Cognitive Behavioural Therapy for schizophrenia - outcomes for functioning, distress and quality of life: a meta-analysis

Conceptualization and characterization of "primary" and "secondary" cognitive impairment in schizophrenia

Cognitive impairment represents one of the core features of schizophrenia, involves both neurocognition and social cognition domains, and has a significant negative impact on real-world functioning. The present review provides a framework for the conceptualization and characterization of "primary" and "secondary" cognitive impairment in schizophrenia. In this conceptualization, primary cognitive impairment can be defined as a consequence of the neurobiological alterations that underlie psychopathological manifestations of the disorder, while secondary cognitive impairment can be defined as the results of a source issue that has a negative impact on cognitive performance. Sources of secondary cognitive impairment are frequent in people with schizophrenia and include several different factors, such as positive and negative symptoms, depressive symptoms, autistic symptoms, pharmacotherapy, substance abuse, metabolic syndrome, social deprivation, and sleep disorders. It can be hypothesized that secondary cognitive impairment may be improved by effectively resolving the source issue, while primary cognitive impairment may benefit from dedicated treatment. Further research is required to confirm this hypothesis, to better characterize the distinction between primary and secondary cognitive impairment in a clinical and in a neurobiological perspective, and to evaluate the impact of systematically assessing and treating secondary cognitive impairment.

Understanding Cognitive Behavioral Therapy for Psychosis Through the Predictive Coding Framework

Psychological treatments for persecutory delusions, particularly cognitive behavioral therapy for psychosis, are efficacious; however, mechanistic theories explaining why they work rarely bridge to the level of cognitive neuroscience. Predictive coding, a general brain processing theory rooted in cognitive and computational neuroscience, has increasing experimental support for explaining symptoms of psychosis, including the formation and maintenance of delusions. Here, we describe recent advances in cognitive behavioral therapy for psychosis-based psychotherapy for persecutory delusions, which targets specific psychological processes at the computational level of information processing. We outline how Bayesian learning models employed in predictive coding are superior to simple associative learning models for understanding the impact of cognitive behavioral interventions at the algorithmic level. We review hierarchical predictive coding as an account of belief updating rooted in prediction error signaling. We examine how this process is abnormal in psychotic disorders, garnering noisy sensory data that is made sense of through the development of overly strong delusional priors. We argue that effective cognitive behavioral therapy for psychosis systematically targets the way sensory data are selected, experienced, and interpreted, thus allowing for the strengthening of alternative beliefs. Finally, future directions based on these arguments are discussed.

Effect of psychological nursing interventions on effectiveness and quality of life in schizophrenia patients receiving modified electroconvulsive therapy

BACKGROUND

Schizophrenia is a common and severe mental disorder characterized by severe thought disturbances, hallucinations, delusions, and emotional instability. For some patients, conventional treatment methods may not effectively alleviate symptoms, necessitating the use of alternative therapeutic approaches. Modified electroconvulsive therapy (MECT) is an effective treatment modality for schizophrenia, inducing anti-depressive and antipsychotic effects through the stimulation of brain electrical activity.

AIM

To explore the impact of psychological nursing intervention (PNI) before and after MECT on the efficacy and quality of life of patients with schizophrenia.

METHODS

Eighty patients with schizophrenia who received MECT treatment from 2021 to 2023 were randomly divided into two groups: The intervention group (n = 40) and the control group (n = 40). The intervention group received PNI before and after MECT, while the control group received routine nursing care. The efficacy of MECT was evaluated by the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression Scale (CGI) before and after the treatment. The quality of life was assessed by the Short Form 36 Health Survey (SF-36) after the treatment.

RESUITS

The intervention group had significantly lower scores of PANSS and CGI than the control group after the treatment (P < 0.05). The intervention group also had significantly higher scores of SF-36 than the control group in all domains except physical functioning (P < 0.05).

CONCLUSION

PNI before and after MECT can improve the efficacy and quality of life of patients with schizophrenia. It is suggested that nurses should provide individualized and comprehensive psychological care for patients undergoing MECT to enhance their recovery and well-being.

Emotional distress and dysregulation as treatment targets to reduce suicide in psychosis: a scoping review

There is a pressing need for effective treatments that address the high rate of suicide observed among people with psychosis. In this scoping review we highlight two suicidogenic treatment targets that have been relatively neglected in people with psychotic disorders: emotional distress and emotion dysregulation. We review the research on these constructs in psychosis and their relationship to suicide in this population, and then make clinical recommendations based on research findings. Emotional distress and emotional dysregulation may be promising treatment targets for suicide among people with psychosis.

Left hemisphere lateralization of the limbic system and frontoparietal network (FPN) correlates with positive and negative symptom improvement following cannabidiol (CBD) administration in psychosis and ultra-high risk (UHR) populations: A voxel-wise meta-analysis

This voxel-wise meta-analysis assesses current findings about the neural correlates of cannabidiol on the positive and negative symptoms among individuals with psychosis or ultra-high risk (UHR) for psychosis. We used PubMed, EMBASE, and ScienceDirect as primary databases and initially retrieved 157 studies. After applying our eligibility criteria, 13 studies remained for inclusion. Ten studies focused on psychosis. Three studies focused on UHR. Quality assessment was performed for included articles using the RoB2 instrument. Statistical analysis implicated a voxel-wise meta-analysis of different task paradigms (emotion recognition, verbal memory recall, and inhibitory control) with a jackknife sensitivity measure, Egger's test of random effects, and a meta-regression with relevant covariates. Article quality was determined to be primarily low risk of bias, with some elements of unclear bias figuring across studies. Our results showed robust, convergent correlations between CBD administration and left hemisphere lateralization of limbic system and frontoparietal network (FPN) subregions across task paradigms in psychosis and UHR populations. Our meta-regression revealed that decreased limbic system activity correlated with positive symptom improvements, and decreased FPN activity correlated with negative symptom improvements. Lastly, sensitivity analyses determined that there was minimal risk bias or risk of confounding variables unduly influencing our meta-analyses (p > 0.05).

Ultra-brief acceptance & commitment therapy for inpatients with psychosis - a single-case experimental design investigating processes of change

People with primary psychosis are among the most seen in inpatient psychiatry. Treatment guidelines recommend both pharmacological and psychological treatments. However, psychological treatments are not routinely offered in many settings. There is also a lack of research on psychological treatments for this vulnerable population in the inpatient setting. The first aim of the current study was to examine treatment effects of a brief form of Acceptance and Commitment Therapy on outcomes valued by the treatment recipients. The second aim was to explore hypothetical processes of change in relation to outcomes over time. Three people with primary psychosis were treated for two to four sessions. A replicated single-case experimental design with multiple baselines across subjects (Clinical Trials registration number ID NCT04704973) was employed to examine treatment effects. The Personal Questionnaire (PQ) was used as primary outcome, symptom believability and preoccupation as proposed processes of change. Data were analyzed using visual inspection, calculation of Tau-U values, and cross-lagged correlation. All participants improved significantly on PQ and the symptom preoccupation measure. Two improved significantly on the symptom believability measure. Cross-lagged correlation analyses showed no clear mediation. Change in proposed processes of change and primary outcome predominantly happened concomitantly, although patterns of results reflected individual differences.

Group Acceptance and Commitment Therapy for Recovery From Psychosis: Protocol for a Single-Group Waitlist Trial

BACKGROUND

Psychological interventions, along with antipsychotic medications, are recommended for adults diagnosed with a psychotic disorder. While initially designed to mitigate positive symptoms, psychological interventions targeting personal recovery were developed and aligned with the recovery framework that many mental health services have adopted. Acceptance and Commitment Therapy (ACT) for psychosis is one such intervention that shows promise when delivered in an individual format. There is preliminary evidence that ACT for psychosis in a group format improves recovery.

OBJECTIVE

This trial aims to evaluate the effectiveness of the "Recovery ACT" group program on personal recovery among adults living with a psychotic disorder.

METHODS

Our unfunded study is a multiagency, prospective, nonrandomized, waitlist control, single-group trial of the Recovery ACT group program. The program involves 7 weekly group sessions of 90 minutes duration and a 90-minute booster session held 1 month later. We intend to recruit 160 adults living with a psychotic disorder who enroll in a group that is offered as a routine clinical service at participating public mental health services in Melbourne, Victoria, Australia. The 4 assessment time points are 4-6 weeks before the start of the group program, at the start of the group program, at the end of the group program, and at the booster session. There is an optional midgroup assessment and follow-up study. The primary outcome is personal recovery. Secondary outcomes include participants' well-being and psychological flexibility processes. Qualitative data are also collected from participants and facilitators.

RESULTS

Recruitment began in September 2019 and is ongoing until 2024, subsequent to a 24-month disruption due to the COVID-19 pandemic. As of the submission of this paper, 93 participants consented to the evaluation, 65 completed T1 measures, and 40 had a complete data set for the proposed analyses.

CONCLUSIONS

This is the first trial evaluating the effectiveness of the Recovery ACT group program on personal recovery for adults living with a psychotic disorder. Findings will contribute to knowledge about psychosocial interventions for adults living with psychosis. This trial may also serve as an example of a partnership between clinicians and academics that can facilitate the translation of research into practice.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12620000223932; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000223932.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49849.

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.

Cognitive behavioural therapy for psychosis: The end of the line or time for a new approach?

