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Background: The 11th revision to the WHO International Classification of Diseases (ICD-11) identified complex post-traumatic stress disorder (CPTSD) as a new condition. There is a pressing need to identify effective CPTSD interventions. Methods: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of psychological interventions for post-traumatic stress disorder (PTSD), where participants were likely to have clinically significant baseline levels of one or more CPTSD symptom clusters (affect dysregulation, negative self-concept and/or disturbed relationships). We searched MEDLINE, PsycINFO, EMBASE and PILOTS databases (January 2018), and examined study and outcome quality. Results: Fifty-one RCTs met inclusion criteria. Cognitive behavioural therapy (CBT), exposure alone (EA) and eye movement desensitisation and reprocessing (EMDR) were superior to usual care for PTSD symptoms, with effects ranging from g = −0.90 (CBT; k = 27, 95% CI −1.11 to −0.68; moderate quality) to g = −1.26 (EMDR; k = 4, 95% CI −2.01 to −0.51; low quality). CBT and EA each had moderate–large or large effects on negative self-concept, but only one trial of EMDR provided useable data. CBT, EA and EMDR each had moderate or moderate–large effects on disturbed relationships. Few RCTs reported affect dysregulation data. The benefits of all interventions were smaller when compared with non-specific interventions (e.g. befriending). Multivariate meta-regression suggested childhood-onset trauma was associated with a poorer outcome. Conclusions: The development of effective interventions for CPTSD can build upon the success of PTSD interventions. Further research should assess the benefits of flexibility in intervention selection, sequencing and delivery, based on clinical need and patient preferences. [ABSTRACT FROM AUTHOR]

To identify factors which may help or hinder decision-making ability in people with psychosis, we did a systematic review and meta-analysis of their performance on the Iowa and Cambridge Gambling Tasks. Analysis of 47 samples found they had moderately poorer performance than healthy individuals (N = 4264, g = −0.57, 95% confidence interval (CI) −0.66 to −0.48). Few studies (k = 8) used non-psychotic clinical comparator groups, although very low-quality evidence (k = 3) found people with bipolar disorder may perform better. Negative symptoms (k = 13, N = 648, r = −0.17, 95% CI −0.26 to −0.07) and lower IQ (k = 11, N = 525, r = 0.20, 95% CI 0.29–0.10), but not positive symptoms (k = 10, N = 512, r = −0.01, 95% CI −0.11 to 0.08), each had small-moderate associations with poorer decision-making. Lower quality evidence suggested general symptoms, working memory, social functioning, awareness of emotional responses to information, and attentional bias towards gain are associated with decision-making, but not education, executive functioning or overall symptoms. Meta-regression suggested an inverse association between decision-making and depression severity (k = 6, Q = 6.41, R 2 100%, p = 0.01). Those taking first-generation (k = 6, N = 305, g = −0.17, 95% CI −0.40 to 0.06, p = 0.147) or low-dose antipsychotics (k = 5, N = 442, g = −0.19, 95% CI −0.44 to 0.06, p = 0.139) had unimpaired decision-making. Although meta-regression found no linear association between dose and performance, non-reporting of the dose was common and associated with larger impairments (k = 46, Q = 4.71, R 2 14%, p = 0.03). Those supporting people with psychosis to make decisions, including treatment decisions, should consider the potential effect of these factors. Interventionist-causal trials are required to test whether reducing antipsychotic dose and treating anxiety and depression can improve decision-making in this group. [ABSTRACT FROM AUTHOR]

