Mindfulness- and Acceptance-based Interventions for Psychosis: A Systematic Review and Meta-analysis

A randomized controlled trial of an acceptance-based, insight-inducing medication adherence therapy (AIM-AT) for adults with early-stage psychosis

This study aimed to test the effectiveness of an acceptance-based medication adherence intervention for people with early-stage psychosis. An assessor-blind, three-arm randomized controlled trial design was used. One hundred and twenty-six participants who were adults with ≤3 years of psychosis were recruited from four district Integrated Community Centers for Mental Wellness in Hong Kong. They were randomly assigned to receive a 10-session acceptance-based, insight-inducing medication adherence therapy (AIM-AT) intervention, a conventional psychoeducation group program, or usual treatment (n = 42 per group). Primary outcomes were medication adherence and insight into the illness/treatment. All study outcomes were measured at recruitment and immediately, 6 months, and 12 months post-intervention. Participants in the AIM-AT experienced statistically significant improvements in the primary outcomes (levels of medication adherence and insight into illness/treatment), when compared to those in the other two groups over the 12-month follow-ups. The AIM-AT group also had significantly greater improvements in psychotic symptoms, psychosocial functioning, service satisfaction, length of rehospitalization, and total number of patients hospitalized over the follow-up period. These findings support the effectiveness of the AIM-AT to improve medication adherence, psychosocial health, and service satisfaction in people with early-stage psychosis.

Systematic review of the safety of mindfulness-based interventions for psychosis

Harmful outcomes of psychological interventions are under-researched, including in mindfulness-based interventions (MBI) for psychosis. This systematic review summarizes reporting and prevalence of 8 harm indices (death, adverse events, hospitalisation, study drop out, noncompletion of therapy, side effects of therapy, symptom deterioration and crisis service use) in Randomised Controlled Trials (RCTs) of MBIs for psychosis. Meta-analyses of risk differences were also calculated for each harm index. The review included 39 studies, with a total n of 2684 participants across studies. The percentage of studies reporting on each index of harm, and the prevalence of harm, varied greatly across each index. 0% of studies reported on side effects of interventions compared to 92% of studies reporting on study dropout. Meta-analyses of risk differences (RD) found a higher risk of hospitalisation (RD (95% CI) = -0.136 (-0.23 to -0.05), p = 0.003) and crisis service use (RD (95% CI) = -0.160 (-0.299, -0.024), p = 0.02) in control arms compared to intervention arms, and no significant difference in adverse events, death, symptom deterioration, noncompletion of therapy, drop out and side effects of therapy. Overall, reporting of harm was inconsistent across studies and the quality of data collection and reporting varied. MBIs for psychosis appear to be safe and may reduce the risk of hospitalisation and use of crisis services. However, the absence of thorough reporting on harm precludes a balanced analysis of benefits versus harms. Future research into the effectiveness of MBIs should consistently operationalise, monitor and report data on harm.

Mindfulness Meditation Training Reduces Gaming Cravings by Reshaping the Functional Connectivity Between the Default Mode Network and Executive Control-Related Brain Regions

BACKGROUND

Internet gaming disorder (IGD) can lead to psychological problems and cause behavioral problems in individuals. Traditional interventions have been ineffective in treating IGD. Meanwhile, mindfulness meditation (MM) is an emerging method that has proven to be effective for treating psychiatric disorders. In this study, MM was used to intervene in IGD and to explore its neural mechanism.

METHODS

Eighty participants were recruited through advertisements. Eventually, 61 completed the 1-month training (MM group, n = 31; progressive muscle relaxation [PMR] group, n = 30), including a pretest, 8 training sessions, and a posttest. Regional homogeneity and degree centrality were calculated, and the tests (pre- and post-) and group (MM and PMR) analysis of variance was performed. The overlapping results were obtained as region of interest for functional connectivity (FC) analyses. Behavioral data and neurotransmitter availability maps were correlated with FC.

RESULTS

Compared with PMR, MM decreased the severity of addiction and game craving in IGD. Brain imaging results showed that the FC between and within the executive control and default mode networks/reward-related regions were enhanced. Significant negative correlations were observed between FC and dopamine receptor D2, dopamine transporter, and vesicular acetylcholine transporter. Significant positive correlations were observed between FCs and serotonin and aminobutyric acid receptors.

CONCLUSIONS

This study confirmed the effectiveness of MM in treating IGD. MM altered the default mode and enhanced top-down control over game cravings. These findings were revealed by the correlations between brain regions and behavioral and biochemical effects. The results show the neural mechanism of MM in reducing IGD and lay the foundation for future research.

The effect of online group based acceptance and commitment therapy on psychotic symptoms and functioning levels of individuals with early psychosis

OBJECTIVE

This study examined the effect of online group-based Acceptance and Commitment Therapy (ACT) applied to individuals with early psychosis on psychotic symptoms and functionality levels.

METHODS

This randomized controlled study population consisted of 77 individuals who had been diagnosed with schizophrenia and other psychotic disorders according to DSM-5 diagnostic criteria at most three years ago. The study sample consisted of 53 individuals who met the inclusion criteria and were assigned to the intervention (n = 26) and control (n = 27) groups by simple randomization method. The intervention group received an eight-session ACT program as online group therapy, while the control group received no application made by the researchers. Data were obtained using the "Positive and Negative Syndrome Scale (PANSS)" and the "Social Functioning Assessment Scale (SFAS)" at pre-test, post-test and 3-month follow-up.

RESULTS

While it was found that the post-test and 3-month follow-up test PANSS mean scores of the individuals in the intervention group were lower than the mean score of the individuals in the control group; it was determined that the mean score of SFAS was higher than the mean score of the individuals in the control group (p < 0.05). In addition, while no hospitalization was observed in the intervention group during the follow-up period, 14.8 % (n = 4) of the individuals in the control group were hospitalized.

DISCUSSION

It was found that online group-based ACT applied to individuals with early psychosis reduced psychotic symptoms and increased their functionality levels. It was also found that hospitalizations were less in the intervention group.

CLINICALTRIALS

gov ID: NCT05210816.

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

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

Eight-month intensive meditation-based intervention improves refractory hallucinations and delusions and quality of life in male inpatients with schizophrenia: a randomized controlled trial

AIM

This study investigated the impact of an 8-month daily-guided intensive meditation-based intervention (iMI) on persistent hallucinations/delusions and health-related quality of life (QoL) in male inpatients with schizophrenia with treatment-refractory hallucinations and delusions (TRHDs).

METHODS

A randomized controlled trial assigned 64 male inpatients with schizophrenia and TRHD equally to an 8-month iMI plus general rehabilitation program (GRP) or GRP alone. Assessments were conducted at baseline and the third and eighth months using the Positive and Negative Syndrome Scale (PANSS), 36-Item Short Form-36 (SF-36), and Five Facet Mindfulness Questionnaire (FFMQ). Primary outcomes measured PANSS reduction rates for total score, positive symptoms, and hallucinations/delusions items. Secondary outcomes assessed PANSS, SF-36, and FFMQ scores for psychotic symptoms, health-related QoL, and mindfulness skills, respectively.

