Successful functional recovery is an important treatment target for people with first-episode psychosis (1, 2), but remains to be challenging (3). Apart from neurocognition being an important determinant of functional recovery (4), social cognition has received increasing attention in prediction of functioning in FEP, such as work functioning (5). Social cognition is defined as a set of mental operations that underlie social interactions, including perceiving, interpreting, and generating responses to the intentions, dispositions, and behaviors of other people (6). It is a complex, multi-faceted construct encompassing several sub-domains including emotion perception, theory of mind (ToM), and attributional style/bias (7, 8). There is much evidence suggesting people with schizophrenia displayed significant impairments in emotion perception and ToM (9, 10). A subgroup with paranoid delusion demonstrated higher tendency in adopting attributional bias (11).

The close connection between poor functional outcomes, such as inability to live, work or socialize independently, and impaired social cognition in people with chronic schizophrenia (12) and FEP (5, 13) indicates that improving social cognition can potentially improve daily functioning. Moreover, people in the early-phase of psychosis were found to display less structural and functional brain changes, such as less widespread gray matter volumetric deficit, than people with chronic schizophrenia (14). This suggests that their cortical representational systems exhibit greater malleability that may optimize the treatment effect (15, 16). It is not clear if pharmacological or psychosocial interventions help to manage social cognitive problems in people with FEP (17). Considering the similarity in social cognitive impairments between people with FEP and people with established schizophrenia, it is plausible that social cognitive interventions designed for people with established schizophrenia can be applicable to people with FEP. Social Cognition and Interaction Training (SCIT) is one of the evidence-based interventions to improve social cognitive functioning (18, 19) in people with schizophrenia. SCIT is a structured and manualized group-based intervention, that addresses dysfunctional social cognitive processes, such as impaired emotion perception, theory of mind (ToM), hasty judgments, and biased social attributions (20, 21). SCIT consists of three phases that target at improving three types of social cognitive process. Phase I - emotion recognition (which addresses emotion perception dysfunction), Phase II - figuring-out situations (which addresses attributional biases and ToM dysfunction), and Phase III - integration (which involves the applications of the learned skills from Phase I and II to participants’ interpersonal problems). The efficacy of SCIT in improving social cognition and other functional recovery outcomes in people with established schizophrenia has been investigated in previous studies using non-randomized (22–24) and randomized (25) controlled trial designs.

While the evidence on the efficacy of SCIT is accumulating, there are several limitations in previous studies and the current study aims to address some of these limitations. First, this study uses a randomized controlled instead of non-randomized designs. The effects of SCIT for people with schizophrenia are promising with social cognitive gains reaching medium to large effect sizes in non-randomized studies (22, 23, 26) though these effects are weaker in randomized-design study and only small improvement in functional performance (25). There is a need to further investigate the effect of SCIT using larger sample and more rigorous design, especially for people with FEP who are believed to have greater brain plasticity to benefit from treatment. To-date, only one previous study (27) has investigated the effect of SCIT on FEP. This study did not have any control group, and only compared pre- and post-intervention outcomes. The preliminary results suggested that people with FEP improved in emotion perception and social/occupational functioning after receiving SCIT (27). Second, most previous studies of SCIT are conducted in U.S., the effect of SCIT for patients of non-Western culture is not well understood (28–30). In the two studies conducted for Chinese samples with schizophrenia, the researchers made minimal adaptation to SCIT to examine potential cultural differences (29, 30). There is initial evidence suggesting cultural differences in social cognitive processing in healthy people. For instance, the Chinese and the Western populations differ in social cognition, such as self-relevance processing (31) and perspective taking mechanism (32–34). Individual’s vocabulary knowledge may also impact their performance in ToM tasks (35, 36). Taken together, it is necessary to have a culturally-adapted SCIT (37) to investigate its effects on social cognition in the Chinese setting. Lastly, previous studies usually use social cognition and functional measures as outcome measures. However, people with schizophrenia and FEP both demonstrated impaired performance in a range of neurocognitive tasks (38, 39). Considering the medium-range correlation between neurocognition and social cognition (13, 40, 41), it is possible that social cognitive training may remediate neurocognition (42, 43) on top of social cognition. In this study, we would include measures of neurocognition as a secondary outcome measure.

