Elsevier

Schizophrenia Research

Volume 215, January 2020, Pages 25-37
Schizophrenia Research

Acceptance- and mindfulness-based interventions for persons with psychosis: A systematic review and meta-analysis

https://doi.org/10.1016/j.schres.2019.11.016Get rights and content

Abstract

Background

Acceptance- and mindfulness-based approaches have gained popularity in recent years.

Objective

A systematic review and meta-analysis of the efficacy and safety of acceptance- and mindfulness-based therapies for persons with a psychotic or schizophrenia spectrum disorder.

Methods

Following PRISMA guidelines, relevant databases were searched for published randomized controlled trials (RCTs) up to October 2018. Outcomes were severity of overall symptomatology, hospitalization, positive and negative symptoms, depression, anxiety, social functioning, quality of life, acceptance, mindfulness skills and safety of the interventions.

Results

Sixteen studies comprising 1268 people with a schizophrenia spectrum disorder were included in the meta-analyses. Moderate to large effect sizes were found for overall symptomatology and hospitalization at endpoint (SMD .80, 95% CI -1.31, -0.29 and MD 4.38, -5.58, -3.17 respectively) and follow-up (SMD 1.10, -2.09, -0.10 and MD 7.18, -8.67, - 5.68 respectively). There were significant small effects on negative symptoms (SMD .24; -0.44, -0.03), small to moderate effects for depression (SMD .47; -0.80, -0.14), social functioning (SMD .43; -0.75, - 0.12) and mindfulness (SMD .51; -0.97, -0.05), moderate to large effects for acceptance (SMD .78; -1.44, -0.12), while no significant effects for positive symptoms (SMD .27; -0.65, 0.00), anxiety (SMD 2.11; -4.64, 0.42) or quality of life (SMD .43; -0.88, 0.02). Majority of studies (75%) had low risk of bias and sensitivity analyses supported the findings.

Conclusion

Acceptance- and mindfulness-based approaches appear to be effective and safe interventions for individuals with schizophrenia spectrum disorders and could be a useful extension of standard casemanagement and psychofarmacology.

Introduction

Recent years have seen a renewed optimism with regards to recovery in people with psychosis (McGorry et al., 2008; Slade et al., 2015; Vita and Barlati, 2018). The first-line treatment is often pharmacotherapy, which has been found to reduce symptoms and relapse short-term (Fervaha et al., 2014; Leucht et al., 2009, Leucht et al., 2012, Leucht et al., 2017). However, the long-term benefits of antipsychotic medication are increasingly being questioned (Murray et al., 2016; Wunderink et al., 2013). For many, medication does not result in clinically meaningful improvement and the side-effects are considerable, which often results in medication discontinuation (Lieberman et al., 2005; Lewis and Lieberman, 2008; Stahl and Buckley, 2007).

Many of the studies supporting the renewed optimism have come from cognitive behavioural therapy for psychosis (CBTp), showing that psychotherapeutic interventions can reduce psychotic symptoms, including voices and delusions (Gould et al., 2001; Jauhar et al., 2014; Lynch et al., 2010; Pilling et al., 2002; Rector and Beck, 2012; Wykes et al., 2008). A recent network meta-analysis showed that CBTp was associated with higher decrease in positive symptoms compared to active and inactive control conditions (Bighelli et al., 2018). Acceptance- and mindfulness-based approaches have also gained popularity in recent years, often as an extension of CBTp interventions, with promising results, as seen in a preliminary meta-analysis of controlled and uncontrolled studies (Khoury et al., 2013), and a more recent meta-analysis (Cramer et al., 2016) that included eight randomised controlled trials. However, the number of high-quality studies has increased in recent years, examining the effects in greater details and taking into account important aspects of recovery such as social functioning.

Mindfulness refers to deliberate attention to the present moment (Kabat-Zinn, 1990) and is incorporated in a range of different therapeutic approaches, including the so-called ‘third-wave’ or contextual behavioural approaches such as acceptance and commitment therapy (ACT; Hayes et al., 1999), dialectical behavioural therapy (DBT; Linehan, 1993), compassion focused therapy (DBT; Gilbert, 2010) and mindfulness-based cognitive therapy (MBCT; Segal et al., 2002). These therapies share a common focus on helping people to foster a mindful or accepting stance towards their symptoms and distressing experiences, instead of struggling to reduce, change or eradicate these.

