Psychosocial interventions for community-dwelling individuals with schizophrenia: study protocol for a systematic review and meta-analysis

INTRODUCTION

Despite the recent global mental health movement of the transition from hospital-centred to integrated community-based services, comprehensive evidence of psychosocial interventions focusing on community-dwelling individuals with schizophrenia is still lacking. To overcome this gap in the current knowledge, we will conduct a systematic review and meta-analysis to assess the efficacy of all types of psychosocial interventions for community-dwelling (non-hospitalised) individuals with schizophrenia when compared with non-active control conditions (eg, treatment as usual).

METHODS AND ANALYSIS

This study protocol has been developed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. By March 2022, the following sources will have been searched, without restrictions for language or publication period: Embase, PubMed, PsycINFO, CINAHL, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We will also try to identify other potentially eligible studies by searching the reference lists of included studies, other relevant systematic reviews and grey literature. All relevant randomised controlled trials from both high-income and low-income to middle-income countries will be allowed. Two independent reviewers will conduct the selection/screening of studies, data extraction and methodological quality assessment of included studies. The primary outcomes are quality of life and psychiatric hospital admission. Standard pairwise meta-analyses with a random-effects model will be conducted. Subgroup and sensitivity analyses will be performed to assess the robustness of the findings. Risk of bias will be assessed with the Revised Cochrane Risk-of-Bias Tool for Randomised Trials. The Grades of Recommendation Assessment, Development and Evaluation approach will be used to assess the quality of evidence.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study. The study findings will be disseminated through conference presentations as well as peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42021266187.

Mental healthcare utilisation by patients before and after receiving paliperidone palmitate treatment: mirror image analyses

OBJECTIVES

To compare mental healthcare use and healthcare professional (HCP) contacts for patients before and after initiation of paliperidone palmitate.

SETTING

The South London and Maudsley NHS Foundation Trust (SLAM) Biomedical Research Centre Clinical Record Interactive Search.

PARTICIPANTS

We identified all adults with a diagnosis of schizophrenia (International Classification of Diseases 10th Revision: F20.x), who had received paliperidone palmitate prescription for at least 365 days and had at least 1 year of recorded treatment from SLAM, prior to the first recorded receipt of paliperidone palmitate.

PRIMARY AND SECONDARY OUTCOME MEASURES

Inpatient and community mental healthcare service use, such as inpatient bed days, number of active days in the service, face-to-face and telephone HCP use in the 12 months before and after paliperidone palmitate initiation.

RESULTS

We identified 664 patients initiated on paliperidone palmitate. Following initiation, inpatient bed days were lower, although patients remained active on the service case load longer for both mirror approach 1 (mean difference of inpatient bed days -10.48 (95% CI -15.75 to -5.22); days active 40.67 (95% CI 33.39 to 47.95)) and mirror approach 2 (mean difference of inpatient bed days -23.96 (95% CI -30.01 to -17.92); mean difference of days active 40.69 (95% CI 33.39 to 47.94)). The postinitiation period was further characterised by fewer face-to-face and telephone contacts with medical and social work HCPs, and an increased contact with clinical psychologists.

CONCLUSIONS

Our findings indicate a change in the profile of HCP use, consistent with a transition from treatment to possible rehabilitation.

Protocol for the Lovisenberg Open Acute Door Study (LOADS): a pragmatic randomised controlled trial to compare safety and coercion between open-door policy and usual-care services in acute psychiatric inpatients

INTRODUCTION

The reduction of coercion in psychiatry is a high priority for both the WHO and many member countries. Open-door policy (ODP) is a service model for psychiatric ward treatment that prioritises collaborative and motivational measures to better achieve acute psychiatric safety - and treatment objectives. Keeping the ward main door open is one such measure. Evidence on the impact of ODP on coercion and violent events is mixed, and only one randomised controlled trial (RCT) has previously compared ODP to standard practice. The main objectives of the Lovisenberg Open Acute Door Study (LOADS) are to implement and evaluate a Nordic version of ODP for acute psychiatric inpatient services. The evaluation is designed as a pragmatic RCT with treatment-as-usual (TAU) control followed by a 4-year observational period.

METHODS AND ANALYSIS

In this 12-month pragmatic randomised trial, all patients referred to acute ward care will be randomly allocated to either TAU or ODP wards. The primary outcome is the proportion of patient stays with one or more coercive measures. Secondary outcomes include adverse events involving patients and/or staff, substance use and users' experiences of the treatment environment and of coercion. The main hypothesis is that ODP services will not be inferior to state-of-the art psychiatric treatment. ODP and TAU wards are determined via ward-level randomisation. Following conclusion of the RCT, a longitudinal observational phase begins designed to monitor any long-term effects of ODP.

ETHICS AND DISSEMINATION

The trial has been approved by the Regional Committees for Medical and Health Research Ethics (REC) in Norway (REC South East #29238), who granted LOADS exemption from consent requirements for all eligible, admitted patients. Data are considered highly sensitive but can be made available on request. Results will be published in peer-reviewed journals and presented at scientific conferences and meetings.

TRIAL REGISTRATION NUMBER

ISRCTN16876467.

PROTOCOL VERSION

1.4, 21 December 2021.

Subjective experiences of the first response to mental health crises in the community: a qualitative systematic review

OBJECTIVE

To review and synthesise qualitative studies that have explored subjective experiences of people with lived experience of mental health-related illness/crisis (MHC), their families and first responders.

DESIGN

A systematic review of qualitative evidence was conducted. English-language articles exploring the content of interactions and participants' experiences were included.

DATA SOURCES

MEDLINE, PsycINFO, EMBASE, CINAHL; Google Scholar, SAGE journals, Science Direct and PubMed.

