A cognitive-behavioral treatment for suicide prevention among adults with schizophrenia spectrum disorders in community mental health: Study protocol for a pilot feasibility and acceptability randomized clinical trial

BACKGROUND

Suicide is among the leading causes of death for adults with schizophrenia spectrum disorders (SSDs), and there is a paucity of evidence-based suicide prevention-focused interventions tailored for this vulnerable population. Cognitive-Behavioral Suicide Prevention for psychosis (CBSPp) is a promising intervention developed in the UK that required modifications for delivery in community mental health (CMH) settings in the United States of American. This pilot trial evaluates the feasibility, acceptability, and preliminary effectiveness of our modified CBSPp intervention in comparison to services as usual (SAU) within a CMH setting in a Midwestern state of the USA.

METHODS

This is a single-site randomized pilot trial with a planned enrollment of 60 adults meeting criteria for both SSD and SI/A. Eligible participants will be randomized 1:1 to either 10 sessions of CBSPp or SAU. Clinical and cognitive assessments will be conducted within a 4-waive design at baseline (prior to randomization and treatment) and approximately 1 month (mid-treatment), 3 months (post-treatment), and 5 months (follow-up) after baseline assessment. Qualitative interviews will also be conducted at post-treatment. The primary objective is to determine whether CBSPp is feasible and acceptable, involving examinations of recruitment rate, treatment engagement and adherence, retention and completion rates, and experiences in the CBSPp treatment and overall study. The secondary objective is to preliminarily evaluate whether modified CBSPp is associated with reductions in clinical (suicide ideation, suicide attempt, symptoms of psychosis, depression, and emergency/hospital service, hopelessness, defeat, and entrapment) and cognitive (information processing biases, appraisals, and schemas) outcomes in comparison to SAU from baseline to post-treatment assessment.

DISCUSSION

This randomized pilot trial will provide clinically relevant information about whether CBSPp can improve SI/A, depression, and psychosis among adults with SSDs. Testing this modified cognitive-behavioral suicide prevention-focused intervention has the potential for a large public health impact by increasing the intervention's utility and usability in CMH where many individuals with SSDs receive care, and ultimately working towards reductions in premature suicide death.

TRIAL REGISTRATION

ClinicalTrials.gov NCT#05345184. Registered on April 12, 2022.

How Does Individual Psychotherapy Promote Recovery for Persons with Psychosis? A Systematic Review of Qualitative Studies to Understand the Patient's Experience

Psychotherapy for individuals with psychosis is an effective treatment that promotes recovery in various ways. While there is strong quantitative evidence across modalities, less is known from the patient's perspective. There are many varied forms of psychotherapy, and gaining the patient's perspective can improve understanding of salient elements of psychotherapy and increase engagement, ultimately improving recovery rates. The purpose of this review is to identify and integrate data from published studies of patient perspectives of psychotherapy for psychosis to understand essential elements across approaches, differences between approaches, and how psychotherapy impacts recovery. We aimed to understand further: what are the perceptions about individual psychotherapy from the perspective of individuals with psychosis? The current study was a systematic review using PRISMA guidelines of studies that included qualitative interviews with persons with experiences of psychosis who participated in psychotherapy. All three authors participated in the literature search using Pubmed, APA PsycInfo, and Psychiatry Online. We identified N = 33 studies. Studies included cognitive therapies, acceptance and mindfulness approaches, trauma therapies, metacognitive therapy, and music therapy. All studies reported participants' perceived benefit with the therapeutic relationship as especially salient. Participants described diverse aspects of objective (e.g., symptoms, functioning) and subjective (e.g., self-experience or quality of life) recovery improvements, with perceived mechanisms of change, and with music therapy having some unique benefits. Participants also reported challenges and suggestions for improvement. Study findings highlight the salient aspects of psychotherapy identified by patients that may help therapists to individualize and improve approaches to psychotherapy when working with individuals experiencing psychosis. Overall, findings support the potential for integrative psychotherapy approaches for maximal treatment personalization.