Acceptance from this perspective is not a passive response to suffering or to incomplete recovery, but rather an active stance or ‘willingness’ to experience or ‘have’ uncomfortable thoughts, feelings and bodily sensations, while engaging in or pursuing personally meaningful behavior (Hayes et al., 2012; Jansen and Morris, 2016). Mindfulness is a core component in acceptance-based therapies and involves the cultivation of awareness, wisdom and compassion (Kabat-Zinn, 1990, Kabat-Zinn, 1994, Kabat-Zinn, 2003). In mindfulness, participants practice the skill of noticing distressing thoughts and feelings, holding such experiences in awareness, and meeting them with acceptance and self-compassion (Kabat-Zinn, 2003). This also converges with the ideas within the recovery movement, suggesting that treatment must move beyond the narrow focus of reducing positive and negative symptoms, towards a greater focus on increasing subjective quality of life and well-being (Slade et al., 2017).

The current synthesis adopts a broad understanding of mindfulness (Baer, 2006), similar to the approach taken by earlier meta-analyses of mindfulness for psychosis (Cramer et al., 2016; Khoury et al., 2013). Broadly speaking, there are two main approaches to foster a more mindful and accepting attitude towards inner experiences, and both have been delivered in versions adapted for people with psychosis. The first is ACT, which uses less formalized versions, often through shorter exercises and in individual sessions (Hayes et al., 1999). The second approach consists of more formalized mindfulness practices, informed by Jon Kabat-Zinn's mindfulness-based stress reduction (MBSR) intervention, and is often delivered in groups (Chadwick, 2014).

With this in mind, we conducted a systematic review and meta-analysis to examine the efficacy and safety of acceptance- and mindfulness-based interventions in reducing symptomatology and hospitalization in persons with psychosis. The current synthesis expands on the existing data by including more recent high-quality studies as well as examining effects for depression, quality of life and social functioning, which increasingly is regarded as central to treatment success and recovery (Juckel and Morosini, 2008; Vita and Barlati, 2018).

Section snippets

Method

Cochrane methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed in reporting the results (Higgins and Green, 2011; Moher et al., 2009) with the exemption of protocol pre-registration.

Study selection

The computerized search retrieved 8811 citations, of which 175 were selected for detailed evaluation. Eighteen studies were included in the systematic review and sixteen studies were included in the meta-analysis after carefully applying the inclusion and exclusion criteria. The study selection process is illustrated in detail in Fig. 1.

Study characteristics

Characteristics of the included studies are presented in Table 1. Eighteen studies comprising 1342 participants with psychotic disorders or schizophrenia

Discussion

The current study examined the evidence of acceptance- and mindfulness-based interventions for persons with a schizophrenia spectrum disorder, and found significant efficacy on many outcomes related to symptomatology and social functioning in comparison with treatment as usual. Eighteen studies met inclusion criteria for the qualitative synthesis, while sixteen studies, comprising 1268 persons with a psychotic or schizophrenia spectrum disorder were included in the meta-analyses. Participants

Contribution

JEJ managed the literature searches. JEJ and MA-J extracted the data. JEJ did the meta-analysis, while MA-J verified the methodology. JEJ wrote the first draft of the paper. All authors contributed to the conceptualization of the project and to the final version, and all approved the final manuscript.

Role of funding source

No official funding was provided to conduct this meta-analysis.

Acknowledgements

The authors acknowledge Dr. Ole Jakob Storebø for helpful discussions regarding the meta-analysis. The authors also thank authors who provided additional information and data including Dr. Andrew Gumley, Dr. Paul Chadwick, Dr. Christine Braehler, Dr. Mark Hayward and Dr. Clara Strauss. Dr. M. A.-J. is supported by the CR Roper Fellowship, Faculty of Medicine, Dentistry, and Health Science, the University of Melbourne, Australia and a Career Development Fellowship from the National Health and

References (77)

  • S. Leucht et al.

    Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis

    Lancet (London, England)

    (2012)
  • E. Lopez-Navarro et al.

