Study protocol of a randomised clinical trial testing whether metacognitive training can improve insight and clinical outcomes in schizophrenia

Decreased insight, but not self-stigma or belief about medicine, is associated with greater severity of delusions in a sample of long-stay patients with schizophrenia: a cross-sectional study

BACKGROUND

There are, to date, limited and inconsistent findings concerning the relationship between insight and psychotic symptoms, despite some evidence in favor of the clinical and therapeutic relevance of the insight construct. We aimed to add to the pool of the available data in this area, by examining the correlations between the severity of insight and positive psychotic symptoms (delusions and auditory hallucinations), while accounting for self-stigma and attitudes towards medication, in a sample of long-stay inpatients with schizophrenia.

METHODS

A cross-sectional study was conducted at the Psychiatric Hospital of the Cross, between July and October 2021. A total of 82 patients diagnosed with schizophrenia (aged 55.55 ± 10.21 years, 54.9% males) were enrolled. The semi-structured psychotic symptom rating scales, the Birchwood Insight Scale, the Belief About Medicine Questionnaire, and the Internalized Stigma of Mental Illness were used.

RESULTS

The mean duration of illness in years was 30.15 ± 11.73, and the mean duration of hospitalization in years was 17.56 ± 9.24. Sixteen out of the 82 patients (19.5%) were considered as having poor insight. Bivariate analyses showed that higher chlorpromazine equivalent dose was significantly associated with more delusions, whereas higher insight was significantly associated with lower delusions. Multivariable analyses revealed that Higher chlorpromazine equivalent dose (Beta = 0.004) was significantly associated with more delusions, whereas higher insight (Beta = - 0.89) was significantly associated with less delusions. No significant associations were found between insight, self-stigma and hallucinations.

CONCLUSION

Our results imply that more impaired insight is associated with greater severity of delusions, above and beyond the effects of self-stigma and medication doses. These findings are valuable to aid clinicians and researchers improve their understanding of the relationship insight-psychotic symptoms, and could help personalize prevention and early intervention strategies in schizophrenia.

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.

Psychometric evaluation of the Chinese version of the media Health Literacy Questionnaire: A validation study

Background

The media play an important role in health promotion and disease prevention, while at the same time, a variety of mixed health messages in the media are beginning to pose new challenges to them. However, there is a lack of media health literacy (MHL) assessment tools in China. Therefore, the purpose of this study was to translate the Media Health Literacy (MeHLit) questionnaire into Chinese and to assess its psychometric properties.

Methods

This cross-sectional study was conducted from October to December 2022, and a methodological study of the translation and validation of the MeHLit questionnaire was conducted.

Results

As a result of an extensive translation and cultural adaptation process, the final MeHLit questionnaire was developed, which includes five dimensions and 21 items. Cronbach's α value of the questionnaire was 0.859, and Cronbach's α value of the dimensions ranged from 0.776 to 0.911, which is fairly good. As a result, the test-retest reliability coefficient and the split-half reliability coefficient of the questionnaire are both equal to 0.907. Its content validity index was 0.946, suggesting a reasonable level of content validity. Through exploratory factor analysis, a five-factor structure was identified based on the eigenvalues, total variance explained, and scree plot. As a result of the validation factor analysis, all recommended fit indicators were appropriate.

Conclusion

The Chinese version of the MeHLit questionnaire has been successfully introduced in China. It has shown good psychometric properties among the Chinese public and can be used as a tool to evaluate MHL in health screening.

Investigating the Role of Insight, Decision-Making and Mentalizing in Functional Outcome in Schizophrenia: A Cross-Sectional Study

Background: Recovery has become a priority in schizophrenia spectrum disorders (SSDs). This study aimed to investigate predictors of objective—general functioning and disability—and subjective—quality of life (QoL)—measures of functional outcomes in SSD. Methods: Sample: n = 77 SSD outpatients (age 18–64, IQ > 70) participating in a randomised controlled trial. Baseline data were used to build three multivariable linear regression models on: (i) general functioning—General Assessment of Functioning (GAF); (ii) disability—the World Health Organization Disability Assessment Schedule (WHODAS-2.0); and (iii) QoL—Satisfaction Life Domains Scale (SLDS). Results: Young age and being employed (R² change = 0.211; p = 0.001), late adolescence premorbid adjustment (R² change = 0.049; p = 0.0050), negative symptoms and disorganization (R² change = 0.087; p = 0.025) and Theory of Mind (R² change = 0.066, p = 0.053) predicted general functioning. Previous suicidal behaviour (R² change = 0.068; p = 0.023) and negative and depressive symptoms (R² change = 0.167; p = 0.001) were linked with disability. Previous suicidal behaviour (R² change = 0.070, p = 0.026), depressive symptoms (R² change = 0.157; p < 0.001) and illness recognition (R² change = 0.046, p = 0.044) predicted QoL. Conclusions: Negative, disorganization and depressive symptoms, older age, unemployment, poor premorbid adjustment, previous suicide attempts and illness awareness appear to underlie a poor global functional outcome in SSD. Achieving recovery in SSD appears to require both symptomatic remission (e.g., through antipsychotics) and measures to improve mastery and relieve low mood.

Use of Ecological Momentary Assessment Through a Passive Smartphone-Based App (eB2) by Patients With Schizophrenia: Acceptability Study

Background

Ecological momentary assessment (EMA) tools appear to be useful interventions for collecting real-time data on patients’ behavior and functioning. However, concerns have been voiced regarding the acceptability of EMA among patients with schizophrenia and the factors influencing EMA acceptability.

Objective

The aim of this study was to investigate the acceptability of a passive smartphone-based EMA app, evidence-based behavior (eB2), among patients with schizophrenia spectrum disorders and the putative variables underlying their acceptance.

Methods

The participants in this study were from an ongoing randomized controlled trial (RCT) of metacognitive training, consisting of outpatients with schizophrenia spectrum disorders (F20-29 of 10th revision of the International Statistical Classification of Diseases and Related Health Problems), aged 18-64 years, none of whom received any financial compensation. Those who consented to installation of the eB2 app (users) were compared with those who did not (nonusers) in sociodemographic, clinical, premorbid adjustment, neurocognitive, psychopathological, insight, and metacognitive variables. A multivariable binary logistic regression tested the influence of the above (independent) variables on “being user versus nonuser” (acceptability), which was the main outcome measure.

Results

Out of the 77 RCT participants, 24 (31%) consented to installing eB2, which remained installed till the end of the study (median follow-up 14.50 weeks) in 14 participants (70%). Users were younger and had a higher education level, better premorbid adjustment, better executive function (according to the Trail Making Test), and higher cognitive insight levels (measured with the Beck Cognitive Insight Scale) than nonusers (univariate analyses) although only age (OR 0.93, 95% CI 0.86-0.99; P=.048) and early adolescence premorbid adjustment (OR 0.75, 95% CI 0.61-0.93; P=.01) survived the multivariable regression model, thus predicting eB2 acceptability.

Conclusions

Acceptability of a passive smartphone-based EMA app among participants with schizophrenia spectrum disorders in this RCT where no participant received financial compensation was, as expected, relatively low, and linked with being young and good premorbid adjustment. Further research should examine how to increase EMA acceptability in patients with schizophrenia spectrum disorders, in particular, older participants and those with poor premorbid adjustment.

Trial Registration

ClinicalTrials.gov NCT04104347; https://clinicaltrials.gov/ct2/show/NCT04104347