PURPOSE

Following its introduction in the early 1990s, cognitive behavioural therapy for psychosis (CBTp) has been evaluated in a large number of clinical trials and is now established as a recommended treatment in the UK National Health Service and elsewhere in the world. Meta-analyses, however, indicate modest effects compared to treatment as usual or comparison therapies such as supportive counselling. Here, we seek to identify factors impacting the effectiveness of CBTp, and avenues for future psychotherapy research that may improve outcomes.

METHOD

We outline two recent umbrella reviews and discuss factors likely to impact the effectiveness of CBTp.

RESULTS

Modest effect sizes from meta-analyses mask heterogeneous outcomes, with some people benefiting and others possibly being harmed by therapy. Common factors such as the therapeutic alliance play an important role in determining outcomes but have been largely neglected by CBTp researchers. There is also the promise of improving outcomes by identifying and targeting the psychological mechanisms that either maintain psychotic symptoms (e.g. worry) or are causally implicated (e.g. trauma).

CONCLUSIONS

It is unlikely that everyone with psychosis will be equally responsive to the same therapeutic protocols. We need a new, personalised psychotherapy approach to CBTp research and practice, and can learn from research for anxiety and depression examining predictors of therapeutic response to inform treatment decisions. Precision psychological therapies informed by a combination of individual characteristics, common factors and a focus on specific mechanisms will require new research strategies and are likely to lead to improved outcomes for people with psychosis.

Cognitive behavioural therapy without medication for schizophrenia

BACKGROUND

Cognitive behavioural therapy (CBT) can be effective in people with schizophrenia when provided in combination with antipsychotic medication. It remains unclear whether CBT could be safely and effectively offered in the absence of concomitant antipsychotic therapy.

OBJECTIVES

To investigate the effects of CBT for schizophrenia when administered without concomitant pharmacological treatment with antipsychotics.

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, and WHO ICTRP.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in people with schizophrenia comparing CBT without antipsychotics to standard care, standard care without antipsychotics, or the combination of CBT and antipsychotics.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references for inclusion, extracted data from eligible studies, and assessed risk of bias using Cochrane's RoB 2 tool. We contacted study authors for missing data and additional information. Our primary outcome was general mental state measured with a validated rating scale. Key secondary outcomes were specific symptoms of schizophrenia, relapse, service use, number of participants leaving the study early, functioning, quality of life, and number of participants actually receiving antipsychotics during the trial. We also assessed behaviour, adverse effects, and mortality.

MAIN RESULTS

We included 4 studies providing data for 300 participants (average age 21.94 years). The mean sample size was 75 participants (range 61 to 90 participants). Study duration was between 26 and 39 weeks for the intervention period and 26 to 104 weeks for the follow-up period. Three studies employed a blind rater, while one study was triple-blind. All analyses included data from a maximum of three studies. The certainty of the evidence was low or very low for all outcomes. For the primary outcome overall symptoms of schizophrenia, results showed a difference favouring CBT without antipsychotics when compared to no specific treatment at long term (> 1 year mean difference measured with the Positive and Negative Syndrome Scale (PANSS MD) -14.77, 95% confidence interval (CI) -27.75 to -1.79, 1 RCT, n = 34). There was no difference between CBT without antipsychotics compared with antipsychotics (up to 12 months PANSS MD 3.38, 95% CI -2.38 to 9.14, 2 RCTs, n = 63) (very low-certainty evidence) or compared with CBT in combination with antipsychotics (up to 12 months standardised mean difference (SMD) 0.30, 95% CI -0.06 to 0.65, 3 RCTs, n = 125). Compared with no specific treatment, CBT without antipsychotics was associated with a reduction in overall symptoms (as described above) and negative symptoms (PANSS negative MD -4.06, 95% CI -7.50 to -0.62, 1 RCT, n = 34) at longer than 12 months. It was also associated with a lower duration of hospital stay (number of days in hospital MD -22.45, 95% CI -28.82 to -16.08, 1 RCT, n = 74) and better functioning (Personal and Social Performance Scale MD -12.42, 95% CI -22.75 to -2.09, 1 RCT, n = 40, low-certainty evidence) at up to 12 months. We did not find a difference between CBT and antipsychotics in any of the investigated outcomes, with the exception of adverse events measured with the Antipsychotic Non-Neurological Side-Effects Rating Scale (ANNSERS) at both 6 and 12 months (MD -4.94, 95% CI -8.60 to -1.28, 2 RCTs, n = 48; MD -6.96, 95% CI -11.55 to -2.37, 2 RCTs, n = 42). CBT without antipsychotics was less effective than CBT combined with antipsychotics in reducing positive symptoms at up to 12 months (SMD 0.40, 95% CI 0.05 to 0.76, 3 RCTs, n = 126). CBT without antipsychotics was associated with a lower number of participants experiencing at least one adverse event in comparison with CBT combined with antipsychotics at up to 12 months (risk ratio 0.36, 95% CI 0.17 to 0.80, 1 RCT, n = 39, low-certainty evidence).

AUTHORS' CONCLUSIONS

This review is the first attempt to systematically synthesise the evidence about CBT delivered without medication to people with schizophrenia. The limited number of studies and low to very low certainty of the evidence prevented any strong conclusions. An important limitation in the available studies was that participants in the CBT without medication group (about 35% on average) received antipsychotic treatment, highlighting the challenges of this approach. Further high-quality RCTs are needed to provide additional data on the feasibility and efficacy of CBT without antipsychotics.

Symptom contributors to quality of life in schizophrenia: Exploratory factor and network analyses

Individuals with schizophrenia and other associated disorders experience significant disturbance to their quality of life (QoL) due to a multitude of co-occurring symptoms. Popular evidence-based practices (EBPs) devote significant effort to reduce positive symptomatology in order to prevent relapse, while emerging research posits that other symptoms (cognitive deficits, negative and affective symptoms) are more indicative of QoL disturbance. This study sought to examine the impact of symptom constructs on QoL and attempt to infer directionality of influence via network analysis. A total of 102 recovery phase adult outpatients with schizophrenia spectrum disorders were assessed on positive, negative, and affective symptomatology, in addition to QoL and cognitive abilities. Exploratory factor analysis and network analysis were performed to identify associations and infer directed influence between symptom constructs, and a directed acyclic graph was constructed to observe associations between symptom domains and QoL. Factor analysis results indicated that individual measures align with their respective symptom constructs. Strong factor correlations were found between QoL and the negative and affective symptom constructs, with weaker associations found between positive symptoms and cognition. Visualization of the network structure illustrated QoL as the central cluster of the network, and examination of the weighted edges found the strongest connectivity between QoL, negative symptomatology, and affective symptoms. More severe negative and affective symptoms were most directly linked with poorer QoL and may prove to be integral in attaining positive outcomes in schizophrenia treatment. Incorporation of psychosocial treatments in addition to pharmacotherapy may prove effective in targeting negative and affective symptoms.

The schizophrenia syndrome, circa 2024: What we know and how that informs its nature

With new data about different aspects of schizophrenia being continually generated, it becomes necessary to periodically revisit exactly what we know. Along with a need to review what we currently know about schizophrenia, there is an equal imperative to evaluate the construct itself. With these objectives, we undertook an iterative, multi-phase process involving fifty international experts in the field, with each step building on learnings from the prior one. This review assembles currently established findings about schizophrenia (construct, etiology, pathophysiology, clinical expression, treatment) and posits what they reveal about its nature. Schizophrenia is a heritable, complex, multi-dimensional syndrome with varying degrees of psychotic, negative, cognitive, mood, and motor manifestations. The illness exhibits a remitting and relapsing course, with varying degrees of recovery among affected individuals with most experiencing significant social and functional impairment. Genetic risk factors likely include thousands of common genetic variants that each have a small impact on an individual's risk and a plethora of rare gene variants that have a larger individual impact on risk. Their biological effects are concentrated in the brain and many of the same variants also increase the risk of other psychiatric disorders such as bipolar disorder, autism, and other neurodevelopmental conditions. Environmental risk factors include but are not limited to urban residence in childhood, migration, older paternal age at birth, cannabis use, childhood trauma, antenatal maternal infection, and perinatal hypoxia. Structural, functional, and neurochemical brain alterations implicate multiple regions and functional circuits. Dopamine D-2 receptor antagonists and partial agonists improve psychotic symptoms and reduce risk of relapse. Certain psychological and psychosocial interventions are beneficial. Early intervention can reduce treatment delay and improve outcomes. Schizophrenia is increasingly considered to be a heterogeneous syndrome and not a singular disease entity. There is no necessary or sufficient etiology, pathology, set of clinical features, or treatment that fully circumscribes this syndrome. A single, common pathophysiological pathway appears unlikely. The boundaries of schizophrenia remain fuzzy, suggesting the absence of a categorical fit and need to reconceptualize it as a broader, multi-dimensional and/or spectrum construct.

