Group cognitive behavioural therapy for psychosis in the Asian context: a review of the recent studies

Abstract

The cardinal symptoms of psychosis include hallucination and delusion, which can be both distressing and disabling. International guidelines recommend cognitive behavioural therapy for psychosis (CBTp) as an adjunctive intervention to medication management. Considering the difficulty in the widespread dissemination of the individual CBTp, group CBTp is an alternative in improving patients’ access to psychological intervention. Although it has been found feasible and effective in various studies, systematic review on group CBTp, particularly in Asia, was not identified. Hence, this systematic review tried to examine the recent evidence of group CBTp in Asia in order to shed light on its implementation in routine psychiatric care. A relevant literature search was conducted in three databases (Pubmed, Web of Knowledge, and PsycINFO) during the period from January 2000 to December 2018. A total of 114 journal articles were identified. After a full-text review, four studies met our inclusion and exclusion criteria. Despite methodological shortcomings, positive results were found in terms of improvements on psychotic symptoms, functioning, and quality-of-life. These encouraging results indicate the need for future research studies with more rigorous methodology, leading to a better understanding on the applicability and effectiveness of group CBTp in the Asian context.     

Group cognitive behavioural therapy for obsessive-compulsive disorder: a systematic review and meta-analysis

Objective: Behaviour therapy with exposure and response prevention (ERP) or cognitive behavioural therapy (CBT) including ERP are considered the psychological treatments of choice for obsessive–compulsive disorder (OCD), but group CBT/ERP has received relatively little research attention in the treatment of OCD. The aim of this study was to provide a meta‐analysis of the effectiveness of group CBT/ERP for OCD. Method: A systematic literature search was conducted and studies were meta‐analysed by means of the Cochrane Review Manager Program with measures of i) pre‐ to post‐effect sizes (ES) and ii) between‐group ES in comparison with different control conditions. Outcome was primarily measured on the Y‐BOCS and ES was calculated in the form of Cohens d. Results: Thirteen trials were included in the meta‐analysis. The overall pre–post‐ES of these trials of 1.18 and a between‐group ES of 1.12 compared with waiting list control in three randomized controlled studies indicate that group CBT/ERP is an effective treatment for OCD. Group CBT achieved better results than pharmacological treatment in two studies. One study found no significant differences between individual and group CBT. Conclusion: Group CBT is an effective treatment for OCD, but more studies are needed to compare the effectiveness of group and individual treatment formats.     

Negative,not positive symptoms predict the early therapeutic alliance in cognitive behavioral therapy for psychosis

Abstract

Objective: The strength of therapeutic alliance is consistently associated with therapy outcome. The aim of this study was to identify relevant predictors for early therapeutic alliance in cognitive behavioral therapy for psychosis. Method: Fifty-six patients with schizophrenia spectrum disorders were included in the analysis. Possible predictors (positive and negative symptoms, depression, insight, social functioning, theory of mind, and medication adherence) were assessed at baseline. Alliance was assessed after each therapy session. Results: Lower negative symptoms significantly predicted higher patient and therapist rated alliance. Conclusions: The findings indicate that negative symptoms might be a barrier to the development of therapeutic alliance. Assumed underlying processes and practical implications are discussed.     

Clinical efficacy of individual cognitive therapy in reducing psychiatric symptoms in people at ultra-high risk for psychosis

Aim: Recently, cognitive therapy in people at ultra‐high risk (UHR) for psychosis has been reported to show modest treatment benefits. The aim of this study was to assess the feasibility and efficacy of cognitive therapy in reducing psychiatric symptoms in UHR people in Korea. Methods: We developed cognitive therapy for people at UHR for psychosis inspired by Morrison in 2004. Twenty‐two UHR subjects were assigned to cognitive therapy, and 18 subjects completed the 10‐session therapy. Psychopathology scores were assessed at baseline and post‐treatment. Results: Cognitive therapy significantly reduced the severity of psychopathology including positive, negative and depressive symptoms. The within‐group effect sizes indicated large treatment benefits for these psychopathologies. Conclusion: These findings suggest that cognitive therapy can be administered to people at UHR for psychosis in non‐western culture.     

