Cognitive therapy and recovery from acute psychosis: a controlled trial. I. Impact on psychotic symptoms

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.

Meta-Analysis of the Effect of Psychotherapy in an Inpatient Setting: Examining the Moderating Role of Diagnosis and Therapeutic Approach

OBJECTIVE

The current meta-analysis investigates the efficacy of psychotherapy during psychiatric hospitalization and examines the moderating role of diagnosis and therapeutic approach.

METHODS

We conducted systematic searches in literature databases, including PubMed, PsycInfo, and Google Scholar. In total, 37 samples were included for the meta-analysis with a total of 4,443 patients. The primary outcome was the standardized mean differences in clinical status measured by symptomatic and functional measures.

RESULTS

The meta-analysis of 22 samples without a control group resulted in the upper end of the medium effect size for the overall effect of treatment during psychiatric hospitalization that included psychotherapy (k = 22, Cohen's d = 0.70, and 95% Cl 0.36 to 1.04). The meta-analysis of 15 samples with a control group resulted in the upper end of the low effect size for the contribution of psychotherapy to the improvement of patients' clinical status measured by symptomatic and functional measures (k = 15, Cohen's d = 0.43, and 95% CI 0.06 to 0.81). No significant effects were uncovered for psychotherapy orientation. Diagnosis was found to moderate the contribution of psychotherapy in an inpatient setting to the improvement of patients' clinical condition.

CONCLUSION

Psychotherapy during psychiatric hospitalization may be an effective treatment. Across the various samples, psychotherapy has a moderate effect on the reduction of psychiatric symptoms beyond the overall effect of ward treatment.

Cognitive-behavioural therapy for clozapine-resistant schizophrenia: the FOCUS RCT

BACKGROUND

Clozapine (clozaril, Mylan Products Ltd) is a first-choice treatment for people with schizophrenia who have a poor response to standard antipsychotic medication. However, a significant number of patients who trial clozapine have an inadequate response and experience persistent symptoms, called clozapine-resistant schizophrenia (CRS). There is little evidence regarding the clinical effectiveness of pharmacological or psychological interventions for this population.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of cognitive-behavioural therapy (CBT) for people with CRS and to identify factors predicting outcome.

DESIGN

The Focusing on Clozapine Unresponsive Symptoms (FOCUS) trial was a parallel-group, randomised, outcome-blinded evaluation trial. Randomisation was undertaken using permuted blocks of random size via a web-based platform. Data were analysed on an intention-to-treat (ITT) basis, using random-effects regression adjusted for site, age, sex and baseline symptoms. Cost-effectiveness analyses were carried out to determine whether or not CBT was associated with a greater number of quality-adjusted life-years (QALYs) and higher costs than treatment as usual (TAU).

SETTING

Secondary care mental health services in five cities in the UK.

PARTICIPANTS

People with CRS aged ≥ 16 years, with an International Classification of Diseases, Tenth Revision (ICD-10) schizophrenia spectrum diagnoses and who are experiencing psychotic symptoms.

INTERVENTIONS

Individual CBT included up to 30 hours of therapy delivered over 9 months. The comparator was TAU, which included care co-ordination from secondary care mental health services.

MAIN OUTCOME MEASURES

The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months and the primary secondary outcome was PANSS total score at the end of treatment (9 months post randomisation). The health benefit measure for the economic evaluation was the QALY, estimated from the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), health status measure. Service use was measured to estimate costs.

RESULTS

Participants were allocated to CBT (n = 242) or TAU (n = 245). There was no significant difference between groups on the prespecified primary outcome [PANSS total score at 21 months was 0.89 points lower in the CBT arm than in the TAU arm, 95% confidence interval (CI) -3.32 to 1.55 points; p = 0.475], although PANSS total score at the end of treatment (9 months) was significantly lower in the CBT arm (-2.40 points, 95% CI -4.79 to -0.02 points; p = 0.049). CBT was associated with a net cost of £5378 (95% CI -£13,010 to £23,766) and a net QALY gain of 0.052 (95% CI 0.003 to 0.103 QALYs) compared with TAU. The cost-effectiveness acceptability analysis indicated a low likelihood that CBT was cost-effective, in the primary and sensitivity analyses (probability < 50%). In the CBT arm, 107 participants reported at least one adverse event (AE), whereas 104 participants in the TAU arm reported at least one AE (odds ratio 1.09, 95% CI 0.81 to 1.46; p = 0.58).

CONCLUSIONS

Cognitive-behavioural therapy for CRS was not superior to TAU on the primary outcome of total PANSS symptoms at 21 months, but was superior on total PANSS symptoms at 9 months (end of treatment). CBT was not found to be cost-effective in comparison with TAU. There was no suggestion that the addition of CBT to TAU caused adverse effects. Future work could investigate whether or not specific therapeutic techniques of CBT have value for some CRS individuals, how to identify those who may benefit and how to ensure that effects on symptoms can be sustained.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN99672552.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 7. See the NIHR Journals Library website for further project information.

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

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

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) involving people with schizophrenia who were randomly allocated to receive, in addition to their standard care, either CBT or any other psychosocial therapy. Outcomes of interest included relapse, global state, mental state, adverse events, social functioning, quality of life and satisfaction with treatment. We included trials meeting our inclusion criteria and reporting useable data.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

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

Holistic Management of Schizophrenia Symptoms Using Pharmacological and Non-pharmacological Treatment

Individuals with schizophrenia lead a poor quality of life, due to poor medical attention, homelessness, unemployment, financial constraints, lack of education, and poor social skills. Thus, a review of factors associated with the holistic management of schizophrenia is of paramount importance. The objective of this review is to improve the quality of life of individuals with schizophrenia, by addressing the factors related to the needs of the patients and present them in a unified manner. Although medications play a role, other factors that lead to a successful holistic management of schizophrenia include addressing the following: financial management, independent community living, independent living skill, relationship, friendship, entertainment, regular exercise for weight gained due to medication administration, co-morbid health issues, and day-care programmes for independent living. This review discusses the relationship between different symptoms and problems individuals with schizophrenia face (e.g., homelessness and unemployment), and how these can be managed using pharmacological and non-pharmacological methods. Thus, the target of this review is the carers of individuals with schizophrenia, public health managers, counselors, case workers, psychiatrists, and clinical psychologists aiming to enhance the quality of life of individuals with schizophrenia.

