Group cognitive behavior therapy or social skills training for individuals with a recent onset of psychosis? Results of a randomized controlled trial

The role of control groups in non-pharmacological randomised controlled trials of treatment-resistant schizophrenia: A systematic review and meta-analysis

Control groups used in randomised controlled trials investigating psychological interventions for depression and anxiety disorders have effects of their own. This has never been investigated for schizophrenia, in particular treatment-resistant schizophrenia. This systematic review and meta-analysis aimed to examine how control groups in randomised controlled trials on psychological interventions for treatment-resistant schizophrenia behave in their effects on general symptomatology. In a search of various databases until July 2023, 31 eligible studies with 3125 participants were found whose control groups were assigned to four categories: active, inactive, treatment as usual and waitlist. The analyses showed that psychological interventions had a greater effect on symptom reduction to all control groups combined. When separating the control groups, only compared to TAU and waitlist controls the psychological interventions were superior. The difference was larger when less active control groups (e.g. waitlist - or treatment as usual control groups) were used. All control groups were associated with an improvement in symptoms from pre- to post-measurement point, with the greatest improvement observed in the inactive control group. The results are preliminary, but they suggest that the choice of the control group has a considerable impact on study effects as it has been shown in other psychiatric diagnoses.

Empathy in the Care of Individuals With Schizophrenia: A Vital Element of Treatment

Although therapist empathy has long been recognized as one of the most important ingredients of successful psychotherapy, its role in the treatment of schizophrenia has been neglected, relative to the treatment of other psychiatric disorders. In this article, the authors aimed to explore historical and modern conceptions of the use of empathy in work with patients with schizophrenia, review the research on empathy as applied generally in psychotherapy and as it pertains to this population, and offer a case study demonstrating empathy's instrumental role in the management of schizophrenia. Empathic understanding of patients with schizophrenia has relevance across treatment settings: in psychotherapy, on inpatient psychiatric units, in the emergency department, and at home with family or caregivers. An empathic understanding of the psychological process occurring in schizophrenia is a vital component of effective treatment.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

A pilot trial examining the effects of veteran voices and visions, an adaptation of hearing voices groups for a large public health system in the United States

BACKGROUND

The Hearing Voices Approach, a community-based peer-led support group model, is generating interest as a novel way to engage with psychosis. Hearing Voices (HV) groups are run by peers, 'experts-by-experience', and emphasize group ownership and community-building rather than adherence to a therapist-led, predetermined structure. Diverse beliefs about experiences are respected and viewed as potentially meaningful. Groups work within each individual's explanatory framework to reframe understandings.

AIMS

This paper describes the effects of participation in Veteran Voices and Visions (VVV) groups, an adaptation of the HV approach, co-led by clinicians and Veteran peer support specialists, adapted for Veterans who have experienced psychosis and receive care at the VA, a large public health system in the United States.

METHOD

This mixed methods pilot study has a convergent parallel design, integrating quantitative and qualitative data from participants in pre-intervention and post-intervention assessments.

RESULTS

Over 16 weeks, quantitative analysis showed a statistically significant reduction in distress, due to auditory hallucinations, as measured by the Psychotic Symptom Rating Scales (PSYRATS). The Beliefs about Voices Questionnaire- Revised (BAVQ-R) results showed a reduction in malevolence and omnipotence and an increase in benevolence related to auditory hallucinations, but no change in resistance. Engagement showed a trend-level reduction. Qualitative data from midpoint (Week 8) and endpoint (Week 16) interviews revealed several perceived benefits from groups: 1) normalization and camaraderie, 2) increased hope and confidence, 3) self-understanding and reframing of experiences, and 4) building relationships outside of groups. Overall, VVV groups reduced distress due to voices, negative beliefs about voices, and perceived power of voices.

CONCLUSIONS

Study findings contribute to a growing body of literature indicating HV groups support those who have experienced psychosis by reducing social isolation and fostering community, which may facilitate social integration. Overall, our findings highlight the potential benefits of adapting HV groups to health systems.

Improving Romantic Relationship Functioning Among Young Men With First-Episode Psychosis: Impact of a Novel Group Intervention

Previous research has highlighted many of the challenges faced by individuals with psychosis in romantic relationships. The present study aimed to evaluate the impact of a novel group intervention for men with first-episode psychosis (FEP) on dating success, romantic and sexual functioning, self-esteem, self-stigma, mentalizing skills, and symptomatology, while using a repeated single-case experimental design and comparing results across two treatment modalities (i.e., in-person or online). Twenty-seven participants from five treatment sites completed a 12-week group intervention. Qualitative data was also collected to assess participants' subjective experiences with the program. In both modalities, significant improvements were observed for romantic functioning, mentalizing skills, and symptomatology, with effect sizes ranging from small to large. Several participants also attended more dates and entered committed relationships after the intervention. Most participants were satisfied with the program and many felt that they had learned new skills and gained confidence in dating. Future research should replicate these findings in larger and more inclusive samples.

Sequential mixed method evaluation of the acceptability, feasibility, and appropriateness of cognitive behavioral therapy for psychosis stepped care

Background

Cognitive Behavioral Therapy for psychosis (CBTp) is recommended by national treatment guidelines yet remains widely inaccessible in the U.S. A stepped care model, favored and feasible for other scarce interventions, may improve access to CBTp.

Methods

We employed an exploratory sequential mixed method design inclusive of two distinct phases to quantitatively evaluate the acceptability, feasibility, and appropriateness of CBTp Stepped Care (CBTp-SC) among practitioners who were trained in low-intensity CBTp (Step 1), Group-Administered CBTp (Step 2), and Formulation-based CBTp (Step 3). In Phase 1, we queried respondents using the Acceptability of Intervention Measure, Intervention Appropriateness Measure, and the Feasibility of Intervention Measure to ascertain perceptions of these leading indicators of implementation success. In Phase 2, we conducted focus groups with CBTp-SC-trained practitioners (n = 10) and administrators (n = 2) from 2 of the 4 Phase 1 study sites to evaluate the theoretical assumptions of stepped care and to better understand key barriers and facilitators.

Results

Forty-six practitioners trained in all three levels of CBTp-SC completed the online survey in Phase 1. All participants were employed by a community mental health agency currently sustaining CBTp-SC. Respondents endorsed high levels of acceptability, feasibility, and appropriateness for the CBTp-SC model. We found evidence to suggest that licensed practitioners and Step 3 practitioners perceived formulation-based CBTp as more appropriate for their clients. In Phase 2, six themes emerged which affirmed the utility of the model for stakeholders, supported stepped care theoretical assumptions, and revealed key areas for improvement.

Conclusions

Early adopters of CBTp-SC in the U.S. perceive it to be acceptable, feasible, and appropriate in community mental health care settings. Practitioners and administrators identified training and implementation barriers, including the importance of organizational readiness, a CBTp coordinator role, and a desire to adapt the intervention. These early findings will facilitate iterative refinement of the stepped care model for U.S. public behavioral health agencies. Additional research is needed to explore perceptions and clinical outcomes among CBTp service users.

Healthy Minds: Group Cognitive-Behavioral Intervention for Sustainable Return to Work After a Sick Leave Due to Depression

Background Depression is one of the major causes for sick leave and loss of productivity at work. Many studies have investigated return to work (RTW) interventions for people with common mental disorders. However, a paucity of studies has targeted depressive symptoms in the workplace, as well as work productivity. Objectives This study presents preliminary results on a novel group intervention based on cognitive behavioral principles in order to optimize sustainable RTW, by reducing clinical symptoms (anxiety and depression) and improving work productivity. Method This pilot study followed a quasi-experimental design, with participants randomly receiving the group intervention (N = 19) or only receiving usual services (N = 11, control group). The group intervention called Healthy Minds for Sustainable RTW consists of eight sessions based on cognitive behavioral therapy principles and techniques. Outcome measures on depressive and anxiety symptoms and work productivity were administered at baseline (i.e. the start of return-to-work or gradual RTW), as well 2 months later (post-intervention), and at 6-month follow-up. Results The results did not show a time × group interaction for symptoms of depression or anxiety (p = 0.07). Those who received the group intervention however did see a within-group reduction in anxiety and depressive symptoms over time, clinically significant for the group intervention only. A significant time × group interaction for work productivity was found, with those in the intervention group improving over time compared to the control condition. Conclusion Although replication is needed, these results suggest that a brief group cognitive-behavioral intervention specifically tailored to work-related issues is promising. Future studies are warranted, particularly with larger samples and remote webconferencing delivery.

