Enhancing stress reactivity and wellbeing in early schizophrenia: A randomized controlled trial of Integrated Coping Awareness Therapy (I-CAT)

Time-varying associations between daily skills practice and affect in a mindfulness and positive psychology-based intervention for early psychosis

OBJECTIVE

Using daily life methods, the present study investigated the impact of Integrated Coping Awareness Therapy (I-CAT), which includes mindfulness and positive psychological interventions, versus treatment-as-usual (TAU) on improving daily affective well-being. Among I-CAT participants only, we also examined the time-varying effect of daily I-CAT skill practice on daily affective well-being.

METHODS

Data are drawn from a randomized controlled treatment trial involving 38 young adults with a schizophrenia spectrum disorder. Participants completed daily reports of positive (happiness, relaxation) and negative (stress, sadness) affect across 9 months of treatment. I-CAT recipients completed daily practice of mindfulness and positive coping skills.

RESULTS

I-CAT and TAU did not differentially impact daily affect across treatment. However, daily skill practice was associated with better daily affective outcomes in certain phases of I-CAT. We also found that increased daily practice of positive coping skills was associated with better daily affective outcomes, whereas mindfulness practice was associated with poorer affective outcomes during certain periods of the I-CAT intervention.

CONCLUSIONS

In general, I-CAT did not improve daily affective outcomes compared with TAU. However, components of I-CAT, specifically the daily practice of positive coping skills, were associated with improved daily emotional well-being in young adults with psychosis. Implications of these findings are discussed.

Effects of psychosocial interventions on wellbeing in individuals with severe mental illness: a systematic review

Introduction

Wellbeing, encompassing hedonic and/or eudaimonic components, provides a two-dimensional framework for evaluating the effects of psychosocial interventions for individuals with severe mental illness (SMI). This study investigates how this conceptualization of wellbeing is reflected in existing research on psychosocial interventions for people with SMI. This is the first systematic review to assess the effects of psychosocial interventions on wellbeing as a purely positive phenomenon in this population. The study was registered in PROSPERO (CRD42024598954).

Method

A systematic review was conducted on intervention studies involving adults with SMI receiving psychosocial interventions in an out-patient setting, with a control condition and a wellbeing outcome aligned with a wellbeing framework. Five databases were searched, supplemented by manual searches, yielding 2,842 potential studies. Due to considerable heterogeneity (I 2 = 94%), interventions were analyzed independently, with results summarized based on the proportion of studies reporting significant effects. The study followed PRISMA guidelines.

Results

Seventeen studies met the inclusion criteria. Only one study (6%) provided a full rationale for using a wellbeing measure as the primary outcome. Over 70% reported a significant positive effect on wellbeing. In 13 studies effect size could be calculated, 29% in reference to all 17 studies demonstrated a positive effect (ranging from small to large). Clinical implications of the wellbeing construct were discussed in 47% of the studies, including an increased emphasis on positive functioning. Fewer than 50% received a high-quality rating, and only three studies reporting significant effects used Intention-To-Treat (ITT) data.

Conclusion

Research on two-dimensional wellbeing is a promising yet underprioritized field, providing a renewed focus on abilities and generating significant clinical implications. Wellbeing ought to be a prioritized outcome in out-patient treatment policies, but today no recommendation as to which interventions are most effective are possible due to insufficient data. The implications of detecting changes in wellbeing in individuals with SMI, along with recommendations for future research, are discussed.

Effectiveness of a Videoconference-Based Cognitive Behavioral Therapy Program for Patients with Schizophrenia: Pilot Randomized Controlled Trial

BACKGROUND

Cognitive behavioral therapy for psychosis (CBTp) is not sufficiently widespread in clinical practice, although evidence has been presented.

OBJECTIVE

The purpose of this study was to explore whether one-on-one videoconference-based CBTp (vCBTp) is more effective than usual care (UC) alone for improving psychiatric symptoms in patients with schizophrenia attending outpatient clinics.

METHODS

In this exploratory randomized controlled trial, patients with schizophrenia and schizoaffective disorders who were still taking medication in an outpatient clinic were randomly assigned to either the vCBTp plus UC group (n=12) or the UC group (n=12). The vCBTp program was conducted once a week, with each session lasting for 50 minutes, for a total of 7 sessions conducted in real-time and in a one-on-one format remotely using a loaned tablet computer (iPad). The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score, which measures the difference in the mean change from baseline (week 0) to posttest (week 8).

