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Early Intervention in Psychiatry 2014; ••: ••–••

doi:10.1111/eip.12130

Original Article Coping as a predictor of treatment outcome in people at clinical high risk of psychosis Mareike Kommescher,1 Michael Wagner,2 Verena Pützfeld,1 Julia Berning,2 Birgit Janssen,3 Petra Decker,4 Ronald Bottlender,4 Hans-Jürgen Möller,4 Wolfgang Gaebel,3 Wolfgang Maier,2 Joachim Klosterkötter1 and Andreas Bechdolf1 Abstract Aim: The concept of coping is relevant to recent models of psychosis, and people with established psychotic disorders have been found to predominately use maladaptive coping strategies. This study aimed to examine the general coping patterns of people at clinical high risk of psychosis (CHR) and to investigate whether pre-therapy coping behaviour plays a role in predicting responsiveness to early interventions. 1 Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, 2Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, 3 Department of Psychiatry and Psychotherapy, University of Düsseldorf, Düsseldorf, and 4Department of Psychiatry and Psychotherapy, University of Munich, Munich, Germany

Corresponding author: Ms Mareike Kommescher, Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Str. 62, 50924 Cologne, Germany. Email: mareike.kommescher @uk-koeln.de Received 5 July 2013; accepted 20 December 2013

Methods: One hundred twenty-eight help-seeking CHR outpatients were randomized into two treatment groups: either receiving integrated psychological intervention (IPI), including cognitive behaviour therapy, or supportive counselling (SC) for 12 months. Of those, 91 persons completed a Stress Coping Questionnaire (SCQ) at intake: 45 in the IPI group and 46 in the SC group. General coping behaviour in this sample was analysed and several regressions were conducted separately for each

Results: Participants relied significantly more on negative than on positive coping strategies, t(90) = −7.185, P < 0.001, and within the positive strategies, stress control was the most preferred one, t(90) = 10.979, P < 0.001. Several pre-therapy coping strategies significantly predicted improvement in symptomatic outcome in both treatment groups, explaining between 16% and 25% of variance. The predictive value of coping was higher in the SC group. Conclusions: Maladaptive coping behaviours were found to emerge in the early stages of psychosis and coping behaviour contributed significantly to the prediction of posttreatment symptom improvement. These findings indicate a need for psychosocial support and coping strategy enhancement in people at risk of psychosis.

Key words: cognitive behaviour therapy, coping, early intervention, predictor, psychosis prodrome.

INTRODUCTION Today, there is strong evidence that psychological interventions are an effective treatment for schizophrenia.1–7 Cognitive behaviour therapy (CBT)-based interventions have been found to decrease symptoms in people at clinical high risk of developing first-episode psychosis (CHR) and also to prevent conversion to a psychotic disorder.6–11 However, clearly, not all individuals with CHR or psychosis respond to psychological treatments.12,13 © 2014 Wiley Publishing Asia Pty Ltd

treatment group to examine coping as a predictor of outcome after 12 months of different forms of treatment.

Therefore, identifying predictors of treatment response may help to improve outcomes of psychological interventions in people with psychosis or CHR.14,15 According to the vulnerability stress coping model (VSCM) of schizophrenia, coping with stress is considered as a relevant factor influencing the onset and course of the illness.16 Lazarus stated that coping strategies could be divided into problemfocused and emotion-focused coping.17 Problemfocused coping is defined as making an effort to 1