RESULTS

In the primary outcome, iMI significantly improved the reduction rates of PANSS total score, positive symptoms, and hallucination/delusion items compared with GRP at both the third and eighth months. Treatment response rates (≥25% reduction) for these measures significantly increased in the iMI group at the eighth month. Concerning secondary outcomes, iMI significantly reduced PANSS total score and hallucination/delusion items, while increasing scores in physical activity and mindfulness skills at both the third and eighth months compared with GRP. These effects were more pronounced with an 8-month intervention compared with a 3-month intervention.

CONCLUSIONS

An iMI benefits patients with TRHDs by reducing persistent hallucinations/delusions and enhancing health-related QoL. Longer iMI duration yields superior treatment outcomes.

Effectiveness of mindfulness-based intervention in schizophrenia: A meta-analysis of randomized controlled trials

Schizophrenia poses significant societal challenges, including interpersonal tension, an increased risk of suicide, and soaring medical costs. Although antipsychotics can prevent relapses, they often give rise to adverse effects and do not provide lasting relief. Mindfulness-based interventions (MBI) emerge as a hopeful avenue for improving outcomes. However, existing research and meta-analyses of the efficacy of MBI in schizophrenia remain limited. This study aimed to evaluate the efficacy of MBI as an adjunctive therapy for schizophrenia. Relevant randomized controlled trials (RCTs) were searched across PubMed, Embase, Web of Science, and Cochrane Library from inception dates up to January 12, 2023. Statistical analyses were conducted using Stata software (version 15.0) and Review Manager 5.4. The quality of the included RCTs was assessed using the revised Cochrane risk of bias tool. A total of 18 RCTs were included, with 675 patients and 704 health controls. Our meta-analysis revealed that MBI significantly improved psychosocial function, insight, and mindfulness in individuals with schizophrenia. The quality of the included RCTs had a low to moderate risk of bias. These findings suggest that MBI holds promise for improving the mental health of individuals with schizophrenia.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49849.

Mindfulness for psychosis: Current evidence, unanswered questions and future directions

PURPOSE & METHOD

Mindfulness for psychosis research has grown exponentially over the last 15 years. In this paper, a brief overview of mindfulness for psychosis is provided followed by a summary of the findings from a systematic search of meta-analyses dated up to February 2023. Current issues in the field are discussed and a future research agenda is presented.

RESULTS

Ten meta-analyses published between 2013 and 2023 were identified. Reported effect sizes on reductions in psychotic symptoms ranged from small-large across reviews. Four key issues in the field are identified and discussed - (1) is mindfulness for psychosis safe? (2) is home practice essential and related to clinical outcomes? (3) what is the impact of mindfulness practice versus metacognitive insights derived from practice, on clinical outcomes? (4) do the benefits translate into routine clinical practice?

CONCLUSIONS

Mindfulness is a promising intervention that is emerging as being both safe and effective for people with psychosis. Future research focused on evaluating mechanisms of change and implementation in routine clinical practice should be prioritised.

Acceptance and commitment therapy for psychosis: Current status, lingering questions and future directions

PURPOSE

Acceptance and Commitment Therapy for psychosis (ACTp) is a contextual behavioural intervention that promotes psychological flexibility by fostering active acceptance, cognitive defusion, values construction and committed action to enhance well-being and recovery. Multiple studies have shown that ACTp is acceptable and efficacious, but questions remain as to its distinction from similar approaches and the conditions under which it would be implemented most effectively.

METHODS

We present the current evidence for processes and outcomes of ACTp and summarise the qualitative findings of experiences of service users in ACT programmes. We compare ACTp with other cognitive behavioural therapies and mindfulness-informed interventions for psychosis.

RESULTS

Acceptance and commitment therapy for psychosis is promising as a pragmatic, process-driven intervention model. Further efforts are needed to investigate psychological flexibility in the context of psychosis with observational, experimental and intervention studies that will inform model scope and treatment refinement. Additionally, implementation research is the necessary next step, including how support persons can be trained in ACTp. Lower intensity and technology-assisted approaches have the potential to reduce barriers to accessing ACTp and extend impact.

CONCLUSIONS

Over the last 20 years, ACTp has demonstrated meaningful effects in individual and group formats in a range of settings, targeting outcomes such as rehospitalisation, depression, psychotic symptom distress and impact. Future work should focus on how best to integrate ACTp with other current evidence-based interventions for psychosis.

Mindfulness-based interventions for patients with schizophrenia spectrum disorders: A systematic review of the literature

BACKGROUND

Mindfulness-based interventions (MBIs) have emerged as secular practices, including elements of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). While MBIs have been widely adopted for physical and mental illness, only a few available programs are explicitly adapted for psychosis. However, previous reviews have reported the vital heterogeneity regarding treatment program structure. Therefore, this review aims to compare the structure of different mindfulness protocols applied to patients with schizophrenia spectrum disorder (SSD).

METHODS

A systematic search was conducted up to March 2023 in PubMed, Embase and PsycInfo. Following our protocol (CRD 42023253356), we followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist.

RESULTS

We included 22 randomized controlled trials (RCTs) involving 1500 patients SSD. All programs varied in structure, session components, duration, and instructor experience. While MBSR-like programs focused on stress reactivity, MBCT-like programs addressed primary symptoms of psychosis and relapse prevention. Despite the heterogeneity of programs, some common mechanisms emerged, including attention training, emotion and stress regulation, decentering, self-compassion, and cognitive restructuring.

CONCLUSIONS

The critical heterogeneity found limits the interpretation of results. However, most recent trials present fewer risks of bias and more homogenous programs. Findings suggested potential benefits, such as reduced negative symptoms, increased well-being, and decreased hospitalization rates. For future studies, authors should align on more congruent MBIs programs for patients with SSD. Further research is needed to identify optimal mindfulness teaching approaches for patients with psychosis and investigate specific mechanisms of action, relevant processes, and optimal doses in varying settings.

Effectiveness of acceptance and commitment therapy for inpatients with psychosis: Implementation feasibility and acceptability from a pilot randomized controlled trial

OBJECTIVE

Acceptance and Commitment Therapy for Inpatients (ACT-IN) with psychosis has been found to be efficacious in previous trials, but its effectiveness has not been studied when implemented by frontline clinicians in routine settings.

METHOD

In this pilot randomized controlled effectiveness trial, inpatients with schizophrenia-spectrum disorders were randomized to ACT-IN plus treatment as usual (TAU) (n = 23) or a time/attention matched (TAM) supportive condition plus TAU (n = 23) delivered by routine hospital staff. Both conditions received individual and group therapy during inpatient care and completed follow-up phone sessions during the first month post-discharge. Patients were assessed through 4 months post-discharge (blinded to condition) to determine feasibility, acceptability, and preliminary effectiveness of ACT-IN.

RESULTS

ACT-IN was feasible to deliver with fidelity by frontline staff when integrated into an acute care setting. At post-treatment, patients reported significantly greater treatment satisfaction in ACT-IN relative to TAM. Overall, results showed significant but similar improvements for both conditions through 4-month follow-up in psychiatric symptoms, functioning, and mindfulness. Only ACT-IN improved over time in distress. Furthermore, patients receiving TAM had a 3.76 times greater risk of rehospitalization over 4 months compared with ACT-IN.

CONCLUSIONS

ACT-IN is feasible and acceptable for patients with psychosis, can be implemented by hospital staff when integrated into acute treatment, and may result in decreased rehospitalization compared to alternative therapies. A future full-scale randomized-controlled implementation trial is warranted.