Which psychological interventions improve quality of life in patients with schizophrenia-spectrum disorders? A meta-analysis of randomized controlled trials

Quality of life (QoL) is a major patient reported outcome used to measure the psychological treatments success in people with schizophrenia-spectrum disorders. To date, the specific impact of different interventions on QoL remains undefined. A meta-analysis of Randomized Controlled Trials (RCTs) was carried out for this purpose. We searched Proquest, PUBMED/MEDLINE, PsycINFO, WOS, Scopus, the Cochrane Library for RCTs published until January 2023. We used multilevel meta-analysis to examine differences between intervention effectiveness of experimental and control conditions whilst accounting for data dependencies. By means of subgroup analyses, we investigated influences of intervention types (i.e. psychoeducation v. CBT v. cognitive v. combination of several types v. other, such as psychodynamic, systemic, etc.) and continuous moderators were examined with precision-weighted meta-regressions. The generalizability of results across moderators, their combinations, and analytical approaches was investigated with multiverse meta-analyses. We examined data of 60 independent studies, reporting intervention effects for objective and subjective QoL (k = 19 and 70 effect sizes based on N = 1024 and 6254 participants, respectively). Overall, psychological interventions seemed to be more effective for objective than for subjective QoL. However, specific intervention results were differentiated, suggesting largest effects of psychoeducation on objective and combined interventions on subjective QoL. Our findings suggest that QoL is a valid outcome criterion for testing intervention effectiveness, as it is sensitive to change. Additionally, psychological interventions can improve patients' QoL, though the effects are small. Further testing of less widely used interventions and a shift toward the multidimensional nature of QoL is still necessary.

Identifying types of problems and relative priorities in the problem lists of participants in CBT for psychosis trials

BACKGROUND

There is wide variation in the problems prioritised by people with psychosis in cognitive behavioural therapy for psychosis (CBTp). While research trials and mental health services have often prioritised reduction in psychiatric symptoms, service users may prioritise issues not directly related to psychosis. This discrepancy suggests potential challenges in treatment outcome research.

AIMS

The present study aimed to examine the types of problems that were recorded on problem lists generated in CBTp trials.

METHOD

Problem and goals lists for 110 participants were extracted from CBTp therapy notes. Subsequently, problems were coded into 23 distinct categories by pooling together items that appeared thematically related.

RESULTS

More than half of participants (59.62%) listed a non-psychosis-related priority problem, and 22.12% did not list any psychosis related problems. Chi-square tests indicated there was no difference between participants from early intervention (EI) and other services in terms of priority problem (χ2 = 0.06, p = .804), but that those from EI were more likely to include any psychosis-related problems in their lists (χ2 = 6.66, p = .010).

CONCLUSIONS

The findings of this study suggest that psychiatric symptom reduction is not the primary goal of CBTp for most service users, particularly those who are not under the care of EI services. The implications for future research and clinical practice are discussed.

The Psychotherapy of Schizophrenia: A Review of the Evidence for Psychodynamic and Nonpsychodynamic Treatments

Following the discovery of chlorpromazine's effectiveness as a treatment for schizophrenia in the 1950s, a gradual shift away from psychotherapeutic and toward biological methods of investigation has ensued. Nevertheless, psychological approaches to schizophrenia have a long history and continue to represent an important component of schizophrenia treatment. In the past 2 decades, there has been renewed interest in psychotherapy for schizophrenia among some clinicians and researchers. This article examines the current evidence for both psychodynamic and nonpsychodynamic (cognitive-behavioral, cognitive enhancement, and psychoeducational) therapies for schizophrenic illness. There is evidence to support the use of both types of therapies though these orientations generally differ in their views on the role of psychological factors in the etiology of schizophrenia. It is argued that a pluralistic or biopsychosocial model of schizophrenia is necessary to account for the complexity of the disease and to provide the most effective treatment.

The application of cognitive behavioral therapy in patients with schizophrenia: A review

The aim of this review is to explore the clinical nursing application of cognitive behavioral therapy (CBT) in patients with schizophrenia. A literature search was conducted using the CINAHL and MEDLINE databases. The database search occurred during the month of December 2022. This article comprehensively summarizes the theoretical basis of CBT in improving schizophrenia in clinical nursing, its application in managing symptoms and improving social function, as well as research progress in this field. There are still inconsistencies in the research results on CBT, but overall, psychological intervention combined with drug treatment is more effective than conventional treatment alone. If social function training can be added at the same time, it is believed that it will have better effects on clinical treatment and can maintain long-lasting effectiveness. Only in this way can patients truly understand and recognize the disease, improve treatment compliance, and ultimately achieve the goal of improving prognosis and quality of life.

Do the various leisure forms have equal effects on mental health? A longitudinal analysis of self-selected leisure activities

The deteriorating trends of unbalanced income, progressive age-related health problems, and loss of traditional ties necessitate ever-flexible interventions that are helpful to overcome a decline in Chinese adults' mental health. This study aimed to test whether engagement in different domains of leisure is associated with a composite index of mental health, both concurrently and subsequently. Longitudinal data including 10,968 participants (females = 5,804) with a mean age of 46.01 years in the Chinese General Social Survey (CGSS) were analyzed using generalized estimating equations with a logit link. The results showed that face-to-face experiences, such as sports with all ORs of < 1 at the significance level of α = 0.01 and meeting with all ORs of < 1 at the significance level of α = 0.01 except daily in-person meeting frequency, are important for protecting mental health owing to the increasing social support by building close ties. The results also indicate that online leisure with all ORs < 1 at the significance level of α = 0.01 has positive effects on lowering the odds of depression. In addition, receptive cognitive leisure, such as watching television or movies with all ORs < 1 at the significance level of α = 0.05 level, was not consistently associated with depression. However, active cognitive leisure, such as reading with all ORs of < 1 at a significance level of α = 0.01, was associated with lower odds of depression.

Unsupervised Machine Learning Driven Analysis of Verbatims of Treatment-Resistant Schizophrenia Patients Having Followed Avatar Therapy

(1) Background: The therapeutic mechanisms underlying psychotherapeutic interventions for individuals with treatment-resistant schizophrenia are mostly unknown. One of these treatment techniques is avatar therapy (AT), in which the patient engages in immersive sessions while interacting with an avatar representing their primary persistent auditory verbal hallucination. The aim of this study was to conduct an unsupervised machine-learning analysis of verbatims of treatment-resistant schizophrenia patients that have followed AT. The second aim of the study was to compare the data clusters obtained from the unsupervised machine-learning analysis with previously conducted qualitative analysis. (2) Methods: A k-means algorithm was performed over the immersive-session verbatims of 18 patients suffering from treatment-resistant schizophrenia who followed AT to cluster interactions of the avatar and the patient. Data were pre-processed using vectorization and data reduction. (3): Results: Three clusters of interactions were identified for the avatar's interactions whereas four clusters were identified for the patient's interactions. (4) Conclusion: This study was the first attempt to conduct unsupervised machine learning on AT and provided a quantitative insight into the inner interactions that take place during immersive sessions. The use of unsupervised machine learning could yield a better understanding of the type of interactions that take place in AT and their clinical implications.

Psychosocial and behavioural interventions for the negative symptoms of schizophrenia: a systematic review of efficacy meta-analyses

BACKGROUND

Currently there is no first-line treatment recommended for the negative symptoms of schizophrenia. Psychosocial and behavioural interventions are widely used to reduce the burden of negative symptoms. Meta-analytic studies have summarised the evidence for specific approaches but not compared evidence quality and benefit.

AIM

To review and evaluate the evidence from meta-analytic studies of psychosocial and behavioural interventions for the negative symptoms of schizophrenia.

METHOD

A systematic literature search was undertaken to identify all meta-analyses evaluating psychosocial and behavioural interventions reporting on negative symptom outcomes in people with schizophrenia. Data on intervention, study characteristics, acceptability and outcome were extracted. Risk of bias was evaluated. Results were summarised descriptively, and evidence ranked on methodological quality.

RESULTS

In total, 31 systematic reviews met the inclusion criteria evaluating the efficacy of negative symptom interventions on 33 141 participants. Exercise interventions showed effect sizes (reduction in negative symptoms) ranging from -0.59 to -0.24 and psychological interventions ranging from -0.65 to -0.04. Attrition ranged between 12% to 32%. Across the studies considered heterogeneity varied substantially (range 0-100). Most of the reviews were of very low to low methodological quality. Methodological quality ranking suggested that the effect size for cognitive remediation and exercise therapy may be more robust compared with other approaches.

CONCLUSIONS

Most of the interventions considered had a small-to-moderate effect size, good acceptability levels but very few had negative symptoms as the primary intervention target. To improve the confidence of these effect sizes being replicated in clinical settings future studies should minimise risk of bias.

Changes in Quality of Life in Treatment-Resistant Schizophrenia Patients Undergoing Avatar Therapy: A Content Analysis

Avatar Therapy has a significant impact on symptoms, beliefs, and quality of life of patients with treatment-resistant schizophrenia. However, little is known about how these changes are implemented into their lives and to which aspects of their lives these improvements relate. Ten consecutive patients enrolled in an ongoing clinical trial were assessed using semi-guided interviews before as well as three months after Avatar Therapy. These encounters have been recorded and transcribed so that the discourse could be thoroughly analyzed, leading to the generation of an extensive theme grid. As the cases were analyzed, the grid was adapted in a back-and-forth manner until data saturation occurred. The content analysis allowed the identification of nine main themes representing different aspects of the patients’ lives, each of which was subdivided into more specific codes. By analyzing the evolution of their frequency, it was observed that, following therapy, patients presented with fewer psychotic symptoms, better self-esteem, more hobbies and projects, and an overall improved lifestyle and mood. Finally, investigating the impact of Avatar Therapy on quality of life allows for a deeper understanding of how people with treatment-resistant schizophrenia can achieve meaningful changes and move towards a certain recovery process.