Coping and outcome in people at risk change the person–environment relationship by altering the situation, whereas emotion-focused coping is defined as altering the person’s thoughts and feelings related to it. Emotion-focused coping is assumed to be less effective than problem-focused coping.18,19 Several studies analysed how individuals with psychotic disorders cope with general stressors. These studies showed that people with schizophrenia use more passive, emotion-focused coping strategies than active, problem-focused strategies compared with healthy controls.20–22 Moreover, maladaptive coping strategies were related to patients’ symptom severities.23,24 Regarding symptom-related coping, there is some evidence that applying a wider range of coping strategies is associated with better symptom management and better outcome.21,25 Until today, three studies have examined coping strategies in the CHR population. Phillips26 applied the Coping Inventory for Stressful Situations27 and reported that CHR patients were more likely to use emotion-focused and avoidance coping and less likely to use problem-focused coping, compared with a healthy control group. Lee et al.28 found that CHR patients relied significantly more on emotionfocused coping strategies (measured by the Korean version of the Ways of Coping Questionnaire29,30) than healthy controls, thereby showing a similar coping pattern as people with recent-onset schizophrenia. Jalbrzikowski et al.31 showed that, compared with healthy controls, CHR youth used more maladaptive and fewer adaptive coping strategies (assessed by the Brief COPE32). So far, only two studies have analysed coping behaviour as predictors of response to psychological interventions in people with psychosis. In the study by Premkumar et al.,33 greater pre-therapy coping ability and self-reflection (assessed by the COPE inventory34) predicted improvement in negative and general psychotic symptoms after CBT treatment for psychosis. Andres et al.35 found that psychopathological and social improvement was best predicted by the patients’ ability to use active, problem-focused coping, measured immediately after the therapy had ended by several coping questionnaires including the Stress Coping Questionnaire (SCQ),36 which was also used in the present study. As far as we know, no study has yet examined the relationship between pre-treatment coping and treatment outcome in people with CHR. Thus, the present study had two aims: first, to replicate and further support earlier findings regarding coping behaviour in people with CHR, which found a predominance of negative coping strategies,26,28,31 and second, to examine the association between 2

pre-therapy coping and treatment outcome in a CHR sample, either receiving 12 months of integrated psychological intervention (IPI), with CBT as core intervention, or supportive counselling (SC) for 12 months. METHODS The protocol was approved by the respective Institutional Review Boards at the Universities of Cologne, Bonn, Dusseldorf and Munich, Germany. All participants provided written informed consent prior to any research activity. This study is registered with ClinicalTrials.gov (registration number NCT00204087). Setting Recruitment took place from January 2001 to January 2004. The study was conducted at four Early Detection and Intervention Centres, located at the Departments of Psychiatry and Psychotherapy at the Universities of Cologne, Bonn, Düsseldorf and Munich, and funded within the German Research Network on Schizophrenia. All centres served as specialized outpatient departments and were designed to provide a low-threshold, non-stigmatizing environment. Referrals were made from primary health care, mental health professionals, counselling services and other youth support services.10 Participants All participants fulfilled the criteria of the early initial prodromal state (EIPS), which were met when at least one of ten thought or perceptual basic symptoms was presented (Table 1). Basic symptoms have been found to predict psychosis in 19% of cases within 12 months and in 70% of cases within 5.4 years.37 A decrease in functioning in conjunction with a genetic risk of psychosis or a history of obstetric complications has also been found to increase the risk of developing psychosis.38–42 More details regarding EIPS criteria are presented in the past research.43 Exclusion criteria included psychosis and sub-threshold psychotic symptoms, which were further divided into attenuated psychotic symptoms (APS) and brief limited intermittent symptoms (BLIPS) in accordance with the ultra high risk concept.44 A total of 1348 persons were screened with the inclusion criteria checklist and 232 met the EIPS inclusion criteria. Of those, 64 met the exclusion criteria, so 168 persons remained eligible for randomization. In the end, 128 participants were randomized in the original study, as 22 © 2014 Wiley Publishing Asia Pty Ltd

M. Kommescher et al. TABLE 1.

Inclusion, exclusion and exit criteria (cf. Bechdolf et al.)10

Inclusion criteria (early initial prodromal state)

