Abstract
Background
Social cognitive deficits are common in people with a psychotic disorder, and may play an important role in social dysfunction. Social cognition training (SCT) has emerged in the past two decades as a way to improve social cognition through strategy training and repeated practice. Several reviews and meta-analyses have indicated that SCT improves social cognition, but several important questions remain. This meta-analysis addresses three of these questions:
Methods
Search results from clinical databases were systematically reviewed by two independent raters. SCTs from included publications were categorized according to their focus (targeted or broad-based) and their inclusion of CRT (with or without). Network meta-analysis was used, since it allows for comparison of more than two treatments, and comparison of any chosen pair of interventions - even those not directly investigated in the literature. It estimates the treatment effect by inference from a network of evidence (i.e., effectAB = effectAC – effectBC), and combines this indirect evidence with original comparisons to estimate treatment effects.
For each treatment arm, a pre-post effect size was determined and pairwise comparisons for each combination of study arms were calculated. With network meta-analysis, all SCTs were compared to treatment as usual (the chosen reference group). Meta-regression was used to evaluate the moderating effects of study (methodological quality, total intervention time, use of groups, static/dynamic measures, inclusion of CRT) and participant (age, illness duration, medication dose, gender) characteristics. Follow-up efficacy was investigated using multivariate meta-analysis.
Results
Compared to TAU, emotion perception was improved most by targeted SCT without CRT (Cohen’s d=.68) and broad-based SCT without CRT (d=.46). All treatments improved social perception (active control, d=.98, targeted SCT with and without CRT, d=1.36 and d=1.38, broad-based SCT with and without CRT, d=1.35 and d=1.45). Only broad-based SCT without CRT improved ToM (d=.42) more than TAU. Social functioning was significantly improved only by broad-based SCT (without CRT, d=.82, with CRT, d=.41). None of the SCTs significantly improved attribution, general social cognition and psychotic symptoms, compared to TAU.
Individual SCT worked better for emotion perception, but SCT in a group was more effective for social functioning. A higher percentage of male participants in a study predicted worse outcomes on functioning and psychotic symptoms.
At follow-up, a moderate effect on social functioning (d=.66) was found, but not on psychotic symptoms. Social cognition could not be investigated quantitatively at follow-up due to insufficient data, but qualitative analysis suggested persisting effects.
Discussion
While targeted SCT is the most effective for emotion perception and social perception, broad-based SCT produced the best overall outcomes. Using CRT did not enhance SCT effects. Our results suggest that (particularly broad-based approaches to) SCT produce generalized, enduring effects, but more methodologically sound research is necessary to investigate key questions that remain, especially regarding mechanisms of treatment.
Is theory of mind a prerequisite for social interactions? A study in psychotic disorder
