Morita therapy for schizophrenia

Yanling He; Chunbo Li

doi:10.1002/14651858.CD006346

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Analysis 1.1

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 1 Leaving the study early: 1. Any reason ‐ by end of therapy.

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Analysis 1.2

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 2 Leaving the study early: 2. Specific reasons ‐ by end of therapy.

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Analysis 1.3

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 3 Mental state: 1a. Overall no clinically important improvement (BPRS).

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Analysis 1.4

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 4 Mental state: 1b. Overall average endpoint score (BPRS, high=poor).

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Analysis 1.5

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 5 Mental state: 1c. Overall average endpoint score (BPRS, high=poor, category C studies removed).

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Study	Intervention	Mean	SD	N	Notes
Wu 1999	Morita therapy	7.32	4.91	25	t=1.49, p>0.05
Wu 1999	Standard care	4.89	5.94	25

Analysis 1.6

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 6 Mental state: 1d. Overall average endpoint score change (BPRS, low=poor, data skewed) ‐ short term.

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Analysis 1.7

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 7 Mental state: 1e. Overall average percent change (BPRS, low=poor).

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Study	Intervention	Mean	SD	N	Notes
Zhu 2002	Morita therapy	14.9	11.0	50	t=2.34, p<0.05
Zhu 2002	Standard care	11.0	5.0	50

Analysis 1.8

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 8 Mental state: 1f. Overall average percent change (BPRS, low=poor, data skewed) ‐ short term.

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Analysis 1.9

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 9 Mental state: 2a. Depressive symptoms ‐ no clinically important improvement (HAMD) ‐ short term.

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Analysis 1.10

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 10 Mental state: 2b. Depression average endpoint score (HAMD, high=poor) ‐ short term.

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Analysis 1.11

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 11 Mental state: 3a. Negative symptoms no clincally important change (SANS).

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Analysis 1.12

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 12 Mental state: 3b. Negative symptoms average endpoint score (SANS, high=poor).

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Analysis 1.13

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 13 Mental state: 3c. Negative symptoms average endpoint score (SANS, high=poor, category C study removed).

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Study	Intervention	Mean	SD	N	Notes
Wu 1999	Morita therapy	38.13	21.52	25
Wu 1999	Standard care	43.95	17.28	25

Analysis 1.14

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 14 Mental state: 3c. Negative symptoms average endpoint score (SANS, high=poor, data skewed) ‐ short term.

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Study	Intervention	Mean	SD	N	Notes
Wu 1999	Morita therapy	20.39	11.25	25	t=2.29, p<0.05
Wu 1999	Standard care	12.91	10.57	25

Analysis 1.15

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 15 Mental state: 3d. Negative symptoms average endpoint score (SANS, high=poor, data skewed) ‐ short term.

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Study	Intervention	Mean	SD	N	Notes
short term
Zhu 2002	Morita therapy	32.6	45.7	50	t=11.6, p<0.01
Zhu 2002	Standard care	6.2	18.0	50
medium term
Lu 1999	Morita therapy	49.27	20.01	55	p<0.001
Lu 1999	Standard care	35.54	19.82	56

Analysis 1.16

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 16 Mental state: 3e. Negative symptoms average percent (SANS, low=poor, data skewed).

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Study	Intervention	Mean	SD	N	Notes
short term
Sheng 2006	Morita therapy	9.07	3.00	40	t=5.245, P<0.001
Sheng 2006	Standard care	4.58	4.04	40

Analysis 1.17

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 17 Mental state: 3f. Insight symptoms average endpoint score (Insight scale, low=poor, data skewed).

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Study	Intervention	Mean	SD	N	Notes
Zhu 2002	Morita therapy	36.4	13.6	50	t=15.6, p<0.01
Zhu 2002	Standard care	4.9	6.0	50

Analysis 1.18

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 18 Quality of life: 1. Overall average percent change (QOLS, low=poor, data skewed) ‐ short term.

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Analysis 1.19

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 19 Social functioning: 1. Overall average endpoint score (ADL, high=poor).

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Study	Intervention	Mean	SD	N	Notes
short term
Wei 2005	Morita therapy	4.05	2.73	52
Wei 2005	Standard care	5.97	3.06	52
medium term
Wang 1994	Morita therapy	8.17	4.32	30	t=5.988, p<0.001
Wang 1994	Standard care	14.10	1.36	18

Analysis 1.20

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 20 Social functioning: 2a. Overall average endpoint score (SDSS, high=poor, data skewed).

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Analysis 1.21

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 21 Social functioning: 2b. Overall average percent change (SDSS, low=poor) ‐ medium term.

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Analysis 1.22

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 22 Social functioning: 2c. Overall average endpoint score (IPROS, high=poor) ‐ short term.