CLINICALTRIALS

gov Identifer: NCT02336581.

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

BACKGROUND

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Mindfulness-based intervention improves residual negative symptoms and cognitive impairment in schizophrenia: a randomized controlled follow-up study

BACKGROUND

Residual negative symptoms and cognitive impairment are common for chronic schizophrenia patients. The aim of this study was to investigate the efficacy of a mindfulness-based intervention (MBI) on negative and cognitive symptoms of schizophrenia patients with residual negative symptoms.

METHODS

In this 6-week, randomized, single-blind, controlled study, a total of 100 schizophrenia patients with residual negative symptoms were randomly assigned to the MBI or control group. The 6-week MBI group and the control group with general rehabilitation programs maintained their original antipsychotic treatments. The scores for the Positive and Negative Syndrome Scale (PANSS), the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and the Symptom Checklist 90 (SCL-90) were recorded at baseline and week 6 to assess psychotic symptoms, cognitive performance, and emotional state, respectively.

RESULTS

Compared with general rehabilitation programs, MBI alleviated the PANSS-negative subscore, general psychopathology subscore, and PANSS total score in schizophrenia patients with residual negative symptoms (F = 33.77, p_Bonferroni < 0.001; F = 42.01, p_Bonferroni < 0.001; F = 52.41, p_Bonferroni < 0.001, respectively). Furthermore, MBI improved RBANS total score and immediate memory subscore (F = 8.80, p_Bonferroni = 0.024; F = 11.37, p_Bonferroni = 0.006), as well as SCL-90 total score in schizophrenia patients with residual negative symptoms (F = 18.39, p_Bonferroni < 0.001).

CONCLUSIONS

Our results demonstrate that MBI helps schizophrenia patients with residual negative symptoms improve clinical symptoms including negative symptom, general psychopathology symptom, and cognitive impairment.

TRIAL REGISTRATION

ChiCTR2100043803.

Mindfulness-based interventions for non-affective psychosis: a comprehensive systematic review and meta-analysis

AIM

Although mindfulness-based interventions (MBIs) are routinely used in clinical practice, a comprehensive synthesis of the effectiveness of MBIs for non-affective psychosis has yet to be conducted. The aim of the present review and meta-analysis was to investigate the effectiveness of MBIs including those with mindfulness as an active treatment component for alleviating symptoms of psychosis to inform future clinical practice.

METHODS

A systematic review of studies published in journals or in dissertations in CINAHL, PubMed, EMBASE, PsycINFO, CENTRAL, ISRCTN, or CNKI from January 1990 until December 2020. A total of 31 eligible studies (n = 2146) were included.

RESULTS

Effect-size estimates suggested that 22 independent samples (n = 1632) produced a statistically significant small effect for psychotic symptoms (g = -0.48), and with a clinically significant reduction of 50% from baseline (pooled OR: 1.84). Separate meta-analyses demonstrated small effects for affective symptoms (g = -0.44) and small-to-large positive effects for quality of life (g = 0.38), mindfulness skills (g = 0.45), and insight into illness/treatment (g = 1.35). The heterogeneity was high across the studies.

CONCLUSION

Results suggest that short-term MBIs can be beneficial for non-affective psychosis. Future research is needed to test the efficacy and safety of dedicated MBIs for this population group over a longer term. KEY MESSAGESSchizophrenia spectrum and other psychotic disorders, also known as non-affective psychosis, is the most chronic and debilitating type of psychosis, seriously affecting every aspect of a person's life, including social, occupational, or general functioning.The aim of the current systematic review and meta-analysis was to investigate formerly unexamined questions regarding the clinical significance of MBIs including yoga as an increasingly utilized, conceptualized psychological intervention on overall psychotic symptoms for people with non-affective psychosis.No serious adverse events were reported in the studies, suggesting that MBIs may be safe interventions, while there is robust evidence to support the view that MBIs are beneficial to young people in particular.

Effectiveness of Acceptance and Commitment Therapy on the Positive and Negative Symptoms and Emotion Regulation of Patients with Schizophrenia Spectrum Disorders: A Single-case Clinical Trial Study

Background: The literature suggests the increasing application of acceptance and commitment therapy (ACT) for people with schizophrenia spectrum disorders (SSD). Objectives: This study aimed to determine the effectiveness of ACT on the positive and negative symptoms and emotion regulation of patients with SSD. Methods: The experimental design of the current study was an AB (baseline and intervention phases) along with the follow-up phase, in addition to Treatment-As-Usual (TAU), ACT sessions were held for the participants. Among the 20 participants who had inclusion criteria to the study, five participant (three men and two women in the age range of 32 - 43 years) were randomly allocated to participate in the intervention through drawing and evaluated using the Positive and Negative Syndrome Scale (PANSS) and Difficulties in Emotion Regulation Scale (DERS) in three phases of baseline, intervention, and follow-up. For data analysis, non-overlapping indices and Cohen's d effect size were measured, and visual diagrams were plotted for interpretation. Results: The present results showed that the effect sizes of psychotic symptoms in the first to fifth participants were 1.7, 1.9, 0.6, 4, and 1.4, respectively in the intervention phase relative to the baseline; the effect size was only large for the fourth participant. Also, the effect sizes of emotion regulation in the first to fifth participants were 0.8, 1.6, 1.5, 1.2, and 2.7, respectively; the effect size was only large for the fifth participant. Conclusions: The results of data analysis showed that ACT is effective in reducing psychotic symptoms and improving emotion regulation. The effect size of ACT was the largest for the fourth participant; medium for the first, second, and fifth participants; and small for the third participant.

Mindfulness meditation for Chinese patients with psychosis: A systematic review and meta-analysis

Mindfulness meditation (MM) and its alignment with the mind-body perspective of health in Chinese cultures indicate its potential to benefit Chinese patients with psychosis. This is the first systematic review and meta-analysis to address the following questions: (1) Does MM improve clinical, well-being, and third-wave outcomes (i.e., mindfulness, acceptance, and compassion levels) among Chinese patients with psychosis? (2) What are the patient- and/or intervention-specific factors that moderate the efficacy of MM? (3) Are improvements on third-wave outcomes associated with improvements on clinical and well-being outcomes? (4) What are the mechanisms underlying the effects of MM? Evidence synthesized from 23 relevant articles (20 studies) involving 1749 patients showed that (1) MM improved a wide range of patients' outcomes, most consistently and sustainably for insight, rehospitalization duration, recovery rate, and social functioning; (2) age and duration of illness, but not the cumulated intervention hours, moderated the overall efficacy of MM; (3) post-MM improvements on mindfulness and on clinical and well-being outcomes were related, and (4) the effects of MM on patients' outcomes may be driven by its ability to promote positive changes in personal growth and enhance one's coping with the illness and its symptoms. Our data showed preliminary support for the benefits of MM in Chinese patients with psychosis. However, results should be considered in light of the varying quality of included studies and their heterogeneity in multiple aspects. Further research is needed to deduce the sustainability of MM's effects, its active ingredients, underlying mechanisms, and additional moderators of its efficacy.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Randomized Controlled Trials of Mindfulness and Acceptance-Based Interventions Over the Past Two Decades: A Bibliometric Analysis