Differential Treatment Responses in Pakistani Schizophrenia Samples: Correlation with Sociodemographic Parameters, Drug Addiction, Attitude to the Treatment and Antipsychotic Agents

Schizophrenia patients demonstrate variations in response to different therapies that are currently being used for the treatment of disorders, such as augmentation therapy (ECT or mood stabilizer) and combination therapy (with antipsychotics). These therapies are also used to treat schizophrenia patients in Pakistan; however, patients show poor overall response. Therefore, this study was conducted to investigate the association between the patients’ response to treatment and the use of antipsychotic agents, with variability in overall response, within different groups of patients. Methods: We conducted a retrospective study that included schizophrenia subjects (N = 200) belonging to different age groups, ethnicities, and regions from different outpatient and inpatient departments in psychiatric institutes located in different cities of Pakistan. These patients were assessed for their response to treatment therapies and categorized into four groups (non-responders (N-R), slow response (S-R), patients with relapse, and completely recovered patients (C-R)) according to their responses. Results: The final analysis included 200 subjects, of which 73.5% were males. Mean age was 34 ± 10 years. Percentage of N-R was 5%, S-R was 42%, patients with relapse were 24%, and C-R was 1.5%. The generalized linear regression model shows a significant association between medication response and age (p = 0.0231), age of onset (p = 0.0086), gender (p = 0.005), and marital status (p = 0.00169). Variability within the medication responses was a result of the treatment regime followed. Antipsychotic agents were significantly associated with the treatment response (p = 0.00258, F = 4.981) of the patients. Significant variation was also observed in the treatment response (p = 0.00128) of the patients that were given augmentation therapy as well as combination therapy. Conclusion: The data suggests proper monitoring of patients’ behavior in response to treatment therapies to implement tailored interventions. Despite several genetic studies supporting the heritability of schizophrenia, an insignificant association between characteristic features and family history might have been due to the limited sample size, suggesting collaborative work with massive sample sizes.

Exploring the Latent Structure and Convergent and Incremental Validity of the Metacognition Assessment Scale - Abbreviated in a Sample of Patients with Non-Affective Psychosis

Synthetic metacognition is a heterogeneous construct related to psychotic disorders. One important tool to assess this construct is the Metacognition Assessment Scale - Abbreviated (MAS-A). In this study, we investigated the latent structure as well as the interrater reliability and convergent and incremental validity of the MAS-A in a sample of patients with non-affective psychosis. Analyses indicated that the scale might be one-dimensional. Interrater reliability of the MAS-A total score was good. In terms of convergent validity, correlational analyses showed significant associations of MAS-A metacognition with the Operationalized Psychodynamic Diagnosis Level of Structural Integration Axis (OPD-LSIA) and the Levels of Emotional Awareness Scale (LEAS). In terms of construct validity, a significant association was observed between MAS-A metacognition and a short version of the International Classification of Functioning, Disability and Health (MINI-ICF), which persisted after self-report measures of impairments in structural capacities (Structure Questionnaire of Operationalized Psychodynamic Diagnosis [OPD-SQS]) and mentalizing abilities (Mentalization Questionnaire [MZQ]) were included as covariates, but not after symptom dimensions were included. There was a significant correlation with the current living situation, but not with other external criteria like diagnosis or duration of illness. Future studies should explore alternative outcomes and replicate results in longitudinal designs.

Efficacy and acceptability of psychosocial interventions in schizophrenia: systematic overview and quality appraisal of the meta-analytic evidence

Psychosocial interventions are recommended in schizophrenia and first-episode psychosis/early psychosis (EP). Nevertheless, literature is heterogeneous and often contradictory. We conducted an umbrella review of (network) meta-analyses of randomized controlled trials (RCTs) comparing psychosocial interventions vs treatment as usual (TAU)/active interventions(ACTIVE)/MIXED controls. Primary outcome was total symptoms (TS); secondary outcomes were positive/negative/depressive symptoms (PS/NS/DS), cognition, functioning, relapse, hospitalization, quality of life (QoL), treatment discontinuation. Standardized mean difference (SMD)/odds ratio (OR)/risk ratio (RR) vs TAU/ACTIVE/MIXED were summarized at end-of-treatment (EoT)/follow-up (FU). Quality was rated as high/medium/low (AMSTAR-PLUS). Eighty-three meta-analyses were included (RCTs = 1246; n = 84,925). Against TAU, regarding TS, Early Intervention Services (EIS) were superior EoT/FU in EP (SMD = -0.32/-0.21), cognitive behavioral therapy (CBT) in schizophrenia EoT/FU (SMD = -0.38/-0.19). Regarding secondary outcomes, in EP, EIS were superior for all outcomes EoT except cognition, and at FU for PS/NS/QoL, specific family interventions (FI-s) prevented relapse EoT; in schizophrenia, superiority emerged EoT for CBT for PS/NS/relapse/functioning/QoL; psychoeducation (EDU)/any FI for relapse; cognitive remediation therapy (CRT) for cognition/functioning; and hallucination-focused integrative treatment for PS. Against ACTIVE, in EP, mixed family interventions (FI-m) were superior at FU regarding TS (SMD = -0.61) and for functioning/relapse among secondary outcomes. In schizophrenia, regarding TS, mindfulness and social skills training (SST) were superior EoT, CBT at FU; regarding secondary outcomes superiority emerged at EoT for computerized cognitive drill-and-practice training for PS/DS, CRT for cognition/functioning, EDU for relapse, individual placement and support (IPS) for employment; and at FU CBT for PS/NS. Against MIXED, in schizophrenia, CRT/EDU were superior for TS EoT (d = -0.14/SMD = -0.33), CRT regarding secondary outcomes EoT for DS/social functioning, both EoT/FU for NS/cognition/global functioning; compensatory cognitive interventions for PS/functioning EoT/FU and NS EoT; CBT for PS at FU, and EDU/SST for relapse EoT. In conclusion, mental health services should consider prioritizing EIS/any FI in EP and CBT/CRT/any FI/IPS for schizophrenia, but other interventions may be helpful for specific outcomes.

Effects of psychological treatments on functioning in people with Schizophrenia: a systematic review and meta-analysis of randomized controlled trials

Functioning is recognized as a key treatment goal in alleviating the burden of schizophrenia. Psychological interventions can play an important role in improving functioning in this population, but the evidence on their efficacy is limited. We therefore aimed to evaluate the effect of psychological interventions in functioning for patients with schizophrenia. To conduct this systematic review and meta-analysis, we searched for published and unpublished randomized controlled trials (RCTs) in EMBASE, MEDLINE, PsycINFO, BIOSIS, Cochrane Library, WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and the Study register of the Cochrane Schizophrenia Group. The outcome functioning was measured with validated scales. We performed random-effects pairwise meta-analysis to calculate standardized mean differences (SMDs) with 95% confidence intervals (CIs). We included 58 RCTs (5048 participants). Psychological interventions analyzed together (SMD =  - 0.37, 95% CI  - 0.49 to  - 0.25), cognitive behavioral therapy (30 RCTs, SMD =  - 0.26, 95% CI  - 0.39 to  - 0.12), and third wave cognitive-behavioral therapies (15 RCTs, SMD =  - 0.60, 95% CI  - 0.83 to  - 0.37) were superior to control in improving functioning, while creative therapies (8 RCTs, SMD = 0.01, 95% CI  - 0.38 to 0.39), integrated therapies (4 RCTs, SMD =  - 0.21, 95% CI  - 1.20 to 0.78) and other therapies (4 RCTs, SMD =  - 0.74, 95% CI  - 1.52 to 0.04) did not show a benefit. Psychological interventions, in particular cognitive behavioral therapy and third wave cognitive behavioral therapies, have shown a therapeutic effect on functioning. The confidence in the estimate was evaluated as very low due to risk of bias, heterogeneity and possible publication bias.

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.

Dopaminergic dysfunction and excitatory/inhibitory imbalance in treatment-resistant schizophrenia and novel neuromodulatory treatment

Antipsychotic drugs are the mainstay in the treatment of schizophrenia. However, one-third of patients do not show adequate improvement in positive symptoms with non-clozapine antipsychotics. Additionally, approximately half of them show poor response to clozapine, electroconvulsive therapy, or other augmentation strategies. However, the development of novel treatment for these conditions is difficult due to the complex and heterogenous pathophysiology of treatment-resistant schizophrenia (TRS). Therefore, this review provides key findings, potential treatments, and a roadmap for future research in this area. First, we review the neurobiological pathophysiology of TRS, particularly the dopaminergic, glutamatergic, and GABAergic pathways. Next, the limitations of existing and promising treatments are presented. Specifically, this article focuses on the therapeutic potential of neuromodulation, including electroconvulsive therapy, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and deep brain stimulation. Finally, we propose multivariate analyses that integrate various perspectives of the pathogenesis, such as dopaminergic dysfunction and excitatory/inhibitory imbalance, thereby elucidating the heterogeneity of TRS that could not be obtained by conventional statistics. These analyses can in turn lead to a precision medicine approach with closed-loop neuromodulation targeting the detected pathophysiology of TRS.

Immediate and Sustained Outcomes and Moderators Associated With Metacognitive Training for Psychosis: A Systematic Review and Meta-analysis

IMPORTANCE

A substantial increase in the number of trials examining metacognitive training (MCT) for psychosis necessitates an updated examination of the outcomes associated with MCT.

