INTRODUCTION
The negative symptoms experienced by patients with schizophrenia have a powerful impact on their poor quality of life, low occupational achievement and productivity, and social dysfunction [1]. Positive symptoms have demonstrated significant therapeutic efficacy with breakthroughs in biological treatments and can be significantly reduced and managed with appropriate pharmacotherapy [2]. On the other hand, negative symptoms are still difficult to address with pharmacological treatments alone [3] and there is a lack of psychosocial treatments that have been clearly demonstrated to be effective [4]. The most recently developed treatments for voice symptoms include 1) social skills training, 2) cognitive behavioral therapy (CBT), and 3) CBT for negative symptoms. However, these treatments have limitations such as limited efficacy with age [5], difficulty in identifying effective treatment components for improving voice symptoms [6], and high dropout rates due to relatively long treatment durations [7].
Behavioral activation (BA) is an evidence-based non-phar-macological treatment for depressive disorders [8]. BA is a treatment that involves increasing access to rewarding environments that reinforce antidepressant behaviors, with corresponding improvements in thoughts, feelings, and overall quality of life [9]. In other words, it is a treatment that activates behaviors by increasing the frequency of behaviors that produce positive experiences through positive reinforcement. Negative symptoms of schizophrenia share symptoms of depression and inactivity, anhedonia and reduced ability to function, social and emotional withdrawal and avoidance, and these symptoms are maintained and exacerbated through negative reinforcement [10,11]. Therefore, BA treatment can be applied to negative symptoms of schizophrenia.
There have been two pilot studies. Mairs et al. [12] were the first to demonstrate that BA therapy improved negative symptoms and depression in eight patients with schizophrenia. In addition, Choi et al. [13] found that motivational BA, which integrates BA with Motivational Interviewing, improved levels of negative symptoms. A recent double-blind randomized controlled trial of BA in community schizophrenia patients in South Korea also reported an effect on negative symptoms [14].
Meanwhile, with the advent of COVID-19, the prevention of the spread of the virus by limiting person-to-person contact has resulted in a different type of social isolation, such as social distancing and home quarantine, and has led to difficulties in continuing treatment for many mental illnesses. Modern psychotherapy, which is based on face-to-face treatment, has been largely suspended or scaled back, which has had a very negative impact on patients with negative symptoms of schizophrenia, which is characterized by social withdrawal. The limited availability of face-to-face psychotherapy services due to COVID-19 has limited the therapeutic opportunities for people with schizophrenia. This has increased the need for different forms of psychotherapy, such as online psychotherapy, which can overcome time and space constraints. Several researchers have suggested that BA treatment is well suited to being delivered via the internet due to its simplicity of treatment structure and the fact that it requires less costly professional training [15,16]. Indeed, several studies have found internet-based BA treatment to be effective in reducing depressive symptoms and increasing daily vitality in patients with depression, and meta-analyses have shown consistent results [17-19].
To date, BA for schizophrenia has only been studied in face-to-face settings and with small sample sizes [12,14]. Therefore, in order to provide BA treatment to people with schizophrenia in different treatment settings, such as the community and hospital, there is a need to confirm the therapeutic rationale in a larger sample of patients that BA treatment can be delivered in different forms. The present study aimed to verify the hypothesis that non-face-to-face BA treatment improves negative symptoms in patients with schizophrenia in the community and in a hospital setting.
METHODS
Study design
This study was designed as a non-randomized controlled trial. Because of COVID-19, some institutions encountered difficulties in providing in-person psychological services to patients. Consequently, the groups were recruited based on the circumstances of each institution. Institutions that were able to operate in a manner that permitted some patient visits constituted the intervention group. In contrast, institutions where patient visits were significantly restricted constituted the control group. All institutions participated in the study in accordance with the limitations imposed by government quarantine guidelines. The intervention group received non-face-toface BA treatment (BA treatment group), while the control group received treatment-as-usual (TAU group), which excluded analytic psychotherapy, CBT, and BA.