Introduction: The past several years have witnessed a significant increase in interest among the public in mindfulness with an unmistakable growth in the scientific literature investigating mindfulness-based therapies. A myriad of therapeutic uses of mindfulness have been studied. Given this burgeoning interest, the authors' objective was to conduct a broad-sweeping bibliometric analysis over the past two decades to describe overarching trends in the publications of randomized controlled trials (RCTs) investigating mindfulness to broadly identify both strengths and gaps in this field and inform a strategic plan for further advancing this research area. Materials and Methods: The authors retrieved mindfulness-focused RCTs available on PubMed in the past two decades (2000-2019). They synthesized the literature with respect to publication numbers, countries of publication, journal type, areas of research focus, characteristics of study designs, sample size, and trends in remote intervention delivery. Results: The resulting 1389 publications represent a near exponential growth trend over the past 20 years. Publications from the top three countries (the United States, the United Kingdom, and the Netherlands) with the highest productivity accounted for 60% of total number of publications. The most published modalities include acceptance-based therapy (n = 260), mindfulness-based stress reduction (n = 238), mindfulness-based cognitive therapy (n = 174), and dialectical behavior therapy (n = 82). Stress, depression, anxiety, pain, cancer, diet/healthy eating, and sleep were the most common major areas of focus. Studies included active (46%) or inactive controls (44%), and increasingly more studies with both types of controls (10%). The top 10 journals that published the most mindfulness RCTs were from behavioral sciences and psychiatry or psychology. There were 187 RCTs utilizing remote delivery, with 146 (87.1%) in the most recent 5 years. Conclusion: Publications of mindfulness-focused RCTs show a continuous increasing trend. Mindfulness research from non-Western countries and studies published in biomedical journals were less prevalent and potentially represent future opportunities. Trends of studies with both inactive and active controls support an overall advancement in research methodology. There has been a significant expansion of studies of remotely delivered mindfulness interventions. Future research might consider evaluation of a broader range of modalities and further examine optimal delivery formats.

Mindfulness-based interventions: an overall review

INTRODUCTION

This is an overall review on mindfulness-based interventions (MBIs).

SOURCES OF DATA

We identified studies in PubMed, EMBASE, CINAHL, PsycINFO, AMED, Web of Science and Google Scholar using keywords including 'mindfulness', 'meditation', and 'review', 'meta-analysis' or their variations.

AREAS OF AGREEMENT

MBIs are effective for improving many biopsychosocial conditions, including depression, anxiety, stress, insomnia, addiction, psychosis, pain, hypertension, weight control, cancer-related symptoms and prosocial behaviours. It is found to be beneficial in the healthcare settings, in schools and workplace but further research is warranted to look into its efficacy on different problems. MBIs are relatively safe, but ethical aspects should be considered. Mechanisms are suggested in both empirical and neurophysiological findings. Cost-effectiveness is found in treating some health conditions.

AREAS OF CONTROVERSY

Inconclusive or only preliminary evidence on the effects of MBIs on PTSD, ADHD, ASD, eating disorders, loneliness and physical symptoms of cardiovascular diseases, diabetes, and respiratory conditions. Furthermore, some beneficial effects are not confirmed in subgroup populations. Cost-effectiveness is yet to confirm for many health conditions and populations.

GROWING POINTS

Many mindfulness systematic reviews and meta-analyses indicate low quality of included studies, hence high-quality studies with adequate sample size and longer follow-up period are needed.

AREAS TIMELY FOR DEVELOPING RESEARCH

More research is needed on online mindfulness trainings and interventions to improve biopsychosocial health during the COVID-19 pandemic; Deeper understanding of the mechanisms of MBIs integrating both empirical and neurophysiological findings; Long-term compliance and effects of MBIs; and development of mindfulness plus (mindfulness+) or personalized mindfulness programs to elevate the effectiveness for different purposes.

The safety and efficacy of acceptance and commitment therapy against psychotic symptomatology: a systematic review and meta-analysis

OBJECTIVE

Acceptance and commitment therapy (ACT) is a third-wave psychological intervention that has attracted considerable clinical and research attention. A previous meta-analysis of ACT trials in psychosis reported a large effect size of ACT against overall psychotic symptomatology. However, there were critical methodological issues in the review that justify replication.

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs) testing ACT vs. any comparator condition in a sample of adults with psychosis. The outcome of interest was overall psychotic symptomatology.

RESULTS

The search identified seven published and eight unpublished trials (of which we were able to obtain data from one). Data on symptomatology were extracted from six trials that involved 274 participants. The summary effect size (Hedge's G) for overall symptomatology was small and not significant (-0.21, 95%CI -0.60-0.18). Trials were generally rated as having a high risk of bias. Safety reporting was inadequate across included trials.

CONCLUSIONS

Our observed effect size contrasted with that reported in a previous meta-analysis; differences were likely explained by errors in data extraction. The findings of this review suggest that there is currently inadequate evidence to conclude that ACT is a safe and effective treatment against psychotic symptomatology.

SYSTEMATIC REVIEW REGISTRATION

CRD42018097200.

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

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

Feasibility, acceptability, and preliminary effectiveness of mindfulness-based interventions for people with recent-onset psychosis: A systematic review

BACKGROUND

Early intervention for psychosis is recommended because the first 5 years beyond the first episode is considered the critical period within which individuals have the most potential to maximize their response to treatment and recovery. Mindfulness-based interventions (MBIs) have been studied extensively in diverse disease groups, but research in people with recent-onset psychosis is still immature.

AIM

This review aims to explore the feasibility, acceptability and summarize any effectiveness data on of the MBIs for people with recent-onset psychosis reported by the study authors.

METHODS

A systematic search of original intervention research studies relevant to the topic published between January 2000 and August 2019 was conducted with 10 databases. Articles published in English with accessible full text were included.

RESULTS

A total of eight studies were included, which reported recruitment rates of between 62.5% and 100%, withdrawal rates between 0% and 37.5% and attendance rates of between 56% and 100%. Participants' qualitative feedback indicated high levels of satisfaction with the MBIs. The intervention approaches adopted in the reviewed studies include mindfulness-based interventions, acceptance and commitment therapy and compassion-based interventions. MBIs have produced promising positive effects on participants' psychiatric and psychosocial outcomes.

CONCLUSION

This review confirms that MBIs are generally feasible and acceptable for people with recent-onset psychosis. The preliminary results suggested the potential effects of MBIs in this area. Fully powered randomized controlled trials are suggested to confirm the effectiveness and exploratory studies to gain greater insight into the active components and mechanism of actions of MBIs for recent-onset psychosis.

Mindfulness-based group therapy for in-patients with schizophrenia spectrum disorders - Feasibility, acceptability, and preliminary outcomes of a rater-blinded randomized controlled trial

BACKGROUND

A Growing body of literature indicates therapeutic effectiveness of mindfulness for mental disorders. Only few trials have been conducted with schizophrenia spectrum disorders (SSD), mostly in outpatient settings. Primary objective was to assess feasibility, acceptability, and preliminary outcomes of mindfulness-based group therapy (MBGT) for in-patients with SSD.

METHODS

A pre-registered randomized controlled trial was conducted to assess feasibility and acceptability of the MBGT. The primary outcome was mindfulness measured with the Southampton Mindfulness Questionnaire (SMQ). Secondary outcomes were rater-blinded positive- and negative symptoms, depression, social functioning, and self-reported mindfulness, depression, anxiety, psychological flexibility, quality of life, and medication regime at baseline, post-intervention, and follow-up (Clinical Trails NCT03671005).

