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Mayer SF, Corcoran C, Kennedy L, Leucht S, Bighelli I. Cognitive behavioural therapy added to standard care for first-episode and recent-onset psychosis. Cochrane Database Syst Rev 2024; 3:CD015331. [PMID: 38470162 PMCID: PMC10929366 DOI: 10.1002/14651858.cd015331.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
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.
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Affiliation(s)
- Susanna Franziska Mayer
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, TUM School of Medicine and Health, Technical University of Munich, München, Germany
| | | | - Liam Kennedy
- Department of Old Age Psychiatry, Carew House, St Vincent's Hospital, Dublin, Ireland
| | - Stefan Leucht
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, TUM School of Medicine and Health, Technical University of Munich, München, Germany
- German Center for Mental Health (DZPG), Munich, Germany
| | - Irene Bighelli
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, TUM School of Medicine and Health, Technical University of Munich, München, Germany
- German Center for Mental Health (DZPG), Munich, Germany
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Bighelli I, Çıray O, Salahuddin NH, Leucht S. Cognitive behavioural therapy without medication for schizophrenia. Cochrane Database Syst Rev 2024; 2:CD015332. [PMID: 38323679 PMCID: PMC10848293 DOI: 10.1002/14651858.cd015332.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) can be effective in people with schizophrenia when provided in combination with antipsychotic medication. It remains unclear whether CBT could be safely and effectively offered in the absence of concomitant antipsychotic therapy. OBJECTIVES To investigate the effects of CBT for schizophrenia when administered without concomitant pharmacological treatment with antipsychotics. 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, and WHO ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) in people with schizophrenia comparing CBT without antipsychotics to standard care, standard care without antipsychotics, or the combination of CBT and antipsychotics. DATA COLLECTION AND ANALYSIS Two review authors independently screened references for inclusion, extracted data from eligible studies, and assessed risk of bias using Cochrane's RoB 2 tool. We contacted study authors for missing data and additional information. Our primary outcome was general mental state measured with a validated rating scale. Key secondary outcomes were specific symptoms of schizophrenia, relapse, service use, number of participants leaving the study early, functioning, quality of life, and number of participants actually receiving antipsychotics during the trial. We also assessed behaviour, adverse effects, and mortality. MAIN RESULTS We included 4 studies providing data for 300 participants (average age 21.94 years). The mean sample size was 75 participants (range 61 to 90 participants). Study duration was between 26 and 39 weeks for the intervention period and 26 to 104 weeks for the follow-up period. Three studies employed a blind rater, while one study was triple-blind. All analyses included data from a maximum of three studies. The certainty of the evidence was low or very low for all outcomes. For the primary outcome overall symptoms of schizophrenia, results showed a difference favouring CBT without antipsychotics when compared to no specific treatment at long term (> 1 year mean difference measured with the Positive and Negative Syndrome Scale (PANSS MD) -14.77, 95% confidence interval (CI) -27.75 to -1.79, 1 RCT, n = 34). There was no difference between CBT without antipsychotics compared with antipsychotics (up to 12 months PANSS MD 3.38, 95% CI -2.38 to 9.14, 2 RCTs, n = 63) (very low-certainty evidence) or compared with CBT in combination with antipsychotics (up to 12 months standardised mean difference (SMD) 0.30, 95% CI -0.06 to 0.65, 3 RCTs, n = 125). Compared with no specific treatment, CBT without antipsychotics was associated with a reduction in overall symptoms (as described above) and negative symptoms (PANSS negative MD -4.06, 95% CI -7.50 to -0.62, 1 RCT, n = 34) at longer than 12 months. It was also associated with a lower duration of hospital stay (number of days in hospital MD -22.45, 95% CI -28.82 to -16.08, 1 RCT, n = 74) and better functioning (Personal and Social Performance Scale MD -12.42, 95% CI -22.75 to -2.09, 1 RCT, n = 40, low-certainty evidence) at up to 12 months. We did not find a difference between CBT and antipsychotics in any of the investigated outcomes, with the exception of adverse events measured with the Antipsychotic Non-Neurological Side-Effects Rating Scale (ANNSERS) at both 6 and 12 months (MD -4.94, 95% CI -8.60 to -1.28, 2 RCTs, n = 48; MD -6.96, 95% CI -11.55 to -2.37, 2 RCTs, n = 42). CBT without antipsychotics was less effective than CBT combined with antipsychotics in reducing positive symptoms at up to 12 months (SMD 0.40, 95% CI 0.05 to 0.76, 3 RCTs, n = 126). CBT without antipsychotics was associated with a lower number of participants experiencing at least one adverse event in comparison with CBT combined with antipsychotics at up to 12 months (risk ratio 0.36, 95% CI 0.17 to 0.80, 1 RCT, n = 39, low-certainty evidence). AUTHORS' CONCLUSIONS This review is the first attempt to systematically synthesise the evidence about CBT delivered without medication to people with schizophrenia. The limited number of studies and low to very low certainty of the evidence prevented any strong conclusions. An important limitation in the available studies was that participants in the CBT without medication group (about 35% on average) received antipsychotic treatment, highlighting the challenges of this approach. Further high-quality RCTs are needed to provide additional data on the feasibility and efficacy of CBT without antipsychotics.
