Social cognitive group treatment for impaired insight in psychosis: A multicenter randomized controlled trial

Analysis of the effectiveness of cognitive rehabilitation for patients with chronic mental illness: A meta-analysis

BACKGROUND

People suffering from chronic mental illness are sensitive to stressful stimuli, lack coping skills, and have low self-esteem due to problems such as social situations. They also experience depression, isolation, fear, and frustration. Due to cognitive dysfunction, people suffering from chronic mental illness have inadequate cognitive processes that lead to distorted thinking.

AIM

To confirm the effectiveness of cognitive rehabilitation therapy in improving cognitive function and alleviating behavioral and psychological symptoms in patients with chronic mental illness, and to identify the cognitive function that had the main effect.

METHODS

The quality of the studies was evaluated using the Assessment of Multiple Systematic Reviews criteria, and data published from 2011 to December 2022 were searched using PubMed, Cochrane, RISS, KISS, and DBpia. The keywords used in the search were “mental illness,” “cognitive rehabilitation,” “cognition,” and “mental.” A meta-analysis was conducted on the 12 selected papers.

RESULTS

The level of evidence for the 12 documents was that of a randomized experimental study. Intervention types in cognitive rehabilitation can be divided into cognitive behavior, cognitive training, cognitive rehabilitation, and computerized cognitive programs. Most of the studies were on schizophrenia, and the measurement areas were cognitive functions (e.g., concentration, memory, and executive function) as well as depression, sociability, and quality of life. As a result of the meta-analysis of each variable, the effect size for cognitive rehabilitation treatment was in the following order: Sociability, memory, concentration, executive function, quality of life, and depression. Particularly, sociability and memory exhibited significant effects.

CONCLUSION

Cognitive rehabilitation aids cognitive function and sociability in patients with chronic mental illness and can be used as evidence for cognitive rehabilitation in mental health and occupational therapy.

Manualized group cognitive behavioral therapy for social anxiety in first-episode psychosis: a randomized controlled trial

BACKGROUND

Social anxiety (SA), a prevalent comorbid condition in psychotic disorders with a negative impact on functioning, requires adequate intervention relatively early. Using a randomized controlled trial, we tested the efficacy of a group cognitive-behavioral therapy intervention for SA (CBT-SA) that we developed for youth who experienced the first episode of psychosis (FEP). For our primary outcome, we hypothesized that compared to the active control of group cognitive remediation (CR), the CBT-SA group would show a reduction in SA that would be maintained at 3- and 6-month follow-ups. For secondary outcomes, it was hypothesized that the CBT-SA group would show a reduction of positive and negative symptoms and improvements in recovery and functioning.

METHOD

Ninety-six patients with an FEP and SA, recruited from five different FEP programs in the Montreal area, were randomized to 13 weekly group sessions of either CBT-SA or CR intervention.

RESULTS

Linear mixed models revealed that multiple measures of SA significantly reduced over time, but with no significant group differences. Positive and negative symptoms, as well as functioning improved over time, with negative symptoms and functioning exhibiting a greater reduction in the CBT-SA group.

CONCLUSIONS

While SA decreased over time with both interventions, a positive effect of the CBT-SA intervention on measures of negative symptoms, functioning, and self-reported recovery at follow-up suggests that our intervention had a positive effect that extended beyond symptoms specific to SA.ClinicalTrials.gov identifier: NCT02294409.

Cognitive behavioural therapy (group) for schizophrenia

BACKGROUND

Schizophrenia is a disabling psychotic disorder characterised by positive symptoms of delusions, hallucinations, disorganised speech and behaviour; and negative symptoms such as affective flattening and lack of motivation. Cognitive behavioural therapy (CBT) is a psychological intervention that aims to change the way in which a person interprets and evaluates their experiences, helping them to identify and link feelings and patterns of thinking that underpin distress. CBT models targeting symptoms of psychosis (CBTp) have been developed for many mental health conditions including schizophrenia. CBTp has been suggested as a useful add-on therapy to medication for people with schizophrenia. While CBT for people with schizophrenia was mainly developed as an individual treatment, it is expensive and a group approach may be more cost-effective. Group CBTp can be defined as a group intervention targeting psychotic symptoms, based on the cognitive behavioural model. In group CBTp, people work collaboratively on coping with distressing hallucinations, analysing evidence for their delusions, and developing problem-solving and social skills. However, the evidence for effectiveness is far from conclusive.

OBJECTIVES

To investigate efficacy and acceptability of group CBT applied to psychosis compared with standard care or other psychosocial interventions, for people with schizophrenia or schizoaffective disorder.

