Patient predictors of symptom and functional outcome following cognitive behaviour therapy or befriending in first-episode psychosis

Exploring the role of clinical and demographic characteristics on the effects of virtual reality cognitive behavioral therapy for psychosis: A moderator analysis

BACKGROUND

Virtual Reality cognitive behavioral therapy (VR-CBT) has proven to be an effective treatment method for paranoia and anxiety in psychosis. However, it is unknown, which individuals benefit most from VR-CBT. Previous studies examined factors affecting the treatment effect of regular CBTp, including illness duration, paranoia, depression, and pre-therapy avoidance behaviors, but results are inconsistent. The study aims to investigate the factors that influence the effectiveness of VR-CBT.

METHODS

A total of 95 participants with a psychotic disorder and at least moderate paranoia (GTPS >40) were included in this explorative study. Data were collected as part of a multicenter randomized controlled trial in which participants were assigned to VR-CBT or treatment as usual (TAU). The VR-CBT group received 16 sessions of individual treatment. A moderator analysis was conducted to examine the influence of baseline demographic (age, gender, and education level) and clinical characteristics (duration of illness, paranoia, anxiety, depression, safety behavior, self-esteem, and social functioning) on treatment effects of paranoia and anxiety as measured with questionnaires and the experience sampling method (ESM) directly after treatment (12 weeks after baseline).

RESULTS

More use of safety behavior at baseline resulted in greater benefits of VR-CBT on paranoid ideation and ESM paranoia. A higher age was associated with greater benefits of VR-CBT on social anxiety but not paranoia outcomes. There was no consistent evidence of moderation by any of the other sociodemographic or clinical variables for paranoid ideation and social anxiety.

CONCLUSIONS

Our findings suggest that a diverse spectrum of patients, with different backgrounds and symptom severity may be able to benefit from VR-CBT. VR-CBT can be recommended to a broad spectrum of patients with psychotic disorders, and particularly those with high levels of safety behaviors, including severe avoidance, seem to benefit more.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Measures of Social and Occupational Function in Early Psychosis: A Systematic Review and Meta-analysis

Deficits in social and occupational function are widely reported in psychosis, yet no one measure of function is currently agreed upon as a gold standard in psychosis research. The aim of this study was to carry out a systematic review and meta-analysis of functioning measures to determine what measures were associated with largest effect sizes when measuring between-group differences, changes over time, or response to treatment. Literature searches were conducted based on PsycINFO and PubMed to identify studies for inclusion. Cross-sectional and longitudinal observational and intervention studies of early psychosis (≤5 years since diagnosis) that included social and occupational functioning as an outcome measure were considered. A series of meta-analyses were conducted to determine effect size differences for between-group differences, changes over time, or response to treatment. Subgroup analyses and meta-regression were carried out to account for variability in study and participant characteristics. One hundred and sixteen studies were included, 46 studies provided data (N = 13 261) relevant to our meta-analysis. Smallest effect sizes for changes in function over time and in response to treatment were observed for global measures, while more specific measures of social and occupational function showed the largest effect sizes. Differences in effect sizes between functioning measures remained significant after variability in study and participant characteristics were accounted for. Findings suggest that more specific measures of social function are better able to detect changes in function over time and in response to treatment.

Is befriending a valuable intervention in schizophrenia? A scoping review

Background

Schizophrenia is a severe, chronic mental disorder that involves disruptions in cognitive processes, emotional responsiveness, and social interactions. Psychotherapeutic and social integration practices have increasingly been added to the pharmacological treatment in an effort to improve the level of functioning and the quality of life of individuals affected by this condition. Befriending, defined as a one-on-one companionship provided by a volunteer who aims to act as an emotionally supportive liaison, is hypothesized to be an effective such intervention, offering support for building and maintaining social relationships in the community. Despite its increase in popularity and acceptance, befriending remains poorly understood and under-researched.