To prevent investigator bias and selection bias, this study adhered to a protocol delineated in advance. For the assignment of therapists and raters, five psychologists divided their duties by day of the week. Each psychologist is assigned to only perform both treatment and assessment duties on a designated day of the week. Second, the co-investigator assumed management of the duty schedule and coordinated evaluation and initial treatment appointments between psychologists and participants. This arrangement ensures that no single psychologist conducts both the assessment and treatment for the same participant in subsequent stages. The recruitment of participants and group assignment is conducted in the following protocol. The recruitment process is coordinated by the coinvestigator. Psychologists are not informed about the group types assigned to each institution. This procedure is intended to prevent psychologists from identifying which institution recruited participants for the BA treatment or TAU group based on the participants they are treating. Second, the recruited participants are not directly informed of their group assignment. This measure is taken to prevent participants from knowing which group they belong to.
Ethical considerations
All study procedures were approved by the Institutional Review Board of INHA University Hospital (protocol code 2021-01-026). Patients who expressed interest in participating in the study were informed about the study period, assessments, and privacy policy and provided written informed consent. They were informed that they had the right to refuse to participate in the study and could withdraw their consent at any time after signing the informed consent form. To protect the personal information of participants, including names, ages, sexes, and education levels, a unique ID was assigned to each individual by the co-investigator. The co-investigator provided psychologists with these unique ID for participants under their treatment and assessment. Psychologists utilized the unique ID to input assessment data and received supervision on treatment procedures without exposing the personal information of the participants. During this process, psychologists did not directly share participant personal information and unique IDs with other psychologists. Participants may derive benefit potentially improving symptoms of negative symptoms and enhancing social functioning. Moreover, the BA treatment group may derive benefit from positive interactions with therapists and a supportive environment provided in the program. However, no financial compensation was provided to any participants.
Participants
Patients with schizophrenia registered at community mental health centers, social rehabilitation facilities, university hospitals, and local psychiatric clinics in Incheon, South Korea, were recruited from July 2020 to June 2023. A total of 151 subjects were recruited, of which 2 refused to participate in the study and 23 were excluded according to the inclusion and exclusion criteria, and the remaining 126 were assigned to the study. During treatment, 5 subjects in the BA treatment group and 23 subjects in the TAU group refused to participate in the study, resulting in 49 subjects in the BA treatment group and 49 subjects in the TAU group completing the study (Figure 1).
The treatment inclusion criteria were as follows: 1) adults aged 18 to 65 years, 2) with a primary diagnosis of schizophrenia, 3) with a score of 3 or higher on at least two of the Positive and Negative Syndrome Scale (PANSS) negative symptom items, and 4) stable on prescribed antipsychotic medication for at least 6 months. Exclusion criteria were 1) a history of organic brain syndrome, traumatic brain injury, or epilepsy, 2) mental retardation, 3) comorbid disorders such as current alcohol or other drug dependence, 4) a score of 5 or higher on at least two of the PANSS positive symptom items, 5) a diagnosis of major depressive disorder, 6) a risk of self-harm or harm to others, and 7) a history of receiving psychological services including a component of BA treatment.
Therapists
All of the pre- and post-clinician assessment interviews and non-face-to-face BA program treatments in this study were conducted by five therapists: one clinical psychologist-intraining and four graduate students majoring in clinical psychology. All sessions were conducted under the supervision of one psychiatrist and one clinical psychologist. The five therapists who participated in the assessments received training in the PANSS and the Clinical Assessment Interview for Negative Symptoms (CAINS) from a psychiatrist and independently evaluated a minimum of ten cases under their supervision. In particular, with respect to the CAINS, the therapists thoroughly reviewed the rating criteria presented in the CAINS manual developed by the CANAS collaboration group. Based on this manual, they engaged in repeated case reviews and received supervision the enhance rating consistency and reliability. After training, the five therapists separately completed the PANSS and CAINS assessments for the same group of 10 patients, and then they aligned their scoring criteria in a calibration session to establish inter-rater reliability. In addition, for training for BA treatment, a group BA program was conducted with nine patients with schizophrenia. A total of 16 sessions were conducted, with one of the five therapists acting as the main therapist and the others as assistant therapists. Each session was supervised by one psychiatrist with extensive experience in BA treatment based on video recordings.
