Cognitive Behavioral Therapy for Prodromal Stage of Psychosis—Outcomes for Transition, Functioning, Distress, and Quality of Life

A Systematic Review and Meta-analysis

Yuchen Zheng; Tingting Xu; Yikang Zhu; Chunbo Li; Jijun Wang; Steven Livingstone; Tianhong Zhang


Schizophr Bull. 2022;48(1):8-19. 

In This Article

Abstract and Introduction


Objective: This study aimed to provide insight into the efficacy of cognitive-behavioral therapy for psychosis (CBTp) in patients with "clinical high risk of psychosis (CHR-P)".

Methods: Major scientific databases were searched up to April 17, 2020. Randomized controlled trials in CHR-P individuals, comparing CBTp with needs-based interventions (NBI, including treatment as usual or nonspecific control treatment) were included, following PRISMA guidelines. The primary outcome (efficacy) was transition to psychosis by 6 months, 12 months, 24 months, and over 24 months. Secondary outcomes were change in attenuated psychotic symptoms, depression, distress, improvements in functioning, and quality of life.

Results: Ten randomized controlled studies met inclusion criteria. The comparisons included 1128 participants. CBTp was significantly more efficacious in reducing rate of transition to psychosis by 6 months (after post-hoc sensitivity analysis) (relative risk [RR] = 0.44, 95% confidence interval [CI]: 0.26, 0.73), 12 months (RR = 0.44, 95% CI: 0.30, 0.64), 12 months (RR = 0.46, 95%CI: 0.30, 0.69), and over 24 months (RR = 0.58, 95% CI: 0.35, 0.95) after treatment, compared with those receiving NBI. CBTp was also associated with more reduced attenuated psychotic symptoms by 12 months (SMD = −0.17, 95% CI: −0.33, −0.02) and by 24 months (SMD = −0.24, 95% CI: −0.43, −0.06). No beneficial effects on functioning, depression, quality of life, or distress were observed favoring CBTp.

Conclusions: CBTp is effective in reducing both psychosis transition rates and attenuated psychotic symptoms for the prodromal stage of psychosis. It is a promising intervention at the preventative stage.


Psychosis is a serious mental health condition with a high global disease burden.[1] The unsatisfying prognosis for psychosis has led to the development of early detection and intervention services. In early intervention for psychosis, patients with "clinical high risk of psychosis (CHR-P)" are identified and treated to postpone and prevent the transition to a first psychotic episode.[2] Among CHR-P, about 20% are at risk of transition (developing psychosis) within 2 years.[3]

Cognitive-behavioral therapy for psychosis (CBTp) is a highly recommended first-line treatment for CHR-P individuals in current international guidelines (eg. the National Institute for Health and Care Excellence, NICE, and the European Psychiatric Association, EPA).[4,5] The effectiveness of CBTp has been tested in high-income, western cultures such as North America, Europe and Australia. These trials showed evidence that the clinical outcomes, such as transition[6] and attenuated psychotic symptoms[7,8] of CHR-P population could be improved by CBTp. Some previous meta-analyses have supported the results demonstrated in these trials.[6,9,10] However, some other meta-analyses and reviews have questioned the effectiveness of CBTp, reporting negative results when comparing the efficacy of different interventions in preventing transition to psychosis,[11] alleviating the severity of positive symptoms[12,13] and negative symptoms,[14] improving social functioning[15] quality of life,[10] and acceptability of treatments.[11]

The latest pairwise meta-analysis published by the Cochrane group concluded that "there is no convincing, unbiased, high-quality evidence to suggest that any type of intervention is of value" for CHR-P people,[16] whereas CBTp is one intervention with evidence to supporting its efficacy. According to some of the latest meta-analyses, CBTp has positive impact on some clinical outcomes for CHR-P individuals, even if the differences were not significant. For example, Devoe et al. claimed that CBTp demonstrated a slight trend at reducing attenuated positive psychotic symptoms at long-term follow-up compared to controls.[13] On the other hand, the results of this meta-analyses might be influenced by the comparably small number of trials in this field of study and the low-quality of evidence under evaluation, which was also reported in the latest Cochrane systematic review by Bosnjak et al.[16] It is necessary to conduct an updated meta-analysis reviewing the comprehensive effectiveness of CBTp for delaying transition and reducing symptoms in subjects with CHR-P, as there are now recently published relevant studies that should be included. In fact, several randomized controlled trials (RCTs) conducted in China, on the effectiveness of CBTp among CHR-P patients, have shown a positive effect.[17–19] These articles were not included in the recent meta-analysis of RCTs of CBT in CHR-P, because they were published in the Chinese language and are not well-known to Western researchers. Moreover, these trials were published after the latest Cochrane review, which was updated on August 2017. These trials are useful to extend the current knowledge of the efficacy of CBTp in CHR-P individuals.

We therefore aimed to conduct a systematic review and meta-analysis of RCTs of CBTp in CHR-P, including RCTs in the Chinese language, to determine whether evidence shows that CBTp improves the clinical outcomes of young people at risk of developing psychosis, by comparing the short- and long-term efficacy of this intervention with usual or nonspecific control treatment. The study focuses on 2 main aspects: first, whether CBTp is associated with a significantly reduced rate of transition to psychosis; and secondly, whether CBTp is associated with improved overall symptoms, functioning, and quality of life. We also examined acceptability, as indicated by dropout rate.