Coping styles predict responsiveness to cognitive behaviour therapy in psychosis

The effect of treatment on insight in psychotic disorders - A systematic review and meta-analysis

BACKGROUND

For people with a psychotic disorder lack of insight can be detrimental on their condition and recovery. For this reason, insight has been considered as a target for therapy. We conducted a systematic review of the literature on pharmacological, psychological and other treatments to test the hypothesis that these interventions could improve insight.

METHODS

We performed a literature search (1970-2020) across the following databases: PubMed, EMBASE, PsychINFO, Medline and Web of Science. Within each database the following search terms and the associated Boolean operatives were used: "Insight AND (treatment OR therapy) AND (psychosis OR schizophrenia) AND (awareness or denial)". Further filters were applied to identify peer reviewed controlled trials on adults. Following assessment for bias and inclusion criteria, we calculated the effect size (Cohen's d) for each study and overall, using a random effects model with 95% confidence intervals.

RESULTS

Of 94 articles found in the initial literature search, 30 studies that examined the treatment of insight in psychosis met the initial selection criteria and were assessed for bias. A total of 21 studies were included in the final meta-analysis. The overall calculated mean effect size for all interventions was 0.441 (95% CI, 0.23-0.66), representing a medium effect size. The effect of psychoeducation studies alone was medium (0.613, 95% CI, -0.35-2.06), but not significant. The effect of CBT studies was small (0.235, 95% CI, 0.01-0.46), and significant. The effect of combined antipsychotic medication and psychosocial intervention was of medium size and significant (0.683, 95% CI = 0.54-0.83). Finally, tDCS over the left fronto-temporal cortex, produced a very large and significant improvement of insight 1.153 (95% CI = 0.61-1.70), which was present for at least a month after the intervention.

CONCLUSIONS

Despite the variation and small number and size of trials into possible interventions, the hypothesis that insight could be improved was confirmed. Whilst most research focuses on psychotherapies, there is scope and potential for pharmacological, as well as other interventions (e.g. physical exercise, self-video observation, Direct Current Stimulation) to improve insight over and above treatment as usual. Given the association of insight with illness severity and treatment adherence, it is important to direct efforts in therapies that target insight improvement in psychosis.

Comparison of three scales (BIS, SUMD and BCIS) for measuring insight dimensions and their evolution after one-year of follow-up: Findings from the FACE-SZ Cohort

The aim of our study was to compare the performance of three different instruments measuring clinical and cognitive dimensions of insight. Data on 182 outpatients with schizophrenia and one-year follow-up assessments was drawn from the FACE-SZ cohort. Awareness of clinical state (« clinical insight ») was measured using both a clinician-rated measure (the Scale to assess Unawareness of Mental Disorder (SUMD)), and a self-report measure (the Birchwood Insight Scale (BIS). Cognitive insight was measured using a self-report measure (the Beck Cognitive Insight Scale (BCIS)). For each scale, change in insight was examined at the follow-up. Correlations between SUMD and BIS subscales measuring same dimensions were significant. BIS-BCIS correlations were weak for all combinations except between BIS illness dimension and BCIS composite score. At the follow-up, BIS and SUMD awareness of treatment need improved whereas illness and symptom awareness increased only on the SUMD. Conversely, cognitive insight composite scores decreased. Despite relatively good overall agreement between the two clinical insight instruments, considerable variability for similar insight dimensions measured by different instruments was found. Agreement between cognitive and clinical insight is moderate. Our study strengthens the argument that insight is harder to operationalize than other symptoms and may explain why it is so seldom explicitly targeted in schizophrenia treatment.

The impact of risk and protective factors on online teaching experience in high school Italian teachers during the COVID-19 pandemic

The lockdown due to COVID-19 in Italy resulted in the sudden closure of schools, with a shift from traditional teaching to the online one. Through an online questionnaire, this survey explores teachers' experience of online teaching, the level of risk factors (e.g., stress) and protective factors (e.g., locus of control) and their impact on satisfaction levels during the social distancing. One hundred seven high school teachers from Lombardy, an Italian region very affected by the COVID-19 outbreak, participated. Results show that depression and stress are the main predictors of satisfaction levels for online teaching. In addition, coping, locus of control and self-efficacy emerge as important protective factors. Finally, although there is great satisfaction with the online teaching experience, critical elements emerged. This study is relevant because it describes the critical elements of the online teaching experience, and identifies some protective factors and the main risk factors in teachers operating in an area strongly marked by social restrictions imposed by the pandemic. High school teachers emerge as a sub-group of the general population with specific psychological reactions. Considering the results, it is possible to suggest providing high-quality educational support and crisis-psychological oriented services to teachers, and help to maintain the psychological well-being.

