Acceptance- and mindfulness-based interventions for persons with psychosis: A systematic review and meta-analysis
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)
- et al.
Predictors of recovery in first episode psychosis: the OPUS cohort at 10year follow-up
Schizophr. Res.
(2013) - et al.
Group mindfulness-based intervention for distressing voices: a pragmatic randomised controlled trial
Schizophr. Res.
(2016) - et al.
Meta-analysis in clinical trials
Control. Clin. Trials
(1986) - et al.
Effect of antipsychotic medication on overall life satisfaction among individuals with chronic schizophrenia: findings from the NIMH CATIE study
Eur. Neuropsychopharmacol.
(2014) - et al.
Acute treatment of inpatients with psychotic symptoms using acceptance and commitment therapy: pilot results
Behav. Res. Ther.
(2006) - et al.
Cognitive therapy for psychosis in schizophrenia: an effect size analysis
Schizophr. Res.
(2001) - et al.
How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies
Clin. Psychol. Rev.
(2015) - et al.
A parallel group randomised open blinded evaluation of Acceptance and Commitment Therapy for depression after psychosis: pilot trial outcomes (ADAPT)
Schizophr. Res.
(2017) - et al.
A pilot study of loving-kindness meditation for the negative symptoms of schizophrenia
Schizophr. Res.
(2011) - et al.
Mindfulness interventions for psychosis: a meta-analysis
Schizophr. Res.
(2013)