An early Phase II randomised controlled trial testing the effect on persecutory delusions of using CBT to reduce negative cognitions about the self: the potential benefits of enhancing self confidence

Automated VR therapy for improving positive self-beliefs and psychological well-being in young patients with psychosis: a proof of concept evaluation of Phoenix VR self-confidence therapy

BACKGROUND

Low self-confidence in patients with psychosis is common. This can lead to higher symptom severity, withdrawal from activities, and low psychological well-being. There are effective psychological techniques to improve positive self-beliefs but these are seldom provided in psychosis services. With young people with lived experience of psychosis we developed a scalable automated VR therapy to enhance positive-self beliefs.

AIMS

The aim was to conduct a proof of concept clinical test of whether the new VR self-confidence therapy (Phoenix) may increase positive self-beliefs and psychological well-being.

METHOD

Twelve young patients with non-affective psychosis and with low levels of positive self-beliefs participated. Over 6 weeks, patients were provided with a stand-alone VR headset so that they could use Phoenix at home and were offered weekly psychologist meetings. The outcome measures were the Oxford Positive Self Scale (OxPos), Brief Core Schema Scale, and Warwick-Edinburgh Well-being Scale (WEMWBS). Satisfaction, adverse events and side-effects were assessed.

RESULTS

Eleven patients provided outcome data. There were very large end-of-treatment improvements in positive self-beliefs (OxPos mean difference = 32.3; 95% CI: 17.3, 47.3; Cohen's d=3.0) and psychological well-being (WEMWBS mean difference = 11.2; 95% CI: 8.0, 14.3; Cohen's d=1.5). Patients rated the quality of the VR therapy as: excellent (n=9), good (n=2), fair (n=0), poor (n=0). An average of 5.3 (SD=1.4) appointments were attended.

CONCLUSIONS

Uptake of the VR intervention was high, satisfaction was high, and side-effects extremely few. There were promising indications of large improvements in positive self-beliefs and psychological well-being. A randomized controlled clinical evaluation is warranted.

Randomised controlled trial of automated VR therapy to improve positive self-beliefs and psychological well-being in young people diagnosed with psychosis: a study protocol for the Phoenix VR self-confidence therapy trial

INTRODUCTION

The confidence of young people diagnosed with psychosis is often low. Positive self-beliefs may be few and negative self-beliefs many. A sense of defeat and failure is common. Young people often withdraw from many aspects of everyday life. Psychological well-being is lowered. Psychological techniques can improve self-confidence, but a shortage of therapists means that very few patients ever receive such help. Virtual reality (VR) offers a potential route out of this impasse. By including a virtual coach, treatment can be automated. As such, delivery of effective therapy is no longer reliant on the availability of therapists. With young people with lived experience, we have developed a staff-assisted automated VR therapy to improve positive self-beliefs (Phoenix). The treatment is based on established cognitive behavioural therapy and positive psychology techniques. A case series indicates that this approach may lead to large improvements in positive self-beliefs and psychological well-being. We now aim to conduct the first randomised controlled evaluation of Phoenix VR.

METHODS AND ANALYSIS

80 patients with psychosis, aged between 16 and 30 years old and with low levels of positive self-beliefs, will be recruited from National Health Service (NHS) secondary care services. They will be randomised (1:1) to the Phoenix VR self-confidence therapy added to treatment as usual or treatment as usual. Assessments will be conducted at 0, 6 (post-treatment) and 12 weeks by a researcher blind to allocation. The primary outcome is positive self-beliefs at 6 weeks rated with the Oxford Positive Self Scale. The secondary outcomes are psychiatric symptoms, activity levels and quality of life. All main analyses will be intention to treat.

ETHICS AND DISSEMINATION

The trial has received ethical approval from the NHS Health Research Authority (22/LO/0273). A key output will be a high-quality VR treatment for patients to improve self-confidence and psychological well-being.

TRIAL REGISTRATION NUMBER

ISRCTN10250113.

The role of loneliness and negative schemas in the moment-to-moment dynamics between social anxiety and paranoia

Social anxiety and paranoia often co-occur and exacerbate each other. While loneliness and negative schemas contribute to the development of social anxiety and paranoia separately, their role in the development of the two symptoms co-occurring is rarely considered longitudinally. This study examined the moment-to-moment relationship between social anxiety and paranoia, as well as the effects of loneliness and negative schemas on both experiences individually and coincidingly. A total of 134 non-clinical young adults completed experience sampling assessments of momentary social anxiety, paranoia, and loneliness ten times per day for six consecutive days. Participants' negative-self and -other schemas were assessed with the Brief Core Schema Scale. Dynamic structural equation modelling revealed a bidirectional relationship between social anxiety and paranoia across moments. Loneliness preceded increases in both symptoms in the next moment. Higher negative-self schema was associated with a stronger link from paranoia to social anxiety; whereas higher negative-other schema was associated with a stronger link from social anxiety to paranoia. Our findings support the reciprocal relationship between social anxiety and paranoia. While loneliness contributes to the development of social anxiety and paranoia, negative self and other schemas appear to modify the relationships between the two symptoms.

Testing the combination of Feeling Safe and peer counselling against formulation-based cognitive behaviour therapy to promote psychological wellbeing in people with persecutory delusions: study protocol for a randomized controlled trial (the Feeling Safe-NL Trial)

BACKGROUND

Persecutory delusions are strong threat beliefs about others' negative intentions. They can have a major impact on patients' day-to-day life. The Feeling Safe Programme is a new translational cognitive-behaviour therapy that helps patients modify threat beliefs and relearn safety by targeting key psychological causal factors. A different intervention approach, with growing international interest, is peer counselling to facilitate personal recovery. Combining these two approaches is a potential avenue to maximize patient outcomes. This combination of two different treatments will be tested as the Feeling Safe-NL Programme, which aims to promote psychological wellbeing. We will test whether Feeling Safe-NL is more effective and more cost-effective in improving mental wellbeing and reducing persecutory delusions than the current guideline intervention of formulation-based CBT for psychosis (CBTp).

METHODS

A single-blind parallel-group randomized controlled trial for 190 out-patients who experience persecutory delusions and low mental wellbeing. Patients will be randomized (1:1) to Feeling Safe-NL (Feeling Safe and peer counselling) or to formulation-based CBTp, both provided over a period of 6 months. Participants in both conditions are offered the possibility to self-monitor their recovery process. Blinded assessments will be conducted at 0, 6 (post-treatment), 12, and 18 months. The primary outcome is mental wellbeing. The overall effect over time (baseline to 18-month follow-up) and the effects at each timepoint will be determined. Secondary outcomes include the severity of the persecutory delusion, general paranoid ideation, patient-chosen therapy outcomes, and activity. Service use data and quality of life data will be collected for the health-economic evaluation.

DISCUSSION

The Feeling Safe-NL Trial is the first to evaluate a treatment for people with persecutory delusions, while using mental wellbeing as the primary outcome. It will also provide the first evaluation of the combination of a peer counselling intervention and a CBT-based program for recovery from persecutory delusions.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN25766661 (retrospectively registered 7 July 2022).

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.

Accelerating the development of a psychological intervention to restore treatment decision-making capacity in patients with schizophrenia-spectrum disorder: a study protocol for a multi-site, assessor-blinded, pilot Umbrella trial (the DEC:IDES trial)

BACKGROUND

A high proportion of patients diagnosed with schizophrenia-spectrum disorders will at some point in their lives be assessed as not having the capacity to make their own decisions about pharmacological treatment or inpatient care ('capacity'). Few will be helped to regain it before these interventions proceed. This is partly because effective and safe methods to do so are lacking. Our aim is to accelerate their development by testing, for the first time in mental healthcare, the feasibility, acceptability and safety of running an 'Umbrella' trial. This involves running, concurrently and under one multi-site infrastructure, multiple assessor-blind randomised controlled trials, each of which is designed to examine the effect on capacity of improving a single psychological mechanism ('mechanism'). Our primary objectives are to demonstrate feasibility of (i) recruitment and (ii) data retention on the MacArthur Competence Assessment Tool-Treatment (MacCAT-T; planned primary outcome for a future trial) at end-of-treatment. We selected three mechanisms to test: 'self-stigma', low self-esteem and the 'jumping to conclusions' bias. Each is highly prevalent in psychosis, responsive to psychological intervention, and hypothesised to contribute to impaired capacity.

METHODS

Sixty participants with schizophrenia-spectrum diagnoses, impaired capacity and one or more mechanism(s) will be recruited from outpatient and inpatient mental health services in three UK sites (Lothian, Scotland; Lancashire and Pennine; North West England). Those lacking capacity to consent to research could take part if the key criteria were met, including either proxy consent (Scotland) or favourable Consultee advice (England). They will be allocated to one of three randomised controlled trials, depending on which mechanism(s) they have. They will then be randomised to receive, over an 8-week period and in addition to treatment as usual (TAU), 6 sessions of either a psychological intervention which targets the mechanism, or 6 sessions of assessment of the causes of their incapacity (control condition). Participants are assessed at 0 (baseline), 8 (end-of-treatment) and 24 (follow-up) weeks post-randomisation using measures of capacity (MacCAT-T), mechanism, adverse events, psychotic symptoms, subjective recovery, quality of life, service use, anxiety, core schemata and depression. Two nested qualitative studies will be conducted; one to understand participant and clinician experiences and one to investigate the validity of MacCAT-T appreciation ratings.