Exclusion criteria

Exit criteria

Self-experienced thought and perception deficits (basic symptoms (BS) ): One or more of the following BS in the last 3 months, several times a week: • Thought interferences • Thought perseveration • Thought pressure • Thought blockages • Disturbances of receptive language, either heard or read • Decreased ability to discriminate between ideas and perception, fantasy and true memories • Unstable ideas of reference (subject-centrism) • Derealization • Visual perception disturbances (blurred vision, transitory blindness, partial sight, hypersensitivity to light, etc.) • Acoustic perception disturbances (hypersensitivity to sounds or noise, acoasms, etc.) and/or Reduction in the Global Assessment of Functioning Score (DSM-IV) of at least 30 points (within the last year) and at least one of the following risk factors: • First-degree relative with a lifetime diagnosis of schizophrenia or a schizophrenia spectrum disorder • Pre- or perinatal complications Attenuated or brief limited intermittent psychotic symptoms Present or past diagnosis of a schizophrenic, schizophreniform, schizoaffective, delusional or bipolar disorder according to DSM-IV Present or past diagnosis of a brief psychotic disorder according to DSM-IV, with a duration of more than 1 week or within the last 4 weeks regardless of its duration Diagnosis of delirium, dementia, amnestic or other cognitive disorder, mental retardation, psychiatric disorders due to a somatic factor or related to the consumption of psychotropic substances according to DSM-IV Organic brain disease (inflammatory, traumatic, epilepsy, etc.) Previous treatment with antipsychotics Acute suicidal tendency Age below 17 and above 35 years Sub-threshold psychotic symptoms: Attenuated psychotic symptoms: One or more of the following symptoms appearing several times a week for a period of at least 1 week: • Ideas of reference • Odd beliefs or magical thinking • Unusual perceptual experiences • Odd thinking and speech • Suspiciousness or paranoid ideation and/or Brief limited intermittent psychotic symptoms: One or more of the following psychotic symptoms for less than 1 week, resolving spontaneously: • Hallucinations • Delusions • Formal thought disorder • Gross disorganized or catatonic behaviour and/or Psychosis: One or more of the following psychotic symptoms for more than 1 week: • Hallucinations • Delusions • Formal thought disorder • Gross disorganized or catatonic behaviour

DSM, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

refused research participation, 15 refused treatment, 2 were lost during assessment and 1 person developed psychosis during assessment.10 For a detailed overview of inclusion, exclusion and exit criteria, see Table 1. Design This study was a prospective, randomized trial with two parallel groups, which were assigned to © 2014 Wiley Publishing Asia Pty Ltd

alternative outpatient interventions: either IPI, including CBT, or SC. Randomization was accomplished by using computer-generated block randomization. Both treatments were regularly supervised, manual-based and provided as an outpatient treatment for 12 months by clinical psychologists with at least 2 years of CBT experience and a specific training in IPI. More details regarding method and primary outcome of the study are presented elsewhere.10 3

Coping and outcome in people at risk Treatments IPI The interventions applied were based upon the VSCM of schizophrenia16,45 and the basic symptom concept.37,46 The treatment components followed established strategies for first-episode or recurrent schizophrenia, anxiety and depressive disorders2,47–50 and contained the following modules: individual CBT, group skills training, cognitive remediation and psychoeducational multi-family groups. For further details of the interventions, see Bechdolf et al.10,51,52 SC SC was a manual-based individual therapy,53 designed to provide a minimal supportive treatment to the help-seeking persons. In this condition, basic assessment, psychoeducation and counselling took place in a supportive, empathic, but unstructured way and within a maximum number of 30 sessions. Measures Assessment procedure All assessments were performed by experienced clinical psychologists or psychiatrists, who attended a multi-day workshop at the beginning of the study and yearly throughout its accomplishment. Coping was assessed at baseline (via self-report questionnaire). The outcome variables were assessed at baseline and post-treatment after 12 months. The reliabilities of all nine raters regarding the outcome variables were good to excellent with Kappas between 0.63 and 0.87.10 Inclusion criteria Inclusion criteria for basic symptoms (BS) were assessed by a short version of the symptom list of the ERIraos.54 A genetic risk of developing schizophrenia was assessed using the Interview for the Retrospective Assessment of the Onset and Course of Schizophrenia and other Psychoses – IRAOS.55 Pre- or perinatal complications were recorded with the correspondent ERIraos module,54 which is based upon the model of obstetric complications by Lewis and Murray.56 Exit criteria Conversion to sub-threshold ‘Attenuated Psychotic Symptoms’ (APS) was assessed by using the symptom list of the ERIraos54 and was considered as 4

