An international team of researchers led by Martin Lepage, Ph.D., of McGill University, a 2002 BBRF Young Investigator, has published a meta-analysis of 43 prior clinical trials testing metacognitive training (MCT) for psychosis. The comprehensive analysis concludes that MCT is an effective treatment, with benefits still evident in patients 1 year following the end of MCT sessions.

In MCT, a therapist or trained facilitator enters into discussions with a group of patients, seeking to discover what they believe about their own thoughts. MCT specifically targets maladaptive thinking styles common to psychosis, which include jumping to conclusions, inflexibly holding on to beliefs, and being overconfident in initial judgments. It is typically delivered in 8 to 10 “modules” which are not consecutive, thus enabling new members to join groups that are receiving MCT together. MCT can also be delivered individually.

MCT as assessed in the meta-analysis by Dr. Lepage and his team, which included Steffen Moritz, Ph.D., a 2014 BBRF Independent Investigator and 2008 and 2005 Young Investigator, focused on MCT for psychosis. The 43 prior clinical studies they analyzed, including a dozen in the years since MCT was last assessed in this way, involved 1,816 participants, about 95% of whom were diagnosed with schizophrenia or schizophrenia spectrum disorder. The typical participant in the 43 trials was 37 years old and had a schizophrenia diagnosis for 13 years; two-thirds were male.

MCT is potentially most useful in addressing schizophrenia’s positive symptoms, which include hallucinations and delusions. These represent “the defining feature of schizophrenia spectrum disorders” the researchers noted, and figure prominently in other psychotic disorders. Despite advances in drug therapy, they add, “approximately 80% of people with schizophrenia spectrum disorder experience recurrent or persistent symptoms.”

Instead of directly targeting psychotic symptoms, the team notes MCT “uses an indirect approach by promoting awareness of cognitive biases,” and for this reason may be more acceptable to some patients than other forms of therapy. Cognitive behavioral therapy (CBT) and cognitive remediation are other therapies that have also been tested in people with schizophrenia and other psychotic disorders.

The meta-analysis by Dr. Lepage’s team sought to understand MCT’s impact on what they call “proximal outcomes,” meaning those directly targeted by MCT: overall positive symptoms, and, individually, delusions, hallucinations, and cognitive biases. They also sought to determine its impact on “distal outcomes,” or ones not directly targeted, including self-esteem, sense of well-being, and “negative symptoms” of schizophrenia such as flatness of affect, difficulty talking, social withdrawal, and loss of interest in pleasurable activities.

In JAMA Psychiatry the team reported its conclusion: that “MCT is a viable treatment for psychosis.” This was based on several factors. One was the magnitude of the impact MCT had, over the 43 prior trials, in lowering the level of patients’ delusions and hallucinations. This they said, “provides evidence to support larger-scale implementation of MCT in the treatment of positive symptoms.”

The researchers noted that MCT was also associated with improved distal outcomes, including “small yet significant” impacts on reducing negative symptoms and raising self-esteem.

Finally, they said their analysis also “supports the sustained effectiveness of MCT,” with benefits “on all significant outcomes” still evident 1 year following the end of therapy sessions.

In calling for MCT to be considered for inclusion in clinical treatment guidelines, the team, in addition to citing its symptomatic impacts, argued that it is also practical and cost-effective, being a “durable, short-term intervention, with a group option,” that could help bring much-needed psychiatric services to a generally underserved and inaccessible patient population. It also urged testing MCT in a completely virtual, online version, something that would enhance accessibility even more and make the therapy readily available, for example, during a public health crisis like the COVID pandemic.

Regarding dissemination of MCT, Dr. Moritz pointed out that the training is currently available at no cost in 37 languages (see www.uke.de/e-mct).