DISCUSSION

This will be the first Umbrella trial in mental healthcare. It will produce the first 3 single-blind randomised controlled trials of psychological interventions to support treatment decision-making in schizophrenia-spectrum disorder. Demonstrating feasibility will have significant implications not only for those seeking to support capacity in psychosis, but also for those who wish to accelerate the development of psychological interventions for other conditions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04309435 . Pre-registered on 16 March 2020.

Identifying victimisation profiles in people with psychosis and a history of childhood trauma: a latent class analysis

Background

People with psychosis experience higher rates of childhood victimisation compared to the general population, which may impact on mental health and recovery. This study aimed to identify childhood victimisation profiles in a clinical sample to inform recommendations for routine care.

Methods

Participants were 146 adults (ages 19-65 years; M = 42.2) with schizophrenia-spectrum diagnoses reporting trauma. Childhood trauma was assessed using two retrospective measures, and a latent class analysis (LCA) was performed on four trauma types (sexual abuse, emotional abuse, physical abuse and neglect). Multinomial logistic regression investigated demographic differences between the classes.

Results

Four distinct childhood trauma classes were identified: Emotional abuse/neglect (n = 29); physical abuse (n = 14); sexual abuse (n = 19); and poly-victimisation (n = 84). There were no differences between the classes in terms of age, ethnicity, relationship status, education or current employment (relative risk (RR) = 0.85-1.27, p > 0.05). Participants in the poly-victimisation class were significantly more likely to be female (RR = 0.22-0.28, p < 0.04).

Discussion

Adults with psychosis, particularly females, are likely to report poly-victimisation in childhood. This highlights the need to comprehensively but concisely assess experiences of abuse and neglect in clinical care, in line with trauma-informed approaches.

What Works to Improve Wellbeing? A Rapid Systematic Review of 223 Interventions Evaluated with the Warwick-Edinburgh Mental Well-Being Scales

INTRODUCTION

The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) is a commonly used scale of mental wellbeing focusing entirely on the positive aspect of mental health. It has been widely used in a broad range of clinical and research settings, including to evaluate if interventions, programmes or pilots improve wellbeing. We aimed to systematically review all interventions that used WEMWBS and evaluate which interventions are the most effective at improving wellbeing.

METHODS

Eligible populations included children and adults, with no health or age restrictions. Any intervention study was eligible if the wellbeing outcome was measured using the 7 or 14-item WEMWBS scale assessed both pre- and post-intervention. We identified eligible intervention studies using three approaches: a database search (Medline, EMBASE, CINAHL, PyschInfo and Web of Science from January 2007 to present), grey literature search, and by issuing a call for evidence. Narrative synthesis and random-effects meta-analysis of standardised mean differences in the intervention group were used to summarise intervention effects on WEMWBS score.

RESULTS

We identified 223 interventions across 209 studies, with a total of 53,834 participants across all studies. Five main themes of interventions were synthesised: psychological (n = 80); social (n = 54); arts, culture and environment (n = 29); physical health promotion (n = 18); and other (n = 28). Psychological interventions based on resilience, wellbeing or self-management techniques had the strongest effect on wellbeing. A broad range of other interventions were effective at improving mental wellbeing, including other psychological interventions such as cognitive behavioural therapy, psychoeducation and mindfulness. Medium to strong effects were also seen for person-centred support/advice (social), arts-based, parenting (social) and social prescribing interventions. However, a major limitation of the evidence was that only 75 (36%) of studies included a control group.

CONCLUSIONS

WEMWBS has been widely used to assess wellbeing across a diverse range of interventions, settings and samples. Despite substantial heterogeneity in individual intervention design, delivery and groups targeted, results indicate that a broad range of intervention types can successfully improve wellbeing. Methodological changes, such as greater use of control groups in intervention evaluation, can help future researchers and policy makers further understand what works for mental wellbeing.

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.

The service user experience of SlowMo therapy: A co-produced thematic analysis of service users' subjective experience

OBJECTIVES

SlowMo is the first blended digital therapy for paranoia, showing significant small-moderate reductions in paranoia in a recent large-scale randomized controlled trial (RCT). This study explored the subjective service-user experience of the SlowMo therapy content and design; the experience of the blended therapy approach, including the triangle of the therapeutic alliance; and the experience of the digital aspects of the intervention.

DESIGN

Qualitative co-produced sub-study of an RCT.

METHODS

Participants were 22 adult service users with schizophrenia-spectrum psychosis and persistent distressing paranoia, who completed at least one SlowMo therapy session and a 24-week follow-up, at one of 3 sites in Oxford, London, and Sussex, UK. They were interviewed by peer researchers, using a topic guide co-produced by the Patient and Public Involvement (PPI) team. The transcribed data were analysed thematically. Multiple coding and triangulation, and lay peer researcher validation were used to reach a consensus on the final theme structure.

RESULTS

Six core themes were identified: (i) starting the SlowMo journey; (ii) the central role of the supportive therapist; (iii) slowing things down; (iv) value and learning from social connections; (v) approaches and challenges of technology; and (vi) improvements in paranoia and well-being.

CONCLUSIONS

For these service users, slowing down for a moment was helpful, and integrated into thinking over time. Learning from social connections reflected reduced isolation, and enhanced learning through videos, vignettes, and peers. The central role of the supportive therapist and the triangle of alliance between service user, therapist, and digital platform were effective in promoting positive therapeutic outcomes.

SlowMo therapy, a new digital blended therapy for fear of harm from others: An account of therapy personalisation within a targeted intervention

OBJECTIVES

SlowMo therapy is a pioneering blended digital therapy for paranoia, augmenting face-to-face therapy with an interactive 'webapp' and a mobile app. A recent large-scale trial demonstrated small-moderate effects on paranoia alongside improvements in self-esteem, worry, well-being and quality of life. This paper provides a comprehensive account of therapy personalisation within this targeted approach.

DESIGN

Case examples illustrate therapy delivery and descriptive data are presented on personalised thought content.

METHOD

Thought content was extracted from the webapp (n = 140 participants) and coded using newly devised categories: Worries: (1) Persecutory, (2) Negative social evaluation, (3) Negative self-concept, (4) Loss/life stresses, (5) Sensory-perceptual experiences and (6) Health anxieties. Safer thoughts: (1) Safer alternative (specific alternatives to worries), (2) Second-wave (generalised) coping, (3) Positive self-concept, (4) Positive activities and (5) Third-wave (mindfulness-based) coping. Data on therapy fidelity are also presented.

RESULTS

Worries: 'Persecutory' (92.9% of people) and 'Negative social evaluation' (74.3%) were most common. 'General worries/ life stresses' (31.4%) and 'Negative self-concept' (22.1%) were present in a significant minority; 'Health anxieties' (10%) and 'Sensory-perceptual' (10%) were less common. Safer thoughts: 'Second-wave (general) coping' (85%), 'Safer alternatives' (76.4%), 'Positive self-concept' (65.7%) and 'Positive activities' (64.3%) were common with 'Third-wave' (mindfulness) coping observed for 30%. Fidelity: Only three therapy withdrawals were therapy related. Session adherence was excellent (mean = 15.2/16; SD = 0.9). Behavioural work was conducted with 71% of people (119/168).

CONCLUSION

SlowMo therapy delivers a targeted yet personalised approach. Potential mechanisms of action extend beyond reasoning. Implications for cognitive models of paranoia and causal interventionist approaches are discussed.

Feasibility and efficacy of an acceptance and mindfulness-based group intervention for young people with early psychosis (Feel-Good group)

BACKGROUND

Over the last decade, researchers have sought for alternative interventions that have better treatment effects than Cognitive Behavioral Therapy (CBT) when treating psychotic symptoms. Mindfulness-based interventions have been a proposed alternative to CBT, yet research regarding its feasibility, acceptance and effectiveness is lacking when treating individuals with early psychosis in inpatient settings.

OBJECTIVE

Before conducting a large-scale randomized-controlled trial (RCT), this pilot study evaluated the feasibility and the potential efficacy of a mindfulness-based inpatient group intervention that targets emotion regulation in patients with early psychosis, and thus indirectly improving psychotic symptoms.

METHODS

A pre-post study was performed. Thirty-six patients with early psychosis treated at the specialized inpatient treatment "Frühinterventions- und Therapiezentrum; FRITZ" (early intervention and therapy center) received eight group therapy sessions. Assessments were performed at baseline, after 8 weeks post treatment and at follow-up after 16 weeks.

RESULTS

Rates of patients who participated in the study suggests that a mindfulness-based group therapy is highly accepted and feasible for patients with early psychosis being treated in an inpatient ward. Friedman analyses revealed significant changes in the primary outcomes of emotional goal attainment (Goal 1: W = 0.79; Goal 2: W = 0.71) and psychotic symptoms (PANSS-T: W = 0.74). Significant, albeit small, effect sizes were found in patients' self-perception of emotion regulation skills (ERSQ: W = 0.23).

DISCUSSION

We found favorable findings regarding the feasibility and acceptance of the Feel-Good mindfulness-based intervention. Results of the study provide a basis for an estimation of an adequate sample size for a fully powered RCT that needs to be conducted to test whether Feel-Good is effective in the inpatient treatment of psychotic symptoms for individuals with early psychosis.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/ct2/show/NCT04592042], identifier [NCT04592042].

The co-occurrence of multidimensional loneliness with depression, social anxiety and paranoia in non-clinical young adults: A latent profile analysis

INTRODUCTION

Loneliness is a negative experience arising from a mismatch between perceived and actual social relationships. Several dimensions of loneliness have been suggested, namely intimate, relational and collective loneliness. Loneliness has been linked to poorer mental health, with its co-occurrence with depression, social anxiety, and paranoia most widely reported. While expressions of these symptoms are heterogeneous across individuals in the non-clinical population, it remains unclear how these symptoms co-occur with one another and with various dimensions of loneliness. It is also of interest how trait factors such as core schemas about self/others may moderate these relationships between loneliness and co-occurring symptoms.

