Metacognitive training (MCT) for psychosis: a systematic review and grade recommendations

Background: Recent meta-analyses support the inclusion of cognitive behavioral therapy (CBT) in schizophrenia treatment. Metacognitive Training (MCT) for psychosis is a psychoeducational program derived from CBT, with most meta-analyses showing favorable results. Although meta-analyses are commonly used in clinical practice to guide evidence-based decision-making, the grading system provides complementary results by offering a structured approach for assessing the strength and reliability of evidence and deriving grades of recommendations accordingly. 

Methods: Our research applies the guidelines from the World Federation of Societies of Biological Psychiatry (WFSBP) to propose grades of recommendation for MCT for psychosis, analyzing 38 randomized controlled trials (RCTs) (n = 1942) and 10 meta- analyses. The primary outcome was positive symptoms, with secondary measures including negative symptoms, general psychopathology, self-esteem, functioning, insight, and cognitive function. 

Results: Our findings are primarily based on the risks of bias attributed to RCTs (11 high, 19 moderate, 6 low) and, when necessary, on the overall confidence attributed to meta- analyses (3 low, 7 critically low). According to the WFSBP guidelines, strong recommendations should be made for using MCT for psychosis to improve post-treatment positive symptoms, delusions, and total psychotic symptoms (WFSBP-grade 1). Limited recommendation (WFSBP-grade 2) could be made for using MCT to improve post- treatment visuospatial abilities and to maintain benefits over time in psychopathology, functioning, self-esteem, episodic memory, and attention. 

Conclusions: MCT for psychosis is an evidence-based program, especially for positive symptoms, with long-lasting clinical benefits. These recommendations should be interpreted with caution given potential residual biases and heterogeneity among studies.