Soft skills for success for job seekers with autism spectrum disorder

BACKGROUND: Direct Skills Teaching (DST) is a method for distilling a skill into digestible components for ease of teaching and learning of a new skill. Job retention is a complex phenomenon requiring numerous social competencies that include verbal and non-verbal fluency among others. Individuals with Autism Spectrum Disorder (ASD) often struggle with social communication and therefore are at a disadvantage in employment settings; even when otherwise qualified for the position. OBJECTIVE: This preliminary pilot study tested the feasibility of a DST group intervention to assist individuals with ASD with work-related soft skills, with a particular focus on informal conversational skills. METHODS: Eight master’s level Rehabilitation Counseling students facilitated groups of adults with autism spectrum disorder seeking employment. Student facilitators followed the Conversing with Others manualized curriculum, designed to teach workplace based informal conversational soft skills. Participant feedback was sought both pre and post intervention, and student facilitators recorded their observations of each group session. RESULTS: The initial findings support the feasibility of soft-skills training for work-related conversational skills teaching for job seekers with ASD. The results also supported the need for significant adjustments to the intervention as well as any future studies of the small group intervention Conversing with Others. CONCLUSIONS: Workplace conversational skills can be facilitated in a small group setting. Master’s level counselors-in-training, were able to follow a manualized DST soft-skills small group.

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.

Can social support be improved in people with a severe mental illness? A systematic review and meta-analysis

People with a severe mental illness often have less social support than other people, yet these people need social support to face the challenges in their lives. Increasing social support could benefit the person's recovery, but it is not clear whether interventions that aim to improve social support in people with a severe mental illness are effective. A systematic literature search and review in MEDLINE (PubMed), PsycINFO, CINAHL, Cochrane, JSTOR, IBSS, and Embase was performed. Studies were included if they had a control group and they were aimed at improving social support in people with a severe mental illness who were receiving outpatient treatment. Summary data were extracted from the research papers and compared in a meta-analysis by converting outcomes to effect sizes (Hedges's g). Eight studies (total n = 1538) that evaluated ten different interventions met the inclusion criteria. All but one of these studies was of sufficient quality to be included in the review. The studies that were included in the meta-analysis had a combined effect size of 0.17 (confidence interval: 0.02 to 0.32), indicating a small or no effect for the interventions that were evaluated. A subgroup analysis of more personalized studies showed a combined effect size of 0.35 (CI = 0.27 to 0.44), indicating a noteworthy effect for these more personalized studies. This evaluation of interventions aimed at improving social support in people with a severe mental illness suggests that these interventions in general have little or no clinical benefit. However, in a subgroup analysis the more personalized interventions have a larger effect on improving social support and merit further research.

Group therapy via videoconferencing for individuals with early psychosis: A pilot study

AIM

The COVID-19 pandemic has introduced many mental health professionals to therapy via videoconferencing. Mostly individual teletherapy has been offered and studied, although group therapy is often offered in clinics. In fact, little is known regarding group therapy's acceptability, feasibility, and potential impact when offered via videoconferencing.

METHODS

This pilot study offered group cognitive-behavioural therapy for psychosis via videoconferencing to 14 individuals with early psychosis either living in remote areas or confined during the pandemic.

RESULTS

The rate of consenting to the study (79%) and actual participation rates were acceptable (18.5 sessions out of 24). Although some technological obstacles were encountered, solutions offered allowed the videoconferencing group to be considered feasible for most participants and therapists. Prepost results on symptoms and self-esteem were comparable to those of other studies using the same group treatment but in-person. Alliance scores seemed similar as well.

CONCLUSIONS

More studies are warranted on the efficacy of group therapy via videoconferencing. This pilot study does offer promising results, suggesting that a wider range of people with early psychosis can be reached and benefit from the advantages of receiving an evidence-based group intervention.

Romantic relationship group intervention for men with early psychosis: A feasibility, acceptability and potential impact pilot study

AIM

To assess the feasibility, acceptability and potential impact of a cognitive behavioural group intervention occurring over 12 sessions and focusing on romantic relationships for single men with early psychosis.

METHODS

Recruitment, drop-out and participation rates were collected. An A-B-A within-subject design (n = 7), where each participant acted as his own control, was used to determine potential impact (on social functioning, romantic relationship functioning, self-esteem, theory of mind [ToM] and self-stigma) across time (six time points).

RESULTS

Feasibility and acceptability were established. As for the potential impact of the intervention, participants did not all evolve the same way. Improvements were found on social functioning ("behaviours" subscale), romantic relationship functioning and ToM ("mentalizing" subscale).

CONCLUSIONS

More studies are warranted to expand on these results and to further help men with early psychosis in their social and romantic development.

Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults

Pediatricians are often the first physicians to encounter adolescents and young adults presenting with psychotic symptoms. Although pediatricians would ideally be able to refer these patients immediately into psychiatric care, the shortage of child and adolescent psychiatry services may sometimes require pediatricians to make an initial assessment or continue care after recommendations are made by a specialist. Knowing how to identify and further evaluate these symptoms in pediatric patients and how to collaborate with and refer to specialty care is critical in helping to minimize the duration of untreated psychosis and to optimize outcomes. Because not all patients presenting with psychotic-like symptoms will convert to a psychotic disorder, pediatricians should avoid prematurely assigning a diagnosis when possible. Other contributing factors, such as co-occurring substance abuse or trauma, should also be considered. This clinical report describes psychotic and psychotic-like symptoms in the pediatric age group as well as etiology, risk factors, and recommendations for pediatricians, who may be among the first health care providers to identify youth at risk.

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)

Using Claims Data to Assess Treatment Quality of First-Episode Psychosis

OBJECTIVE

Coordinated specialty care (CSC) has become the standard of care for first-episode psychosis (FEP). The gap between CSC best practices and the actual care delivered is unknown. This longitudinal study aimed to measure that gap by using a large Medicaid claims database and 10 quality indicators (QIs) reflecting aspects of CSC and to study the relationship between these QIs and future health care utilization.

METHODS

Individuals with FEP were identified in a Missouri Medicaid claims database. Participants were required to have been eligible for Medicaid benefits for at least 10 months in the year prior to and the year after their first episode of psychosis and to have had no evidence of a prior psychosis diagnosis. Descriptive statistics were generated for each of the QIs, and a stratified Cox regression was used to identify predictors of subsequent health care utilization.

RESULTS

Data were obtained for 6,246 participants, and follow-up lasted a mean of 4.24 years. Significant practice gaps were found in the use and monitoring of antipsychotic medications. Of those prescribed antipsychotic medication, 5% received prescriptions above recommended daily doses, 16% received two or more antipsychotics, and 20% were treated with olanzapine or clozapine. Among the QIs, lack of monitoring for smoking (hazard ratio [HR]=2.71, 95% confidence interval [CI]=2.47-2.97) and lack of integrated care delivery in treatment (HR=2.00, 95% CI=1.92-2.08) were most associated with psychiatric hospitalization.

CONCLUSIONS

In most cases, treatment was far from meeting CSC recommendations, suggesting that implementation of CSC requires substantial modifications to delivery of care for individuals with FEP.

Psychological interventions for psychosis in adolescents

BACKGROUND

Psychosis is an illness characterised by alterations in thoughts and perceptions resulting in delusions and hallucinations. Psychosis is rare in adolescents but can have serious consequences. Antipsychotic medications are the mainstay treatment, and have been shown to be effective. However, there is emerging evidence on psychological interventions such as cognitive remediation therapy, psycho-education, family therapy and group psychotherapy that may be useful for adolescents with psychosis.