Methods

We performed a systematic search for studies targeting befriending either as an intervention or a controlled condition in studies on schizophrenia. Searches were performed in four databases: APA PsycInfo, Pubmed, Medline and EBSCO. The keywords "schizophrenia," AND "befriending," were searched for on all databases.

Results

The search yielded 93 titles and abstracts, of which 18 met the criteria for inclusion. The studies included in this review have all incorporated befriending as an intervention or a controlled condition, as per our search criteria, and aimed at depicting the value and feasibility of this intervention to address social and clinical deficits in individuals with schizophrenia.

Conclusion

The studies selected for this scoping review revealed inconsistent findings regarding the effect of befriending on overall symptoms and the subjective reporting of quality of life in individuals with schizophrenia. This inconsistency may be attributed to differences between the studies and their specific limitations.

Cognitive behavioural therapy (group) for schizophrenia

BACKGROUND

Schizophrenia is a disabling psychotic disorder characterised by positive symptoms of delusions, hallucinations, disorganised speech and behaviour; and negative symptoms such as affective flattening and lack of motivation. Cognitive behavioural therapy (CBT) is a psychological intervention that aims to change the way in which a person interprets and evaluates their experiences, helping them to identify and link feelings and patterns of thinking that underpin distress. CBT models targeting symptoms of psychosis (CBTp) have been developed for many mental health conditions including schizophrenia. CBTp has been suggested as a useful add-on therapy to medication for people with schizophrenia. While CBT for people with schizophrenia was mainly developed as an individual treatment, it is expensive and a group approach may be more cost-effective. Group CBTp can be defined as a group intervention targeting psychotic symptoms, based on the cognitive behavioural model. In group CBTp, people work collaboratively on coping with distressing hallucinations, analysing evidence for their delusions, and developing problem-solving and social skills. However, the evidence for effectiveness is far from conclusive.

OBJECTIVES

To investigate efficacy and acceptability of group CBT applied to psychosis compared with standard care or other psychosocial interventions, for people with schizophrenia or schizoaffective disorder.

SEARCH METHODS

On 10 February 2021, we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, four other databases and two trials registries. We handsearched the reference lists of relevant papers and previous systematic reviews and contacted experts in the field for supplemental data.

SELECTION CRITERIA

We selected randomised controlled trials allocating adults with schizophrenia to receive either group CBT for schizophrenia, compared with standard care, or any other psychosocial intervention (group or individual).

DATA COLLECTION AND ANALYSIS

We complied with Cochrane recommended standard of conduct for data screening and collection. Where possible, we calculated risk ratio (RR) and 95% confidence interval (CI) for binary data and mean difference (MD) and 95% CI for continuous data. We used a random-effects model for analyses. We assessed risk of bias for included studies and created a summary of findings table using GRADE.

MAIN RESULTS

The review includes 24 studies (1900 participants). All studies compared group CBTp with treatments that a person with schizophrenia would normally receive in a standard mental health service (standard care) or any other psychosocial intervention (group or individual). None of the studies compared group CBTp with individual CBTp. Overall risk of bias within the trials was moderate to low. We found no studies reporting data for our primary outcome of clinically important change. With regard to numbers of participants leaving the study early, group CBTp has little or no effect compared to standard care or other psychosocial interventions (RR 1.22, 95% CI 0.94 to 1.59; studies = 13, participants = 1267; I2 = 9%; low-certainty evidence). Group CBTp may have some advantage over standard care or other psychosocial interventions for overall mental state at the end of treatment for endpoint scores on the Positive and Negative Syndrome Scale (PANSS) total (MD -3.73, 95% CI -4.63 to -2.83; studies = 12, participants = 1036; I2 = 5%; low-certainty evidence). Group CBTp seems to have little or no effect on PANSS positive symptoms (MD -0.45, 95% CI -1.30 to 0.40; studies =8, participants = 539; I2 = 0%) and on PANSS negative symptoms scores at the end of treatment (MD -0.73, 95% CI -1.68 to 0.21; studies = 9, participants = 768; I2 = 65%). Group CBTp seems to have an advantage over standard care or other psychosocial interventions on global functioning measured by Global Assessment of Functioning (GAF; MD -3.61, 95% CI -6.37 to -0.84; studies = 5, participants = 254; I2 = 0%; moderate-certainty evidence), Personal and Social Performance Scale (PSP; MD 3.30, 95% CI 2.00 to 4.60; studies = 1, participants = 100), and Social Disability Screening Schedule (SDSS; MD -1.27, 95% CI -2.46 to -0.08; studies = 1, participants = 116). Service use data were equivocal with no real differences between treatment groups for number of participants hospitalised (RR 0.78, 95% CI 0.38 to 1.60; studies = 3, participants = 235; I2 = 34%). There was no clear difference between group CBTp and standard care or other psychosocial interventions endpoint scores on depression and quality of life outcomes, except for quality of life measured by World Health Organization Quality of Life Assessment Instrument (WHOQOL-BREF) Psychological domain subscale (MD -4.64, 95% CI -9.04 to -0.24; studies = 2, participants = 132; I2 = 77%). The studies did not report relapse or adverse effects.