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Affiliation(s)
- Irene Bighelli
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Germany
- German Center for Mental Health (DZPG), Munich, Germany
| | - Oğulcan Çıray
- Child and Adolescent Psychiatry Department, Mardin State Hospital Child and Adolescent Psychiatry Department, Mardin, Turkey
| | - Nurul Husna Salahuddin
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Stefan Leucht
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Germany
- German Center for Mental Health (DZPG), Munich, Germany
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Spencer HM, Dudley R, Johnston L, Freeston MH, Turkington D, Tully S. Case formulation-A vehicle for change? Exploring the impact of cognitive behavioural therapy formulation in first episode psychosis: A reflexive thematic analysis. Psychol Psychother 2022; 96:328-346. [PMID: 36480353 DOI: 10.1111/papt.12442] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Formulation is considered a fundamental process of cognitive behavioural therapy for psychosis (CBTp). However, an exploration into the personal impact of different levels of case formulation (CF) from a service user perspective (SU) is lacking, particularly for those experiencing a first episode of psychosis. DESIGN This Big Q qualitative design used semi-structured interviews. METHODS Reflexive thematic analysis (TA) was used to analyse 10 participant interviews. NVivo 12 computer-assisted qualitative data analysis software aided data organisation and analysis. RESULTS One overarching theme 'CF - A vehicle for change?' was developed as a pattern of shared meaning across the data set. Three main themes related to the overarching theme: (1) Vicious cycles: 'I never really thought about it being me maintaining the problems' (including one subtheme - Self-empowerment: 'Only you can make the changes for yourself'); (2) Early life experiences: 'My experiences have shaped the person that I am, therefore, it's not my fault' (including one subtheme - Disempowerment: '[My] core beliefs have been damaged'); and (3) Keep it simple: 'Don't push it too far over the top in case it becomes like spaghetti'. CONCLUSIONS Maintenance formulations may be experienced as self-blaming, but also self-empowering, which may help to facilitate change. Longitudinal formulations may be experienced as non-blaming, but also disempowering, which may inhibit change. Simple CF diagrams may also facilitate change, whereas overly complex CFs may inhibit change. How CBTp therapists might look to improve the impact of different levels of CF for service users (SUs) in first episode psychosis (FEP) are described.