METHODS

A demographically diverse sample of young adults was recruited from multiple sources. The validated sample consisted of 2,089 participants (68.4% female), who completed an online survey consisting of questionnaires assessing levels of multidimensional loneliness, depression, social anxiety, paranoia, core schemas, and demographic characteristics. Latent profile analysis (LPA) was used to identify distinct profiles of loneliness and the three symptoms. Positive and negative core schemas about self and others were modeled as predictors of these profiles.

RESULTS

Five distinct profiles were identified. Profile 1 had low levels across all symptoms and dimensions of loneliness (n = 1,273, 60.9%). Profiles 2-5 were elevated on dimensions of loneliness, and were heightened in depression (n = 189, 9.0%), social anxiety (n = 206, 9.9%), paranoia (n = 198, 9.5%), and all symptoms (n = 223, 10.7%), respectively. Relative to Profile 1, the other four profiles scored higher on negative-self (adjusted ORs = 1.36-1.49, ps < 0.001) and negative-other schemas (adjusted ORs = 1.24-1.44, ps < 0.001), and lower on positive-self (adjusted ORs = 0.82-0.85, ps < 0.001) and positive-other schemas (adjusted ORs = 0.81-0.90, ps < 0.001).

CONCLUSION

More marked intimate, relational and collective loneliness were evident across profiles that had heightened depression, social anxiety and/or paranoia, suggesting that loneliness may serve as a general risk factor for these psychopathologies. Our findings shed light on the heterogeneity of the co-occurrence of loneliness and various mental health difficulties in non-clinical young adults. Core schemas are suggested to be putative psychological mechanisms underlying their co-occurrence and even development.

Do Positive Psychology Interventions Impact on the Subjective Wellbeing and Depression of Clients? A Systematic Methodological Review

Mental health services are placing a greater emphasis on wellbeing and recovery. The current research investigated if positive psychology interventions (PPIs) increase peoples’ subjective wellbeing and reduce clinical depression. A systematic methodological review was conducted on randomized-control-trials with people attending clinical services. Five databases were searched. A hand search was then completed on the reference lists of the identified articles and the associated journals. Eleven research interventions were reviewed. PPIs were found to significantly increase wellbeing, relative to controls and there were fewer studies indicating a difference in decreasing depression. However, subsequent analysis revealed that the interventions were heterogeneous which limits the drawing of definitive systematic conclusions. A methodological evaluation also found that there were recurring issues: in delivering the interventions, measuring subjective wellbeing, and applying the design. Thus, the methodological quality of the research interventions, as measured by the current review was low. There is emerging evidence that PPIs improve peoples’ mental health. However, there is scope to standardize and to improve the quality of the research interventions.

Cognitive behavioral group treatment for low self-esteem in psychosis: a proof of concept study

BACKGROUND

Patients with a psychotic disorder often suffer from low self-esteem, which has been related to higher suicidal risk, poor quality of life and, the maintenance of psychotic and depression symptoms. However, intervention studies are scarce and reported interventions concern individual therapies provided by highly educated psychologists. Both the individual setting and the required qualifications of the therapist may contribute to a low level of availability of an intervention. Therefore we aimed to investigate the efficacy of an easily accessible psychological group treatment targeting self-esteem in patients with a psychotic disorder.

METHODS

Thirty patients with a psychotic disorder were included in this pilot study. All participants received nine weekly group sessions of 90 min. The therapy was offered in groups of six to eight patients and was provided by a psychiatry nurse and a graduate psychologist. To assess self-esteem the Rosenberg Self-esteem Scale and the Self-Esteem Rating Scale were used, to measure depression symptoms the Beck Depression Inventory-II was administered. Questionnaires were completed at baseline and post-treatment.

RESULTS

Twenty-seven patients (90%) completed treatment. At post-treatment, self-esteem was significantly increased and depression symptoms were significantly decreased compared to baseline.

DISCUSSION

This pilot study demonstrates the feasibility and treatment potential of a self-esteem group treatment provided by a psychiatry nurse and graduate psychologist in a patient population that receives little psychological treatment. Results suggest that this easily accessible intervention may be effective in improving self-esteem and reducing depression symptoms.

Paranoia and negative schema about the self and others: A systematic review and meta-analysis

Negative self and negative other schema have been implicated in the development of paranoia. The current study provides a meta-analysis, narrative review and quality appraisal of quantitative studies investigating the relationship between negative self and negative other schema and paranoia across the paranoia continuum. A systematic search identified 43 eligible studies; 25 were included in the meta-analysis. Meta-analytic findings demonstrated a medium to large relationship between paranoia and negative self-schema (r = 0.46, 95% CI 0.39 to 0.53) and negative other schema (r = 0.48, 95% CI 0.38 to 0.56). The magnitude of associations was similar across people with and without psychosis. Findings demonstrated that associations between negative self-schema and paranoia were not always statistically significant when controlling for confounding variables, particularly depression. The association between negative other schema and paranoia tended to remain significant when controlling for confounding variables. Findings also demonstrated that negative schema may mediate relationships between adverse experiences in childhood and paranoia. Overall, findings support theoretical proposals that both negative self and negative other schema are associated with paranoia. Longitudinal studies are required to confirm the direction of effects. Findings provide support for incorporating and targeting negative self and negative other schema in psychological formulations and therapeutic work.

Self-esteem in individuals at ultra-high risk for psychosis: A systematic review and meta-analysis

AIM

Low self-esteem (LSE) has been reported among individuals with psychosis and is hypothesized to act as a risk and maintenance factor for the disorder. However, the extent to which LSE also characterizes individuals deemed at ultra-high risk (UHR) for psychosis (who present features consistent with the prodromal phase of illness), has yet to be quantified using meta-analysis. This is important given that LSE is a potentially modifiable target for early intervention services aiming to reduce the risk of psychosis transition in this population.

METHODS

We searched Medline, Embase, PsycINFO and Web of Science Core Collection for studies examining self-esteem in UHR and healthy individuals. Random-effects models were used to examine group differences in self-esteem (Hedges'g) with exploratory meta-regression analyses employed to investigate the effect of study characteristics (mean age of UHR group, the proportion of male participants in the UHR group and study quality) on standardized mean differences.

RESULTS

Six studies were eligible for inclusion. Significant differences in self-esteem were observed, with individuals at UHR showing reduced self-esteem relative to healthy controls (g = -1.33 [-1.73 to -0.94] P < .001).However, there was evidence of substantial heterogeneity (I²  = 75%). Exploratory meta-regression analyses indicated a significant effect of the mean age of the UHR group on effect sizes (B = -0.26, P = .02).

CONCLUSIONS

UHR youth present with lower levels of self-esteem than healthy individuals, a difference that appears to be more pronounced with advancing age. We discuss clinical implications and provide recommendations for future studies.

Comparison of a theoretically driven cognitive therapy (the Feeling Safe Programme) with befriending for the treatment of persistent persecutory delusions: a parallel, single-blind, randomised controlled trial

BACKGROUND

There is a large clinical need for improved treatments for patients with persecutory delusions. We aimed to test whether a new theoretically driven cognitive therapy (the Feeling Safe Programme) would lead to large reductions in persecutory delusions, above non-specific effects of therapy. We also aimed to test treatment effect mechanisms.

METHODS

We did a parallel, single-blind, randomised controlled trial to test the Feeling Safe Programme against befriending with the same therapists for patients with persistent persecutory delusions in the context of non-affective psychosis diagnoses. Usual care continued throughout the duration of the trial. The trial took place in community mental health services in three UK National Health Service trusts. Participants were included if they were 16 years or older, had persecutory delusions (as defined by Freeman and Garety) for at least 3 months and held with at least 60% conviction, and had a primary diagnosis of non-affective psychosis from the referring clinical team. Patients were randomly assigned to either the Feeling Safe Programme or the befriending programme, using a permuted blocks algorithm with randomly varying block size, stratified by therapist. Trial assessors were masked to group allocation. If an allocation was unmasked then the unmasked assessor was replaced with a new masked assessor. Outcomes were assessed at 0 months, 6 months (primary endpoint), and 12 months. The primary outcome was persecutory delusion conviction, assessed within the Psychotic Symptoms Rating Scale (PSYRATS; rated 0-100%). Outcome analyses were done in the intention-to-treat population. Each intervention was provided individually over 6 months. This trial is registered with the ISRCTN registry, ISRCTN18705064.

FINDINGS

From Feb 8, 2016, to July 26, 2019, 130 patients with persecutory delusions (78 [60%] men; 52 [40%] women, mean age 42 years [SD 12·1, range 17-71]; 86% White, 9% Black, 2% Indian; 2·3% Pakistani; 2% other) were recruited. 64 patients were randomly allocated to the Feeling Safe Programme and 66 patients to befriending. Compared with befriending, the Feeling Safe Programme led to significant end of treatment reductions in delusional conviction (-10·69 [95% CI -19·75 to -1·63], p=0·021, Cohen's d=-0·86) and delusion severity (PSYRATS, -2·94 [-4·58 to -1·31], p<0·0001, Cohen's d=-1·20). More adverse events occurred in the befriending group (68 unrelated adverse events reported in 20 [30%] participants) compared with the Feeling Safe group (53 unrelated adverse events reported in 16 [25%] participants).

