Psychosis is a medical condition that interferes with one’s thoughts and perceptions, making it difficult to distinguish what is real. Psychosocial interventions are used to treat psychosis by targeting behavioral, cognitive, biological, and interpersonal environment factors. Significant challenges follow the onset of psychosis or its symptoms in day-to-day social interactions that hinder an individual’s ability to interact within their community effectively, often rendering a psychosocial intervention necessary. The current role of psychosocial interventions is characterized by improving psychotic symptoms, social functioning, medication adoption, and the overall quality of life for individuals at high risk of developing or being diagnosed with psychosis. However, the expansion of their role within the clinical practice is substantially impeded by the low accessibility of interventions, concerns about ensuring patient engagement in digital implementation, and limited research on alternative methods (Devoe et al., 2020).
Cognitive Behavioral Therapy (CBT) and Cognitive Remediation Training (CRT) are effective interaction techniques that limit the challenges of faced by psychosocial interventions. This paper will focus on the problem of psychological intervention, how significant that problem is, as well as their possible solutions in the future using such interaction mechanisms as (CBT) and cognitive remediation training (CRT) at ultra-high risk (UHR). Keywords are psychosis, preventive treatment plan, distressing psychotic symptoms, neurocognition, psychosocial interventions, and digital treatment. It is important to understand its significance to cover the topic which will be discussed fully. Then how does psychological intervention affect people with high levels of psychosis, and does it affect them at all? CBT and CRT interventions enhance psychosocial patients’ cognitive and social abilities.
Currently, the most widely implemented psychosocial interventions include CBT and CRT, with the former focusing on alleviating psychosis symptoms while the latter aims to enhance cognitive abilities through training. Despite the heterogeneity in measured outcomes and participants, studies indicate the general effectiveness of these psychosocial interventions in repairing social and occupational functions during high-risk and early psychosis stages (Frawley et al., 2021). Nonetheless, the authors remark that CRT showed substantially higher rates of improvement of symptoms than CBT, while multi-component interventions, combining pharmacological and psychosocial components, within community-based rather than clinical-based settings yielded the highest improvement rates.
Combined psychosocial treatment with CBT, skill-based intervention, and CRT effectively manage psychosis symptoms. Moreover, a meta-analysis of 95 studies by Lutgens et al. (2017) suggests that while antipsychotic medications offer limited improvement when delivered supplementary to psychosocial interventions, they can be significantly effective in alleviating psychosis symptoms. Furthermore, their analysis concluded that while clinical guidelines traditionally recommend using CBT, skills-based interventions, including CRT, are “likely to have comparative, if not enhanced utility” in treating psychotic symptoms (p. 5). While the clinical landscape appears heterogeneous in implementation variability, it agrees on the efficacy of multi-component interventions for patients diagnosed with psychosis.
While international guidelines suggest the treatment of patients with psychosis should include both psychosocial and pharmacological interventions, the same treatment might have better treatment for individuals at UHR of developing psychosis. With potential unintended side effects and a relatively low chance of progression from UHR to full psychosis, the application of pharmacological intervention, including antipsychotic medications, to prevent psychosis remains ethically questionable (Burkhardt et al., 2020). In other words, an intervention, especially pharmacological, should be part of a preventative treatment plan only if it has proven efficacy and implies a low risk of side effects, with no practical alternative methods available (McGorry et al., 2017). However, as Burkhardt et al. (2020) remark, most individuals at UHR “experience poor quality of life” due to the distressing psychotic symptoms that lead to a deterioration in social and occupational functioning (p. 1). Indeed, the overall decline in these functions entails considerable discontinuation in social engagement and employment, with nearly 20% of people with psychotic symptoms resorting to self-employment (Frawley et al., 2021). Therefore, counteracting these socially undermining implications of psychotic symptoms may involve adopting a modified early psychosocial intervention with minimized side effects for the UHR population. Experimental approaches to pharmacological intervention should be applied with proven efficacy and side effects.