OBJECTIVES

To review the immediate and sustained associations of MCT with proximal (directly targeted) and distal (indirectly influenced) outcomes and assess treatment- and participant-related moderators to identify the potential factors associated with the expected heterogeneity of effect sizes.

DATA SOURCES

Eleven electronic databases were searched from 2007 to June 3, 2021 (alert until September 10, 2021). Reference lists of earlier meta-analyses and included reports were screened.

STUDY SELECTION

Reports examined MCT and included participants with schizophrenia spectrum and related psychotic disorders (1045 reports identified; 281 assessed). There were no age, sex, gender, race and ethnicity, language, or study design restrictions. Two reviewers performed the selection of studies to be analyzed.

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was followed. Data were extracted by 3 reviewers and pooled using random effects models. Hedges g effect sizes were computed. The Mixed-Methods Appraisal tool was used to assess study quality.

MAIN OUTCOMES AND MEASURES

Proximal outcomes were global positive symptoms, delusions, hallucinations, and cognitive biases. Distal outcomes were self-esteem, negative symptoms, quality of life, well-being, and functioning. Immediate and sustained outcomes were examined. Meta-regressions, subgroup, and sensitivity analyses assessed moderators.

RESULTS

This systematic review and meta-analysis included 43 studies (46 reports). Forty reports were synthesized in meta-analysis (N=1816 participants) and 6 reports were included in narrative review. In the studies examined, MCT was associated with positive symptoms (g = 0.50; 95% CI, 0.34-0.67), delusions (g = 0.69; 95% CI, 0.45-0.93), hallucinations (g = 0.26; 95% CI, 0.11-0.40), cognitive biases (g = 0.16; 95% CI, 0.03-0.29), self-esteem (g = 0.17; 95% CI, 0.03-0.31), negative symptoms (g = 0.23; 95% CI, 0.10-0.37), and functioning (g = 0.41; 95% CI, 0.12-0.69). These associations were maintained up to 1 year. The quality of life effect size was nonsignificant (g = 0.20; 95% CI, -0.07 to 0.47); only 1 study assessed well-being. Publication year was associated with moderated hallucinations (β = 0.04; 95% CI, 0.00-0.07). Overall, narrative review results corroborated meta-analytic findings.

CONCLUSIONS AND RELEVANCE

In this meta-analysis, MCT for psychosis was associated with benefits up to 1 year postintervention in several treatment contexts. These findings suggest that MCT may merit integration in treatment guidelines for schizophrenia.

Psychosocial interventions for community-dwelling individuals with schizophrenia: study protocol for a systematic review and meta-analysis

INTRODUCTION

Despite the recent global mental health movement of the transition from hospital-centred to integrated community-based services, comprehensive evidence of psychosocial interventions focusing on community-dwelling individuals with schizophrenia is still lacking. To overcome this gap in the current knowledge, we will conduct a systematic review and meta-analysis to assess the efficacy of all types of psychosocial interventions for community-dwelling (non-hospitalised) individuals with schizophrenia when compared with non-active control conditions (eg, treatment as usual).

METHODS AND ANALYSIS

This study protocol has been developed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. By March 2022, the following sources will have been searched, without restrictions for language or publication period: Embase, PubMed, PsycINFO, CINAHL, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We will also try to identify other potentially eligible studies by searching the reference lists of included studies, other relevant systematic reviews and grey literature. All relevant randomised controlled trials from both high-income and low-income to middle-income countries will be allowed. Two independent reviewers will conduct the selection/screening of studies, data extraction and methodological quality assessment of included studies. The primary outcomes are quality of life and psychiatric hospital admission. Standard pairwise meta-analyses with a random-effects model will be conducted. Subgroup and sensitivity analyses will be performed to assess the robustness of the findings. Risk of bias will be assessed with the Revised Cochrane Risk-of-Bias Tool for Randomised Trials. The Grades of Recommendation Assessment, Development and Evaluation approach will be used to assess the quality of evidence.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study. The study findings will be disseminated through conference presentations as well as peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42021266187.

Characterizing Use of a Multicomponent Digital Intervention to Predict Treatment Outcomes in First-Episode Psychosis: Cluster Analysis

BACKGROUND

Multicomponent digital interventions offer the potential for tailored and flexible interventions that aim to address high attrition rates and increase engagement, an area of concern in digital mental health. However, increased flexibility in use makes it difficult to determine which components lead to improved treatment outcomes.

OBJECTIVE

This study aims to identify user profiles on Horyzons, an 18-month digital relapse prevention intervention for first-episode psychosis that incorporates therapeutic content and social networking, along with clinical, vocational, and peer support, and to examine the predictive value of these user profiles for treatment outcomes. A secondary objective is to compare each user profile with young people receiving treatment as usual (TAU).

METHODS

Participants comprised 82 young people (aged 16-27 years) with access to Horyzons and 84 receiving TAU, recovering from first-episode psychosis. In addition, 6-month use data from the therapy and social networking components of Horyzons were used as features for K-means clustering for joint trajectories to identify user profiles. Social functioning, psychotic symptoms, depression, and anxiety were assessed at baseline and 6-month follow-up. General linear mixed models were used to examine the predictive value of user profiles for treatment outcomes and between each user profile with TAU.

RESULTS

A total of 3 user profiles were identified based on the following system use metrics: low use, maintained use of social components, and maintained use of both therapy and social components. The maintained therapy and social group showed improvements in social functioning (F_2,51=3.58; P=.04), negative symptoms (F_2,51=4.45; P=.02), and overall psychiatric symptom severity (F_2,50=3.23; P=.048) compared with the other user profiles. This group also showed improvements in social functioning (F_1,62=4.68; P=.03), negative symptoms (F_1,62=14.61; P<.001), and overall psychiatric symptom severity (F_1,63=5.66; P=.02) compared with the TAU group. Conversely, the maintained social group showed increases in anxiety compared with the TAU group (F_1,57=7.65; P=.008). No differences were found between the low use group and the TAU group on treatment outcomes.

CONCLUSIONS

Continued engagement with both therapy and social components might be key in achieving long-term recovery. Maintained social use and low use outcomes were broadly comparable with TAU, emphasizing the importance of maintaining engagement for improved treatment outcomes. Although the social network may be a key ingredient to increase sustained engagement, as users engaged with this more consistently, it should be leveraged as a tool to engage young people with therapeutic content to bring about social and clinical benefits.

How does attachment style affect psychosis? A systematic review of causal mechanisms and guide to future inquiry

PURPOSE

The link between attachment and psychosis is now well established, but less is known about the causal mechanisms underlying this relationship. This systematic review synthesises the studies that examine mediating mechanisms in the attachment and psychosis relationship, in both clinical and non-clinical samples.

METHOD

We conducted a database search (PsychINFO, MEDLINE, Web of Science) to identify all eligible studies irrespective of publication status, the language of article or article date. We assessed methodological quality and completed a narrative synthesis given the heterogeneity of studies to date.

RESULTS

We identified 17 papers, comprising 3,672 participants. The relationship between attachment and psychosis is mediated by four variables or groups of variables. There is good evidence for the causal role of affective factors (affective dysregulation and affective disturbances) and cognitive factors (e.g., self-beliefs and self-esteem and beliefs about symptoms). Affective factors differed by attachment style. Tentative evidence was found for the role of duration of untreated psychosis and baseline negative symptoms.

CONCLUSIONS

Cognitive and affective factors mediate the relationship between attachment style and psychosis. Whilst cognitive factors are routinely targeted in recommended psychological interventions for psychosis, affective factors and attachment style are less commonly considered. Psychological therapies may be improved by calibrating cognitive and affective interventions by attachment style, which should be subjected to experimental and then field studies to assess the impact on clinical and recovery outcomes.

PRACTITIONER POINTS

The relationship between attachment and psychosis is now well established, and studies have started to examine mediating mechanisms. Affective and cognitive factors mediate the attachment-psychosis relationship. Affective factors differ by attachment style. There is limited evidence for the duration of untreated psychosis and negative psychotic symptoms as mediating mechanisms, and research replication is needed. Cognitive factors are routinely targeted in recommended psychological therapies for psychosis, but affective factors and attachment style are less commonly considered. Research should be conducted into the effectiveness of psychological therapies which calibrate cognitive and affective interventions, according to attachment style.

Clinical and cost-effectiveness of social recovery therapy for the prevention and treatment of long-term social disability among young people with emerging severe mental illness (PRODIGY): randomised controlled trial

BACKGROUND

Young people with social disability and severe and complex mental health problems have poor outcomes, frequently struggling with treatment access and engagement. Outcomes may be improved by enhancing care and providing targeted psychological or psychosocial intervention.

AIMS

We aimed to test the hypothesis that adding social recovery therapy (SRT) to enhanced standard care (ESC) would improve social recovery compared with ESC alone.

METHOD

A pragmatic, assessor-masked, randomised controlled trial (PRODIGY: ISRCTN47998710) was conducted in three UK centres. Participants (n = 270) were aged 16-25 years, with persistent social disability, defined as under 30 hours of structured activity per week, social impairment for at least 6 months and severe and complex mental health problems. Participants were randomised to ESC alone or SRT plus ESC. SRT was an individual psychosocial therapy delivered over 9 months. The primary outcome was time spent in structured activity 15 months post-randomisation.