Development and Initial Testing of an mHealth Transitions of Care Intervention for Adults with Schizophrenia-Spectrum Disorders Immediately Following a Psychiatric Hospitalization

An important period in the care of patients with schizophrenia-spectrum disorders is when they transition from inpatient to outpatient services and are at increased risk for relapse and rehospitalization. Thus, we developed and examined the initial feasibility, acceptability, and clinical effects of an mHealth transitions of care intervention (Mobile After-Care Support; MACS) in an open trial. Ten adults with schizophrenia-spectrum disorders were recruited during their index psychiatric hospitalization and enrolled prior to discharge. Measures of feasibility, acceptability, and MACS targets were administered at baseline and a 1-month follow-up. Drawing on skills from Cognitive Behavioral Therapy for Psychosis (CBTp), MACS delivered brief assessments of clinically relevant variables, followed by just-in-time interventions for patients starting immediately post-discharge. Individuals completed about one session per day on average as expected. Overall, measures of MACS usability and satisfaction were positive. T-test analyses showed that dysfunctional coping strategies significantly decreased from baseline to 1-month follow-up. Results also revealed statistically significant reductions in psychiatric symptoms over 1-month follow-up. This study demonstrates the feasibility and acceptability of MACS, a new app-based intervention targeting transitions of care for patients with psychosis. The field is turning to the use of mobile technology as a means of augmenting service delivery and providing real-time assessment and intervention for patients at risk. MACS is a promising adjunctive intervention that warrants further testing in a randomized controlled trial.

Understanding sex differences in cognitive insight across first-and-multiple episode psychosis

OBJECTIVE

Cognitive insight represents the capacity to self-reflect and consider external feedback when re-evaluating faulty beliefs. It is associated with specific cognitive capacities such as verbal memory, of which there is substantial evidence for sex differences in psychotic disorders. Like more general cognitive capacities, cognitive insight might too be modulated by sex differences.

METHOD

One hundred and seventy-one first episode psychosis (FEP; 123 males, 48 females), and 203 multiple episode psychosis (MEP; 147 males, 56 females) participants completed the Beck Cognitive Insight Scale (BCIS). A two-way MANOVA was conducted on the three BCIS measures (self-reflectiveness, self-certainty, composite index) with sex (male, female) and illness stage (FEP, MEP) as factors, followed by two-way ANOVAs and a post hoc test of simple effects.

RESULTS

The only significant interaction to emerge was between sex and illness stage in self-certainty (F(1, 373) = 5.88, p = .016). A test of simple effects revealed that self-certainty group means were significantly different for males and females in FEP, where females had lower self-certainty than males (p = .053) but not during MEP (p = .119).

CONCLUSION

Sex differences do not modulate cognitive insight in MEP, which may be attributable to females having greater positive symptom severity than males. In FEP however, results revealed that females were significantly less self-certain than males. Lower self-certainty relative to self-reflectiveness predicts treatment response in psychological interventions, and as such future FEP studies should explore sex differences in psychological interventions.

Cognitive-behavioural therapy for personal recovery of patients with schizophrenia: A systematic review and meta-analysis

BACKGROUND

To date, cognitive-behavioural therapy (CBT) trials have primarily focused on clinical recovery; however, personal recovery is actually the fundamental aspect of the recovery process. The aim of this study was to summarise and synthesise the existing evidence regarding the effectiveness of CBT for personal recovery in patients with schizophrenia.

AIM

This study aimed to determine the effectiveness of CBT for personal recovery in patients with schizophrenia.

METHODS

A systematic search of the literature in PsycINFO, PubMed, Cochrane (CENTRAL), Embase and Web of Science (SCI) was conducted to identify randomised controlled trials reporting the impact of CBT interventions on personal recovery in patients with schizophrenia. The estimated effect sizes of the main study outcomes were calculated to estimate the magnitude of the treatment effects of CBT on personal recovery. We also evaluated the CBT's effect size at the end-of-treatment and long-term (follow-up) changes in some aspects of personal recovery.

RESULTS

Twenty-five studies were included in the analysis. The effect of CBT on personal recovery was 2.27 (95% CI 0.10 to 4.45; I2=0%; p=0.04) at post-treatment and the long-term effect size was 2.62 (95% CI 0.51 to 4.47; I2=0%; p=0.02). During the post-treatment period, the pooled effect size of CBT was 0.01 (95% CI -0.12 to 0.15; I2=33.0%; p>0.05) for quality of life (QoL), 0.643 (95% CI 0.056 to 1.130; I2=30.8%; p<0.01) for psychological health-related QoL, -1.77 (95% CI -3.29 to -0.25; I2=40%; p=0.02) for hopelessness and 1.85 (95% CI 0.69 to 3.01; I2=41%; p<0.01) for self-esteem. We also summarised the effects of CBT on QoL (subscale scores not included in the evaluation of the pooled effect size), self-confidence and connectedness, and all results corresponded to positive effects. However, there was insufficient evidence regarding the long-term effects of CBT on personal recovery.