fulfilled if one of the symptoms was rated as present. The sub-threshold ‘Brief Limited Intermittent Psychotic Symptoms’ (BLIPS) as well as the conversion to psychosis was quantified by the Positive and Negative Syndrome Scale (PANSS).57 BLIPS were defined as psychotic symptoms for less than 7 days, whereas the criteria for psychosis were symptoms lasting longer than 7 days. Coping strategies Coping strategies were assessed using the Stress Coping Questionnaire (SCQ 120) by Janke et al.36 This self-report questionnaire is based upon the coping model developed by Lazarus58 and designed to assess individual coping in response to general stress. Coping is assessed by 120 items on a 5-point scale, which can be assigned to 20 subscales, with every subscale containing six items. The subscales 1–10 (trivializing, downplaying by comparison with others, guilt defence, distraction, vicarious satisfaction, self-affirmation, relaxation, situation control, reaction control and positive self-instructions) refer to actions aiming at stress reduction and are described as positive strategies (POS).36 Following the classification of Lazarus,17 these strategies can be assigned to the category ‘problem-focused’. The subtests 13–18 (escape, social isolation, continual mental preoccupation, resignation, self-pity and self-accusation) refer to coping strategies that are suspected to increase stress in the long term and are therefore summarized as negative strategies (NEG)36 or emotion-focused coping.17 The subtests 11 ‘need for social support’, 12 ‘avoidance’, 19 ‘aggression’ and 20 ‘intake of pharmaceuticals’ cannot be assigned to one of these groups and were therefore not considered in further analyses. The positive strategies can be further differentiated into three subgroups: Pos 1 (devaluation – subtests 1–3), Pos 2 (distraction – subtests 4–7) and Pos 3 (stress control – subtests 8–10). Internal consistencies of the subtests ranged from 0.62 to 0.92, those of the aggregated positive and negative strategies from 0.84 to 0.94.36 Outcome variables Psychopathology was assessed by using the PANSS.57 The PANSS total score was used as it indicates broad psychopathology. The basic symptom total score was calculated by using the total score of the 10 basic symptoms defining the EIPS.37 They were assessed by applying the respective items of the symptom list of the ERIraos,54 which score from 0 (not present) to 3 (severe). Depression was measured by the Montgomery Åsberg Depression Scale © 2014 Wiley Publishing Asia Pty Ltd

M. Kommescher et al. (MADRS).59 Global functioning was assessed with the Global Assessment of Functioning Scale (GAF) of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).60 Statistical analysis Change in outcome from baseline to follow-up after 12 months Absolute change from baseline to follow-up was computed for each outcome variable (calculated so that a positive change score indicated improvement and a negative change score indicated decline in clinical status). To make more reliable use of the data, the change scores were used, as the application of categorical criteria for improvement would have led to seriously reduced sample sizes, impeding statistically reliable regression analyses. Paired t-tests were conducted for each outcome variable to find out whether the outcome changes in both groups were significant.

the coping questionnaire at intake: 45 in the IPI group and 46 in the SC group. In this subsample, the IPI group contained significantly younger persons than the SC group. Therefore, age was entered as covariate in secondary multivariate analyses, which, however, did not change the results and is therefore not presented here. Demographic, coping, symptomatic and functional data at baseline and posttreatment are presented in Table 2. Coping at baseline All persons in this sample relied significantly more on negative than on positive coping styles at baseline prior to any study intervention, t(90) = −7.185, P < 0.001. Within the positive strategies, stress control was the most frequently applied strategy, t(90) = 10.979, P < 0.001. It was followed by distraction, whereas devaluation was the least preferred positive strategy, t(90) = −3.332, P = 0.001. Outcome post-treatment

First, a series of univariate regressions with the subtests 1–10 (positive strategies) and the subtests 13–18 (negative strategies) was conducted for each outcome variable to assess the associations between each predictor candidate and outcome change at 12-months follow-up. Separate analyses were conducted for the IPI and the SC groups. Those predictors that were associated with one or more of the change variables at an a priori specified probability value of 0.20 were then entered into stepwise backward multiple regressions in order to determine the best predictors of the four outcome variables for each group. Any variables that differed significantly between groups at baseline were also included as covariates in secondary multiple regressions. All analyses were conducted using the Statistical Package for Social Sciences (SPSS) for Mac (version 19.0; SPSS Inc., Chicago, IL, USA). Only adjusted regression coefficients are presented below in order to avoid an overestimation of the results.61

