Impact of Cognitive Behaviour Therapy for Psychosis on Quality of Life in Schizophrenia - Recent Findings

Background: With its complex etiology and presenting symptoms, schizophrenia continues to challenge clinicians and researchers alike in finding the most effective approach to alleviating symptoms and enhancing the quality of life of those affected by it. Here we explore the impact Cognitive Behavioral Therapy for psychosis (CBTp) has on the quality of life of individuals with schizophrenia, as reported in recent randomized controlled trials. Methods: We systematically searched four databases: Web of Science, PubMed, Embase and Google Scholar. The Boolean operator “AND” was used between each keyword


Introduction
The currently accepted approach in the treatment of schizophrenia involves pharmacotherapy as well as adjunctive psychosocial interventions. Schizophrenia is a complex, debilitating mental disorder, and its implications concern the individual, family and society as a whole. It continues to challenge clinicians and researchers alike in finding the most effective approach to alleviating symptoms and enhancing the quality of life of those affected. Considering the cognitive deficits the disorder leads to, Cognitive therapy was one of the first forms of psychotherapy used for individuals with schizophrenia. Aaron T Beck -the father of CBT (Cognitive Behavioural Therapy), reported its successful use in the early 1950s [1]. The core assumption of this approach has been that identifying and modifying the dysfunctional beliefs of individuals with psychosis may lead to increased engagement with the therapeutic process and constructive social activity. Numerous randomized controlled trials have examined CBT's efficacy for psychosis (CBTp) since then. Usually focusing on improving the core symptoms of schizophrenia, these trials rarely assess the quality of life. When they do, it is always seen in the secondary outcomes category, almost as an afterthought. Defined as a person's sense of well-being and satisfaction with their life circumstances as well as his/her health status and access to resources and opportunities [2], quality of life has been deemed as a crucial component in the recovery process in psychosis [3]. Assessed through various tools over the years and covering different dimensions of the concept, all measures appear to have transitioned to a more subjective appraisal of one's life in recent decades, mirroring the personcentred approach the health care adopted.
A recent systematic review [4] on the role of CBT in the management of psychosis concludes that CBT, in addition to standard care in the management of psychotic symptoms, leads to improved quality of life. CBT was found to decrease psychotic and affective symptoms and to improve functioning, particularly effective in preventing first-episode psychosis in high-risk individuals. CBT was also found to be effective in Clozapine resistant schizophrenia in their review, as patients who received CBT had fewer hospitalizations than those who received treatment as usual. Same authors summarized the challenges encountered in CBT delivery: severe intensity of psychotic symptoms and lack of insight; large caseloads and lack of supervision for clinicians to use CBT; lack of peer and family support for patients, among other factors. They also emphasize that "CBTp is complex, and its effective administration depends on the interaction between therapist and patient. Hence, factors such as readiness and willingness of the patient, nature of symptoms, and awareness level of distress on the part of the patient can influence the overall result" [4].
An equally recent meta-analysis, however, pinpoints a different set of findings regarding quality of life assessed in CBTp studies, finding no evidence that CBTp increases the quality of life post-intervention. Covering a number of 36 RCTs investigating the effectiveness of CBTp for functioning, distress, and quality of life in individuals with schizophrenia, Law and his team (2018) found that although there was a small benefit of CBT for reducing distress, this became no significant when adjusted for possible publication bias. Considering these intriguingly conflicting findings, we are exploring here the most recent findings about quality of life as assessed in RCTs of CBTp for schizophrenia done in the last ten years.

Methods
Due to limited RCTs on CBT in schizophrenia, our search used the results from 4 databases. Articles that reported on an RCT on patients with schizophrenia and assessed the quality of life as an outcome measure were included in this review. All studies had to include a control group of any type -TAU (Treatment As Usual), waitlist, or other intervention designed to control for the non-specific effects of CBT.
he keywords "schizophrenia," "CBT OR Cognitive Behavioural Therapy," and "quality of life" were searched for on all databases (Web of Science, PubMed, Embase and Google Scholar). The Boolean operator "AND" was used between each of the keywords. The 10 years/ 2013-2023 filter was applied where the database allowed.
The search on Web of Science returned 44 articles, PubMed returned 49 articles, Embase returned 106 articles, and Google Scholar 5 articles. After duplicate records were removed and titles and abstracts were reviewed for eligibility, there were 66 articles remaining that were assessed for the final review. Of those studies, 7 met the criteria for the present scoping review (

Results
Improvement in quality of life because of a CBT intervention was found in several of these studies: [5-,8]. On the other hand, no improvement was found in [9,10], while quality of life assessment results were not discussed by [11].
The study population mainly consisted of adult participants with schizophrenia and schizophrenia spectrum disorders [5,6,8,9,10,11]. but also adolescents with early onset psychosis -with a current diagnosis of schizophrenia, schizophreniform, schizoaffective or delusional disorder The protocol consisted of a CBT intervention plus treatment as usual for the intervention group, while the control group was treated as usual in all studies considered for this review, except for Delazizzo et al.,(2021) [24] study, where the CBTp is compared to VRT. No statistically significant differences between the two groups posttreatment.
Small to medium between-group effect sizes in favour of CBT + TAU at posttreatment on Both PANSS (negative subscale) and MSQoL.