A combined therapeutic approach may either delay or assist in managing psychosis. Outside of experimental techniques, a prevalent treatment modification proposal suggests the implementation of psychosocial intervention, such as symptom-targeting CBT, in combination with second-generation antipsychotics (SGA) medication with minimal side effects (van Os & Guloksuz, 2017). For instance, a randomized controlled trial (RCT) with 124 participants showed that a needs-oriented intervention with family counseling combined with amisulpride prescription significantly improved symptoms and social functioning (Burkhardt et al., 2020). The authors add that another RCT with 60 participants with a comparable psychosocial intervention, but with olanzapine as an SGA agent, “led to significant improvement of positive symptoms” (p. 3). Nevertheless, side effects included prolactin-related galactorrhea, amenorrhea, erectile dysfunction for the former, and the high risk of substantial weight gain for the latter. A Frawley et al. (2021) review of 10 studies suggests that CRT interventions, including process speed training, neurocognition, and auditory processing programs, showed substantial improvements in social functioning in the high-risk and early psychosis groups. As the authors remark, a multi-component intervention with psychopharmacological treatment components integrated into psychosocial intervention reported “superior outcomes” in social function improvement (p. 9). Thus, improved symptoms and functions associated with the combined therapeutic approach may delay or prevent psychosis.
However, while these improvements are promising, the clinical, technical, and workforce resources needed to deploy multi-component treatment initiatives might render them currently considerably unavailable for patients. In fact, less than 10% of individuals at UHR or diagnosed with psychosis have access to these psychosocial interventions (Baker et al., 2018). Considering the role of psychological interventions in improving psychotic symptoms, social functioning, and medication adoption, increasing access to them would be instrumental in enhancing the quality of life for people struggling with these symptoms (Woods et al., 2017). Moreover, as Baker et al. (2018) note, psychosocial interventions help target key health priorities for adults experiencing psychotic symptoms, including “reducing relapse, improving medication adherence, and modifying health risk behaviors” (p. 1). One of the proposed methods of substantially expanding access is online-delivered psychosocial intervention (Guloksuz & van Os, 2018). Contrary to the belief that psychotic symptoms would hinder online interaction, preliminary research suggests that digital interventions are feasible, but patients’ views are also optimistic about engaging in technology.
Although extensive digitization of interventions would enhance accessibility to psychosis treatment, it remains doubtable which digital implementation method would promote higher patient engagement. An examination of 20 trials with 2473 participants by Baker et al. (2018) suggests that the combined approach of face-to-face CBT treatment with telephone-delivered intervention shows encouraging results in the key health priorities (Bechdolf et al., 2017). The authors add that entirely telephone-delivered intervention showed promising results in the targeting of relapse prevention, medication adherence, and health risk behavior, which were “at least equivalent if not superior” to standard care (p. 19). As the authors note, while digital implementation can be cost-effective with “limited resource requirements and potentially low costs,” the “qualification of the support provider does not impact on adherence” (p. 8). Consequently, the strongest predictor of sustained engagement might not be the high efficacy of technology per se but the internal stressors that prompted to utilization of this digital treatment in the first place.
Various experimental methods such as the RCT, CBT, SGA, and skill-based intervention are elemental in the intervention of psychosocial and psychotic symptoms. While increasing access remains crucial in expanding the role of psychological interventions, identifying high-quality alternative treatment options that would stimulate autonomous engagement may be of equal importance. One promising avenue is further research into the beneficial effects of psychotropic medications, such as antidepressants and nutritional supplements, instead of antipsychotic drugs, due to the latter’s unfavorable side effects (Davies et al., 2018). For instance, Burkhardt et al. (2020) note that a few studies found that antidepressants were associated with a lower rate of transitioning from UHR to full psychosis and a higher adherence rate than antipsychotics. Furthermore, an RCT with 81 UHR participants showed that the group receiving omega-3 polyunsaturated fatty acids had a 5% transition rate while the placebo group had 28% at the one-year follow-up (Burkhardt et al., 2020). Although exercise therapy, including resistance training, tai chi, yoga, music therapy, and body psychotherapy, showed moderate effectiveness in treating negative symptoms compared to treatment, as usual the results are largely inconclusive (Lutgens et al., 2017). Currently, the generalizability of these results remains limited, warranting further investigation into the implications and efficacy of alternative treatment methods, which might suit more patient preferences.
In summary, impairing psychotic symptoms for individuals at UHR or diagnosed with psychosis sanction the use of psychosocial intervention to avert or delay the further onset of negative symptoms. The role of psychosocial interventions is to ameliorate psychotic symptoms, enhance social and occupational functioning, and advance medication adoption to improve the overall well-being of these individuals. Although this multi-component treatment is considered effective, the general accessibility to this intervention method remains relatively low, which could be remedied by online treatment delivery. While the efficacy of digital implementation relies on patient engagement and motivation, increased access should go in parallel with the development of alternative methods, which would offer various treatment options for different patient preferences. Suppose one proceeds from the information provided in the sources analyzed. In that case, it can be concluded that in most cases, despite the presence of treatment methods, there is still a problem with personal motivation. It is no less important than the development of new rehabilitation systems.
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