INTERPRETATION

The Feeling Safe Programme led to a significant reduction in persistent persecutory delusions compared with befriending. To our knowledge, these are the largest treatment effects seen for patients with persistent delusions. The principal limitation of our trial was the relatively small sample size when comparing two active treatments, meaning less precision in effect size estimates and lower power to detect moderate treatment differences in secondary outcomes. Further research could be done to determine whether greater effects could be possible by reducing the hypothesised delusion maintenance mechanisms further. The Feeling Safe Programme could become the recommended psychological treatment in clinical services for persecutory delusions.

FUNDING

NIHR Research Professorship and NIHR Oxford Health Biomedical Research Centre.

A compassionate imagery intervention for patients with persecutory delusions

BACKGROUND

Negative beliefs about the self, including low self-compassion, have been identified as a putative causal factor in the occurrence of paranoia. Therefore, improving self-compassion may be one route to reduce paranoia.

AIMS

To assess the feasibility, acceptability, and potential clinical effects of a brief compassionate imagery intervention for patients with persecutory delusions.

METHOD

Twelve patients with persecutory delusions received an individual four-session compassionate imagery intervention. Assessments of self-concept and paranoia were completed before treatment, immediately after treatment, and at 1-month follow-up. A qualitative study exploring participants' experiences of the treatment was also completed.

RESULTS

Twelve out of 14 eligible patients referred to the study agreed to take part. All participants completed all therapy sessions and assessments. Post-treatment, there were improvements in self-compassion (change score -0.64, 95% CI -1.04, -0.24, d = -1.78), negative beliefs about the self (change score 2.42, 95% CI -0.37, 5.20, d = 0.51), and paranoia (change score 10.08, 95% CI 3.47, 16.69, d = 0.61). There were no serious adverse events. Three themes emerged from the qualitative analysis: 'effortful learning', 'seeing change' and 'taking it forward'. Participants described a process of active and effortful engagement in therapy which was rewarded with positive changes, including feeling calmer, gaining clarity, and developing acceptance.

CONCLUSION

This uncontrolled feasibility study indicates that a brief compassionate imagery intervention for patients with persecutory delusions is feasible, acceptable, and may lead to clinical benefits.

A systematic review and meta-analysis of psychological interventions to improve mental wellbeing

Our current understanding of the efficacy of psychological interventions in improving mental states of wellbeing is incomplete. This study aimed to overcome limitations of previous reviews by examining the efficacy of distinct types of psychological interventions, irrespective of their theoretical underpinning, and the impact of various moderators, in a unified systematic review and meta-analysis. Four-hundred-and-nineteen randomized controlled trials from clinical and non-clinical populations (n = 53,288) were identified for inclusion. Mindfulness-based and multi-component positive psychological interventions demonstrated the greatest efficacy in both clinical and non-clinical populations. Meta-analyses also found that singular positive psychological interventions, cognitive and behavioural therapy-based, acceptance and commitment therapy-based, and reminiscence interventions were impactful. Effect sizes were moderate at best, but differed according to target population and moderator, most notably intervention intensity. The evidence quality was generally low to moderate. While the evidence requires further advancement, the review provides insight into how psychological interventions can be designed to improve mental wellbeing.

Parenting behaviour and paranoia: a network analysis and results from the National Comorbidity Survey-Adolescents (NCS-A)

PURPOSE

Parenting behaviours-including the extent to which parents are protective, hostile, or caring-likely impacts whether a child develops a sense of vulnerability that carries forward into adulthood. Ideas of vulnerability are a contributory factor to the occurrence of paranoia. Our aim was to assess whether there is an association between specific parenting behaviours and paranoia.

METHOD

We examined cross-sectional associations of parenting and paranoia in an epidemiologically representative cohort of 10,148 adolescents (National Comorbidity Survey-Adolescents; NCS-A) and a second dataset of 1286 adults in Oxfordshire. Further, a network analysis was conducted with paranoia, parenting behaviours, and cognitive-affective variables (compassion, self-esteem, anxiety, and depression). Overprotectiveness, verbal abuse, physical abuse, and amount of care were assessed in mothers and fathers separately.

RESULTS

Nearly all parenting variables were significantly associated with paranoia, with parental verbal and physical abuse showing the largest associations. For example, the odds of reporting paranoia was over four times higher for those in the adult sample reporting a lot of paternal verbal abuse, compared to those reporting none (OR = 4.12, p < 0.001, CI 2.47-6.85). Network analyses revealed high interconnectivity between paranoia, parenting behaviours, and cognitive-affective variables. Of the parenting variables, paranoia most strongly interacted with paternal abuse and maternal lack of care.

CONCLUSION

There are associations between participants' self-reported experiences of parental behaviours and paranoia. Despite being associated with paranoia, cognitive-affective variables did not appear to mediate the relationship between parenting and paranoia, which is surprising. What might explain the link therefore remains to be determined.

The revised Green et al., Paranoid Thoughts Scale (R-GPTS): psychometric properties, severity ranges, and clinical cut-offs

BACKGROUND

The Green et al., Paranoid Thoughts Scale (GPTS) - comprising two 16-item scales assessing ideas of reference (Part A) and ideas of persecution (Part B) - was developed over a decade ago. Our aim was to conduct the first large-scale psychometric evaluation.

METHODS

In total, 10 551 individuals provided GPTS data. Four hundred and twenty-two patients with psychosis and 805 non-clinical individuals completed GPTS Parts A and B. An additional 1743 patients with psychosis and 7581 non-clinical individuals completed GPTS Part B. Factor analysis, item response theory, and receiver operating characteristic analyses were conducted.

RESULTS

The original two-factor structure of the GPTS had an inadequate model fit: Part A did not form a unidimensional scale and multiple items were locally dependant. A Revised-GPTS (R-GPTS) was formed, comprising eight-item ideas of reference and 10-item ideas of persecution subscales, which had an excellent model fit. All items in the new Reference (a = 2.09-3.67) and Persecution (a = 2.37-4.38) scales were strongly discriminative of shifts in paranoia and had high reliability across the spectrum of severity (a > 0.90). The R-GPTS score ranges are: average (Reference: 0-9; Persecution: 0-4); elevated (Reference: 10-15; Persecution: 5-10); moderately severe (Reference: 16-20; Persecution:11-17); severe (Reference: 21-24; Persecution: 18-27); and very severe (Reference: 25+; Persecution: 28+). Recommended cut-offs on the persecution scale are 11 to discriminate clinical levels of persecutory ideation and 18 for a likely persecutory delusion.

CONCLUSIONS

The psychometric evaluation indicated a need to improve the GPTS. The R-GPTS is a more precise measure, has excellent psychometric properties, and is recommended for future studies of paranoia.

Exploring the Development, Validity, and Utility of the Short-Form Version of the CHoice of Outcome In Cbt for PsychosEs: A Patient-Reported Outcome Measure of Psychological Recovery

The original CHoice of Outcome In Cbt for psychosEs (CHOICE) measure was designed in collaboration with experts by experience as a patient-reported "Psychological Recovery" outcome measure for cognitive-behavioral therapy for psychosis (CBTp). A short version (CHOICE-SF) was developed to use as a brief outcome measure, with a focus on sensitivity to change, for use in future research and practice. CHOICE-SF was developed and validated using 3 separate samples, comprising 640 service users attending 1 of 2 transdiagnostic clinics for (1) CBTp or (2) therapies for voice hearing or (3) who took part in the treatment as usual arm of a trial. In the initial subsample of 69 participants, items from the original CHOICE measure with medium to large effect sizes for change pre- to post-CBTp were retained to form the CHOICE-SF. Internal consistency, construct validity, and sensitivity to change were confirmed, and the factor structure was examined in 242 participants. Specificity was confirmed by comparison with 44 participants who completed CHOICE at 2 time points but did not receive therapy. Validation of CHOICE-SF was carried out by confirming factor structure and sensitivity to change in a new sample of 354 and a subsample of 51 participants, respectively. The CHOICE-SF comprised 11 items and 1 additional personal goal item. A single-factor structure was confirmed, with high internal consistency, construct validity, and sensitivity to change. The CHOICE-SF is a brief, psychometrically robust measure to assess change following psychological therapies in research and clinical practice for people with psychosis and severe mental illness.

What Constitutes Sufficient Evidence for Case Formulation-Driven CBT for Psychosis? Cumulative Meta-analysis of the Effect on Hallucinations and Delusions

OBJECTIVE

Following 2 decades of research on cognitive behavioral therapy for psychosis (CBTp), it is relevant to consider at which point the evidence base is considered sufficient. We completed a cumulative meta-analysis to assess the sufficiency and stability of the evidence base for hallucinations and delusions.

METHOD

We updated the systematic search from our previous meta-analytic review from August 2013 until December 2019. We identified 20 new randomized controlled trials (RCTs) resulting in inclusion of 35 RCTs comparing CBTp with treatment-as-usual (TAU) or active controls (AC). We analyzed data from participants with psychosis (N = 2407) over 75 conventional meta-analytic comparisons. We completed cumulative meta-analyses (including fail-safe ratios) for key comparisons. Publication bias, heterogeneity, and risk of bias were examined.

RESULTS

Cumulative meta-analyses demonstrated sufficiency and stability of evidence for hallucinations and delusions. The fail-safe ratio demonstrated that the evidence base was sufficient in 2016 for hallucinations and 2015 for delusions. In conventional meta-analyses, CBTp was superior for hallucinations (g = 0.34, P < .01) and delusions (g = 0.37, P < .01) when compared with any control. Compared with TAU, CBTp demonstrated superiority for hallucinations (g = 0.34, P < .01) and delusions (g = 0.37, P < .01). Compared with AC, CBT was superior for hallucinations (g = 0.34, P < .01), but not for delusions although this comparison was underpowered. Sensitivity analyses for case formulation, primary outcome focus, and risk of bias demonstrated increases in effect magnitude for hallucinations.

