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Psychological and psychosocial interventions for negative symptoms in psychosis: Systematic review and meta-analysis

  • Danyael Lutgens (a1), Genevieve Gariepy (a2) and Ashok Malla (a3)

Negative symptoms observed in patients with psychotic disorders undermine quality of life and functioning. Antipsychotic medications have a limited impact. Psychological and psychosocial interventions, with medication, are recommended. However, evidence for the effectiveness of specific non-biological interventions warrants detailed examination.


To conduct a meta-analytic and systematic review of the literature on the effectiveness of non-biological treatments for negative symptoms in psychotic disorders.


We searched for randomised controlled studies of psychological and psychosocial interventions in psychotic disorders that reported outcome on negative symptoms. Standardised mean differences (SMDs) in values of negative symptoms at the end of treatment were calculated across study domains as the main outcome measure.


A total of 95 studies met our criteria and 72 had complete quantitative data. Compared with treatment as usual cognitive–behavioural therapy (pooled SMD –0.34, 95% CI –0.55 to –0.12), skills-based training (pooled SMD –0.44, 95% CI –0.77 to –0.10), exercise (pooled SMD –0.36, 95% CI –0.71 to –0.01), and music treatments (pooled SMD –0.58, 95% CI –0.82 to –0.33) provide significant benefit. Integrated treatment models are effective for early psychosis (SMD –0.38, 95% CI –0.53 to –0.22) as long as the patients remain in treatment. Overall quality of evidence was moderate with a high level of heterogeneity.


Specific psychological and psychosocial interventions have utility in ameliorating negative symptoms in psychosis and should be included in the treatment of negative symptoms. However, more effective treatments for negative symptoms need to be developed.

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Corresponding author
Ashok Malla, Department of Psychiatry, Douglas Mental Health University Institute, ACCESS-Canada Pavilion, 6625 LaSalle Boulevard, Montréal, Quebec, H4H 1R3, Canada. Email:
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Psychological and psychosocial interventions for negative symptoms in psychosis: Systematic review and meta-analysis

  • Danyael Lutgens (a1), Genevieve Gariepy (a2) and Ashok Malla (a3)
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Psychosocial Intervention for Negative Symptoms: a note on meta-analyses

Matteo Cella, Clinical Psychologist / Lecturer, King's College London, UK
Antonio Preti, Psychiatrist / Associate Professor, Center for Liaison Psychiatry and Psychosomatics, Cagliari University Hospital, Cagliari, Italy
24 March 2017

We read with interest the paper by Lutgens et al., 1 describing the results of their meta-analytic study on the effect of psychosocial interventions on negative symptoms for people with psychosis. Despite commending the aims of the study we have some methodological reservations on the results presented.

We believe the number of the studies included is only a partial representation of the research conducted in the therapeutic modalities considered. For example, we have recently completed a meta-analysis on the effect of cognitive remediation on negative symptoms 2. Our study had a similar time frame to Lutgens et al., 1 and the same participants’ inclusion criteria. Our search retrieved 45 eligible studies compared to only 16 retrieved by Lutgens et al., 1 in their neurocognitive therapies category. We believe this is due to the search strategy used, which included the term “negative symptom” and therefore retrieve only studies with this term in the abstracts. This has two effects. It is more likely to retrieve studies reporting positive findings, and when investigating interventions not specifically designed to target negative symptom will miss a large body of studies across all the therapies modalities considered.

The nature of the control condition is also important when considering effect sizes. In their study Lutgens et al., 1 conflate passive with active control conditions. Active control conditions for one study (e.g. cognitive remediation) were then considered active treatment condition in subsequent analyses. We also noted some overlap in therapy groups considered. Both art and music and exercise therapy included dance-based interventions. The miscellaneous category adds to the limited clarity in categories definition by considering comprehensive “care packages” such as Garety et al., 3 which include medication management and allocation to a psychosocial intervention amongst a number recommended by clinical guidelines (i.e. family therapy or CBT). These limitations, in our view, make it difficult to reliably compare effect sizes from the intervention groups considered.

We also wish to point out some methodological considerations that may limit the accuracy of the results reported. Firstly, it appears the authors considered only end of therapy data to estimate effect sizes. This does not account for relative change. In other words, this method considers a symptoms reduction of a hypothetical 3 points of a negative symptoms scale to be the same in individuals entering the study with an initial score of 5 or 23. The importance of taking into account baseline levels in meta-analysis is clear and it is considered best practice 4. There is also evidence that the DerSimonian and Laird method has limitations when compared to other methods using restricted maximum likelihood estimator 5.

Lastly, it is unclear how the authors considered the treatment participants received as part of treatment as usual (TAU). The authors stated: “Compared with TAU, 59% (10/17) of studies reported CBT to be more effective at the end of treatment”. From this statement one may assume that participants received either TAU (e.g. medication) or CBT. In all likelihood studies compared CBT + TAU to TAU only.


1.Lutgens D, Gariepy G, Malla A. Psychological and psychosocial interventions for negative symptoms in psychosis: systematic review and meta-analysis. Br J Psychiatry 2017, in Press.

2.Cella M, Preti A, Edwards C, Dow T, Wykes T. Cognitive remediation for negative symptoms of schizophrenia: A network meta-analysis. Clin Psychol Rev 2017; 52: 43-51.

3.Garety PA, Craig TKJ, Dunn G, Fornells-Ambrojo M, Colbert S, Rahaman N, et al. Specialised care for early psychosis: symptoms, social functioning and patient satisfaction. Randomised controlled trial. Br J Psychiatry 2006; 188: 37–45.

4.Achana FA, Cooper NJ, Dias S, Lu G, Rice SJ, Kendrick D, Sutton AJ. Extending methods for investigating the relationship between treatment effect and baseline risk from pairwise meta-analysis to network meta-analysis. Stat Med 2013; 32: 752-71.

5.Veroniki AA, Jackson D, Viechtbauer W, Bender R, Bowden J, Knapp G, Kuss O, Higgins JP, Langan D, Salanti G. Methods to estimate the between-study variance and its uncertainty in meta-analysis. Res Synth Methods 2016; 7:55-79.

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Conflict of interest: None Declared

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