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Affiliation(s)
- Helen M Spencer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Robert Dudley
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Psychology, University of York, York, UK
| | - Lynne Johnston
- Halley Johnston Associates Ltd, Newcastle upon Tyne, UK.,NHS Golden Jubilee, Glasgow, UK.,Clinical Psychology, Glasgow University, Glasgow, UK.,School of Psychology, University of Sunderland, Sunderland, UK
| | - Mark H Freeston
- School of Psychology, Newcastle University, Newcastle upon Tyne, UK
| | - Douglas Turkington
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sarah Tully
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Fei X, Wang S, Zheng X, Liu K, Liang X. Global research on cognitive behavioural therapy for schizophrenia from 2000 to 2019: a bibliometric analysis via CiteSpace. Gen Psychiatr 2021; 34:e100327. [PMID: 33585791 PMCID: PMC7845669 DOI: 10.1136/gpsych-2020-100327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 09/26/2020] [Accepted: 12/08/2020] [Indexed: 11/12/2022] Open
Abstract
Background Cognitive behavioural therapy (CBT) is considered to be an effective treatment for schizophrenia. In recent years, researchers have published clinical research results on CBT for schizophrenia. However, there is currently a lack of bibliometric analysis on CBT for schizophrenia. Aims To understand the current situation and research trends of CBT for schizophrenia, and to provide valuable information for researchers in this field. Methods Literature was retrieved from the Web of Science Core Collection database. CiteSpace was used to visually analyse the current status of research on CBT for schizophrenia, as well as trends and points of general interest on this topic. Results A total of 1151 papers were retrieved. The annual number of publications has increased 417.65% from 2000 to 2019. Schizophrenia Research was the most active journal. McGorry enjoys considerable influence. The University of London is deemed to be the most active research institution. England and the USA retain the highest scientific productivity in this field. China and Norway might make more contributions to this field in the future. The most important research topics are randomised controlled trials of CBT for schizophrenia, meta-analysis, scale selection and research on the improvement of quality of life. Results from the following keywords ‘psychoeducation’, ‘insomnia’, ‘individual’, ‘mental illness’, ‘major depressive disorder’, ‘efficacy’, ‘internalised stigma’ and ‘remediation’ indicated new research frontiers in this field. Conclusions The field of CBT for schizophrenia is progressing and has great potential. The level and quality of research in this field is high. The proposal of research hotspots and frontiers serves as a direction for researchers in this field. Researchers around the world should strengthen their cooperation and communication to promote further development of this field.
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Affiliation(s)
- Xinxing Fei
- Psychiatry Department, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Shiqi Wang
- Rehabilitation Medicine Department, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Xiaojiao Zheng
- Psychiatry Department, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Kezhi Liu
- Psychiatry Department, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Xuemei Liang
- Psychiatry Department, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
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Spencer HM, Dudley R, Freeston MH, Turkington D. What are the essential ingredients of a CBT case conceptualization for voices and delusions in schizophrenia spectrum disorders? A study of expert consensus. Schizophr Res 2020; 224:74-81. [PMID: 33069578 DOI: 10.1016/j.schres.2020.09.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/26/2020] [Accepted: 09/26/2020] [Indexed: 11/17/2022]
Abstract
Evidence supports the use of cognitive behavioural therapy (CBT) for the treatment of patients with schizophrenia spectrum disorders. A case conceptualization (CC) (or case formulation) is seen as the keystone of CBT in terms of making sense of a patient's difficulties, to guide and inform such treatment. Despite the importance placed on CC there is no known consensus amongst experts as to the essential ingredients involved in this fundamental process. This study used the Delphi method to establish expert consensus for the essential components of a CC when working to treat auditory hallucinations (voices), and persecutory delusions. An international panel of 78 CBT for psychosis (CBTp) experts from 12 different countries participated in the main stage of this study. This 3-stage process involved producing and rating statements that addressed key areas of CC in terms of: presenting issues, predisposing, precipitating, perpetuating and protective factors. One presenting issue and 6 perpetuating factors were endorsed as essential by >80% of the expert panel. The exact same items were endorsed for both voices, and persecutory delusions. The findings are unique in that a large panel of international experts reached consensus that case conceptualizations (CCs) should be parsimonious and focused on the perpetuating (maintaining) factors to facilitate change. Overall, the proposed recommendations should lead to core guidance for the process of developing CCs, and improvements in training for clinicians that conceptualize voices, and persecutory delusions in CBT for schizophrenia spectrum disorders.