In both treatment groups, participants significantly improved in symptoms and post-treatment functioning (PANSS total score, t(67) = 8.565, P < 0.001, d = 1.12; basic symptoms, t(71) = 5.384, P < 0.001, d = 0.76; depression symptoms, t(63) = 8.122, P < 0.001, d = 1.07; and GAF score, t(56) = −4.870, P < 0.001, d = −0.73; see Table 2). The results remained statistically significant after Bonferroni correction with α = 0.0125 for the four performed t-tests. However, there were no significant betweengroup differences regarding symptoms and functioning post-treatment in the subsample. Despite these non-significant group differences, there was a significant difference in the conversion rates between the IPI and the SC conditions at 12 months in the original sample.10 Out of 65 in the SC group, 11 people converted to psychosis, whereas in the IPI condition, there were only 2 transitions out of 63 within 12 months.10 However, as the absolute numbers of the converters in the subsample were small, conversion to psychosis was not used as dependent variable in the following regression analyses.

RESULTS

Prediction of PANSS total change score by pre-therapy coping

Participant characteristics

IPI

A total of 128 help-seeking outpatients in the EIPS agreed to participate in the study and were assigned to one of the two interventions through randomization.10 Of those, 91 subjects completed

Separate univariate regressions revealed three predictors associated with PANSS total change at the 12-months follow-up at a probability level below 0.20. All of them belonged to the SCQ’s negative

Prediction of change in outcome by pre-therapy coping

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5

Coping and outcome in people at risk TABLE 2.

Sample characteristics (n = 91) IPI, n = 45

Age, years (mean (SD) ) Male (n (%) ) Met BS criteria at intake (n (%) ) Met reduced function and risk factor criteria at intake (n (%) ) Marital status (n (%) ) Married, cohabitation Living alone, divorced Employment status (n (%) ) Full/Part time Student/Apprentice Unemployed/Other Housing status (n (%) ) Independent Primary family Other Baseline coping (mean (SD) ) Pos 1 – Devaluation Pos 2 – Distraction Pos 3 – Stress control POS NEG Baseline symptoms and functioning scores (mean (SD) ) PANSS total BS total MADRS GAF Symptom and functioning change score post treatment (mean (SD) ) PANSS total BS total MADRS GAF

24.1 (4.3) 30 (66.7) 41 (91.1) 12 (26.7)

SC, n = 46 26.9 (6.0) 27 (58.7) 46 (100.0) 14 (30.4)

13 (28.9) 32 (71.1)

19 (41.3) 27 (58.7)

6 (13.3) 30 (66.7) 9 (20.0)

12 (26.1) 21 (45.6) 13 (28.3)

27 (60.0) 14 (31.1) 5 (8.9)

33 (71.7) 13 (28.3)

P 0.010 0.432 0.039 0.691 0.215

0.116

0.099

8.8 (2.8) 9.3 (3.2) 13.9 (3.6) 10.6 (2.5) 13.1 (3.9)

7.9 (2.5) 9.5 (3.2) 13.0 (4.4) 10.0 (2.8) 15.1 (3.2)

0.087 0.803 0.269 0.348 0.009

50.6 (9.7) 3.9 (3.0) 19.1 (7.4), n = 44 60.1 (12.0), n = 42

48.8 (8.6) 4.8 (3.3), n = 45 19.0 (8.2), n = 43 59.6 (10.5), n = 41

0.347 0.176 0.956 0.837

11.2 (10.2), n = 33 2.0 (2.9), n = 36 8.8 (8.8), n = 32 10.1 (14.1), n = 23

9.7 (9.9), n = 35 2.6 (4.4), n = 36 8.5 (8.4), n = 32 9.8 (16.3), n = 34

0.542 0.485 0.907 0.939

BS, basic symptoms; GAF, Global Assessment of Functioning Score; IPI, integrated psychological intervention; MADRS, Montgomery Åsberg Depression Rating Scale; NEG, overall negative strategies; PANSS, Positive and Negative Syndrome Scale; POS, overall positive strategies; SC, supportive counselling; SD, standard deviation.