OBJECTIVES

To assess the effects of various psychological interventions for adolescents with psychosis.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's study-based Register of Trials including clinical trials registries (latest, 8 March 2019).

SELECTION CRITERIA

All randomised controlled trials comparing various psychological interventions with treatment-as-usual or other psychological treatments for adolescents with psychosis. For analyses, we included trials meeting our inclusion criteria and reporting useable data.

DATA COLLECTION AND ANALYSIS

We independently and reliably screened studies and we assessed risk of bias of the included studies. For dichotomous data, we calculated risk ratios (RRs) and 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous data, we used mean differences (MDs) and the 95% CIs. We used a random-effects model for analyses. We created a 'Summary of findings' table using GRADE.

MAIN RESULTS

The current review includes 7 studies (n = 319) assessing a heterogenous group of psychological interventions with variable risk of bias. Adverse events were not reported by any of the studies. None of the studies was sponsored by industry. Below, we summarise the main results from four of six comparisons, and the certainty of these results (based on GRADE). All scale scores are average endpoint scores. Cognitive Remediation Therapy (CRT) + Treatment-as-Usual (TAU) versus TAU Two studies compared adding CRT to participants' TAU with TAU alone. Global state (CGAS, high = good) was reported by one study. There was no clear difference between treatment groups (MD -4.90, 95% CI -11.05 to 1.25; participants = 50; studies = 1, very low-certainty). Mental state (PANSS, high = poor) was reported by one study. Scores were clearly lower in the TAU group (MD 8.30, 95% CI 0.46 to 16.14; participants = 50; studies = 1; very low-certainty). Clearly more participants in the CRT group showed improvement in cognitive functioning (Memory digit span test) compared to numbers showing improvement in the TAU group (1 study, n = 31, RR 0.58, 95% CI 0.37 to 0.89; very low-certainty). For global functioning (VABS, high = good), our analysis of reported scores showed no clear difference between treatment groups (MD 5.90, 95% CI -3.03 to 14.83; participants = 50; studies = 1; very low-certainty). The number of participants leaving the study early from each group was similar (RR 0.93, 95% CI 0.32 to 2.71; participants = 91; studies = 2; low-certainty). Group Psychosocial Therapy (GPT) + TAU versus TAU One study assessed the effects of adding GPT to participants' usual medication. Global state scores (CGAS, high = good) were clearly higher in the GPT group (MD 5.10, 95% CI 1.35 to 8.85; participants = 56; studies = 1; very low-certainty) but there was little or no clear difference between groups for mental state scores (PANSS, high = poor, MD -4.10, 95% CI -8.28 to 0.08; participants = 56; studies = 1, very low-certainty) and no clear difference between groups for numbers of participants leaving the study early (RR 0.43, 95% CI 0.15 to 1.28; participants = 56; studies = 1; very low-certainty). Cognitive Remediation Programme (CRP) + Psychoeducational Treatment Programme (PTP) versus PTP One study assessed the effects of combining two types psychological interventions (CRP + PTP) with PTP alone. Global state scores (GAS, high = good) were not clearly different (MD 1.60, 95% CI -6.48 to 9.68; participants = 25; studies = 1; very low-certainty), as were mental state scores (BPRS total, high = poor, MD -5.40, 95% CI -16.42 to 5.62; participants = 24; studies = 1; very low-certainty), and cognitive functioning scores (SPAN-12, high = good, MD 2.40, 95% CI -2.67 to 7.47; participants = 25; studies = 1; very low-certainty). Psychoeducational (PE) + Multifamily Treatment (MFT) Versus Nonstructured Group Therapy (NSGT, all long-term) One study compared (PE + MFT) with NSGT. Analysis of reported global state scores (CGAS, high = good, MD 3.38, 95% CI -4.87 to 11.63; participants = 49; studies = 1; very low-certainty) and mental state scores (PANSS total, high = poor, MD -8.23, 95% CI -17.51 to 1.05; participants = 49; studies = 1; very low-certainty) showed no clear differences. The number of participants needing hospital admission (RR 0.84, 95% CI 0.36 to 1.96; participants = 49; studies = 1) and the number of participants leaving the study early from each group were also similar (RR 0.52, 95% CI 0.10 to 2.60; participants = 55; studies = 1; low-certainty).

AUTHORS' CONCLUSIONS

Most of our estimates of effect for our main outcomes are equivocal. An effect is suggested for only four outcomes in the SOF tables presented. Compared to TAU, CRT may have a positive effect on cognitive functioning, however the same study reports data suggesting TAU may have positive effect on mental state. Another study comparing GPT with TAU reports data suggesting GPT may have a positive effect on global state. However, the estimate of effects for all the main outcomes in our review should be viewed with considerable caution as they are based on data from a small number of studies with variable risk of bias. Further data could change these results and larger and better quality studies are needed before any firm conclusions regarding the effects of psychological interventions for adolescents with psychosis can be made.

Meta-analysis and Meta-regression of Cognitive Behavioral Therapy for Psychosis (CBTp) Across Time: The Effectiveness of CBTp has Improved for Delusions

Published research shows small-to-medium effects of Cognitive Behavioral Therapy for Psychosis (CBTp) on reducing psychotic symptoms. Given the on-going development of CBTp interventions, the aim of this systematic review is to examine whether the effectiveness of CBTp has changed across time. MEDLINE, EMBASE, PsycINFO, and CENTRAL were searched for randomized controlled trials examining CBTp interventions targeting positive and/or negative symptoms vs treatment as usual. Four meta-analyses were carried out to examine the effectiveness of CBTp for: positive symptoms; delusions; hallucinations; and negative symptoms. Four meta-regressions examined whether the effectiveness of CBTp changed across time for these groups of symptoms. A total of 28 studies (n = 2698) yielded a pooled g of −0.24 (95% confidence interval [CI] −0.32, −0.16, P < .001) favoring CBTp for positive symptoms, with nonsignificant heterogeneity (Q = 26.87, P = .47; I2 =0%); 13 studies (n = 890) yielded a pooled g of −0.36 (95% CI −0.59, −0.13, P = .002) for delusions, with substantial heterogeneity (Q = 31.99, P = .001; I2 =62%); 16 studies (n = 849) yielded a pooled g of −0.26 (95% CI −0.42, −0.11, P < .001) for hallucinations, with nonsignificant heterogeneity (Q = 18.10, P = .26; I2 =17%); 19 studies (n = 1761) yielded a pooled g of −0.22 (95% CI −0.33, −0.12, P < .001) for negative symptoms, with nonsignificant heterogeneity (Q = 20.32, P = .32, I2 =11%). Meta-regressions indicated a significant effect of year on the effectiveness of CBTp only for delusions (F[1, 11] = 5.99, P = .032; R2 = 0.594); methodological quality did not effect this finding. Findings indicate small-to-medium effects of CBTp for psychotic symptoms, with increasing effectiveness across time for delusions.

Efficacy and Moderators of Cognitive Behavioural Therapy for Psychosis Versus Other Psychological Interventions: An Individual-Participant Data Meta-Analysis

BACKGROUND

Study-level meta-analyses have demonstrated the efficacy of cognitive-behavioural therapy for psychosis (CBTp). Limitations of conventional meta-analysis may be addressed using individual-participant-data (IPD). We aimed to determine a) whether results from IPD were consistent with study-level meta-analyses and b) whether demographic and clinical characteristics moderate treatment outcome.

METHODS

We systematically searched PubMed, Embase, PsychInfo and CENTRAL. Authors of RCTs comparing CBTp with other psychological interventions were contacted to obtain original databases. Hierarchical mixed effects models were used to examine efficacy for psychotic symptoms. Patient characteristics were investigated as moderators of symptoms at post-treatment. Sensitivity analyses were conducted for risk of bias, treatment format and study characteristics.