AUTHORS' CONCLUSIONS

Group CBTp appears to be no better or worse than standard care or other psychosocial interventions for people with schizophrenia in terms of leaving the study early, service use and general quality of life. Group CBTp seems to be more effective than standard care or other psychosocial interventions on overall mental state and global functioning scores. These results may not be widely applicable as each study had a low sample size. Therefore, no firm conclusions concerning the efficacy of group CBTp for people with schizophrenia can currently be made. More high-quality research, reporting useable and relevant data is needed.

Psychological Interventions for Young People With Psychotic Disorders: A Systematic Review

BACKGROUND

Psychotic disorders are commonly accompanied by intense psychological burden, and psychological interventions are usually needed in order to reduce the symptoms and help in maintaining or improving the level of psychological and social functioning after the onset of psychosis. The evidence-base for treating young people at risk for psychosis and adults with psychotic disorders is accumulating. Yet, pervasive systematic literature reviews that would include patients from the full age range being the most essential period for the risk of developing a psychotic disorder, a wide range of psychological interventions, and various types of clinical trials, have been lacking. The aim of this systematic review is to fill the gap by presenting the current research evidence from clinical trials on the effectiveness of psychological interventions for treating young people (12-30) with psychotic disorders.

METHODS

A systematic search was conducted in PubMed and PsycINFO followed by a 3-step screening process based on the PICOS strategy. Risk of bias of the included studies was assessed by the Mixed Methods Appraisal Tool (MMAT). Extracted data from the included studies is reported using a narrative synthesis.

RESULTS

Of the 1,449 publications screened, 40 from 25 studies were included in the review. Of these, 10 studies reported results from cognitive or behavioral therapy, nine from cognitive remediation therapy (CRT), and six from other types of therapies (i.e., integrative interventions combining psychoeducation and family/group interventions). All but one study found the target interventions to be effective, but the results mostly did not differ significantly from the control conditions in reducing symptoms and improving functioning, preventing relapses and hospitalization, or improving psychological or family variables. The most consistent findings were from CRT, showing more improvement in cognitive functioning compared to control conditions while not being superior in reducing symptom severity. Integrative interventions might be effective in treating young people suffering from psychotic disorders.

CONCLUSION

There is some evidence that psychological interventions are effective for young people with psychotic disorders. However, with regard to symptom severity, psychotherapy does not outperform control conditions, and the results do not strongly favor any specific type of treatment.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020166756], identifier [CRD42020166756].

Improving social functioning in people with schizophrenia-spectrum disorders via mobile experimental interventions: Results from the CLIMB pilot trial

Background

Patients with Schizophrenia Spectrum Disorders (SSD) demonstrate poor social functioning. While group-based approaches show long-term improvements, access to treatments is limited. Digital platforms hold promise to overcome barriers to treatment delivery and improve outcomes.