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Affiliation(s)
- Helen M Spencer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom; Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, United Kingdom.
| | - Robert Dudley
- School of Psychology, Newcastle University, Newcastle upon Tyne, United Kingdom; Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, United Kingdom
| | - Mark H Freeston
- School of Psychology, Newcastle University, Newcastle upon Tyne, United Kingdom; Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, United Kingdom
| | - Douglas Turkington
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, United Kingdom
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Turner DT, Burger S, Smit F, Valmaggia LR, van der Gaag M. What Constitutes Sufficient Evidence for Case Formulation-Driven CBT for Psychosis? Cumulative Meta-analysis of the Effect on Hallucinations and Delusions. Schizophr Bull 2020; 46:1072-1085. [PMID: 32221536 PMCID: PMC7505201 DOI: 10.1093/schbul/sbaa045] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Following 2 decades of research on cognitive behavioral therapy for psychosis (CBTp), it is relevant to consider at which point the evidence base is considered sufficient. We completed a cumulative meta-analysis to assess the sufficiency and stability of the evidence base for hallucinations and delusions. METHOD We updated the systematic search from our previous meta-analytic review from August 2013 until December 2019. We identified 20 new randomized controlled trials (RCTs) resulting in inclusion of 35 RCTs comparing CBTp with treatment-as-usual (TAU) or active controls (AC). We analyzed data from participants with psychosis (N = 2407) over 75 conventional meta-analytic comparisons. We completed cumulative meta-analyses (including fail-safe ratios) for key comparisons. Publication bias, heterogeneity, and risk of bias were examined. RESULTS Cumulative meta-analyses demonstrated sufficiency and stability of evidence for hallucinations and delusions. The fail-safe ratio demonstrated that the evidence base was sufficient in 2016 for hallucinations and 2015 for delusions. In conventional meta-analyses, CBTp was superior for hallucinations (g = 0.34, P < .01) and delusions (g = 0.37, P < .01) when compared with any control. Compared with TAU, CBTp demonstrated superiority for hallucinations (g = 0.34, P < .01) and delusions (g = 0.37, P < .01). Compared with AC, CBT was superior for hallucinations (g = 0.34, P < .01), but not for delusions although this comparison was underpowered. Sensitivity analyses for case formulation, primary outcome focus, and risk of bias demonstrated increases in effect magnitude for hallucinations. CONCLUSIONS The evidence base for the effect of CBTp on hallucinations and delusions demonstrates sufficiency and stability across comparisons, suggesting limited value of new trials evaluating generic CBTp.
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Affiliation(s)
- David T Turner
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Simone Burger
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Filip Smit
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam Medical Centers, Amsterdam, the Netherlands
- Trimbos Institute, Netherlands Institute of Mental Health, Utrecht, the Netherlands
| | - Lucia R Valmaggia
- Department of Psychology, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Mark van der Gaag
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Parnassia Psychiatric Institute, The Hague, the Netherlands
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Measuring adherence in social recovery therapy with people with first episode psychosis. Behav Cogn Psychother 2019; 48:82-90. [PMID: 31379311 DOI: 10.1017/s1352465819000432] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The SUPEREDEN3 study, a phase II randomized controlled trial, suggests that social recovery therapy (SRT) is useful in improving functional outcomes in people with first episode psychosis. SRT incorporates cognitive behavioural therapy (CBT) techniques with case management and employment support, and therefore has a different emphasis to traditional CBT for psychosis, requiring a new adherence tool. AIMS This paper describes the SRT adherence checklist and content of the therapy delivered in the SUPEREDEN3 trial, outlining the frequency of SRT techniques and proportion of participants who received a full therapy dose. It was hypothesized that behavioural techniques would be used frequently, consistent with the behavioural emphasis of SRT. METHOD Research therapists completed an adherence checklist after each therapy session, endorsing elements of SRT present. Data from 1236 therapy sessions were reviewed to determine whether participants received full, partial or no therapy dose. RESULTS Of the 75 participants randomized to receive SRT, 57.3% received a full dose, 24% a partial dose, and 18.7% received no dose. Behavioural techniques were endorsed in 50.5% of sessions, with cognitive techniques endorsed in 34.9% of sessions. CONCLUSIONS This report describes an adherence checklist which should be used when delivering SRT in both research and clinical practice. As hypothesized, behavioural techniques were a prominent feature of the SRT delivered in SUPEREDEN3, consistent with the behavioural emphasis of the approach. The use of this adherence tool would be considered essential for anyone delivering SRT looking to ensure adherence to the model.
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