CONCLUSIONS

The evidence base for the effect of CBTp on hallucinations and delusions demonstrates sufficiency and stability across comparisons, suggesting limited value of new trials evaluating generic CBTp.

The experience of body image concerns in patients with persecutory delusions: 'People don't want to sit next to me'

OBJECTIVE

Persecutory delusions typically build on feelings of inter-personal vulnerability linked to negative views of the self. Negative body image is an overlooked aspect of this link between the self-concept and paranoia.

DESIGN

This study explores body image from the first-person perspective of patients with persecutory delusions.

METHOD

Semi-structured interviews, analysed using interpretative phenomenological analysis, were conducted with twelve patients with persecutory delusions in the context of psychotic disorders.

RESULTS

Four super-ordinate themes emerged. First, appearance as a source of threat accounted for how negative body image increased feelings of vulnerability and fed into the content of paranoia and voices (e.g., 'I feel that everybody is noticing that I'm getting bigger and bigger and laughing at me'). Second, there was the negative impact of uncontrollable and unwanted weight gain, especially following antipsychotic medication (e.g., 'I ballooned up to 23 stone'). Third, feeling stuck captured the hopelessness and resignation in relation to appearance (e.g., 'I've become so accustomed to being overweight that I've accepted it as my lot'). Finally, looking well symbolises feeling well represented the importance of appearance in determining mental well-being (e.g., 'If I've got clean clothes and I put makeup on, at least I feel that I'm looking after myself').

CONCLUSIONS

Patients with persecutory delusions described appearance-related concerns making them feel negative towards themselves, inferior to other people, and vulnerable to harm. Appearance-related distress was broader than weight gain, including dissatisfaction with skin, clothing, and attractiveness. Negative body image may be a contributory factor in the occurrence of paranoia.

PRACTITIONER POINTS

Body image concerns may be of particular relevance in patients with persecutory delusions due to weight gain, inactivity, and medication side effects. Body image concerns include weight gain and broader aspects of appearance. Negative body image contributes to feelings of vulnerability, potentially worsening paranoid fears. It may be helpful for practitioners to explore the psychological impact of weight gain and body image concerns in patients with psychosis.

Power posing for paranoia: A double-blind randomised controlled experimental test using virtual reality

Paranoia is theorised to build upon feelings of inferior social rank. Power posing has been shown to increase feelings of power, and hence could reduce paranoia. One hundred participants with current paranoia and 50 individuals without paranoia were recruited. Using a double-blind randomised controlled experimental design, participants twice held powerful or neutral postures before entering neutral virtual reality social environments. In the paranoid sample, those who held a powerful pose did not significantly increase in feelings of power by the end of testing in comparison to controls (group difference = 0.67, C.I. = -1.12; 1.46; p = 0.098), or decrease in paranoia (group difference = -0.23, C.I. = -1.17; 0.72; p = 0.634). In the non-paranoid sample, there was a small significant increase in powerful feelings by the end of testing in the powerful group (group difference = 1.13, C.I. = 0.23; 2.02; p = 0.013), but no significant decrease in paranoia (group difference = -0.71, C.I. = -2.16; 0.74; p = 0.338). Paranoia status was not a modifier on the relationship between condition and feelings of power. We conclude that power posing results in only very small changes in self-reported feelings of power and has no subsequent effect on paranoia.

Beliefs about voices in voice-hearers: the role of schema functioning

BACKGROUND

Evidence is emerging that beliefs about voices are influenced by broader schematic beliefs about the self and others. Similarly, studies indicate that the relationship an individual has with their voice may mirror wider patterns of relating observed in social relationships, which may be influenced by schematic beliefs.

AIMS

This study examined associations between beliefs about voices and self and other schemas. Furthermore, associations between schemas and the perceived relationship between the hearer and their predominant voice were explored.

METHOD

Forty-four voice-hearing participants were recruited across mental health services. Participants completed self-report measures of beliefs about voices, schema functioning, and relating between the hearer and their voice. Dimensions of voice experience, such as frequency and content, were assessed using a clinician-rated scale.

RESULTS

Beliefs about voices correlated with negative voice content and schemas. After controlling for negative voice content, schemas were estimated to predict between 1 and 17% of the variance in the six measured beliefs about voices; three of the associations reached statistical significance. Negative-self schema were the strongest predictors of beliefs about voices, whilst positive-self also showed potential relationships. Schemas also correlated with dimensions of relating between the hearer and their voice.

CONCLUSIONS

In line with previous research, this study provides evidence that schemas, particularly self-schema, may be important in the development of beliefs about voices. This study offers preliminary findings to suggest that schemas are also associated with the perceived relationship between the hearer and their voice.

iMAgery focused psychological therapy for persecutory delusions in PSychosis (iMAPS): a multiple baseline experimental case series

Background:

Many people with psychosis experience persecutory delusions and report negative schematic beliefs and intrusive mental images which may be maintaining factors for psychotic symptoms.

Aims:

This study examined the feasibility and acceptability of a new psychological therapy targeting schemas and images (iMAPS therapy).

Method:

The study used a randomised multiple baseline design. Participants with first episode psychosis were randomised using a multiple baseline design with 2–5 assessments. Six sessions of therapy, consisting of a combination of imagery techniques and imagery rescripting techniques, was used. In each session, participants completed a Mental Imagery in Psychosis Questionnaire (MIPQ) and imagery interview. Mood and delusional beliefs (PSYRATS) were also measured at each session.

Results:

Five participants with first episode psychosis completed the baseline visits and attended all therapy sessions. One participant declined the final assessment. Results demonstrated significant reductions in negative schematic beliefs, delusions, imagery distress and other measures of schema (YSQ, SMI). Although multiple baseline randomisation strengthens the study, it lacked a control arm and blind assessments.

Conclusions:

iMAPS appears a feasible and acceptable treatment for psychosis, and further evaluation is indicated.

Cognitive behavior therapy in early psychosis with a focus on depression and low self-esteem: A randomized controlled trial

BACKGROUND

Patients in early phases of psychosis often struggle with depressive symptoms and low self-esteem. The main aims of the present study were to examine whether cognitive behavior therapy (CBT) compared to treatment as usual (TAU) would reduce depressive symptoms (primary outcome) and increase self-esteem (secondary outcome). Furthermore, we wanted to examine whether CBT reduces symptoms measured with the PANSS (positive, negative, cognitive, or excited symptoms) or increases general functioning compared to TAU.

METHODS

A total of 63 early psychosis patients were included and randomly assigned to receive either CBT (maximum 26 sessions) or TAU for a period of up to six months. A linear mixed model was used for longitudinal analysis, with a focus on whether patients in the CBT group or the TAU group changed differently to one another between the baseline and 15-month follow-up.

RESULTS

There were no differences between the CBT group and TAU group regarding improvements in depressive symptoms measured with the Calgary Depression Scale for Schizophrenia (P = 0.188) or self-esteem measured with the Rosenberg Self-Esteem Scale (P = 0.580). However, patients in the CBT group improved significantly more on negative symptoms (P = 0.002) and social functioning (P = 0.001).

CONCLUSIONS

We did not find CBT to be more effective than TAU in reducing depressive symptoms or increasing self-esteem in patients with early psychosis. However, CBT seems to improve negative symptoms and functioning. These results still need to be replicated in further studies as the present one was merely an exploratory analysis. ClinicalTrials.gov Identifier: NCT01511406.

A health promotion intervention to improve lifestyle choices and health outcomes in people with psychosis: a research programme including the IMPaCT RCT

Background

People with psychotic disorders have reduced life expectancy largely because of physical health problems, especially cardiovascular disease, that are complicated by the use of tobacco and cannabis.

Objectives

We set out to (1) chart lifestyle and substance use choices and the emergence of cardiometabolic risk from the earliest presentation with psychosis, (2) develop a pragmatic health promotion intervention integrated within the clinical teams to improve the lifestyle choices and health outcomes of people with psychosis and (3) evaluate the clinical effectiveness and cost-effectiveness of that health promotion intervention.

Design

We performed a longitudinal cohort study of people presenting with their first episode of psychosis in three mental health trusts and followed up participants for 1 year [work package 1, physical health and substance use measures in first episode of psychosis (PUMP)]. We used an iterative Delphi methodology to develop and refine a modular health promotion intervention, improving physical health and reducing substance use in psychosis (IMPaCT) therapy, which was to be delivered by the patient’s usual care co-ordinator and used motivational interviewing techniques and cognitive–behavioural therapy to improve health choices of people with psychosis (work package 2). We then conducted a multicentre, two-arm, parallel-cluster, randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of using the intervention with people with established psychosis (work package 3: IMPaCT randomised controlled trial) in five UK mental health trusts. The work took place between 2008 and 2014.

Participants

All people aged between 16 and 65 years within 6 months of their first presentation with a non-organic psychosis and who were proficient in English were eligible for inclusion in the PUMP study. Participants in the work package 2 training development were staff selected from a range of settings, working with psychosis. Participants in the phase 3 Delphi consensus and manual development comprised three expert groups of (1) therapists/researchers recruited from the local and national community, (2) clinicians and (3) service users, each of whom took part in two iterative review and feedback sessions. For work package 3, IMPaCT randomised controlled trial, care co-ordinators in participating community mental health teams who were permanently employed and had a minimum of four eligible patients (i.e. aged between 18 and 65 years with a diagnosis of a psychotic disorder) on their caseload were eligible to participate. In studies 1 and 3, patient participants were ineligible if they were pregnant or had a major illness that would have had an impact on their metabolic status or if they had a significant learning disability. All participants were included in the study only after giving written confirmed consent.