RESULTS

We randomised 132 participants to SRT plus ESC and 138 to ESC alone. Mean weekly hours in structured activity at 15 months increased by 11.1 h for SRT plus ESC (mean 22.4, s.d. = 21.4) and 16.6 h for ESC alone (mean 27.7, s.d. = 26.5). There was no significant difference between arms; treatment effect was -4.44 (95% CI -10.19 to 1.31, P = 0.13). Missingness was consistently greater in the ESC alone arm.

CONCLUSIONS

We found no evidence for the superiority of SRT as an adjunct to ESC. Participants in both arms made large, clinically significant improvements on all outcomes. When providing comprehensive evidence-based standard care, there are no additional gains by providing specialised SRT. Optimising standard care to ensure targeted delivery of existing interventions may further improve outcomes.

How does insecure attachment lead to paranoia? A systematic critical review of cognitive, affective, and behavioural mechanisms

Background

The relationship between attachment and paranoia is now well established. There is good theoretical reason and evidence to indicate that attachment style affects cognitive, affective, and behavioural processes which, in turn, contribute to the maintenance of paranoia, but this research has not been integrated. We critically and systematically review research that examines relevant cognitive, affective, and behavioural processes, which may explain how attachment insecurity leads to paranoia and constitute key targets in psychotherapeutic interventions for people with psychosis.

Method

We conducted three systematic searches across six databases (PsycINFO, CINAHL, Medline, Web of Science, Embase, and Google Scholar), from inception to September 2021, to investigate key cognitive, affective, and behavioural processes in the attachment–paranoia association.

Results

We identified a total of 1930 papers and critically reviewed 16. The literature suggests that negative self‐ and other‐beliefs, inability to defuse from unhelpful cognitions, and use of maladaptive emotion regulation strategies mediate the association between attachment insecurity and paranoia in people with psychosis/psychotic experience. Attachment‐secure people with psychosis are more likely to seek help and engage with services than attachment‐insecure people.

Conclusions

Attachment styles impact help‐seeking behaviours in people with psychosis and are likely to influence paranoia via self‐ and other‐beliefs, cognition fusion, and emotion regulation – these candidate mechanisms may be targeted in psychological therapy to improve clinical outcomes for people with psychosis, characterized by paranoia.

Practitioner points

Insecure attachment is likely to lead to paranoia via negative beliefs about self and others, cognitive fusion, and use of maladaptive emotion regulation strategies. These mechanisms can be targeted in psychotherapeutic interventions for psychosis, such as cognitive behaviour therapy, to improve clinical and recovery outcomes.

People with psychosis who are attachment‐secure are more likely to seek help and engage with services than those who are attachment‐insecure (particularly avoidant). Attachment style can be assessed to predict service engagement and help‐seeking behaviours in people with psychosis.

Attachment styles are important predictors of key cognitive, affective, and behavioural processes in people with psychosis. These processes can be assessed and incorporated into individualised formulations, and then targeted in therapy to effect psychotherapeutic change.

Whole Life: a feasibility study of a recovery-focussed intervention in patients with stabilised schizophrenia

Background

The Recovery Approach is about supporting people to live the best life they possibly can. This paper reports on a 2008-11 study of a recovery-focussed, one-to-one coaching programme called Whole Life (WL) in a group of people with stabilised schizophrenia. WL comprises 15 modules, each addressing an aspect of life that may pose challenges for someone with mental illness. It involves regular meetings with a coach, additional homework activities and lasts approximately one-year. This level of commitment requires participants to be motivated and enthusiastic.

Methods

This was a non-randomised feasibility study, designed to assess acceptability and potential benefits of WL. The WL group was compared to another group of people with the same diagnosis, who received their usual treatment. This was not a strict control group. The primary outcome measure was the Social Adaptation Self-Assessment Scale.

Results

Of those recruited to the WL group, 33/44 (75%) completed the full programme. WL participants showed an 11-point increase in mean SASS between baseline and Week 60. Subjective ratings showed benefits of WL at 3 and 6 months after the intervention had ceased, with most saying they felt better and none saying that they felt worse. The comparison group was more ill than the WL group at baseline and showed some improvement over the course of the study, albeit at a lower level than the WL group. However, controlling for baseline group differences meant that none of the outcome measures could reliably distinguish between WL and comparison groups.

Conclusions

The study showed that WL is an acceptable and helpful intervention for motivated and enthusiastic individuals. It may have wider applicability for people with a less serious and chronic mental illness, although we do not know how it compares to other interventions. We discuss some methodological limitations of the study.

Pathways from insecure attachment to paranoia: the mediating role of emotion regulation

Background:

Paranoia is common across the clinical and non-clinical spectrum. Cognitive behavioural therapy for psychosis currently yields modest results, warranting research into symptom-specific maintenance factors to improve outcomes. There is strong evidence of a relationship between insecure attachment and increased paranoia, but little is known about the mediating mechanisms. Emotion dysregulation is associated with both insecure attachment and paranoia, and a candidate causal mechanism.

Aims:

This study aimed to determine if emotion dysregulation mediates the association between attachment and paranoia.

Method:

Sixty-two individuals with elevated paranoia were recruited from NHS services and community settings across the South of England. Mediation analyses were conducted on trait attachment, emotion regulation and paranoia variables, which were collected at one time point.

Results:

As predicted, emotion dysregulation mediated the relationship between attachment avoidance and paranoia, and between attachment anxiety and paranoia. Emotion suppression did not mediate the relationship between attachment avoidance and paranoia, possibly due to power. Attachment avoidance correlated with deactivating emotion regulation strategies (e.g. lack of emotional awareness) and attachment anxiety correlated with hyperactivating emotion regulation strategies (e.g. impulse control difficulties). Both deactivating and hyperactivating strategies correlated with paranoia.

Conclusion:

Emotion dysregulation is not routinely targeted in cognitive behavioural therapy for psychosis. This study suggests that incorporating emotion regulation strategies in therapy may improve clinical outcomes. Experimental studies are now required to support a causal argument, and pilot intervention studies should investigate if emotion regulation skills development (aligned with attachment style) is effective in reducing non-clinical and clinical paranoia.

Formulating psychosis: a thematic analysis of CBTp trainees’ experiences

The NICE guidance states that cognitive behavioural therapy (CBT) should now be offered to everyone with psychosis in the UK. This has rightly resulted in an increased demand for adherent therapy from qualified clinicians. Individualised formulation is a key component of CBT for psychosis, yet many trainees struggle to make sense of and apply the theoretical models on which these are based. This study explored trainee and recently qualified therapists’ experience of formulating CBT for psychosis, to help us understand how best to guide training and clinical practice. We ran focus groups with trainees who were completing, or had recently completed, postgraduate training in CBT for psychosis. We then analysed verbatim transcripts of the semi-structured interviews. and completed a thematic analysis of the data using inductive open coding. Three over-arching themes were generated: (1) purpose of formulation, (2) formulation in practice, and (3) (reflection on) learning to formulate. Training programmes and clinical supervisors should focus on fostering trainees’ and newly qualified therapists’ ability to develop simple, targeted formulations. These will draw on maintenance and developmental models of psychosis, depending on the person’s needs and goals. Opportunities for procedural learning are likely to improve skilful formulation, and use as the basis for therapeutic change.

Key learning aims

(1)

European Psychiatric Association guidance on treatment of cognitive impairment in schizophrenia

Background

Although cognitive impairment is a core symptom of schizophrenia related to poorer outcomes in different functional domains, it still remains a major therapeutic challenge. To date, no comprehensive treatment guidelines for cognitive impairment in schizophrenia are implemented.

Methods

The aim of the present guidance paper is to provide a comprehensive meta-review of the current available evidence-based treatments for cognitive impairment in schizophrenia. The guidance is structured into three sections: pharmacological treatment, psychosocial interventions, and somatic treatments.

Results

Based on the reviewed evidence, this European Psychiatric Association guidance recommends an appropriate pharmacological management as a fundamental starting point in the treatment of cognitive impairment in schizophrenia. In particular, second-generation antipsychotics are recommended for their favorable cognitive profile compared to first-generation antipsychotics, although no clear superiority of a single second-generation antipsychotic has currently been found. Anticholinergic and benzodiazepine burdens should be kept to a minimum, considering the negative impact on cognitive functioning. Among psychosocial interventions, cognitive remediation and physical exercise are recommended for the treatment of cognitive impairment in schizophrenia. Noninvasive brain stimulation techniques could be taken into account as add-on therapy.

Conclusions

Overall, there is definitive progress in the field, but further research is needed to develop specific treatments for cognitive impairment in schizophrenia. The dissemination of this guidance paper may promote the development of shared guidelines concerning the treatment of cognitive functions in schizophrenia, with the purpose to improve the quality of care and to achieve recovery in this population.

Psychoeducation, motivational interviewing, cognitive remediation training, and/or social skills training in combination for psychosocial functioning of patients with schizophrenia spectrum disorders: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

Psychoeducation, motivational interviewing, cognitive remediation training, and social skills training have been found to be effective interventions for patients with schizophrenia spectrum disorders. However, their efficacy on psychosocial functioning when provided in combination remains unclear, compared with all types of control conditions. It would also be meaningful to explore the differences of efficacy in patients with first-episode psychosis (FEP) and those with longer term of illness.