RESULTS

We included 14 of 23 eligible RCTs in IPD meta-analyses including 898 patients. Ten RCTs minimised risk of bias. There was no significant difference in efficacy between RCTs providing IPD and those not (p >0.05). CBTp was superior vs. other interventions for total psychotic symptoms and PANSS general symptoms. No demographic or clinical characteristics were robustly demonstrated as moderators of positive, negative, general or total psychotic symptoms at post-treatment. Sensitivity analyses demonstrated that number of sessions moderated the impact of treatment assignment (CBTp or other therapies) on total psychotic symptoms (p = 0.02).

CONCLUSIONS

IPD suggest that patient characteristics, including severity of psychotic symptoms, do not significantly influence treatment outcome in psychological interventions for psychosis while investing in sufficient dosage of CBTp is important. IPD provide roughly equivalent efficacy estimates to study-level data although significant benefit was not replicated for positive symptoms. We encourage authors to ensure IPD is accessible for future research.

Evidence-Based Psychosocial Treatment for Individuals with Early Psychosis

Coordinated specialty care (CSC) first-episode models are an evidence-based practice in the treatment of first-episode psychosis. Group, individual, and family therapies in CSC aim to help the client and family understand and cope with the experience of psychosis, promote symptomatic and functional recovery and improve quality of life, and support the pursuit of personally meaningful goals of the client. Common elements to these interventions include building a therapeutic alliance, recovery orientation, education, and skills training, which can be directed to a range of targets, including problem-solving, communication, social skills, and social cognition.

Change in the Neural Response to Auditory Deviance Following Cognitive Therapy for Hallucinations in Patients With Schizophrenia

Adjunctive psychotherapeutic approaches recommended for patients with schizophrenia (SZ) who are fully or partially resistant to pharmacotherapy have rarely utilized biomarkers to enhance the understanding of treatment-effective mechanisms. As SZ patients with persistent auditory verbal hallucinations (AVH) frequently evidence reduced neural responsiveness to external auditory stimulation, which may impact cognitive and functional outcomes, this study examined the effects of cognitive behavioral therapy for voices (CBTv) on clinical and AVH symptoms and the sensory processing of auditory deviants as measured with the electroencephalographically derived mismatch negativity (MMN) response. Twenty-four patients with SZ and AVH were randomly assigned to group CBTv treatment or a treatment as usual (TAU) condition. Patients in the group CBTv condition received treatment for 5 months while the matched control patients received TAU for the same period, followed by 5 months of group CBTv. Assessments were conducted at baseline and at the end of treatment. Although not showing consistent changes in the frequency of AVHs, CBTv (vs. TAU) improved patients' appraisal (p = 0.001) of and behavioral/emotional responses to AVHs, and increased both MMN generation (p = 0.001) and auditory cortex current density (p = 0.002) in response to tone pitch deviants. Improvements in AVH symptoms were correlated with change in pitch deviant MMN and current density in left primary auditory cortex. These findings of improved auditory information processing and symptom-response attributable to CBTv suggest potential clinical and functional benefits of psychotherapeutical approaches for patients with persistent AVHs.

Group cognitive behavioural therapy for psychosis in the Asian context: a review of the recent studies

The cardinal symptoms of psychosis include hallucination and delusion, which can be both distressing and disabling. International guidelines recommend cognitive behavioural therapy for psychosis (CBTp) as an adjunctive intervention to medication management. Considering the difficulty in the widespread dissemination of the individual CBTp, group CBTp is an alternative in improving patients' access to psychological intervention. Although it has been found feasible and effective in various studies, systematic review on group CBTp, particularly in Asia, was not identified. Hence, this systematic review tried to examine the recent evidence of group CBTp in Asia in order to shed light on its implementation in routine psychiatric care. A relevant literature search was conducted in three databases (Pubmed, Web of Knowledge, and PsycINFO) during the period from January 2000 to December 2018. A total of 114 journal articles were identified. After a full-text review, four studies met our inclusion and exclusion criteria. Despite methodological shortcomings, positive results were found in terms of improvements on psychotic symptoms, functioning, and quality-of-life. These encouraging results indicate the need for future research studies with more rigorous methodology, leading to a better understanding on the applicability and effectiveness of group CBTp in the Asian context.

Stepped Care as an Implementation and Service Delivery Model for Cognitive Behavioral Therapy for Psychosis

Cognitive behavioral therapy for schizophrenia spectrum disorders is an evidence-based treatment that is recommended by United States schizophrenia treatment guidelines. Based on recent estimates, only 0.3% of individuals with a primary psychotic disorder are able to access this treatment in the United States. Stepped care interventions have shown promise as an applied treatment delivery model in other settings and for other psychotherapeutic interventions. The current paper describes how the stepped care model can be applied to CBT for psychosis in the US to increase access to the intervention in community mental health settings by leveraging the multidisciplinary team.

Psychological interventions in psychosis in children and adolescents: a systematic review

BACKGROUND

Early onset psychosis (EOP), referring to psychosis with onset before the age of 18 years, is a more severe form of psychosis associated with worse prognosis. While medication is the treatment of choice, psychological interventions are also considered to have an important role in the management of symptoms and disability associated with this condition. The present review aimed to explore the effectiveness of such interventions.

METHOD

An electronic search was conducted on the Embase, Medline, and PsychInfo databases for papers of randomized controlled trials (RCTs) referring to psychological interventions in EOP. References of identified papers were hand searched for additional studies. Identified studies were quality assessed.

RESULTS

Eight studies were included in the present review evaluating cognitive remediation therapy (CRT), cognitive behavioural therapy (CBT), a family intervention and psychoeducation. CRT was associated with improvement in cognitive function and CBT and CRT seem to also have a positive effect in psychosocial functioning. Symptom reduction appears to not be significantly affected by the proposed treatments.

CONCLUSIONS

There is some evidence supporting the effectiveness of psychological interventions in EOP. However, most research on adolescents is focused on CRT and its effects on cognitive deficits. More studies on the effects of psychological interventions in EOP are needed.

Group cognitive behavioural therapy for Chinese patients with psychotic disorder: A feasibility controlled study

AIM

Evidence for the effectiveness of individual cognitive behavioural therapy for psychosis (CBTp) is promising but evidence for presenting CBTp in a group setting and in the Asian context is limited. The present study is to evaluate the feasibility and effectiveness of Group CBTp in clinical practice.

METHOD

Forty-eight out-patients and day-patients with the schizophrenia spectrum disorders were recruited and randomly assigned to the group CBTp plus treatment as usual (TAU), or psychoeducation group (PsyEdI) plus TAU. Both interventions consisted of 7 consecutive weekly sessions with a booster session 4 weeks after the last session. Patients were assessed on outcome measures such as the Psychotic Symptom Rating Scales (PSYRATS), the Beck Depression Inventory (BDI), a Chinese version of the Beliefs About Voice Questionnaire-Revised version (BAVQ-R), at baseline and after treatment.

RESULTS

Patients received group CBTp (n = 25) showed significantly greater improvement in their delusion compared with those receiving PsyEdI (n = 23). Nearly 61% of patients in the group CBTp showed at least 50% reduction on their score of delusion in the PSYRATS. Group CBTp was also found to be effective in reducing patients' dysfunctional beliefs towards voices, especially in the subscale of benevolence and omnipotence, their conviction on delusion, as well as their distress from positive psychotic symptoms.

CONCLUSION

Group CBTp can be an effective adjunctive psychological intervention in improving positive psychotic experiences among people with persistent psychotic symptoms, and can be applied in routine clinical practice.

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.

Cognitive behavioural therapy plus standard care versus standard care plus other psychosocial treatments for people with schizophrenia

BACKGROUND

Cognitive behavioural therapy (CBT) is a psychosocial treatment that aims to help individuals re-evaluate their appraisals of their experiences that can affect their level of distress and problematic behaviour. 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. Other psychosocial therapies that are often less expensive are also available as an add-on treatment for people with schizophrenia. This review is also part of a family of Cochrane Reviews on CBT for people with schizophrenia.