    Mindfulness improves psychological quality of life in community-based patients with severe mental health problems: a pilot randomized clinical trial

    Schizophr. Res.

    (2015)
  • R. Rosenthal

    The file drawer problem and tolerance for null results

    Psychol. Bull.

    (1979)
  • F. Shawyer et al.

    A randomised controlled trial of acceptance-based cognitive behavioural therapy for command hallucinations in psychotic disorders

    Behav. Res. Ther.

    (2012)
  • M. Slade et al.

    Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial

    Lancet Psychiatry

    (2015)
  • R. White et al.

    A feasibility study of Acceptance and Commitment Therapy for emotional dysfunction following psychosis

    Behav. Res. Ther.

    (2011)
  • S.F. Austin et al.

    Metacognitive Capacity and Negative Symptoms in First Episode Psychosis: Evidence of a Prospective Relationship Over a 3-Year Follow-up

    (2019)
  • P. Bach et al.

    The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: a randomized controlled trial

    J. Consult. Clin. Psychol.

    (2002)
  • P. Bach et al.

    Long-term effects of brief acceptance and commitment therapy for psychosis

    Behav. Modif.

    (2012)
  • R.A. Baer

    Mindfulness training as a clinical intervention: a conceptual and empirical review

    Clin. Psychol. Sci. Pract.

    (2006)
  • I. Bighelli et al.

    Psychological interventions to reduce positive symptoms in schizophrenia: systematic review and network meta-analysis

    World Psychiatry

    (2018)
  • C. Braehler et al.

    Exploring change processes in compassion focused therapy in psychosis: results of a feasibility randomized controlled trial

    Br. J. Clin. Psychol.

    (2013)
  • P. Chadwick

    Person-based Cognitive Therapy for Distressing Psychosis

    (2006)
  • P. Chadwick

    Mindfulness for psychosis

    Br. J. Psychiatry

    (2014)
  • P. Chadwick et al.

    Mindfulness groups for distressing voices and paranoia: a replication and randomized feasibility trial

    Behav. Cogn. Psychother.

    (2009)
  • W.T. Chien et al.

    The mindfulness-based psychoeducation program for Chinese patients with schizophrenia

    Psychiatr. Serv.

    (2013)
  • W.T. Chien et al.

    Effects of a mindfulness-based psychoeducation programme for Chinese patients with schizophrenia: 2-year follow-up

    Br. J. Psychiatry

    (2014)
  • W.T. Chien et al.

    An international multi-site, randomized controlled trial of a mindfulness-based psychoeducation group programme for people with schizophrenia

    Psychol. Med.

    (2017)
  • J. Cohen

    Statistical Power Analysis for the Behavioral Sciences

    (1988)
  • H. Cramer et al.

    Mindfulness- and acceptance-based interventions for psychosis: a systematic review and meta-analysis

    Glob. Adv. Heal. Med.

    (2016)
  • L.W. Davis et al.

    Effect of mindfulness on vocational rehabilitation outcomes in stable phase schizophrenia

    Psychol. Serv.

    (2015)
  • M. Egger et al.

    Bias in meta-analysis detected by a simple, graphical test

    BMJ

    (1997)
  • S.M. Erhart et al.

    Treatment of schizophrenia negative symptoms: future prospects

    Schizophr. Bull.

    (2006)
  • T.A. Furukawa et al.

    Comparative efficacy and acceptability of first-generation and second-generation antidepressants in the acute treatment of major depression: protocol for a network meta-analysis

    BMJ Open

    (2016)
  • B.A. Gaudiano et al.

    An open trial of a new acceptance-based behavioral treatment for major depression with psychotic features

    Behav. Modif.

    (2013)
  • P. Gilbert

    Compassion-Focused Therapy: Distinctive Features (CBT Distinctive Features)

    (2010)
  • M. Goyal et al.

    Meditation programs for psychological stress and well-being: a systematic review and meta-analysis

    JAMA Intern. Med.

    (2014)
  • J.M. Haro et al.

    The Clinical Global Impression-Schizophrenia scale: a simple instrument to measure the diversity of symptoms present in schizophrenia

    Acta Psychiatr. Scand.

    (2003)
  • Cited by (81)

    View all citing articles on Scopus
    View full text