Objective

In a parallel arm, double-blind RCT, we tested CLIMB, a clinician-assisted, adjunct to treatment that includes computerized social cognition training (SCT), ecological momentary assessments (EMAs), group tele-therapy, and moderated messaging. CLIMB was compared to an active control that includes computerized general cognitive training (GCT), unstructured support groups, and unmoderated messaging.

Methods

The primary outcome was social functioning. Secondary outcomes were negative symptoms and quality of life (QoL). Given the sample size, Propensity Score Models were used to ensure balanced baseline covariates. Mixed-effects models examined change over time.

Results

24 participants completed the study (12 per arm). No significant between-group differences emerged in engagement. CLIMB participants engaged in a median of 8 sessions (IQR = 2), 2.8 h of SCT (IQR = 7.5), and 2710 EMAs; control participants engaged in a median of 9 sessions (IQR = 3) and 2.2 h of GCT (IQR = 7.9). As a group, participants showed significant improvements in social functioning (p = .046), with no between-group differences. Intent-to-treat analyses indicated greater improvements in QoL (p = .025) for the active control.

Conclusions

Delivering group-based mobile interventions to individuals with SSD is feasible. EMAs allow clinicians to maintain inter-session engagement, build participant self-awareness, and tailor treatment delivery. In this treatment model, whether SCT or GCT is more effective remains unclear. Further research will evaluate group-based mobile interventions to improve outcomes in SSD.

Effects of Integrated Violence Intervention on Alexithymia, Cognitive, and Neurocognitive Features of Violence in Schizophrenia: A Randomized Controlled Trial

Patients with schizophrenia and repetitive violence express core impairments that encompass multiple domains. To date, there have been few interventions integrating neurocognition, social cognition, alexithymia, and emotion regulation together as an approach to manage repetitive violence. The aim of this open-label randomized controlled trial was to examine more comprehensively the effectiveness of a novel Integrated Cognitive Based Violence Intervention Program on management of repetitive violence in patients with schizophrenia (vSZ). Sixty recruited patients were aged ≥20 years, diagnosed with schizophrenia for >2 years, had repetitive violent behavior within one year, and were psychiatrically hospitalized. The vSZ patients were randomly allocated to two groups and received either the intervention or treatment as usual. The intervention module, consisting of all defined 11 cognitive and social cognitive domains as well as emotion regulation, which were grouped into four modules. The intervention placed emphasis on the patients’ behavioral problems or intrinsic conflicts in relation to repetitive violence. The results indicate a statistically significant trend toward reducing impulsivity, anger with resentment, physical aggression, suspicion, and hostility (p < 0.05). The intervention significantly alleviated the intensity of cognitive failure, improved the management of alexithymic features and attribution styles and errors, and fostered adequate decision-making styles and emotion regulation capacity (p < 0.05). The intervention, when applied in conjunction with psychiatric standard care, could exert synergistic effects on alexithymia and cognitive, clinical, and neurocognitive features of repetitive violence in schizophrenia. This intervention provided patients a more active role to manage their violent behavior with the involvement of alexithymia.

Protocol for individual participant data meta-analysis of randomised controlled trials of patients with psychosis to investigate treatment effect modifiers for CBT versus treatment as usual or other psychosocial interventions

INTRODUCTION

Aggregate data meta-analyses have shown heterogeneous treatment effects for cognitive-behavioural therapy (CBT) for patients with schizophrenia spectrum diagnoses. This heterogeneity could stem from specific intervention or patient characteristics that could influence the clinical effectiveness of CBT, termed treatment effect modifiers. This individual participant data meta-analysis will investigate a range of potential treatment effect modifiers of the efficacy of CBT.

METHODS AND ANALYSIS

We will perform a systematic review and meta-analysis of studies investigating CBT versus treatment as usual, or CBT versus other psychosocial interventions, for patients with schizophrenia spectrum diagnoses. The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE and the online clinical trials registers of the US government, European Union, WHO and Current Controlled Trials will be searched. Two researchers will screen titles and abstracts identified by the search. Individual participant data will be requested for any eligible study, for the primary outcome (overall psychotic symptoms), secondary outcomes and treatment effect modifiers. Data will be checked and recoded according to an established statistical analysis plan. One-stage and two-stage random effects meta-analyses investigating potential treatment effect modifiers will be conducted. A list of potential treatment effect modifiers for CBT will be produced, motivating future research into particular modifiers.