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Study	Intervention	Mean	SD	N	Notes
Zhu 2002	Morita therapy	43.5	18.2	50	t=13.6, p<0.01
Zhu 2002	Standard care	5.5	7.7	50

Analysis 1.23

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 23 Social functioning: 2d. Overall average percent change (IPROS, low=poor, data skewed) ‐ short term.

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Analysis 1.24

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 24 Behaviour: 1. Average overall endpoint score (NOSIE, high=poor) ‐ short term.

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Study	Intervention	Mean	SD	N	Notes
Wu 1999	Morita therapy	5.26	6.38	25
Wu 1999	Standard care	8.95	6.59	25

Analysis 1.25

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 25 Behaviour: 2. Average overall endpoint score (NOSIE, high=poor, data skewed) ‐ short term.

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Study	Intervention	Mean	SD	N	Notes
Wu 1999	Morita therapy	7.26	6.23	25	t=2.52, p<0.05
Wu 1999	Standard care	3.60	2.76	25

Analysis 1.26

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 26 Behaviour: 3. Average change (NOSIE, high=good, data skewed) ‐ short term.

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Analysis 1.27

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 27 Adverse events: 1. Specific problems ‐ short term.

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Analysis 1.28

Comparison 1 MORITA THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 28 Adverse events: 2. Overall average endpoint score (TESS, high=poor) ‐ short term.

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Analysis 2.1

Comparison 2 MORITA THERAPY + STANDARD CARE versus REHABILITATION + STANDARD CARE, Outcome 1 Leaving the study early ‐ by end of therapy ‐ short term.

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Analysis 2.2

Comparison 2 MORITA THERAPY + STANDARD CARE versus REHABILITATION + STANDARD CARE, Outcome 2 Mental state: 1a. Overall no clinically important improvement (BPRS) ‐ short term.

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Analysis 2.3

Comparison 2 MORITA THERAPY + STANDARD CARE versus REHABILITATION + STANDARD CARE, Outcome 3 Mental state: 1b. Overall average endpoint score (BPRS, high = poor) ‐ short term.

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Analysis 2.4

Comparison 2 MORITA THERAPY + STANDARD CARE versus REHABILITATION + STANDARD CARE, Outcome 4 Mental state: 2. Insight average endpoint score (clinician's judgement, high = poor) ‐ short term.

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Analysis 2.5

Comparison 2 MORITA THERAPY + STANDARD CARE versus REHABILITATION + STANDARD CARE, Outcome 5 Social functioning: Average overall endpoint score (IPROS, high = poor) ‐ short term.

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Table 1. Suggested design for future study

Methods	Participants	Interventions	Outcomes	Notes
Allocation: randomised, block, fully explicit description.. Blinding: single, tested. Duration: 12‐24 weeks treatment, and then follow up to at least 1 year.	Diagnosis: schizophrenia (ICD). N=300.* Age: adults. Sex: both. History: non‐acute phase.	1. Morita therapy + standard care: 4 phases, a. bed phase + diary, 1 week; b. light work, discussion, reading, diary, 2 weeks; c. heavy work, diary, physical exercise, 2 weeks; d. social/communication skills, diary, 1 week; total 6 weeks. N=150. 2. Standard care: as before. N=150.	General: relapse, general impression of clinician (CGI), carer/other (CGI), compliance with treatment., healthy days, Mental state: CGI. Quality of life. CGI. Family burden: CGI. Social functioning: return to everyday living for 80% of time.* Adverse events: any adverse event recorded. Economic outcomes.	* powered to be able to identify a difference of ˜20% between groups for primary outcome with adequate degree of certainty.

Table 1. Suggested design for future study

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Morita therapy for schizophrenia
Patient or population:people with schizophrenia Settings:Inpatient care Intervention:Morita therapy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Morita therapy
Mental state: 1a. Overall no clinically important improvement (BPRS) ‐ short term 25‐30% change BPRS^1,2 (follow‐up: 10 weeks³)	Medium risk population		RR 0.36 (0.13 to 1.03)	66 (1)	⊕⊕⊝⊝ low^4,5
	333 per 1000	120 per 1000 (43 to 343)
Mental state: 1a. Overall no clinically important improvement (BPRS) ‐ medium term 25‐30% change BPRS^1,2 (follow‐up: 5 months⁶)	Medium risk population		RR 0.36 (0.14 to 0.89)	76 (1)	⊕⊕⊝⊝ low^4,5
	368 per 1000	132 per 1000 (52 to 328)
*The basis for theassumed risk(e.g. the median control group risk across studies) is provided in footnotes. Thecorresponding risk(and its 95% confidence interval) is based on the assumed risk in the comparison group and therelative effectof the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidance High quality:Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality:Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality:Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality:We are very uncertain about the estimate.
¹Not pre‐stated primary outcome of review, but as close as could be gleaned from data. ²May not be important for many people. ³Rating of effect after 10 weeks of treatment but no real treatment‐free follow up period. ⁴Randomisation stated but not described. Blinding attempted but not tested. In hospital setting. ⁵Single very small positive trial undertaken by skilled Morita therapists. ⁶Rating of effect undertaken after 5 months of treatment but no real treatment‐free follow‐up period.