' Like I said about culture. You don't talk about mental health' : An interpretative phenomenological analysis of the experience of first-episode psychosis in South Asian individuals

BACKGROUND

There is strong evidence of inequalities in mental healthcare access, experiences and outcomes for service users belonging to Black and Asian Minority Ethnic groups experiencing psychosis. Clinicians and academics have speculated that cultural variation in conceptualisations of psychosis, alongside inequitable service provision may explain disparities. There is, however, a dearth of literature exploring this in a South Asian population, despite this ethnic group being the second largest in the United Kingdom. The present study aimed to explore how people from this minority group have experienced and made sense of first-episode psychosis (FEP).

METHODS

A qualitative approach was used to explore the lived experience and sense-making of South Asian individuals experiencing FEP and accessing early intervention services. Eight people were interviewed using a semi-structured format. The data were analysed using Interpretative Phenomenological Analysis.

RESULTS

Three superordinate themes were identified in the group analysis: (1) Disconnection from self and others (2) Doubt and dispute (3) Power and shame.

CONCLUSIONS

Distinctive ethnic, cultural and systemic influences were strongly evident in how people conceptualized their experiences, how they managed their sense-making and where they sought support. Experiences were discussed in the context of power and shame, and this research proposes that socio-cultural context and racialised discourses have an impact on self-concept, the experiences of help-seeking (formal and informal), and fundamentally how services help individuals from marginalized communities.

Safety Planning in Context: A Case Study Integrating DBT Techniques and ACT for Overlapping Suicide and Psychosis Risk

Suicide risk is markedly higher for clients at clinical high risk for psychosis (CHR-p) compared to the general population. Dialectical behavior therapy (DBT) has a strong evidence base supporting its utility for managing suicide risk. Meanwhile, acceptance and commitment therapy (ACT) has been shown to effectively treat individuals with psychosis symptoms, as well as comorbid anxiety and mood disorders in CHR-p clients. Despite the robust evidence for each of these modalities in addressing concerns around suicidality and psychosis risk independently, there is a paucity of literature on how to support clients experiencing co-occurring suicide and psychosis risk. Such overlapping risk is often central to presenting concerns in CHR-p clients. Our manuscript presents a case example of an integrated DBT-ACT approach to managing risk surrounding both suicide and psychosis symptoms in an outpatient setting. We highlight how an integrated approach may help outpatient providers to implement and modify effective treatment that promotes continued outpatient care focused on goals beyond immediate risk management of both suicide and emerging psychosis. We provide specific examples of DBT techniques and ACT interventions used by a supervised doctoral-level student clinician in treatment with a CHR-p client and discuss implications for future clinical research.

The design and process of a family and community-based intervention for relapse prevention in people living with schizophrenia in Iran

BACKGROUND

People living with schizophrenia (PLS) suffer frequent relapse accompanied by emergency room visits, premature mortality, lower quality of life and a substantial social and economic burden on families and health systems. There is a dearth of community-based relapse prevention interventions (RPIs) in Iran.

AIMS

To determine an ideal model for a community-based RPIs for PLS.

METHODS

A qualitative study with 27 experts in Iran was carried out to understand the ideal RPIs for PLS and the key components of such interventions.

RESULTS

In 16 semi-structured interviews and 8 group-discussions, the participants identified six major stages of family and community-based RPIs including preparation, social mobilization, local team formation, design an RPI, implementing the RPI, participatory monitoring, and evaluation of the RPI.

CONCLUSIONS

Given the suboptimal healthcare systems and lack of professionals and services, PLS in Iran may benefit from family and community-based RPIs. Our findings warrant pilot testing of such initiatives across developing communities like Iran to improve health outcomes of PLS.

Comorbid early psychosis and borderline personality disorder: Conceptualizing clinical overlap, etiology, and treatment

Despite substantial efforts aimed at the detection and intervention for early symptoms of mental illness, there is relatively limited research on the clinical overlap between borderline personality disorder (BPD) and early psychosis, for example, clinical high risk (CHR) for psychosis, in young people. We present a narrative review of the clinical overlap between BPD and psychosis spectrum symptoms. Both conditions have unstable temporal course, and both are marked by functional impairment, increased suicide risk, and higher rates of psychiatric inpatient services. We then review evidence-based treatments for psychosis and BPD, emphasizing treatments for early presentations of these symptoms and initial research considering treatments for the overlap. Psychotherapies with the strongest empirical support include cognitive behavioral models, with BPD showing limited response to adjunctive pharmacotherapy. We end by discussing specific recommendations for future research, including longitudinal studies to determine the predictors of the course of illness and the development of treatments to target comorbid BPD and CHR symptoms.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

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. 25, No. 9. See the NIHR Journals Library website for further project information.