METHODOLOGY

The present review followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Full-text English journal articles of randomized controlled trials published in the past decade in the databases of PubMed, CINAHL Complete, Embase, and PsycINFO were searched. Included studies were all randomized controlled trials (RCTs) with participants diagnosed with schizophrenia spectrum disorders. The included studies should test combined interventions with at least two components from: psychoeducation, motivational interviewing, cognitive remediation training, and social skills training and incorporate assessment of psychosocial functioning at least at baseline and post-intervention.

RESULTS

Seven studies were included for systematic review, and six of them were eligible for meta-analysis. Five out of the seven studies reported effects on psychosocial functioning that favored combined interventions over any type of control condition. A significant pooled effect was derived from the six studies, SMD = 1.03, 95% CI [0.06, 2.00], Z = 2.09, p = 0.04, I ² = 96%. However, the pool effect became insignificant when synthesizing five of the studies with non-FEP patients as participants and four of the studies testing relative effects of combined interventions compared with stand-alone interventions/interventions with one less component. None of the included studies adopted motivational interviewing and only one of the studies worked with FEP patients.

CONCLUSION

Psychoeducation, cognitive remediation training, and social skills training in combination can effectively enhance psychosocial functioning of patients with schizophrenia spectrum disorders. It is warranted to conduct more RCTs to test the effects of different specific combinations of the above interventions on psychosocial functioning, especially in FEP patients.

Factors influencing the outcome of integrated therapy approach in schizophrenia: A narrative review of the literature

The integration of pharmacotherapy with psychosocial interventions has an important role to play in the improvement of functional outcome of subjects with schizophrenia (SCZ), in all stages of the disorder. It is essential for the adequate management of unmet therapeutic needs, such as negative symptoms and cognitive dysfunctions which account for most of the functional impairment of subjects with SCZ and do not respond to available antipsychotics. Enhancing the knowledge on factors involved in the effectiveness of integrated treatment plans is an important step forward for SCZ care. This review aims to identify factors that might influence the impact of integrated treatments on functional outcome. Most studies on the impact of psychosocial treatments on functional outcome of subjects with SCZ did not control for the effect of prescribed antipsychotics or concomitant medications. However, several factors relevant to ongoing pharmacological treatment might influence the outcome of integrated therapy, with an impact on the adherence to treatment (e.g., therapeutic alliance and polypharmacotherapy) or on illness-related factors addressed by the psychosocial interventions (e.g., cognitive dysfunctions or motivational deficits). Indirect evidence suggests that treatment integration should consider the possible detrimental effects of different antipsychotics or concomitant medications on cognitive functions, as well as on secondary negative symptoms. Cognitive dysfunctions can interfere with participation to an integrated treatment plan and can be worsened by extrapyramidal or metabolic side effects of antipsychotics, or concomitant treatment with anticholinergics or benzodiazepines. Secondary negative symptoms, due to positive symptoms, sedation, extrapyramidal side effects or untreated depression, might cause early drop-out and poor adherence to treatment. Researchers and clinicians should examine all the above-mentioned factors and implement appropriate and personalized integrated treatments to improve the outcome of SCZ.

Mentalization-based treatment for psychotic disorder: a rater-blinded, multi-center, randomized controlled trial

BACKGROUND

Impaired mentalizing ability - an impaired ability to understand one's own and other people's behavior in terms of mental states - is associated with social dysfunction in non-affective psychotic disorder (NAPD). We tested whether adding mentalization-based treatment for psychotic disorder (MBTp) to treatment as usual (TAU) results in greater improvement in social functioning.

METHODS

Multicenter, rater-blinded, randomized controlled trial. Eighty-four patients with NAPD were assigned to TAU or MBTp plus TAU. Patients in the MBTp group received 18 months of MBTp, consisting of weekly group sessions and one individual session per 2 weeks. Social functioning was measured using the Social Functioning Scale. We conducted ANCOVAs to examine the difference between treatment conditions directly after treatment and at 6-month follow-up and performed moderation and mediation analyses.

RESULTS

Intention-to-treat analyses showed no significant differences between groups post-treatment (p = 0.31) but revealed the MBTp group to be superior to TAU at follow-up (p = 0.03). Patients in the MBTp group also seemed to perform better on measures of mentalizing ability, although evidence of a mediation effect was limited (p = 0.06). Lastly, MBTp treatment was less effective in chronic patients than in recent-onset patients (p = 0.049) and overall symptoms at baseline were mild, which may have reduced the overall effectiveness of the intervention.

CONCLUSION

The results suggest that MBTp plus TAU may lead to more robust improvements in social functioning compared to TAU, especially for patients with a recent onset of psychosis.

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

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

How does attachment imagery for paranoia work? Cognitive fusion and beliefs about self and others mediate the impact on paranoia and anxiety

OBJECTIVES

Paranoia describes unfounded and distressing interpersonal threat beliefs. Secure attachment imagery has been shown to attenuate paranoia and anxiety in non-clinical and clinical groups, but little is known about the differential effects of anxious and avoidant imagery or mechanisms of change. In this study, we tested the impact of secure, anxious, and avoidant attachment imagery on paranoia, anxiety, and help-seeking intentions. We also examined hypothesized mechanisms of change, specifically whether cognitive fusion and negative self- and other-beliefs mediate these relationships.

DESIGN

This study utilized an experimental, cross-sectional design.

METHODS

A large (N = 303), international general population sample with high levels of non-clinical paranoia completed a series of measures before and after engaging in secure, anxious, or avoidant imagery.

RESULTS

Relative to anxious and avoidant attachment imagery, secure attachment imagery reduced paranoia and anxiety and increased help-seeking intentions. Cognitive fusion and negative self- and other-beliefs mediated the impact of attachment imagery on paranoia and anxiety, but not help-seeking.

CONCLUSIONS

In line with attachment and cognitive theory, secure attachment imagery is effective in reducing paranoia and anxiety and works by reducing cognitive fusion and negative self- and other-beliefs. These novel findings suggest that the secure imagery task could be incorporated into cognitive and behavioural therapies to reduce distressing interpersonal threat beliefs and associated negative affect, and increase help-seeking intentions.

PRACTITIONER POINTS

When working with people experiencing paranoia, secure attachment imagery may be effective in reducing state paranoia and anxiety and improving help-seeking intentions. Attachment imagery works by influencing beliefs about self and others, and the degree to which people are fused with their beliefs. In clinical practice, the rationale for the imagery task fits well with psychological models of paranoia and the secure imagery task can be introduced as a way to cope when struggling with distressing beliefs about self and others, and feeling overwhelmed by these fears.

The MAC-P program: A pilot study of a mindfulness and compassion program for youth with psychotic experiences

BACKGROUND

The purpose of this pilot study was to determine the feasibility, acceptability and the potential clinical utility of a novel mindfulness and compassion program (MAC-P) designed for youth with a range of psychotic experiences.

METHOD

A non-randomised, non-controlled prospective follow-up study was conducted. Eighteen participants who either met criteria for the 'at risk mental state' or were experiencing a psychotic episode or had a recent diagnosis of schizophrenia attended the 8-week program. Participants completed clinical assessments pre-treatment, post-treatment and at 6-week follow-up which measured a range of symptoms (psychosis, anxiety, depression and stress) and psychosocial outcomes.

RESULTS

Attendance and retention data indicated that MAC-P is a feasible and acceptable program. There was a large significant increase in self-compassion. Mindfulness demonstrated a positive change over time. There was a large significant effect on one subscale-acting with awareness. There were significant reductions in distress associated with psychotic experiences as well as anxiety, depression, stress and self-criticism. Significant improvements in functioning and insecure attachment styles were also found. Regression results demonstrated that self-compassion was associated with a number of these findings.

CONCLUSION

The MAC-P for youth shows potential as a clinically effective intervention provided as an addition to treatment as usual for youth with psychotic experiences. A larger controlled study is needed to validate the effectiveness of this intervention.

A Group Intervention for Motivational Deficits: Preliminary Investigation of a Blended Care Approach Using Ambulatory Assessment

Motivational deficits are an important predictor of functional outcomes in individuals with a serious mental illness such as schizophrenia and mood spectrum disorders. The aim of the present study was to explore the feasibility, acceptability, and preliminary efficacy of a group version of "Switch," an intervention that targets motivational deficits, enriched with an ecological momentary intervention (EMI) approach (i.e., prompts on the participants' smartphone to encourage the use of trained strategies in their daily life). Eight participants with schizophrenia, schizoaffective, or major depressive disorder entered the study. The intervention took place twice a week for 2 months. Assessment measures included traditional evaluations of motivational negative symptoms, apathy, quality of life and daily functioning, in addition to ambulatory assessment methods strategies, including the experience sampling method (ESM) to assess motivation and related processes, and actigraphy (daily step-count) to assess participants' activity level. Four participants were considered as non-completers (followed less than 2/3 of the program) and four were considered as completers. Only completers presented a decrease in amotivation/apathy and an improvement in functional outcomes after the intervention and at follow-up. Furthermore, mixed-effects ESM models showed significant interaction effects on multiple processes related to motivation, indicating improvements only in completers: heightened motivation, increased engagement in meaningful and effortful activities, better mood, higher levels of confidence, increased frequency of projection into the future (pleasure anticipation), and of positive reminiscence. This preliminary investigation provides evidence that Switch may be an effective intervention, with specific effects on motivation and associated processes.

