Targeting relapse prevention and positive symptom in first-episode schizophrenia using brief cognitive behavioral therapy: A pilot randomized controlled study

Cognitive behavioural therapy added to standard care for first-episode and recent-onset psychosis

BACKGROUND

Cognitive behavioural therapy (CBT) can be effective in the general population of people with schizophrenia. It is still unclear whether CBT can be effectively used in the population of people with a first-episode or recent-onset psychosis.

OBJECTIVES

To assess the effects of adding cognitive behavioural therapy to standard care for people with a first-episode or recent-onset psychosis.

SEARCH METHODS

We conducted a systematic search on 6 March 2022 in the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, ISRCTN, and WHO ICTRP.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing CBT added to standard care vs standard care in first-episode or recent-onset psychosis, in patients of any age.

DATA COLLECTION AND ANALYSIS

Two review authors (amongst SFM, CC, LK and IB) independently screened references for inclusion, extracted data from eligible studies and assessed the risk of bias using RoB2. Study authors were contacted for missing data and additional information. Our primary outcome was general mental state measured on a validated rating scale. Secondary outcomes included other specific measures of mental state, global state, relapse, admission to hospital, functioning, leaving the study early, cognition, quality of life, satisfaction with care, self-injurious or aggressive behaviour, adverse events, and mortality.

MAIN RESULTS

We included 28 studies, of which 26 provided data on 2407 participants (average age 24 years). The mean sample size in the included studies was 92 participants (ranging from 19 to 444) and duration ranged between 26 and 52 weeks. When looking at the results at combined time points (mainly up to one year after start of the intervention), CBT added to standard care was associated with a greater reduction in overall symptoms of schizophrenia (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.47 to -0.08, 20 RCTs, n = 1508, I2 = 68%, substantial heterogeneity, low certainty of the evidence), and also with a greater reduction in positive (SMD -0.22, 95% CI -0.38 to -0.06, 22 RCTs, n = 1565, I² = 52%, moderate heterogeneity), negative (SMD -0.20, 95% CI -0.30 to -0.11, 22 RCTs, n = 1651, I² = 0%) and depressive symptoms (SMD -0.13, 95% CI -0.24 to -0.01, 18 RCTs, n = 1182, I² = 0%) than control. CBT added to standard care was also associated with a greater improvement in the global state (SMD -0.34, 95% CI -0.67 to -0.01, 4 RCTs, n = 329, I² = 47%, moderate heterogeneity) and in functioning (SMD -0.23, 95% CI -0.42 to -0.05, 18 RCTs, n = 1241, I² = 53%, moderate heterogeneity, moderate certainty of the evidence) than control. We did not find a difference between CBT added to standard care and control in terms of number of participants with relapse (relative risk (RR) 0.82, 95% CI 0.57 to 1.18, 7 RCTs, n = 693, I² = 48%, low certainty of the evidence), leaving the study early for any reason (RR 0.87, 95% CI 0.72 to 1.05, 25 RCTs, n = 2242, I² = 12%, moderate certainty of the evidence), adverse events (RR 1.29, 95% CI 0.85 to 1.97, 1 RCT, n = 43, very low certainty of the evidence) and the other investigated outcomes.

AUTHORS' CONCLUSIONS

This review synthesised the latest evidence on CBT added to standard care for people with a first-episode or recent-onset psychosis. The evidence identified by this review suggests that people with a first-episode or recent-onset psychosis may benefit from CBT additionally to standard care for multiple outcomes (overall, positive, negative and depressive symptoms of schizophrenia, global state and functioning). Future studies should better define this population, for which often heterogeneous definitions are used.

Effects of brief cognitive behavioral therapy on mental health in substance-related disorder: a randomized controlled trial

BACKGROUND & OBJECTIVES

Population and aging are major contributing factors influencing the increase in substance use disorder (SUD), which in itself affects mental health, particularly anxiety and depression. Cognitive behavioral therapy (CBT) and pharmacotherapy co-treatment are considered the gold standard for the treatment of SUD. Thus, the present study has been carried out to investigate the efficacy of brief CBT on the general health of opioid users.

METHODS

A randomized controlled trial (RCT) was conducted with forty opioid users whose addiction was dully confirmed by a psychiatrist at the drop-in center of the Ahvaz Jundishapur University of Medical Sciences. The patients were then randomly divided into two equal groups (n = 20). The control group was treated solely using methadone maintenance therapy (MMT); however, the intervention group underwent four sessions of CBT in addition to MMT. The general health questionnaire (GHQ) consisting of 28 items (Goldberg, 1979) was applied to both groups at the beginning and end of the study. The collected data was analyzed using IBM SPSS ver. 26, and data analysis was carried out using chi-square, t-test, Mann-Whitney, and Poisson regression model. P < 0.05 was statistically significant for all the aforementioned tests.

