Contextual Cognitive-Behavioral Therapies Across the Psychosis Continuum: A Review of Evidence for Schizophrenia, Schizoaffective and Bipolar Disorders

May combine two claims.

CBT limitations have been identified, particularly high dropout rates, relapse prevention, and difficulties in maintaining the focus of treatment on positive symptoms after remission.

“Nevertheless, despite the considerable body of evidence concerning CBT efficacy for the psychosis continuum (e.g., Wykes et al., 2008;Thase, Kingdon, & Turnington, 2014), CBT limitations have been identified, particularly regarding high dropout rates (Startup, Jackson, Evans, & Bendix, 2005), relapse prevention (Garety et al., 2008;Lam, Hayward, Watkins, Wright, & Sham, 2005), and difficulties in”

• cites Startup, Jackson, Evans, & Bendix, 2005 sourceNot checked — no full text of the source
• cites Garety et al., 2008 sourceSupported
• cites Lam, Hayward, Watkins, Wright, & Sham, 2005 sourceNot checked — no full text of the source

May combine two claims.

The psychosis continuum includes cases with both psychotic and affective features (schizoaffective or mixed disorders) that often are treated as diagnosis of exclusion and disregarded from research.

“This continuum would include cases with both psychotic and affective features (schizoaffective or mixed disorders) that often are treated as diagnosis of exclusion and disregarded from research (Cheniaux et al., 2008;Craddock et al., 2009).”

• cites Cheniaux et al., 2008 sourceNot checked — no full text of the source
• cites Craddock et al., 2009 sourceSupported

May combine two claims.

Psychosocial interventions appear beneficial for patients with a diagnosis within the psychosis continuum in a wide range of areas, namely positive symptoms, functioning, relapse rates, affective symptoms, anxiety symptoms, social and vocational functioning.

“Data suggests that psychosocial interventions appear beneficial for patients with a diagnosis within the psychosis continuum in a wide range of areas, namely regarding positive symptoms, functioning, relapse rates, affective symptoms, anxiety symptoms, social and vocational func-tioning (e.g., Huxley, Rendall, & Sederer, 2000;Miziou et al., 2015;Richardson, 2010;Wykes, Steel, Everitt, & Tarrier, 2”

• cites Huxley, Rendall, & Sederer, 2000 sourceNot checked — no full text of the source
• cites Miziou et al., 2015 sourcePartly supported

  The Discussion (page unavailable) reports benefits for selected outcomes in bipolar disorder, including relapse prevention, depressive symptoms, anxiety and overall functioning. It says most evidence concerns bipolar I disorder, with only rare data on schizoaffective disorder; it does not establish benefits across the psychosis continuum or for positive symptoms. The Results (page unavailable) also report no improvement in social functioning in a bipolar/schizoaffective trial. (LLM, conf=0.88)

  Experimental — accuracy not yet measured
• cites Richardson, 2010 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The methods of the present review were based on the recommendations of the Cochrane Collaboration and the PRISMA guidelines.

“The methods of the present review were based on the recommended by the Cochrane Collaboration (Higgins & Green, 2011) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Liberati et al., 2009).”

• cites Higgins & Green, 2011Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Liberati et al., 2009 sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Within the recovery-oriented approach, several integrative models have emerged, including contextual cognitive-behavioral therapies (CCBT).

“Within this approach several integrative models have emerged (for a review, see Hamm, Hasson-Ohayon, Kukla, & Lysaker, 2013), including the contextual cognitive-behavioral therapies (CCBT).”

• cites Hamm, Hasson-Ohayon, Kukla, & Lysaker, 2013 sourcePartly supported

  The section “Recovery movement and implications for the evolution of psychotherapy for schizophrenia” says that several integrative psychotherapy models have been proposed in response to the recovery movement. The paper does not identify contextual cognitive-behavioral therapies (CCBT) as one of those models; its Conclusions instead say it did not include ACT, a third-wave behavioral therapy, among the emerging integrative treatments. No page numbers were provided in our copy. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim.

A recovery-oriented approach to psychotherapy for the psychosis continuum has been advocated, focused on self-experience and promoting more flexible courses of action to pursue a meaningful and self-determined life.

“It has been advocated, for the psychosis continuum, a recovery-oriented approach to psychotherapy which is focused on self-experience and promotes more flexible courses of action in order to pursue a meaningful and self-determined life (Lysaker, Glynn, Wilkniss, & Silverstein, 2010).”

• cites Lysaker, Glynn, Wilkniss, & Silverstein, 2010 sourcePartly supported

  The conceptual-basis section proposes recovery-oriented psychotherapy focused on self-experience in schizophrenia. The Summary and conclusions says it might help people with schizophrenia formulate courses of action more flexibly and shape meaningful, self-determined lives. The cited paper frames this proposal around schizophrenia, not the broader psychosis continuum named in the claim. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim.