Chinese mental health professionals' perceptions of shared decision-making regarding people diagnosed with schizophrenia: A qualitative study

The implementation of shared decision-making regarding people diagnosed with schizophrenia is limited, although it is reported to have a positive impact on improving treatment adherence, therapeutic relationships and saving medical costs. The successful implementation of it is mainly dependent on the active engagement of mental health professionals. This study aims to identify mental health professionals' perceptions of shared decision-making regarding people diagnosed with schizophrenia in collectivist cultures such as Chinese culture. A qualitative descriptive approach was used, involving ten individual interviews with psychiatrists and four focus groups with twenty-three mental health nurses from the psychiatry department of a tertiary hospital in mainland China. An inductive thematic approach was used to analyze the data. Two main themes with five subthemes generated: willingness to engage in shared decision-making and perceiving shared decision-making as unachievable. The last theme included five subthemes: (i) deference to authority, (ii) tension between family decision-making and patient autonomy, (iii) uncertainty of trusting therapeutic relationships, (iv) implicit persuasion and (v) insufficient consultation time. Patients often lack opportunity and support to engage in decision-making. Mental health nurses in other countries need to be aware that Chinese patients and patients with a similar background are not knowledgeable about or value shared decision-making to the extent that other countries might. They need to evaluate and support them, including encouraging them to engage in decision-making as well as providing appropriate information. Mental health nurses need to collaborate with patients and their families to achieve patient-centred care when family involvement is expected.

Effectiveness of mindfulness-based intervention on psychotic symptoms for patients with schizophrenia: A meta-analysis of randomized controlled trials

AIMS

To evaluate the effects of mindfulness-based intervention on psychotic symptoms, positive symptoms, negative symptoms, depressive symptoms, anxiety, and rehospitalization.

DESIGN

A meta-analysis of randomized controlled trials.

DATA SOURCES

Medline, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, CINAHL, National Digital Library of Theses and Dissertations in Taiwan, and Airiti Library were searched from their earliest available date up to April 2019.

REVIEW METHODS

The guidelines of the Cochrane Collaboration were followed to report this systematic review. Two authors conducted this meta-analysis independently.

RESULTS

Nine randomized controlled trials were included. Meta-analysis showed that mindfulness-based intervention significantly decreased psychotic symptoms, positive symptoms, negative symptoms, depressive symptoms, and duration of rehospitalization among patients with schizophrenia, and that the reduction in negative symptoms lasted through short-term follow-up. The moderation analysis showed that significantly decreased positive symptoms occurred in the nurse-led intervention group, while no significant impact was found in the psychologist-led intervention group.

CONCLUSION

The psychotic symptoms of the patients with schizophrenia are improved after mindfulness-based intervention and the effects on the negative symptoms can be maintained for at least 3 to 6 months. Mindfulness-based intervention provided by nurses produces more improvements in positive symptoms than intervention provided by psychologists.

IMPACT

A growing number of mindfulness-based interventions have been implemented for patients with schizophrenia, although the effectiveness had not previously been established by meta-analysis. Mindfulness-based interventions appear to reduce the symptom severity of schizophrenia patients. Further suggestions for healthcare providers and researchers are provided and discussed.

Remote CBT for Psychosis During the COVID-19 Pandemic: Challenges and Opportunities

The COVID pandemic is now leading to the emergence of a secondary mental health pandemic. Clients with psychosis are at increased risk of poorer medium- and long-term psychosocial and clinical outcomes. In response to the pressing need to flexibly deliver high-quality care to individuals with psychosis, this brief report proposes high yield cognitive behavioral techniques for psychosis (HY-CBt-p) facilitated by task sharing and digital enhancements. HY-CBt-p is delivered over fewer sessions than formulation-based Cognitive Behavioral Therapy for psychosis (CBTp), can be learned by a range of providers, and includes techniques such as developing a normalizing explanation; techniques to reduce anxiety, depression, and insomnia, which perpetuate psychotic symptoms; self-monitoring; reality testing; and wellness planning. Previous research suggests that effect sizes will be lower than that of 16-session formulation-driven CBTp, but additional research is needed to test the feasibility, acceptability, efficacy, and comparative effectiveness of different forms of remote-delivered CBTp.