Objectives: The effectiveness of psychological therapies for those receiving acute adult mental health inpatient care remains unclear, partly because of the difficulty in conducting randomized controlled trials (RCTs) in this setting. The aim of this meta‐analysis was to synthesize evidence from all controlled trials of psychological therapy carried out with this group, to estimate its effects on a number of important outcomes and examine whether the presence of randomization and rater blinding moderated these estimates. Method: A systematic review and meta‐analysis of all controlled trials of psychological therapy delivered in acute inpatient settings was conducted, with a focus on psychotic symptoms, readmissions or emotional distress (anxiety and depression). Studies were identified through ASSIA, EMBASE, CINAHL, Cochrane, MEDLINE, and PsycINFO using a combination of the key terms ‘inpatient’, ‘psychological therapy’, and ‘acute’. No restriction was placed on diagnosis. The moderating effect of the use of assessor‐blind RCT methodology was examined via subgroup and sensitivity analyses. Results: Overall, psychological therapy was associated with small‐to‐moderate improvements in psychotic symptoms at end of therapy but the effect was smaller and not significant at follow‐up. Psychological therapy was also associated with reduced readmissions, depression, and anxiety. The use of single‐blind randomized controlled trial methodology was associated with significantly reduced benefits on psychotic symptoms and was also associated with reduced benefits on readmission and depression; however, these reductions were not statistically significant. Conclusions: The provision of psychological therapy to acute psychiatric inpatients is associated with improvements; however, the use of single‐blind RCT methodology was associated with reduced therapy‐attributable improvements. Whether this is a consequence of increased internal validity or reduced external validity is unclear. Trials with both high internal and external validity are now required to establish what type, format, and intensity of brief psychological therapy is required to achieve sustained benefits. Practitioner points: Clinical implications: This review provides the first meta‐analytical synthesis of brief psychological therapy delivered in acute psychiatric inpatient settings. This review suggests that brief psychological therapy may be associated with reduced emotional distress and readmissions. Limitations: The evidence in this review is of limited quality. The type, format, and intensity of brief psychological therapy required to achieve sustained benefits are yet to be established. [ABSTRACT FROM AUTHOR]

Background Previous meta-analyses have only found small correlations ( r = .10 to r = .19) between therapeutic alliance and clinical outcomes in samples of adolescents receiving psychological therapy. Although study-level variables have been found to moderate this, little is known about the impact of therapist variability. The present meta-analysis aimed to address this gap by using patient-therapist ratio as a moderator variable. Methods Contrary to previous reviews of adolescent alliance, individual effect sizes were extracted using a preregistered conceptual hierarchy. Controlling for treatment-level confounds, a random effects meta-analysis assessed the moderating effect of patient-therapist ratio on the alliance-outcome relationship in predefined single-predictor and multipredictor meta-regressions. Results The alliance-outcome relationship was found to be larger than previously thought ( k = 28, N = 2,911, r = .29, 95% Confidence Interval 0.21, 0.37; p < .0001, I 2 = 80%). When study samples exceeding the adolescent 12-19 age range were removed, the correlation rose ( k = 15, N = 1,797, r = .34, 95% Confidence Interval 0.23, 0.45; p < .0001, I 2 = 83%). In contrast to research with adults, patient-therapist ratio did not moderate this relationship in either single-predictor ( p = .26) or multi-predictor ( p = .22) models. Conclusions The alliance-outcome relationship for adolescents was larger than previously thought, and comparable to estimates in adult samples. The failure of patient-therapist ratio to moderate its strength, however, challenges the hypothesis that variability in therapist characteristics is an important determinant of the alliance-outcome effect in this age group. [ABSTRACT FROM AUTHOR]

Loneliness may be related to psychotic symptoms but a comprehensive synthesis of the literature in this area is lacking. The primary aim of the current study is to provide a systematic review and meta-analysis of the association between loneliness and psychotic symptoms in people with psychosis. A search of electronic databases was conducted (PsychINFO, MEDLINE, EMBASE, and Web of Science). A random effects meta-analysis was used to compute a pooled estimate of the correlation between loneliness and psychotic symptoms. Study and outcome quality were assessed using adapted versions of the Agency for Healthcare Research and Quality (AHRQ) tool and GRADE approach, respectively. Thirteen studies were included, providing data from 15 647 participants. A moderate association between psychosis and loneliness was observed (k = 13, N = 15 647, r = .32, 95% CI 0.20, 0.44; I² = 97.56%; moderate quality evidence). Whether loneliness was assessed by a single-item or a more comprehensive measure had no moderating effect on the estimate. Results indicate that there is a significant positive relationship between loneliness and psychosis. Further studies are needed to determine the causal status of this relationship, but this robust finding should be considered in clinical practice and treatment provision for those with psychotic disorders. [ABSTRACT FROM AUTHOR]