Main outcome measures

Cardiometabolic risk markers, including rates of obesity and central obesity, and levels of glycated haemoglobin (HbA1c) and lipids, were the main outcomes in work package 1 (PUMP), with descriptive data presented on substance use. Our primary outcome measure for the IMPaCT randomised controlled trial was the physical or mental health component Short Form questionnaire-36 items quality-of-life scores at 12 months.

Results

Obesity rates rose from 18% at first presentation with psychosis to 24% by 1 year, but cardiometabolic risk was not associated with baseline lifestyle and substance use choices. Patterns of increase in the levels of HbA1c over the year following first presentation showed variation by ethnic group. We recruited 104 care co-ordinators, of whom 52 (with 213 patients) were randomised to deliver IMPaCT therapy and 52 (with 193 patients) were randomised to deliver treatment as usual, in keeping with our power calculations. Of these 406 participants with established psychosis, 318 (78%) and 301 (74%) participants, respectively, attended the 12- and 15-month follow-ups. We found no significant effect of IMPaCT therapy compared with treatment as usual on the physical or mental health component Short Form questionnaire-36 items scores at either time point in an intention-to-treat analysis [physical health score (‘d’) –0.17 at 12 months and –0.09 at 15 months; mental health score (‘d’) 0.03 at 12 months and –0.05 at 15 months] or on costs. Nor did we find an effect on other cardiovascular risk indicators, including diabetes, except in the case of high-density lipoprotein cholesterol, which showed a trend for greater benefit with IMPaCT therapy than with treatment as usual (treatment effect 0.085, 95% confidence interval 0.007 to 0.16; p = 0.034).

Limitations

Follow-up in work package 1 was challenging, with 127 out of 293 participants attending; however, there was no difference in cardiometabolic measures or demographic factors at baseline between those who attended for follow-up and those who did not. In work package 3, the IMPaCT randomised controlled trial, care co-ordinators struggled to provide additional time to their patients that was devoted to the health promotion intervention on top of their usual clinical care contact with them.

Conclusions

Cardiometabolic risk is prominent even soon after first presentation with psychosis and increases over time. Lifestyle choices and substance use habits at first presentation do not predict those who will be most cardiometabolically compromised 1 year later. Training and supervising care co-ordinators to deliver a health promotion intervention to their own patients on top of routine care is not effective in the NHS for improving quality of life or reducing cardiometabolic risk.

Future work

Further work is needed to develop and evaluate effective, cost-effective and affordable ways of preventing the emergence of and reversing existing cardiometabolic risk indicators in people with psychosis.

Trial registration

Current Controlled Trials ISRCTN58667926.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

Characterizing core beliefs in psychosis: a qualitative study

BACKGROUND

Cognitive behavioural treatments are recommended for people with psychosis. Core beliefs regarding the self and others are a key part of the models underpinning cognitive behavioural therapy but detailed understanding of these putative beliefs in people with psychosis are limited. A greater understanding of these mechanisms is necessary to improve and refine treatments.

AIMS

This study utilized a qualitative approach to explore core schematic beliefs in psychosis (strongly held positive and negative beliefs about the self and others) and their relation to hallucinations and delusions.

METHOD

Twenty individuals with psychosis participated in individual semi-structured interviews. Inductive thematic analysis was used to analyse the interviews.

RESULTS

Four emergent themes were identified: (i) the solidity and permanency of core beliefs, (ii) the causes and development of core beliefs, (iii) a synergistic relationship between core beliefs and symptoms, and (iv) core beliefs associated with images and their influence on psychotic symptoms.

CONCLUSIONS

This study provides new insights into the range and character of core beliefs in psychosis and provides important data to guide ongoing and future development of treatment approaches for psychosis.

Immediate and short term effects of values-based interventions on paranoia

BACKGROUND AND OBJECTIVES

Paranoia is a common, distressing, and persistent experience that can negatively impact on health, wellbeing, and functioning. This study examined the immediate and short term (2-weeks) effects of two values-based interventions, versus a non-values control, on paranoia, as well as the moderating effect of self-esteem.

METHODS

171 non-clinical adults were randomised to a value-affirmation and goals task (VAG: clarifying and reflecting on core values and setting value-based goals) (n = 57), a value-affirmation task (VA: clarifying and reflecting on core values without setting value-based goals) (n = 57), or a non-affirmation control task (NAC) (n = 57). Paranoia was assessed at baseline (T1), post-intervention (T2), and two weeks post-intervention (T3). Self-esteem was measured at baseline.

RESULTS

VAG participants had significantly lower state paranoia scores at T3 than VA (d = .34) and NAC (d = .31) participants. This effect was moderated by trait self-esteem: At follow-up, the differential effect of condition on state paranoia was greatest amongst those with low self-esteem, with the VAG condition being most beneficial for participants with low self-esteem and the VA condition being least beneficial.

LIMITATIONS

Without a goals only control group it is possible that the benefits of VAG over VA were attributable to setting and achieving goals. Use of a nonclinical sample limits generalisability to clinical groups.

CONCLUSIONS

The findings suggest that focusing on a deeply held value and setting goals in line with that value reduced paranoia. This intervention may be most beneficial for individuals with low self-esteem.

The cognitive, affective motivational and clinical longitudinal determinants of apathy in schizophrenia

Apathy is a frequent and debilitating condition with few treatment options available in schizophrenia patients. Despite evidence of its multidimensional structure, most of past studies have explored apathy through a categorical approach. The main objective of this study was to identify the cognitive, emotional, motivational, and clinical factors at baseline that best predicted the three subtypes of apathy dimensions at follow-up. In a longitudinal study, 137 participants diagnosed with schizophrenia underwent different assessments including clinical, motivational, affective and cognitive measurements, at 1-month (referred to as baseline) and 12-month follow-ups. Data were analyzed using partial least squares variance-based structural equation modeling. Three latent variables representing the three previously described domains of apathy reaching consensus in the literature were extracted from the Lille Apathy Rating Scale. Results showed that in addition to baseline apathy, positive symptoms, anticipatory pleasure and sensibility to punishment at baseline predicted cognitive apathy at follow-up. Likewise, both baseline apathy and sensibility to punishment predicted emotional apathy at follow-up. Finally, baseline anhedonia and episodic memory were the main variables the predicted behavioral apathy at follow-up. This is the first study to show specific associations between apathy subtypes and clinical and cognitive motivational dysfunction in individual with schizophrenia, indicating possible distinct underlying mechanisms to these demotivational symptoms. Treatment for apathy should address both types of processes. Importantly, our results demonstrate the interest of multidimensional approaches in the understanding of apathy in schizophrenia.

The weeks before 100 persecutory delusions: the presence of many potential contributory causal factors

BACKGROUND

The period before the formation of a persecutory delusion may provide causal insights. Patient accounts are invaluable in informing this understanding.

AIMS

To inform the understanding of delusion formation, we asked patients about the occurrence of potential causal factors - identified from a cognitive model - before delusion onset.

METHOD

A total of 100 patients with persecutory delusions completed a checklist about their subjective experiences in the weeks before belief onset. The checklist included items concerning worry, images, low self-esteem, poor sleep, mood dysregulation, dissociation, manic-type symptoms, aberrant salience, hallucinations, substance use and stressors. Time to reach certainty in the delusion was also assessed.

RESULTS

Most commonly it took patients several months to reach delusion certainty (n = 30), although other patients took a few weeks (n = 24), years (n = 21), knew instantly (n = 17) or took a few days (n = 6). The most frequent experiences occurring before delusion onset were: low self-confidence (n = 84); excessive worry (n = 80); not feeling like normal self (n = 77); difficulties concentrating (n = 77); going over problems again and again (n = 75); being very negative about the self (n = 75); images of bad things happening (n = 75); and sleep problems (n = 75). The average number of experiences occurring was high (mean 23.5, s.d. = 8.7). The experiences clustered into six main types, with patients reporting an average of 5.4 (s.d. = 1.0) different types.

CONCLUSIONS

Patients report numerous different experiences in the period before full persecutory delusion onset that could be contributory causal factors, consistent with a complex multifactorial view of delusion occurrence. This study, however, relied on retrospective self-report and could not determine causality.

DECLARATION OF INTEREST

None.

Treatable clinical intervention targets for patients with schizophrenia

BACKGROUND

Treatment approaches for patients with psychosis need major improvement. Our approach to improvement is twofold: target putative causal mechanisms for psychotic experiences that are treatable and also that patients wish treated. This leads to greater treatment engagement and clinical benefit. To inform mental health service provision we assessed the presence of treatable causal mechanisms and patient treatment preferences.

METHODS

Patients with non-affective psychosis attending NHS mental health services completed assessments of paranoia, hallucinations, anxious avoidance, worry, self-esteem, insomnia, analytic reasoning, psychological well-being, and treatment preferences.

RESULTS

1809 patients participated. Severe paranoia was present in 53.4% and frequent voices in 48.2%. Of the causal mechanisms, severe worry was present in 67.7%, avoidance at agoraphobic levels in 64.5%, analytic reasoning difficulties in 55.9%, insomnia in 50.1%, poor psychological well-being in 44.3%, strongly negative self-beliefs in 36.6%, and weak positive self-beliefs in 19.2%. Treatment target preferences were: feeling happier (63.2%), worrying less (63.1%), increasing self-confidence (62.1%), increasing activities (59.6%), improving decision-making (56.5%), feeling safer (53.0%), sleeping better (52.3%), and coping with voices (45.3%). Patients with current paranoia and/or hallucinations had higher levels of the causal factors and of wanting these difficulties treated.