Mindfulness-Based Interventions for People with Schizophrenia: A Systematic Review and Meta-Analysis

(1) Background: There is increasing interest in the practice of mindfulness-based interventions (MBIs) to treat people with schizophrenia, as evidenced by the publication of different randomized controlled trials (RCTs). However, no meta-analysis of RCTs has been carried out to date with the exclusive inclusion of this type of interventions. (2) Objective: To analyze empirical evidence regarding the effectiveness of MBIs for the improvement of clinical parameters associated with schizophrenia. Method: A systematic review and meta-analysis was conducted of RCTs published in the databases PsycINFO, PubMed, WOS, and Cochrane Library. (3) Results: A total of 10 articles (n = 1094) fulfilled the criteria for inclusion in the review. The analysis of these studies suggests that MBIs combined with standard interventions are able to generate significant improvements in a variety of clinical schizophrenia-related parameters, such as the intensity of overall symptomatology (g = 0.72), positive symptoms (g = 0.32), negative symptoms (g = 0.40), functioning level (g = 1.28), and awareness of illness (g = 0.65). (4) Conclusions: There is evidence that supports the effectiveness and safety of MBIs for the treatment of people with schizophrenia. The results obtained by MBIs are comparable to those obtained by cognitive-behavioral therapy for psychosis. However, given the heterogeneity of the applied interventions and the methodological limitations found in the reviewed trials, the results should be interpreted with caution.

Can Cognitive Remediation in Groups Prevent Relapses?: Results of a 1-Year Follow-up Randomized Controlled Trial

International guidelines define relapse prevention for schizophrenia patients as a key therapeutic aim. However, approximately 80% to 90% of schizophrenia patients experience further symptom exacerbation after the first episode. The purpose of this study was to investigate whether group integrated neurocognitive therapy (INT), a cognitive remediation approach, reduces relapse rates in schizophrenia outpatients. INT was compared with treatment as usual (TAU) in a randomized controlled trial. Fifty-eight stabilized outpatients participated in the study with 32 allocated to the INT group and 26 to the TAU group. A test battery was used at baseline, posttreatment at 15 weeks, and a 1-year follow-up. Relapse rates were significantly lower in the INT condition compared with TAU during therapy as well as at follow-up. The relapse rate after therapy was associated with significant reductions in negative and general symptoms, improvements in functional outcome, and overall cognition. Out of these variables, negative symptoms were identified to show the strongest association with relapses after therapy. The primary outcome of this study suggests that INT can prevent relapses in schizophrenia outpatients.

An Overview of the Evidence for Psychological Interventions for Psychosis: Results From Meta-Analyses

There are numerous psychological approaches to psychosis that differ in focus, specificity and formats. These include psychodynamic, humanistic, cognitive-behavioural and third-wave-approaches, psychoeducation, various types of training-based approaches and family interventions.

We briefly describe the main aims and focus of each of these approaches, followed by a review of their evidence-base in regard to improvement in symptoms, relapse and functioning. We conducted a systematic search for meta-analyses dating to 2017 for each of the approaches reviewed. Where numerous meta-analyses for an approach were available, we selected the most recent, comprehensive and methodologically sound ones.

We found convincing short- and long-term evidence for cognitive behavioural approaches if the main aim is to reduce symptom distress. Evidence is also strong for psychoeducative family interventions that include skills training if the main aim is to reduce relapse and rehospitalisation. Acceptance and commitment therapy, mindfulness-based approaches, meta-cognitive and social skills training, as well as systemic family interventions, were also found to be efficacious, depending on the outcome of interest, but meta-analyses for these approaches were based on a comparatively lower number of outcome studies and a narrower selection of outcome measures. We found no convincing evidence for psychodynamic approaches, humanistic approaches or patient-directed psychoeducation (without including the family).

An array of evidence-based psychological therapies is available for psychotic disorders from which clinicians and patients can choose, guided by the strength of the evidence and depending on the outcome area focused on. Increased effort is needed in terms of dissemination and implementation of these therapies into clinical practice.

Meta-analyses show convincing evidence for CBT if the main target is psychotic symptoms.