Procedures
Pre- and post-test procedures
Pre-screening was conducted at seven community mental health centers, Inha University Hospital, and a psychiatric clinic in Incheon for 156 participants who volunteered to participate in the study. The pre-test consisted of a diagnostic interview with a psychiatrist (approximately 30 minutes), a psychiatric interview assessment including negative symptoms and psychosocial functioning (approximately 50 minutes), neurocognitive testing (approximately 60 minutes), and a self-report questionnaire assessment including depression, anxiety, and insight (approximately 20 minutes). The tests were organized and administered under the supervision of one psychiatrist and one clinical psychologist. The post-test was conducted in the same manner as the pre-test, with an average interval of approximately 4 months between the pre-test and post-test.
Treatment program
The overall duration of the program was from August 2020 to November 2023, with a total of 49 cases conducted by five therapists. The online face-to-face BA therapy program was conducted once a week, 40 minutes per session, for a total of 12 sessions, including 11 sessions and one follow-up session. The therapists were one clinical psychologist-in-training and four graduate students majoring in clinical psychology who were trained in the BA therapy modules used in this study. All sessions were videotaped with the patient’s consent and subsequently used for supervision by a psychiatrist. This was done to increase the consistency of the counselor’s behavior and treatment regime. After each session, each therapist recorded a brief summary and assessment of the session’s progress, and once a week, therapists shared their progress with each other to ensure consistency in treatment. In terms of how the program was delivered, the first session was conducted faceto-face at the patients’ centers and hospitals, recognizing that online face-to-face therapy can be a bit unfamiliar. All subsequent sessions were conducted virtually using an online-based video conferencing platform (Zoom). Patients who were comfortable with electronics participated at home, while those who were not electronically literate accessed the study with institutional support, using the day of their visit to the center or hospital to facilitate the process.
Treatments
BA treatment for negative symptoms
The non-face-to-face BA treatment program for negative symptoms was adapted from the core treatment elements of BA proposed by Martell et al. [20] by Lee et al. [21] and reorganized for the non-face-to-face and one-on-one method. The BA for negative symptoms consisted of 12 sessions. The duration of the sessions was shortened to 40 minutes in consideration of the somewhat lower attention span of patients with schizophrenia. The BA treatment for schizophrenia proposed by Lee et al. [21] included the following treatment components, considering that negative symptoms of schizophrenia are characterized by a decrease in goal-directed activities: 1) daily activity monitoring (looking at one’s daily activities), 2) concomitant management (understanding the consequences of one’s activities, such as mood), 3) values and goals assessment (exploring one’s own values and goals), 4) activity planning (planning activities according to values and goals), 5) dealing with avoidance behaviors (dealing with things that interfere with the implementation of goal behaviors), 6) skills training (practicing skills to achieve one’s activities and goals), and 7) implementing activities and goals. The details of the program reconstructed in this study based on the above are attached in Table 1.
The current program was changed from the Behavioral Activation Treatment for Depression to better suit individuals with schizophrenia and to work well in online settings. Earlier BA models [20,22,23] included a range of treatment components. These typically comprised: 1) activity monitoring, 2) contingency management, 3) activity scheduling, 4) values and goals assessment, 5) skills training, 6) strategies for addressing rumination and avoidance, and 7) relaxation. These components are widely recognized as the core techniques of BA.
In consideration of the cognitive limitations and reduced self-awareness often observed in individuals with schizophrenia, the present program excluded components requiring cognitive processing, such as managing rumination. Contingency management was simplified, and relaxation training was omitted due to difficulties in applying it in a remote treatment setting. Instead, the program focused on values clarification to strengthen motivation for behavior change. Participants were guided to monitor their daily activities, recognize the relationship between behavior and mood, set goals consistent with their values, plan activities, and carry them out as tasks. In addition, the program included strategies to identify and overcome avoidance behaviors that may interfere with goal-directed activity.
The features of the program used in this study and its differences from other BA treatment studies for schizophrenia are as follows:
1) BA treatment included the value-dealing task as a treatment factor to strongly motivate and uplift each participant’s BA. Participants were asked to discover their personal values and increase the frequency of behaviors consistent with their values.
2) The activities and goals were set at a minimum level of action to ensure that they were realistic and achievable.
3) Given the online, non-face-to-face nature of the program, a workbook was distributed to participants to facilitate the process.