CONCLUSIONS

Patients with non-affective psychosis have high levels of treatable problems such as agoraphobic avoidance, worry, low self-esteem, and insomnia and they would like these difficulties treated. Successful treatment of these difficulties is also likely to decrease psychotic experiences such as paranoia.

Post-psychotic depression: Paranoia and the damage done

To mitigate the often chronic course of schizophrenia and improve functional outcome, researchers are increasingly interested in prodromal states and psychological risk factors that may predict the outbreak of psychotic symptoms, but are also amenable to change. In recent years, depressive symptoms have been proposed as precursors of psychosis and some interventional studies indicate that the amelioration of depressive symptoms and depression-related thinking styles (e.g., worrying) improves positive symptoms, thereby "killing two birds with one stone". Yet, in a prior study, we were unable to find a strong specific predictive role of depression on paranoia over three years, which may have been due to the use of a nonclinical sample with minimal/mild symptom fluctuations. To address this further, in the present study we adopted a similar methodological approach but assessed a large patient sample with a schizophrenia spectrum disorder at three assessment points; baseline (N = 250), 6 weeks later (n = 207, 82.8% retention) and 6 months after baseline (n = 185, 74% retention). Using cross-lagged modeling, we assessed paranoia with the respective items from the Positive and Negative Syndrome Scale (PANSS) and the Psychosis Rating Scales (PSYRATS) delusions subscale. Depression was measured using the Patient Health Questionnaire-9 (PHQ-9) and the Calgary Depression Scale for Schizophrenia (CDSS). We could identify a significant pathway from depression to paranoia from baseline to post (negative association) but not from post to follow-up. Paranoia significantly predicted depressive symptoms for both intervals. Our findings do not refute claims that depression may precede or even predict psychosis, but such a linkage does not seem to be ubiquitous.

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.

The relationship between insecure attachment and paranoia in psychosis: A systematic literature review

Objectives

Paranoia is a key symptom in psychosis and associated with a range of poor outcomes. Earlier life experiences increase vulnerability to paranoid thinking, and attachment theory has been proposed as a key model in explaining this causal pathway. Previous reviews highlight evidence of associations between insecure attachment styles and overall severity of psychotic symptoms. Studies report on associations between insecure attachment and paranoia, but to date, this literature has not been adequately synthesized. The aim of the current review was to report the strength and consistency of associations between paranoia and insecure attachment across published studies, and provide systematic appraisal of study quality.

Method

We carried out a systematic review of electronic databases using search terms to capture concepts of adult attachment, paranoia, and psychosis. We pre‐registered the review protocol and followed PRISMA guidelines.

Results

Significant associations were reported in 11 out of 12 studies between an insecure attachment and paranoia, with associations remaining significant in studies that controlled for comorbid symptoms. The strongest, most commonly reported relationship was between an anxious attachment style and paranoia.

Conclusions

The findings support the proposed role of attachment insecurity in the development and maintenance of paranoia in psychosis and highlight the need to address insecure attachment representations in the treatment of paranoia.

Practitioner points

There is consistent evidence of associations between insecure attachment style and paranoia.

Insecure anxious attachment is more consistently associated with paranoia than an insecure avoidant attachment.

Associations between attachment and paranoia remain significant when key confounders are controlled for in the analyses.

Interventions that address insecure attachment representations and promote a more secure attachment are likely to help reduce paranoia.

The challenge of well-being and quality of life: A meta-analysis of psychological interventions in schizophrenia

Well-being is a critical outcome in the recovery from psychosis and the prevention of symptoms. Previous reviews of the effectiveness of psychological interventions have focused on psychotic symptoms and general psychopathology, not recognising well-being as an essential outcome. This study conducted a meta-analysis of the effects of psychological interventions on the well-being and quality of life (QoL) of people with schizophrenia and analysed some critical moderating factors. A systematic literature search was conducted yielding 12986 published reports, 2043 of which were clinical trials. After a detailed review, 36 articles were included in the analyses. Measures of related concepts, well-being and quality of life were included in the present meta-analysis to reflect the current state of the literature and to ensure the representativeness of RCTs that have evaluated the effect of psychological interventions on the extent to which people with schizophrenia experience a good life. Our findings reflect a significant, small, treatment effect on the outcomes of well-being. Subgroup analysis also suggested a significant moderating effect when the primary aim of the intervention was well-being. These findings suggest that symptom or functional improvement does not necessarily lead to an improvement in well-being and would imply the need to focus specifically on those. We recommend psychological interventions that target well-being as a complementary strategy in mental health promotion and treatment. In addition, we stress the need to include well-being outcome measure in RCT as well as to clearly identify the different domains of well-being being measured.

A systematic review and discussion of symptom specific cognitive behavioural approaches to delusions and hallucinations

Studies on cognitive behavioural therapy for psychosis (CBTp) have developed from evaluating generic approaches to focusing on specific symptoms. The evidence for targeted studies on delusions and hallucinations was reviewed. We included randomized controlled trials (RCTs) examining the effect of individualized CBT-based interventions focusing either on delusions or on hallucinations. Twelve suitable RCTs were identified. Four RCTs focused on delusions, of which three took a focused approach targeting mechanisms assumed causal to persecutory delusions. Eight RCTs focused on hallucinations, a common component of these studies being a focus on the perceived power imbalance between the voice(s) and the voice-hearer, to reduce distress and dysfunction. Only three RCTS were powered adequately; the remainder were pilot trials. All trials reported effect sizes against treatment-as-usual above d=0.4 on at least one primary outcome at post-therapy, with several effects in the large range. Effects on the primary outcome were maintained for five of the seven studies that had significant outcomes and reported a follow-up comparison, but most of the follow-up periods were brief. Although targeted studies are still in their infancy, the results are promising with a tendency towards higher effects compared to the small-to-moderate range found for generic CBTp. In clinical practice, CBTp will need to continue including a range of approaches that can be adapted to patients in a flexible manner according to the primary goals and prevalent combination of symptoms. However, symptom-focused and causal-interventionist approaches are informative research strategies to evaluate the efficacy of separate components or mechanisms of generic CBTp.

Cognitive behavioural therapy plus standard care versus standard care for people with schizophrenia

BACKGROUND

Cognitive behavioural therapy (CBT) is a psychosocial treatment that aims to re-mediate distressing emotional experiences or dysfunctional behaviour by changing the way in which a person interprets and evaluates the experience or cognates on its consequence and meaning. This approach helps to link the person's feelings and patterns of thinking which underpin distress. CBT is now recommended by the National Institute for Health and Care Excellence (NICE) as an add-on treatment for people with a diagnosis of schizophrenia. This review is also part of a family of Cochrane CBT reviews for people with schizophrenia.

OBJECTIVES

To assess the effects of cognitive behavioural therapy added to standard care compared with standard care alone for people with schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (up to March 6, 2017). This register is compiled by systematic searches of major resources (including AMED, BIOSIS CINAHL, Embase, MEDLINE, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register.

SELECTION CRITERIA

We selected all randomised controlled clinical trials (RCTs) involving people diagnosed with schizophrenia or related disorders, which compared adding CBT to standard care with standard care given alone. Outcomes of interest included relapse, rehospitalisation, mental state, adverse events, social functioning, quality of life, and satisfaction with treatment.We included studies fulfilling the predefined inclusion criteria and reporting useable data.

DATA COLLECTION AND ANALYSIS

We complied with the Cochrane recommended standard of conduct for data screening and collection. Where possible, we calculated relative risk (RR) and its 95% confidence interval (CI) for binary data and mean difference (MD) and its 95% confidence interval for continuous data. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

This review now includes 60 trials with 5,992 participants, all comparing CBT added to standard care with standard care alone. Results for the main outcomes of interest (all long term) showed no clear difference between CBT and standard care for relapse (RR 0.78, 95% CI 0.61 to 1.00; participants = 1538; studies = 13, low-quality evidence). Two trials reported global state improvement. More participants in the CBT groups showed clinically important improvement in global state (RR 0.57, 95% CI 0.39 to 0.84; participants = 82; studies = 2 , very low-quality evidence). Five trials reported mental state improvement. No differences in mental state improvement were observed (RR 0.81, 95% CI 0.65 to 1.02; participants = 501; studies = 5, very low-quality evidence). In terms of safety, adding CBT to standard care may reduce the risk of having an adverse event (RR 0.44, 95% CI 0.27 to 0.72; participants = 146; studies = 2, very low-quality evidence) but appears to have no effect on long-term social functioning (MD 0.56, 95% CI -2.64 to 3.76; participants = 295; studies = 2, very low-quality evidence, nor on long-term quality of life (MD -3.60, 95% CI -11.32 to 4.12; participants = 71; study = 1, very low-quality evidence). It also has no effect on long-term satisfaction with treatment (measured as 'leaving the study early') (RR 0.93, 95% CI 0.77 to 1.12; participants = 1945; studies = 19, moderate-quality evidence).

AUTHORS' CONCLUSIONS

Relative to standard care alone, adding CBT to standard care appears to have no effect on long-term risk of relapse. A very small proportion of the available evidence indicated CBT plus standard care may improve long term global state and may reduce the risk of adverse events. Whether adding CBT to standard care leads to clinically important improvement in patients' long-term mental state, quality of life, and social function remains unclear. Satisfaction with care (measured as number of people leaving the study early) was no higher for participants receiving CBT compared to participants receiving standard care. It should be noted that although much research has been carried out in this area, the quality of evidence available is poor - mostly low or very low quality and we still cannot make firm conclusions until more high quality data are available.

