history, an outcome based on length and number of admissions, respectively. Webgestalt was used for Gene Ontology enrichment analysis.

RESULTS

ExprAP PRS was associated with ever readmission (OR = 1.48, 95%CI:1.10-1.97) and admission history (OR = 1.30, 95%CI 1.07-1.57). SCZ PRS (OR = 1.22, 95%CI: 1.01-1.48) and unrestored PRS (OR = 1.26, 95%CI 1.04-1.53) were only associated with admission history. Genes at exprAP PRS were enriched in regulation of cytokine production.

CONCLUSION

Our findings suggest that PRS based on genes with altered expression by antipsychotics may be better predictors of readmission than SCZ PRS, warranting further investigation in larger cohorts of patients. The action of antipsychotics may be related to brain gene expression, mainly in genes involved in immunity.

Brain stimulation and other biological non-pharmacological interventions in mental disorders: An umbrella review

BACKGROUND

The degree of efficacy, safety, quality, and certainty of meta-analytic evidence of biological non-pharmacological treatments in mental disorders is unclear.

METHODS

We conducted an umbrella review (PubMed/Cochrane Library/PsycINFO-04-Jul-2021, PROSPERO/CRD42020158827) for meta-analyses of randomized controlled trials (RCTs) on deep brain stimulation (DBS), transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), electro-convulsive therapy (ECT), and others. Co-primary outcomes were standardized mean differences (SMD) of disease-specific symptoms, and acceptability (for all-cause discontinuation). Evidence was assessed with AMSTAR/AMSTAR-Content/GRADE.

RESULTS

We selected 102 meta-analyses. Effective interventions compared to sham were in depressive disorders: ECT (SMD=0.91/GRADE=moderate), TMS (SMD=0.51/GRADE=moderate), tDCS (SMD=0.46/GRADE=low), DBS (SMD=0.42/GRADE=very low), light therapy (SMD=0.41/GRADE=low); schizophrenia: ECT (SMD=0.88/GRADE=moderate), tDCS (SMD=0.45/GRADE=very low), TMS (prefrontal theta-burst, SMD=0.58/GRADE=low; left-temporoparietal, SMD=0.42/GRADE=low); substance use disorder: TMS (high frequency-dorsolateral-prefrontal-deep (SMD=1.16/GRADE=moderate), high frequency-left dorsolateral-prefrontal (SMD=0.77/GRADE=very low); OCD: DBS (SMD=0.89/GRADE=moderate), TMS (SMD=0.64/GRADE=very low); PTSD: TMS (SMD=0.46/GRADE=moderate); generalized anxiety disorder: TMS (SMD=0.68/GRADE=low); ADHD: tDCS (SMD=0.23/GRADE=moderate); autism: tDCS (SMD=0.97/GRADE=very low). No significant differences for acceptability emerged. Median AMSTAR/AMSTAR-Content was 8/2 (suggesting high-quality meta-analyses/low-quality RCTs), GRADE low.

DISCUSSION

Despite limited certainty, biological non-pharmacological interventions are effective and safe for numerous mental conditions. Results inform future research, and guidelines.

FUNDING

None.

Modified assertive community treatment program for patients with schizophrenia: Effectiveness and perspectives of service consumers from a South Indian setting

BACKGROUND

Schizophrenia is a disabling mental illness. Antipsychotic treatment in conjunction with comprehensive psychosocial rehabilitation services is essential in promoting functional recovery. Assertive Community Treatment (ACT) is an evidence-based approach in promoting recovery in schizophrenia. The evidence for the effectiveness and feasibility of such community-based assertive interventions in low and middle-income countries is limited.

AIM

To evaluate the effectiveness of modified assertive community treatment in a South Indian setting and evaluate the perspectives of patients and caregivers who participated in the program.

METHODOLOGY

Socio-demographic details, illness characteristics, course of the illness including the number of relapses and hospitalization, adherence level at baseline, the scores on the Social and Occupational Functioning Assessment Scale (SOFAS), and Global disability score on Indian Disability Evaluation and Assessment Scale (IDEAS) were compared before and after the initiation of the M-CAT program using retrospective file review. The perspectives of the clients were assessed using a 6-item questionnaire.

RESULTS

Ten patients (six male and four female) with a diagnosis of schizophrenia were under the Manipal Assertive Community Treatment (M-ACT) program for a median duration of 3 years (IQR 1.25) participated in the study. There was a significant improvement in the overall level of functioning, medication adherence, relapse rates, and disability after the enrolment into the program. The majority of the respondents had a positive attitude towards the M-ACT program.

CONCLUSION

Assertive community interventions with suitable modifications for local resource-limited conditions may be an effective option in promoting functional recovery in Schizophrenia.