RESULTS

The study included 24 participants. There were no significant differences between the 2 groups at baseline. With regard to significant differences between the 2 groups in terms of the primary outcome, the mean change in the PANSS total score from baseline to week 8 in the vCBTp plus UC group was -9.5 (95% CI -12.09 to -6.91) and the mean change in the UC alone group was 6.9 (95% CI 1.54-12.30). The difference between the 2 groups was significant (P<.001). In addition, significant improvements were observed in the subscales of positive (P<.001) and negative (P=.004) symptoms and general psychopathology (P<.001). Significant differences were also observed in the secondary outcomes of the General Anxiety Disorder-7 (GAD-7; P=.04) and EQ-5D-5L (P=.005). There were no dropouts and no serious adverse events in this study.

CONCLUSIONS

A total of 7 remote vCBTp sessions conducted in the vCBTp plus UC group could be safely administered to patients with schizophrenia. They were also observed to be effective for psychiatric symptoms, general anxiety, and quality of life. However, because of the observed worsening of scores in the UC group, caution is required in interpreting significant differences between the 2 groups. This approach is expected to improve accessibility to CBTp for outpatients with schizophrenia and social anxiety regarding transportation use and financial and physical burdens related to transportation, and to contribute to promoting CBTp acceptability by compensating for the shortage of implementers.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry UMIN000043396; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000049544.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2022-069734.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A systematic review of persons of color participation in first episode psychosis coordinated specialty care randomized controlled trials in North America

The population of persons of color (POC) are increasing in the United States. Unfortunately, POC are significantly impacted by serious mental illness; psychosis represents a mental health disparity among POC. Fortunately, first episode coordinated specialty care (CSC) is an effective treatment for individuals who are in the early phases of a psychotic disorder. This systematic review of the literature examined POC inclusion rates in randomized controlled trials (RCT) examining First Episode Psychosis (FEP) programs. Our review yielded seven articles that met inclusion criteria. Our findings were mixed-researchers conducting RCTs on FEP programs did an excellent job including African American participants suggesting that findings from RCTs on FEP programs may generalize to African American participants. Regarding Latines, they were broadly underrepresented in RCTs on FEP CSC. Based on the data, we cannot definitively conclude to what extent findings from RCTs on FEP CSC generalize to Latines although results from studies that included a reasonable number of Latines offer promising results. Asians were overrepresented in three of the seven studies included in this review; thus it seems that the findings from RCTs on FEP CSC generalize to the Asian population in the United States.

COMT but Not 5HTTLPR Gene Is Associated with Depression in First-Episode Psychosis: The Role of Stressful Life Events

Serotonergic and dopaminergic systems are involved in the regulation of mood and reactivity to psychological stress. This study explores, in a sample of first episode psychosis (FEP) patients, whether more severe depressive symptoms were found in those who: (1) experienced a major stressful event in the 6 months preceding illness onset; and (2) were homozygous for the COMT Val158 allele or carrying the S allele of 5-HTTLPR. A total of 186 FEP patients recruited were assessed using the Hamilton Rating Scale for Depression (HAMD) for depressive symptoms. Stressful life events (SLEs) were collected by the List of Events Scale. The genotypes of 5-HTTLPR, rs25531, and COMT Val158 Met were performed. It has been found that higher levels of depression is associated with the presence of SLEs (p = 0.019) and with COMT Val158 allele homozygosity (p = 0.029), but not with carrying the S allele of 5-HTTLPR. The COMT gene moderates the association between depression and SLEs as Val158 allele homozygote patients experiencing SLEs had the highest level of depressive symptoms compared to the others (p = 0.002). The present study provides initial evidence for an effect of the COMT Val158 homozygosity and severe stressful life events on the severity of depressive symptoms in first episode psychosis.

The use of diary methods to evaluate daily experiences in first-episode psychosis

Integrated Coping Awareness Therapy (I-CAT) is an intervention that targets stress reactivity in first-episode psychosis (FEP). This study extends prior outcome research on I-CAT by examining predictors of online daily diary completion among 38 young adults with FEP and treatment group differences in diary ratings. We found no significant predictors of daily diary completion rate and no effect of treatment condition on diary ratings. These results are consistent with Halverson et al. (2021) and suggest that diaries are a valuable method of data collection in FEP.