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Comparison 1. MORITA THERAPY + STANDARD CARE versus STANDARD CARE

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Leaving the study early: 1. Any reason ‐ by end of therapy Show forest plot	10	761	Risk Ratio (M‐H, Random, 95% CI)	1.01 [0.36, 2.84]

1.1 short term	6	475	Risk Ratio (M‐H, Random, 95% CI)	0.67 [0.11, 3.96]
1.2 medium term	4	286	Risk Ratio (M‐H, Random, 95% CI)	1.25 [0.35, 4.43]
2 Leaving the study early: 2. Specific reasons ‐ by end of therapy Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

2.1 discharge ‐ short term	2	132	Risk Ratio (M‐H, Random, 95% CI)	0.43 [0.07, 2.84]
2.2 discharge ‐ medium term	1	120	Risk Ratio (M‐H, Random, 95% CI)	0.33 [0.01, 8.02]
2.3 discharge & lost follow‐up ‐ medium term	1	120	Risk Ratio (M‐H, Random, 95% CI)	1.0 [0.15, 6.87]
2.4 relapse ‐ short term	1	82	Risk Ratio (M‐H, Random, 95% CI)	3.0 [0.13, 71.56]
2.5 unco‐operative ‐ medium term	1	120	Risk Ratio (M‐H, Random, 95% CI)	3.0 [0.32, 28.03]
3 Mental state: 1a. Overall no clinically important improvement (BPRS) Show forest plot	2	142	Risk Ratio (M‐H, Random, 95% CI)	0.36 [0.18, 0.72]

3.1 short term	1	66	Risk Ratio (M‐H, Random, 95% CI)	0.36 [0.13, 1.03]
3.2 medium term	1	76	Risk Ratio (M‐H, Random, 95% CI)	0.36 [0.14, 0.89]
4 Mental state: 1b. Overall average endpoint score (BPRS, high=poor) Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Subtotals only

4.1 short term	3	189	Mean Difference (IV, Random, 95% CI)	‐4.33 [‐10.28, 1.62]
4.2 medium term	2	124	Mean Difference (IV, Random, 95% CI)	‐5.19 [‐9.64, ‐0.74]
5 Mental state: 1c. Overall average endpoint score (BPRS, high=poor, category C studies removed) Show forest plot	1	66	Mean Difference (IV, Fixed, 95% CI)	‐1.70 [‐4.21, 0.81]

6 Mental state: 1d. Overall average endpoint score change (BPRS, low=poor, data skewed) ‐ short term Show forest plot			Other data	No numeric data

7 Mental state: 1e. Overall average percent change (BPRS, low=poor) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

7.1 short term	1	100	Mean Difference (IV, Random, 95% CI)	3.90 [0.55, 7.25]
7.2 medium term	1	111	Mean Difference (IV, Random, 95% CI)	4.46 [‐2.26, 11.18]
8 Mental state: 1f. Overall average percent change (BPRS, low=poor, data skewed) ‐ short term Show forest plot			Other data	No numeric data

9 Mental state: 2a. Depressive symptoms ‐ no clinically important improvement (HAMD) ‐ short term Show forest plot	1	104	Risk Ratio (M‐H, Random, 95% CI)	0.36 [0.12, 1.07]

10 Mental state: 2b. Depression average endpoint score (HAMD, high=poor) ‐ short term Show forest plot	1	104	Mean Difference (IV, Random, 95% CI)	‐3.59 [‐5.64, ‐1.54]

11 Mental state: 3a. Negative symptoms no clincally important change (SANS) Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

11.1 short term	1	50	Risk Ratio (M‐H, Random, 95% CI)	0.89 [0.41, 1.93]
11.2 medium term	1	42	Risk Ratio (M‐H, Random, 95% CI)	0.25 [0.08, 0.76]
12 Mental state: 3b. Negative symptoms average endpoint score (SANS, high=poor) Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Subtotals only

12.1 short term	4	323	Mean Difference (IV, Random, 95% CI)	‐12.94 [‐21.57, ‐4.32]
12.2 medium term	1	76	Mean Difference (IV, Random, 95% CI)	‐4.57 [‐8.56, ‐0.58]
13 Mental state: 3c. Negative symptoms average endpoint score (SANS, high=poor, category C study removed) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