This study aimed to examine the feasibility, acceptability and initial effectiveness of a culturally-adapted SCIT version on social cognition and neurocognition in people with FEP in a non-Western context, using the robust method of randomized-controlled trial. Following Horan & Green (18)‘s recommendation, we administered SCIT as an additional intervention to the conventional rehabilitation programs. We hypothesized that the SCIT group (which received both SCIT and conventional rehabilitation programs) would show a higher level of improvement over time in social cognition, neurocognition and functioning, when compared with the control group (which received conventional rehabilitation program). The primary outcome of this study was social cognition, and the secondary outcomes were neurocognition, social competence and quality of life.

This study evaluated the feasibility, acceptability and the initial effectiveness of the Chinese version of the SCIT in enhancing social cognitive performance among a group of relatively high-functioning first-episode psychosis outpatients in Hong Kong. To our knowledge, this study is the first randomized clinical trial of SCIT for patients with first-episode psychosis. After cultural adaptations on the training content, the SCIT is suitable and is well-tolerated in first-episode psychosis outpatients in Hong Kong. Participants rated the training as highly relevant in enhancing their social understandings and functioning. Despite participants’ positive accounts, our findings did not show social cognitive gains in most of the social cognitive domains using social cognitive scales, except that SCIT completers showed an advantage over the comparison group in reducing hostile attributional bias and jumping to conclusion tendency after treatment. This effect did not persist at follow-up. In short, our findings support the feasibility and acceptability of the SCIT among FEP in the Chinese setting and suggest that attributional bias may reduce after SCIT.

The persistence rate and attendance rate of the participants support the feasibility of SCIT for individuals with FEP in Hong Kong. The participants gave high ratings on usefulness of SCIT in particular in enhancing their understandings towards other people’s thoughts and in getting along with other people. These support that SCIT is well-accepted and is valued in our FEP sample. Despite good treatment compliance and perceived usefulness among our participants, minimal effect of SCIT on social cognitive improvements could be detected using social cognitive scales. Among the studied social cognitive domains, the lack of effect of SCIT on enhancing emotion perception is unexpected, and this result is contrary to previous evidence showing substantial improvements in emotion perception in patients with established schizophrenia after social cognitive intervention (19). One possible explanation may be related to the relatively preserved emotion perception ability among our high-functioning early schizophrenia sample. The distributions of our sample’s FEIT performance is highly left-skewed, with above-half of our sample (54%) performing within the normative range at baseline (49). Thus, the limited impact of SCIT on emotion perception performance may be attributable to ceiling effect in the baseline of FEIT. Notably, some research suggests that deficits in emotion perception among FEP or early psychosis may be less consistent than that seen in chronic schizophrenia (60), despite the support from prior studies suggesting consistent emotion perception deficit in FEP or early psychosis. In one review, longer duration of illness was a significant moderator of treatment effect on emotion perception after social cognitive intervention (61). It would be interesting for future studies to examine if duration of illness, degree of impairments or other clinical characteristics would moderate the treatment effect considering the inadequate and inconsistent findings reported in existing studies (25, 61, 62). Another possible reason for the small effect sizes across social cognitive domains may be related to our outcome measurements. The FEIT and the SCSQ used in our study were validated locally with patients with schizophrenia of around middle-aged (49). However, the suitability of these measures for use in clinical trials among FEP has not been thoroughly examined. One recent study concluded that only one social cognitive measure, the Hinting Task, was appropriate for use in people with early psychosis (63) while several measures were recommended for middle-aged persons with schizophrenia in the SCOPE study (44). The Hinting Task bears its own limitation, including poor test–retest reliability in an early psychosis sample (63) and high chances of having ceiling effects in community samples (25, 64). There is a need to develop more refined outcome measurements for the SCIT, such as self−/informant-report or ecological social cognition measures (65, 66) to capture social cognitive processes which are typically unfold in daily life (67, 68) that cannot be reflected in traditional scales.

