Metacognitive training for schizophrenia: a multicentre randomised controlled trial

A pilot 1-year follow-up randomised controlled trial comparing metacognitive training to psychoeducation in schizophrenia: effects on insight

Poor insight in schizophrenia spectrum disorders (SSD) is linked with negative outcomes. This single-centre, assessor-blind, parallel-group 1-year follow-up randomised controlled trial (RCT) tested whether metacognitive training (MCT) (compared to psychoeducation) may improve insight and outcomes in outpatients with SSD assessed: at baseline (T0); after treatment (T1) and at 1-year follow-up (T2). Insight (primary outcome) was measured with (i) the Schedule for Assessment of Insight-Expanded version- (SAI-E), including illness recognition (IR), symptom relabelling (SR), treatment compliance (TC) and total insight scores (TIS); and (ii) the Beck Cognitive Insight Scale (BCIS). Between-group comparisons were nonsignificant, while within the MCT group (but not within controls) there was a significant medium effect size for improved TIS at T2 (d = 0.67, P = 0.02). Secondary outcomes included cognitive measures: Jumping to Conclusions (JTC), Theory of Mind (ToM), plus symptom severity and functioning. Compared to psychoeducation, MCT improved the PANSS excitement (d = 1.21, P = 0.01) and depressed (d = 0.76, P = 0.05) factors at T2; and a JTC task both at T1 (P = 0.016) and at T2 (P = 0.031). Participants in this RCT receiving MCT showed improved insight at 1-year follow-up, which was associated with better mood and reduced JTC cognitive bias. In this pilot study, no significant benefits on insight of MCT over psychoeducation were detected, which may have been due to insufficient power.

Is Metacognitive Training effective for improving neurocognitive function in patients with a recent onset of psychosis?

The aims are to assess improvements in memory, attention and executive function in first-episode psychosis after Metacognitive Training (MCT). A multicenter randomized clinical trial was performed with two arms: MCT and psychoeducational intervention. A total of 126 patients with a diagnosis of psychosis, less than 5 years from the onset of the disease, were included. Patients were assessed two or three moments (baseline, post-treatment, 6 months follow-up) depending on the test, with a battery of neurocognitive tests (TAVEC, TMTA-B, CPT, WCST, Stroop and premorbid IQ). General linear models for repeated measures were performed.  A better improvement in the MCT was found by an interaction between group and time in CPT Hit index, TMTB, Stroop, recent memory and number of perseverations of the TAVEC. Considering three assessments, a better improvement was found in non-perseverative, perseverative and total errors of the WCST and TMTB. The MCT is an effective psychological intervention to improve several cognitive functions.

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

IMPORTANCE

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

OBJECTIVES

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION AND SYNTHESIS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Efficacy of Metacognitive Training for Patients With Schizophrenia in Psychiatric Emergency Wards: A Pilot Randomized Controlled Trial

Introduction

Metacognitive training (MCT) is a group program for improving cognitive bias in patients with schizophrenia. MCT has a reported positive effect on psychiatric symptoms and cognitive bias in patients with schizophrenia, but the effect of the intervention on patients with schizophrenia in the early recovery stage during hospitalization is not comprehensible. Therefore, this study aimed to investigate the efficacy of MCT in the early recovery stage of patients with schizophrenia in a Japanese emergency psychiatric ward.

Method

This unblinded, pilot randomized controlled trial recruited 24 patients with schizophrenia aged 20–65 years. Patients were randomly divided into two groups: occupational therapy (OT) + MCT group and OT-only group. Using the two-way repeated-measures analysis of variance (ANOVA), changes in cognitive function, psychiatric symptoms, cognitive insight, and intrinsic motivation were compared between those at baseline and post-intervention and between the two groups. Furthermore, patient readmission during the year after discharge was compared between the groups.

Results

The final analysis included eight patients in each group, owing to the withdrawal of some patients from the study. The two-way repeated-measures analysis of variance revealed significant differences in cognitive function in several domains within subjects. However, no significant differences between subjects were observed. Psychiatric symptoms showed significant within-subject improvement, and interaction was found for general psychopathology (p = 0.03). The variable of cognitive insight and self-reflectiveness was significantly different between subjects (p = 0.03). There was no significant difference in intrinsic motivation. Readmission within a year was significantly lower in the OT + MCT group than in the OT-only group (2 [25%] vs. 6 [75%]; p = 0.046).

Conclusion

In a Japanese emergency psychiatric ward, this pilot randomized controlled study was the first attempt to investigate the efficacy of MCT in patients with schizophrenia suggesting that MCT may be effective in preventing psychiatric symptoms, poor self-reflectiveness, and readmissions.