L’amélioration de la qualité de vie chez les patients atteints d’une schizophrénie réfractaire ayant suivi la Thérapie assistée par la Réalité Virtuelle : une analyse de contenu

Objectifs La schizophrénie, en particulier la schizophrénie résistante aux traitements (SRT), est considérée comme l’un des troubles psychiatriques les plus invalidants en termes d’effets indésirables sur la qualité de vie (QV) des patients. La QV subjective est devenue une cible particulièrement cruciale qui devrait être améliorée avec le traitement, car une QV améliorée peut entraîner le rétablissement chez les patients atteints de schizophrénie. Il existe cependant peu de preuves des effets des interventions psychosociales recommandées sur les mesures non symptomatiques comme la QV. À cet égard, le traitement de la schizophrénie peut être renforcé si, en plus du traitement des symptômes, l’accent thérapeutique est mis sur d’autres sphères importantes pour les patients. Avec les progrès technologiques, la Thérapie assistée par la Réalité Virtuelle (TRV) permet aux entendeurs de voix d’entrer en dialogue direct avec un avatar, animé entièrement par le thérapeute, qui représente leur voix la plus persécutrice. Ceci dans le but de leur permettre d’acquérir un meilleur contrôle sur leurs voix et de travailler sur leur estime de soi. Au-delà de la symptomatologie, les résultats des projets pilotes sur cette thérapie innovante ont montré des résultats significatifs sur la QV.

Méthode Afin de peaufiner les résultats quantitatifs trouvés, cet article a exploré les thèmes émergents d’une analyse de contenu découlant du discours spontané de 10 patients ayant bien répondu à la TRV.

Résultats Quatre thèmes généraux ont émergé : 1) impact de la thérapie sur les voix ; 2) relations interpersonnelles ; 3) bien-être psychologique ; et 4) mode de vie. Cette analyse de contenu a permis d’identifier plusieurs sphères de vie qui sont davantage améliorées chez les patients ayant une SRT à l’aide de la TRV.

Conclusion : La TRV met en évidence l’avenir des approches adaptées aux objectifs des patients qui intègrent plusieurs processus pertinents pour potentiellement améliorer leur QV. La TRV peut avoir des implications potentiellement immenses sur la santé et la qualité de vie des patients. Cette étude fut une première étape vers l’exploration des effets subjectifs de la TRV sur la vie des patients au-delà des symptômes.

Preliminary Outcomes of an Ecological Momentary Intervention for Social Functioning in Schizophrenia: Pre-Post Study of the Motivation and Skills Support App

BACKGROUND

People with schizophrenia and other serious mental illnesses often lack access to evidence-based interventions, particularly interventions that target meaningful recovery outcomes such as social functioning and quality of life. Mobile technologies, including smartphone apps, have the potential to provide scalable support that places elements of evidence-based interventions at the palm of patients' hands.

OBJECTIVE

We aim to develop a smartphone app-called Motivation and Skills Support-to provide targeted social goal support (eg, making new friends and improving existing relationships) for people with schizophrenia enrolled in a stand-alone open trial.

METHODS

In this paper, we presented preliminary outcomes of 31 participants who used the Motivation and Skills Support app for 8 weeks, including social functioning pre- to postintervention, and momentary reports of treatment targets (eg, social motivation and appraisals) during the intervention.

RESULTS

The findings suggest that the intervention improved self-reported social functioning from baseline to treatment termination, particularly in female participants. Gains were not maintained at the 3-month follow-up. Furthermore, increased social functioning was predicted by momentary reports of social appraisals, including perceived social competence and the extent to which social interactions were worth the effort.

CONCLUSIONS

The implications of these findings and future directions for addressing social functioning in schizophrenia using mobile technology have been discussed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03404219; https://clinicaltrials.gov/ct2/show/NCT03404219.

The Recovery Process for Individuals With Schizophrenia in the Context of Evidence-Based Psychotherapy and Rehabilitation

Abstract. This systematic review aimed to evaluate the efficacy of Cognitive Behavioral Therapy (CBT), META Cognitive Therapy (MCT), Metacognitive Training (MCTR), Metacognitive Reflection and Insight Therapy (MERIT), of various rehabilitation programs and of recovery programs in schizophrenia. Medline/Pubmed was searched for studies published in English from January 2010 to August 2018, which were screened against inclusion criteria by two reviewers. The methodological quality of the included studies was evaluated by two independent raters, which are the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies and the fidelity criteria. The study included 41 RCTs and 12 case studies with n = 3,059 persons with schizophrenia. Cognitive Behavioral Therapy (CBT) proved to be superior in terms of the improvement of primary and secondary outcomes. MCT decreased positive symptoms and improved metacognitive capacity and insight. MCTR reduced positive symptoms and socially disruptive behavior. MERIT improved metacognitive capacity and insight. Rehabilitation programs were efficacious in the improvement of cognition, symptoms, and functional outcome. The recovery programs enhanced illness-management knowledge, attitudes toward medication and insights related to negative symptoms. It is recommended to combine the above evidence based psychotherapeutic interventions. Limitations of this systematic review are discussed toward the end of the essay. Some important factors have to be considered in the future have been mentioned.

'Someone on my level': A Meta-Ethnographic Review of Therapeutic Relationships in Cognitive Behavioural Therapy for Psychosis

OBJECTIVES

Cognitive Behavioural Therapy for Psychosis (CBTp) demonstrates variable and at times mild to moderate effect sizes; thus, its therapeutic processes are important to explore. Establishing a secure therapeutic relationship is one such key process where barriers may exist, including those related to psychotic symptoms and associated stigma. This review synthesizes the available qualitative research pertaining to the experience of the therapeutic relationship from the perspective of those experiencing psychosis.

METHODS

A systematic review was undertaken using PRISMA guidelines. Search terms included variants of 'psychosis', 'therapy' and 'qualitative'. PsycInfo, CINAHL, EmBase, MedLine and Web of Science were searched, and reference lists were hand-scanned. Yardley's quality appraisal tool was utilized and Noblit and Hare's seven-stage process for conducting a meta-ethnographic review. A line-of-argument synthesis is presented.

RESULTS

Fourteen papers were identified using inclusion and exclusion criteria. Twelve papers were deemed to have satisfactory quality. The line-of-argument synthesis used attachment theory to propose four semi-distinct stages to establishing a therapeutic relationship: beginning; safety, hope and trust; the practicalities of therapy; and branching out. Findings suggest that the therapist's persona and use of CBTp techniques such as collaboration and shared agency over the process were important in establishing for the patient a sense of self as normal, equal and worthwhile.

CONCLUSIONS

Attachment security may be an important strand of CBTp and warrants further research and clinical investigation as a process and an outcome. Future research can benefit from increased transparency regarding researcher positionality as a potential source of bias.

One-year randomized trial comparing virtual reality-assisted therapy to cognitive-behavioral therapy for patients with treatment-resistant schizophrenia

The gold-standard cognitive-behavioral therapy (CBT) for psychosis offers at best modest effects. With advances in technology, virtual reality (VR) therapies for auditory verbal hallucinations (AVH), such as AVATAR therapy (AT) and VR-assisted therapy (VRT), are amid a new wave of relational approaches that may heighten effects. Prior trials have shown greater effects of these therapies on AVH up to a 24-week follow-up. However, no trial has compared them to a recommended active treatment with a 1-year follow-up. We performed a pilot randomized comparative trial evaluating the short- and long-term efficacy of VRT over CBT for patients with treatment-resistant schizophrenia. Patients were randomized to VRT (n = 37) or CBT (n = 37). Clinical assessments were administered before and after each intervention and at follow-up periods up to 12 months. Between and within-group changes in psychiatric symptoms were assessed using linear mixed-effects models. Short-term findings showed that both interventions produced significant improvements in AVH severity and depressive symptoms. Although results did not show a statistically significant superiority of VRT over CBT for AVH, VRT did achieve larger effects particularly on overall AVH (d = 1.080 for VRT and d = 0.555 for CBT). Furthermore, results suggested a superiority of VRT over CBT on affective symptoms. VRT also showed significant results on persecutory beliefs and quality of life. Effects were maintained up to the 1-year follow-up. VRT highlights the future of patient-tailored approaches that may show benefits over generic CBT for voices. A fully powered single-blind randomized controlled trial comparing VRT to CBT is underway.

A narrative review of mindfulness-based therapy for schizophrenia, co-occurring substance use and comorbid cardiometabolic problems

Mindfulness-based therapy (MBT) has gained attention in recent years as a promising treatment for patients with schizophrenia for whom traditional interventions are not effective. Research demonstrates improvements in psychotic symptoms, emotion regulation, and other areas including re-hospitalization rates and insight into illness following MBT interventions. Yet MBT studies have not carefully reported results in patients with schizophrenia and co-occurring substance use or comorbid medical problems, bringing into question the generalizability of these findings. This narrative review explores the literature regarding the use of mindfulness-based interventions for patients with schizophrenia as well as for patients with substance use disorder, cardiovascular disease, obesity, and diabetes. Findings suggest that MBTs can improve craving in substance use disorder, eating related behaviors in obesity, diabetes-related distress, and metabolic regulation in patients with diabetes. Increased insula and anterior cingulate cortex volumes and activities following MBTs might be associated with the potential benefit of MBTs in patients with schizophrenia. Our review provides a foundational basis in support of the need for future studies evaluating the safety and efficacy of MBTs for schizophrenia with co-occurring substance use disorder and/or comorbid cardiometabolic problems.