There is a problem of positive bias in reviews toward or in favor of the testing hypothesis.

“Several authors alert for the problem of a positive bias in reviews toward or in favor of the testing hypothesis (e.g., Fanelli, 2010).”

• cites Fanelli, 2010 sourcePartly supported

  The Introduction (page unavailable) says confirmation bias can affect how scientists collect, interpret, and publish data, producing an excess of results supporting tested hypotheses. The Discussion section on non-publication (page unavailable) also describes a bias against negative results. Neither passage establishes that this bias occurs specifically in reviews; the paper discusses research papers and publication decisions. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

The review included 17 articles.

“A total of 17 articles were included.”

May combine two claims.

Efficacy data regarding clinical outcomes, although preliminary and in need of further replication, show promising results both in terms of symptom reduction and regarding increased quality of life and relationship with symptoms.

“Efficacy data regarding clinical outcomes, although preliminary and in need of further replication, show promising results both in terms of symptom reduction and regarding increased quality of life and relationship with symptoms.”

May combine two claims.

CFT found improvement regarding depressive symptoms, social marginalization, and observed clinical improvement.

“Although with only one study each, CFT found improvement regarding depressive symptoms, social marginalization, and observed clinical improvement;”

Probably not a substantial claim: may not pass S4 (based).

To the authors' knowledge, there are no comprehensive reviews of CCBT considering the psychosis continuum.

“To our knowledge there are no comprehensive reviews of CCBT considering the psychosis continuum.”

May combine two claims.

Overall this approach revealed to be feasible and highly acceptable for this population.

“Overall this approach revealed to be feasible and highly acceptable for this population.”

May combine two claims.

Attrition rates were higher than expected, but this result can be influenced by sample size.

“Regarding attrition rates, we found higher values than expected but this result can be influenced by sample size (small samples may be causing small dropout numbers appear as high percentages).”

May combine two claims.

Acceptance-based interventions found improvement in distress related to symptoms, social interference, depressive symptoms, psychotic symptoms, global functioning, quality of life, and insight.

“acceptance-based interventions found improvement in distress related to symptoms, social interference, depressive symptoms, psychotic symptoms, global functioning, quality of life, insight.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Six studies did not report effect size analysis for the between-group comparisons.

“Six studies did not report effect size analysis for the between-group comparisons.”

May combine two claims.

Long-term therapy effects' studies reported maintained or enhanced effects at follow-up (up to 24 months for Mindfulness, and 12 months for ACT).

“Long-term therapy effects' studies reported maintained or enhanced effects at follow-up (up to 24 months for Mindfulness, and 12 months for ACT).”

May combine two claims.

The main outcomes with benefits from CCBT were psychotic symptoms (four studies), hospitalization rates (two studies), social interference, functioning, or work performance (four studies), distress and emotion regulation (two studies), depressive symptoms and/or anxiety (six studies), and insight (one study).

“In terms of outcome measures, a wide range of measures were found, the main outcomes with benefits from CCBT reported were related to psychotic symptoms (four studies), hospitalization rates (two studies), social interference, functioning, or work performance (four studies), distress and emotion regulation (two studies), depressive symptoms and/or anxiety (six studies), insight (one study).”

Classified as probably not a substantial claim.

The trial regarding DBT was not necessarily intended to address bipolar disorder with psychotic features.

“Specifically, the trial regarding DBT was not necessarily intended to address bipolar disorder with psychotic features; therefore, studies should also address the efficacy of this approach in affective and non-affective psychosis.”

May combine two claims.

The largest sample size (for randomization) was 96 patients and the smallest study included 23 participants.

“In this review, we found that the largest sample size (for randomization) was 96 patients and the smallest study included 23 participants.”

May combine two claims.

A small number of studies performed mediational analysis, correlational analysis, or used an active control condition.

“A small number of studies performed mediational analysis, correlational analysis (changes in outcome associated with changes in process measures) or used an active control condition.”

May combine two claims.

The included studies were all treatment studies, randomized and controlled, assessing efficacy and/or feasibility of CCBT for disorders in the psychosis continuum.

“The studies included in this review were all treatment studies, randomized and controlled, assessing efficacy and/or feasibility of CCBT for disorders in the psychosis continuum (schizophrenia, schizoaffective disorder, and/or bipolar disorder).”

Probably not a substantial claim: may not pass S3 (load-bearing).

The most common design was pre and post intervention assessments (seven studies).

“Regarding post-intervention assessment, the most common design was pre and post intervention assessments (seven studies).”

May combine two claims.

Mindfulness interventions found improvement regarding anxiety, depressive symptoms, insight, psychotic symptoms, and functioning.