The study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR; UMIN000034106).

Metacognitive Training Modified for Negative Symptoms (MCT-N): A Feasibility study

OBJECTIVE

Although patients often prioritise the treatment of negative symptoms, few psychological interventions targeting negative symptoms exist. This study attempts to fill this gap by piloting a modified Metacognitive training programme, specifically targeted at negative symptoms (MCT-N), with a group of patients with prominent negative symptoms.

METHOD

We adopted a mixed methods case series design, providing detailed quantitative data on changes over time, to focus on potential mechanisms underlying the intervention, in combination with qualitative interviews.

RESULTS

The intervention showed good feasibility as demonstrated by the attendance rate, the positive feedback from participants and the multidisciplinary team, and the improvements on negative symptoms observed following the intervention. Multilevel modelling showed that depression, internalised stigma, and reflective functioning explained the variance in negative symptoms.

DISCUSSION

The pilot study indicated that the intervention has high feasibility and that improvements in negative symptoms can be partially explained by improvements on depression, stigma, and reflective functioning.

Metacognitive training: a useful complement to community-based rehabilitation for schizophrenia patients in China

BACKGROUND

The traditional general practitioner-based model (community-based rehabilitation [CBR]) for Chinese schizophrenia patients lacks sufficient content, usefulness, and theoretical basis for rehabilitation. Based on previous research, we postulate that Metacognitive Training (MCT) is effective in the community for schizophrenic patients.

METHOD

A randomized controlled, assessor-blinded trial was conducted. A total of 124 schizophrenia patients were recruited from Ningbo China and were randomly assigned to an intervention or a control group. A general practitioner (GP) training plan was carried out before intervention. Intervention and control groups received two CBR follow-ups once a month, while the intervention group, received an additional eight once-a-in-week session of MCT. The Positive and Negative Syndrome Scale (PANSS), and the Psychotic Symptom Rating Scales (PSYRATS) were the primary outcome instruments, while the Quality of Life Scale (SQLS) was the secondary outcome instrument.

RESULTS

In the post-treatment between-groups assessment, the patients in the intervention group showed significantly more reductions on PSYRATS delusions, PSYRATS total, PANSS P6, PANSS core delusions, PANSS positive, PANSS negative, PANSS general and PANSS total, and a significant improvement in SQLS psychosocial aspect.

CONCLUSIONS

The study provides preliminary evidence for the usefulness of MCT as a complementary measure for community-based rehabilitation of schizophrenia patients.

TRIAL REGISTRATION

ISRCTN, ISRCTN17333276 . Registered 09 August 2020 - Retrospectively registered.

Assessing the efficacy and feasibility of providing metacognitive training for patients with schizophrenia by mental health nurses: A randomized controlled trial

AIM

To evaluate the efficacy of metacognitive group training in reducing psychotic symptoms and improving cognitive insight and functions in people with schizophrenia.

DESIGN

Randomized controlled trial. It was carried out between July 2019 -February 2020.

METHODS

Fifty-six patients with schizophrenia were enrolled and randomly assigned to either a control group (N = 29) or a metacognitive training group (N = 27). Blinded assessments were made at baseline, 1-week post-treatment and at follow-up 3 months after treatment. The primary outcome measure was psychotic symptoms based on the Psychotic Symptom Rating Scales (PSYRATS). Secondary outcomes were assessed by the Beck Cognitive Insight Scale (BCIS), the Personal and Social Performance (PSP) scale and the World Health Organization Disability Assessment Schedule (WHODAS).

RESULTS

Completion at follow-up was high (92.86%). The intention-to-treat analyses demonstrated that patients in the metacognitive training group had significantly greater improvements of the Psychotic Symptom Rating Scales delusion score and total score and the Personal and Social Performance Scale, after 3 months, compared with the control group. The effect size was medium to large. The intention-to-treat analyses also demonstrated that patients in the metacognitive training group had significantly greater reductions of the Psychotic Symptom Rating Scales hallucination score and Beck Cognitive Insight Scale self-certainty score post-treatment, compared with the control group. The effect size was medium to large.

CONCLUSION

The metacognitive training administered by psychiatric and mental health nurses was effective in ameliorating delusions and social functioning over time and it immediately reduced hallucinations post-treatment.

IMPACT

Metacognitive training for treating psychosis in patients with schizophrenia is efficacious and administration is clinically feasible in the Portuguese context.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov ID NCT03891186.

Psychological interventions for acute psychiatric inpatients with schizophrenia-spectrum disorders: A systematic review and meta-analysis

BACKGROUND

Acute inpatient psychiatric wards are important yet challenging environments in which to implement psychological interventions for people with schizophrenia-spectrum disorders. No meta-analysis to date has evaluated whether psychological interventions are effective in this context.