Cognitive-behaviour therapy for medication-resistant positive symptoms in early psychosis: a case series

Introduction: Cognitive-behaviour therapy (CBT) for psychosis reduces the severity of medication-resistant positive symptoms in chronic schizophrenia, but its efficacy for early psychosis outpatients with a similar profile has not been established. Objective: This paper describes an uncontrolled evaluation of CBT, added to medication and comprehensive care in an early psychosis program, in a group of stable outpatients. Patients: The sample was drawn from 24 consecutive referrals. Fourteen were eligible, i.e. had positive symptom(s) and had been on the same medication regime for 3 months. Treatment: Patients received an average of 16 individual sessions with a senior psychologist. Measures: Symptom severity was assessed both by an independent rater, and by patient self-report. Results: Eleven of 14 patients completed treatment. Both clinician and self-report post-treatment ratings of positive symptoms were significantly reduced following CBT. For positive symptom totals, effect sizes ranged from d = 1.0 to 1.3. Clinically significant changes were apparent in at least eight of 11 patients. Discussion: While case-series studies have significant limitations, the large effect sizes described here suggest that CBT shows promise for effectiveness with early psychosis patients. A randomized trial is needed to establish both the effect size over and above a control condition, and the durability of gains of CBT for medication-resistant symptoms in early psychosis.     

Delivering cognitive therapy to people with psychosis in a community mental health setting: an effectiveness study

OBJECTIVE: Cognitive therapy (CT) has been shown to be an efficacious treatment for persistent psychotic symptoms. However, there is some debate regarding whether this is transportable to real life clinical settings. This study aimed to evaluate the effectiveness of CT for psychosis in a community mental health team (CMHT) setting. METHOD: Patients referred for CT for psychosis were naturalistically allocated (determined by the availability of a therapist) to CT or waiting-list (WL)/treatment-as-usual (TAU). Outcome assessments were performed at WL, pre-CT, post-CT and 1-year follow-up. Data from 59 patients were analysed. RESULTS: Random effects regression analyses showed there was a significant improvement, attributable to CT, on most outcome measures, and that many of the symptomatic improvements were maintained at follow-up. Wilcoxon signed ranks tests indicated that there was a significant reduction in psychiatric hospital use following CT. CONCLUSION: These results confirm that CT is an effective treatment for psychosis that is generalizable to a community setting.     

认知行为疗法对首发精神分裂症疗效观察

目的:观察认知行为疗法对首发精神分裂症的临床疗效.方法:将首发精神分裂症患者177例,随机分为有无认知行为疗法两组.用简明精神病评定量表(BPRS)、自知力量表(insight scale)、功 能大体评定量表(GAF)、副反应量表(TESS)分别于入组前、治疗第2、4、8周末各评定1次,并比较两组住院时间、90项症状清单(SCL-90)总分.结果:研究组(有认知行为治疗)在治疗第4、8周末BPRS、insightscale、GAF评分较对照组(无认知行为治疗)改变显著.结论:早期认知行为疗法干预能明显改善首发精神分裂症临床症状,缩短住院时间.     

Stigma and treatment delay in first-episode psychosis: a grounded theory study

Aim: A longer duration of untreated psychosis (DUP) is associated with greater morbidity in the early course of schizophrenia. This formative, hypothesis-generating study explored the effects of stigma, as perceived by family members, on DUP. Methods: Qualitative interviews were conducted with 12 African American family members directly involved in treatment initiation for a relative with first-episode psychosis. Data analysis relied on a grounded theory approach. A testable model informed by constructs of Link's modified labelling theory was developed. Results: Four main themes were identified, including: (i) society's beliefs about mental illnesses; (ii) families' beliefs about mental illnesses; (iii) fear of the label of a mental illness; and (iv) a raised threshold for the initiation of treatment. A grounded theory model was developed as a schematic representation of the themes and subthemes uncovered in the family members' narratives. Conclusions: The findings suggest that due to fear of the official label of a mental illness, certain coping mechanisms may be adopted by families, which may result in a raised threshold for treatment initiation, and ultimately treatment delay. If the relationships within the grounded theory model are confirmed by further qualitative and quantitative research, public educational programs could be developed with the aim of reducing this threshold, ultimately decreasing DUP.     

Global research on cognitive behavioural therapy for schizophrenia from 2000 to 2019: a bibliometric analysis via CiteSpace

BackgroundCognitive 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.AimsTo understand the current situation and research trends of CBT for schizophrenia, and to provide valuable information for researchers in this field.MethodsLiterature 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.ResultsA 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.ConclusionsThe 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.     