TAU
The TAU group received consistent individual case management, supportive psychotherapy and counseling, psychoeducation, and ongoing or planned treatments (including art therapy, music therapy, and psychosocial rehabilitation encompassing social skills training). Analytic psychotherapy, cognitive behavior therapy, or behavior activation were not permitted during the study. TAU was offered by hospitals and community mental health centers. These interventions were administered weekly throughout the study period.
Measures
Positive and Negative Syndrome Scale
The PANSS is a clinician rating scale developed to comprehensively assess the severity of psychotic symptoms in patients with schizophrenia [24]. It consists of 30 items and assesses three symptom dimensions: seven items each for positive and negative symptoms and 16 items for general psychopathology, divided into sub-rails. This study used the K-PANSS, which was adapted and validated in Korean patients with schizophrenia [25]. In this study, the internal consistency (Cronbach’s α) was 0.640 for positive symptoms, 0.789 for negative symptoms, and 0.660 for general psychopathology. In this study, the change in PANSS score is the primary outcome.
CAINS
The CAINS was developed to assess the severity of negative symptoms in patients with schizophrenia by overcoming the limitations of existing scales and reflecting emerging trends in negative symptoms [26]. It consists of a total of 13 items. The subscales consist of 9 items for Motivation and Pleasure (assesses motivation, pleasure, and future expectations in family, friendship, and social relationships, as well as in work and academic and leisure activities) and 4 items for Expression (assesses the amount of facial expressions, vocalizations, gestures, and speech displayed during the interview). In this study, Cronbach’s α was 0.884 for total, 0.850 for motivation and enjoyment, and 0.877 for expression, indicating good internal consistency.
Behavioral Activation for Depression Scale
The Behavioral Activation for Depression Scale (BADS) is a self-report survey scale developed to assess the degree of activation and response to treatment in patients with depression based on BA theory [27]. It consists of 25 questions and is organized into four subscales (activation, avoidance/rumination, work/academic impairment, and social impairment). The internal consistency (Cronbach’s α) for this study was very good with a total score of 0.910.
Premorbid intelligence quotients
To estimate premorbid intelligence quotients (IQ), we administered the Information and Matrix Reasoning subtest of the Korea-Wechsler Adult Intelligence Scale-IV [28]. The information subtest measures the depth of an individual’s general knowledge, while the Matrix Reasoning subtest assess nonverbal reasoning by requiring the selection of responses to complete an incomplete matrix or a series of designs. Premorbid intelligence was calculated using the algorithm of the Korea Premorbid Intelligence Estimate for K-Wechsler Adult Intelligence Scale-IV [29].
Statistical analyses
All data collected in this study were analyzed using IBM SPSS 23.0 (IBM Corp.). Cronbach’s α was used to analyze inter-rater reliability and internal consistency of the self-report measures. Descriptive statistics were performed to determine the demographic characteristics of the study population. Independent t-tests were conducted on the demographic characteristics and pre-measures of the treatment and control groups to ensure homogeneity between groups prior to testing the effectiveness of the treatment.
The differences between pre- and post-treatment were compared using paired t-tests. To analyze the relationship between the BA treatment and clinical outcome (PANSS, CAINS, and BADS), linear mixed models (LMMs) were used, controlling for age, sex, and institution. Age, sex, institution and BA treatment, and time of measurement were included as the independent variables and fixed effects. PANSS (total, positive, negative, and general psychopathology), CAINS (total, motivation/pleasure, and expression), and BADS (activation, avoidance/rumination, work/school impairment, and social impairment) were included as random effects. A first-order autoregressive model was selected as the repeated covariance type, considering the correlation of each participant’s iteration.
Two-tailed analyses were conducted, and p-values less than 0.05 were defined as statistically significant. The Bonferroni correction was used to adjust for multiple testing, focusing on the primary outcome of the PANSS score, and statistical significance was determined at p<0.017 (0.05/3).
RESULTS
Table 2 presents the basic characteristics of the study participants. The mean age of the treatment group was 39.27±11.88 years, which was significantly lower than the control group (45.94±10.77). In terms of sex, the treatment group had 28 males (28/49, 57.1%) and 21 females (21/49, 42.9%), which was significantly different from the control group (males: 18/49, 36.7%; females: 31/49, 63.3%). There was a significant difference between the groups in the proportion of participants assigned to each group and the institution (community center or hospital) from which they were recruited (p<0.001). There was a significant difference in the level of BA between the groups (p=0.012). Otherwise, there were no differences between groups in education, estimated premorbid intelligence, or level of negative symptoms.