METHODS

We systematically searched Embase, Medline and PsycInfo databases for randomised controlled trials (RCTs) of psychological interventions implemented in acute inpatient psychiatric settings with individuals with schizophrenia-spectrum disorders. We conducted random effects meta-analyses of between-groups outcomes at post-intervention and relapse/re-hospitalisation rates by follow-up.

RESULTS

Twenty-nine trials were suitable for meta-analysis. Psychological interventions improved post-intervention positive symptoms, social functioning and treatment compliance and reduced the risk of relapse/ re-hospitalisation, relative to control conditions. Analyses of specific intervention effects found positive effects of psychoeducation on several key outcomes (power > 80%) and preliminary evidence for positive effects of acceptance and commitment therapy (ACT), cognitive behaviour therapy (CBT) and metacognitive training (MCT) on some outcomes (power < 80%).

CONCLUSION

Psychological interventions can be helpful for acute inpatients with schizophrenia-spectrum disorders. However, risk of bias was often high or unclear, and some analyses were underpowered. Further research should use more rigorous RCT designs and publish meta-analysable data on positive symptoms, general psychopathology, relapse/ re-hospitalisation, social functioning and treatment compliance.

Can metacognitive interventions improve insight in schizophrenia spectrum disorders? A systematic review and meta-analysis

BACKGROUND

Patients with schizophrenia spectrum disorders (SSD) tend to lack insight, which is linked to poor outcomes. The effect size of previous treatments on insight changes in SSD has been small. Metacognitive interventions may improve insight in SSD, although this remains unproved.

METHODS

We carried out a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the effects of metacognitive interventions designed for SSD, namely Metacognitive Training (MCT) and Metacognitive Reflection and Insight Therapy (MERIT), on changes in cognitive and clinical insight at post-treatment and at follow-up.

RESULTS

Twelve RCTs, including 10 MCT RCTs (n = 717 participants) and two MERIT trials (n = 90), were selected, totalling N = 807 participants. Regarding cognitive insight six RCTs (n = 443) highlighted a medium effect of MCT on self-reflectiveness at post-treatment, d = 0.46, p < 0.01, and at follow-up, d = 0.30, p < 0.01. There was a small effect of MCT on self-certainty at post-treatment, d = -0.23, p = 0.03, but not at follow-up. MCT was superior to controls on an overall Composite Index of cognitive insight at post-treatment, d = 1.11, p < 0.01, and at follow-up, d = 0.86, p = 0.03, although we found evidence of heterogeneity. Of five MCT trials on clinical insight (n = 244 participants), which could not be meta-analysed, four of them favoured MCT compared v. control. The two MERIT trials reported conflicting results.

CONCLUSIONS

Metacognitive interventions, particularly Metacognitive Training, appear to improve insight in patients with SSD, especially cognitive insight shortly after treatment. Further long-term RCTs are needed to establish whether these metacognitive interventions-related insight changes are sustained over a longer time period and result in better outcomes.

Combined Neurocognitive And Metacognitive Rehabilitation In Schizophrenia: Effects On Bias Against Disconfirmatory Evidence

Background

A Metacognitive Training for Schizophrenia patients (MCT) was developed to target the cognitive biases that characterize the illness. Results suggest positive MCT effects encompassing several aspects of psychopathology and subjective well-being. There are still open questions concerning the effect on different cognitive biases and the interplay between them and both psychopathology and neurocognition. Specifically, the bias against disconfirmatory evidence (BADE) has never been tested in previous trials on MCT. In this study we evaluated the feasibility of MCT combined with a cognitive remediation therapy (CACR) in schizophrenia and its effect on BADE. Moreover, we investigated the relationships between BADE and both neuropsychology and psychopathology, taking into account mutual influences on the degree of improvement.

Methods

Fifty-seven schizophrenia outpatients were randomly assigned to CACR + control group or MCT+CACR and assessed at baseline and after treatment for psychopathology, neurocognition and BADE.

Results

After MCT+CACR patients showed significantly greater improvements on BADE. Although BADE baseline performances correlated with several cognitive domains, no association was found between BADE improvement and neurocognitive nor psychopathological measures.

Conclusions

This study enlightened for the first time the efficacy of MCT+CACR on BADE in schizophrenia, suggesting the importance to develop a more specific intervention tailored on individual needs of patients.