coping strategies. After these variables were entered in a backwards multiple regression, continual mental preoccupation was the only coping strategy with predictive value retaining in the final model, explaining about 15% of variance (P = 0.015) and indicating that more continual cognitive engagement at baseline was associated with stronger improvement in psychotic symptoms at follow-up in the IPI condition (Table 3). SC In the SC group, univariate regressions identified four positive and two negative coping strategies associated with PANSS total change post-treatment. After entering these variables in multivariate backwards regression, the two negative coping candidates were the only strategies remaining in the final regression model, explaining about 25% of variance (P = 0.004). It was found that less escape tendency 6

and more social withdrawal at baseline were associated with greater improvement in psychotic symptoms after 12 months.

Prediction of basic symptom change score by pre-therapy coping IPI In the IPI group, separate univariate regressions identified two coping strategies associated with basic symptom change post-treatment. After being entered in a multiple backwards regression, these two strategies remained in the final regression model, explaining 16% of variance (P = 0.021). The results indicated that less guilt defence and more continual mental preoccupation at baseline were associated with better change in basic symptoms at follow-up. © 2014 Wiley Publishing Asia Pty Ltd

M. Kommescher et al. SC According to the results of separate univariate regressions, there were six coping strategies in the SC group predicting basic symptom change. After backwards multiple regression, downplaying by comparison with others and vicarious satisfaction contributed significantly to the final multivariate regression model, both belonging to the positive strategies. These two strategies explained about 19% of variance (P = 0.011) in 12-month basic symptom change following SC. This indicates that better competence in these coping strategies at baseline was related to greater improvement at follow-up. No negative coping variables remained in the final regression model. Prediction of depression change score by pre-therapy coping IPI There were six univariate candidates associated with depression change at 12-months follow-up. After being entered in multivariate backwards regression, search for self-affirmation and continual mental preoccupation were the only remaining predictors, explaining about 24% of variance (P = 0.008). The results indicated that the greater presence of both strategies was associated with stronger improvement in depression values after 12 months of IPI intervention, despite belonging to opposing groups of coping strategies. SC In the SC group, separate univariate regressions established six predictors of change in depression after 12 months. Distraction and continual mental preoccupation remained in the final model after multiple backwards regression, explaining more than 21% of variance (P = 0.011). Although belonging to opposing groups of coping strategies, higher developed baseline distraction ability and more continual mental preoccupation were both associated with greater depression enhancement at follow-up. Prediction of global functioning change score by pre-therapy coping IPI In the IPI group, univariate regressions did not find any coping variables associated with change in global functioning below a probability level of 0.20. © 2014 Wiley Publishing Asia Pty Ltd

Coping strategies were not able to predict change in global functioning after 12 months of intervention. SC The only predictor associated with change in global functioning after 12 months below the probability level of 0.20 was continual mental preoccupation. However, this negative coping strategy did not remain in the final regression model after the backwards regression, so that in the SC group, coping also did not predict change in global functioning (Table 3). DISCUSSION The present study examined coping styles in people at CHR and the role of coping in predicting response to two different types of psychological treatment. One main finding was that people with CHR seemed to rely more on negative than on positive coping strategies at baseline prior to the study interventions (measured by the SCQ by Janke et al.).36 Among the positive strategies, they clearly preferred those aiming at stress control. When compared with healthy controls (the SCQ evaluation sample),36 healthy subjects displayed more positive than negative coping behaviours. These findings are in line with earlier studies in people with CHR, showing that they used more emotion-focused rather than problem-focused coping strategies compared with healthy controls.26,28,31 The results indicate that at-risk persons might be limited in their ability to apply a broad range of coping strategies, instead they are seemingly restricted to mainly negative coping strategies. According to earlier findings, predominant use of negative coping strategies is associated with less effective symptom handling and outcome in individuals with fully established psychosis.23,25 These findings also support the notion that a limited availability of coping strategies might already be present in people at risk of psychosis, prior to the onset of the full illness, indicating an already existing vulnerability.28 To our knowledge, this was the first study to examine coping as a predictor of response to psychological treatment in CHR. In both treatment groups, IPI and SC, pre-therapy coping was significantly related to symptom improvement after treatment (broad psychopathology, basic and depression symptoms), explaining between 16% and 25% of variance. These findings indicate that coping can be seen as a relevant predictor of symptomatic outcome following psychological interventions in CHR, but does not predict functional 7

Coping and outcome in people at risk TABLE 3.