OBJECTIVES

To assess the effects of CBT compared with other psychosocial therapies as add-on treatments for people with schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study Based Register of Trials (latest 6 March, 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 randomised controlled trials (RCTs) involving people with schizophrenia who were randomly allocated to receive, in addition to their standard care, either CBT or any other psychosocial therapy. Outcomes of interest included relapse, global state, mental state, adverse events, social functioning, quality of life and satisfaction with treatment. We included trials meeting our inclusion criteria and reporting useable data.

DATA COLLECTION AND ANALYSIS

We reliably screened references and selected trials. Review authors, working independently, assessed trials for methodological quality and extracted data from included studies. We analysed dichotomous data on an intention-to-treat basis and continuous data with 60% completion rate. Where possible, for binary data we calculated risk ratio (RR), for continuous data we calculated mean difference (MD), all with 95% confidence intervals (CIs). We used a fixed-effect model for analyses unless there was unexplained high heterogeneity. We assessed risk of bias for the included studies and used the GRADE approach to produce a 'Summary of findings' table for our main outcomes of interest.

MAIN RESULTS

The review now includes 36 trials with 3542 participants, comparing CBT with a range of other psychosocial therapies that we classified as either active (A) (n = 14) or non active (NA) (n = 14). Trials were often small and at high or unclear risk of bias. When CBT was compared with other psychosocial therapies, no difference in long-term relapse was observed (RR 1.05, 95% CI 0.85 to 1.29; participants = 375; studies = 5, low-quality evidence). Clinically important change in global state data were not available but data for rehospitalisation were reported. Results showed no clear difference in long term rehospitalisation (RR 0.96, 95% CI 0.82 to 1.14; participants = 943; studies = 8, low-quality evidence) nor in long term mental state (RR 0.82, 95% CI 0.67 to 1.01; participants = 249; studies = 4, low-quality evidence). No long-term differences were observed for death (RR 1.57, 95% CI 0.62 to 3.98; participants = 627; studies = 6, low-quality evidence). Only average endpoint scale scores were available for social functioning and quality of life. Social functioning scores were similar between groups (long term Social Functioning Scale (SFS): MD 8.80, 95% CI -4.07 to 21.67; participants = 65; studies = 1, very low-quality evidence), and quality of life scores were also similar (medium term Modular System for Quality of Life (MSQOL): MD -4.50, 95% CI -15.66 to 6.66; participants = 64; studies = 1, very low-quality evidence). There was a modest but clear difference favouring CBT for satisfaction with treatment - measured as leaving the study early (RR 0.86, 95% CI 0.75 to 0.99; participants = 2392; studies = 26, low quality evidence).

AUTHORS' CONCLUSIONS

Evidence based on data from randomised controlled trials indicates there is no clear and convincing advantage for cognitive behavioural therapy over other - and sometimes much less sophisticated and expensive - psychosocial therapies for people with schizophrenia. It should be noted that although much research has been carried out in this area, the quality of evidence available is mostly low or of very low quality. Good quality research is needed before firm conclusions can be made.

Mobile Intensive Care Unit: A case management team dedicated to early psychosis in France

AIM

To present the activities of a Mobile Intensive Care Unit in France.

METHODS

We summarize participant recruitment as well as the diagnostic procedures and therapeutic interventions offered to individuals with an at-risk mental state or first-episode psychosis (FEP).

RESULTS

Since its inception in 2010, 266 individuals from 16 to 30 years old living in an area of 120 000 citizens have been recruited by the Mobile Intensive Care Unit. Patients are evaluated by clinical and neuropsychological assessments, and therapeutic interventions include medication, individual case management and both individual and group cognitive behavioural therapy. Diagnostic assessments are also provided for the patients outside of our geographic area.

CONCLUSIONS

The Mobile Intensive Care Unit is a functional unit enabling young adults with a high-risk mental state or FEP to receive high standard of care and mobile management over 2 years, aimed at diminishing the risk of transition to chronic disease and decreasing functional impairment.

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.

Multilevel factorial designs with experiment-induced clustering

Factorial experimental designs have many applications in the behavioral sciences. In the context of intervention development, factorial experiments play a critical role in building and optimizing high-quality, multicomponent behavioral interventions. One challenge in implementing factorial experiments in the behavioral sciences is that individuals are often clustered in social or administrative units and may be more similar to each other than to individuals in other clusters. This means that data are dependent within clusters. Power planning resources are available for factorial experiments in which the multilevel structure of the data is due to individuals' membership in groups that existed before experimentation. However, in many cases clusters are generated in the course of the study itself. Such experiment-induced clustering (EIC) requires different data analysis models and power planning resources from those available for multilevel experimental designs in which clusters exist prior to experimentation. Despite the common occurrence of both experimental designs with EIC and factorial designs, a bridge has yet to be built between EIC and factorial designs. Therefore, resources are limited or nonexistent for planning factorial experiments that involve EIC. This article seeks to bridge this gap by extending prior models for EIC, developed for single-factor experiments, to factorial experiments involving various types of EIC. We also offer power formulas to help investigators decide whether a particular experimental design involving EIC is feasible. We demonstrate that factorial experiments can be powerful and feasible even with EIC. We discuss design considerations and directions for future research. (PsycINFO Database Record

Treatment Retention Among Patients Participating in Coordinated Specialty Care for First-Episode Psychosis: a Mixed-Methods Analysis

Young adults experiencing first-episode psychosis have historically been difficult to retain in mental health treatment. Communities across the United States are implementing Coordinated Specialty Care to improve outcomes for individuals experiencing first-episode psychosis. This mixed-methods research study examined the relationship between program services and treatment retention, operationalized as the likelihood of remaining in the program for 9 months or more. In the adjusted analysis, male gender and participation in home-based cognitive behavioral therapy were associated with an increased likelihood of remaining in treatment. The key informant interview findings suggest the shared decision-making process and the breadth, flexibility, and focus on functional recovery of the home-based cognitive behavioral therapy intervention may have positively influenced treatment retention. These findings suggest the use of shared decision-making and improved access to home-based cognitive behavioral therapy for first-episode psychosis patients may improve outcomes for this vulnerable population.

A Meta-Analysis of Social Skills Training and Related Interventions for Psychosis

Objective

Evidence suggests that social skills training (SST) is an efficacious intervention for negative symptoms in psychosis, whereas evidence of efficacy in other psychosis symptom domains is limited. The current article reports a comprehensive meta-analytic review of the evidence for SST across relevant outcome measures, control comparisons, and follow-up assessments. The secondary aim of this study was to identify and investigate the efficacy of SST subtypes.

Methods

A systematic literature search identified 27 randomized controlled trials including N = 1437 participants. Trials assessing SST against active controls, treatment-as-usual (TAU), and waiting list control were included. Risk of bias was assessed using the Cochrane risk of bias assessment tool. A series of 70 meta-analytic comparisons provided effect sizes in Hedges' g. Heterogeneity and publication bias were assessed.

Results

SST demonstrated superiority over TAU (g = 0.3), active controls (g = 0.2-0.3), and comparators pooled (g = 0.2-0.3) for negative symptoms, and over TAU (g = 0.4) and comparators pooled (g = 0.3) for general psychopathology. Superiority was indicated in a proportion of comparisons for all symptoms pooled and social outcome measures. SST subtype comparisons were underpowered, although social-cognitive approaches demonstrated superiority vs comparators pooled. SST treatment effects were maintained at proportion of follow-up comparisons.

Conclusions

SST demonstrates a magnitude of effect for negative symptoms similar to those commonly reported for cognitive-behavioral therapy (CBT) for positive symptoms, although unlike CBT, SST is not routinely recommended in treatment guidelines for psychological intervention. SST may have potential for wider implementation. Further stringent effectiveness research alongside wider pilot implementation of SST in community mental health teams is warranted.