The efficacy of extended metacognitive training for psychosis: A randomized controlled trial

This study investigated the efficacy of 10-module metacognitive training (MCT) among Japanese patients with schizophrenia by conducting a multicenter randomized controlled trial to test the influence of the most recent and extended version of MCT on positive symptoms. A six-center, randomized, assessor-blind, controlled trial between "treatment as usual" (TAU) and TAU + MCT was conducted. Fifty inpatients and outpatients with schizophrenia, schizotypal, and delusional disorders (ICD 10) were enrolled, then randomly assigned to TAU (n = 26) or TAU + MCT (n = 24). Assessments were made at baseline, after six weeks, immediately posttreatment, and 1-month post-treatment. The primary outcome was positive symptom score, as measured by the Positive and Negative Syndrome Scale (PANSS). General assessment of functioning (GAF) and measures of cognitive biases were secondary outcomes. Completion at post-treatment (10 weeks later) and 1-month follow-up was high-TAU + MCT, n = 22 (91.67%) and TAU, n = 23 (88.46%). The severity of PANSS positive symptoms declined significantly in the TAU + MCT treatment group compared with the TAU group. GAF also showed significantly greater improvement in the TAU + MCT group compared with the TAU group. There was also a trend for greater efficacy of MCT on cognitive biases. In conclusion, this study provides support for the efficacy of 10 module MCT concerning positive symptomatology (especially, delusion) and general functioning.

Metacognitive Training Modulates Default-Mode Network Homogeneity During 8-Week Olanzapine Treatment in Patients With Schizophrenia

BACKGROUND

Previous studies have revealed the efficacy of metacognitive training for schizophrenia. However, the underlying mechanisms of metacognitive training on brain function alterations, including the default-mode network (DMN), remain unknown. The present study explored treatment effects of metacognitive training on functional connectivity of the brain regions in the DMN.

METHODS

Forty-one patients with schizophrenia and 20 healthy controls were scanned using resting-state functional magnetic resonance imaging. Patients were randomly assigned to drug plus psychotherapy (DPP) and drug therapy (DT) groups. The DPP group received olanzapine and metacognitive training, and the DT group received only olanzapine for 8 weeks. Network homogeneity (NH) was applied to analyze the imaging data, and pattern classification techniques were applied to test whether abnormal NH deficits at baseline might be used to discriminate patients from healthy controls. Abnormal NH in predicting treatment response was also examined in each patient group.

RESULTS

Compared with healthy controls, patients at baseline showed decreased NH in the bilateral ventral medial prefrontal cortex (MPFC), right posterior cingulate cortex (PCC)/precuneus, and bilateral precuneus and increased NH in the right cerebellum Crus II and bilateral superior MPFC. NH values in the right PCC/precuneus increased in the DPP group after 8 weeks of treatment, whereas no substantial difference in NH value was observed in the DT group. Support vector machine analyses showed that the accuracy, sensitivity, and specificity for distinguishing patients from healthy controls were more than 0.7 in the NH values of the right PCC/precuneus, bilateral ventral MPFC, bilateral superior MPFC, and bilateral precuneus regions. Support vector regression analyses showed that high NH levels at baseline in the bilateral superior MPFC could predict symptomatic improvement of positive and negative syndrome scale (PANSS) after 8 weeks of DPP treatment. No correlations were found between alterations in the NH values and changes in the PANSS scores/cognition parameters in the patients.

CONCLUSION

This study provides evidence that metacognitive training is related to the modulation of DMN homogeneity in schizophrenia.

Data, diagnoses, and interventions addressing the nursing focus "delusion": A scoping review

PURPOSE

To explore and synthesize literature related to the nursing process addressing the focus "Delusion".

DESIGN AND METHODS

This literature review is integrated with a scoping study framework. From the total 252 papers found, 39 were selected.

FINDINGS

Relevant data and diagnostic activities, hypothetic nursing diagnoses, and interventions addressing the focus "Delusion" were identified.

PRACTICE IMPLICATIONS

This literature review allowed the development of a clinical data model addressing the focus "Delusion", based on the steps of the nursing process identified. This clinical data model may contribute towards improving nursing clinical decision-making and nursing care quality in relation to a client suffering from delusion as well as producing more reliable nursing-sensitive indicators.