ETHICS AND DISSEMINATION

This study does not require ethical approval as it is based on data from existing studies, although best ethical practice for secondary analysis of clinical data will be followed. The findings will be submitted for publication in peer-reviewed journals, and promoted to relevant stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42017060068.

Improved social functioning following social recovery therapy in first episode psychosis: Do social cognition and neurocognition change following therapy, and do they predict treatment response?

There is a need to develop and refine psychosocial interventions to improve functioning in First Episode Psychosis (FEP). Social cognition and neurocognition are closely linked to functioning in psychosis; examinations of cognition pre- and post- psychosocial intervention may provide insights into the mechanisms of these interventions, and identify which individuals are most likely to benefit.

METHOD

Cognition was assessed within a multi-site trial of Social Recovery Therapy (SRT) for individuals with FEP experiencing poor functioning (<30 h weekly structured activity). Fifty-nine participants were randomly allocated to the therapy group (SRT + Early intervention), and 64 were allocated to treatment as usual group (TAU - early intervention care). Social cognition and neurocognition were assessed at baseline and 9 months; assessors were blind to group allocation. It was hypothesized that social cognition would improve following therapy, and those with better social cognition prior to therapy would benefit the most from SRT.

RESULTS

There was no significant impact of SRT on individual neurocognitive or social cognitive variables, however, joint models addressing patterns of missingness demonstrate improvement across a number of cognitive outcomes following SRT. Further, regression analyses showed those who had better social cognition at baseline were most likely to benefit from the therapy (ß = 0.350; 95% CI = 0.830 to 8.891; p = .019).

CONCLUSION

It is not clear if SRT impacts on social cognitive or neurocognitive function, however, SRT may be beneficial in those with better social cognition at baseline.

How to Include Patients' Perspectives in the Study of the Mind: A Review of Studies on Depression

Depression has been widely studied by researchers from different fields, but its causes, and mechanism of action are still not clear. A difficulty emerges from the shifting from objective diagnosis or analysis to exploration of subjective feelings and experiences that influence the individuals' expression, communication and coping in facing depression. The integration of the experiential dimension of the first-person in studies on depression-and related methodological recommendations-are needed to improve the validity and generalizability of research findings. It will allow the development of timely and effective actions of care. Starting from providing a summary of the literature on theoretical assumptions and considerations for the study of the mind, with particular attention to the experiential dimension of patients with depression (aim #1 and #2), this contribution is aimed to provide practical suggestions for the design of research able to incorporate first- and third-person accounts (aim #3). It is also aimed to review qualified phenomenological methods for the acquisition and interpretation of experiential data in patients with depression (aim #4). Recognizing the first-person perspective in the study of depression is a major step toward a better understanding and treatment of this disorder. Theoretical constructs and technique suggestions that result from this review offer a valid starting point for the inclusion of the experiential dimension to common third-person research in the study of the mind.

A Synthetic Literature Review on the Management of Emerging Treatment Resistance in First Episode Psychosis: Can We Move towards Precision Intervention and Individualised Care?

Treatment resistance is prevalent in early intervention in psychosis services, and causes a significant burden for the individual. A wide range of variables are shown to contribute to treatment resistance in first episode psychosis (FEP). Heterogeneity in illness course and the complex, multidimensional nature of the concept of recovery calls for an evidence base to better inform practice at an individual level. Current gold standard treatments, adopting a ‘one-size fits all’ approach, may not be addressing the needs of many individuals. This following review will provide an update and critical appraisal of current clinical practices and methodological approaches for understanding, identifying, and managing early treatment resistance in early psychosis. Potential new treatments along with new avenues for research will be discussed. Finally, we will discuss and critique the application and translation of machine learning approaches to aid progression in this area. The move towards ‘big data’ and machine learning holds some prospect for stratifying intervention-based subgroups of individuals. Moving forward, better recognition of early treatment resistance is needed, along with greater sophistication and precision in predicting outcomes, so that effective evidence-based treatments can be appropriately tailored to the individual. Understanding the antecedents and the early trajectory of one’s illness may also be key to understanding the factors that drive illness course.