CONCLUSIONS

CBT is an effective therapy with meaningful clinical effect sizes on personal recovery and some aspects of personal recovery of schizophrenia after treatment. However, the effect is relatively immediate and rapidly decreases as time progresses. Therefore, in the future, more studies should focus on the mechanism of CBT for personal recovery and the factors that influence the long-term effects of CBT.

TRIAL REGISTRATION NUMBER

CRD42018085643.

Decision-making ability in psychosis: a systematic review and meta-analysis of the magnitude, specificity and correlates of impaired performance on the Iowa and Cambridge Gambling Tasks

To identify factors which may help or hinder decision-making ability in people with psychosis, we did a systematic review and meta-analysis of their performance on the Iowa and Cambridge Gambling Tasks. Analysis of 47 samples found they had moderately poorer performance than healthy individuals (N = 4264, g = -0.57, 95% confidence interval (CI) -0.66 to -0.48). Few studies (k = 8) used non-psychotic clinical comparator groups, although very low-quality evidence (k = 3) found people with bipolar disorder may perform better. Negative symptoms (k = 13, N = 648, r = -0.17, 95% CI -0.26 to -0.07) and lower IQ (k = 11, N = 525, r = 0.20, 95% CI 0.29-0.10), but not positive symptoms (k = 10, N = 512, r = -0.01, 95% CI -0.11 to 0.08), each had small-moderate associations with poorer decision-making. Lower quality evidence suggested general symptoms, working memory, social functioning, awareness of emotional responses to information, and attentional bias towards gain are associated with decision-making, but not education, executive functioning or overall symptoms. Meta-regression suggested an inverse association between decision-making and depression severity (k = 6, Q = 6.41, R2 100%, p = 0.01). Those taking first-generation (k = 6, N = 305, g = -0.17, 95% CI -0.40 to 0.06, p = 0.147) or low-dose antipsychotics (k = 5, N = 442, g = -0.19, 95% CI -0.44 to 0.06, p = 0.139) had unimpaired decision-making. Although meta-regression found no linear association between dose and performance, non-reporting of the dose was common and associated with larger impairments (k = 46, Q = 4.71, R2 14%, p = 0.03). Those supporting people with psychosis to make decisions, including treatment decisions, should consider the potential effect of these factors. Interventionist-causal trials are required to test whether reducing antipsychotic dose and treating anxiety and depression can improve decision-making in this group.

Pituitary volume reduction in schizophrenia following cognitive behavioural therapy

Cognitive behavioural therapy (CBT) for psychosis (CBTp) aims to lower the stress of psychotic symptoms. Given that the pituitary is involved in stress regulation, CBT-led stress reduction may be accompanied by a change in pituitary volume. This study aimed to determine whether CBTp reduces pituitary volume in schizophrenia. The relation between pre-therapy memory and CBTp-led pituitary volume change was also examined given that poor memory relates to a blunted cortisol awakening response, denoting impaired stress response, in schizophrenia. Pituitary volume was measured at baseline in 40 schizophrenia or schizoaffective disorder patients and 30 healthy participants before therapy. Pituitary volume was measured again 6-9months after patients had either received CBTp in addition to standard care (CBTp+SC, n=24), or continued with standard care alone (SC, n=16). CBTp+SC and SC groups were compared on pituitary volume change from baseline to follow-up. Pre-therapy memory performance (Hopkins Verbal Learning and Wechsler Memory Scale - Logical memory) was correlated with baseline-to-follow-up pituitary volume change. Pituitary volume reduced over time in CBTp+SC patients. Additionally, pre-therapy verbal learning correlated more strongly with longitudinal pituitary volume reduction in the CBTp+SC group than the SC group. To conclude, CBTp reduces pituitary volume in schizophrenia most likely by enhancing stress regulation and lowering the distress due to psychotic symptoms.