Effects of Metacognitive Training on Cognitive Insight in a Sample of Patients with Schizophrenia

Metacognitive training (MCT) is a group intervention that addresses cognitive biases and distortions that could help maintain delusions and hallucinations in people with schizophrenia. This program has proven its effectiveness in reducing the symptoms, but its impact on cognitive insight has scarcely been investigated. Therefore, the aim of the study was to assess the program’s impact on cognitive insight in patients with long-term schizophrenia. A sample of 22 patients with schizophrenia was divided into two groups: one received 16 sessions of MCT (n = 11), while the other received the usual treatment (n = 11). They were assessed using the Beck Cognitive Insight Scale which measures two components, self-reflection and self-certainty, and the Positive and Negative Syndrome Scale (PANSS). The experimental group showed high levels of adherence, an increase in self-reflection, and a decrease in self-assurance levels as hypothesized. We found statistically significant differences between the control and experimental groups in excitation, hostility, positive symptomatology total score, hallucinatory behavior, and suspicion. In the usual treatment group, a non-significant decrease in positive symptoms was also observed. The findings showed that the implementation of the MCT program in real clinical settings can contribute to an improvement in the metacognitive ability and symptomatology of people with schizophrenia.

Towards an improved access to psychiatric rehabilitation: availability and effectiveness at 1-year follow-up of psychoeducation, cognitive remediation therapy, cognitive behaviour therapy and social skills training in the FondaMental Advanced Centers of Expertise-Schizophrenia (FACE-SZ) national cohort

Psychosocial Interventions (PIs) have shown positive effects on clinical and functional outcomes of schizophrenia (SZ) in randomized controlled trials. However their effectiveness and accessibility remain unclear to date in "real world" schizophrenia. The objectives of the present study were (i) to assess the proportion of SZ outpatients who benefited from PIs between 2010 and 2015 in France after an Expert Center Intervention in a national multicentric non-selected community-dwelling sample; (ii) to assess PIs' effectiveness at 1-year follow-up. 183 SZ outpatients were recruited from FondaMental Advanced Centers of Expertise for Schizophrenia cohort. Baseline and 1-year evaluations included sociodemographic data, current treatments, illness characteristics and standardized scales for clinical severity, adherence to treatment, quality of life, a large cognitive battery, and daily functioning assessment. Only 7 (3.8%) received a PI before the evaluation, and 64 (35%) have received at least one PI during the 1-year follow-up. Having had at least one PI during the follow-up has been associated in multivariate analyses with significantly higher improvement in positive and negative symptoms (respectively p =0.031; p = 0.011), mental flexibility (TMT B, p = 0.029; C-VF, p = 0.02) and global functioning (p =0.042). CBT and SST were associated with higher cognitive improvements, while CRT was associated with clinical improvement. These results have not been demonstrated before and suggest that the effect of each PI is larger than its initial target. The present study has confirmed the PIs' effectiveness in a large sample of community-dwelling SZ outpatients at 1 year follow-up. Efforts to improve access to PI should be reinforced in public health policies.

The challenge of well-being and quality of life: A meta-analysis of psychological interventions in schizophrenia

Well-being is a critical outcome in the recovery from psychosis and the prevention of symptoms. Previous reviews of the effectiveness of psychological interventions have focused on psychotic symptoms and general psychopathology, not recognising well-being as an essential outcome. This study conducted a meta-analysis of the effects of psychological interventions on the well-being and quality of life (QoL) of people with schizophrenia and analysed some critical moderating factors. A systematic literature search was conducted yielding 12986 published reports, 2043 of which were clinical trials. After a detailed review, 36 articles were included in the analyses. Measures of related concepts, well-being and quality of life were included in the present meta-analysis to reflect the current state of the literature and to ensure the representativeness of RCTs that have evaluated the effect of psychological interventions on the extent to which people with schizophrenia experience a good life. Our findings reflect a significant, small, treatment effect on the outcomes of well-being. Subgroup analysis also suggested a significant moderating effect when the primary aim of the intervention was well-being. These findings suggest that symptom or functional improvement does not necessarily lead to an improvement in well-being and would imply the need to focus specifically on those. We recommend psychological interventions that target well-being as a complementary strategy in mental health promotion and treatment. In addition, we stress the need to include well-being outcome measure in RCT as well as to clearly identify the different domains of well-being being measured.

Three-Year Follow-Up Study Exploring Metacognition and Function in Individuals With First Episode Psychosis

Introduction: Research has demonstrated that functional outcome in psychosis is predicted by factors such as neurocognition, functional capacity, symptoms and, more recently, metacognition. Metacognitive ability has been demonstrated to mediate between neurocognition and functional outcome in First Episode Psychosis (FEP). Whether metacognition also predicts longer-term recovery in first episode psychosis is unknown. This study assessed whether neurocognition, functional capacity and metacognitive ability in FEP predicted functional outcome three years later. Methods: Eighty individuals with First Episode Psychosis were re-contacted after an average 3 years (range: 26-45 month follow-up) from baseline. Twenty-six participants (33%) completed completed measures of neurocognition, metacognition, functional capacity, functional outcome (hours spent in structured activity per week) and psychopathology at baseline and at follow-up. Results: Individual regression analyses demonstrated neurocognition, functional capacity, and metacognitive ability at baseline significantly predicted functional outcome at three years. However, when baseline functional outcome was controlled, only metacognitive ability was a significant predictor of change in functional outcome from baseline to follow-up, p < 0.001. This model explained 72% (adjusted r ² = 0.69) of the variance in functional outcome at follow-up. Negative symptoms did not change the model. Discussion: This study demonstrated that better metacognitive ability significantly predicted improvement in functioning in FEP across a 3-year period. This highlights the potential value of clinical interventions that focus on improving metacognitive ability at first point of illness to maximize recovery.