Schizophrenia: early warning signs

Relapse in schizophrenia remains common and cannot be entirely eliminated even by the best combination of biological and psychosocial interventions (Linszen et al, 1998). Relapse prevention is crucial as each relapse may result in the growth of residual symptoms (Shepherd et al, 1989) and accelerating social disablement (Hogarty et al, 1991). Many patients feel ‘entrapped’ by their illnesses, a factor highly correlated with depression (Birchwood et al, 1993), and have expressed a strong interest in learning to recognise and prevent impending psychotic relapse.

Users' movement and the challenge to psychiatrists

In recent years the psychiatric users' movement has become more prominent and powerful. In this article aspects of the movement and some of the resultant challenges to psychiatrists are described. Psychiatrists are often regarded by users as resistant to its development. The author argues that psychiatrists may benefit from a creative engagement with this process of change.

Identification of young people at risk of psychosis

Operational criteria for detecting prodromal, or at-risk, mental states have been developed largely on the basis of individuals seeking help for attenuated or brief, self-limiting symptoms that do not meet threshold criteria for psychotic disorder. These individuals present largely to primary care and other non-specialist mental health settings. Follow-up studies have confirmed that 15–40% will make the transition to full psychosis within 12 months. Cognitive therapy alone or in combination with low-dose atypical antipsychotics has been shown to be efficacious in reducing or delaying the transition to psychosis, as well as in ameliorating the severity of non-psychotic symptoms and distress. Antipsychotic medication alone has not shown significant efficacy, but results are suggestive of some advantage from drug treatment. Further work is needed to clarify the relative merits of these interventions.

Randomised controlled trial of early detection and cognitive therapy for preventing transition to psychosis in high-risk individuals

Background

There is interest in the possibility of indicated prevention of psychosis. There is a strong case for using psychological approaches to prevent transition to psychosis in high-risk patients.

Aims

To identify individuals at high risk of transition to psychosis, and psychological characteristics relevant to the development of psychosis in this group.

Method

The design of a randomised controlled trial of cognitive therapy for the prevention of psychosis in people at high risk (meeting operational criteria of brief or attenuated psychotic symptoms, or first-degree family history with functional decline) is outlined. The first patients recruited are compared with non-patient samples on cognitive and personality factors; an interim analysis of transition rate is reported.

Results

Cases (n=31) were recruited mainly from primary care. Of the 23 high-risk patients monitored for 6–12 months, 5 (22%) made the transition to psychosis. The high-risk group scored significantly higher than non-patients on measures of schizotypy, metacognitive beliefs and dysfunctional self-schemas (sociotropy).

Conclusions

The findings validate the methods of identifying individuals at high risk of experiencing a psychotic episode. Compared with non-patient controls, the cases showed dysfunctional metacognitive beliefs and self-schemas.

Helping patients with paranoid and suspicious thoughts: a cognitive–behavioural approach

Paranoid and suspicious thoughts are a significant clinical topic. They regularly occur in 10–15% of the general population, and persecutory delusions are a frequent symptom of psychosis. In the past, patients were discouraged from talking about paranoid experiences. In contrast, it is now recommended that patients are given time to talk about them, and cognitive–behavioural techniques are being used to reduce distress. In this article we present the theoretical understanding of paranoia that underpins this transformation in the treatment of paranoid thoughts and summarise the therapeutic techniques derived. Emphasis is placed on the clinician approaching the problem from a perspective of understanding and making sense of paranoid experiences rather than simply challenging paranoid thoughts. Ways of overcoming difficulties in engaging people with paranoid thoughts are highlighted.

Cognitive therapy for the treatment of delusions

Traditionally, delusions have been viewed as false, unshakeable beliefs which arise out of internal morbid processes and are out of keeping with a person's educational and cultural background (Hamilton, 1978). Primary delusions appear to arise without understandable cause, and secondary delusions appear more understandable in relation to the prevailing affective state or cultural climate (Sims, 1995), for example. However, during the cognitive therapy process we would expect that even primary delusions might become more understandable as the patient's life history and belief profile are gradually disclosed.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Music therapy for people with schizophrenia and schizophrenia-like disorders

BACKGROUND

Music therapy is a therapeutic approach that uses musical interaction as a means of communication and expression. Within the area of serious mental disorders, the aim of the therapy is to help people improve their emotional and relational competencies, and address issues they may not be able to using words alone.

OBJECTIVES

To review the effects of music therapy, or music therapy added to standard care, compared with placebo therapy, standard care or no treatment for people with serious mental disorders such as schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Study-Based Register (December 2010 and 15 January, 2015) and supplemented this by contacting relevant study authors, handsearching of music therapy journals and manual searches of reference lists.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that compared music therapy with standard care, placebo therapy, or no treatment.

DATA COLLECTION AND ANALYSIS

Review authors independently selected, quality assessed and data extracted studies. We excluded data where more than 30% of participants in any group were lost to follow-up. We synthesised non-skewed continuous endpoint data from valid scales using a standardised mean difference (SMD). We employed a fixed-effect model for all analyses. If statistical heterogeneity was found, we examined treatment dosage (i.e. number of therapy sessions) and treatment approach as possible sources of heterogeneity.

MAIN RESULTS

Ten new studies have been added to this update; 18 studies with a total 1215 participants are now included. These examined effects of music therapy over the short, medium, and long-term, with treatment dosage varying from seven to 240 sessions. Overall, most information is from studies at low or unclear risk of biasA positive effect on global state was found for music therapy compared to standard care (medium term, 2 RCTs, n = 133, RR 0.38 95% confidence interval (CI) 0.24 to 0.59, low-quality evidence, number needed to treat for an additional beneficial outcome NNTB 2, 95% CI 2 to 4). No binary data were available for other outcomes. Medium-term continuous data identified good effects for music therapy on negative symptoms using the Scale for the Assessment of Negative Symptoms (3 RCTs, n = 177, SMD - 0.55 95% CI -0.87 to -0.24, low-quality evidence). General mental state endpoint scores on the Positive and Negative Symptoms Scale were better for music therapy (2 RCTs, n = 159, SMD -0.97 95% CI -1.31 to -0.63, low-quality evidence), as were average endpoint scores on the Brief Psychiatric Rating Scale (1 RCT, n = 70, SMD -1.25 95% CI -1.77 to -0.73, moderate-quality evidence). Medium-term average endpoint scores using the Global Assessment of Functioning showed no effect for music therapy on general functioning (2 RCTs, n = 118, SMD -0.19 CI -0.56 to 0.18, moderate-quality evidence). However, positive effects for music therapy were found for both social functioning (Social Disability Screening Schedule scores; 2 RCTs, n = 160, SMD -0.72 95% CI -1.04 to -0.40), and quality of life (General Well-Being Schedule scores: 1 RCT, n = 72, SMD 1.82 95% CI 1.27 to 2.38, moderate-quality evidence). There were no data available for adverse effects, service use, engagement with services, or cost.