Symptom fluctuations, self-esteem, and cohesion during group cognitive behaviour therapy for early psychosis

Group cohesion has been linked to positive changes in self-esteem and in symptoms during group psychotherapy in people with psychosis. These changes may be linked to changes in symptoms as fluctuations in self-esteem have been linked to symptom fluctuations.

OBJECTIVE

We aimed to determine the relationship between these three factors - group cohesion, self-esteem, and symptoms - during group cognitive behaviour therapy for psychosis (GCBTp). We hypothesized that group cohesion would precede changes in symptoms and self-esteem and that improvements in self-esteem would precede improvements in symptoms.

DESIGN

This is an uncontrolled longitudinal study recruiting from a convenience sample within two early psychosis clinics.

METHODS

Sixty-six individuals from first episode of psychosis treatment programmes participated in this study and received 24 sessions of a validated GCBTp protocol. Participants answered a brief questionnaire at the end of each session, measuring their group cohesion, self-esteem, and perception of their symptoms as worse, same, or better than usual.

RESULTS

Orthogonal polynomial contrasts for time effects were estimated with a mixed model for repeated measures with a random cluster effect and revealed a quartic trend regarding changes in symptoms over the 24 sessions. Self-esteem, symptoms, and group cohesion were strongly linked during a given session. Also, self-esteem changes predicted changes in symptoms up to two sessions later, and symptoms changes predicted self-esteem changes at the next session. Group cohesion preceded improvements in both self-esteem and symptoms; self-esteem also predicted improvements in group cohesion.

CONCLUSION

These results suggest that self-esteem and symptoms influence each other during therapy, with improvements in one leading to improvements in the other. Group cohesion also appears to be an essential prerequisite to positive changes in self-esteem and symptoms during GCBTp.

PRACTITIONER POINTS

This study emphasizes the interrelation between self-esteem improvements and symptom improvements, with improvements in one leading to improvements in the other, during group CBT for psychosis. Group cohesion, in this study, is a predictor of self-esteem and symptom improvements, suggesting that a special attention should be given to developing a strong alliance and group cohesion early on during CBT for psychosis.

Improving functional outcomes in college and university students with schizophrenia in the Western world

Retrospective research from patients with schizophrenia suggests that remission becomes increasingly less likely the longer psychosis goes untreated. Yet symptoms of schizophrenia are insidious and disease evolution varies between patients, requiring an ongoing diagnostic process. One way of justifying early treatment is by focusing on functionality rather than symptomatology. Most patients are diagnosed with schizophrenia between the ages of 17 and 25-when many young adults are undergraduates or pursuing post-graduate education. The extent to which schools partner with mental health services has implications for the short-term success of students' recovery and their future employability. Translating study findings on schizophrenia to the college setting remains an important area of investigation.

Une intervention cognitive comportementale de groupe pour prévenir les rechutes chez les employés en processus de retour au travail à la suite d’une dépression : protocole et faisabilité

La dépression est une des causes d’absence maladie (ou arrêt maladie) les plus fréquentes en milieu organisationnel. Plusieurs études se sont intéressées aux facteurs individuels, organisationnels, et ceux relatifs aux interventions qui peuvent prédire le retour au travail des personnes ayant vécu une dépression. Toutefois, peu d’études s’intéressent à la prévention des rechutes de dépression à la suite d’un retour au travail, alors que plus de la moitié des personnes ayant vécu une première dépression est à risque de faire une rechute dans un délai assez court.

Objectif Cet article présente le protocole de recherche relatif à une intervention de groupe novatrice, d’orientation cognitive comportementale, en vue d’optimiser la santé mentale des employés lors de leur retour au travail et ainsi diminuer d’éventuelles rechutes. Nous visons aussi à présenter la faisabilité de cette approche.

Méthode L’étude consiste en un essai pilote randomisé avec groupe contrôle dont la moitié des participants (n= 25) suit l’intervention de groupe et l’autre moitié (n = 25) reçoit les services/interventions usuels. Les bases théoriques et empiriques soutenant l’intervention proposée ainsi qu’une description de l’intervention et des objectifs de l’étude sont ici présentées.

RésultatsNous décrirons succinctement les propos tenus par les participants des deux premières cohortes concernant leur appréciation à l’égard de l’intervention de groupe.

ConclusionEnfin, les retombées d’une telle intervention seront aussi évoquées.

Canadian Treatment Guidelines on Psychosocial Treatment of Schizophrenia in Children and Youth

OBJECTIVE

A panel of experts, including researchers, clinicians and people with lived experience, was brought together to develop the new Canadian schizophrenia guidelines for the psychosocial treatment of children and youth with schizophrenia or psychotic disorders.

METHOD

The ADAPTE process, which relies on adapting existing high-quality guidelines, was used. Existing guidelines for children and youth (mostly from the National Institute for Health and Care Excellence [NICE]), as well as CPA adult guidelines, were reviewed and discussed in terms of their adaptability to the Canadian context and their level of recommendation for children and youth. New treatments were also considered when recent meta-analyses suggested their usefulness.

RESULTS

The children and youth psychosocial guidelines include many cross-sectional recommendations in terms of clinical and interpersonal skills needed to work with this clientele, setting and collaboration issues and needed adaptations for specific subpopulations. In terms of specific treatments, the treatments most strongly recommended are family intervention and cognitive behavior therapy. Also recommended, although with different degrees of support, are supported employment/supported education programs, patient education, cognitive remediation, and social skills training. Novel and upcoming psychosocial treatments are also briefly discussed.

CONCLUSION

These novel Canadian guidelines for the psychosocial treatment of children and youth with schizophrenia or psychotic disorders report evidence-based treatments as well as important considerations for providers who work with this clientele. More studies with children and youth with schizophrenia and psychotic disorders are warranted. If followed, these guidelines should facilitate the recovery of children and youth with schizophrenia or psychotic disorders as well as the recovery of their families.

Aspects of Theory of Mind that attenuate the relationship between persecutory delusions and social functioning in schizophrenia spectrum disorders

BACKGROUND AND OBJECTIVES

Despite the apparent relevance of persecutory delusions to social relationships, evidence linking these beliefs to social functioning has been inconsistent. In this study, we examined the hypothesis that theory of mind moderates the relationship between persecutory delusions and social functioning.

METHODS

88 adults with schizophrenia or schizoaffective disorder were assessed concurrently for social functioning, severity of persecutory delusions, and two components of theory of mind: mental state decoding and mental state reasoning. Mental state decoding was assessed using the Eyes Test, mental state reasoning using the Hinting Task, and social functioning assessed with the Social Functioning Scale. Moderation effects were evaluated using linear models and the Johnson-Neyman procedure.

RESULTS

Mental state reasoning was found to moderate the relationship between persecutory delusions and social functioning, controlling for overall psychopathology. For participants with reasoning scores in the bottom 78th percentile, persecutory delusions showed a significant negative relationship with social functioning. However, for those participants with mental state reasoning scores in the top 22nd percentile, more severe persecutory delusions were not significantly associated with worse social functioning. Mental state decoding was not a statistically significant moderator.

LIMITATIONS

Generalizability is limited as participants were generally men in later phases of illness.

CONCLUSIONS

Mental state reasoning abilities may buffer the impact of persecutory delusions on social functioning, possibly by helping individuals avoid applying global beliefs of persecution to specific individuals or by allowing for the correction of paranoid inferences.

Effects of Group Cognitive-Behavioral Therapy in Young Patients in the Early Stage of Psychosis

OBJECTIVE

To develop a model of group cognitive-behavioral therapy (CBT) for Korean patients with early psychosis.

METHODS

The group CBT utilized in the present study consisted of metacognitive training, cognitive restructuring, and lifestyle managements. The Subjective Well-being Under Neuroleptics (SWN-K), Ambiguous Intentions Hostility Questionnaire (AIHQ), Drug Attitude Inventory (DAI), Beck Depression Inventory (BDI), Perceived Stress Scale (PSS), and Clinical Global Impression (CGI) were administered prior to and after CBT sessions. The participants were categorized into two groups according to the median duration of untreated psychosis (DUP; 4 months).