Thinking dispositions and cognitive reflection performance in schizotypy

Schizotypy refers to the continuum of normal variability of psychosis-like characteristics and experiences, often classified as positive schizotypy (‘unusual experiences’; UE) and negative schizotypy (‘introvertive anhedonia’; IA). Here, we investigated the link between schizotypy and cognitive processing style and performance. A particular focus was on whether schizotypy is associated more with Type 1 (automatic/heuristic) than Type 2 (reflective/effortful) processes, as may be expected from findings of impaired top-down control in schizophrenia. A large sample (n = 1,512) completed online measures pertaining to schizotypy (Oxford-Liverpool Inventory for Feelings and Experiences; O-LIFE), thinking style (Rational Experiential Inventory-10, Actively Open-Minded Thinking Scale), and reasoning performance (Cognitive Reflection Test). Higher positive (UE) and negative (IA) schizotypy were associated with more pronounced Type 1 processing, i.e. greater self-reported Faith in Intuition (FI), lower Need for Cognition (NFC), lower Actively Open-Minded Thinking (AOT), and lower cognitive reflection test (CRT) scores. Canonical correlation analysis confirmed a significant association between UE and increased FI, lower AOT and lower CRT performance, accounting for 12.38% of the shared variance between schizotypy and thinking dispositions. IA was more highly associated with reduced NFC. These findings suggest that schizotypy may be associated with similar thinking dispositions to those reported in psychosis, with different patterns of associations for positive and negative schizotypy. This result informs research on reasoning processes in psychosis and has clinical implications, including potential treatment targets and refinements for cognitive therapies.

Evidence for Interventions to Improve and Maintain Occupational Performance and Participation for People With Serious Mental Illness: A Systematic Review

OBJECTIVE

This systematic review evaluates the evidence for the effectiveness of interventions within the scope of occupational therapy to improve and maintain performance and participation for people with serious mental illness. Areas included in this review are activities of daily living, instrumental activities of daily living, leisure, social participation, and rest and sleep.

METHOD

Databases searched included MEDLINE, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews. Reviewers read and assessed citations, abstracts, and full-text articles for inclusion and analysis.

RESULTS

Sixty-one articles were selected for inclusion. The review yielded strong evidence for psychoeducation and occupation- and cognitive-based interventions, moderate evidence for skills-based interventions, and limited evidence for technology-supported interventions.

CONCLUSION

Results of this review support use of evidence-based practice within the scope of occupational therapy, inclusion of occupational therapy practitioners as mental health service providers, and continued research.

The Effects of Metacognition-Oriented Social Skills Training on Psychosocial Outcome in Schizophrenia-Spectrum Disorders: A Randomized Controlled Trial

A pilot study of the effects of metacognition-oriented social skills training (MOSST) on social functioning in patients with schizophrenia spectrum disorders (SSDs) reported promising results. The main purpose of the current trial was to compare the effectiveness and potential benefits of MOSST vs conventional social skills training (SST). Single-blind randomized controlled trial with 2 groups of patients aged 18-65 with SSDs on partial hospitalization. Participants were randomly assigned (1:1) to receive 16 group sessions with MOSST or conventional SST, both in addition to standard care, over 4 months, with a 6-month follow-up. Psychosocial functioning, metacognition, and symptom outcomes were measured by blind assessors. Statistical analyses used mixed models to estimate treatment effects in each postrandomization time point. Thirty-six patients were randomly assigned to the MOSST group and 33 patients to the conventional SST group. Between-group differences were significant in favor of MOSST on Social and Occupational Functioning Assessment Scale (SOFAS) and Personal and Social Performance Scale (PSP) total scores at post-treatment and follow-up. Concerning PSP subscales, there were significant between-group differences in favor of MOSST at follow-up on socially useful activities, personal and social relationships, and disturbing and aggressive behaviors. Metacognition only improved following MOSST group. For people with SDDs, MOSST appears to have short- and long-term beneficial effects on social functioning and symptoms. Further studies are required to replicate the current results in other samples.