Right Frontotemporal Cortex Mediates the Relationship between Cognitive Insight and Subjective Quality of Life in Patients with Schizophrenia

Although prior studies identified a relationship between cognitive insight and subjective quality of life (QOL) in patients with schizophrenia, the brain regions mediating this relationship remain unknown. Recent studies have shown that the ventrolateral prefrontal cortex may be particularly important for cognitive insight in individuals with schizophrenia. Here, we examined whether frontotemporal function mediates the relationship between cognitive insight and QOL in 64 participants, including 32 patients with schizophrenia and 32 healthy controls. Cognitive insight was measured using the Beck Cognitive Insight Scale (BCIS), while participants' subjective QOL was assessed using the Medical Outcomes Study 36-item Short-form Health Survey. Frontotemporal function was evaluated during a verbal fluency task using multichannel near-infrared spectroscopy. Consistent with previous findings, we found that frontotemporal function was impaired in patients with schizophrenia. Interestingly, our data also revealed that the right ventrolateral PFC and the right anterior part of the temporal cortex significantly mediated the relationship between the self-reflectiveness (SR) subscale of the BCIS and subjective QOL. These findings suggest that cognitive insight, particularly SR, is associated with subjective QOL in patients with schizophrenia via right frontotemporal function. The findings of this study provide important insight into a QOL model of schizophrenia, which may guide the development of cost-effective interventions that target frontotemporal function in patients with schizophrenia.

Cognitive insight and objective quality of life in people with schizophrenia and auditory hallucinations

Poor cognitive insight in schizophrenia has been linked to delusions, hallucinations, and negative symptoms as well as to depressive/anxiety symptoms. Its impact on quality of life has been less studied, especially in schizophrenia subjects with ongoing auditory hallucinations. The Beck Cognitive Insight Scale (BCIS) and the Quality of Life Scale (QLS) were administered to subjects who met DSM IV criteria for schizophrenia after due translation and validation. All subjects reported ongoing auditory hallucinations at recruitment. Mean composite cognitive insight scores from participants (N = 60) (2.97 ± 2.649) were in the lower range as compared to published literature. Cognitive insight scores as well as self-reflectiveness subscale scores, but not self-certainty scores, correlated significantly with the QLS scores p < 0.001. Results suggest that better cognitive insight, especially self-reflectiveness, may be linked to better quality of life. Self-reflectiveness could be a useful construct to address in psychotherapy to improve rehabilitation.

A systematic review examining factors predicting favourable outcome in cognitive behavioural interventions for psychosis

Psychosis is a debilitating mental health condition affecting approximately 4 persons per 1000. Cognitive behavioural therapy for psychosis (CBTp) has been shown to be an effective treatment for psychosis and is recommended by several national guidelines. CBTp does not work equally well with everyone, however, with some 50% of clients receiving little benefit. This review sets out to systematically assess the literature and methodological quality of a number of studies, which examine factors predicting successful outcome in CBTp. The databases CINAHL, Cochrane, EBSCO, EMBASE, ISI Web of Science, MEDLINE (Ovid), PsycARTICLES, PsycINFO, PubMed, and Scopus were electronically searched. English language articles in peer reviewed journals were reviewed. Search terms "psychosis", "psychotic disorder", "cognitive behavioural therapy", "cognitive therapy", "randomised controlled trial", "predictor", and "treatment outcome" in various combinations were used as needed. Only randomised controlled trials (RCTs) were included. Results suggest that female gender, older age, and higher clinical insight at baseline, each predicted better outcome in CBT interventions with psychotic patients, as did a shorter duration of the illness, and higher educational attainment. Several other factors, such as higher symptom severity at baseline, were suggestive of predictive capacity but further research to clarify was indicated. Providers of mental healthcare should consider these findings when offering CBTp. The onus is also on healthcare providers to better equip non-responders to CBTp. Further investigation into a limited number of predictive factors, with an agreed set of outcome measures, would allow future researchers more direct comparisons between studies.

Brain connectivity changes occurring following cognitive behavioural therapy for psychosis predict long-term recovery

Little is known about the psychobiological mechanisms of cognitive behavioural therapy for psychosis (CBTp) and which specific processes are key in predicting favourable long-term outcomes. Following theoretical models of psychosis, this proof-of-concept study investigated whether the long-term recovery path of CBTp completers can be predicted by the neural changes in threat-based social affective processing that occur during CBTp. We followed up 22 participants who had undergone a social affective processing task during functional magnetic resonance imaging along with self-report and clinician-administered symptom measures, before and after receiving CBTp. Monthly ratings of psychotic and affective symptoms were obtained retrospectively across 8 years since receiving CBTp, plus self-reported recovery at final follow-up. We investigated whether these long-term outcomes were predicted by CBTp-led changes in functional connections with dorsal prefrontal cortical and amygdala during the processing of threatening and prosocial facial affect. Although long-term psychotic symptoms were predicted by changes in prefrontal connections during prosocial facial affective processing, long-term affective symptoms were predicted by threat-related amygdalo-inferior parietal lobule connectivity. Greater increases in dorsolateral prefrontal cortex connectivity with amygdala following CBTp also predicted higher subjective ratings of recovery at long-term follow-up. These findings show that reorganisation occurring at the neural level following psychological therapy can predict the subsequent recovery path of people with psychosis across 8 years. This novel methodology shows promise for further studies with larger sample size, which are needed to better examine the sensitivity of psychobiological processes, in comparison to existing clinical measures, in predicting long-term outcomes.