AUTHORS' CONCLUSIONS

Moderate- to low-quality evidence suggests that music therapy as an addition to standard care improves the global state, mental state (including negative and general symptoms), social functioning, and quality of life of people with schizophrenia or schizophrenia-like disorders. However, effects were inconsistent across studies and depended on the number of music therapy sessions as well as the quality of the music therapy provided. Further research should especially address the long-term effects of music therapy, dose-response relationships, as well as the relevance of outcome measures in relation to music therapy.

Acceptance and Commitment Therapy for Inpatients with Psychosis (the REACH Study): Protocol for Treatment Development and Pilot Testing

Patients with schizophrenia-spectrum disorders frequently require treatment at inpatient hospitals during periods of acute illness for crisis management and stabilization. Acceptance and Commitment Therapy (ACT), a "third wave" cognitive-behavioral intervention that employs innovative mindfulness-based strategies, has shown initial efficacy in randomized controlled trials for improving acute and post-discharge outcomes in patients with psychosis when studied in acute-care psychiatric hospitals in the U.S. However, the intervention has not been widely adopted in its current form because of its use of an individual-only format and delivery by doctoral-level research therapists with extensive prior experience using ACT. The aim of the Researching the Effectiveness of Acceptance-based Coping during Hospitalization (REACH) Study is to adapt a promising acute-care psychosocial treatment for inpatients with psychosis, and to pilot test its effectiveness in a routine inpatient setting. More specifically, we describe our plans to: (a) further develop and refine the treatment and training protocols, (b) conduct an open trial and make further modifications based on the experience gained, and

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

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

Exploring narratives of psychological input in the acute inpatient setting

OBJECTIVES

This research explored what happens when psychological input is offered in the inpatient setting and examined service users' and staff members' understanding and portrayal of these experiences.

DESIGN

Narrative analysis, an interview design, was used to examine experiences of inpatient psychological interventions in National Health Service inpatient mental health settings.

METHODS

Ten participants (four service users and six staff members; five males and five females; seven White British, one White Irish, one Black African, and one Black Caribbean) were recruited via clinical psychologists from an inpatient psychology department and participated in 18- to 90-min interviews.

RESULTS

Evidence suggested that direct, indirect, and strategic psychological interventions were used in the inpatient setting, with formulation and the therapeutic relationship conceptualized as common features. Connections between inpatient psychology and change, evidenced in the stories, suggested that interventions can help people make sense of a crisis, improve relationships, and contribute to meaningful recovery. Evidence of barriers suggests that psychological input in this setting might not always be compatible with everyone's needs.

CONCLUSIONS

This paper explored service users' and staff members' experiences of psychological input in the inpatient setting. The analysis revealed that psychological provision in the inpatient mental health setting is varied and encompasses direct and indirect input, valued by service users and clinicians. It also identified that psychological input in the acute inpatient mental health setting is perceived as meaningful and can lead to changes at an interpersonal and intrapersonal level. There is a sense that providing psychological thinking in the inpatient setting can be challenging due to environmental constraints and individual factors. This highlights the need for further research focused on the costs and clinical effectiveness of providing psychological thinking within the acute inpatient mental health setting.

PRACTITIONER POINTS

Staff members and service users made connections between psychological input and change, suggesting that interventions can improve relationships, help people make sense of a crisis, and contribute to meaningful recovery. There are significant barriers to and challenges of providing psychological input in this setting: Some participants suggested that this approach might not suit everyone.

Developing a research agenda for reducing the stigma of addictions, part II: Lessons from the mental health stigma literature

BACKGROUND AND OBJECTIVES

Although advocates and providers identify stigma as a major factor in confounding the recovery of people with SUDs, research on addiction stigma is lacking, especially when compared to the substantive literature examining the stigma of mental illness.

METHODS

A comprehensive review of the stigma literature that yielded empirically supported concepts and methods from the mental health arena was contrasted with the much smaller and mostly descriptive findings from the addiction field. In Part I of this two part paper (American Journal of Addictions, Vol 26, pages 59-66, this issue), constructs and methods from the mental health stigma literature were used to summarize research that seeks to understand the phenomena of addiction stigma.

RESULTS

In Paper II, we use this summary, as well as the extensive literature on mental illness stigma change, to outline a research program to develop and evaluate strategies meant to diminish impact on public and self-stigma (eg, education and contact).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The paper ends with recommendations for next steps in addiction stigma research. (Am J Addict 2017;26:67-74).

[Integrated management of patients with schizophrenia: beyond psychotropic drugs]

INTRODUCTION

Schizophrenia is a complex disease with severe functional repercussions; therefore it merits treatment which goes beyond drugs.

THEME DEVELOPMENT

It requires an approach that considers a diathesis-stress process that includes rehabilitation, psychotherapeutic strategies for persistent cognitive, negative and psychotic symptoms, psychoeducation of patient and communities, community adaptation strategies, such as the introduction to the work force, and the community model, such as a change in the asylum paradigm.

DISCUSSION

It is necessary to establish private and public initiatives for the integrated care of schizophrenia in the country, advocating the well-being of those with the disease.

CONCLUSIONS

The integrated management of schizophrenic patients requires a global view of the patient and his/her disease, and its development is essential.

Early psychosis research at Orygen, The National Centre of Excellence in Youth Mental Health

BACKGROUND

Specialised early intervention (SEI) programs have offered individuals with psychotic disorders and their families new hope for improving illness trajectories and outcomes. The Early Psychosis Prevention and Intervention Centre (EPPIC) was one of the first SEI programs developed in the world, providing services for young people experiencing their first episode of psychosis.

METHODS

We conducted a narrative synthesis of controlled and uncontrolled studies that have been conducted at EPPIC.