Negative schemata about the self and others and paranoid ideation in at-risk states and those with persisting positive symptoms

BACKGROUND

The objective of this study is to test the conflicting theories concerning the association of negative self and other schemata and paranoid ideation.

METHODS

A risk-based approach, including risk stratification, is used to gain insight into the association of the negative self and other schemata that may be shared by individuals or differentiate between individuals at clinical high risk (CHR) for a first-episode psychosis and those with full-blown psychosis. The dataset includes a sample of individuals at CHR (n = 137) and a sample of individuals with persisting positive symptoms (PPS, n = 211). The CHR sample was subdivided according to a prognostic index yielding 4 CHR sub-classes with increasing risk for transition to psychosis.

RESULTS

Negative beliefs about the self were associated with paranoid ideation in CHR and a lower risk state. In the highest risk state and full-blown psychosis, there is an association with negative beliefs about others.

CONCLUSION

These findings are in line with theories suggesting a switch from a predominantly activated negative self-schema to a malevolent others-schema in association with paranoid ideation along the risk-continuum. However, due to methodological limitations these results should be replicated by future studies.

The paranoia as defence model of persecutory delusions: a systematic review and meta-analysis

BACKGROUND

An influential psychological model of persecutory delusions proposed that they are caused by a bias towards holding others responsible for negative events (an externalising attributional bias), preventing the individual from becoming aware of underlying low self-esteem. An early version of the model predicted self-esteem would, therefore, be preserved in people with these delusions, but a later version suggested it would be unstable, and that there would be a discrepancy between explicit and implicit self-esteem, with the latter being lower. We did a comprehensive meta-analytical test of the key predictions of this model and assessed the quality of evidence.

METHODS

We searched PubMed from Jan 1, 1994, to July 31, 2018, and collated systematic reviews of the defensive model's predictions in relation to persecutory delusions. We also searched PsycINFO, MEDLINE, Embase, and Web of Science for articles published from Jan 1, 2012, to Sept 10, 2016. Cross-sectional data from case-control, longitudinal, or experimental studies that examined self-esteem or the externalising attributional bias in individuals diagnosed as having schizophrenia-spectrum disorder were eligible for meta-analyses of group differences if at least 50% of participants with psychosis also had current persecutory delusions. Uncontrolled and longitudinal studies were included in meta-analyses of correlations and self-esteem instability, respectively. Study and outcome quality were assessed with the Agency for Healthcare Research and Quality assessment tool, and a modified version of Grading of Recommendations Assessment, Development and Evaluation, respectively. The study protocol is registered with PROSPERO, number CRD42016032782.

FINDINGS

We screened 3053 records, examined 104 full-text reports, and included 64 eligible studies. Consistent with the predictions of both versions of the model, paranoia severity in psychosis was positively correlated with the degree of externalising attributional bias (21 studies involving 1128 individuals; r=0·18, 95% CI 0·08 to 0·27, with moderate quality evidence). People with persecutory delusions also had a greater externalising attributional bias than non-clinical individuals (27 studies involving 1442 individuals; g=0·48, 95% CI 0·23 to 0·73) and depressed individuals (ten studies involving 421 individuals; g=1·06, 0·48 to 1·63), and people with psychosis without persecutory delusions (11 studies involving 480 individuals; g=0·40, 0·12 to 0·68), all based on moderate quality evidence. Contrary to the predictions in the early version of the model, paranoia severity in psychosis was negatively correlated with explicit self-esteem (23 studies involving 1866 individuals; r=-0·26, 95% CI -0·34 to -0·17, with high quality evidence). People with persecutory delusions also had lower explicit self-esteem than non-clinical individuals (22 studies involving 1256 individuals; g=-0·88, 95% CI -1·10 to -0·66, with high quality evidence) and explicit self-esteem similarly low to that in people with psychosis without persecutory delusions (11 studies involving 644 individuals; g=-0·26, -0·54 to 0·02, with moderate quality evidence). Consistent with the predictions in the later version of the model, self-esteem instability was positively correlated with paranoia severity in psychosis (four studies involving 508 individuals; r=0·23, 95% CI 0·11-0·34, with high quality evidence), and people with persecutory delusions had a greater discrepancy between their implicit and explicit self-esteem than depressed individuals (seven studies involving 398 individuals; g=0·61, 95% CI 0·37 to 0·85, with moderate quality evidence). They had higher explicit self-esteem than depressed individuals (13 studies involving 647 individuals; g=0·89, 95% CI 0·51 to 1·28, with moderate quality evidence), but similarly low implicit self-esteem (seven studies involving 398 individuals; g=-0·19, -0·45 to 0·07, with low quality evidence). In contrast to the later predictions, people with persecutory delusions did not have a greater self-esteem discrepancy than non-clinical individuals (ten studies involving 592 individuals; g=-0·17, 95% CI -0·45 to 0·12), although the evidence was very low quality. People with psychosis with or without persecutory delusions did not differ for implicit self-esteem (four studies involving 167 individuals; g=-0·24, 95% CI -0·77 to 0·30, with low quality evidence) or self-esteem discrepancies (four studies involving 165 individuals; g=0·17, -0·19 to 0·53, with moderate quality evidence).

INTERPRETATION

The predictions that self-esteem would be preserved in people with persecutory delusions in the early version of the paranoia as defence model and that implicit-explicit self-esteem discrepancy would be greater in people with persecutory delusions than in non-clinical individuals and people with psychosis without persecutory delusions in the later version of the model were not supported. By contrast, the later version correctly predicted that people with persecutory delusions have a greater self-esteem discrepancy than people with depression and a greater externalising attributional bias than all control groups, and that both this bias and self-esteem instability are associated with increased paranoia severity. Nevertheless, the reviewed data had limitations. Experimental studies, which might include interventionist-causal trials, are needed.

FUNDING

None.

Psychological interventions to reduce positive symptoms in schizophrenia: systematic review and network meta-analysis

Psychological treatments are increasingly regarded as useful interventions for schizophrenia. However, a comprehensive evaluation of the available evidence is lacking and the benefit of psychological interventions for patients with current positive symptoms is still debated. The present study aimed to evaluate the efficacy, acceptability and tolerability of psychological treatments for positive symptoms of schizophrenia by applying a network meta-analysis approach, that can integrate direct and indirect comparisons. We searched EMBASE, MEDLINE, PsycINFO, PubMed, BIOSIS, Cochrane Library, World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov for randomized controlled trials of psychological treatments for positive symptoms of schizophrenia, published up to January 10, 2018. We included studies on adults with a diagnosis of schizophrenia or a related disorder presenting positive symptoms. The primary outcome was change in positive symptoms measured with validated rating scales. We included 53 randomized controlled trials of seven psychological interventions, for a total of 4,068 participants receiving the psychological treatment as add-on to antipsychotics. On average, patients were moderately ill at baseline. The network meta-analysis showed that cognitive behavioural therapy (40 studies) reduced positive symptoms more than inactive control (standardized mean difference, SMD=-0.29; 95% CI: -0.55 to -0.03), treatment as usual (SMD=-0.30; 95% CI: -0.45 to -0.14) and supportive therapy (SMD=-0.47; 95% CI: -0.91 to -0.03). Cognitive behavioural therapy was associated with a higher dropout rate compared with treatment as usual (risk ratio, RR=0.74; 95% CI: 0.58 to 0.95). Confidence in the estimates ranged from moderate to very low. The other treatments contributed to the network with a lower number of studies. Results were overall consistent in sensitivity analyses controlling for several factors, including the role of researchers' allegiance and blinding of outcome assessor. Cognitive behavior therapy seems to be effective on positive symptoms in moderately ill patients with schizophrenia, with effect sizes in the lower to medium range, depending on the control condition.

Remission of depression in patients with schizophrenia and comorbid major depressive disorder: results from the FACE-SZ cohort

BACKGROUND

Major depressive disorder (MDD) is underdiagnosed and undertreated in schizophrenia, and has been strongly associated with impaired quality of life.AimsTo determine the prevalence and associated factors of MDD and unremitted MDD in schizophrenia, to compare treated and non-treated MDD.

METHOD

Participants were included in the FondaMental Expert Centers for Schizophrenia and received a thorough clinical assessment. MDD was defined by a Calgary score ≥6. Non-remitted MDD was defined by current antidepressant treatment (unchanged for >8 weeks) and current Calgary score ≥6.

RESULTS

613 patients were included and 175 (28.5%) were identified with current MDD. MDD has been significantly associated with respectively paranoid delusion (odds ratio 1.8; P = 0.01), avolition (odds ratio 1.8; P = 0.02), blunted affect (odds ratio 1.7; P = 0.04) and benzodiazepine consumption (odds ratio 1.8; P = 0.02). Antidepressants were associated with lower depressive symptoms score (5.4 v. 9.5; P < 0.0001); however, 44.1% of treated patients remained in non-remittance MDD. Nonremitters were found to have more paranoid delusion (odds ratio 2.3; P = 0.009) and more current alcohol misuse disorder (odds ratio 4.8; P = 0.04). No antidepressant class or specific antipsychotic were associated with higher or lower response to antidepressant treatment. MDD was associated with Metabolic syndrome (31.4 v. 20.2%; P = 0.006) but not with increased C-reactive protein.

CONCLUSIONS

Antidepressant administration is associated with lower depressive symptom level in patients with schizophrenia and MDD. Paranoid delusions and alcohol misuse disorder should be specifically explored and treated in cases of non-remission under treatment. MetS may play a role in MDD onset and/or maintenance in patients with schizophrenia.Declaration of interestNone.