brain sciences Review Systematic Review of Cognitive-Behavioural Therapy for Social Anxiety Disorder in Psychosis Maria Michail 1,*, Max Birchwood 2 and Lynda Tait 1 1 School of Health Sciences, University of Nottingham, Jubilee Campus, Nottingham NG7 2TU, UK; [email protected] 2 Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK; [email protected] * Correspondence: [email protected]; Tel.: +44-115-748-4310 Academic Editor: Wai Kwong TANG Received: 21 February 2017; Accepted: 19 April 2017; Published: 25 April 2017 Abstract: Background: Social anxiety is highly prevalent among people with psychosis and linked with significant social disability and poorer prognosis. Although cognitive-behavioural therapy (CBT) has shown to be effective for the treatment of social anxiety in non-psychotic populations, there is a lack of evidence on the clinical effectiveness of CBT for the treatment of social anxiety when this is co-morbid in psychosis. Methods: A systematic review to summarise and critically appraise the literature on the effectiveness of CBT interventions for the treatment of social anxiety in psychosis. Results: Two studies were included in the review assessing the effectiveness of group CBT for social anxiety in schizophrenia, both of poor methodological quality. Preliminary findings suggest that group-based CBT is effective in treating symptoms of social anxiety, depression and associated distress in people with schizophrenia. Conclusion: The evidence-base is not robust enough to provide clear implications for practice about the effectiveness of CBT for the treatment of social anxiety in psychosis. Future research should focus on methodologically rigorous randomised controlled trials with embedded process evaluation to assess the effectiveness of CBT interventions in targeting symptoms of social anxiety in psychosis and identify mechanisms of change. Keywords: social anxiety; psychosis; cognitive-behavioural therapy 1. Introduction Social anxiety is among the most commonly reported anxiety disorders with a 12-month prevalence of 2% reported in European countries [1] and 7.1% in the US [2]. It usually develops during childhood or adolescence, follows a chronic course [3–5], and has a lower likelihood of a full remission compared to other anxiety disorders [6]. Social anxiety disorder is highly co-morbid and poses a significant risk for the emergence of other anxiety and mood disorders [7]. Social anxiety is particularly prevalent in psychosis, with rates ranging between 8% and 36% [8–16]. Its presence in psychosis is linked with poorer prognosis, greater likelihood of an early relapse [17], and significant levels of social disability [13]. Cognitive-behavioural therapy (CBT) is recommended by the National Institute for Health and Care Excellence (NICE) as an indispensable treatment option for people with psychosis and as a first line treatment for those refusing antipsychotic medication [18]. Traditionally, CBT has focused on the reduction of psychotic symptoms rather than on affective co-morbidities such as depression, social anxiety and distress despite the highly debilitating nature and impact of these co-morbidities [12,13,19]. Although CBT has shown to be effective for the treatment of social anxiety disorder in non-psychotic populations [20], there is lack of evidence on the clinical effectiveness and cost-effectiveness of CBT for the treatment of social anxiety when this is co-morbid in psychosis. Brain Sci. 2017, 7, 45; doi:10.3390/brainsci7050045 www.mdpi.com/journal/brainsci Brain Sci. 2017, 7, 45 2 of 11 We carried out a systematic review to summarise and critically analyse the evidence on the effectiveness of CBT interventions in improving social anxiety symptoms, general anxiety, distress, depression, positive and negative symptoms of schizophrenia, and quality of life in people with psychosis. 2. Methods 2.1. Study Design This paper comprises a systematic review reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [21] following the Cochrane Handbook for Systematic Reviews of Interventions [22]. 2.2. Search Strategy We searched the following databases: Cochrane Central Register of Controlled Trials, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, MEDLINE, PsychINFO, SCI (Science Citation Index); and trial registries https://clinicaltrials.gov/ and ISRCTN for grey literature. We set the following search limits: (1) Study design: randomised controlled trials (RCTs) and quasi-experimental studies; (2) English language only. No date restrictions were applied. The electronic search strategy terms used were: (phobic disorders OR social *anxi* OR social anxiety disorder) AND (psychotic disorders OR schizophrenia) AND (Cognitive Therapy OR Cognitive Behaviour Therapy) AND (clinical trial OR cross-over studies OR double-blind method OR random allocation OR randomised controlled trial OR single-blind method). EndNote was used to record titles, abstracts and inclusion/exclusion decisions. 