SEARCH METHODS

On 10 February 2021, we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, four other databases and two trials registries. We handsearched the reference lists of relevant papers and previous systematic reviews and contacted experts in the field for supplemental data.

SELECTION CRITERIA

We selected randomised controlled trials allocating adults with schizophrenia to receive either group CBT for schizophrenia, compared with standard care, or any other psychosocial intervention (group or individual).

DATA COLLECTION AND ANALYSIS

We complied with Cochrane recommended standard of conduct for data screening and collection. Where possible, we calculated risk ratio (RR) and 95% confidence interval (CI) for binary data and mean difference (MD) and 95% CI for continuous data. We used a random-effects model for analyses. We assessed risk of bias for included studies and created a summary of findings table using GRADE.

MAIN RESULTS

The review includes 24 studies (1900 participants). All studies compared group CBTp with treatments that a person with schizophrenia would normally receive in a standard mental health service (standard care) or any other psychosocial intervention (group or individual). None of the studies compared group CBTp with individual CBTp. Overall risk of bias within the trials was moderate to low. We found no studies reporting data for our primary outcome of clinically important change. With regard to numbers of participants leaving the study early, group CBTp has little or no effect compared to standard care or other psychosocial interventions (RR 1.22, 95% CI 0.94 to 1.59; studies = 13, participants = 1267; I2 = 9%; low-certainty evidence). Group CBTp may have some advantage over standard care or other psychosocial interventions for overall mental state at the end of treatment for endpoint scores on the Positive and Negative Syndrome Scale (PANSS) total (MD -3.73, 95% CI -4.63 to -2.83; studies = 12, participants = 1036; I2 = 5%; low-certainty evidence). Group CBTp seems to have little or no effect on PANSS positive symptoms (MD -0.45, 95% CI -1.30 to 0.40; studies =8, participants = 539; I2 = 0%) and on PANSS negative symptoms scores at the end of treatment (MD -0.73, 95% CI -1.68 to 0.21; studies = 9, participants = 768; I2 = 65%). Group CBTp seems to have an advantage over standard care or other psychosocial interventions on global functioning measured by Global Assessment of Functioning (GAF; MD -3.61, 95% CI -6.37 to -0.84; studies = 5, participants = 254; I2 = 0%; moderate-certainty evidence), Personal and Social Performance Scale (PSP; MD 3.30, 95% CI 2.00 to 4.60; studies = 1, participants = 100), and Social Disability Screening Schedule (SDSS; MD -1.27, 95% CI -2.46 to -0.08; studies = 1, participants = 116). Service use data were equivocal with no real differences between treatment groups for number of participants hospitalised (RR 0.78, 95% CI 0.38 to 1.60; studies = 3, participants = 235; I2 = 34%). There was no clear difference between group CBTp and standard care or other psychosocial interventions endpoint scores on depression and quality of life outcomes, except for quality of life measured by World Health Organization Quality of Life Assessment Instrument (WHOQOL-BREF) Psychological domain subscale (MD -4.64, 95% CI -9.04 to -0.24; studies = 2, participants = 132; I2 = 77%). The studies did not report relapse or adverse effects.

AUTHORS' CONCLUSIONS

Group CBTp appears to be no better or worse than standard care or other psychosocial interventions for people with schizophrenia in terms of leaving the study early, service use and general quality of life. Group CBTp seems to be more effective than standard care or other psychosocial interventions on overall mental state and global functioning scores. These results may not be widely applicable as each study had a low sample size. Therefore, no firm conclusions concerning the efficacy of group CBTp for people with schizophrenia can currently be made. More high-quality research, reporting useable and relevant data is needed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An Update on Clinical Insight, Cognitive Insight, and Introspective Accuracy in Schizophrenia-Spectrum Disorders: Symptoms, Cognition, and Treatment

INTRODUCTION

Poor insight, or unawareness of morbid changes in cognition, emotional states, or behavior, is commonly observed among people with schizophrenia. Poor insight represents a persistent barrier to wellness because it interferes with treatment and self-direction. Paradoxically, good insight may also be a barrier to health when awareness of these changes leads to depression or self-stigma.

AREAS COVERED

This paper builds upon this previous work by exploring these issues in schizophrenia separately as they have appeared in published research over the last three years in three different kinds of insight: clinical, cognition, and introspective accuracy. Specifically, studies are reviewed that address: the adverse effects of poor insight, the paradoxical effects of good insight, correlates with other forms of cognition, and emerging treatments.

EXPERT OPINION

The evidence continues to offer a nuanced picture of the complex effects of good insight in schizophrenia. Incremental improvements were also found in the development of novel integrative treatment approaches. This work also highlights the intricacy of the concept of insight, the need for further exploration of the effects of culture, and conceptual work that distinguishes the points of convergence and divergence of these forms of insight.