RESULTS

A total of 34 patients were included in this analysis. From pre- to post-therapy, there were significant increases in the SWN-K and DAI scores and significant decreases in the hostility subscale of the AIHQ, PSS, and CGI scores. Significant time × DUP interaction effects were observed for the SWN-K, DAI, and BDI scores, such that there were significant changes in patients with a short DUP but not in those with a long DUP.

CONCLUSION

The group CBT program had a positive effect on subjective wellbeing, attitude toward treatment, perceived stress, and suspiciousness of young Korean patients with early psychosis. These effects were particularly significant in patients with a short DUP.

Psychological and psychosocial interventions for negative symptoms in psychosis: systematic review and meta-analysis

BackgroundNegative symptoms observed in patients with psychotic disorders undermine quality of life and functioning. Antipsychotic medications have a limited impact. Psychological and psychosocial interventions, with medication, are recommended. However, evidence for the effectiveness of specific non-biological interventions warrants detailed examination.AimsTo conduct a meta-analytic and systematic review of the literature on the effectiveness of non-biological treatments for negative symptoms in psychotic disorders.MethodWe searched for randomised controlled studies of psychological and psychosocial interventions in psychotic disorders that reported outcome on negative symptoms. Standardised mean differences (SMDs) in values of negative symptoms at the end of treatment were calculated across study domains as the main outcome measure.ResultsA total of 95 studies met our criteria and 72 had complete quantitative data. Compared with treatment as usual cognitive-behavioural therapy (pooled SMD -0.34, 95% CI -0.55 to -0.12), skills-based training (pooled SMD -0.44, 95% CI -0.77 to -0.10), exercise (pooled SMD -0.36, 95% CI -0.71 to -0.01), and music treatments (pooled SMD -0.58, 95% CI -0.82 to -0.33) provide significant benefit. Integrated treatment models are effective for early psychosis (SMD -0.38, 95% CI -0.53 to -0.22) as long as the patients remain in treatment. Overall quality of evidence was moderate with a high level of heterogeneity.ConclusionsSpecific psychological and psychosocial interventions have utility in ameliorating negative symptoms in psychosis and should be included in the treatment of negative symptoms. However, more effective treatments for negative symptoms need to be developed.

Development of a group and family-based cognitive behavioural therapy program for youth at risk for psychosis

OBJECTIVE

The onset of psychosis typically occurs during adolescence or early adulthood and can have a detrimental impact on social and cognitive development. Cognitive behavioural therapy (CBT) shows promise in reducing the risk of psychosis. Teaching families to apply CBT with their offspring may bolster therapeutic gains made in time-limited treatment. We developed a comprehensive group-and-family-based CBT (GF-CBT) program that aims to facilitate psychosocial recovery, decrease symptoms and prevent transition to psychosis in youth at risk. GF-CBT is grounded in ecological systems and cognitive theories, resilience models and research on information processing in delusions. The theoretical rationale and description of GF-CBT are presented together with a pilot study that evaluated the program's feasibility and explored participants' outcomes.

METHODS

Youth ages 16-21 at risk for psychosis and their families participated in an open trial with pre, post and 3-month follow-up assessments conducted by an independent evaluator. The Comprehensive Assessment of At-Risk Mental States was the primary clinical outcome measure.

RESULTS

All enrolled participants (n = 6) completed GF-CBT and all remitted from at-risk mental state (ARMS). As a group participants showed statistically significant decreases in attenuated psychotic symptoms, negative symptoms, depression, cognitive biases and improvements in functioning. Family members showed significant improvements in use of CBT skills, enhanced communication with their offspring, and greater confidence in their ability to help. Gains were maintained at follow-up.

CONCLUSIONS

GF-CBT may delay or prevent transition to psychosis in youth at risk, and potentially facilitate recovery from ARMS. More rigorous, controlled research is needed to further evaluate this program.

Group cognitive behaviour therapy combining early intervention with an exclusive focus on single medication-resistant delusional beliefs: a service evaluation

Cognitive behaviour therapy (CBT) is now the psychological treatment of choice for psychosis but meta-analyses indicate a low effect size on delusions, so further innovations are clearly needed, and group CBT for psychosis (GCBTp) is an under-researched area. This study aimed to service-evaluate the feasibility, satisfaction, safety, and effectiveness of a CBT group specifically targeting medication-resistant single delusions in early psychosis patients (EI-GCBTp). Three separate EI-GCBTp groups were run resulting in a total of 11 medication-resistant early psychosis patients. A within-subjects design tested for group change across two time points: pre-baseline (4 weeks before treatment) to baseline (session 1 of treatment) and sessions 1–8 (the treatment period). Thirteen delusion dimensions were measured from three psychosis-specific questionnaires: The Psychotic Symptom Rating Scale (PSYRATS), Characteristics of Delusion Rating Scale, and the Belief Rating Scale. At least three patients attended each group, satisfaction scores were high, and no harm to patients was identified. With reference to effectiveness, the pre-baseline period showed virtually no change. In contrast, across the EI-GCBTp treatment period, the PSYRATS total demonstrated a statistically significant decrease in delusional severity (p < 0.01), a 31% symptom reduction, and a large effect size (Cohen's d = 1.2, 95% confidence interval = −2.53 to 0.05), statistically significant across four delusion dimensions. EI-GCBTp appears feasible, acceptable, safe, and preliminary uncontrolled effectiveness results suggest merit for larger-scale more rigorous testing of this treatment format for possible dimensional improvements of persistent delusions.

Metacognitive therapy (MCT+) in patients with psychosis not receiving antipsychotic medication: A case study

Background: Psychotherapies for psychosis typically aim to develop an awareness of the implausible content of a delusion or target the underlying cognitive biases (i.e., problematic thinking styles, such as hasty decisions and illusory control) that foster and maintain delusional beliefs. A recently designed individual-based treatment entitled metacognitive therapy (MCT+) combines these two approaches. Emerging evidence suggests individualized MCT+, when used concurrently with antipsychotic medication, may be an effective psychological treatment for reducing delusional symptoms. However, it remains to be tested whether MCT+ can be effective in patients with active delusions who are not currently receiving psychotropic drugs.

Method: We present two cases (one patient with schizophrenia and the other with delusional disorder) experiencing active delusions who underwent 4-weeks of intensive MCT+, without concurrent antipsychotic medication (minimum 6-months unmedicated). Baseline and 6-week follow-up data are presented on a variety of measures assessing delusion symptom severity (i.e., PANSS, PSYRATS, SAPS), clinical insight, and cognitive bias propensity.

Results: After 4-weeks of MCT+, both patients showed substantial reduction in delusional symptoms, reported improved clinical insight, and were less prone to making illusory correlations.

Conclusions: The presented case studies provide preliminary evidence for the feasibility of MCT+ in treating patients not taking, or resistant to, antipsychotic medication.

Implementing Coordinated Specialty Care for Early Psychosis: The RAISE Connection Program

OBJECTIVE

The RAISE (Recovery After an Initial Schizophrenia Episode) Connection Program Implementation and Evaluation Study developed tools necessary to implement and disseminate an innovative team-based intervention designed to promote engagement and treatment participation, foster recovery, and minimize disability among individuals experiencing early psychosis. This article describes the treatment model and reports on service utilization and outcomes. It was hypothesized that individuals' symptoms and functioning would improve over time.

METHODS

A total of 65 individuals in RAISE Connection Program treatment across two sites (Baltimore and New York City) were enrolled and received services for up to two years. Primary outcomes, including social and occupational functioning and symptoms, were evaluated. Trajectories for individuals' outcomes over time were examined with linear and quadratic mixed-effects models with repeated measures.

RESULTS

Measures of occupational and social functioning improved significantly over time, symptoms declined, and rates of remission improved. Visits were most frequent during the first three months, with a mean±SD of 23.2±11.5 unduplicated staff encounters per quarter. Such encounters decreased to 8.8±5.2 in the final quarter of year 2.

