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Articles   |    
Psychological Interventions for Psychosis: A Meta-Analysis of Comparative Outcome Studies
David Trevor Turner, M.Sc., M.Sc.Res.; Mark van der Gaag, Ph.D.; Eirini Karyotaki, M.Sc.Res.; Pim Cuijpers, Ph.D.
Am J Psychiatry 2014;171:523-538. doi:10.1176/appi.ajp.2013.13081159
View Author and Article Information

The authors report no financial relationships with commercial interests.

From the Department of Clinical Psychology, VU University, Amsterdam, the Netherlands; and the Department of Psychosis Research, Parnassia Psychiatric Institute, The Hague, the Netherlands.

Address correspondence to Mr. Turner (d.t.turner@vu.nl).

Copyright © 2014 by the American Psychiatric Association

Received August 30, 2013; Revised November 21, 2013; Accepted December 19, 2013.


Objective  Meta-analyses have demonstrated the efficacy of various interventions for psychosis, and a small number of studies have compared such interventions. The aim of this study was to provide further insight into the relative efficacy of psychological interventions for psychosis.

Method  Forty-eight outcome trials comparing psychological interventions for psychosis were identified. The comparisons included 3,295 participants. Categorization of interventions resulted in six interventions being compared against other interventions pooled. Hedges’ g was calculated for all comparisons. Risk of bias was assessed using four items of the Cochrane risk of bias tool, and sensitivity analyses were conducted. Researcher allegiance was assessed, and sensitivity analyses were conducted for robust significant findings.

Results  Cognitive-behavioral therapy (CBT) was significantly more efficacious than other interventions pooled in reducing positive symptoms (g=0.16). This finding was robust in all sensitivity analyses for risk of bias but lost significance in sensitivity analyses for researcher allegiance, which suffered from low power. Social skills training was significantly more efficacious in reducing negative symptoms (g=0.27). This finding was robust in sensitivity analyses for risk of bias and researcher allegiance. Significant findings for CBT, social skills training, and cognitive remediation for overall symptoms were not robust after sensitivity analyses. CBT was significantly more efficacious when compared directly with befriending for overall symptoms (g=0.42) and supportive counseling for positive symptoms (g=0.23).

Conclusions  There are small but reliable differences in efficacy between psychological interventions for psychosis, and they occur in a pattern consistent with the specific factors of particular interventions.

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FIGURE 1. Flowchart of Study Selection

FIGURE 2. Main Results of Comparisons of Psychological Interventions for Psychotic Symptomsa

a The other main comparisons did not result in significant findings. This figure does not include sensitivity analyses for risk of bias or researcher allegiance; complete results are presented in Tables 3 and 4. CBT=cognitive-behavioral therapy.

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TABLE 1.Definitions of Psychological and Psychosocial Treatments of Psychosisa
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a Nst=number of studies; Np=number of participants who received the intervention.

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TABLE 2.Selected Characteristics of Studies Comparing Psychological or Psychosocial Interventions for Psychosisa
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a AT=art therapy; BAI=Beck Anxiety Inventory; BAVQ=Beliefs About Voices Questionnaire; BDI=Beck Depression Inventory; BF=befriending; BPRS=Brief Psychiatric Rating Scale; BSI=Brief Symptom Inventory; BP=body psychotherapy; CBT=cognitive-behavioral therapy; CDSS=Calgary Depression Scale for Schizophrenia; CGI=Clinical Global Impressions scale; CH=command hallucinations; CPRS=Comprehensive Psychopathological Rating Scale; CR=cognitive remediation; FI=family intervention; GAS=Global Assessment Scale; HAM-D=Hamilton Depression Rating Scale; MADRS=Montgomery-Åsberg Depression Rating Scale; MADS=Maudsley Assessment of Delusions Schedule; N=number of participants in treatment group; OT=occupational therapy; PANSS=Positive and Negative Syndrome Scale; PAS=Psychiatric Assessment Scale; PE=psychoeducation; PSE=Present State Examination; PSYRATS=Psychotic Symptom Rating Scale; PST=problem-solving therapy; RDC=Research Diagnostic Criteria; SANS=Scale for the Assessment of Negative Symptoms; SAPS=Scale for the Assessment of Positive Symptoms; SC=supportive counseling; SCL-90=Symptom Checklist–90; SST=social skills training.

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TABLE 3.Effect Sizes for Psychological Interventions Compared With Other Interventions Pooleda
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a All comparisons were made using a random-effects model. Risk-of-bias analyses were included only in instances where at least four studies were available. N=number of comparisons; PANSS=Positive and Negative Syndrome Scale.

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TABLE 4.Direct Comparisons of Interventions, Segregation of CBT Subtypes, and Subgroup Analyses for Therapy Format, and for Researcher Allegiance in Robust Significant Findingsa