Positive coping styles and perigenual ACC volume: two related mechanisms for conferring resilience?

Stress exposure has been linked to increased rates of depression and anxiety in adults, particularly in females, and has been associated with maladaptive changes in the anterior cingulate cortex (ACC), which is an important brain structure involved in internalizing disorders. Coping styles are important mediators of the stress reaction by establishing homeostasis, and may thus confer resilience to stress-related psychopathology. Anatomical scans were acquired in 181 healthy participants at age 25 years. Positive coping styles were determined using a self-report questionnaire (German Stress Coping Questionnaire, SVF78) at age 22 years. Adult anxiety and depression symptoms were assessed at ages 22, 23 and 25 years with the Young Adult Self-Report. Information on previous internalizing diagnoses was obtained by diagnostic interview (2-19 years). Positive coping styles were associated with increased ACC volume. ACC volume and positive coping styles predicted anxiety and depression in a sex-dependent manner with increased positive coping and ACC volume being related to lower levels of psychopathology in females, but not in males. These results remained significant when controlled for previous internalizing diagnoses. These findings indicate that positive coping styles and ACC volume are two linked mechanisms, which may serve as protective factors against internalizing disorders.

Coping as a predictor of treatment outcome in people at clinical high risk of psychosis

AIM

The concept of coping is relevant to recent models of psychosis, and people with established psychotic disorders have been found to predominately use maladaptive coping strategies. This study aimed to examine the general coping patterns of people at clinical high risk of psychosis (CHR) and to investigate whether pre-therapy coping behaviour plays a role in predicting responsiveness to early interventions.

METHODS

One hundred twenty-eight help-seeking CHR outpatients were randomized into two treatment groups: either receiving integrated psychological intervention (IPI), including cognitive behaviour therapy, or supportive counselling (SC) for 12 months. Of those, 91 persons completed a Stress Coping Questionnaire (SCQ) at intake: 45 in the IPI group and 46 in the SC group. General coping behaviour in this sample was analysed and several regressions were conducted separately for each treatment group to examine coping as a predictor of outcome after 12 months of different forms of treatment.

RESULTS

Participants relied significantly more on negative than on positive coping strategies, t(90) = -7.185, P < 0.001, and within the positive strategies, stress control was the most preferred one, t(90) = 10.979, P < 0.001. Several pre-therapy coping strategies significantly predicted improvement in symptomatic outcome in both treatment groups, explaining between 16% and 25% of variance. The predictive value of coping was higher in the SC group.

CONCLUSIONS

Maladaptive coping behaviours were found to emerge in the early stages of psychosis and coping behaviour contributed significantly to the prediction of post-treatment symptom improvement. These findings indicate a need for psychosocial support and coping strategy enhancement in people at risk of psychosis.

Does the Beck Cognitive Insight Scale Predict Response to Cognitive Remediation in Schizophrenia?

Cognitive remediation therapy (CRT) has emerged as a viable treatment option for people diagnosed with schizophrenia presenting disabling cognitive deficits. However, it is important to determine which variables can influence response to CRT in order to provide cost-effective treatment. This study's aim was to explore cognitive insight as a potential predictor of cognitive improvement after CRT. Twenty patients with schizophrenia completed a 24-session CRT program involving 18 hours of computer exercises and 6 hours of group discussion to encourage generalization of cognitive training to everyday activities. Pre- and posttest assessments included the CogState Research Battery and the Beck Cognitive Insight Scale (BCIS). Lower self-certainty on the BCIS at baseline was associated with greater improvement in speed of processing (r s = -0.48; p < 0.05) and visual memory (r s = -0.46; p < 0.05). The results of this study point out potential associations between self-certainty and cognitive improvement after CRT, a variable that can easily be measured in clinical settings to help evaluate which patients may benefit most from the intervention. They also underline the need to keep investigating the predictors of good CRT outcomes, which can vary widely between patients.

