Cognitive behaviour therapy for first episode psychosis: Good for nothing or fit for purpose?

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].

Pilot study of a group worry intervention for recent onset psychosis

Worry is common among individuals with psychosis and has been found to be a causal factor in the development of paranoia. Previous research has shown that a cognitive behavioural therapy protocol targeting worry helps to reduce persecutory delusions and associated distress in a population experiencing longstanding psychotic symptoms. However, there has yet to be a published adaptation of the protocol for individuals experiencing a recent onset of psychosis. The current study aims to examine the feasibility of adapting the worry intervention for recent onset psychosis in a group setting. Six young adults with a recent onset of psychosis, aged 18–32 years, participated in a pilot study of an 8-week group intervention covering cognitive behavioural strategies for managing worry, including worry periods, worry postponement techniques, mindfulness and relaxation, and problem solving. Pre- and post-intervention data were collected on worry, anxiety, depressive symptoms, psychotic symptoms, and perceived recovery from psychosis. In addition, qualitative feedback from group members was gathered during a post-intervention focus group. Feasibility of the group appeared promising, despite high participant attrition. All components of the intervention were successfully implemented, and group members provided positive feedback regarding acceptability of the group. Contrary to prediction, there was not a consistent decrease in worry from pre- to post-intervention. Findings from secondary symptom measures were mixed and may have been related to participants’ subjective experience of the group. Specifically, participants who experienced high levels of group cohesion seemed to benefit more from the intervention.

Key learning aims

(1)

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.

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

The present study aimed to provide preliminary evaluation of the effectiveness of a brief CBT intervention focusing on relapse prevention and positive symptom in a Chinese first episode schizophrenia (FES) population. This randomized controlled trial recruited eighty outpatients with FES (as determined using the DSM-IV), aged 16-45 years, and on a current atypical antipsychotic. Patients were randomized to either 10 sessions of individual CBT (intervention group) adjunctive to treatment as usual (TAU) or TAU alone (control group). Outcome assessment of symptoms, relapse, hospitalization, insight and social functioning were administered at baseline and then post treatment (10 weeks), and at 6-month and 12-month follow ups. At 12 months, patients in the intervention group had significantly greater improvements in positive symptoms, general psychopathology and social functioning, as well as significantly lower rates of relapse, compared to the control group. Although patients in both groups demonstrated significantly improved negative symptom and insight scores from baseline, no group differences were found. This RCT demonstrates that FES patient can greatly benefit from CBT designed to target relapse prevention and positive symptom, with improvements sustained for 1 year following treatment.

Cognitive Behavioral Therapy for Psychosis - Training Practices and Dissemination in the United States

OBJECTIVE

Cognitive-Behavioral Therapy for psychosis (CBTp) is an evidence-based treatment for psychosis-related disorders. However, despite the strong evidence-base and inclusion in national treatment guidelines, CBTp remains poorly disseminated in the US. It is proposed that this state is a product of lack of CBTp knowledge among clinical training leaders along with limited availability of training opportunities.

METHOD

We surveyed training directors in US psychiatry residency and clinical psychology doctoral programs to characterize the penetration of CBTp training and to assess their familiarity with basic CBTp facts.

RESULTS

Directors displayed limited knowledge of CBTp effectiveness, with only 50% of psychiatry and 40% of psychology directors believing that CBTp is efficacious. Only 10% of psychiatry and 30% of psychology directors were aware that the CBTp evidence-base is based on meta-analyses. While 45% of all directors reported that their program offer CBTp training, trainees received limited training - 4 hours of didactics, 21 hours of treatment, and 12 hours of supervision.

CONCLUSIONS

CBTp dissemination in the US is characterized by training directors' minimal awareness of the CBTp evidence-base along with training opportunities that are so limited, as to be unlikely to be adequate to provide CBTp effectively, hence unlikely to improve patients' psychoses.

Do personality traits matter when choosing a group therapy for early psychosis?

OBJECTIVES

This study aimed at determining the predictive value of personality traits, based on the Five Factor Model (FFM) of personality, on therapeutic outcomes according to specific group treatments for first episode psychosis: cognitive-behavioural therapy (CBT) or skills training for symptom management (SM).