DISCUSSION

The history of the EPPIC model is first described. This is followed by a discussion of clinical research emerging from EPPIC, including psychopharmacological, psychotherapeutic trials and outcome studies. Neurobiological studies are also described. Issues pertaining to the conduct of clinical research and future research directions are then described. Finally, the impact of the EPPIC model on the Australian environment is discussed.

A randomized controlled trial comparing cognitive behavior therapy, cognitive adaptation training, their combination and treatment as usual in chronic schizophrenia

Following baseline assessment, 166 patients in medication maintenance at a community mental health center who were experiencing both persistent positive symptoms of schizophrenia and impairments in functioning were randomized to 1 of 4 treatments for 9 months: (1) Cognitive Behavior Therapy for psychosis (CBTp)-a therapy designed to identify and alter reasoning and appraisal biases that contribute to the formation and maintenance of positive symptoms, (2) Cognitive Adaptation Training (CAT)-a treatment using environmental supports including signs, alarms, checklists and the organization of belongings established at weekly home visits to compensate for impairments in cognitive functioning and improve everyday functional outcomes, (3) Multi-modal Cognitive treatment-a combination of CBTp and CAT, and (4) Treatment as Usual. Data on symptoms and functional outcomes were obtained every 3 months. A mixed effects regression model with repeated measures using a 2 (CAT/no CAT) × 2 (CBT/no CBT) design indicated that functioning as measured by the Multnomah Community Ability Scale improved more in groups receiving CAT than other treatment groups. Auditory hallucinations and associated distress improved slightly more in groups receiving CAT. In this study, CBTp did not improve outcomes. Combining CAT with CBTp did not improve outcomes more than CAT alone.

Supportive therapy for schizophrenia

BACKGROUND

Supportive therapy is often used in everyday clinical care and in evaluative studies of other treatments.

OBJECTIVES

To review the effects of supportive therapy compared with standard care, or other treatments in addition to standard care for people with schizophrenia.

SEARCH METHODS

For this update, we searched the Cochrane Schizophrenia Group's register of trials (November 2012).

SELECTION CRITERIA

All randomised trials involving people with schizophrenia and comparing supportive therapy with any other treatment or standard care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the risk ratio (RR) using a fixed-effect model with 95% confidence intervals (CIs). Where possible, we undertook intention-to-treat analyses. For continuous data, we estimated the mean difference (MD) fixed-effect with 95% CIs. We estimated heterogeneity (I(2) technique) and publication bias. We used GRADE to rate quality of evidence.

MAIN RESULTS

Four new trials were added after the 2012 search. The review now includes 24 relevant studies, with 2126 participants. Overall, the evidence was very low quality.We found no significant differences in the primary outcomes of relapse, hospitalisation and general functioning between supportive therapy and standard care.There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (4 RCTs, n = 306, RR 1.82 CI 1.11 to 2.99, very low quality of evidence), clinical improvement in mental state (3 RCTs, n = 194, RR 1.27 CI 1.04 to 1.54, very low quality of evidence) and satisfaction of treatment for the recipient of care (1 RCT, n = 45, RR 3.19 CI 1.01 to 10.7, very low quality of evidence). For this comparison, we found no evidence of significant differences for rate of relapse, leaving the study early and quality of life.When we compared supportive therapy to cognitive behavioural therapy CBT), we again found no significant differences in primary outcomes. There were very limited data to compare supportive therapy with family therapy and psychoeducation, and no studies provided data regarding clinically important change in general functioning, one of our primary outcomes of interest.

AUTHORS' CONCLUSIONS

There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies where we graded the evidence as very low quality. Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.

Psychotherapy for adolescents and young adults at high risk for psychosis: a systematic review

AIM

Unlike medication treatment, which may confer an unfavourable risk-benefit ratio, psychosocial intervention has been an emerging target of recent randomized controlled trials (RCTs) assessing its efficacy in delaying or preventing the onset of psychosis in individuals identified at 'clinical high risk'. Literature comparing qualitative differences in these psychotherapeutic interventions is scarce. The aim of the current study was to conduct a PRISMA systematic review evaluating the efficacy of psychotherapeutic interventions in reducing the rates of conversion to psychosis in clinical high-risk individuals.

METHODS

RCTs were identified in PubMed, Medline and PsycINFO databases up to 30 November 2013. Six studies (comprising 800 participants) met review inclusion criteria. Three investigators performed data extraction independently by using a pre-structured selection form, and conducted risk of bias assessment employing the Cochrane approach.

RESULTS

All six studies employed cognitive behaviour therapy as a core element. Three trials achieved a significant effect. The two trials that employed cognitive behaviour therapy enhanced for the specialized needs of clinical high-risk patients maintained significant effects at post-treatment follow up.

CONCLUSION

Evidence from recent trials suggest that cognitive behaviour therapy may be beneficial in delaying or preventing onset of psychosis in clinical high-risk individuals, although effect sizes to date appear small. Further research is needed in larger samples to establish whether cognitive behaviour therapy is efficacious, and if additional intervention components can enhance established psychotherapies.

Preliminary Evaluation of Culturally Adapted CBT for Psychosis (CA-CBTp): Findings from Developing Culturally-Sensitive CBT Project (DCCP)

Background: Cognitive Behaviour Therapy for Psychosis (CBTp) has a strong evidence base and is practised widely in the Western World. Psycho-social interventions, on the other hand, including Cognitive Behaviour Therapy (CBT) are hardly used in the low and middle income countries for psychosis. It has been suggested that adaptations in content, format and delivery are needed before CBT can be used outside the Western cultures. We describe preliminary evaluation of Culturally Adapted Cognitive Behaviour Therapy for Psychosis (CaCBTp) in in-patient settings in Lahore, Pakistan. Aims: We aimed to evaluate the efficacy of culturally adapted CBT for psychosis (CaCBTp) in Pakistan in a pilot project. Method: In a randomized controlled trial we tested CaCBTp against treatment as usual (TAU) in in-patient settings in Pakistan. Those diagnosed with schizophrenia according to the DSM-IV-TR, and who fulfilled the inclusion criteria, were recruited into the study. Patients (n = 42) were randomized into two equal groups, i.e. CaCBTp and TAU. Assessments were carried out both at the baseline and then at the end of the therapy by raters blind to the groupings. Psychopathology was measured using PANSS (Positive and Negative Syndrome Scale of Schizophrenia), PSYRATS (Psychotic Symptom Rating Scales), and the Insight Scale. Results: Patients receiving CaCBTp showed statistically significant improvement on measures of positive symptoms (p = .000), negative symptoms (p = .000), overall psychotic symptoms (p = .000), hallucinations (p = .000), delusions (p = .000) and insight (p = .000) at the end of the therapy. Conclusions: The CaCBTp was effective in reducing symptoms of psychosis and in improving insight in in-inpatient settings in Pakistan.

Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias

BACKGROUND

Cognitive-behavioural therapy (CBT) is considered to be effective for the symptoms of schizophrenia. However, this view is based mainly on meta-analysis, whose findings can be influenced by failure to consider sources of bias.

AIMS

To conduct a systematic review and meta-analysis of the effectiveness of CBT for schizophrenic symptoms that includes an examination of potential sources of bias.

METHOD

Data were pooled from randomised trials providing end-of-study data on overall, positive and negative symptoms. The moderating effects of randomisation, masking of outcome assessments, incompleteness of outcome data and use of a control intervention were examined. Publication bias was also investigated.

RESULTS

Pooled effect sizes were -0.33 (95% CI -0.47 to -0.19) in 34 studies of overall symptoms, -0.25 (95% CI -0.37 to -0.13) in 33 studies of positive symptoms and -0.13 (95% CI -0.25 to -0.01) in 34 studies of negative symptoms. Masking significantly moderated effect size in the meta-analyses of overall symptoms (effect sizes -0.62 (95% CI -0.88 to -0.35) v. -0.15 (95% CI -0.27 to -0.03), P = 0.001) and positive symptoms (effect sizes -0.57 (95% CI -0.76 to -0.39) v. -0.08 (95% CI -0.18 to 0.03), P<0.001). Use of a control intervention did not moderate effect size in any of the analyses. There was no consistent evidence of publication bias across different analyses.

CONCLUSIONS

Cognitive-behavioural therapy has a therapeutic effect on schizophrenic symptoms in the 'small' range. This reduces further when sources of bias, particularly masking, are controlled for.

Psychosocial treatments for negative symptoms in schizophrenia: current practices and future directions

Schizophrenia can be a chronic and debilitating psychiatric disorder. Though advancements have been made in the psychosocial treatment of some symptoms of schizophrenia, people with schizophrenia often continue to experience some level of symptoms, particularly negative symptoms, throughout their lives. Because negative symptoms are associated with poor functioning and quality of life, the treatment of negative symptoms is a high priority for intervention development. However, current psychosocial treatments primarily focus on the reduction of positive symptoms with comparatively few studies investigating the efficacy of psychosocial treatments for negative symptoms. In this article, we review and evaluate the existing literature on three categories of psychosocial treatments--cognitive behavioral therapy (CBT), social skills training (SST), and combined treatment interventions--and their impact on the negative symptoms of schizophrenia. Of the interventions reviewed, CBT and SST appear to have the most empirical support, with some evidence suggesting that CBT is associated with maintenance of negative symptom improvement beyond six months after treatment. It remains unclear if a combined treatment approach provides improvements above and beyond those associated with each individual treatment modality. Although psychosocial treatments show promise for the treatment of negative symptoms, there are many unanswered questions about how best to intervene. We conclude with a general discussion of these unanswered questions, future directions and methodological considerations, and suggestions for the further development of negative symptom interventions.

Cognitive-behavioural therapy for schizophrenia: a critical commentary on the Newton-Howes and Wood meta-analysis

Newton-Howes and Wood (published online, this journal, 8 Dec 2011) report the results of their systematic review and meta-analysis of clinical trials of cognitive-behavioural therapy (CBT) for schizophrenia. They ran a random effects analysis of endpoint data from trials where participants were randomly allocated to receive either CBT or a control therapy, which could be inactive (e.g., befriending) or active (e.g., analytic supportive psychotherapy), found no difference between the groups and concluded 'it (CBT) does not outperform supportive therapy in effecting change in phenomenology.' Such a conclusion is premature, if not unwarranted, for a number of reasons, including basic mistakes, lack of transparency, and failure to consider dose.

Cognitive behavioural therapy and the psychopathology of schizophrenia: systematic review and meta-analysis

PURPOSE

To examine whether cognitive behaviour therapy (CBT) reduces psychopathology in patients with schizophrenia more effectively than the use of non-cognitive psychotherapies.

METHOD

Systematic review and meta-analysis of the literature was performed. All Randomized Controlled Trials meeting the inclusion criteria were analysed using RevMan software. This design was used to maximize power and study efficacy. Medline, PsycINFO, and Embase were searched using free-text keywords to identify potential papers. Nine were included in the final meta-analysis. Change in psychopathology at the end of therapy was the end point investigated. A random effects model was used to assess the standard mean difference between the CBT and supportive control groups.

RESULTS

Meta-analysis of CBT versus supportive therapy did not find significant differences between the therapy groups at the end of treatment in respect of psychopathology. There was no evidence of publication bias. Post hoc power analysis using the Z test ruled out type one error.

CONCLUSIONS

Theoretically based CBT therapies, although proving effective, may not out perform more accessible and simpler forms of therapy for patients with schizophrenia in reducing psychopathology. Consideration of supportive therapy should be made for patients with psychotic mental disorder.

Training to recognise the early signs of recurrence in schizophrenia

BACKGROUND

Schizophrenia has a lifetime prevalence of less than one per cent. Studies have indicated that early symptoms that are idiosyncratic to the person with schizophrenia (early warning signs) often precede acute psychotic relapse. Early warning signs interventions propose that learning to detect and manage early warning signs of impending relapse might prevent or delay acute psychotic relapse.

OBJECTIVES

To compare the effectiveness of early warning signs interventions plus treatment as usual involving and not involving a psychological therapy on time to relapse, hospitalisation, functioning, negative and positive symptomatology.

SEARCH METHODS

Search databases included the Cochrane Schizophrenia Group Trials Register (July 2007 and May 2012) which is based on regular searches of BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were reviewed for inclusion. We inspected the UK National Research Registe and contacted relevant pharmaceutical companies and authors of trials for additional information.