RESULTS

40 participants received either treatment-as-usual (TAU; n=19) or (MBGT+TAU; n = 21) for four weeks. At post-intervention, protocol adherence was 95.2%, and retention rate was 95%. ANCOVA revealed significant improvements in the MBGT+TAU for the primary outcome SMQ as well as negative symptoms at post-intervention between groups. In exploratory analyses, secondary outcomes showed medium-to-large pre-to-post-intervention effects on mindfulness, positive-, negative-, and depressive symptoms, psychological flexibility, quality of life, and social functioning for MBGT+TAU and small-to-moderate changes on positive symptoms and social functioning for TAU. No serious adverse effects were reported.

CONCLUSIONS

MBGT appears feasible and acceptable for in-patient settings, with high protocol adherence and retention rates. Preliminary findings highlight a proof of concept of MBGT and various improvements in clinical- and process dimensions. A fully powered trial is warranted to determine efficacy, cost-efficiency, and longitudinal changes based on these promising outcomes.

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.

A systematic review and meta-analysis of mindfulness- and acceptance-based interventions for affect intolerance/sensitivity

Affect intolerance/sensitivity, defined as one's sensitivity to, or inability to tolerate, affective states, is a transdiagnostic process implicated in the development and maintenance of numerous forms of psychopathology. Mindfulness and acceptance interventions are posited to improve affect intolerance/sensitivity; however, there has been no quantitative synthesis of this research to date. Seven electronic databases were searched up until November 2018. Hedges' g values, 95% confidence intervals, p-values, and Q-values were calculated for a series of random-effects models. Twenty-five studies (pooled N = 1778) met eligibility criteria and were included in the qualitative synthesis (n = 22 included in the meta-analysis). There was a small, significant effect of mindfulness and acceptance interventions on improving affect intolerance/sensitivity from pre-to post-intervention (Hedges' g = -0.37, 95% CI = -0.52 to -0.23, p < .001), with effects maintained up to 6-months (Hedges' g = -0.35, 95% CI = -0.61 to -0.09, p < .01). There was a significantly larger effect for studies with inactive compared to active controls. No significant effect size differences were found for intervention length (<8 vs. ≥ 8 sessions), intervention type (mindfulness vs. acceptance) or sample type (clinical vs. non-clinical). Mindfulness and acceptance interventions modestly improve affect intolerance/sensitivity.

An Analysis of the Pattern of Adaptive Emotion Regulation Associated with Low Paranoid Ideation in Healthy and Clinical Samples

Background

Research on emotion regulation and paranoid ideation has mostly focused on isolated regulation strategies and has remained largely inconclusive. According to the emotion regulation model by Berking and Whitley (in: Affect Regulation Training, Springer, New York 2014) successful modification or acceptance/tolerance of emotions requires an adequate comprehension (awareness, clarity, understanding) of emotions and adequate self-support.

Method

Building on this model, we investigated whether comprehension and self-support strengthen the negative association between modification and acceptance/tolerance and paranoid ideation. In study 1, we examined the hypotheses cross-sectionally based on questionnaire data from a combined sample (N = 125) consisting of people with a psychotic disorder, people at risk of developing psychosis, and healthy controls. In study 2, we examined the same hypotheses longitudinally by employing the experience sampling method in people with clinically relevant psychopathology below diagnostic threshold (N = 138).

Results

In study 1, the association between modification and paranoid ideation was not moderated by comprehension or self-support. However, comprehension and self-support moderated the association between acceptance/tolerance and paranoid ideation. In study 2, the interaction effect between comprehension and acceptance/tolerance on paranoid ideation was confirmed.

Conclusion

The results indicate that comprehending and accepting/tolerating emotions could be protective against paranoid ideation.

Group acceptance and commitment therapy for patients and caregivers in psychosis services: Feasibility of training and a preliminary randomized controlled evaluation

OBJECTIVE

Psychological interventions reduce the impact of psychosis, but widescale implementation is problematic. We tested the feasibility of group acceptance and commitment therapy for Psychosis (G-ACTp), delivered by frontline staff, and co-facilitated by service-user experts-by-experience (SU-EbyE), for service-users and informal caregivers (ISRCTN: 68540929). We estimated recruitment/retention rates and outcome variability for future evaluation.

METHODS

Staff and SU-EbyE facilitators completed 1-day workshops, then delivered closely supervised G-ACTp, comprising four sessions (weeks 1-4) and two boosters (10 and 12 weeks). Participants recruited from adult community psychosis services were randomized to receive G-ACTp immediately or after 12 weeks, completing outcome assessments at 0, 4, and 12 weeks. Service-use/month was calculated for 1-year pre-randomization, weeks 0-12, and 5-year uncontrolled follow-up.

RESULTS

Of 41 facilitators trained (29 staff, 12 SU-EbyE), 29 (71%; 17 staff, 12 SU-EbyE) delivered 18 G-ACTp courses. Participant refusal rates were low (9% of service-users [10/112]; 5% of caregivers [4/79]); 60% of those invited to participate attended ≥1 G-ACTp session (64% of service-users [39/61]; 56% of caregivers [35/63]). Randomization of facilitators and participants proved problematic and participant follow-up was incomplete (78% [66/85]; 82% of service-users [36/44]; 73% of caregivers [30/41]). Effect sizes ranged from very small to large mostly favouring treatment. Service-use reductions require cautious interpretation, as very few participants incurred costs.

CONCLUSIONS

Implementation appears feasible for service-users; for caregivers, retention needs improving. Outcome variability indicated n = 100-300/arm followed up (α = 0.05, 90% power). Methodological limitations' mean replication is needed: identified sources of potential bias may be reduced in a cluster randomized design with sessional outcome completion.

PRACTITIONER POINTS

Group acceptance and commitment therapy can be successfully adapted for people with psychosis and their caregivers. Implementation (training and delivery) is possible in routine community mental health care settings. Clinical and economic outcomes are promising, but replication is needed. Recommendations are made for future studies.

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.

Mindfulness-based interventions in the early phase of affective and non-affective psychoses: Special Section on "Translational and Neuroscience Studies in Affective Disorders" Section Editor, Maria Nobile MD, PhD

BACKGROUND

In the last 10 years, psychological approaches based on mindfulness techniques have been proposed for the management of psychotic experiences.

METHOD

In this brief review we summarized, to our knowledge for the first time, published studies on mindfulness-based interventions (MBIs) applied to the early phase of major psychoses (affective and non-affective).

RESULTS

Despite the great variability in terms of MBIs protocols, available studies on young people at risk to develop or with a first episode of psychosis suggest MBIs as a feasible, well-tolerated and effective approach in ameliorating symptoms, functioning, emotion regulation, and finally reducing the psychological distress associated with the onset of mania and/or psychotic experience.

LIMITATIONS

The small sample size and inconsistencies between studies in terms of design, MBIs protocols and outcome measures suggest being cautious in interpreting and generalizing results. Moreover, specific guidelines are missing for the adaptation of MBIs to youth at risk of developing affective psychoses.

CONCLUSIONS

Preliminary findings show that MBIs may be considered a promising adjunctive therapy for the treatment of major psychoses in the early phases of the illness. However, the conduct of further studies in larger samples and with a more rigorous methodology is warranted to confirm the beneficial effect of MBIs in the early stages of major psychoses.