Insight and the number of completed modules predict a reduction of positive symptoms in an Internet-based intervention for people with psychosis

Emerging evidence suggests that Internet-based interventions for people with psychosis (ICBTp) are feasible and efficacious. However, predictors of adherence and treatment outcomes are largely unknown. To narrow this research gap, we conducted secondary analyses on data from a randomized controlled trial, which evaluated an eight-week ICBTp intervention targeting topics, such as voice hearing, mindfulness, and others. In n = 100 participants with psychosis, we aimed at identifying sociodemographic, psychopathological, and treatment-related predictor variables of post-treatment symptoms and adherence (i.e., at least four completed modules). We followed a two-stage approach. First, we conducted regression analyses to examine the effect of single candidate predictors on post-treatment symptoms as well as adherence. Subsequently, we selected variables that met a significance threshold of p < .1 and entered them into linear and logistic multiple regression models. Whereas no variable was able to predict adherence, the number of completed modules was negatively associated with self-reported delusion severity at post-treatment. Additionally, higher pre-treatment insight predicted fewer hallucinations after treatment. Because this was one of the first studies to investigate predictors in ICBTp, more research is needed to customize future interventions to the needs of users.

Pharmacotherapy for Neuropsychiatric Symptoms in Frontotemporal Dementia

Despite significant progress in the understanding of the frontotemporal dementias (FTDs), there remains no disease-modifying treatment for these conditions, and limited effective symptomatic treatment. Behavioural variant frontotemporal dementia (bvFTD) is the most common FTD syndrome, and is characterized by severe impairments in behaviour, personality and cognition. Neuropsychiatric symptoms are common features of bvFTD but are present in the other FTD syndromes. Current treatment strategies therefore focus on ameliorating the neuropsychiatric features. Here we review the rationale for current treatments related to each of the main neuropsychiatric symptoms forming the diagnostic criteria for bvFTD relevant to all FTD subtypes, and two additional symptoms not currently part of the diagnostic criteria: lack of insight and psychosis. Given the paucity of effective treatments for these symptoms, we highlight how contributing mechanisms delineated in cognitive neuroscience may inform future approaches to clinical trials and more precise symptomatic treatments for FTDs.

Cognitive insight in psychotic patients institutionalized and living in the community: an examination using the Beck Cognitive Insight Scale

Improving cognitive insight can reduce delusions in patients with psychotic disorders. Although institutionalized patients usually have more severe delusions than outpatients, little is known about the differences in cognitive insight between these two groups. In this study, we evaluated the psychometric properties of the Beck Cognitive Insight Scale (BCIS) for a sample of Portuguese patients with psychotic disorders and compared the cognitive insight of institutionalized patients with patients living in the community. Participants in this study were 150 patients diagnosed with psychotic disorder (78 institutionalized patients and 72 outpatients). The tested model of the BCIS was a very good fit. Our study shows that patients living in the community showed higher levels of cognitive insight (total BCIS and self-reflectiveness) than institutionalized patients. Future studies assessing cognitive insight should take into account differences between the cognitive insights of institutionalized psychotic patients and psychotic patients living in the community.

Can metacognitive interventions improve insight in schizophrenia spectrum disorders? A systematic review and meta-analysis

BACKGROUND

Patients with schizophrenia spectrum disorders (SSD) tend to lack insight, which is linked to poor outcomes. The effect size of previous treatments on insight changes in SSD has been small. Metacognitive interventions may improve insight in SSD, although this remains unproved.

METHODS

We carried out a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the effects of metacognitive interventions designed for SSD, namely Metacognitive Training (MCT) and Metacognitive Reflection and Insight Therapy (MERIT), on changes in cognitive and clinical insight at post-treatment and at follow-up.

RESULTS

Twelve RCTs, including 10 MCT RCTs (n = 717 participants) and two MERIT trials (n = 90), were selected, totalling N = 807 participants. Regarding cognitive insight six RCTs (n = 443) highlighted a medium effect of MCT on self-reflectiveness at post-treatment, d = 0.46, p < 0.01, and at follow-up, d = 0.30, p < 0.01. There was a small effect of MCT on self-certainty at post-treatment, d = -0.23, p = 0.03, but not at follow-up. MCT was superior to controls on an overall Composite Index of cognitive insight at post-treatment, d = 1.11, p < 0.01, and at follow-up, d = 0.86, p = 0.03, although we found evidence of heterogeneity. Of five MCT trials on clinical insight (n = 244 participants), which could not be meta-analysed, four of them favoured MCT compared v. control. The two MERIT trials reported conflicting results.