SELECTION CRITERIA

We included all randomised clinical trials (RCTs) comparing early warning signs interventions plus treatment as usual to treatment as usual for people with schizophrenia or other non-affective psychosis

DATA COLLECTION AND ANALYSIS

We assessed included studies for quality and extracted data. If more than 50% of participants were lost to follow-up, the study was excluded. For binary outcomes, we calculated standard estimates of risk ratio (RR) and the corresponding 95% confidence intervals (CI), for continuous outcomes, we calculated mean differences (MD) with standard errors estimated, and for time to event outcomes we calculated Cox proportional hazards ratios (HRs) and associated 95 % CI. We assessed risk of bias for included studies and assessed overall study quality using the GRADE approach.

MAIN RESULTS

Thirty-two RCTs and two cluster-RCTs that randomised 3554 people satisfied criteria for inclusion. Only one study examined the effects of early warning signs interventions without additional psychological interventions, and many of the outcomes for this review were not reported or poorly-reported. Significantly fewer people relapsed with early warning signs interventions than with usual care (23% versus 43%; RR 0.53, 95% CI 0.36 to 0.79; 15 RCTs, 1502 participants; very low quality evidence). Time to relapse did not significantly differ between intervention groups (6 RCTs, 550 participants; very low quality evidence). Risk of re-hospitalisation was significantly lower with early warning signs interventions compared to usual care (19% versus 39%; RR 0.48, 95% CI 0.35 to 0.66; 15 RCTS, 1457 participants; very low quality evidence). Time to re-hospitalisation did not significantly differ between intervention groups (6 RCTs; 1149 participants; very low quality evidence). Participants' satisfaction with care and economic costs were inconclusive because of a lack of evidence.

AUTHORS' CONCLUSIONS

This review indicates that early warning signs interventions may have a positive effect on the proportions of people re-hospitalised and on rates of relapse, but not on time to recurrence. However, the overall quality of the evidence was very low, indicating that we do not know if early warning signs interventions will have similar effects outside trials and that it is very likely that further research will alter these estimates. Moreover, the early warning signs interventions were used along side other psychological interventions, and we do not know if they would be effective on their own. They may be cost-effective due to reduced hospitalisation and relapse rates, but before mental health services consider routinely providing psychological interventions involving the early recognition and prompt management of early warning signs to adults with schizophrenia, further research is required to provide evidence of high or moderate quality regarding the efficacy of early warning signs interventions added to usual care without additional psychological interventions, or to clarify the kinds of additional psychological interventions that might aid its efficacy. Future RCTs should be adequately-powered, and designed to minimise the risk of bias and be transparently reported. They should also systematically evaluate resource costs and resource use, alongside efficacy outcomes and other outcomes that are important to people with serious mental illness and their carers.

Assessing suitability for short-term cognitive-behavioral therapy in psychiatric outpatients with psychosis: a comparison with depressed and anxious outpatients

OBJECTIVE

The Suitability for Short-Term Cognitive Therapy (SSCT) rating procedure has predicted outcome in depressed and anxious patients. This study examines its relevance in assessing patients with psychosis.

METHOD

Outpatients with psychosis (n=56), depression (n=93), and anxiety (n=264) received cognitive- behavioral therapy in a university hospital teaching unit (mean number of sessions=16, SD=11). Demographic, clinical, and suitability variables were assessed as potential predictors of dropout and success as measured by the Reliable Change Index.

RESULTS

Despite lower suitability scores in the psychosis group, dropout and success rates were similar across groups, although the magnitude of symptom reduction was less in the psychosis group. Across diagnoses, dropout was predicted by unemployment and by reluctance to take personal responsibility for change. In the psychosis group only, dropout was predicted by hostility. Success of completed therapy was predicted by higher baseline agoraphobic anxiety and "responsibility for change" scores.

CONCLUSION

Attention to hostility early in therapy may reduce dropout in psychotic patients. Fostering acceptance of responsibility for change may improve both treatment retention and success across diagnoses. Agoraphobic fear is associated with success, possibly reflecting the effectiveness of behavioral interventions in psychosis and anxiety alike.

Cognitive behavioral therapy for schizophrenia: an empirical review

Early case studies and noncontrolled trial studies focusing on the treatment of delusions and hallucinations have laid the foundation for more recent developments in comprehensive cognitive behavioral therapy (CBT) interventions for schizophrenia. Seven randomized, controlled trial studies testing the efficacy of CBT for schizophrenia were identified by electronic search (MEDLINE and PsychInfo) and by personal correspondence. After a review of these studies, effect size (ES) estimates were computed to determine the statistical magnitude of clinical change in CBT and control treatment conditions. CBT has been shown to produce large clinical effects on measures of positive and negative symptoms of schizophrenia. Patients receiving routine care and adjunctive CBT have experienced additional benefits above and beyond the gains achieved with routine care and adjunctive supportive therapy. These results reveal promise for the role of CBT in the treatment of schizophrenia although additional research is required to test its efficacy, long-term durability, and impact on relapse rates and quality of life. Clinical refinements are needed also to help those who show only minimal benefit with the intervention.

Group psychosocial interventions for adults with schizophrenia and bipolar illness: the evidence base in the light of publications between 1986 and 2006

AIM

The treatment of major mental disorders usually combines medical and psychosocial interventions. The present study reviews research pertaining to the efficacy of group psychosocial interventions for people with psychotic illness.

METHOD

An electronic search was conducted through Medline and PsychINFO to identify articles relevant to group therapy for people with schizophrenia and bipolar affective disorder. Articles published in the English language, between January 1986 and May 2006, were considered. Studies were included if they had a control group and at least 20 participants. The search resulted in 23 articles concerning patients with schizophrenia and five concerning patients with bipolar affective disorder.

RESULTS AND CONCLUSION

The therapeutic approach in the majority of the studies was along the lines of cognitive behaviour therapy and psychoeducation. All studies reported improvement in at least one parameter. Most of them report improvement in skills and overall functioning.

Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia

BACKGROUND

Cognitive behavioural therapy (CBT) is now a recommended treatment for people with schizophrenia. This approach helps to link the person's distress and problem behaviours to underlying patterns of thinking.

OBJECTIVES

To review the effects of CBT for people with schizophrenia when compared with other psychological therapies.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (March 2010) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. We inspected all references of the selected articles for further relevant trials, and, where appropriate, contacted authors.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) of CBT for people with schizophrenia-like illnesses.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected and assessed for methodological quality. Two review authors, working independently, extracted data. We analysed dichotomous data on an intention-to-treat basis and continuous data with 65% completion rate are presented. Where possible, for dichotomous outcomes, we estimated a risk ratio (RR) with the 95% confidence interval (CI) along with the number needed to treat/harm.

