Article Text

Sustained antipsychotic effect and delayed self-esteem improvement of metacognitive training for schizophrenia
  1. Jerome Favrod1,
  2. Alexandra Nguyen2
  1. 1University of Applied Sciences and Arts of Western Switzerland/University Hospital Center of Lausanne, Lausanne, Switzerland
  2. 2University of Applied Sciences and Arts of Western Switzerland, Lausanne, Switzerland
  1. Correspondence to Professor Jerome Favrod, j.favrod{at}

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ABSTRACT FROM: Moritz S, Veckenstedt R, Andreou C, et al. Sustained and “sleeper” effects of group metacognitive training for schizophrenia: a randomized clinical trial. JAMA Psychiatry 2014;71:1103–11.

What is already known on this topic

Metacognitive training (MCT) is an intervention that aims to raise patients’ awareness for cognitive biases involved in the formation and maintenance of psychotic symptoms. The programme is freely downloadable in 31 languages at The majority of studies confirm that MCT is effective in improving delusion, cognitive biases and insight.1 ,2 However the long-term effects of MCT were not known.

Methods of the study

150 patients between 18 and 65 years with DSM-IV schizophrenia spectrum disorders, with present or prior delusional symptoms were randomly assigned to either MCT or COGPACK, a programme that aims to improve basic neuropsychological functions. As they may have been a distraction to other group members, severely psychotic patients were excluded as well as participants with substance dependence, IQ <70 or severe organic brain damage. Participants were assessed at baseline assessment, at post-test, 6 months and 3 years later. The MCT group comprised between 4 and 8 participants who could participate to 16 consecutive sessions, 8 before post-test assessment and 8 after. MCT trainers were psychologists or psychology trainee who had 1–3 years of experience with the programme. MCT modules cover attributional style, jumping to conclusion, changing beliefs, social cognition, memory overconfidence and self-esteem. The COGPACK programme was performed individually on a computer in a group setting for the 16 sessions, 8 before post-test assessment and 8 sessions immediately thereafter. Sessions for both conditions lasted between 45 and 60 min. Participants were assessed by blind raters with the Positive and Negative Syndrome Scale (PANSS) and the Psychotic Symptom Rating Scales (PSYRATS). The main outcome was the PANSS core delusion score. Procedures were used to keep the rater blinded. Participants were explicitly instructed not to disclose their group assignment to the assessor and assessor did not work when training groups were performed. ‘Jumping to conclusion’ was assessed with a computerised probabilistic reasoning task. Self-esteem was measured with the Rosenberg Self-Esteem Scale, quality of life with WHOQOL-BREF and neuropsychological functioning with the Rivermead Behavioural Memory Task. The completion rate at 3 years follow-up was 62% in the MCT group and 61% in the control group. Statistical analyses (ANCOVA) were performed both as per-protocol and intention-to-treat (considering all participants with available baseline data). Eta-squared (η2) was used as a measure of effect size for ANCOVA.

What does this paper add?

  • Participants receiving MCT showed a greater reduction, even though bordered significant, in PANSS delusion score after 3 years compared to the active control group, with small to medium effect size (η2 partial=0.037; p=0.05). Among the secondary outcomes, the intention-to-treat analyses also demonstrated that patients in the MCT group had significantly greater reductions in the PANSS positive syndrome score (η2 partial=0.055; p=0.02) and the Psychotic Symptom Rating Scales (η2 partial=0.109; p=0.001).

  • Measure of self-esteem (η2 partial=0.061; p=0.01) and quality of life (η2 partial=0.037; p=0.05) which did not distinguish groups at earlier assessment points, were improved at 3 years follow-up.


  • The drop-out rate of nearly 40%, since the missing participants could have changed the results for example if the missing participants in the MCT group change the observed pattern.

  • Both groups improved on jumping to conclusion, a main training target is a limitation because the change on this variable would not be a specific effect of MCT, as MCT is intended for reducing this cognitive bias.

What next in research?

While jumping to conclusion is considered the most important cognitive bias, further studies should address other cognitive biases, such as overconfidence in memory errors or lack of cognitive flexibility to better understand the underlining cognitive changes generated by MCT. The non-confronting approach which emphasises similarities with normal cognitive functioning should be studied as a normalising approach, eg, in studying its impact on internalised stigma and mental health literacy.3 Improvement of self-esteem should be studied in relation with improvement of insight in delusion. The experiential learning approach of MCT should also be highlighted from an educational perspective, particularly in relation to participants’ learning styles. As the training value concrete experience, participants who favour other learning styles such as abstract conceptualisation or reflective observation could benefit less of the intervention.

Do these results change your practices and why?

Yes, these results bring additional support to the use of MCT in our routine practice and to prescribe it to patients with schizophrenia spectrum disorders with delusional symptoms. These results also confirm the need of psychological intervention to complement neuroleptic medication. The 3-year sustained effects of this programme is very promising and strengthen the results that our group as already obtained.4 The delayed improvement on self-esteem and quality of life was not as clearly identified prior to this study.


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  • Competing interests JF led a randomised controlled study on MCT.

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