The relationship between cognitive insight and quality of life in schizophrenia spectrum disorders: Symptom severity as potential moderator

Cognitive insight is implicated in the formation and maintenance of hallucinations and delusions. However, it is not yet known whether cognitive insight relates to broader outcome measures like quality of life. In the current study, we investigated whether the component elements of cognitive insight-self-certainty and self-reflectiveness-were related to quality of life for 43 outpatients with schizophrenia or schizoaffective disorder. Cognitive insight was assessed using the Beck Cognitive Insight Scale (BCIS) while quality of life was assessed with Quality of Life Scale (QLS). We tested whether this relationship was moderated by clinical insight and symptom severity using the Scale to Assess Unawareness of Mental Disorder (SUMD) and the Positive and Negative Syndrome Scale (PANSS). We found that self- reflectiveness had an unmoderated positive relationship with quality of life. Self-certainty was associated with better quality of life for people with more severe symptoms. Theoretical and clinical implications of these findings are discussed and areas of future research are proposed.

How to Respond to a Paranoid Thought: A Comparison of Patients With Clinically Relevant Delusions and Healthy Controls in Chile

Although paranoid thoughts occur frequently in the population, most people do not develop clinically relevant delusions. The main purpose of the study was to explore whether participants without a mental disorder will respond in a more functional way to paranoid thoughts and be more flexible in their cognitive processes than patients with clinically relevant delusions. The Responses to Paranoid Thoughts Scale was translated into Spanish and was completed by patients (n = 36) and healthy controls (n = 39) in Chile (South America). The Beck Cognitive Insight Scale was used to assess cognitive insight. The patients responded in a more depressive, physical, and concealing way to paranoid thoughts than the healthy controls. Moreover, they showed significantly less cognitive insight and self-reflectiveness. Higher cognitive insight and self-reflectiveness were associated with more normalizing and communicative responses to paranoid thoughts.

Can we respond mindfully to distressing voices? A systematic review of evidence for engagement, acceptability, effectiveness and mechanisms of change for mindfulness-based interventions for people distressed by hearing voices

Adapted mindfulness-based interventions (MBIs) could be of benefit for people distressed by hearing voices. This paper presents a systematic review of studies exploring this possibility and we ask five questions: (1) Is trait mindfulness associated with reduced distress and disturbance in relation to hearing voices? (2) Are MBIs feasible for people distressed by hearing voices? (3) Are MBIs acceptable and safe for people distressed by hearing voices? (4) Are MBIs effective at reducing distress and disturbance in people distressed by hearing voices? (5) If effective, what are the mechanisms of change through which MBIs for distressing voices work? Fifteen studies were identified through a systematic search (n = 479). In relation to the five review questions: (1) data from cross-sectional studies showed an association between trait mindfulness and distress and disturbance in relation to hearing voices; (2) evidence from qualitative studies suggested that people distressed by hearing voices could engage meaningfully in mindfulness practice; (3) MBIs were seen as acceptable and safe; (4) there were no adequately powered RCTs allowing conclusions about effectiveness to be drawn; and (5) it was not possible to draw on robust empirical data to comment on potential mechanisms of change although findings from the qualitative studies identified three potential change processes; (i) reorientation of attention; (ii) decentring; and (iii) acceptance of voices. This review provided evidence that MBIs are engaging, acceptable, and safe. Evidence for effectiveness in reducing distress and disturbance is lacking however. We call for funding for adequately powered RCTs that will allow questions of effectiveness, maintenance of effects, mechanisms of change and moderators of outcome to be definitively addressed.

Orbitofrontal cortex, emotional decision-making and response to cognitive behavioural therapy for psychosis

Grey matter volume (GMV) in the orbitofrontal cortex (OFC) may relate to better response to cognitive behavioural therapy for psychosis (CBTp) because of the region׳s role in emotional decision-making and cognitive flexibility. This study aimed to determine the relation between pre-therapy OFC GMV or asymmetry, emotional decision-making and CBTp responsiveness. Emotional decision-making was measured by the Iowa Gambling task (IGT). Thirty patients received CBTp+standard care (CBTp+SC; 25 completers) for 6-8 months. All patients (before receiving CBTp) and 25 healthy participants underwent structural magnetic resonance imaging. Patients׳ symptoms were assessed before and after therapy. Pre-therapy OFC GMV was measured using a region-of-interest approach, and IGT performance was measured as overall learning, attention to reward, memory for past outcomes and choice consistency. Both these measures, were comparable between patient and healthy groups. In the CBTp+SC group, greater OFC GMV correlated with positive symptom improvement, specifically hallucinations and persecution. Greater rightward OFC asymmetry correlated with improvement in several negative and general psychopathology symptoms. Greater left OFC GMV was associated with lower IGT attention to reward. The findings suggest that greater OFC volume and rightward asymmetry, which maintain the OFC׳s function in emotional decision-making and cognitive flexibility, are beneficial for CBTp responsiveness.