Table 3 shows the estimated coefficient in the rate of change of PANSS, CAINS, and BADS in the predictor controlling for age, sex, and institution. The estimated coefficient in the change of PANSS negative score was 2.94 (95% confidence interval [CI]=1.08-4.80, p=0.002) in the BA treatment group. The statistical significance of PANSS negative scores was maintained even after applying the Bonferroni correction. Betweengroup differences in the change CAINS total score were 5.14 (95% CI=2.59-7.70, p<0.001). The between-group differences in the change CAINS motivation/pleasure score 4.08 (95% CI=2.16-6.00, p<0.001). The estimated coefficiency in the change of BADS total score was -8.74 (95% CI=-15.64- -1.83, p=0.014) in the BA treatment group. The between-group differences in the change BADS activation score -3.63 (95% CI=-6.94- -0.33, p=0.032).
Table 4 presents the within-group changes for the variables that showed significant interaction effects in the LMM analysis. The PANSS negative decreased (22.69±5.13 vs. 18.90±5.38, p<0.001) in the BA treatment group, while it did not change (20.82±4.61 vs. 19.90±6.00) in the TAU group. After adjusting for fixed effects such as age, sex, education, premorbid IQ, and institution, there was a statistically significant difference in the degree of improvement from pre- to post-treatment of PANSS negative in the BA group compared to the TAU group (95% CI=1.02-4.73, p=0.003). There was a significant decrease in the CAINS total score (36.14±6.49 vs. 31.98±7.49, p<0.001), CAINS motivation/pleasure (26.45±4.61 vs. 23.61± 5.04, p<0.001) in the BA treatment group, whereas there were no statistically significant changes in the CAINS total score and CAINS motivation/pleasure in the TAU group. Addition-ally, the BADS total score significantly increased in the BA treatment group (78.98±24.75 vs. 91.24±24.35, p< 0.001), and the BADS activation showed a significant improvement (15.49±7.90 vs. 17.78±8.73, p<0.045). In contrast, no significant changes were found in these scores within the TAU group.
Figure 2 presents the mean change trajectory of the PANSS and CAINS from pre-treatment to post-treatment. The BA treatment group showed significantly greater improvement in PANSS negative scores, CAINS total scores, and CAINS motivation/pleasure scores compared to the TAU group. There was no significant difference in PANSS total scores, PANSS positive scores, PANSS general psychopathology scores, and CAINS expression scores between the BA group and the TAU group.
Therapists kept a close watch (throughout the treatment period) on participants, resulting in most participants successfully completing the study without severe adverse events such as suicide attempts, suicidal ideation, or self-harmful behaviors. However, a few participants experienced temporary adverse events. Some experienced interpersonal conflicts in both personal and professional contexts, which resulted in temporary mood fluctuations. This occasionally arises during BA therapy as participants attempt goal-directed actions but did not exacerbate their symptoms significantly. Another patient experienced a temporary worsening of positive symptoms. The therapist discussed the participant’s symptoms with their psychiatrist, and the symptoms stabilized quickly, allowing the participant to complete all sessions. However, this necessitated excluding the patient from the analysis due to concerns about data reliability (Figure 1). Additionally, two participants found the regular 40-minute therapy sessions burdensome and opted to discontinue treatment after one to two sessions (Figure 1).
DISCUSSION
This study was conducted to determine the effectiveness of a non-face-to-face BA treatment using an online platform for patients with schizophrenia. For this purpose, the BA Treatment for Depression was reformulated and applied to the characteristics of patients with schizophrenia negative symptoms. Based on the similarity of behavioral models of depression and negative symptoms, attempts have been made to apply BA treatment to negative symptoms, and the feasibility of treating negative symptoms with BA treatment has been reported [12]. Since then, many studies have applied BA treatment to patients with negative symptoms, and the therapeutic effect of BA treatment on negative symptoms has been proven in several studies [13,14,21]. Given the current lack of evidencebased psychotherapeutic interventions for negative symptoms in schizophrenia [3], it is clinically useful to demonstrate the effectiveness of BA treatment for negative symptoms in schizophrenia in a non-face-to-face manner.