Multivariate pre-therapy coping predictors of outcome in both groups

Outcome differences

IPI

SC

Predictors (POS/NEG)

Model

Predictors (POS/NEG)

Model

PANSS total†

Continual mental preoccupation (NEG) (β = 0.418, P = 0.015)

R2 = 0.148 P = 0.015

Escape (NEG) (β = −0.434, P = 0.007) Social withdrawal (NEG) (β = 0.406, P = 0.011)

R2 = 0.247 P = 0.004

BS total‡

Guilt defence (Pos 1) (β = −0.290, P = 0.072) continual mental preoccupation (NEG) (β = 0.320, p = 0.048)

R2 = 0.160 P = 0.021

Downplaying by comparison with others (Pos 1) (β = 0.291, P = 0.066) Vicarious satisfaction (Pos 2) (β = 0.362, P = 0.024)

R2 = 0.191 P = 0.011

MADRS total§

Search for self-affirmation (Pos 2) (β = 0.315, P = 0.058) Continual mental preoccupation (NEG) (β = 0.378, P = 0.025)

R2 = 0.237 P = 0.008

Distraction (Pos 2) (β = 0.325, p = 0.052) Continual mental preoccupation (NEG) (β = 0.356, P = 0.035)

R2 = 0.215 P = 0.011

GAF¶ †IPI: n = 33; SC: n = 35. ‡IPI: n = 36; SC: n = 36. §IPI: n = 32; SC: n = 32. ¶IPI: n = 23; SC: n = 34. The presented R2 have been adjusted. BS total, basic symptom total score; GAF, Global Assessment of Functioning Score; IPI, integrated psychological intervention; MADRS total, total score of the Montgomery Åsberg Depression Rating Scale; NEG, belonging to negative coping strategies; PANSS total, total score of the Positive and Negative Syndrome Scale; Pos 1, devaluaton; Pos 2, distraction; Pos 3, stress control; SC, supportive counselling.

outcome. Our findings that coping style predicts symptom improvement after treatment are in line with studies examining people with fully established psychosis. These studies found that posttreatment assessed coping predicted 57% of the variance in psychological and social outcome,35 and improvement in negative and general psychotic symptoms was predicted by greater pre-therapy coping and self-reflection abilities, explaining up to 21% of variance in symptom improvement.33 In both conditions, certain specific positive and negative pre-therapy coping strategies were significantly associated with outcome and there was no clear predominance of either positive or negative coping. The percentage of variance explained by pre-therapy coping was higher in the SC group. This can be seen as an indicator for the fact that established behaviour patterns such as coping style have greater influence on outcome when the treatment is rather unspecific. Continual mental preoccupation seemed to play an important role in the prediction of outcome, especially in the IPI condition, indicating that people suffering from continual negative thoughts may benefit more from specific psychological interventions. Thus, one 8

important factor in coping strategy enhancement should focus on therapeutic intervention with negative and weakening cognitions, as these maladaptive thoughts have a strong impact on the course of the illness. Methodological considerations Although this is the first study that has investigated coping as a predictor of therapy response in people with CHR, there are some methodological limitations that need to be addressed in future research. There are some methodological problems with the assessment of coping in this study and coping research in general. First, there is a broad variety of instruments, which limits comparability. Second, it is sometimes difficult to distinguish between symptoms and coping behaviour. For example, withdrawal from social activities by someone who experiences command hallucinations telling him to hurt others can be viewed as a symptom of impaired social functioning or as a coping technique for dealing with the illness.62 Third, the classification of coping in positive and negative coping © 2014 Wiley Publishing Asia Pty Ltd

