Read Full Text: Psychological and psychosocial interventions for negative symptoms in psychosis: Systematic review and meta-analysis (Free to Access)
Journal: British Journal of Psychiatry
Year Published: 2017
Ranked 24th on our 2016-2021 list of the 100 Most Influential OT Research Articles
Wow! I wish I had this week’s article when I worked in inpatient psych.
The article does an excellent job of discussing the symptoms of psychosis. Even with my background in mental health, I still learned some new language for familiar symptoms that I’d never had the words to describe.
You’ll also find that OT presents an evidence-based way to address the symptoms of psychosis. The authors give a very helpful rundown of what seems to work (and what doesn’t) when addressing these symptoms.
I believe that OTs’ understanding of mental health is something that truly sets us apart on our teams—and this is the case regardless of setting. So, even if you don’t think of your primary focus as mental health, I hope you take the time to engage with this important information!
Let’s dive in.
Quick refresher on psychosis
Ok, the article does not start with a refresher on psychosis—but I’m going to. I’m doing so because, unless you’re actively working in mental health (or even if you are), the lines between different diagnoses and symptoms can get blurry!
In the simplest sense, psychosis occurs when a person experiences some loss of connection with external reality. This can present as hallucinations and delusions.
Psychosis, itself, is not a disease; rather, it is a symptom of a broader disease, such as:
- Schizophrenia
- Schizoaffective disorder
- Brief psychotic disorder
- Delusional disorder
- Bipolar psychosis
- Psychotic depression
- Postpartum (also called postnatal) psychosis
- Substance-induced psychosis
(For more information on how OT can play a role in identifying those at high risk of psychosis, I highly recommend our previous article: Sensory characteristics of youth at clinical high risk for psychosis)
What are the “negative symptoms” of psychosis?
The most well-known symptoms of psychosis are “positive symptoms,” which means additional traits expressed by those affected. Such symptoms include hallucinations and delusions.
On the other hand, “negative symptoms” can be thought as “taking away” from normal self-expression. Such symptoms are categorized by the absence or reduction of:
- Affect
- Social expression
- Behavioral expression
These negative symptoms are extremely important to recognize in psychosis patients. That’s because the degree to which they present is one of the most important predictors of both quality of life and functional outcomes.
Negative symptoms can be transitory. They can also present secondary to co-occurring depression and/or as a side effect of antipsychotic medication.
Persistent negative symptoms are present in around 25% of patients with first-episode psychosis, and in an even greater percentage of those with chronic schizophrenia.
What about medication?
New medications have revolutionized the treatment of psychosis. Antipsychotic medication can be highly effective for the treatment of positive symptoms.
However, these medications have, at best, a “modest” impact on negative symptoms. Therefore, best practice suggests the use of psychological and psychosocial interventions for negative symptoms.
Why was this paper written?
Even though psychological and psychosocial interventions are considered best practice, their effectiveness has not really been explored in much depth. Hence, the authors found and analyzed randomized control trials related to their efficacy.
What interventions did they find?
The authors found 72 studies that met their inclusion criteria.
Below are the interventions they found. I’m putting the number of studies they found next to the type; this gives a sense of how well studied each intervention is.
In terms of effectiveness, I’m also putting a rudimentary 
for those that overall had a positive effect, compared to treatment as usual. I’ll use a:question:by those with mixed results or insufficient data, and an 🅇 by those that did not perform as well as treatment as usual.
Cognitive-behavioral therapy (CBT) (26 studies)
Skills training (11)
Occupational therapy (3)
🅇 Cognitive adaptation training (2)
Neurocognitive therapies (16):
- Cognitive remediation (11)
- Cognitive training (2)
- Neurocognitive therapy (1)
- Cognitive enhancement (1)
Exercise (10):
- Yoga
- Aerobic
- Resistance training
- Structured walking
- Tai chi
- Traditional dance
Art and music therapy
🅇 Family-based interventions
Miscellaneous
- Humor therapy (2) 🅇
- Specialized early intervention for first-episode psychosis (2)
- Body psychotherapy
- Acceptance and commitment therapy 🅇
- Adherence therapy 🅇
- Token therapy 🅇
Assessments
For the occupational therapy trials, one assessment was used across all trials it was:
Discussion
The authors concluded that negative symptoms can be improved, at least modestly, with psychosocial and psychological interventions. The interventions with the most efficacy are indicated above.
Historically, best-practice guidelines have favored CBT. But, this updated review suggests that skills-based interventions may be just as effective, if not more so. (By “skills-based”, the authors mean a broad category that involves OT and/or skills-training.)
They note that improved skills—particularly social skills—are likely to be associated with prosocial behaviors, which are key indicators of negative symptom improvement.
Across all interventions, treatment intensity of 45 minutes (or more) per week was associated with better outcomes. The authors also found that group format was as effective as individual treatment.
3 Takeaways for OT practitioners
(These are my own takeaways, and were not mentioned directly in the article.)
1.) All OTs should be following mental health developments like this one.
Part of what makes OTs unique is our ability to not only explicitly treat mental conditions, but also take mental health into account for all patients.
While you may not have a patient with psychosis on your caseload, I think it is important to remember that engagement in activity can boost mental well-being—which, of course, goes hand-in-hand with physical health.
2.) Why do skills-based interventions work?
Ok. I don’t actually have the answer to this question, but I have recently learned of a framework called “self-determination theory,” which has given me new language to describe why I think OT works.
The theory asserts that the human psyche needs three things to flourish: autonomy, competence, and relatedness. Both occupational therapy and skills training groups provide a safe way to grow in all 3 of these areas.
This is true not only in mental health work, but in occupational therapy on the whole. After all, what greater gifts could we give our patients than autonomy, competence, and relatedness?
3.) We, of course, need to take a trauma-informed approach with these patients.
I cannot talk about extreme cases of mental health struggles, like psychosis, without bringing up trauma-informed care. (Even though it was not mentioned in the article.)
I cannot think of a single patient I worked with in inpatient rehab who did not have a history of some form of trauma. And, I cannot help but think that negative symptoms are, in some ways, protective measures in a circumstance (psychosis) that simply does not feel safe. I hope to review new research on OT and trauma-based care sometime this year. (Suggestions welcome!!)
But, in the meantime, I just listened to Brene Brown with Oprah Winfrey and Dr. Bruce Perry on Trauma, Resilience, and Healing, and I highly recommend it!
Here’s the full APA citation for this article:
Lutgens D, Gariepy G, Malla A. Psychological and psychosocial interventions for negative symptoms in psychosis: systematic review and meta-analysis. Br J Psychiatry. 2017 May;210(5):324-332. doi: 10.1192/bjp.bp.116.197103. Epub 2017 Mar 16. PMID: 28302699.