Meta-analyses show convincing evidence for family interventions if the main target is relapse.

Effects are promising for ACT, mindfulness-based and systemic approaches, but more research is needed.

The array of effective approaches allows clinicians and patients to select the most appropriate one.

Culturally-adapted cognitive behavioural therapy based intervention for maternal depression: a mixed-methods feasibility study

BACKGROUND

British Pakistanis are one of the largest ethnic minority groups living in the UK, with high rates of maternal depression being reported in this population. Evidence suggests that culturally-adapted Cognitive Behavioural Therapy (CBT)-based interventions for depression, may improve clinical outcomes and patient satisfaction. This study was conducted to develop and test the feasibility and acceptability of a culturally-adapted, CBT-based, manual-assisted intervention in British Pakistani mothers experiencing maternal depression.

METHODS

A mixed-method feasibility study that included qualitative interviews followed by the development of a CBT-based intervention for mothers with mild to moderate depression. Following the qualitative interviews, a CBT-based intervention called the Positive Health Program (PHP) was developed and delivered consisting of 12-weekly sessions. A before and after design was used to explore the feasibility and acceptability of the Positive Health Programme.

RESULTS

A culturally-adapted CBT-based group intervention (PHP) was acceptable to this group and improvements were reported in depression and health-related quality of life. The women's understanding of 'depression' as a general consensus was in physical terms, but with an onset triggered by psychosocial causes. The most commonly reported factors contributing to depression were marital disharmony, lack of social support, and financial difficulties. Past help offered was primarily antidepressants, which were not welcomed by most of the women. A lack of availability of culturally sensitive interventions and the limited cultural sensitivity of NHS staff was also reported.

CONCLUSION

This study provides preliminary evidence for the feasibility and acceptability of a CBT-based culturally-adapted group psychological intervention for British Pakistani mothers.

TRIAL REGISTRATION

Study ethics registration number: 10/H1005/62 (University of Manchester).

A systematic review and discussion of symptom specific cognitive behavioural approaches to delusions and hallucinations

Studies on cognitive behavioural therapy for psychosis (CBTp) have developed from evaluating generic approaches to focusing on specific symptoms. The evidence for targeted studies on delusions and hallucinations was reviewed. We included randomized controlled trials (RCTs) examining the effect of individualized CBT-based interventions focusing either on delusions or on hallucinations. Twelve suitable RCTs were identified. Four RCTs focused on delusions, of which three took a focused approach targeting mechanisms assumed causal to persecutory delusions. Eight RCTs focused on hallucinations, a common component of these studies being a focus on the perceived power imbalance between the voice(s) and the voice-hearer, to reduce distress and dysfunction. Only three RCTS were powered adequately; the remainder were pilot trials. All trials reported effect sizes against treatment-as-usual above d=0.4 on at least one primary outcome at post-therapy, with several effects in the large range. Effects on the primary outcome were maintained for five of the seven studies that had significant outcomes and reported a follow-up comparison, but most of the follow-up periods were brief. Although targeted studies are still in their infancy, the results are promising with a tendency towards higher effects compared to the small-to-moderate range found for generic CBTp. In clinical practice, CBTp will need to continue including a range of approaches that can be adapted to patients in a flexible manner according to the primary goals and prevalent combination of symptoms. However, symptom-focused and causal-interventionist approaches are informative research strategies to evaluate the efficacy of separate components or mechanisms of generic CBTp.

Cognitive Behavioral Therapy for antipsychotic-free schizophrenia spectrum disorders: Does therapy dose influence outcome?

This study investigated the effect of "dose" and the components of Cognitive Behavioral Therapy (CBT) on treatment effects. It is a secondary analysis of the ACTION (Assessment of Cognitive Therapy Instead of Neuroleptics) trial which investigated CBT for people with schizophrenia spectrum disorders that chose not to take antipsychotic medication. Using instrumental variable methods, we found a "dose-response" such that each CBT session attended, reduced the primary outcome measure (the PANSS total score) by approximately 0.6 points (95% CI -1.20 to -0.06, p = 0.031). This suggests that length of therapy is important for those that receive CBT in the absence of antipsychotic medication. Secondly, using principal stratification we examined the process variables that modified treatment effects. Findings revealed that those who received a longitudinal formulation in the first 4 sessions of CBT had poorer treatment effects than those who did not, however this finding was not statistically significant (95% CI -37.244, 6.677, p = 0.173). However, it is important to note that these findings were evident in an exploratory analysis with a small sample. Future larger scale studies are needed to help understand components of effective treatment.