Coping strategies and quality of life in schizophrenia: cross-sectional study

BACKGROUND

The modern psychiatric view of schizophrenia spectrum disorders and their treatment has led to an increasing focus on coping strategies and the quality of life of these patients. In the present study, the authors examined the relationship between demographic data, the severity of symptoms, coping strategies, and the quality of life in psychotic patients. It is important to study the inner experience and striving of these individuals as it has been linked to their well-being and treatment adherence.

METHODS

Psychiatric outpatients who met International Classification of Diseases, Tenth Revision criteria for a psychotic disorder (schizophrenia, schizoaffective disorder, or delusional disorder) were recruited in the study. Questionnaires measuring the coping strategies (The Stress Coping Style Questionnaire [SVF-78]), the quality of life (Quality of Life Satisfaction and Enjoyment Questionnaire [Q-LES-Q]), and symptom severity (objective and subjective Clinical Global Impression - objCGI; subjCGI) were assessed. The data were analyzed using one-way analysis of variance, Mann-Whitney U test, Pearson and Spearman correlation coefficients, and multiple regression analysis.

RESULTS

A total of 109 psychotic patients were included in the study. The quality of life was significantly related to both the positive and negative coping strategies. The severity of disorder was highly negatively correlated with the quality of life score. The results of multiple stepwise regression analysis using the quality of life as a dependent variable showed that symptom severity (subjCGI, difference between subjCGI, and objCGI), negative coping strategies, positive coping strategies, and the difference between positive and negative coping strategies explain more than half variance.

CONCLUSION

Our study suggests the importance of utilizing the positive coping strategies in improving the quality of life in patients with psychotic disorders.

Treatment seeking and unmet need for care among persons reporting psychosis-like experiences

OBJECTIVE

Psychosis-like experiences may be clinically significant given their demonstrated associations with concurrent psychological distress and the later development of diagnosable psychotic disorders. Prior studies of treatment for psychosis-like experiences have yielded conflicting results. The aims of this study were to investigate help seeking and need for care among individuals with psychosis-like experiences in a large general population sample.

METHODS

Data from the Collaborative Psychiatric Epidemiology Surveys (N=10,541) were used to examine help-seeking behaviors among survey respondents who reported psychosis-like symptoms over a 12-month period. Adjusted odds ratios were calculated for a variety of help-seeking variables, with control for demographic factors and co-occurring psychiatric conditions.

RESULTS

Among the 10,541 respondents, 3.4% reported a psychosis-like experience in the past 12 months. Respondents who reported psychosis-like experiences were more than twice as likely as those who did not to seek treatment. Those who reported such experiences but who did not seek treatment were more likely to have felt the need for or to have been encouraged by others to seek treatment and less likely to have felt that they had no psychiatric problem. Associations with unmet need for care were largely attributable to co-occurring psychiatric disorders.

CONCLUSIONS

Respondents with psychosis-like experiences had elevated rates of help seeking, as well as significant unmet clinical need among those not in treatment.

Who stays, who benefits? Predicting dropout and change in cognitive behaviour therapy for psychosis

This study investigates the predictors of outcome in a secondary analysis of dropout and completer data from a randomized controlled effectiveness trial comparing CBTp to a wait-list group (Lincoln et al., 2012). Eighty patients with DSM-IV psychotic disorders seeking outpatient treatment were included. Predictors were assessed at baseline. Symptom outcome was assessed at post-treatment and at 1-year follow-up. The predictor×group interactions indicate that a longer duration of disorder predicted less improvement in negative symptoms in the CBTp but not in the wait-list group whereas jumping-to-conclusions was associated with poorer outcome only in the wait-list group. There were no CBTp specific predictors of improvement in positive symptoms. However, in the combined sample (immediate CBTp+the delayed CBTp group) baseline variables predicted significant amounts of positive and negative symptom variance at post-therapy and 1-year follow-up after controlling for pre-treatment symptoms. Lack of insight and low social functioning were the main predictors of drop-out, contributing to a prediction accuracy of 87%. The findings indicate that higher baseline symptom severity, poorer functioning, neurocognitive deficits, reasoning biases and comorbidity pose no barrier to improvement during CBTp. However, in line with previous predictor-research, the findings imply that patients need to receive treatment earlier.

Poor insight into schizophrenia: contributing factors, consequences and emerging treatment approaches

Poor insight or unawareness of illness has been commonly observed in schizophrenia and has been long recognized as a potent barrier to treatment adherence and a risk factor for a range of poorer outcomes. Paradoxically, the achievement of insight often poses a different set of problems including depression and low self-esteem. One barrier to the treatment of poor insight has been a lack of understanding of the phenomenon, which causes poor insight to develop and persist over time. Without knowing what promotes poor insight, treatment to date has had little to offer beyond the supportive provision of information. To explore these issues, this article reviews emerging literature on the correlates of poor insight in schizophrenia, and newly developing ways of conceptualizing insight. It then details a number of innovative integrative group and individual treatment approaches in the early stages of development, which take into account some of the potential causal forces behind poor insight, including deficits in neurocognition, social cognition, metacognition and heightened self-stigma. A plan for further research is presented to develop a model of the factors whose interaction influences insight, and to refine and test integrative treatments.