Real-time fMRI neurofeedback reduces auditory hallucinations and modulates resting state connectivity of involved brain regions: Part 2: Default mode network -preliminary evidence

Auditory hallucinations (AHs) are one of the most distressing symptoms of schizophrenia (SZ) and are often resistant to medication. Imaging studies of individuals with SZ show hyperactivation of the default mode network (DMN) and the superior temporal gyrus (STG). Studies in SZ show DMN hyperconnectivity and reduced anticorrelation between DMN and the central executive network (CEN). DMN hyperconnectivity has been associated with positive symptoms such as AHs while reduced DMN anticorrelations with cognitive impairment. Using real-time fMRI neurofeedback (rt-fMRI-NFB) we trained SZ patients to modulate DMN and CEN networks. Meditation is effective in reducing AHs in SZ and to modulate brain network integration and increase DMN anticorrelations. Consequently, patients were provided with meditation strategies to enhance their abilities to modulate DMN/CEN. Results show a reduction of DMN hyperconnectivity and increase in DMNCEN anticorrelation. Furthermore, the change in individual DMN connectivity significantly correlated with reductions in AHs. This is the first time that meditation enhanced through rt-fMRI-NFB is used to reduce AHs in SZ. Moreover, it provides the first empirical evidence for a direct causal relation between meditation enhanced rt-fMRI-NFB modulation of DMNCEN activity and post-intervention modulation of resting state networks ensuing in reductions in frequency and severity of AHs.

Acceptance- and mindfulness-based interventions for persons with psychosis: A systematic review and meta-analysis

BACKGROUND

Acceptance- and mindfulness-based approaches have gained popularity in recent years.

OBJECTIVE

A systematic review and meta-analysis of the efficacy and safety of acceptance- and mindfulness-based therapies for persons with a psychotic or schizophrenia spectrum disorder.

METHODS

Following PRISMA guidelines, relevant databases were searched for published randomized controlled trials (RCTs) up to October 2018. Outcomes were severity of overall symptomatology, hospitalization, positive and negative symptoms, depression, anxiety, social functioning, quality of life, acceptance, mindfulness skills and safety of the interventions.

RESULTS

Sixteen studies comprising 1268 people with a schizophrenia spectrum disorder were included in the meta-analyses. Moderate to large effect sizes were found for overall symptomatology and hospitalization at endpoint (SMD .80, 95% CI -1.31, -0.29 and MD 4.38, -5.58, -3.17 respectively) and follow-up (SMD 1.10, -2.09, -0.10 and MD 7.18, -8.67, - 5.68 respectively). There were significant small effects on negative symptoms (SMD .24; -0.44, -0.03), small to moderate effects for depression (SMD .47; -0.80, -0.14), social functioning (SMD .43; -0.75, - 0.12) and mindfulness (SMD .51; -0.97, -0.05), moderate to large effects for acceptance (SMD .78; -1.44, -0.12), while no significant effects for positive symptoms (SMD .27; -0.65, 0.00), anxiety (SMD 2.11; -4.64, 0.42) or quality of life (SMD .43; -0.88, 0.02). Majority of studies (75%) had low risk of bias and sensitivity analyses supported the findings.

CONCLUSION

Acceptance- and mindfulness-based approaches appear to be effective and safe interventions for individuals with schizophrenia spectrum disorders and could be a useful extension of standard casemanagement and psychofarmacology.

Mindfulness-Based Interventions for In-Patients With Schizophrenia Spectrum Disorders-A Qualitative Approach

In recent years, mindfulness-based interventions (MBI) have gained clinical relevance in the treatment of patients with schizophrenia spectrum disorders (SSDs). High symptom burden, long durations of hospitalization and high rehospitalization rates demonstrate the severity and cost-intensity of these disorders. MBIs have shown promising treatment outcomes in a small number of trials, primarily taking place in English-speaking countries. The current study aims to explore mechanisms and processes as well as adverse effects of MBIs on in-patients with SSDs in a German university hospital setting. A qualitative design based on inductive thematic analysis accompanied by quantitative assessments was chosen. A semi-structured interview guide was developed by psychiatrists and psychologists to assess patient experiences, perceptions, thoughts, and feelings during and after taking part in a MBI. Twenty-seven interviews were conducted between September 2017 and October 2018 with in-patients who are diagnosed with schizophrenia or schizoaffective disorder. Rater-based questionnaires, such as the Positive and Negative Syndrome Scale (PANSS), Montgomery Asberg Depression Rating Scale (MADRS), and Psychotic Symptom Rating Scales-Auditory Hallucination (PSYRATS-AH) were administered at baseline to collect clinical outcomes. Qualitative analysis revealed two domains: content and function. In the first domain related to content with the core elements "detachment and rumination", "presence and getting lost", "non-judgment and judgment", and effects with "emotions", "cognition", and "symptom changes". A second domain related to function was extracted, including the relevance of perception of context and transfer to everyday life. Overall, improvements concerning cognition, distress, and psychopathology were detected, while no adverse effects, such as increased psychotic symptoms, were revealed. As the first study of its kind, mechanisms, processes, and the safety of MBIs were explored and confirmed in a sample of German in-patients with SSDs. The results of this qualitative study are in line with recent findings on MBIs amongst patients with psychotic disorders from other countries. Results lay the ground for future research to focus on the systematic study of MBIs in large samples, its treatment processes, outcomes, and effectiveness for in-patients with SSDs.

Mindfulness Mediates the Effect of a Psychological Online Intervention for Psychosis on Self-Reported Hallucinations: A Secondary Analysis of Voice Hearers From the EviBaS Trial

BACKGROUND

Psychological online interventions (POIs) could represent a promising approach to narrow the treatment gap in psychosis but it remains unclear whether improving mindfulness functions as a mechanism of change in POIs. For the present study, we examined if mindfulness mediates the effect of a comprehensive POI on distressing (auditory) hallucinations.

METHODS

We conducted a secondary analysis on voice hearers (n = 55) from a randomized controlled trial evaluating a POI for psychosis (EviBaS; trial registration NCT02974400, clinicaltrials.gov). The POI includes a module on mindfulness and we only considered POI participants in our analyses who completed the mindfulness module (n = 16).

RESULTS

Participants who completed the mindfulness module reported higher mindfulness (p = 0.015) and lower hallucinations (p = 0.001) at post assessment, compared to controls, but there was no effect on distress by voices (p = 0.598). Mindfulness mediated the POI's effect on hallucinations (b = -1.618, LLCI = -3.747, ULCI = -0.054) but not on distress by voices (b = -0.057, LLCI = -0.640, ULCI = 0.915).

LIMITATIONS AND DISCUSSION

Completion of the mindfulness module was not randomized. Hence, we cannot draw causal inferences. Even if we assumed causality, it remains unclear which contents of the POI could have resulted in increased mindfulness and reduced hallucinations, as participants completed other modules as well. In addition, confounding variables could explain the mediation and the sample size was small. Nonetheless, the overall pattern of results indicates that the POI is likely to improve mindfulness, and that increased mindfulness could partially explain the POI's efficacy.