MAIN RESULTS

Thirty papers described 20 trials. Trials were often small and of limited quality. When CBT was compared with other psychosocial therapies, no difference was found for outcomes relevant to adverse effect/events (2 RCTs, n = 202, RR death 0.57 CI 0.12 to 2.60). Relapse was not reduced over any time period (5 RCTs, n = 183, RR long-term 0.91 CI 0.63 to 1.32) nor was rehospitalisation (5 RCTs, n = 294, RR in longer term 0.86 CI 0.62 to 1.21). Various global mental state measures failed to show difference (4 RCTs, n = 244, RR no important change in mental state 0.84 CI 0.64 to 1.09). More specific measures of mental state failed to show differential effects on positive or negative symptoms of schizophrenia but there may be some longer term effect for affective symptoms (2 RCTs, n = 105, mean difference (MD) Beck Depression Inventory (BDI) -6.21 CI -10.81 to -1.61). Few trials report on social functioning or quality of life. Findings do not convincingly favour either of the interventions (2 RCTs, n = 103, MD Social Functioning Scale (SFS) 1.32 CI -4.90 to 7.54; n = 37, MD EuroQOL -1.86 CI -19.20 to 15.48). For the outcome of leaving the study early, we found no significant advantage when CBT was compared with either non-active control therapies (4 RCTs, n = 433, RR 0.88 CI 0.63 to 1.23) or active therapies (6 RCTs, n = 339, RR 0.75 CI 0.40 to 1.43)

AUTHORS' CONCLUSIONS

Trial-based evidence suggests no clear and convincing advantage for cognitive behavioural therapy over other - and sometime much less sophisticated - therapies for people with schizophrenia.

Early intervention in psychosis: Insights from Korea

Subjects at clinical high risk (CHR) for psychosis have been the focus of clinical attention in psychiatry for the last 15 years, leading to the development of valid and reliable diagnostic instruments to detect these individuals early in the course of their illness. These efforts have resulted in research into optimal preventive measures. Our experiences at and data from the Seoul Youth Clinic support the validity of the CHR concept and its underlying neurobiological basis and provide valuable information related to the determination of appropriate clinical interventions. The limitations of the current criteria for CHR, such as the relatively low transition rates to psychosis and the "false-positive" problem, are also common critical issues in Korea. Additionally, concerns about social stigmatization and the potential side effects of pharmacotherapy render individuals at CHR reluctant to visit clinical settings. Therefore, further investigations using a combination of predictive markers based on clinical and neurobiological studies of those at CHR are needed to refine the diagnostic criteria, overcome their current limitations including ethical issues, and develop phase-specific and individualized therapeutic interventions.

A population based analysis of subclinical psychosis and help-seeking behavior

Clinically defined psychosis is recognizable and distinguishable from nonclinical or subclinical psychosis by virtue of its clinical relevance (ie, its associated distress and its need for care and/or treatment). According to the continuum hypothesis, subclinical psychosis is merely quantitatively different from more extreme phenotypic expressions and as such should also be indicative of distress and help-seeking behavior but to a lesser extent. Using data from the Adult Psychiatric Morbidity Survey, the current study focused on self-reported psychosis and help-seeking experiences in a general population sample free from clinically defined psychosis (N = 7266). After statistically controlling for the effects of a series of potential help-seeking correlates the findings showed that subclinical psychosis symptom experience was significantly associated with various forms of help-seeking behavior. Individuals who reported subclinical experiences of thought control, paranoia, and strange experiences were on average 2 times more likely to attend their general practitioner for emotional problems compared with those individuals who reported no psychosis. Individuals who reported subclinical experiences of paranoia were 3 times more likely to be in receipt of counseling/therapy compared with those with no experience of paranoia. Multiple subclinical psychotic experiences also predicted elevated help-seeking behavior. These findings may have a positive impact on the detection of individuals who are at increased risk of psychological distress and aid in the design and implementation of more effective treatments at both clinical and subclinical levels.

Narrative enhancement and cognitive therapy: a new group-based treatment for internalized stigma among persons with severe mental illness

Internalized stigma has been suggested to play a major role in negative changes in identity in severe mental illness. Evidence suggests that roughly one-third of people with severe mental illness show elevated internalized stigma and that it is linked to compromised outcomes in both subjective and objective aspects of recovery. Despite substantial evidence for the impact of internalized stigma, few efforts have been made to develop professionally led treatment to address this issue. In this article, we discuss our development of a new group-based approach to the treatment of internalized stigma which we have termed "narrative enhancement and cognitive therapy (NECT)". We describe the treatment approach and offer an illustration of it by way of a case vignette.

Music therapy for people with schizophrenia and schizophrenia-like disorders

BACKGROUND

Music therapy is a therapeutic method that uses musical interaction as a means of communication and expression. The aim of the therapy is to help people with serious mental disorders to develop relationships and to address issues they may not be able to using words alone.

OBJECTIVES

To review the effects of music therapy, or music therapy added to standard care, compared with 'placebo' therapy, standard care or no treatment for people with serious mental disorders such as schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (December 2010) and supplemented this by contacting relevant study authors, handsearching of music therapy journals and manual searches of reference lists.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that compared music therapy with standard care, placebo therapy, or no treatment.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality assessed and data extracted. We excluded data where more than 30% of participants in any group were lost to follow-up. We synthesised non-skewed continuous endpoint data from valid scales using a standardised mean difference (SMD). If statistical heterogeneity was found, we examined treatment 'dosage' and treatment approach as possible sources of heterogeneity.

