Cognitive remediation and social recovery in early psychosis (THE CReSt-R STUDY)
Frawley, Emma
Frawley, Emma
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Publication Date
2023-05-11
Type
Thesis
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Abstract
Background Psychosis, even in its early stages, is associated with significant disability, causing it to be ranked ahead of paraplegia and blindness in those aged 18–35 in terms of years lived with disability. Current pharmacological and psychological interventions have focused primarily on the reduction of positive symptoms (hallucinations and delusions), with little benefit to domains of psychosis such as cognitive difficulties and social and occupational functioning. The overall aim of this doctoral research was to further explore and develop the evidence base for psychosocial intervention in early psychosis with a particular emphasis on social and occupational function and social cognition as outcomes of interest. Methods The overall aim of this research was achieved by addressing a number of key objectives: 1) Completion of a systematic review of the literature to collate current empirical evidence for the impact of psychosocial intervention on functional outcomes in the at-risk and early psychosis cohorts. An electronic search was conducted using PubMed and PsycINFO to identify original articles reporting on trials of psychosocial interventions in early-stage psychosis, published up to December 2020 and is reported following PRISMA guidelines. Data were extracted on validated measures of functioning from included studies and pooled standardised mean difference (SMD) was estimated (chapter 2). 2) Development of a protocol for a multi-component intervention which targets both cognitive and functional domains in early psychosis (Cognitive Remediation and Social Recovery in Early Psychosis (CReSt-R). Protocol development was informed by the Medical Research Council framework for developing and evaluating complex interventions (chapter 3). 3) Completion of a randomised pilot study of this novel, multi-component CReSt-R intervention in the early psychosis cohort. This study reports on a number of feasibility indicators, progression criteria, and exploratory statistical analysis using a linear mixed model and descriptive statistics (chapter 4). 4) Completion of an acceptability study of the CReSt-R intervention to young people living with psychosis. This study employed a qualitative research design, based on semi-structured interviews and reflexive thematic analysis (chapter 5). Results Study one, a systematic review and meta-analysis, reported improved function across interventions, (SMD = 0.239; 95% confidence interval 0.115–0.364, p < 0.001). Effect sizes varied by intervention type, stage of illness, length and duration of treatment, treatment setting, and outcome measure used. In particular, interventions based on CRT significantly outperformed symptom-focused CBT interventions, while multi-component interventions were associated with largest gains. Study two presents the research protocol for the Cognitive Remediation and Social Recovery in Early Psychosis (CReSt-R) study. This publication is a culmination of in-depth research on existing cognitive remediation training and psychosocial therapies, trial methodologies, and collaboration with international experts which led to the development of the protocol. Study three reports that the CReSt-R intervention met feasibility and progression criteria, Exploratory linear mixed-effects model (LMM) analysis demonstrated that both control and intervention groups were found to improve on a number of social and occupational functioning, social cognitive and symptom outcome measures over the duration of the study and follow-up time points. However, there was no significant difference observed between the control and intervention group across outcome measures. Study four describes four themes developed through the analytical process of a qualitative study, namely, (1) a solid therapeutic foundation, (2) multi-directional flow of knowledge, (3) a tailored toolset, and (4) an individual pathway to recovery. Participants also provided pragmatic feedback about how to improve the delivery of the therapy intervention. Both the themes and pragmatic feedback are described. Conclusion Cognition is an important (and often overlooked) intervention target in early intervention in psychosis. Multi-component interventions appear to have the greatest impact on functional outcomes. New evidence emerging from this thesis highlights the effectiveness of psychosocial intervention on social and occupational function while reporting on methodological limitations and recommendations for optimising future research study design. New feasibility and acceptability data of a novel psychosocial intervention is also reported, providing a platform for further development of the intervention. Consensus studies of the definition of clinical recovery, measures of social and occupational functioning with the inclusion of public patient involvement at the core, is a recommendation for future research
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NUI Galway