Guided self-help cognitive-behaviour Intervention for VoicEs (GiVE): Results from a pilot randomised controlled trial in a transdiagnostic sample

BACKGROUND

Few patients have access to cognitive behaviour therapy for psychosis (CBTp) even though at least 16 sessions of CBTp is recommended in treatment guidelines. Briefer CBTp could improve access as the same number of therapists could see more patients. In addition, focusing on single psychotic symptoms, such as auditory hallucinations ('voices'), rather than on psychosis more broadly, may yield greater benefits.

METHOD

This pilot RCT recruited 28 participants (with a range of diagnoses) from NHS mental health services who were distressed by hearing voices. The study compared an 8-session guided self-help CBT intervention for distressing voices with a wait-list control. Data were collected at baseline and at 12weeks with post-therapy assessments conducted blind to allocation. Voice-impact was the pre-determined primary outcome. Secondary outcomes were depression, anxiety, wellbeing and recovery. Mechanism measures were self-esteem, beliefs about self, beliefs about voices and voice-relating.

RESULTS

Recruitment and retention was feasible with low study (3.6%) and therapy (14.3%) dropout. There were large, statistically significant between-group effects on the primary outcome of voice-impact (d=1.78; 95% CIs: 0.86-2.70), which exceeded the minimum clinically important difference. Large, statistically significant effects were found on a number of secondary and mechanism measures.

CONCLUSIONS

Large effects on the pre-determined primary outcome of voice-impact are encouraging, and criteria for progressing to a definitive trial are met. Significant between-group effects on measures of self-esteem, negative beliefs about self and beliefs about voice omnipotence are consistent with these being mechanisms of change and this requires testing in a future trial.

Brief Coping Strategy Enhancement for Distressing Voices: an Evaluation in Routine Clinical Practice

Background: Hearing voices can be a common and distressing experience. Psychological treatment in the form of cognitive behavioural therapy for psychosis (CBTp) is effective, but is rarely available to patients. The barriers to increasing access include a lack of time for clinicians to deliver therapy. Emerging evidence suggests that CBTp delivered in brief forms can be effective and offer one solution to increasing access. Aims: We adapted an existing form of CBTp, coping strategy enhancement (CSE), to focus specifically on distressing voices in a brief format. This intervention was evaluated within an uncontrolled study conducted in routine clinical practice. Method: This was a service evaluation comparing pre–post outcomes in patients who had completed CSE over four sessions within a specialist out-patient service within NHS Mental Health Services. The primary outcome was the distress scale of the Psychotic Symptoms Rating Scale – Auditory Hallucinations (PSYRATS-AH). Results: Data were available from 101 patients who had completed therapy. A reduction approaching clinical importance was found on the PSYRATS distress scale post-therapy when compared with the baseline. Conclusions: The findings from this study suggest that CSE, as a focused and brief form of CBTp, can be effective in the treatment of distressing voices within routine clinical practice. Within the context of the limitations of this study, brief CSE may best be viewed as the beginning of a therapeutic conversation and a low-intensity intervention in a stepped approach to the treatment of distressing voices.

Barriers to disseminating brief CBT for voices from a lived experience and clinician perspective

Access to psychological therapies continues to be poor for people experiencing psychosis. To address this problem, researchers are developing brief interventions that address the specific symptoms associated with psychosis, i.e., hearing voices. As part of the development work for a brief Cognitive Behaviour Therapy (CBT) intervention for voices we collected qualitative data from people who hear voices (study 1) and clinicians (study 2) on the potential barriers and facilitators to implementation and engagement. Thematic analysis of the responses from both groups revealed a number of anticipated barriers to implementation and engagement. Both groups believed the presenting problem (voices and psychosis symptoms) may impede engagement. Furthermore clinicians identified a lack of resources to be a barrier to implementation. The only facilitator to engagement was reported by people who hear voices who believed a compassionate, experienced and trustworthy therapist would promote engagement. The results are discussed in relation to how these barriers could be addressed in the context of a brief intervention using CBT techniques.