MAIN RESULTS

We included eight studies (total 483 participants). These examined effects of music therapy over the short- to medium-term (one to four months), with treatment 'dosage' varying from seven to 78 sessions. Music therapy added to standard care was superior to standard care for global state (medium-term, 1 RCT, n = 72, RR 0.10 95% CI 0.03 to 0.31, NNT 2 95% CI 1.2 to 2.2). Continuous data identified good effects on negative symptoms (4 RCTs, n = 240, SMD average endpoint Scale for the Assessment of Negative Symptoms (SANS) -0.74 95% CI -1.00 to -0.47); general mental state (1 RCT, n = 69, SMD average endpoint Positive and Negative Symptoms Scale (PANSS) -0.36 95% CI -0.85 to 0.12; 2 RCTs, n=100, SMD average endpoint Brief Psychiatric Rating Scale (BPRS) -0.73 95% CI -1.16 to -0.31); depression (2 RCTs, n = 90, SMD average endpoint Self-Rating Depression Scale (SDS) -0.63 95% CI -1.06 to -0.21; 1 RCT, n = 30, SMD average endpoint Hamilton Depression Scale (Ham-D) -0.52 95% CI -1.25 to -0.21 ); and anxiety (1 RCT, n = 60, SMD average endpoint SAS -0.61 95% CI -1.13 to -0.09). Positive effects were also found for social functioning (1 RCT, n = 70, SMD average endpoint Social Disability Schedule for Inpatients (SDSI) score -0.78 95% CI -1.27 to -0.28). Furthermore, some aspects of cognitive functioning and behaviour seem to develop positively through music therapy. Effects, however, were inconsistent across studies and depended on the number of music therapy sessions as well as the quality of the music therapy provided.

AUTHORS' CONCLUSIONS

Music therapy as an addition to standard care helps people with schizophrenia to improve their global state, mental state (including negative symptoms) and social functioning if a sufficient number of music therapy sessions are provided by qualified music therapists. Further research should especially address the long-term effects of music therapy, dose-response relationships, as well as the relevance of outcomes measures in relation to music therapy.

Early intervention for psychosis

BACKGROUND

Proponents of early intervention have argued that outcomes might be improved if more therapeutic efforts were focused on the early stages of schizophrenia or on people with prodromal symptoms. Early intervention in schizophrenia has two elements that are distinct from standard care: early detection, and phase-specific treatment (phase-specific treatment is a psychological, social or physical treatment developed, or modified, specifically for use with people at an early stage of the illness).Early detection and phase-specific treatment may both be offered as supplements to standard care, or may be provided through a specialised early intervention team. Early intervention is now well established as a therapeutic approach in America, Europe and Australasia.

OBJECTIVES

To evaluate the effects of: (a) early detection; (b) phase-specific treatments; and (c) specialised early intervention teams in the treatment of people with prodromal symptoms or first-episode psychosis.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (March 2009), inspected reference lists of all identified trials and reviews and contacted experts in the field.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) designed to prevent progression to psychosis in people showing prodromal symptoms, or to improve outcome for people with first-episode psychosis. Eligible interventions, alone and in combination, included: early detection, phase-specific treatments, and care from specialised early intervention teams. We accepted cluster-randomised trials but excluded non-randomised trials.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention-to-treat analysis (ITT).

MAIN RESULTS

Studies were diverse, mostly small, undertaken by pioneering researchers and with many methodological limitations (18 RCTs, total n=1808). Mostly, meta-analyses were inappropriate. For the six studies addressing prevention of psychosis for people with prodromal symptoms, olanzapine seemed of little benefit (n=60, 1 RCT, RR conversion to psychosis 0.58 CI 0.3 to 1.2), and cognitive behavioural therapy (CBT) equally so (n=60, 1 RCT, RR conversion to psychosis 0.50 CI 0.2 to 1.7). A risperidone plus CBT plus specialised team did have benefit over specialist team alone at six months (n=59, 1 RCT, RR conversion to psychosis 0.27 CI 0.1 to 0.9, NNT 4 CI 2 to 20), but this was not seen by 12 months (n=59, 1 RCT, RR 0.54 CI 0.2 to 1.3). Omega 3 fatty acids (EPA) had advantage over placebo (n=76, 1 RCT, RR transition to psychosis 0.13 CI 0.02 to 1.0, NNT 6 CI 5 to 96). We know of no replications of this finding.The remaining trials aimed to improve outcome in first-episode psychosis. Phase-specific CBT for suicidality seemed to have little effect, but the single study was small (n=56, 1 RCT, RR suicide 0.81 CI 0.05 to 12.26). Family therapy plus a specialised team in the Netherlands did not clearly affect relapse (n=76, RR 1.05 CI 0.4 to 3.0), but without the specialised team in China it may (n=83, 1 RCT, RR admitted to hospital 0.28 CI 0.1 to 0.6, NNT 3 CI 2 to 6). The largest and highest quality study compared specialised team with standard care. Leaving the study early was reduced (n=547, 1 RCT, RR 0.59 CI 0.4 to 0.8, NNT 9 CI 6 to 18) and compliance with treatment improved (n=507, RR stopped treatment 0.20 CI 0.1 to 0.4, NNT 9 CI 8 to 12). The mean number of days spent in hospital at one year were not significantly different (n=507, WMD, -1.39 CI -2.8 to 0.1), neither were data for 'Not hospitalised' by five years (n=547, RR 1.05 CI 0.90 to 1.2). There were no significant differences in numbers 'not living independently' by one year (n=507, RR 0.55 CI 0.3 to 1.2). At five years significantly fewer participants in the treatment group were 'not living independently' (n=547, RR 0.42 CI 0.21 to 0.8, NNT 19 CI 14 to 62). When phase-specific treatment (CBT) was compared with befriending no significant differences emerged in the number of participants being hospitalised over the 12 months (n=62, 1 RCT, RR 1.08 CI 0.59 to 1.99).Phase-specific treatment E-EPA oils suggested no benefit (n=80, 1 RCT, RR no response 0.90 CI 0.6 to 1.4) as did phase-specific treatment brief intervention (n=106, 1 RCT, RR admission 0.86 CI 0.4 to 1.7). Phase-specific ACE found no benefit but participants given vocational intervention were more likely to be employed (n=41, 1 RCT, RR 0.39 CI 0.21 to 0.7, NNT 2 CI 2 to 4). Phase-specific cannabis and psychosis therapy did not show benefit (n=47, RR cannabis use 1.30 CI 0.8 to 2.2) and crisis assessment did not reduce hospitalisation (n=98, RR 0.85 CI 0.6 to 1.3). Weight was unaffected by early behavioural intervention.

AUTHORS' CONCLUSIONS

There is emerging, but as yet inconclusive evidence, to suggest that people in the prodrome of psychosis can be helped by some interventions. There is some support for specialised early intervention services, but further trials would be desirable, and there is a question of whether gains are maintained. There is some support for phase-specific treatment focused on employment and family therapy, but again, this needs replicating with larger and longer trials.