Visual P300 as a neurophysiological correlate of symptomatic improvement by a virtual reality-based computer AT system in patients with auditory verbal hallucinations: A Pilot study

Previous comparative trials showed that virtual reality (VR) therapies achieved larger effects than gold-standard cognitive-behavioral therapy (CBT) on overall auditory verbal hallucinations (AVHs). However, no trial has examined the corresponding underlying electrophysiological mechanisms. We performed a pilot randomized comparative trial evaluating the efficacy of a virtual reality-based computer AT system (CATS) over CBT for schizophrenia (SCZ) patients with treatment-resistant AVHs and explored these potential electrophysiological changes via the visual P300 component. Patients (CATS, n = 32; CBT, n = 33) completed the clinical assessments pre- and post-interventions and at 12-week follow-up. The visual P300 were measured before and after both therapies. The analysis of changes in psychiatric symptoms used linear mixed-effects models, and the P300 response in temporal and time-frequency domains was analyzed with repeated-measures analysis of variance. There was no interaction effect between change in clinical symptoms and treatment group. However, several statistically significant within-group improvements were found for CATS and CBT over time. AVH improved significantly after both treatments, as measured with the Psychotic Symptom Rating Scales-Auditory Hallucinations (PSYRATS-AH) sub-scores. Especially for the CATS group, omnipotence beliefs, anxiety symptoms, self-esteem, and quality of life also remained improved at the 12-week follow-up. Moreover, P300 amplitude had a significant interaction effect and correlation with AVH response. Overall, our analysis did not demonstrate general clinical superiority of CATS over CBT, but CATS improved refractory AVH in SCZ patients, likely by increasing P300 amplitude. These findings support the continued development of CATS for persistent AVH and suggest further trials to clarify the neurological effects of CATS.

Toward recovery in schizophrenia: Current concepts, findings, and future research directions

Schizophrenia was initially defined as "dementia praecox" by E. Kraepelin, which implies progressive deterioration. However, recent studies have revealed that early effective intervention may lead to social and functional recovery in schizophrenia. In this review, we provide an overview of current concepts in schizophrenia and pathophysiological hypotheses. In addition, we present recent findings from clinical and basic research on schizophrenia. Recent neuroimaging and neurophysiological studies have consistently revealed specific biological differences in the structure and function of the brain in those with schizophrenia. From a basic research perspective, to determine the essential pathophysiology underlying schizophrenia, it is crucial that findings from all lines of inquiry-induced pluripotent stem cell (iPSC)-derived neural cells from patients, murine models expressing genetic mutations identified in patients, and patient clinical data-be integrated to contextualize the analysis results. However, the findings remain insufficient to serve as a diagnostic tool or a biomarker for predicting schizophrenia-related outcomes. Collaborations to conduct clinical research based on the patients' and their families' values are just beginning, and further development is expected.

Evidence-based Shared-Decision-Making Assistant (SDM-assistant) for choosing antipsychotics: protocol of a cluster-randomized trial in hospitalized patients with schizophrenia

BACKGROUND

Choosing an antipsychotic medication is an important medical decision in the treatment of schizophrenia. This decision requires risk-benefit assessments of antipsychotics, and thus, shared-decision making between physician and patients is strongly encouraged. Although the efficacy and side-effect profiles of antipsychotics are well-established, there is no clear framework for the communication of the evidence between physicians and patients. For this reason, we developed an evidence-based shared-decision making assistant (SDM-assistant) that presents high-quality evidence from network meta-analysis on the efficacy and side-effect profile of antipsychotics and can be used as a basis for shared-decision making between physicians and patients when selecting antipsychotic medications.

METHODS

The planned matched-pair cluster-randomised trial will be conducted in acute psychiatric wards (n = 14 wards planned) and will include adult inpatients with schizophrenia or schizophrenia-like disorders (N = 252 participants planned). On the intervention wards, patients and their treating physicians will use the SDM-assistant, whenever a decision on choosing an antipsychotic is warranted. On the control wards, antipsychotics will be chosen according to treatment-as-usual. The primary outcome will be patients' perceived involvement in the decision-making during the inpatient stay as measured with the SDM-Q-9. We will also assess therapeutic alliance, symptom severity, side-effects, treatment satisfaction, adherence, quality of life, functioning and rehospitalizations as secondary outcomes. Outcomes could be analysed at discharge and at follow-up after three months from discharge. The analysis will be conducted per-protocol using mixed-effects linear regression models for continuous outcomes and logistic regression models using generalised estimating equations for dichotomous outcomes. Barriers and facilitators in the implementation of the intervention will also be examined using a qualitative content analysis.

DISCUSSION

This is the first trial to examine a decision assistant specifically designed to facilitate shared-decision making for choosing antipsychotic medications, i.e., SDM-assistant, in acutely ill inpatients with schizophrenia. If the intervention can be successfully implemented, SDM-assistant could advance evidence-based medicine in schizophrenia by putting medical evidence on antipsychotics into the context of patient preferences and values. This could subsequently lead to a higher involvement of the patients in decision-making and better therapy decisions.

TRIAL REGISTRATION

German Clinical Trials Register (ID: DRKS00027316 , registration date 26.01.2022).

Do cognitive impairments limit treatment gains in a standalone digital intervention for psychosis? A test of the digital divide

Digital mental health interventions, such as those provided by smartphone applications (apps), show promise as cost-effective approaches to increasing access to evidence-based psychosocial interventions for psychosis. Although it is well known that limited financial resources can reduce the benefits of digital approaches to mental healthcare, the extent to which cognitive functioning in this population could impact capacity to engage in and benefit from these interventions is less studied. In the current study we examined the extent to which cognitive functioning (premorbid cognitive abilities and social cognition) were related to treatment engagement and outcome in a standalone digital intervention for social functioning. Premorbid cognitive abilities generally showed no association with aggregated treatment engagement markers, including proportion of notifications responded to and degree of interest in working on app content, though there was a small positive association with improvements in social functioning. Social cognition, as measured using facial affect recognition ability, was unrelated to treatment engagement or outcome. These preliminary findings suggest that cognitive functioning is generally not associated with engagement or outcomes in a standalone digital intervention designed for and with people with schizophrenia spectrum disorders.