Psychological interventions for psychosis in adolescents

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

Current Controlled Trials ISRCTN99672552.

FUNDING

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

Predictors of treatment response to psychological interventions in people at clinical high risk of first-episode psychosis

AIM

Psychological interventions, such as cognitive behavioural therapy (CBT) and supportive counselling (SC), are used to treat people with schizophrenia and people at clinical high risk (CHR) of psychosis. However, little information is available on predictors of treatment response. This study aims to identify such predictors of psychological interventions in CHR.

METHODS

A total of 128 help-seeking CHR outpatients were randomized into two groups-integrated psychological intervention (IPI), including CBT, and SC-for 12 months. Multiple regression analysis was used to identify demographic, symptomatic and functional variables that predict improvement in positive (PANSS Positive), negative (PANSS Negative) and basic symptoms (Basic symptom total score) and improvement in functioning (GAF) at 1-year follow up.

RESULTS

In the merged group (IPI + SC), people who lived independently, were younger and presented with higher baseline functioning showed more improvement in symptomatic outcomes at follow up. Negative symptoms at baseline predicted less improvement in positive and basic symptoms. Being married or cohabiting and living in the primary family were found to correlate with good functioning at 1-year follow up.

CONCLUSIONS

Younger CHR individuals and those who are functioning well may particularly benefit from early intervention. Treatment might need to be modified for low-functioning CHR and those who already display higher scores of negative symptoms. Registration number: NCT00204087.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Identifying the "Therapy Targets" for Treating the Negative Symptoms of Psychosis Using Cognitive Behavioral Therapy

The division of psychotic symptoms into positive and negative categories has largely divided the research on them. While the research on positive symptoms of psychosis has rapidly developed over the last three decades, the literature on negative symptoms has noticeably lagged behind. Negative symptoms have likely been ignored in the treatment literature because they were previously thought to remit following the treatment of positive symptoms. Recent evidence does not consistently support this theory and indicates that the different manifestations of negative symptoms require distinct approaches to treatment. The current review provides a re-evaluation of the theoretical literature on negative symptoms to inform and identify "treatment targets" to reduce them. The "treatment targets" are then translated into intervention strategies using a cognitive behavioral framework. A review of the empirical literature on cognitive behavior therapy for treating negative symptoms is then offered along with a critical discussion of where cognitive behavior therapy stands compared to other interventions and what research is still needed.

A systematic review examining factors predicting favourable outcome in cognitive behavioural interventions for psychosis

Psychosis is a debilitating mental health condition affecting approximately 4 persons per 1000. Cognitive behavioural therapy for psychosis (CBTp) has been shown to be an effective treatment for psychosis and is recommended by several national guidelines. CBTp does not work equally well with everyone, however, with some 50% of clients receiving little benefit. This review sets out to systematically assess the literature and methodological quality of a number of studies, which examine factors predicting successful outcome in CBTp. The databases CINAHL, Cochrane, EBSCO, EMBASE, ISI Web of Science, MEDLINE (Ovid), PsycARTICLES, PsycINFO, PubMed, and Scopus were electronically searched. English language articles in peer reviewed journals were reviewed. Search terms "psychosis", "psychotic disorder", "cognitive behavioural therapy", "cognitive therapy", "randomised controlled trial", "predictor", and "treatment outcome" in various combinations were used as needed. Only randomised controlled trials (RCTs) were included. Results suggest that female gender, older age, and higher clinical insight at baseline, each predicted better outcome in CBT interventions with psychotic patients, as did a shorter duration of the illness, and higher educational attainment. Several other factors, such as higher symptom severity at baseline, were suggestive of predictive capacity but further research to clarify was indicated. Providers of mental healthcare should consider these findings when offering CBTp. The onus is also on healthcare providers to better equip non-responders to CBTp. Further investigation into a limited number of predictive factors, with an agreed set of outcome measures, would allow future researchers more direct comparisons between studies.