Premorbid adjustment and remission of positive symptoms in first-episode psychosis

The impact of premorbid social and intellectual functioning in childhood and early adolescence on the developmental course of schizophrenia is not sufficiently understood. In a retrospective case study (93 consecutive in-patients, 43 males and 50 females) of first-episode psychosis occurring in adolescence, the relationship between premorbid adjustment and short-term therapeutic outcome under treatment conditions was examined. All of the patients had a DSM-111-R diagnosis of schizophrenia (n=56) or schizoaffective disorder (n=37). The mean age of the patients at the time of the study was 15.8 (SD=1.0). Premorbid functioning during childhood and early adolescence was assessed by using the Cannon-Spoor et al. Premorbid Adjustment Scale (PAS) and studied with respect to its prognostic relevance for short-term therapeutic outcome (eight weeks) under neuroleptic treatment (350–700 mg Chlorpromazin dose equivalent). Criteria for clinical outcome were obtained from the study by Pearlson et al. (1989) which defines three grades (complete remission, partial remission and no response), according to the degree of positive symptomatology. Statistical analysis was based on nonparametric variance analysis. Patients with complete remission of positive symptoms after eight weeks of therapy had experienced far better premorbid adjustment in early adolescence and in childhood. Diagnosis and gender did not bias this result. Our data suggest that premorbid social functioning is a crucial variable with regard to therapeutic outcome in first-episode psychosis. Previous studies have reported a relation between poor premorbid functioning and negative symptoms. We found premorbid adjustment related to the course of positive symptoms.     

Cognitive function and clinical symptoms in first-episode psychosis and chronic schizophrenia before and after the 2009 L'Aquila earthquake

Aim: On 6 April 2009, at 3:32 GMT, central Italy was struck by a 6.3‐magnitude earthquake with its epicentre near L'Aquila, the capital city of the Abruzzo region. Earthquakes may precipitate psychiatric symptoms. The aim of this study was to investigate cognitive functioning and positive and negative symptoms before and after the 2009 L'Aquila earthquake in patients with first‐episode psychosis (FEP) and chronic schizophrenia (CS). Methods: A total of 54 FEP patients (34 males and 20 females) and 63 CS patients (39 males and 24 females) were investigated. Psychometric scores were submitted to a 2 × 2 mixed analysis of variance, with group (FEP and CS) as the between‐subjects variable and time (pre‐ and post‐earthquake) as the within‐subjects variable. Results: Positive symptoms increased significantly from the pre‐ to the post‐earthquake assessment in FEP patients but not in those with CS. There were no significant differences between the pre‐ and post‐earthquake period in terms of negative symptoms in both groups. Compared with the pre‐earthquake assessment, FEP patients scored significantly worse at the post‐earthquake evaluation in terms of Wisconsin Card Sorting Test categories achieved, immediate verbal memory and delayed verbal memory. However, there were no significant differences in cognitive scores between the pre‐ and post‐earthquake periods in patients with CS. Conclusions: Our findings suggest that a disastrous earthquake has a negative impact on cognitive functioning and positive symptoms in FEP patients, but not in those with CS.     

Intensive group cognitive treatment and individual cognitive therapy vs. treatment as usual in social phobia: a randomized controlled trial

To compare the effects of an intensive group cognitive treatment (IGCT) to individual cognitive therapy (ICT) and treatment as usual (TAU) in social phobia (DSM-IV). METHOD: Hundred patients were randomized to: IGCT involving 16 group sessions spread over three weeks; ICT involving 16 shorter weekly sessions in 4 months and; TAU involving an indicated selective serotonin reuptake inhibitor (SSRI) with therapy sessions as required for 1 year. The main outcome measure was a Social Phobia Composite that combined several standardized self-report measures. Diagnostic assessment was repeated at 1-year follow-up. RESULTS: Significant improvements were observed with all treatments. ICT was superior to IGCT and TAU, which did not differ in overall effectiveness. CONCLUSION: The study confirms and extends previously reported findings that ICT is more effective than group cognitive treatment and treatment with SSRIs. IGCT lasts only 3 weeks, and is as effective as more protracted TAU.     

Three-year follow-up of a randomized controlled trial of cognitive therapy for the prevention of psychosis in people at ultrahigh risk

There have been recent advances in the ability to identify people at high risk of developing psychosis. This has led to interest in the possibility of preventing the development of psychosis. A randomized controlled trial compared cognitive therapy (CT) over 6 months with monthly monitoring in 58 patients meeting criteria for ultrahigh risk of developing a first episode of psychosis. Participants were followed up over a 3-year period. Logistic regression demonstrated that CT significantly reduced likelihood of being prescribed antipsychotic medication over a 3-year period, but it did not affect transition to psychosis defined using the Positive and Negative Syndrome Scale (PANSS) or probable Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis. However, exploratory analyses revealed that CT significantly reduced the likelihood of making progression to psychosis as defined on the PANSS over 3 years after controlling for baseline cognitive factors. Follow-up rate at 3 years was 47%. There appear to be enduring benefits of CT over the long term, suggesting that it is an efficacious intervention for people at high risk of developing psychosis.