Efficacy of metacognitive therapies in first-episode psychosis: a systematic review

Metacognitive interventions have emerged as promising therapeutic approaches for individuals experiencing a first episode of psychosis (FEP), given the relationship between metacognitive deficits, reduced cognitive insight, and symptom persistence. This systematic review synthesizes the available evidence on the effectiveness of metacognitive therapies in adults with FEP, focusing on their impact on cognitive insight, psychotic symptoms, and global functioning.

A systematic search was conducted in PubMed, PsycINFO, Web of Science, and Scopus following PRISMA guidelines, with prior registration in PROSPERO (CRD420261281443). Studies published between 2014 and 2025 were included if they applied metacognitive interventions to adult FEP samples and evaluated changes in psychotic symptomatology and/or cognitive insight using validated instruments. Methodological quality was assessed using the Mixed Methods Appraisal Tool.

A total of 15 studies met the inclusion criteria. Overall, metacognitive interventions demonstrated consistent improvements in cognitive insight, notably increased self-reflectivity, and reduced overconfidence. Findings regarding psychotic symptom reduction were heterogeneous, although several studies reported significant improvements. Additional benefits were observed in neurocognitive domains, whereas results concerning social cognition were mixed. Interventions varied substantially in duration, format, and intensity, with most being delivered individually.

The available evidence suggests that metacognitive therapies constitute a promising treatment option for individuals with FEP, showing robust effects on cognitive insight and potential benefits for clinical and functional outcomes. Nonetheless, further high-quality research, particularly comparative trials and long-term follow-up studies, is needed to consolidate these findings and clarify their applicability across diverse clinical settings.