6.
[ VRT showed significant results on persecutory beliefs and quality of life.
CBT did not.

Discussions
Only a few studies could be found in the recent literature to fit the criteria for this review. Consistent with recent systematic reviews and meta-analyses [25][26][27][28][29], our findings show that the RCTs selected for this review did not consider quality of life as a primary outcome. Contrary to a natural expectation that improving quality of life should be a significant outcome in any intervention, these studies focus mainly on clinical and cognitive improvement. Numerous RCTs on CBT in schizophrenia that did not fit our criteria for this review only indirectly hint at an improvement in quality of life due to the improvements obtained in the clinical/cognitive domain. Although quality of life refers to a state of well-being beyond the treatment of symptoms, most studies remain focused on deficits and dysfunction. Even when explicitly assessed, like in the studies examined here, the quality of life remains an elusive concept -difficulties in capturing its meaning stemming from the diversity of study designs and protocols of intervention, as well as the type of quality of life questionnaire used, sample size and demographic characteristics of it.
Four out of the seven studies selected for this review reported improvement in quality of life due to a CBT intervention. These studies report using health-related quality of life questionnairesthe EQ-5D-5L and the MSQoL-R. The EQ-5D-5L scale measures the quality of life on a 5-component scale, including mobility, selfcare, usual activities, pain/discomfort, and anxiety/depression. One other study used the MSQoL-R -which consists of one "G-factor" (life in general) and six specific dimensions (physical health, vitality, psychosocial relationships, material resources, affect, and leisure time). Similar in their focus on health and health-related issues, these assessments lack an emphasis on the positives -like the enjoyment and satisfaction captured by other scales -like the Q-LES-Q or sense of fulfillment like the QoLS. An interesting addition to the EQ-5D-5L was the QALYs in the [6] study, looking into an economic evaluation of CBT and finding the improvement statistically significant.
Several limitations in these studies are important to mention in order for further studies to capture a more accurate assessment of the quality of life in relation to CBT. First, the small sample size is usually the "norm" in psychiatric populations. A second limitation refers to the difficulty in quantifying the impact the expertise of the clinician delivering the intervention has on the results. It is well known that the quality of the therapeutic report and the therapist's experience will influence the therapeutic engagement, and these factors can vary greatly from one study or setting to another. The difficulty in blinding the condition the participants are randomized to may add another confounding factor of expectation and likelihood of adherence to therapy. Another interesting question remains the impact an improvement in clinical symptoms may have on the individual's quality of life. If the lifting of psychosis symptoms leads to increased insight -the quality of life may be evaluated from a different perspective and not necessarily a favourable one. It is then crucial that along with clinical improvement, efforts are made to ensure the individual has adequate support in identifying and staying anchored in the positives of their life, where a meaning becomes accessible and the human experience is embraced in its entirety. In this regard, CBT stands out as a flexible approach -allowing for the addition of elements from different other psychotherapies -and the inclusion of strategies meant to increase satisfaction with life could be beneficial. A focus on building a sense of well-being instead of coping with symptoms (more efforts at grounding and acceptance) may provide more normalization and possibly more engagement with the therapeutic process in general.

Conclusions
Although quality of life is known to be considerably affected in individuals with schizophrenia, rigorous studies assessing the effectiveness of CBT interventions for this disorder tend to focus on clinical symptoms and cognitive deficits. Only a small number of RCTs (7) reporting on the quality of life changes as a result of a CBT intervention could be identified in the last ten years, and were included in this review. The findings are mixed, with four of the studies reporting quality of life improvement post-treatment and two studies at follow-up, while three reported no improvements or did not explicitly discuss it. With one exception, the quality of life improved along with the clinical symptoms, highlighting the connection and interdependence of the two concepts. Questions remain on whether CBT could be valuable in addressing quality of life more strategically, bypassing the persistence of symptoms and focusing on enjoyment and satisfaction, while preserving treatment adherence.

Funding
Providence Care Innovation Grant 2019: "Innovative pathways to the impactful treatment of chronic schizophrenia: disrupting the status-quo moving toward biological-driven, combined pharmacological and non-pharmacological therapeutic approaches to define markers of therapeutic improvement in cognitive behavioural therapy for psychosis promoted recovery."