BackgroundThe evidence on factors that may influence treatment decisional capacity ('capacity') in psychosis has yet to be comprehensively synthesised, which limits the development of effective strategies to improve or support it.AimsTo determine the direction, magnitude and reliability of the relationship between capacity in psychosis and a range of clinical, demographic and treatment-related factors, thus providing a thorough synthesis of current knowledge.MethodWe conducted a systematic review, meta-analytical and narrative synthesis of factors that help or hinder treatment decision-making capacity in psychosis, assessing the direction, magnitude, significance and reliability of reported associations.ResultsWe identified 23 relevant studies (n = l823). Psychotic symptoms had small, moderate and strong associations with appreciation, understanding and reasoning respectively. Both verbal cognitive functioning and duration of education had small to moderate correlations with understanding and reasoning. Better capacity was also associated with better insight, better metacognitive ability, higher anxiety and lower perceived coercion. No linear relationship with depression was observed. Interventions linked to improved capacity over time were in-patient care, information simplification, shared decision-making and metacognitive training.ConclusionsAlthough much is known about the role of symptoms and other clinical variables, effective and acceptable psychological interventions to support capacity in this group are lacking. [ABSTRACT FROM AUTHOR]

Background: In the UK almost 60% of people with a diagnosis of schizophrenia who use mental health services say they are not involved in decisions about their treatment. Guidelines and policy documents recommend that shared decision-making should be implemented, yet whether it leads to greater treatment-related empowerment for this group has not been systematically assessed.Aims: To examine the effects of shared decision-making on indices of treatment-related empowerment of people with psychosis.Method: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of shared decision-making concerning current or future treatment for psychosis (PROSPERO registration CRD42013006161). Primary outcomes were indices of treatment-related empowerment and objective coercion (compulsory treatment). Secondary outcomes were treatment decision-making ability and the quality of the therapeutic relationship.Results: We identified 11 RCTs. Small beneficial effects of increased shared decision-making were found on indices of treatment-related empowerment (6 RCTs; g = 0.30, 95% CI 0.09-0.51), although the effect was smaller if trials with >25% missing data were excluded. There was a trend towards shared decision-making for future care leading to reduced use of compulsory treatment over 15-18 months (3 RCTs; RR = 0.59, 95% CI 0.35-1.02), with a number needed to treat of approximately 10 (95% CI 5-∞). No clear effect on treatment decision-making ability (3 RCTs) or the quality of the therapeutic relationship (8 RCTs) was found, but data were heterogeneous.Conclusions: For people with psychosis the implementation of shared treatment decision-making appears to have small beneficial effects on indices of treatment-related empowerment, but more direct evidence is required. [ABSTRACT FROM AUTHOR]

Background Immediate-release (IR) quetiapine has been used to treat schizophrenia since 1997, although all the principal placebo-controlled trials have 450% missing outcome data. New studies with relatively lower rates of participant withdrawal have since been published. Aims To assess the efficacy and adverse effects of quetiapine IR for schizophrenia, with consideration of outcome quality and clinical meaningfulness of results, and to examine the potential impact of missing data on the main efficacy findings. Method We conducted a systematic review and meta-analysis of randomised controlled trials comparing quetiapine IR and placebo (or subtherapeutic dose in relapse prevention trials) for the treatment of schizophrenia (PROSPERO registration CRD4201100165). Primary outcomes were change in overall symptoms and response rates. We also examined whether high rates of participant withdrawal (550%) attenuated effect sizes, and assessed the impact of making different assumptions about these people's outcomes. Results We identified 15 relevant trials (including 2 unpublished), providing the first 12-week data for this drug and the first data on self-reported quality of life. We found quetiapine IR to have a weighted mean difference (WMD) of 6.5 points (95% CI 78.9 to 74) on Positive and Negative Syndrome Scale (PANSS) total scores, which corresponds to a standardised mean difference (SMD) of 70.33 (95% CI 70.46 to 70.21). Longer trials reported larger mean differences favouring quetiapine IR, but the overall estimate was smaller if more conservative assumptions about the outcomes of people who left the trial early were made. Approximately 21 people needed to take quetiapine IR for 1 person to experience at least a 50% improvement in PANSS score. No difference in quality of life was observed (two RCTs), although small to moderate improvements in social functioning were found (three RCTs). Quetiapine IR caused sedation and increased rates of clinically significant weight gain, but no extrapyramidal effects were observed. Conclusions Quetiapine IR has a small beneficial effect on overall psychotic symptoms over 2-12 weeks, but also leads to weight gain and sedation. [ABSTRACT FROM AUTHOR]