Predictors and moderators of treatment outcome in patients receiving multi-element psychosocial intervention for early psychosis: results from the GET UP pragmatic cluster randomised controlled trial

BackgroundThe GET UP multi-element psychosocial intervention proved to be superior to treatment as usual in improving outcomes in patients with first-episode psychosis (FEP). However, to guide treatment decisions, information on which patients may benefit more from the intervention is warranted.AimsTo identify patients' characteristics associated with (a) a better treatment response regardless of treatment type (non-specific predictors), and (b) a better response to the specific treatment provided (moderators).MethodSome demographic and clinical variables were selected a priori as potential predictors/moderators of outcomes at 9 months. Outcomes were analysed in mixed-effects random regression models. (Trial registration: ClinicalTrials.gov, NCT01436331)ResultsAnalyses were performed on 444 patients. Education, duration of untreated psychosis, premorbid adjustment and insight predicted outcomes regardless of treatment. Only age at first contact with the services proved to be a moderator of treatment outcome (patients aged ⩾35 years had greater improvement in psychopathology), thus suggesting that the intervention is beneficial to a broad array of patients with FEP.ConclusionsExcept for patients aged over 35 years, no specific subgroups benefit more from the multi-element psychosocial intervention, suggesting that this intervention should be recommended to all those with FEP seeking treatment in mental health services.

Nicotine restores functional connectivity of the ventral attention network in schizophrenia

While previous work has suggested that nicotine may transiently improve attention deficits in schizophrenia, the neuronal mechanisms are poorly understood. This study is the first to examine the effects of nicotine on connectivity within the ventral attention network (VAN) during a selective attention task in schizophrenia. Using a crossover design, 17 nonsmoking patients with schizophrenia and 20 age/gender-matched nonsmoking healthy controls performed a go/no-go task with environmental noise distractors during application of a 7 mg nicotine or placebo patch. Psychophysiological interaction analysis was performed to analyze task-associated changes in connectivity between a ventral parietal cortex (VPC) seed and the inferior frontal gyrus (IFG), key components of the human VAN. Effects of nicotine on resting state VAN connectivity were also examined. A significant diagnosis × drug interaction was observed on task-associated connectivity between the VPC seed and the left IFG (F(1,35) = 8.03, p < 0.01). This effect was driven by decreased connectivity after placebo in patients and greater connectivity after nicotine. Resting state connectivity analysis showed a significant main effect of diagnosis between the seed and right IFG (F = 4.25, p = 0.023) due to increased connectivity in patients during placebo, but no drug × diagnosis interactions or main effects of drug. This study is the first to demonstrate that 1) the VAN is disconnected in schizophrenia during selective attention, and 2) nicotine may normalize this pathological state.

Essential components of early intervention programs for psychosis: Available intervention services in the United States

Programs providing interventions for early psychosis are becoming commonplace in the United States (U.S.); however, the characteristics of existing services remain undocumented. We examined program characteristics, clinical services, and program eligibility criteria for outpatient early intervention programs across the U.S. using a semi-structured telephone interview. Content analysis was used to identify the presence or absence of program components, based in part on a recent list of essential evidence-based components recommended for early intervention programs (Addington, MacKenzie, Norman, Wang and Bond, 2013) as well as program characteristics, including eligibility criteria. A total of 34 eligible programs were identified; 31 (91.2%) program representatives agreed to be interviewed. Of the examined components, the most prevalent were individual psychoeducation and outcomes tracking; the least prevalent were outreach services and communication with inpatient units. The populations served by US programs were most frequently defined by restrictions on the duration of psychosis and age. This study provides critical feedback on services for the early psychosis population and identifies research to practice gaps and areas for future improvement.