Associations of self-esteem, dysfunctional beliefs and coping style with depression in patients with schizophrenia: a preliminary survey

Psychological models of depression in schizophrenia have proposed that cognitive structures (e.g., self-esteem, dysfunctional beliefs) may have a role in the development and maintenance of depression. However, it has not been clear what the characteristics of these cognitive structures were in people with schizophrenia and whether they have an independent association with depression, especially in those from a Chinese cultural background. The present investigation examined 133 people with schizophrenia and 50 healthy controls and indicated that compared to the controls people with schizophrenia showed lower self-esteem, higher levels of dysfunctional beliefs and negative coping styles. Multiple linear regression analysis revealed that only low frustration tolerance, problem solving and self-blame were found to be the independent correlates of depression in schizophrenia. Results are discussed with the view of clinical implications of cognitive formulation and therapy for schizophrenia in China.

Changes in insight during treatment for psychotic disorders: a meta-analysis

OBJECTIVE

Poor insight, or awareness of illness, has a negative impact on the outcome of the psychosis, and is therefore a logical target for treatment. A meta-analysis of the effect of psychological and pharmacological treatments on insight in psychosis was conducted to give a comprehensive overview of effective interventions.

METHODS

An inclusive literature search (1975-April 2012) was performed in PubMed, ISI Web of Science, and EMBASE. The search terms used were "Insight", "Awareness", "Treatment", "Psychosis", "Therapy" and "Schizophrenia", no language specified. A cross-reference search of eligible articles was performed to identify studies not found in the computerized search. Effect sizes (Cohen's d) of each study and overall were calculated under a random effects model with 95% confidence intervals.

RESULTS

Our literature search resulted in approximately 350 abstracts. Nineteen RCTs that examined treatment effects on insight in patients with psychotic disorders were included. Overall, the interventions had a medium effect (d=.34, 95% CI, 0.12-0.57). The effects of CBT, adherence therapy and psycho-education were small to moderate, but not significant, probably due to a lack of power. There were insufficient data to allow a statistical evaluation of the effect of skills training, medication, video-confrontation and comprehensive intervention programs consisting of multiple components. Few adverse effects on mood were documented but this aspect was seldom quantified.

CONCLUSION

There is a paucity of studies providing data regarding treatment for impaired insight in psychosis. Nevertheless, from the published literature in this meta-analysis, we can confirm that it is a potential therapeutic target and that it is amenable to improvement. Comprehensive intervention programs consisting of multiple components may be particularly promising. Improvements in insight did not seem to be associated with increased depression.

Sensorimotor gating and clinical outcome following cognitive behaviour therapy for psychosis

BACKGROUND

Prepulse inhibition (PPI) of the startle response refers to the ability of a weak prestimulus to transiently inhibit the response to a closely following strong sensory stimulus. PPI provides an operational index of sensorimotor gating and is reduced, on average, in people with schizophrenia, relative to healthy people. Given the variable response to Cognitive Behaviour Therapy for psychosis (CBTp) and positive associations between pre-therapy brain and cognitive functions and CBT outcome across disorders, we examined whether pre-therapy level of PPI is associated with clinical outcome following CBTp.

METHOD

Fifty-six outpatients stable on medication with at least one distressing symptom of schizophrenia and willing to receive CBTp in addition to their usual treatment were assessed on acoustic PPI. Subsequently, 28 patients received CBTp (CBTp+treatment-as-usual, 23 completers) for 6-8months and 28 continued with their treatment-as-usual (TAU-alone, 17 completers). Symptoms were assessed (blindly) at entry and follow-up.

RESULTS

The CBTp+TAU and TAU-alone groups did not differ demographically, clinically or in PPI at baseline. The CBTp+TAU group showed improved symptoms relative to the TAU-alone group, which showed no change, at follow-up. Pre-therapy PPI level correlated positively with post-CBTp symptom improvement.

CONCLUSIONS

Relatively intact sensorimotor gating is associated with a good clinical response following a 6-8months course of NICE compliant CBTp in schizophrenia. Pharmacological or psychological interventions capable of improving PPI may enhance the effectiveness of CBTp in people with schizophrenia, particularly in those who fail to show clinical improvement with currently available antipsychotic drugs and adjunctive CBTp.