CONCLUSIONS

The overall project was successful in that the treatment program was delivered and tools useful to other clinical settings were produced. The strengths of this study lie in the demonstrated feasibility of delivering the coordinated specialty care model and the associated high rates of engagement among individuals who are typically difficult to engage in treatment. Notwithstanding the lack of a built-in comparison group, participant outcomes were promising, with improvements comparable to those seen with other successful interventions.

Understanding process in group cognitive behaviour therapy for psychosis

BACKGROUND

Group cognitive behaviour therapy for psychosis (GCBTp) has shown to be effective in diminishing symptoms, as well as in improving other psychosocial dimensions such as self-esteem. But little is known regarding the processes that generate these therapeutic improvements and might be harnessed to further improve its effectiveness.

OBJECTIVES

The current study aimed at investigating these processes, particularly those linked to interpersonal relationships.

DESIGN

The participants were all assessed at baseline, were given 24 sessions of GCBTp over the course of 3 months and were assessed again at post-treatment as well as 6 months later (9 months from baseline).

METHOD

Sixty-six individuals with early psychosis took part in a study of GCBTp where therapist alliance and group cohesion were assessed at three time points during the therapy, and punctual (each session) self-perceptions on symptoms and optimism were collected.

RESULTS

Improvements in symptoms (BPRS), self-esteem (SERS-SF) and in self-perceived therapeutic improvements (CHOICE) were linked to specific aspects of the alliance, group cohesion, as well as optimism. The variables retained were not always overall scores, suggesting the importance of the variables at key moments during the therapy.

CONCLUSIONS

The results clearly demonstrate the importance of the alliance and group cohesion, together significantly explaining improvements measured at post-therapy or follow-up.

PRACTITIONER POINTS

This study has attempted to focus mostly on relational aspects, as well as on self-perceptions, in the context of a GCBTp for individuals with early psychosis. This study also showed that these therapeutic relationships are especially useful when they are more stable and at specific moments during the therapy, namely when more difficult psychological work is done.

An investigation of the relationship between therapist characteristics and alliance in group therapy for individuals with treatment-resistant auditory hallucinations

BACKGROUND

Alliance is a well-studied construct; however, little research has investigated predictors of alliance in a group context.

AIMS

This study investigates the relationship between therapist characteristics and group alliance in 65 individuals with schizophrenia receiving outpatient group therapy for treatment-resistant auditory hallucinations.

METHODS

Raters coded 120 sessions of cognitive behavioral therapy or supportive therapy for therapist warmth and friendliness, therapist exploration and negative therapist attitude. Alliance was assessed at week six.

RESULTS

Higher average levels of therapist warmth and friendliness and lower average levels of negative therapist attitude in sessions one to five were associated with stronger alliance at week six at the trend level (p < 0.10). Therapist exploration did not predict alliance at week six. Higher negative therapist attitude at treatment engagement was associated with higher post-treatment symptom scores.

CONCLUSIONS

Our results suggest that therapist attributes but not therapist techniques are associated with client's perceptions of alliance and that negative therapist behaviors are associated with higher symptom levels at post-treatment. Implications for clinical practice are discussed.

Adapted cognitive-behavioural therapy required for targeting negative symptoms in schizophrenia: meta-analysis and meta-regression

BACKGROUND

There is an increasing interest in cognitive-behavioural therapy (CBT) interventions targeting negative symptoms in schizophrenia. To date, CBT trials primarily focused on positive symptoms and investigated change in negative symptoms only as a secondary outcome. To enhance insight into factors contributing to improvement of negative symptoms, and to identify subgroups of patients that may benefit most from CBT directed at ameliorating negative symptoms, we reviewed all available evidence on these outcomes.

METHOD

A systematic search of the literature was conducted in PsychInfo, PubMed and the Cochrane register to identify randomized controlled trials reporting on the impact of CBT interventions on negative symptoms in schizophrenia. Random-effects meta-analyses were performed on end-of-treatment, short-term and long-term changes in negative symptoms.

RESULTS

A total of 35 publications covering 30 trials in 2312 patients, published between 1993 and 2013, were included. Our results showed studies' pooled effect on symptom alleviation to be small [Hedges' g = 0.093, 95% confidence interval (CI) -0.028 to 0.214, p = 0.130] and heterogeneous (Q = 73.067, degrees of freedom = 29, p < 0.001, τ 2 = 0.081, I 2 = 60.31) in studies with negative symptoms as a secondary outcome. Similar results were found for studies focused on negative symptom reduction (Hedges' g = 0.157, 95% CI -0.10 to 0.409, p = 0.225). Meta-regression revealed that stronger treatment effects were associated with earlier year of publication, lower study quality and with CBT provided individually (as compared with group-based).

CONCLUSIONS

The co-occurring beneficial effect of conventional CBT on negative symptoms found in older studies was not supported by more recent studies. It is now necessary to further disentangle effective treatment ingredients of older studies in order to guide the development of future CBT interventions aimed at negative symptom reduction.

Metacognitive training for patients with schizophrenia: preliminary evidence for a targeted, single-module programme

OBJECTIVE

Metacognitive training is an eight-module, group-based treatment programme for people with schizophrenia that targets the cognitive biases (i.e. problematic thinking styles) thought to contribute to the genesis and maintenance of delusions. The present article is an investigation into the efficacy of a shorter, more targeted, single-module metacognitive training programme, administered individually, which focuses specifically on improving cognitive biases that are thought to be driven by a 'hypersalience of evidence-hypothesis matches' mechanism (e.g. jumping to conclusions, belief inflexibility, reasoning heuristics, illusions of control). It was hypothesised that a more targeted metacognitive training module could still improve performance on these bias tasks and reduce delusional ideation, while improving insight and quality of life.

METHOD

A sample of 28 patients diagnosed with schizophrenia and mild delusions either participated in the hour-long, single-session, targeted metacognitive training programme (n = 14), or continued treatment as usual (n = 14). All patients were assessed using clinical measures gauging overall positive symptomology, delusional ideation, quality of life and insight, and completed two cognitive bias tasks designed to elucidate the representativeness and illusion of control biases.

RESULTS

After a 2-week, post-treatment interval, targeted metacognitive training patients exhibited significant decreases in delusional severity and conviction, significantly improved clinical insight, and significant improvements on the cognitive bias tasks, relative to the treatment-as-usual controls. Performance improvements on the cognitive bias tasks significantly correlated with the observed reductions in overall positive symptomology. Patients also evaluated the training positively.

CONCLUSIONS

Although interpretations of these results are limited due to the lack of an optimally designed, randomised controlled trial and a small sample size, the results are promising and warrant further investigation into targeted versions of the metacognitive training programme.

Metacognitive training (MCT) for schizophrenia improves cognitive insight: a randomized controlled trial in a Chinese sample with schizophrenia spectrum disorders

Metacognitive training (MCT) is a group-based treatment program for people with schizophrenia that targets the cognitive biases thought to contribute to the pathogenesis and maintenance of delusions. Although effective in reducing the severity of delusions, the influence of MCT on cognitive insight, and its feasibility in Chinese culture, has yet to be investigated. The present randomized-controlled trial attempted to address these inconsistencies. A Chinese sample of 80 participants with schizophrenia spectrum disorders was randomized to the eight-module MCT program or continued treatment as usual (TAU). All participants were assessed using the Beck Cognitive Insight Scale, which assesses two components of cognitive insight (self-reflectiveness and self-certainty). Participants in the MCT condition subjectively rated their satisfaction with the training. Retention rates were high after four-weeks of MCT (n = 38) or TAU (n = 39). Clients randomized into the MCT condition rated the program favourably and showed significant improvements in cognitive insight (i.e., increased self-reflectiveness), relative to TAU controls, who exhibited decreases in cognitive insight at follow-up. These findings suggest that the MCT program is not only subjectively efficacious in Chinese samples, but also improves metacognitive awareness of the processes underlying delusional symptoms.