Systematic Review and Meta-Analysis of Correlates of FFMQ Mindfulness Facets

Background: A number of meta-analyses of mindfulness have been performed, but few distinguished between different facets of mindfulness, despite it being known that facets of mindfulness behave differently in different populations; and most studied the outcome of interventions, which tend to involve additional ingredients besides mindfulness. Furthermore, there has recently been some concern regarding possible publication bias in mindfulness research. Objective: Systematic review and meta-analysis of the relationship of different facets of mindfulness with various outcomes, taking into account possible moderators, and controlling for publication bias using a method appropriate given the substantial heterogeneity present. Methods: Random effects meta-analysis with a number of robustness checks and estimation of the possible impact of publication bias on the results. Included are all studies that report correlations of outcomes with all five FFMQ facets, in English, French, German, or Spanish. Study Registration: PROSPERO International prospective register of systematic reviews http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016041863. Results: For the designated primary measure (SWLS) estimated correlations were: 0.15 [0.07, 0.22] for the Observing facet, 0.31 [0.27, 0.36] for Describing, 0.35 [0.31, 0.38] for Acting-with-Awareness, 0.30 [0.10, 0.47] for Non-judging and 0.28 [0.18, 0.37] for Non-reacting. Grouping all desirable outcomes together, Describing has the highest zero-order (though not partial) correlation; Non-judging the highest effect on avoiding undesirable outcomes. Results seem to be reasonably robust even to severe publication bias.

Mindfulness for psychosis: a humanising therapeutic process

Mindfulness for psychosis has been slow to develop, in part because of the fear and stigma that surrounds psychosis. Breakthrough research showing how to adapt mindfulness groups for people with current distressing psychosis has led to a growing research base and it is now clear that adapted mindfulness for psychosis is both safe and therapeutic. However, how it works is less clear. This article argues that at its heart is a core humanising therapeutic process, characterised by key metacognitive insights and increased acceptance both of psychotic experience and the self. This core therapeutic process is underpinned not only by commitment to mindfulness practice, but also through active, constructive engagement with the group process. Individuals discover that that they are more than the psychosis, and that the self is balanced (positive and negative) and changing. It is recommended that future research explores these intra-personal and inter-personal therapeutic processes alongside outcome trials.

Youth-focused group mindfulness-based intervention in individuals with early psychosis: A randomized pilot feasibility study

AIM

To assess the feasibility of a randomized pilot trial that evaluated the acceptability and potential clinical utility of the Mindfulness Ambassador Program (MAP), a unique, standardized 12-session facilitated group mindfulness-based intervention (MBI) for youth experiencing early psychosis.

METHODS

Twenty-one patients of an early psychosis intervention program were randomized to receive MAP (n = 11) or treatment as usual (n = 10). Acceptability was measured by group attendance rate and client satisfaction; feasibility of the study design was measured by the recruitment and retention rate. The means, standard deviations, and 95% confidence intervals were described for outcomes of interest.

RESULTS

MAP is associated with a high degree of acceptability and has beneficial effects for depression and fatigue. The randomized trial design is feasible.

CONCLUSIONS

This study provides important pilot data supporting a larger randomized trial of effectiveness for MAP as a group MBI for early psychosis. Details of MAP and study limitations are discussed.

An integrated neurocognitive and social-cognitive treatment for youth at clinical high risk for psychosis: Cognition for Learning and for Understanding Everyday Social Situations (CLUES)

BACKGROUND

Cognitive deficits, a core feature contributing to disability in schizophrenia, are present in milder form in individuals at clinical high risk (CHR) for psychosis. This study investigated the feasibility of Cognition for Learning and Understanding Everyday Social Situations (CLUES), an integrated neurocognitive and social cognitive treatment for youth at CHR.

METHOD

This was an open, pilot feasibility trial. Seventeen individuals meeting CHR criteria were assessed prior to and following participation in CLUES for changes in symptoms, social and role functioning, and cognition. Participant attitudes towards CLUES were also examined.

RESULTS

Participants significantly improved in social functioning [t(16) = -4.20, p = .001, d = 1.02], and trended for improvement in reaction time [t(15) = 2.09, p = .054, d = 0.52] from baseline to end of treatment. No other measures significantly changed. No participants transitioned to full psychosis during the treatment and follow up period. Participants reported they generally liked CLUES and found it helpful.

CONCLUSION

While limited by the small sample size and the open label design, our preliminary results indicate that CLUES is feasible and shows promise in improving social functioning. However, further investigation is warranted in order to determine its efficacy. Future directions should include conducting a randomized controlled trial in order to compare the efficacy of CLUES to another intervention.

Mindfulness-Based Social Cognition Training (SocialMind) for People With Psychosis: A Feasibility Trial

Introduction: Difficulties in social functioning are common among people with psychosis. Negative symptoms such as blunted affect or social withdrawal are often linked to these difficulties and worsen real-life outcomes. One important dimension associated with social functioning is social cognition, which refers to the psychological processes that are necessary to perceive, encode, store, retrieve, and regulate social information. Mindfulness-based interventions for people with psychosis are safe and effective in improving anxiety and depressive symptoms; however, no mindfulness-based interventions addressing social cognition have yet been developed. Method: A pilot, single-arm, nonrandomized, noncontrolled feasibility trial is proposed. The main objectives are to assess the tolerability of mindfulness-based social cognition training (SocialMind) and to test the feasibility of a further randomized controlled trial. Results: A final sample of 25 outpatients with schizophrenia spectrum disorders was included. Attrition rate was lower than usual for this population, and most participants completed the training. No adverse effects were identified in terms of hospitalizations, emergency room visits, dissociative and psychotic symptoms, or state of anxiety during the sessions. Conclusion: This is the first implementation of SocialMind, which is the first mindfulness-based social cognition training. It is well tolerated by participants with schizophrenia spectrum disorders, and a further randomized controlled trial is proposed for people who have suffered their first episode of psychosis within the past 5 years. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03434405.

A randomized controlled trial of mindfulness in patients with schizophrenia✰

Cognitive Behavioral Therapy (CBT) is frequently used to attenuate the severity of positive schizophrenia symptoms; however, few studies have focused on attenuating negative symptoms. Recently, researchers have become interested in the effects of mindfulness-based intervention (MBI) on schizophrenia, but the lack of evidence-based results from random clinical trials (RCTs) has limited their effectiveness. Moreover, longitudinal data must be examined using appropriate study designs. We recruited 60 schizophrenia patients and randomly assigned them to an MBI or to a treatment-as-usual group. Negative symptoms, positive symptoms, mindfulness, and depression were assessed at baseline, post-course, and at a 3-month follow-up. Descriptive analysis and generalized estimating equations (GEEs) were used to examine the effects of MBI. We found that MBI mitigated the severity of negative symptoms and of general schizophrenic psychopathology except for the positive symptoms and for those of depression. Unexpectedly, we did not find long-term effect of mindfulness on negative symptoms. Larger sample sizes, long-term practical course, more rigorous study procedures, and a double-blind design should be considered in future studies.

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.

Relations of mindfulness facets with psychological symptoms among individuals with a diagnosis of obsessive-compulsive disorder, major depressive disorder, or borderline personality disorder

OBJECTIVES

To explore differences in mindfulness facets among patients with a diagnosis of either obsessive-compulsive disorder (OCD), major depressive disorder (MDD), or borderline personality disorder (BPD), and healthy controls (HC), and their associations with clinical features.