The BA treatment group consisted of 49 participants (mean age=39.27 years, SD=11.88) who underwent 12 sessions of remote BA therapy. The remote BA therapy included the core treatment components of BA, such as daily activity monitoring, concomitant management, values and goals assessment, and activity planning. Considering the characteristics of schizophrenia patients, the components involving the handling of rumination was excluded, and the contingency concomitant management factor was simplified. The TAU group, comprising 49 participants (mean age=45.94 years, SD=10.77), received psychological treatments that excluded analytic psychotherapy, cognitive behavior therapy, and behavior activation.
In this study, non-face-to-face BA treatment was effective in reducing negative symptoms in patients with schizophrenia. The BA treatment group showed significant improvement in PANSS negative symptoms compared to the TAU group. It is noteworthy that the treatment had no effect on PANSS positive symptoms and general psychopathology symptoms, but only on negative symptoms. In the two-factor structure of negative symptoms assessed by the CAINS, significant improvements were seen in the motivation/pleasure, but not in the reduced expression. This suggests that the non-face-toface BA program increased motivation levels and subjective experiences of pleasure but did not extend to the expressive domain. The BA treatment group showed improved levels of BA, particularly demonstrating significant therapeutic effects in the “activation” domain. This indicates that non-face-to-face BA treatment enhanced the planning and achievement of goal-directed activities.
The present study is significant in that it validated the effects of a program solely composed of BA therapy elements, conducted remotely. Particularly, considering the accessibility and convenience of remote therapy, the results of this study are highly promising.
These findings are consistent with previous research which indicates that face-to-face BA therapy for patients with schizophrenia effectively reduces negative symptoms [12,14,21]. As with previous studies, there was no therapeutic effect on PANSS positive symptoms and general psychopathology factors. However, improvement was observed specifically in negative symptom factors [12,13,14]. This suggests that BA therapy demonstrates specialized therapeutic effects on negative symptoms in both face-to-face and remote settings.
In contrast to previous studies [13,14,21], significant improvement was observed only in the motivation/pleasure factor among the CAINS. These findings may reflect the limitations of nonface- to-face treatment settings. In face-to-face BA treatment in previous studies [13,14,21], it may be natural to practice expressive skills such as talking at an appropriate pace, using the right amount of language, or making appropriate facial expressions while telling emotional stories, but it may be somewhat limited in non-face-to-face therapy. This suggests the need to consider therapeutic factors that allow for the acquisition of expressive skills in the context of non-face-to-face BA treatment. However, the significant improvement in motivation/pleasure has clinical implications as it confirms that non-face-to-face BA can increase motivation levels and enhance satisfaction by increasing reinforcement experiences in life.
Only the activation domains significantly showed a treatment effect with the non-face-to-face BA treatment among the multiple BA domains. These results are consistent with the findings of Lee et al. [21] There were no treatment effects in the domains of avoidance/rumination, work/school impairment, and social impairment, for the following reasons. The first explanation is that cognitive avoidance and rumination were not addressed as key treatment components in the nonface- to-face BA therapy in this study. In addition, patients with schizophrenia often do not attend school or work and are often socially isolated, making it difficult for treatment effects to be reflected in these settings. Therefore, it is important to note that this study confirms the effectiveness of non-face-toface BA treatment in initiating and maintaining goal-directed activity.
In summary, the present findings indicate that non-faceto-face BA treatment demonstrates a level of effectiveness for reducing negative symptoms in individuals with schizophrenia that is comparable to the effects reported in previous studies on face-to-face interventions. This study is important because, unlike earlier research that mainly looked at in-person delivery, it shows evidence that remotely delivered BA works well, suggesting it could be used in online treatments for people with schizophrenia. Additionally, unlike earlier studies that usually mixed BA with other methods like motivational enhancement, this study specifically looked at the effects of a program that only included the main parts of BA. These results suggest the potential utility of non-face-to-face BA, particularly for individuals with limited access to traditional, in-person mental health services. Considering all of this, future research should assess their applicability across diverse population groups.