This study observed a small effect of reduction in attributional bias and jumping to conclusion tendency among SCIT completers, as compared with those receiving conventional rehabilitation only. Therefore, the findings lend initial support that attributional bias among people with FEP may be amendable through the SCIT. Attributional bias describes how individuals make sense of the causes of positive and negative social events encountered in daily life. Attributional bias, together with the tendency of jumping to conclusion, may result in perceiving and concluding more hostile intention from other people in negative social events (69), adversely affecting social behaviors (70). Attributional bias may be a particularly important treatment target among FEP because of its links with development of paranoia (71), recurrent relapses, and difficulties in occupational functioning (5). Our sample attained a lower mean score in attributional bias than that of the schizophrenia samples with longer duration of illness in previous studies using the SCSQ measure (49, 51). This may suggest a worsening trend of bias with increasing duration of illness and supports the value of identifying effective interventions for reducing attributional bias among FEP in their early phase of illness. Furthermore, jumping to conclusion in people with FEP is associated with more implausible delusional subtypes (72) and may predict a worse prognosis (73). Most previous intervention studies in established (chronic) schizophrenia samples failed to find an effect in attributional bias (61, 74), except a trend level of improvement in one study (25); or did not evaluate the effect on jumping to conclusion. It is encouraging to find that SCIT could reduce attributional bias and jumping to conclusion tendency, even though the change is not sustained at follow-up in our study. In view of our findings, future research should consider longer training sessions, because a significant dose–response effect on attributional bias has been found in previous (25) and our studies. Booster sessions in social cognitive intervention may also be needed (18).

The study did not find any interaction effects in all secondary measures. There are limited compelling evidence of social cognition treatment on secondary outcomes observed in previous well-designed studies among schizophrenia (25, 75) despite the extensive support on associations between social cognition and functional measures (76). This urges for more work in identifying effective treatment contents or protocol to bring impact on both social cognitive tasks and secondary outcomes. One potential reason for the lack of interaction effect in our study may be related to the nature of comparison group which received intensive rehabilitation like work or social skills training on a regular basis. This could greatly reduce the effect sizes in secondary outcomes. However, we found a small within-group effect that SCIT completers rated themselves as having higher competence in understanding others in social situations after treatment. This is consistent with their high level agreement on usefulness of SCIT in understanding about the thoughts of other people in different social situations, suggesting that the SCIT could bring impact to participants’ self-perceived social competence.

Another observation is that the total sample had significant improvements in some neurocognitive domains, but not any of the social cognitive domains, at follow-up. This is consistent with previous findings on selective improvements in some cognitive domains over time, with or without treatment, among individuals with FEP (77, 78), which may suggest different pathophysiological mechanism underlying deficits in different mental functions (79). On the other hand, the results of the few studies on social cognitive performance were mixed (60). The stability of social cognitive performance across different phases of schizophrenia remains controversial. Future studies can use a follow-up design to address this issue.

Our study has several limitations. First, we did not employ intention-to-treat (ITT) analysis. Although we found no significant differences in most of the baseline clinical, demographic or outcome variables between participants retained for analysis and those who dropped out, we agree ITT is the best approach to give an unbiased estimate of treatment effect. However, ITT is not possible in our study as we could not make contact with participants who dropped out or did not attend the re-assessments at the post-intervention and follow-up. Second, the participants were not blinded to treatment allocation which may induce bias, though the bias on the primary social cognitive measures should be minimal as the measures are objective performance-based measures. Third, we used the same social cognitive measures at baseline, post-treatment and follow-up that may result in potential practice effect. Although we did account for this by controlling participants’ baseline performances and by examining the Group x Time interaction effect as our main analysis, we suggest future clinical trials can develop and use alternate forms for social cognitive measures.

To conclude, our study supports the feasibility and acceptability of the Chinese version of SCIT for use in patients with FEP in Hong Kong. Attributional bias may be amendable through the SCIT. Further research should replicate the current research design, use a larger sample, more refined outcome measures of social cognition and function. Longitudinal design using a longer follow-up period, and intention-to-treat (ITT) analysis will strengthen the study.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Research Ethics Committee of the New Territories West Cluster, Hospital Authority. The patients/participants provided their written informed consent to participate in this study.

PL, SL, and CL designed the study protocol. PL and AS undertook the statistical analysis. PL wrote the first draft of the manuscript. DR, AS, SL, and CL commented on the manuscript. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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