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

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

Insight in schizophrenia spectrum disorders: relationship with behavior, mood and perceived quality of life, underlying causes and emerging treatments

Poor insight in schizophrenia is prevalent across cultures and phases of illness. In this review, we examine the recent research on the relationship of insight with behavior, mood and perceived quality of life, on its complex roots, and on the effects of existing and emerging treatments. This research indicates that poor insight predicts poorer treatment adherence and therapeutic alliance, higher symptom severity and more impaired community function, while good insight predicts a higher frequency of depression and demoralization, especially when coupled with stigma and social disadvantage. This research also suggests that poor insight may arise in response to biological, experiential, neuropsychological, social-cognitive, metacognitive and socio-political factors. Studies of the effects of existing and developing treatments indicate that they may influence insight. In the context of earlier research and historical models, these findings support an integrative model of poor insight. This model suggests that insight requires the integration of information about changes in internal states, external circumstances, others' perspectives and life trajectory as well as the multifaceted consequences and causes of each of those changes. One implication is that treatments should, beyond providing education, seek to assist persons with schizophrenia to integrate the broad range of complex and potentially deeply painful experiences which are associated with mental illness into their own personally meaningful, coherent and adaptive picture.

Feasibility and acceptability of brief cognitive remediation targeting metacognition in acute inpatients with psychosis: a case series

Cognitive remediation (CR) is an intensive intervention targeting cognitive impairment with the aim of improving functioning in people with psychotic disorders. Shorter forms of CR based on metacognition and targeting awareness of cognitive problems may be more appropriate for acute inpatient settings where time is limited. The objective of the study was to evaluate the feasibility and acceptability of a new brief course of CR targeting cognitive and metacognitive difficulties within an acute inpatient psychiatric setting. Thirteen male service users with psychosis received a three-week course of CR. Participants were assessed at baseline and post-treatment on cognitive measures, subjective cognitive complaints, functional impairment, and symptom severity. Feasibility was assessed based on engagement, attendance, and attrition. Acceptability was evaluated through treatment satisfaction. Eight participants completed therapy, with 81% session attendance. Therapy was considered acceptable, with the majority of participants considering it satisfactory. Potential benefit analysis showed a significant post-treatment improvement in global cognition and memory. Subjective cognitive complaints did not change over time. It was concluded that it is feasible to deliver brief CR in an acute inpatient setting. Context of delivery and engagement are challenges for optimal therapy implementation. CR protocol adaptations made to promote metacognitive competencies may compensate for lack of intensive practice.

Acceptance and Efficacy of Metacognitive Training (MCT) on Positive Symptoms and Delusions in Patients With Schizophrenia: A Meta-analysis Taking Into Account Important Moderators

Metacognitive training (MCT) is a new, widely used intervention for psychosis. The present meta-analysis examines the efficacy of MCT in schizophrenia. Fifteen studies comparing effects of MCT on positive symptoms, delusions or acceptance of MCT with a control group were included in this meta-analysis. These studies comprised a total of 408 patients in the MCT condition and 399 in the control condition. The moderating effects of masking of outcome assessment, randomization, incomplete outcome data, use of an active control intervention, and individual vs group MCT were investigated. Possible effects of sensitivity analyses and publication bias were also examined. The results show a significant overall effect of MCT for positive symptoms (g = -0.34, 95% CI [-0.53, -0.15]), delusions (g = -0.41, 95% CI [-0.74, -0.07]) and acceptance of the intervention (g = -0.84, 95% CI [-1.37, -0.31]). Using only studies being at low risk for bias regarding randomization, masking and incomplete outcome data reduced effect sizes for positive symptoms and delusions (g = -0.28, 95% CI [-0.50, -0.06] and g = -0.18, 95% CI [-0.43, 0.06]), respectively. This meta-analysis demonstrates that MCT exerts a small to moderate effect on delusions and positive symptoms and a large effect on acceptance of the intervention. The effect on delusions is reduced, but remains significant when potential biases are considered.

An integrative model of the impairments in insight in schizophrenia: emerging research on causal factors and treatments

INTRODUCTION

Poor insight, or unawareness of some major aspect of mental illness, is a major barrier to wellness when it interferes with persons seeking out treatment or forming their own understanding of the challenges they face. One barrier to addressing impaired insight is the absence of a comprehensive model of how poor insight develops.

AREAS COVERED

To explore this issue we review how poor insight is the result of multiple phenomena which interfere with the construction of narrative accounts of psychiatric challenges, rather than a single social or biological cause. Expert commentary: We propose an integrative model of poor insight in schizophrenia which involves the interaction of symptoms, deficits in neurocognition, social cognition, metacognition, and stigma. Emerging treatments for poor insight including therapies which focus on the development of metacognition are discussed.

