Anthony P. Morrison

Antipsychotic drugs versus cognitive behavioural therapy versus a combination of both in people with psychosis: a randomised controlled pilot and feasibility study

Summary Background Little evidence is available for head-to-head comparisons of psychosocial interventions and pharmacological interventions in psychosis. We aimed to establish whether a randomised controlled trial of cognitive behavioural therapy (CBT) versus antipsychotic drugs versus a combination of both would be feasible in people with psychosis. Methods We did a single-site, single-blind pilot randomised controlled trial in people with psychosis who used services in National Health Service trusts across Greater Manchester, UK. Eligible participants were aged 16 years or older; met ICD-10 criteria for schizophrenia, schizoaffective disorder, or delusional disorder, or met the entry criteria for an early intervention for psychosis service; were in contact with mental health services, under the care of a consultant psychiatrist; scored at least 4 on delusions or hallucinations items, or at least 5 on suspiciousness, persecution, or grandiosity items on the Positive and Negative Syndrome Scale (PANSS); had capacity to consent; and were help-seeking. Participants were assigned (1:1:1) to antipsychotics, CBT, or antipsychotics plus CBT. Randomisation was done via a secure web-based randomisation system (Sealed Envelope), with randomised permuted blocks of 4 and 6, stratified by gender and first episode status. CBT incorporated up to 26 sessions over 6 months plus up to four booster sessions. Choice and dose of antipsychotic were at the discretion of the treating consultant. Participants were followed up for 1 year. The primary outcome was feasibility (ie, data about recruitment, retention, and acceptability), and the primary efficacy outcome was the PANSS total score (assessed at baseline, 6, 12, 24, and 52 weeks). Non-neurological side-effects were assessed systemically with the Antipsychotic Non-neurological Side Effects Rating Scale. Primary analyses were done by intention to treat; safety analyses were done on an as-treated basis. The study was prospectively registered with ISRCTN, number ISRCTN06022197. Findings Of 138 patients referred to the study, 75 were recruited and randomly assigned—26 to CBT, 24 to antipsychotics, and 25 to antipsychotics plus CBT. Attrition was low, and retention high, with only four withdrawals across all groups. 40 (78%) of 51 participants allocated to CBT attended six or more sessions. Of the 49 participants randomised to antipsychotics, 11 (22%) were not prescribed a regular antipsychotic. Median duration of total antipsychotic treatment was 44·5 weeks (IQR 26–51). PANSS total score was significantly reduced in the combined intervention group compared with the CBT group (–5·65 [95% CI −10·37 to −0·93]; p=0·019). PANSS total scores did not differ significantly between the combined group and the antipsychotics group (–4·52 [95% CI −9·30 to 0·26]; p=0·064) or between the antipsychotics and CBT groups (–1·13 [95% CI −5·81 to 3·55]; p=0·637). Significantly fewer side-effects, as measured with the Antipsychotic Non-neurological Side Effects Rating Scale, were noted in the CBT group than in the antipsychotics (3·22 [95% CI 0·58 to 5·87]; p=0·017) or antipsychotics plus CBT (3·99 [95% CI 1·36 to 6·64]; p=0·003) groups. Only one serious adverse event was thought to be related to the trial (an overdose of three paracetamol tablets in the CBT group). Interpretation A head-to-head clinical trial of CBT versus antipsychotics versus the combination of the two is feasible and safe in people with first-episode psychosis. Funding National Institute for Health Research.

Are Causal Beliefs Associated With Stigma? A Test of the Impact of Biogenetic Versus Psychosocial Explanations on Stigma and Internalized Stigma in People Experiencing Psychosis

Individuals with psychosis are often subject to external stigma and discrimination and commonly also experience internalized stigma. Attempts to improve attitudes have tended to medicalize the experiences associated with psychosis; however, research increasingly indicates an association between biogenetic attitudes and stigma. This study aims to evaluate this approach by investigating the impact of two different etiological explanations on both internalized and external stigma in people experiencing psychosis. A total of 60 participants who have a diagnosis of schizophrenia or meet criteria for early intervention services for psychosis were randomly allocated to one of two conditions (psychosocial vs. biogenetic). Attitudes were assessed before and after the intervention. Both interventions resulted in a decrease in internalized stigma. Only the psychosocial intervention decreased external stigma. Although further research is necessary, providing education to individuals could be an effective way to reduce internal stigma. Antistigma campaigns should avoid a singular focus on biogenetic explanations of psychosis, and a psychosocial viewpoint may be a suitable alternative.

Experimental Manipulation of Metacognitive Beliefs and Paranoia in a Non-clinical Population

Abstract Objective: The application of metacognitive processes in the development of paranoia has been examined, with tentative support evident. In the absence of causal conclusions, the present study examined the causal role of metacognitive beliefs in the development of paranoia by manipulating positive and negative metacognitive beliefs on paranoia frequency and distress. Method: A non-clinical sample (n = 110) was randomly assigned to either a positive or negative manipulation experimental group intended to alter beliefs about paranoia followed by a paranoia induction task (Cyberball task). Results: The positive beliefs induction was successful in manipulating metacognitive beliefs. Following the paranoia induction, the positive beliefs group reported an increase in paranoia frequency (F(1, 106) = 12.4, p = .001); the negative beliefs group reported a decrease in paranoia related distress (F(1, 104) = 8.21, p = .005). Conclusions: This is the first experimental manipulation of beliefs about paranoia study to show that positive beliefs about paranoia leads to the adoption of paranoia as a deliberate strategy for managing interpersonal threat. Findings from this novel experimental paradigm support the metacognitive prediction of the Self-Referent Executive Function model. Further investigation is needed in manipulating negative beliefs about paranoia and its impact on paranoia-related distress.

Internalised stereotypes across ultra-high risk of psychosis and psychosis populations

Abstract Internalised stigma is associated with negative psychological and social outcomes for people with psychosis. Research has shown stigma can impact on wellbeing and increase the risk of transition for people at risk of developing psychosis. There is limited knowledge regarding how internalised stigma differs across ultra-high risk of psychosis and psychosis populations. Using a cross sectional analysis, people at risk of psychosis (n = 238), with a first episode of psychosis (n = 39), and with recurrent episodes of psychosis (n = 27) were compared on a measure of internalised stigma. The strength of relationship between internalised stigma and emotional dysfunction was compared between the groups. Analysis of covariance revealed no differences between the three groups on level of internalised stereotypes or in the strength of relationship between internalised stereotypes and emotional dysfunction. For both groups greater levels of internalised stigma was associated with greater levels of anxiety and depression. Findings suggest that internalised stigma is equally problematic for people who meet criteria for being at risk as those who have established psychosis. Recommendations for educational campaigns which address stigma are made. Services which work with people at risk of psychosis and with psychosis should adopt optimistic, recovery-orientated approaches to minimise stereotype agreement.