2.3. Selection Criteria 2.3.1. Types of Studies Randomised controlled trials (RCTs) and quasi-experimental studies (pre- and post-test design) were eligible for inclusion. 2.3.2. Types of Intervention Cognitive-behavioural/cognitive interventions (group-based and one-to-one) targeting social anxiety in people with psychosis. No limitations in terms of psychological theory informing the intervention, the person delivering the intervention or the setting in which the intervention was delivered were imposed. 2.3.3. Comparator Any other treatment; no treatment; treatment-as-usual and a waiting list control were included as control conditions. 2.4. Types of Participants Participants aged 16–65 years; with schizophrenia or related psychoses and social anxiety disorder, diagnosed using any recognised diagnostic criteria e.g., ICD-10 [23] or DSM-V [24] were included. Studies with a primary diagnosis of organic brain disorder were excluded. 2.5. Primary Outcome Social anxiety was assessed using any psychometrically validated scale, including self-report and clinician administered. Brain Sci. 2017, 7, 45 3 of 11 2.6. Secondary Outcomes Secondary outcomes included general anxiety symptoms; distress; depression; positive and negative symptoms of schizophrenia; quality of life assessed using any psychometrically validated scale, both self-report and clinician administered; cost of CBT intervention. 2.7. Selection Procedure, Data Extraction and Data Management MM and LT independently screened the title and abstract of retrieved studies for inclusion. The EPOC (Effective Practice and Organisation of Care) data extraction form and the EPOC data checklist were used to extract data from eligible studies. The researchers extracted the following data: setting, population and demographic characteristics of participants; baseline characteristics; details of intervention and control conditions; methodology; recruitment, completion and attrition rates; outcomes and times of measurement; suggested mechanisms of intervention action; information for assessment of the risk of bias. MM and LT independently assessed study quality and risk of bias using the Cochrane’s Collaboration tool for assessing risk of bias [25]. 3. Data Synthesis Due to the low number of included studies, we undertook a narrative synthesis following guidance by Popay et al. [26]. The narrative synthesis involved describing, organising, exploring and interpreting the study findings, taking into account the methodological adequacy. We investigated the similarities and differences between study findings including study design; quality; study power; intervention characteristics and delivery; participants and outcome measures. Where particular patterns of findings have emerged, we have presented possible explanations for these findings. 4. Results 4.1. Description of Studies Figure1 presents a detailed flow diagram of the study selection process. Two studies were included in the review (Table1), both conducted in Australia. Halperin et al. [ 27] assessed the efficacy of a group-based CBT for social anxiety in schizophrenia using a randomly assigned design (group-based CBT vs. waitlist control) with pre-, post-, and six-week follow-up ratings. Kingsep et al. [28] investigated the effectiveness of a CBT treatment model as an intervention for social anxiety in people with schizophrenia using a controlled clinical trial (CBT vs. waitlist control) with alternation as an allocation method and a two-month follow-up. Table 1. Overview of characteristics of included studies. Study Country Design Participants Intervention Control Outcome Measures Randomised Social anxiety: BSPS; SIAS controlled trial Group CBT based on Heimberg Waitlist- Depression: CDSS Halperin et al. Australia (no details of 16 (13 males) et al. (1995) [28] model; eight control Quality of life: QLESQ (2000) [27] randomisation 2-h weekly sessions group Psychological symptom: BSI provided) Alcohol use: AUDIT Social anxiety: BSPS; SIAS; Group CBT based on Heimberg Controlled trial with Waitlist- BFNE Kingsep et al. 33 (no data et al. (1995) [28] model; twelve Australia alternation as control Depression: CDSS (2003) [28] on gender) 2-h weekly sessions plus one allocation method group Quality of life: QLESQ follow-up session Psychological symptom: BSI CBT: Cognitive-behavioural therapy; BSPS: Brief Social Phobia Scale; SIAS: Social Interaction Anxiety Scale; CDSS: Calgary Depression Rating Scale; BSI-GSI: Brief