RESULTS

The mean age for the control and intervention groups were 37.95 ± 7.64 and 43.85 ± 9.92, respectively (p = 0.042). There was no statistically significant difference in terms of gender and levels of education (p = 0.311 and p = 0.540). Both groups differed statistically regarding marital status and occupation (p = 0.025 and 0.002). There was no significant statistical difference in all subclasses and the total scores of GHQ-28 for both groups, except for anxiety and insomnia in the intervention group (p = 0.038). After applying a Likert scale with a 23-point cut-off score, there was no statistically significant difference in terms of psychosis after intervention in the intervention group (p = 0.077).

CONCLUSION

The results of the current study show that brief CBT is effective on psychiatric health, especially anxiety and sleep disorders, whereas brief CBT fails to affect the patient's depression, somatic symptoms, and social dysfunction.

TRIAL REGISTRATION

The Iranian Registry of Clinical Trials (IRCT) approved the study design (IRCT registration number: IRCT20190929044917N1, registration date: 13/01/2020).

The Role of Cognitive Behavioral Therapy in the Management of Psychosis

Cognitive behavioral therapy for psychosis (CBTp) as a modality of treatment is gaining attention. A number of authors have reported their experiences, including challenges, in administering CBTp for psychotic patients. With CBTp still evolving a lot more research is ongoing to fine-tune its benefits while mitigating the limitations to its use. The objectives of this review are to determine the role of CBTp in the overall improvement of a patient's quality of life, ascertain the number of hospitalizations with acute symptoms after the start of CBTp; and address the common drawbacks to CBTp in the management of psychosis. It was found that cognitive behavioral therapy (CBT) use can prevent the first episode of psychosis in ultra-high risk (UHR) and is effective in improving depression, self-esteem, and psychological well-being. Its use was associated with positive changes in thinking and mood, and sleep quality leading to improved everyday life. Patients who underwent CBT had fewer hospitalizations with a higher number of voluntary hospitalizations as compared to patients with usual care, who underwent a higher number of involuntary hospitalizations. Drawbacks included cost-ineffectiveness and resource limitation.

Facial affect recognition in first-episode psychosis is impaired but not associated with psychotic symptoms

Introduction

Aims

Method

Results

Discussion

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Impaired affect recognition (FAR) present already in first episode psychosis (FEP).

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Preserved FAR of happiness found in individuals with FEP.

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Individuals with FEP mainly have impaired FAR of negative affects.

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Both FEP and controls mainly mistook negative affects for other negative affects.

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Psychotic symptoms are not associated with FAR in individuals with FEP.

Structural brain imaging abnormalities correlate with positive symptom in schizophrenia

Accumulating evidence indicates neuroanatomical mechanisms underlying positive symptoms in schizophrenia; however, the exact structural determinants of positive symptoms remain unclear. This study aimed to investigate associations between positive symptoms and structural brain changes, including alterations in grey matter (GM) volume and cortical thickness, in patients with first-episode schizophrenia (FES). This study included 44 patients with FES and 48 healthy controls (HCs). Clinical symptoms of patients were evaluated and individual-level GM volume and cortical thickness were assessed. Patients with FES showed reduced GM volume in the right superior temporal gyrus (STG) and increased cortical thickness in the left inferior segment of the circular sulcus of the insula (S_circular_insula_inf) compared with HCs. Increased thickness of the left S_circular_insula_inf correlated positively with positive symptoms in patients with FES. Exploratory correlation analysis found that increased thickness of the left S_circular_insula_inf correlated positively with conceptual disorganization and excitement symptoms, and the right STG GM volume correlated negatively with hallucinations. This study suggests that GM abnormalities in the STG and altered cortical thickness of the S_circular_insula_inf, which were detected at the early stage of schizophrenia, may underlie positive symptoms in patients with FES.

Cognitive-Behavioral Therapy in Intensive Case Management: A Multimethod Quantitative-Qualitative Study

Cognitive-behavioral therapy (CBT) has been shown to improve clinical outcomes in schizophrenia and severe and persistent mental illness, but access to it remains limited. One potential way to improve access to CBT is to provide it through intensive case management (ICM) teams. A 90-week quality improvement study was designed to assess if CBT could be implemented in ICM teams. Self-selected ICM clinicians (N=8) implemented CBT with their patients (N=40). These clinicians attended weekly seminars (36 h total) and group supervision (1.5 h/wk). Patient outcomes for this group were compared with those of other clinicians who did not attend the seminars [treatment as usual (TAU) clinicians (N=4)] and their patient population (N=49). Prescore and postscore on the Clinical Global Impressions scale and a quality-of-life scale (Montreal Life Skill Survey) were analyzed for completers in both groups (Clinical Global Impressions scores were analyzed for 25 patients in the CBT group and 29 patients in the TAU group). Weekly session reports by clinicians in the CBT group measured CBT interventions, session focus, and satisfaction with CBT. Qualitative data were obtained from clinicians in the CBT group. After 90 weeks, patients in the CBT group had fewer negative symptoms compared with patients in the TAU group. Our qualitative data describe 2 trajectories of patients: those who improved with CBT and those who did not, and they suggest factors that may impact patient trajectories in CBT. This study suggests that CBT can be used effectively in ICM teams working with patients suffering from severe and persistent mental illness.