CONCLUSIONS

Metacognitive interventions, particularly Metacognitive Training, appear to improve insight in patients with SSD, especially cognitive insight shortly after treatment. Further long-term RCTs are needed to establish whether these metacognitive interventions-related insight changes are sustained over a longer time period and result in better outcomes.

Insight and psychosis: the next 30 years

Academic interest in the concept of insight in psychosis has increased markedly over the past 30 years, prompting this selective appraisal of the current state of the art. Considerable progress has been made in terms of measurement and confirming a number of clinical associations. More recently, the relationship between insight and involuntary treatment has been scrutinised more closely alongside the link between decision-making capacity and insight. Advances in the clinical and cognitive neurosciences have influenced conceptual development, particularly the field of 'metacognition'. New therapies, including those that are psychologically and neurophysiologically based, are being tested as ways to enhance insight.

Study protocol of a randomised clinical trial testing whether metacognitive training can improve insight and clinical outcomes in schizophrenia

BACKGROUND

Although insight in schizophrenia spectrum disorders (SSD) has been associated with positive outcomes, the effect size of previous treatments on insight has been relatively small to date. The metacognitive basis of insight suggests that metacognitive training (MCT) may improve insight and clinical outcomes in SSD, although this remains to be established.

METHODS

This single-center, assessor-blind, parallel-group, randomised clinical trial (RCT) aims to investigate the efficacy of MCT for improving insight (primary outcome), including clinical and cognitive insight, which will be measured by the Schedule for Assessment of Insight (Expanded version) (SAI-E) and the Beck Cognitive Scale (BCIS), respectively, in (at least) n = 126 outpatients with SSD at three points in time: i) at baseline (T0); ii) after treatment (T1) and iii) at 1-year follow-up (T2). SSD patients receiving MCT and controls attending a non-intervention support group will be compared on insight level changes and several clinical and cognitive secondary outcomes at T1 and T2, whilst adjusting for baseline data. Ecological momentary assessment (EMA) will be piloted to assess functioning in a subsample of participants.

DISCUSSION

To the best of our knowledge, this will be the first RCT testing the effect of group MCT on multiple insight dimensions (as primary outcome) in a sample of unselected patients with SSD, including several secondary outcomes of clinical relevance, namely symptom severity, functioning, which will also be evaluated with EMA, hospitalizations and suicidal behaviour.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04104347. Date of registration: 26/09/2019 (Retrospectively registered).

Brain function differences in drug-naïve first-episode auditory verbal hallucination-schizophrenia patients with versus without insight

Background:

Few studies have reported brain function differences in drug-naïve first-episode schizophrenia patients who had auditory verbal hallucinations (AVH) with insight vs. those without insight. This study aimed to investigate brain function differences between drug-naïve first-episode AVH-schizophrenia patients with and without insight.

Methods:

Forty first-episode drug-naïve AVH-schizophrenia patients with or without insight and 40 healthy controls between December 2016 and December 2018 were recruited in this study. The auditory hallucinations rating scale (AHRS) was used to assess AVH severity, while the insight and treatment attitudes questionnaire was used to distinguish insight. The global functional connectivity density (gFCD) between different groups was compared using a voxel-wise one-way analysis of covariance. The relationship between gFCD and AHRS total scores were analyzed using voxel-wise multiple regression.

Results:

Finally, 13 first-episode drug-naïve AVH-schizophrenia patients with insight, 15 AVH-schizophrenia patients without insight, and 20 healthy controls were included for analysis. Except for global assessment of functioning scores, there were no significant differences in sociodemographic information between the AVH-schizophrenia and healthy groups (P > 0.05). Compared to the healthy controls, AVH-schizophrenia patients with insight demonstrated a decreased gFCD in the supra-marginal gyrus within the primary auditory cortex, while those without insight demonstrated an increased gFCD in the inferior frontal gyrus and superior temporal gyrus and decreased gFCD in the supplemental motor area. Compared to the AVH-schizophrenia patients with insight, those without insight demonstrated an increased gFCD in the supra-marginal gyrus and posterior superior temporal lobule and a decreased gFCD in the frontal lobe. No significant correlation between gFCD and AVH severity (AHRS total score: r = 0.23, P = 0.590; and frequency: r = 0.42, P = 0.820) was found in both AVH-schizophrenia groups.

Conclusions:

The gFCD-aberrant brain regions in the AVH-schizophrenia patients without insight were wider compared to those with insight, although the AHRS scores were not significantly different. The AVH-schizophrenia patients without insight had wide functional impairment in the frontal lobule, which may underlie the lack of insight and the abnormal hyperactivity in the inferior frontal gurus and temporal lobe related to the AVH symptoms.