METHODS

Individuals experiencing early psychosis were recruited to participate in a randomized- controlled trial (RCT). Participants were randomized to one of two group treatments or to a wait-list control group. Measures included a personality inventory (NEO-FFI) and outcome measures of symptomatology (BPRS-E) and coping strategies (CCS). Pearson correlation analyses were conducted on 78 individuals and linear regression analyses on 66.

RESULTS

Links were found between personality traits, symptoms, and coping outcome measures, according to specific group treatments. Personality traits were particularly linked to therapeutic changes in active coping strategies, with Conscientiousness accounting for 14% of the variance in the CBT group, Extraversion accounting for 41% of the variance in the SM group, and Openness to experience accounting for 22% of the variance in the control group.

CONCLUSIONS

Individual differences in personality traits for people experiencing early psychosis should be considered when offering psychosocial treatments, since it appears that those with specific traits might benefit more than others in specific group interventions, particularly for interventions that do not solely aim at improving symptoms.

Psychosocial treatments for schizophrenia

The current state of the literature regarding psychosocial treatments for schizophrenia is reviewed within the frameworks of the recovery model of mental health and the expanded stress-vulnerability model. Interventions targeting specific domains of functioning, age groups, stages of illness, and human service system gaps are classified as evidence-based practices or promising practices according to the extent to which their efficacy is currently supported by meta-analyses and individual randomized controlled trials (RCTs). Evidence-based practices include assertive community treatment (ACT), cognitive behavior therapy (CBT) for psychosis, cognitive remediation, family psychoeducation, illness self-management training, social skills training, and supported employment. Promising practices include cognitive adaptive therapy, CBT for posttraumatic stress disorder, first-episode psychosis intervention, healthy lifestyle interventions, integrated treatment for co-occurring disorders, interventions targeting older individuals, peer support services, physical disease management, prodromal stage intervention, social cognition training, supported education, and supported housing. Implications and future directions are discussed.

Time to abandon the bio-bio-bio model of psychosis: Exploring the epigenetic and psychological mechanisms by which adverse life events lead to psychotic symptoms

Mental health services and research have been dominated for several decades by a rather simplistic, reductionistic focus on biological phenomena, with minimal consideration of the social context within which genes and brains inevitably operate. This ‘medical model’ ideology, enthusiastically supported by the pharmaceutical industry, has been particularly powerful in the field of psychosis, where it has led to unjustified and damaging pessimism about recovery. The failure to find robust evidence of a genetic predisposition for psychosis in general, or ‘schizophrenia’ in particular, can be understood in terms of recently developed knowledge about how epigenetic processes turn gene transcription on and off through mechanisms that are highly influenced by the individual's socio-environmental experiences. To understand the emerging evidence of the relationship between adverse childhood events and subsequent psychosis, it is necessary to integrate these epigenetic processes, especially those involving the stress regulating functions of the HPA axis, with research about the psychological mechanisms by which specific types of childhood trauma can lead to specific types of psychotic experiences. The implications, for research, mental health services and primary prevention, are profound.

Declaration of Interest: None of the authors have any conflicts of interest in relation to this paper.

Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review

BACKGROUND

Early intervention services for psychosis aim to detect emergent symptoms, reduce the duration of untreated psychosis, and improve access to effective treatments.

AIMS

To evaluate the effectiveness of early intervention services, cognitive-behavioural therapy (CBT) and family intervention in early psychosis.

METHOD

Systematic review and meta-analysis of randomised controlled trials of early intervention services, CBT and family intervention for people with early psychosis.

RESULTS

Early intervention services reduced hospital admission, relapse rates and symptom severity, and improved access to and engagement with treatment. Used alone, family intervention reduced relapse and hospital admission rates, whereas CBT reduced the severity of symptoms with little impact on relapse or hospital admission.

CONCLUSIONS

For people with early psychosis, early intervention services appear to have clinically important benefits over standard care. Including CBT and family intervention within the service may contribute to improved outcomes in this critical period. The longer-term benefits of this approach and its component treatments for people with early and established psychosis need further research.