The Effects of Cognitive Behavior Therapy and Social Skill Training among Schizophrenia with Risk of Violent Behavior

BACKGROUND: Schizophrenia is a condition in which people suffer from impaired ability to think, perceive, and show emotional responses and interact socially. Patients with schizophrenia can experience the risk of violent behavior (RVB). Psychotherapy is needed to deal with the problem. AIM: This study aimed to investigate the effects of cognitive behavior therapy (CBT) and social skill training (SST) on signs and symptoms of risks of violent behavior (RVB). METHODOLOGY: This study employed a quasi-experimental without a control group. The research samples used purposive sampling were 30 patients with symptoms of risks of violent behavior. Meanwhile, the measurement used the sign and symptom questioners of risks of violent behavior (Z = 0.791). RESULT: This study revealed that signs and symptoms decreased significantly (p < 0.05) from 10.45 to 5.41 after the respondents had obtained the CBT. Moreover, after the respondents had received CBT and SST, the sign and symptoms decreased significantly (p < 0.05) from 5.41 to 0.52. CONCLUSION: This study recommends that the combination of CBT and SST be administered to patients with schizophrenia with risks of violent behavior.

Clinical and demographic factors associated with early relapse in patients with schizophrenia: a naturalistic observation study

Schizophrenia is a chronic psychiatric disorder progressing in relapses. Identification of many factors that may potentially increase the risk of relapse will be an important step in preventing relapses. The aim of this study was to determine the rate of early relapse in patients with schizophrenia and possible risk factors related to early relapse. The sample of this prospective study with the naturalistic observation design consisted of 308 patients with schizophrenia. The cutoff value for early relapse was determined as 1 year. The mean age of participants was 37.38 ± 12.28 years and 66.6% of them were male (n = 205). The early relapse rate was 38.3%. The age younger than 35 [hazard ratio (HR) = 2.313; 95% confidence interval (CI), 1.518-3.526; P < 0.001], use of psychoactive substance (HR = 2.200; 95% CI, 1.407-3.440; P = 0.001), previous attempt of suicide (HR = 1.565; 95% CI, 1.028-2.384; P = 0.037), bad adherence to treatment (HR = 3.102; 95% CI, 1.358-7.086; P = 0.007), long-acting injectables (LAIs) antipsychotics in the treatment (HR = 0.534; 95% CI, 0.351-0.812; P = 0.003), combination typical-atypical antipsychotics (HR = 0.326; 95% CI, 0.131-0.807; P = 0.015), number of episodes (HR = 1.088; 95% CI, 1.043-1.134), and the score on the Side Effect factor of the Clinical Global Impressions Scale (HR = 1.826; 95% CI, 1.357-2.458; P < 0.001) were identified as the independent predictors of early relapse. It is remarkable that treatment bad adherence, use of psychoactive substance, no LAIs antipsychotics included in the treatment, and the no presence of the combination of typical and atypical antipsychotics are alterable predictors of early relapse.

Characteristics of men who are bothered by rapid ejaculation: results from clinical intake surveys

The objective of this study is to identify factors associated with bother with rapid ejaculation in a cohort of men presenting to a sexual dysfunction clinic, independent of a diagnosis of PE. A prospective institutional database has been maintained on patients completing an 89-item intake questionnaire querying various areas of sexual dysfunction. Regarding ejaculatory dysfunction, patients are asked "Do you feel bothered, annoyed, and/or frustrated by ejaculating too quickly?" Statistical modeling was performed to identify associations. A total of 1359 men completed the intake survey, and 694 responded to the question on bother with rapid ejaculation. Overall, 42.9% (298/694) of respondents reported bother with rapid ejaculation. Men reporting bother were more likely to report lower intravaginal ejaculatory latency (IELT) time (4.2 vs 12.2 min, p < 0.0001), problems with depression (32% vs 21%, p = 0.001), negative impact on relationship (73% vs 51%, p < 0.0001), and negative impact on partner's sexual satisfaction (26% vs 15%, p < 0.001). These results highlight the importance of asking all men presenting with sexual health concerns about their bother with rapid ejaculation for complete assessment of sexual and mental wellbeing.

The experience of long-stay patients in a forensic psychiatric hospital in China: a qualitative study

Background

Long stay in forensic psychiatric hospitals is common in patients who are defined as “not criminally responsible on account of mental disorder”. However, little is known about how these patients experience and perceive the long stay within these settings. The aim of this study is to explore the perception and needs of long-stay patients in forensic psychiatric hospitals in China.

Methods

In-depth semi-structured interviews were conducted with 21 participants who had lived in the forensic psychiatry hospital for more than 8 years. We used thematic analysis strategies to analyse the qualitative data.

Results

Participants’ perceptions clustered seven themes: hopelessness, loneliness, worthlessness, low mood, sleep disturbances, lack of freedom, and lack of mental health intervention.

Conclusions

The views and opinions expressed by long-stay patients showed that psychological distress is prevailing in forensic psychiatric hospitals. Adequate and effective care and mental health interventions are recommended to be tailored for their special needs.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4458-6) contains supplementary material, which is available to authorized users.