“Specifically, mindful-ness interventions found improvement regarding anxiety, depressive symptoms, insight, psychotic symptoms, and functioning;”

May combine two claims.

DBT reduced depressive symptoms, fear of emotional states, and improved control over emotional states.

“and DBT reduced depressive symptoms, fear of emotional states, and improved control over emotional states.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A total of 519 potentially relevant articles were identified, retrieved, and screened for potential inclusion.

“A total of 519 potentially relevant articles were identified, retrieved, and screened for potential inclusion.”

May combine two claims.

The most common comparison group used was TAU and only three studies included active control groups.

“The most common comparison group used was TAU and only three studies included active control groups.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

A growing number of studies are including more than one follow-up assessment in their research protocols.

“A growing number of studies are including more than one follow-up assessment in their research protocols.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A total of 17 studies were included in the final stage of the review.

“a total of 17 studies were included in the final stage of the review”

May combine two claims.

Few studies have associated changes in acceptance, mindfulness, and compassion with changes in other outcomes (e.g., depression, social interference) or used these variables to perform mediational analysis.

“few studies have associated changes in these variables with changes in other outcomes (e.g., depression, social interference) or used these variables to perform mediational analysis.”

May combine two claims.

The overall evidence on efficacy of CCBT for the psychosis continuum was promising and preliminary (in need of replication).

“The overall evidence on efficacy was promising and although preliminary (and in need of replication)”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Four studies used previous studies' samples to analyze long-term effects of intervention (N = 2) and mechanisms of change (N = 2).

“Four studies used previous studies' samples to analyze long-term effects of intervention (N = 2) and mechanisms of change (N = 2).”

Classified as probably not a substantial claim.

The included interventions encompass several common characteristics if analyzed in the light of CCBT framework.

“the included interventions encompass several common characteristics if analyzed in the light of CCBT framework.”

Classified as probably not a substantial claim. May combine two claims.

International clinical guidelines recommend several psychosocial interventions such as CBT both for people with persisting psychotic symptoms and people in remission, family interventions, arts therapies, assertive community treatment, supported employment, skills training, and token economy interventions.

“Therefore, international clinical guidelines recommend the offer of several psychosocial interventions such as Cognitive-Behavioral Therapy (CBT) both for people with persisting psychotic symptoms and people in remission, family interventions (Kreyenbuhl, Buchanan, Dickerson, & Dixon, 2009;NICE, 2014), and additionally arts therapies (NICE, 2014), assertive community treatment, supported employ”

• cites Kreyenbuhl, Buchanan, Dickerson, & Dixon, 2009Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites NICE, 2014Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

The conceptual perspective on treatment has changed.

“The conceptual perspective on treatment has changed, nevertheless the outcomes assessed are still symptom-focused and there is still need for improvement.”

May combine two claims.

There are neuropharmacological mechanisms in common between schizophrenia and bipolar disorder, such as elevations in dopamine receptor and good response to dopamine blockade.

“(b) neuropharmacological mechanisms in common, such as elevations in dopamine receptor (Pearlson et al., 1995) and good response to dopamine blockade in both disorders (for a review, see Murray et al., 2004);”

• cites Pearlson et al., 1995Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Murray et al., 2004 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Three main diagnostic categories emerge in the literature and are corroborated by DSM-5 as distinctive and independent entities: schizophrenia, schizoaffective disorder, and bipolar disorder.

“Regarding psychotic disorders and major affective disorders, three main diagnostic categories emerge in the literature and are corroborated by DSM-5 as distinctive and independent entities: schizophrenia, schizoaffective disorder, and bipolar disorder.”

• cites American Psychiatric Association, 2013Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Limitations such as small sample sizes, passive control conditions, and no control of confounding variables limit the generalizability of results.

“Limitations such as small sample sizes, passive control conditions, no control of confounding variables among others limit the generalizability of results.”

• cites Shonin et al., 2014 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Davis and Kurzban (2012) concluded that there is preliminary evidence to support that mindfulness-based treatment provides benefits for patients regarding symptom-associated distress, self-efficacy, and hospitalizations.

“Davis and Kurzban (2012) concluded that there is preliminary evidence to support the notion that mindful-ness-based treatment provides benefits for patients namely regarding symptom-associated distress, self-efficacy, and hospitalizations.”

• cites Davis and Kurzban, 2012 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Shonin et al. (2014) concluded that mindfulness meditation appears to have a beneficial role in the treatment of psychosis when specific adaptations are made.

“Shonin et al. (2014) presented a systematic review specifically on mindfulness meditation for psychosis (excluding therapeutic approaches using mindfulness as adjunct as for instance, ACT) and concluded that mindfulness meditation appears to have a beneficial role in the treatment of psychosis when specific adaptations are made.”

