Therapy Challenging Cognitive Biases Reduces Symptoms of Psychosis, Meta-Analysis Suggests

Metacognitive training (MCT) for psychosis—which helps patients learn to question unfounded assumptions known as cognitive biases that contribute to their symptoms—was associated with reduced delusions and hallucinations and improved self-esteem and functioning, according to a report in JAMA Psychiatry. Common cognitive biases in people with psychosis include jumping to conclusions, inflexibility about one’s beliefs, and overconfidence in one’s judgments.

“[T]he benefits of MCT were maintained up to one year after the intervention,” said lead author Danielle Penney, a Ph.D. candidate at Douglas Research Center of McGill University, in a press release. “More generally, these findings support the utility of MCT as an effective tool that can be offered by mental health care workers across health care settings … .”

The researchers analyzed 43 studies of MCT involving 1,816 participants. Of the 43 studies, 30 were randomized, controlled trials (RCTs); 11 were non-RCTs; and two were quantitative descriptive studies. The researchers examined the effect of MCT on global symptoms, delusions, hallucinations, and cognitive biases. They also looked at the effect of MCT on self-esteem, negative symptoms, quality of life, well-being, and functioning.

MCT reduced all symptoms examined, with effect sizes that ranged from small (0.16 for cognitive biases, 0.17 for self-esteem, 0.23 for negative symptoms, and 0.26 for hallucinations) to medium (0.41 for functioning and 0.50 for positive symptoms) and large (0.69 for delusions). Moreover, analysis of RCTs found that both treatment and control groups maintained the therapeutic level reached at the end of treatment for all outcomes at the one-year follow-up.

The effects of MCT on symptoms in people with psychosis were similar to the effects reported in studies of cognitive-behavioral therapy for psychosis and cognitive remediation. Previous analyses of cognitive-behavioral therapy for psychosis found small to moderate effects on delusions and small effects on hallucinations, negative symptoms, and functioning. Similarly, prior meta-analyses of cognitive remediation have reported small to moderate effects for negative symptoms, global symptoms, and functioning.

The researchers concluded: “These findings provide some evidence to consider MCT in international treatment guidelines, and the focus may now shift toward implementation and cost-effectiveness trials in real-world clinical settings.”

For related information, see the Psychiatric News article “Therapy Targeting Cognitive Biases Reduces Delusions in Psychosis.”

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Specialized Psychotherapy Found to Reduce Severity of Delusions in Patients With Schizophrenia

Participating in a brief course of individualized metacognitive training—a psychotherapy designed to specifically target delusional beliefs—can reduce the severity of delusions and positive symptoms in patients with schizophrenia, according to a study published Tuesday in Schizophrenia Bulletin.

The study found that patients who received metacognitive training had significant reductions in delusional thinking compared with patients who received cognitive remediation, a program designed to improve cognitive abilities. These improvements were maintained at six months.

The findings “suggest that even brief psychotherapy can help to ameliorate the symptoms of psychosis,” Ryan P. Balzan, Ph.D., of Findlers University in Adelaide, Australia, and colleagues wrote.

Patients aged 18 to 65 with a schizophrenia spectrum diagnosis and delusional beliefs were recruited for the study. Of the 54 patients included in the trial, 52 were taking antipsychotic medications; these patients continued to receive their medication throughout the study.

The patients were randomly assigned to metacognitive training or cognitive remediation. Patients in the metacognitive training group completed four two-hour sessions with a therapist over one month, where they learned techniques for increasing awareness of their own cognitive biases that may contribute to the formation and maintenance of their delusional beliefs (for example, overconfidence and belief inflexibility). Patients in the cognitive remediation group completed four therapist-led, 90-minute to two-hour sessions over the same timeframe, during which they focused on improving working and verbal memory, processing speed, problem-solving, and attention—cognitive domains commonly impaired in patients with schizophrenia.

The researchers assessed the patients’ delusions, positive symptoms, performance in several cognitive domains, and clinical insight (awareness of and attitudes toward mental illness) at the start of the trial, following the completion of the four therapy sessions, and six months later. Two patients did not complete the six-month assessment.

Patients in the metacognitive training group showed significant reductions in delusional and overall positive symptom severity and improved clinical insight relative to patients in the cognitive remediation group. In contrast, compared with those in the metacognitive training group, patients in the cognitive remediation group showed moderate improvement in problem-solving ability but in no other cognitive domains. The authors wrote that this suggests “more CR [cognitive remediation] might be required to be effective in these domains.”

In conclusion, the authors wrote, “While larger multisite trials investigating MCT+ [metacognitive training] are warranted, the present study adds to the growing literature that psychological interventions can be effective in people with psychosis.”

For related information, see the American Journal of Psychotherapy article “Application of Integrative Metacognitive Psychotherapy for Serious Mental Illness.”

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