# Comparative Effectiveness of Cognitive Behavioral Therapies in Schizophrenia and Schizoaffective Disorder: A Systematic Review and Meta-Regression Analysis

## TL;DR

This study reviews how effective cognitive behavioral therapy is for people with schizophrenia and schizoaffective disorder, focusing on how the presence of affective symptoms might influence treatment outcomes.

## Contribution

The study introduces a meta-regression analysis to explore how the proportion of schizoaffective disorder participants affects CBT efficacy in psychosis.

## Key findings

- CBT showed a trend toward lower effectiveness for positive symptoms in schizoaffective disorder, though not statistically significant.
- No significant associations were found between schizoaffective disorder proportion and CBT outcomes for negative or depressive symptoms.
- Substantial heterogeneity and possible publication bias were observed across symptom domains.

## Abstract

Background: Cognitive behavioral therapy (CBT) has shown consistent efficacy in individuals with psychosis, as supported by many trials. One classical distinction is that between affective and non-affective psychosis. Few studies have specifically examined the possible moderating role of substantial affective elements. In this systematic review and meta-regression analysis, we assess how CBT response differs across the affective spectrum in psychosis. Methods: We included studies assessing various CBT modalities, including third-wave therapies, administered in people with psychosis. The study protocol is published in the Open Science Framework. Meta-regression was conducted to assess whether the proportion of participants with affective psychosis (AP), as proxied by a documented diagnosis of schizoaffective (SZA) disorder, moderated CBT efficacy across positive, negative, and depressive symptom domains. Results: The literature search identified 4457 records, of which 39 studies were included. The median proportion of SZA disorder participants was 17%, with a total of 422 AP participants represented. Meta-regression showed a trend toward lower CBT efficacy for positive symptoms with a higher SZA disorder proportion (β = +0.10 SMD per 10% increase in AP; p = 0.12), though it was not statistically significant. No significant associations were found for negative (β = +0.05; p = 0.73) or depressive symptoms (β = −0.02; p = 0.78). Heterogeneity was substantial across all models (I2 ranging from 54% to 80%), and funnel plot asymmetry was observed in negative and depressive symptoms, indicating possible publication bias. Risk of bias assessment showed the anticipated inherent difficulty of psychotherapies in blinding and possibly dropout rates affecting some studies. Conclusions: Affective symptoms may reduce the effectiveness of CBT for positive symptoms in psychotic disorders, although the findings did not reach statistical significance. Other patient-level characteristics in psychosis could indicate which patients can benefit most from CBT modalities.