Poor premorbid school performance, but not severity of illness, predicts cognitive decline in schizophrenia in midlife

Neurocognitive dysfunction is common in schizophrenia but its course and determinants remain uncertain. Our aim was to analyse if premorbid school performance and the severity of illness and functioning predict change in cognition in schizophrenia in a general population sample. The sample included cases with schizophrenia spectrum disorder from the Northern Finland Birth Cohort 1966. Data on school marks at the age of 16 years, educational level at the age of 34 years, severity of symptoms and occupational functioning around first episode and after years of illness were gained from national registers, hospital notes and interviews. Change of verbal and visual learning and memory and executive functioning were examined between ages 34 and 43 years. The number of cases varied in analyses from 29 to 41, depending on missing data in particular cognitive tests. Lower school marks at age 16 years and lower education at age 34 years predicted more decline of cognition. Measures of severity of illness or functioning were not associated statistically significantly with change of cognition. Premorbid school performance, but not later course of schizophrenia, related to change of cognition in midlife. Poor premorbid scholastic performance and post-onset cognitive decline may represent related processes as part of an endophenotype of schizophrenia.

Understanding process in group cognitive behaviour therapy for psychosis

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

PRACTITIONER POINTS

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

Who stays, who benefits? Predicting dropout and change in cognitive behaviour therapy for psychosis

This study investigates the predictors of outcome in a secondary analysis of dropout and completer data from a randomized controlled effectiveness trial comparing CBTp to a wait-list group (Lincoln et al., 2012). Eighty patients with DSM-IV psychotic disorders seeking outpatient treatment were included. Predictors were assessed at baseline. Symptom outcome was assessed at post-treatment and at 1-year follow-up. The predictor×group interactions indicate that a longer duration of disorder predicted less improvement in negative symptoms in the CBTp but not in the wait-list group whereas jumping-to-conclusions was associated with poorer outcome only in the wait-list group. There were no CBTp specific predictors of improvement in positive symptoms. However, in the combined sample (immediate CBTp+the delayed CBTp group) baseline variables predicted significant amounts of positive and negative symptom variance at post-therapy and 1-year follow-up after controlling for pre-treatment symptoms. Lack of insight and low social functioning were the main predictors of drop-out, contributing to a prediction accuracy of 87%. The findings indicate that higher baseline symptom severity, poorer functioning, neurocognitive deficits, reasoning biases and comorbidity pose no barrier to improvement during CBTp. However, in line with previous predictor-research, the findings imply that patients need to receive treatment earlier.

Thioredoxin, a novel oxidative stress marker and cognitive performance in chronic and medicated schizophrenia versus healthy controls

Oxidative stress-induced damage to neurons may contribute to cognitive deficits during aging and in neurodegenerative disorders. Schizophrenia has a range of cognitive deficits that may evolve from oxidative stress. Thioredoxin (TRX), a redox-regulating protein with antioxidant activity recognized as an oxidative-stress marker has recently been found to be involved in pathogenesis and psychopathology of schizophrenia. The aim of this study was to examine the association of TRX with cognitive deficits in schizophrenia. We recruited 45 chronic schizophrenic patients and 66 healthy control subjects and examined the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and serum TRX in both groups. Schizophrenic symptoms were assessed using the positive and negative syndrome scale (PANSS). We found no significant difference in TRX levels between patients and healthy controls. Cognitive scores on the RBANS and four of its five subscales (all p<0.001) except for the Visuospatial/Constructional index (p>0.05) were significantly lower in schizophrenic patients than normal controls. For the patients, TRX was inversely associated with the Attention domain of cognitive deficits in schizophrenia; however, TRX was positively associated with Attention in controls. The significantly lower TRX levels in attention impaired schizophrenia compared to controls suggest that oxidative stress may be involved in the cognitive impairment, especially attention in schizophrenia. The differential association of TRX and cognitive performance in schizophrenia and controls may be related to the impaired oxidative stress status of schizophrenia patients.