13.1 short term	2	170	Mean Difference (IV, Fixed, 95% CI)	‐4.75 [‐6.45, ‐3.05]
14 Mental state: 3c. Negative symptoms average endpoint score (SANS, high=poor, data skewed) ‐ short term Show forest plot			Other data	No numeric data

15 Mental state: 3d. Negative symptoms average endpoint score (SANS, high=poor, data skewed) ‐ short term Show forest plot			Other data	No numeric data

16 Mental state: 3e. Negative symptoms average percent (SANS, low=poor, data skewed) Show forest plot			Other data	No numeric data

16.1 short term			Other data	No numeric data
16.2 medium term			Other data	No numeric data
17 Mental state: 3f. Insight symptoms average endpoint score (Insight scale, low=poor, data skewed) Show forest plot			Other data	No numeric data

17.1 short term			Other data	No numeric data
18 Quality of life: 1. Overall average percent change (QOLS, low=poor, data skewed) ‐ short term Show forest plot			Other data	No numeric data

19 Social functioning: 1. Overall average endpoint score (ADL, high=poor) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

19.1 short term	1	104	Mean Difference (IV, Random, 95% CI)	‐4.14 [‐7.67, ‐0.61]
19.2 medium term	1	48	Mean Difference (IV, Random, 95% CI)	‐10.5 [‐12.50, ‐8.50]
20 Social functioning: 2a. Overall average endpoint score (SDSS, high=poor, data skewed) Show forest plot			Other data	No numeric data

20.1 short term			Other data	No numeric data
20.2 medium term			Other data	No numeric data
21 Social functioning: 2b. Overall average percent change (SDSS, low=poor) ‐ medium term Show forest plot	1	111	Mean Difference (IV, Random, 95% CI)	16.40 [9.71, 23.09]

22 Social functioning: 2c. Overall average endpoint score (IPROS, high=poor) ‐ short term Show forest plot	1	80	Mean Difference (IV, Random, 95% CI)	‐45.87 [‐50.68, ‐41.06]

23 Social functioning: 2d. Overall average percent change (IPROS, low=poor, data skewed) ‐ short term Show forest plot			Other data	No numeric data

24 Behaviour: 1. Average overall endpoint score (NOSIE, high=poor) ‐ short term Show forest plot	1	66	Mean Difference (IV, Random, 95% CI)	15.20 [9.00, 21.40]

25 Behaviour: 2. Average overall endpoint score (NOSIE, high=poor, data skewed) ‐ short term Show forest plot			Other data	No numeric data

26 Behaviour: 3. Average change (NOSIE, high=good, data skewed) ‐ short term Show forest plot			Other data	No numeric data

27 Adverse events: 1. Specific problems ‐ short term Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

27.1 somnolence	1	104	Risk Ratio (M‐H, Random, 95% CI)	0.86 [0.31, 2.38]
27.2 postural hypotension	1	104	Risk Ratio (M‐H, Random, 95% CI)	1.33 [0.31, 5.67]
28 Adverse events: 2. Overall average endpoint score (TESS, high=poor) ‐ short term Show forest plot	1	104	Mean Difference (IV, Random, 95% CI)	‐0.18 [‐0.90, 0.54]

Comparison 1. MORITA THERAPY + STANDARD CARE versus STANDARD CARE

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Comparison 2. MORITA THERAPY + STANDARD CARE versus REHABILITATION + STANDARD CARE

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Leaving the study early ‐ by end of therapy ‐ short term Show forest plot	2	302	Risk Ratio (M‐H, Random, 95% CI)	1.0 [0.47, 2.11]

2 Mental state: 1a. Overall no clinically important improvement (BPRS) ‐ short term Show forest plot	1	120	Risk Ratio (M‐H, Random, 95% CI)	0.89 [0.52, 1.55]

3 Mental state: 1b. Overall average endpoint score (BPRS, high = poor) ‐ short term Show forest plot	2	278	Mean Difference (IV, Random, 95% CI)	‐6.95 [‐9.26, ‐4.64]

4 Mental state: 2. Insight average endpoint score (clinician's judgement, high = poor) ‐ short term Show forest plot	2	278	Mean Difference (IV, Random, 95% CI)	‐1.11 [‐1.32, ‐0.91]

5 Social functioning: Average overall endpoint score (IPROS, high = poor) ‐ short term Show forest plot	2	278	Mean Difference (IV, Random, 95% CI)	‐18.14 [‐21.33, ‐14.95]

Comparison 2. MORITA THERAPY + STANDARD CARE versus REHABILITATION + STANDARD CARE

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