• cites Shonin et al., 2014 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims. The quote only partly states this claim.

Within the psychosis continuum, CCBT may have the potential to be particularly suited for several reasons, including promoting awareness and acceptance, reducing shame and self-criticism, focusing on values, helping regulate emotions, and the absence of questioning content or rationality might bring advantages in therapy adherence.

“Within the psychosis continuum, CCBT may have the potential to be particularly suited for several reasons:”

May combine two claims.

The quality assessment was dependent on the information reported in the articles retrieved, so the evaluation may have suffered from a positive bias (unclear assessment instead of a high risk of bias assessment).

“This quality assessment was dependent on the information reported in the articles retrieved; therefore, our evaluation may have suffered from a positive bias (unclear assessment instead of a high risk of bias assessment).”

Probably not a substantial claim: may not pass S3 (load-bearing).

When compared with a control group, a smaller effect size was found for mindfulness-based interventions for psychosis.

“However, when compared with a control group, a smaller effect size was found.”

• cites Khoury, Lecomte, Gaudiano, and Paquin, 2013 sourceNot checked — no full text of the source

May combine two claims.

A 2013 meta-analysis by Khoury, Lecomte, Gaudiano, and Paquin presented results emphasizing the moderate efficacy (pre-post analyses) of mindfulness-based interventions for psychosis, with therapeutic gains being maintained at follow-up.

“In 2013, a meta-analysis conducted by Khoury, Lecomte, Gaudiano, and Paquin, presented results emphasizing the moderate efficacy (pre-post analyses) of mindfulness-based interventions for psychosis, with therapeutic gains being maintained at follow-up.”

• cites Khoury, Lecomte, Gaudiano, and Paquin, 2013 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

A PICOS approach was used for defining criteria for inclusion and exclusion of studies.

“A PICOS approach was used for defining criteria for inclusion and exclusion of studies and can be consulted on Table 1.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Recent efforts are being made to test the efficacy of MCT in the psychosis continuum.

“Nevertheless, to our knowledge recent efforts are being made to test the efficacy of MCT in this population (e.g., Morrison et al., 2014).”

• cites Morrison et al., 2014 sourceNot checked — no full text of the source

Classified as probably not a substantial claim. May combine two claims.

Leading electronic databases (MEDLINE/PUBMED, PsycINFO, Cochrane Library), OpenGrey, and ClinicalTrials.gov were searched.

“Therefore OpenGrey database was additionally searched and during the identification and selection phases all types of records were considered (including dissertation abstracts, proceedings abstracts, and other).Registered clinical trials (ClinicalTrials.gov)with results were also considered.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The Shonin et al. review stated that results from available studies are not yet sufficient to demonstrate efficacy of mindfulness-based interventions for psychosis.

“Nevertheless, the review stated that the results from available studies are not yet sufficient to demonstrate efficacy of mindfulness-based interventions for psychosis.”

• cites Shonin et al., 2014 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Results were found stronger for negative symptoms.

“Results were found stronger for negative symptoms.”

• cites Khoury, Lecomte, Gaudiano, and Paquin, 2013 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The records were independently reviewed for eligibility by two authors.

“The records were independently reviewed for eligibility by two authors (MJM and PC): the screening phase was based on title and abstract examination; and the eligibility phase was performed through full text review.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The broad scope of terms analyzed in this review can introduce bias in the generalization of the results.

“Such a broad scope of terms being analyzed can introduce bias in the generalization of the results.”

Probably not a substantial claim: may not pass S2 (checkable).

Including all diagnoses in the psychosis continuum may be an advantage to inform clinical practice.

“the fact that this review included all diagnosis in the psychosis continuum may be an advantage to inform clinical practice.”

• AssumptionRests on an assumption: Schizophrenia, schizoaffective disorder, and bipolar disorder belong to a single psychosis continuum.

Probably not a substantial claim: may not pass S3 (load-bearing).

This review did not include quantitative analysis of data.

“the other limitation that can be pointed out is the absence of quantitative analysis of data.”

May combine two claims.

This review only included published results, which can introduce a bias in the results.

“in its final results this review only included published results (as a result of the rigorous eligibility criteria) which can introduce a bias in the results.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Other intervention study designs (practical studies) can bring valuable contributions in terms of effectiveness assessment, adaptability to the real settings where the intervention will be applied, and generalizability for the majority of the target population.

“other intervention study designs (practical studies) can bring valuable contributions in terms of effectiveness assessment, adaptability to the real settings where the intervention will be applied, and generalizability for the majority of the target population (Prince, Stewart, Tamsin, & Hotopf, 2003).”

• cites Prince, Stewart, Tamsin, & Hotopf, 2003Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.