M. Kommescher et al. styles is somewhat arbitrary and there is no empirical evidence for the assignment of the SCQ’s subscales to either positive or negative coping. Therefore, the subscales instead of only positive or negative coping style were used in the analyses of this study. It could be shown that the classification in positive and negative coping did not reflect our empirical results in all cases, since the direction of influence in the regression model did not always correspond to the respective theoretical categories.36 Fourth, the SCQ is not a specific instrument for the assessment of coping behaviour in individuals at CHR of psychosis and might thus not be sensitive to typical coping strategies of this population. Fifth, coping was only assessed at baseline, so no statement can be made about eventual modifications in coping patterns due to the interventions. Another fact to consider is the rather small size of the groups, eventually contributing to some of the non-significant results of the study, which could potentially change with bigger group sizes. There are further methodological limitations that need to be considered in future research. There was no non-psychotic control group in this study. Although we compared the CHR data with data from the literature of healthy controls, who had been assessed with the same coping measure, employing a healthy control group would have improved the validity of the findings. Moreover, all participants received some form of treatment (IPI or SC) and there was no ‘no treatment’ condition. Therefore, we cannot rule out the idea that coping did not predict treatment response but rather correlated with the ‘natural’ course of the syndrome. Clinical consequences The results of this study show that people at CHR apply more negative rather than positive coping strategies prior to psychological interventions. The observed coping pattern is thereby similar to those applied by patients who already developed the fullblown syndrome.20–22 Thus, maladaptive coping strategies might have already emerged in early stages of the illness, leaving the at-risk person less protected against stress and thereby causing additional vulnerability for developing psychosis. Moreover, pretreatment coping explained up to 25% of the variance of symptomatic treatment response to psychological interventions. Coping style seemed to have a greater influence on outcome when the treatment was unspecific. When it was specific, continual negative thinking had the greatest influence on © 2014 Wiley Publishing Asia Pty Ltd

the outcome of all coping strategies and should therefore be explicitly taken into account in psychological treatments. The fact that strategies labelled as ‘positive’ or ‘negative’ did not always predict outcome in the anticipated way (e.g. greater competence in a positive strategy being related to stronger symptom improvement) shows the relevance of individual coping strategy enhancement. Psychological treatments should focus on a person’s individual functional strategies instead of acting on the assumption of global ‘functional’ and ‘dysfunctional’ coping strategies. These findings – that people with CHR seemed to apply negative rather than positive coping and that coping behaviour might influence the efficacy of early psychological interventions in this clinical population – underline the importance of specific early coping enhancement and offer a good basis for further research concerning coping and CHR as well as other possible predictors of treatment outcome. ACKNOWLEDGEMENT This work was supported by the German Federal Ministry for Education and Research (BMBF, Grant No. 01 GI 9935). The sponsor of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report. REFERENCES 1. Gould RA, Mueser KT, Bolton E, Mays V, Goff D. Cognitive therapy for psychosis in schizophrenia: an effect size analysis. Schizophr Res 2001; 48: 335–42. 2. Pilling S, Bebbington P, Kuipers E et al. Psychological treatment in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychol Med 2002; 32: 763–82. 3. Pfammatter M, Junghan UM, Brenner HD. Efficacy of psychological therapy in schizophrenia: conclusions from metaanalyses. Schizophr Bull 2006; 32 (Suppl. 1): S64–80. 4. Wykes T, Steel C, Everitt B, Tarrier N. Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophr Bull 2008; 34: 523– 37. 5. Zimmermann G, Favrod J, Trieu VH, Pomini V. The effect of cognitive behavioural treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophr Res 2005; 77: 1–9. 6. NICE. Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. NICE clinical guideline 82. London: NICE, 2009. 7. Kreyenbuhl J, Buchanan RW, Dickerson FB, Dixon LB. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull 2010; 36: 94–103. 8. Addington J, Epstein I, Liu L, French P, Boydell KM, Zipursky RB. A randomized controlled trial of cognitive behavioral therapy for individuals at clinical high risk of psychosis. Schizophr Res 2011; 125: 54–61.

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