DESIGN AND METHOD

One hundred and fifty-three patients and 50 HC underwent a clinical assessment including measures of mindfulness (Five Facets Mindfulness Questionnaire - FFMQ), psychopathological symptoms (Symptom Check List-90-R), dissociation (Dissociative Experience Scale), alexithymia (Alexithymia Scale 20), and depression (Beck Depression Inventory-II). Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) were performed to assess differences in mindfulness scores and their associations with clinical features.

RESULTS

The three diagnostic groups scored lower on all mindfulness facets (apart from FFMQobserving) compared to the HC group. OCD group had a significant higher FFMQ total score (FFMQ-TS) and FFMQacting with awareness compared to the BPD group, and scored higher on FFMQdescribing compared to BPD and MDD groups. The scores in non-judging facet were significantly lower in all the three diagnostic groups compared to the HC group. Interestingly, higher FFMQ-TS was inversely related to all psychological measures, regardless of diagnostic group.

CONCLUSIONS

Deficits in mindfulness skills were present in all diagnostic groups. Furthermore, we found disease-specific relationships between some mindfulness facets and specific psychological variables. Clinical implications are discussed.

PRACTITIONER POINTS

The study showed deficits in mindfulness scores in all diagnostic groups compared to a healthy control group. Overall, mindfulness construct has a significantly negative association with indexes of global distress, dissociative symptoms, alexithymia, and depression. Mindfulness-based interventions in clinical settings should take into account different patterns of mindfulness skills and their impact on disease-specific maladaptive cognitive strategies or symptomatology.

Mindfulness for Psychosis Groups; Within-Session Effects on Stress and Symptom-Related Distress in Routine Community Care

BACKGROUND

There is an emerging evidence base that mindfulness for psychosis is a safe and effective intervention. However, empirical data on the within-session effects of mindfulness meditation was hitherto lacking.

AIMS

The aim of the study was to assess the impact of taking part in a mindfulness for psychosis group, using a within-session self-report measure of general stress, and symptom-related distress.

METHOD

Users of a secondary mental health service (n = 34), who experienced enduring psychotic symptoms, took part in an 8-week mindfulness for psychosis group in a community setting. Mindfulness meditations were limited to 10 minutes and included explicit reference to psychotic experience arising during the practice. Participants self-rated general stress, and symptom-related distress, before and after each group session using a visual analogue scale.

RESULTS

Average ratings of general stress and symptom-related distress decreased from pre- to post-session for all eight sessions, although not all differences were statistically significant. There was no increase in general stress, or symptom-related distress across any session.

CONCLUSIONS

There was evidence of positive effects and no evidence of any harmful effects arising from people with psychotic symptoms taking part in a mindfulness for psychosis session.

Rationale, Methods, Feasibility, and Preliminary Outcomes of a Transdiagnostic Prevention Program for At-Risk College Students

PURPOSE

Early adulthood represents one period of increased risk for the emergence of a serious mental illness. The college campus provides a unique opportunity to assess and monitor individuals in this at-risk age group. However, there are no validated early detection programs that are widely implemented on college campuses. In an effort to address this gap, we designed and tested an early detection and prevention program tailored to college students. A transdiagnostic approach was employed because of evidence for shared risk factors across major mental illnesses.

DESIGN

Single arm, prospective study evaluating outcomes following a 4-week intervention.

METHOD

Three in-person mental health screenings were conducted on the campus of one university. Undergraduate students with at least mildly elevated, self-reported levels of depressive or subclinical psychotic symptoms, who were not receiving treatment for these symptoms, were invited to participate in a 4-session workshop focused on increasing self- and other- awareness and emotion regulation using established mindfulness, self-compassion, and mentalization principles and experiential exercises. Symptoms, resilience-promoting capacities, and aspects of social functioning were assessed pre- and post- intervention.

RESULTS

416 students were screened and a total of 63 students participated in the workshop. 91% attended at least 3 of the 4 sessions. The majority of participants found the workshop interesting and useful and would recommend it to a friend. Significant pre-to-post reductions in symptoms (depression, anxiety, and subclinical psychotic symptoms, ps < 0.004) and improvements in resilience-promoting capacities (self-compassion and self-efficacy, ps < 0.006) and indices of social functioning (social motivation, activity, and a measure of comfort with the physical presence of others, ps < 0.04) were observed. Moreover, the significant increases in resilience-promoting capacities correlated with the reductions in affective symptoms (ps < 0.03).

CONCLUSIONS

These findings suggest that an on-campus mental health screening and early intervention program is feasible, acceptable, and may be associated with improvements in resilience-related capacities and symptom reductions in young adults with non-impairing, subclinical symptoms of psychopathology. Follow-up work will determine whether this program can improve both shorter and longer-term mental health and functional outcomes in this at-risk population.

Enhancing social functioning in young people at Ultra High Risk (UHR) for psychosis: A pilot study of a novel strengths and mindfulness-based online social therapy

BACKGROUND

Psychological and pharmacological treatments have been shown to reduce rates of transition to psychosis in Ultra High Risk (UHR) young people. However, social functioning deficits have been unresponsive to current treatments.

AIMS

The study aims were to: i) describe the theoretical basis and therapeutic targets of a novel intervention targeting social functioning in UHR young people; and ii) examine its acceptability, safety and preliminary effect on social functioning.

METHODS

An international, multidisciplinary team developed a new intervention (MOMENTUM) to improve social functioning in UHR young people. MOMENTUM blends two novel approaches to social recovery: strengths and mindfulness-based intervention embedded within a social media environment, and application of the self-determination theory of motivation. The acceptability and safety of MOMENTUM were tested through a 2-month pilot study with 14 UHR participants.

RESULTS

System usage was high, with over 70% of users being actively engaged over the trial. All participants reported a positive experience using MOMENTUM, considered it safe and would recommend it to others. 93% reported it to be helpful. There were large, reliable improvements in social functioning (d = 1.83, p < 0.001) and subjective wellbeing (d = 0.75, p = 0.03) at follow-up. There were significant increases in the mechanisms targeted by the intervention including strengths usage (d = 0.70, p = 0.03), mindfulness skills (d = 0.66, p = 0.04) and components of social support. Social functioning improvement was significantly correlated with indicators of system usage.

CONCLUSION

MOMENTUM is engaging and safe. MOMENTUM appeared to engage the hypothesized mechanisms and showed promise as a new avenue to improve social functioning in UHR young people.

Mindfulness in severe and persistent mental illness: a systematic review

OBJECTIVE

This systematic review summarises the current state of research on mindfulness in SPMI, given the pressing need to provide alternative, scalable and cost-effective treatment modalities for patients with severe and persistent mental illness (SPMI).

METHODS

Articles included mindfulness-based interventions for SPMI. Excluded articles included qualitative studies, acceptance and compassion therapies, case reports and reviews. Studies were identified by searching the databases Medline, Embase and PsycINFO.

RESULTS

Six randomised controlled trials, seven prospective studies and one retrospective study were identified. Clinical improvements were observed on psychotic symptoms, and on improvements of depression symptoms, cognition, mindfulness, psycho-social and vocational factors.

CONCLUSIONS

Findings suggest that mindfulness is feasible for individuals with SPMI, and displays potential benefits in outcomes aside from psychotic symptoms. The effects of mindfulness in psychotic symptoms needs further investigation in larger definitive studies using methodological rigor and thorough assessments of other psychiatric populations who are also representative of SPMI.