Metacognitive training for schizophrenia spectrum patients: a meta-analysis on outcome studies

BACKGROUND

Metacognitive training (MCT) for schizophrenia spectrum is widely implemented. It is timely to systematically review the literature and to conduct a meta-analysis.

METHOD

Eligible studies were selected from several sources (databases and expert suggestions). Criteria included comparative studies with a MCT condition measuring positive symptoms and/or delusions and/or data-gathering bias. Three meta-analyses were conducted on data gathering (three studies; 219 participants), delusions (seven studies; 500 participants) and positive symptoms (nine studies; 436 participants). Hedges' g is reported as the effect size of interest. Statistical power was sufficient to detect small to moderate effects.

RESULTS

All analyses yielded small non-significant effect sizes (0.26 for positive symptoms; 0.22 for delusions; 0.31 for data-gathering bias). Corrections for publication bias further reduced the effect sizes to 0.21 for positive symptoms and to 0.03 for delusions. In blinded studies, the corrected effect sizes were 0.22 for positive symptoms and 0.03 for delusions. In studies using proper intention-to-treat statistics the effect sizes were 0.10 for positive symptoms and -0.02 for delusions. The moderate to high heterogeneity in most analyses suggests that processes other than MCT alone have an impact on the results.

CONCLUSIONS

The studies so far do not support a positive effect for MCT on positive symptoms, delusions and data gathering. The methodology of most studies was poor and sensitivity analyses to control for methodological flaws reduced the effect sizes considerably. More rigorous research would be helpful in order to create enough statistical power to detect small effect sizes and to reduce heterogeneity. Limitations and strengths are discussed.

Neurocognitive functioning as an intermediary variable between psychopathology and insight in schizophrenia

Based on the neuropsychological deficit model of insight in schizophrenia, we constructed exploratory prediction models for insight, designating neurocognitive measures as the intermediary variables between psychopathology and insight into patients with schizophrenia. The models included the positive, negative, and autistic preoccupation symptoms as primary predictors, and activation symptoms as an intermediary variable for insight. Fifty-six Korean patients, in the acute stage of schizophrenia, completed the Positive and Negative Syndrome Scale, as well as a comprehensive neurocognitive battery of tests at the baseline, 8-weeks, and 1-year follow-ups. Among the neurocognitive measures, the Korean Wechsler Adult Intelligence Scale (K-WAIS) picture arrangement, Controlled Oral Word Association Test (COWAT) perseverative response, and the Continuous Performance Test (CPT) standard error of reaction time showed significant correlations with the symptoms and the insight. When these measures were fitted into the model as intermediaries between the symptoms and the insight, only the perseverative response was found to have a partial mediating effect - both cross-sectionally, and in the 8-week longitudinal change. Overall, the relationship between insight and neurocognitive functioning measures was found to be selective and weak.

Metacognitive training for schizophrenia: a systematic review

Background

Metacognitive training (MCT) is a novel group psychotherapy method for schizophrenia, but there is, as yet, no conclusive evidence of its efficacy.

Aims

Conduct a meta-analysis to assess the effectiveness of MCT in schizophrenia.

Methods

Electronic and hand searches were conducted to identify randomized controlled trials about the effects of MCT in schizophrenia that met pre-defined inclusion criteria. The Cochrane Risk of Bias tool was employed to assess of risk of biases, and Cochrane Review Manager version 5.3 and R version 3.1.1 were used to conduct the data synthesis.

Results

Ten trials from 54 unduplicated reports were included in the review, but differences in the methods of assessing outcomes limited the number of studies that could be included in the meta-analysis. Pooling four studies that assessed the positive symptom subscale of the Positive and Negative Syndrome Scale (PANSS) at the end of the trial identified a small but statistically significant greater reduction in the MCT group than in the control group. But pooling four studies that assessed the delusion subscale of the Psychotic Symptom Rating Scales (PSYRATS) at the end of the trial found no significant difference between the groups. Results from the qualitative assessment of the other results that could not be pooled across studies were mixed, some showed a trend in favor of MCT but many found no difference between the groups.

Conclusions

The limited number of RCT trials, the variability of the method and time of the outcome evaluation, and methodological problems in the trials make it impossible to come to a conclusion about the effectiveness of MCT for schizophrenia. More randomized trials that use standardized outcome measures, that use intention-to-treat (ITT) analyses, and that follow-up participants at regular intervals after the intervention are needed to determine whether or not MCT should become a recommended adjunctive treatment for schizophrenia.