Meanwhile, the COVID-19 pandemic has made it difficult to facilitate psychosocial interventions, many of which are face-to-face, and the need for online treatment methods has emerged [30]. The effectiveness of non-face-to-face BA treatment has already been demonstrated in a study by Arjadi et al. [18] for depression. The results showed that negative symptoms could be improved through non-face-to-face BA treatment, just as negative symptoms were improved through face-toface BA treatment. Contrary to expectations that patients with schizophrenia would be less familiar with digital devices and that online treatment would be less effective, the finding of improving of negative symptoms in a BA treatment using an online platform is clinically significant in that it expands the applicability of online treatment for patients with schizophrenia. As there may be difficulties in applying BA treatment to schizophrenia patients depending on their familiarity with digital devices and experience in using the internet, future studies should reconfirm the results with more patients in different regions.
The primary limitation of the study is the lack of randomized in the recruitment of participants and the assignment of groups. This study was conducted as a non-randomized controlled trial, with group assignments based on institutional circumstances. COVID-19 disrupted not only usual activities such as light walks but also the access to mental health services that they regularly require. Consequently, it was challenging to evenly recruit participants across institutions and impossible to randomly assign them to the two groups. In order to prevent this issue from arising, the relevant protocols were established; it should be noted that there are some limitations. Although explicit group assignment instructions were not provided to participants, the possibility remains that complete blinding was not achieved. This is due to the differences between the BA treatment and TAU treatment. The results indicated significant differences between the BA and TAU groups regarding institution, sex, and age. According to previous studies, sex and age are factors that may influence the effectiveness of psychological interventions for individuals with psychosis [31,32]. In addition, the type of institution to which a patient belongs may lead to differences in the type of treatment provided, depending on the characteristics of the treatment environment [33], and this may serve as a potential factor influencing symptom outcomes. This study used a LMM to statistically control for baseline differences, including sex, age, and institution as fixed effects. This analytical strategy enabled us to assess the group×time interaction effects while reducing potential bias arising from structural differences between the two groups. Nonetheless, it is important to acknowledge that such statistical adjustments could not eliminate the impact of these variables. The need for randomized controlled designs in future research is highlighted by the possibility that baseline differences could have influenced results due to the lack of randomization. Second, only observer rating instruments were used to assess negative symptoms, and therapists and raters were not fully separated. This is a very important limitation that may have introduced observer bias into the symptom assessment. To reduce investigator bias due to the lack of independence of the therapist and rater, the role of a co-investigator was employed. The coinvestigator cross-assigned treatment and assessment duties to ensure that the same psychologist did not conduct both for any given patient. This protected psychologists from knowing the list of other psychologist a particular patient had interacted with. Despite these measures, it is inherently challenging to eliminate researcher bias completely since therapists and evaluators were the same group. Future studies should improve on this by separating the roles of therapist and rater, applying a double-blind procedure, and adding a self-report rating instrument for voice symptoms to assess subjective experience. Third, congruence between therapist did not analyze. All therapists underwent a therapist training course under the guidance of a psychiatrist and a clinical psychologist for at least 6 months to increase their proficiency in BA treatment to improve treatment congruence. Fourth, the study did not include a follow-up analysis, although follow-up sessions were conducted one month after treatment completion. While this allows for an evaluation of the short-term effects of non-face-to-face BA on negative symptoms, it is insufficient to assess its long-term impact. In a previous study, Oh et al. [14] reported that the therapeutic effects of face-to-face BA were maintained for up to 6 months. Therefore, future longitudinal studies are needed to verify the long-term impact of non-face-to-face BA and to optimize its clinical utility for broader application. Finally, the study was conducted as an individual treatment, so further validation is needed to see if the same results are seen in a group. To expand the use of non-face-to-face BA group treatment, future studies should examine whether the results of this study are replicated in group-based non-face-to-face BA treatment.
In conclusion, non-face-to-face BA treatment is a more effective psychological treatment than TAU for negative symptoms of patients with schizophrenia. Additionally, BA treatment might increase motivation/pleasure and BA. Future randomized controlled studies are vital to provide stronger evidence for non-face-to-face BA treatment for negative symptoms of patients with schizophrenia.
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