Background:Cognitive behavioural therapy (CBT) is a recommended treatment for people with psychosis, with meta-analyses showing important benefits when compared to treatment as usual (TAU). However, there has been growing debate as to whether CBT has specific benefits over and above those attributable to less intensive psychosocial interventions, such as befriending and supportive counselling. Recent meta-analyses examining this question have suffered from various difficulties including potential bias and error. After detailing these problems, we present a protocol for a new review.Methods and design:The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, previous reviews and online trial registers will be systematically searched for randomised trials examining the efficacy and safety of CBT for psychosis, when compared to (a) TAU and (b) other psychosocial treatments. Primary outcomes are symptomatic change and numbers achieving clinically significant improvement. Secondary outcomes include adverse effects, change in target complaint, subjectively defined recovery and relapse.Discussion:This review will provide service users, relatives and policy-makers with a comprehensive and up-to-date assessment of the efficacy and safety of CBT for psychosis. Advance publication and peer-review of hypotheses and methods should maximise transparency, enhancing the reliability and quality of the findings. [ABSTRACT FROM PUBLISHER]

Newton-Howes and Wood (published online, this journal, 8 Dec 2011) report the results of their systematic review and meta-analysis of clinical trials of cognitive-behavioural therapy ( CBT) for schizophrenia. They ran a random effects analysis of endpoint data from trials where participants were randomly allocated to receive either CBT or a control therapy, which could be inactive (e.g., befriending) or active (e.g., analytic supportive psychotherapy), found no difference between the groups and concluded 'it ( CBT) does not outperform supportive therapy in effecting change in phenomenology.' Such a conclusion is premature, if not unwarranted, for a number of reasons, including basic mistakes, lack of transparency, and failure to consider dose. [ABSTRACT FROM AUTHOR]

Background: No previous meta-analyses have specifically investigated the effectiveness of psychological group therapy for symptoms associated with complex interpersonal trauma, including whether trauma memory processing (TMP) therapies are superior to psychoeducational approaches alone.Methods: A systematic review identified 36 randomised control trials (RCTs) which were included in the meta-analysis.Results: Large significant effect sizes were evident for TMP interventions when compared to usual care for three outcome domains including: PTSD (k = 6, g = -0.98, 95% CI -1.53, -0.43), Depression (k = 7, g = -1.12, 95% CI -2.01, -0.23) and Psychological Distress (k = 6, g = -0.98, 95% CI 1.66, -0.40). When TMP and psychoeducation interventions were directly compared, results indicated a small non-significant effect in favour of the former for PTSD symptoms, (k = 4, g = -0.34, 95% CI -1.05, 0.36) and small non-significant effect sizes in favour of the latter for Depression (k = 3, g = 0.29, 95% CI -0.83, 1.4) and Psychological Distress (k = 6, g = 0.19, 95% CI -0.34, 0.71).Limitations: Heterogeneity and a limited number of high quality RCTs, particularly in the Substance Misuse and Dissociation domains, resulted in uncertainty regarding meta-analytical estimates and subsequent conclusions.Conclusions: Results suggest that TMP interventions are useful for traumatic stress whereas non-TMP interventions can be useful for symptoms of general distress (e.g. anxiety and depression). Thus, both TMP and psychoeducation can be useful for the treatment of complex interpersonal trauma symptoms and further research should unravel appropriate sequencing and dose of these interventions. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Cognitive behavioural therapy for psychosis: Rationale and protocol for a systematic review and meta-analysis" that was published in the previous issue.

Background: People diagnosed with schizophrenia have significant difficulty accurately recognising emotions expressed by others. This may generate anomalous experiences which, if misinterpreted, could contribute to experiences of social defeat, psychotic symptoms and reduced social functioning. It remains unclear whether this impairment is responsive to non-pharmacological intervention, or what the effect of modifying it is.Methods: We did a systematic review and meta-analysis to examine whether and to what extent facial affect recognition impairments can be improved by psychological intervention and, if so, whether this leads to improvements in psychotic symptoms and social functioning.Results: A total of 8 randomised controlled trials (RCTs) consisting of 300 participants were included. Focused yet brief psychological interventions led to very large improvements in facial affect recognition ability in psychosis [k=8, N=300, g=1.26, 95% Confidence Interval (CI) 0.92, 1.60, I2 41%]. Early evidence suggests this may cause large improvements in social functioning (k=3, N=109, g=0.98, 95% CI 0.37, 1.36, I2 38%), but not psychotic symptoms.Conclusions: Facial affect recognition difficulties in schizophrenia are highly responsive to psychological interventions designed to improve them, and there is early evidence that this may lead to large gains in social functioning for this group - but not symptoms. A large-scale high-quality RCT with longer-term follow-up period is now required to overcome the limitations of the existing evidence. [ABSTRACT FROM AUTHOR]