DATA EXTRACTION AND SYNTHESIS

Two reviewers read and systematically extracted data from the included papers. Papers were appraised for methodological rigour using the Critical Appraisal Skills Programme Qualitative Checklist. Data were thematically analysed.

RESULTS

We identified 3483 unique records, 404 full-texts were assessed against the inclusion criteria and 79 studies were included in the qualitative synthesis. First responders (FRs) identified in studies were police and ambulance staff. Main factors influencing response are persistent stigmatised attitudes among FRs, arbitrary training and the triadic interactions between FRs, people with mental illness and third parties present at the crisis. In addition, FR personal experience of mental illness and focused training can help create a more empathetic response, however lack of resources in mental health services continues to be a barrier where 'frequent attenders' are repeatedly let down by mental health services.

CONCLUSION

Lack of resources in mental healthcare and rise in mental illness suggest that FR response to MHC is inevitable. Inconsistent training, complexity of procedures and persistent stigmatisation make this a very challenging task. Improving communication with family carers and colleagues could make a difference. Broader issues of legitimacy and procedural barriers should be considered in order to reduce criminalisation and ensure an empathetic response.

Duration of untreated psychosis and pathways to care in Suriname: a qualitative study among patients, relatives and general practitioners

PURPOSE

Psychosis is a severe mental health problem and is responsible for poor health outcomes, premature mortality and morbidity, especially in low- and middle-income countries. The duration of untreated psychosis (DUP), that is the time period between onset of symptoms until initiation of appropriate treatment by a healthcare professional, is one of the main determinants for successful treatment in western settings. This study aims to explore the factors related to the DUP among Surinamese patients using the perspectives from patients, their families and first-line healthcare professionals in Suriname.

METHODS

Semi-structured interviews were conducted with patients having a history of psychosis, family members and general practitioners between February 2019 and April 2019 in Suriname. Interviews were tape-recorded and transcribed verbatim. Data were analysed using a thematic analysis for which an inductive and deductive approach was applied.

RESULTS

In total, 28 patients, 13 family members and 8 general practitioners were interviewed. Five patients were excluded from the study. A median DUP of 4 months was found (IQR 1-36). Identified themes related to DUP included presentation of symptoms and illness awareness, help-seeking behaviour and alternative medicine, social support and stigma, financial and practical factors.

CONCLUSION

Multiple factors were related to DUP, of which poor illness awareness, traditional medicine, stigma and social support were predominant. Poor illness awareness and use of alternative medicine were related to a longer DUP. Stigma was often an obstacle for patients and their families. Social and family support was important in helping patients to get medical help sooner. Other explored factors including financial and practical factors did not contribute to DUP.

Metformin in the management of antipsychotic-induced weight gain in adults with psychosis: development of the first evidence-based guideline using GRADE methodology

BACKGROUND

Adjunctive metformin is the most well-studied intervention in the pharmacological management of antipsychotic-induced weight gain (AIWG). Although a relatively unaddressed area, among guidelines recommending consideration of metformin, prescribing information that would facilitate its applied use by clinicians, for example, provision of a dose titration schedule is absent. Moreover, recommendations differ regarding metformin's place in the hierarchy of management options. Both represent significant barriers to the applied, evidence-based use of metformin for this indication.

OBJECTIVE

To produce a guideline solely dedicated to the optimised use of metformin in AIWG management, using internationally endorsed guideline methodology.

METHODS

A list of guideline key health questions (KHQs) was produced. It was agreed that individual recommendations would be 'adopted or adapted' from current guidelines and/or developed de novo, in the case of unanswered questions. A systematic literature review (2008-2020) was undertaken to identify published guidelines and supporting (or more recent) research evidence. Quality appraisal was undertaken using the Appraisal of Guidelines Research and Evaluation II tool, A Measurement Tool to Assess Systematic Reviews (AMSTAR) assessment,and the Cochrane Risk of Bias 2 tool, where appropriate. Assessment of evidence certainty and recommendation development was undertaken using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

FINDINGS

We confirmed that no published guideline-of appropriate quality, solely dedicated to the use of metformin to manage AIWG was available. Recommendations located within other guidelines inadequately addressed our KHQs.

CONCLUSION

All 11 recommendations and 7 supporting good practice developed here were formulated de novo.

CLINICAL IMPLICATIONS

These recommendations build on the number and quality of recommendations in this area, and facilitate the optimised use of metformin when managing AIWG.

Hypertension and psychosis

Hypertension, a prevalent component of metabolic syndrome (MetS), is a well-known risk factor for cardiovascular diseases (CVD). Psychosis is a feature in the schizophrenia spectrum. Meta-analysis suggests that the prevalence of hypertension in schizophrenia and related disorders is 39%. This may be explained by a unidirectional association between hypertension and psychosis, in that psychosis can be a causative factor of hypertension via antipsychotic medication, inflammation and irregular autonomic nervous system activity through multiple mechanisms. Obesity is a side effect of antipsychotic medication and is a risk factor for hypertension. Obesity leads to raised blood pressure, atherosclerosis, increased triglyceride concentration and decreased high-density lipoprotein concentration. Inflammation accompanies hypertension and obesity. In recent years, the role of inflammation in the onset of psychosis has been increasingly recognised. It underlies the immune dysregulation observed in both schizophrenia and bipolar disorder. Interleukin-6, a marker and driver of inflammation, is related to obesity and plays a role in the pathogenesis of MetS and hypertension. The lack of preventive care of hypertension and other MetS risk factors for patients on antipsychotic medication is reflected in the high incidence of CVD in this population. It is important to detect and treat MetS and hypertension in patients with psychosis in order to reduce cardiovascular morbidity and mortality in this population.

Prospective, observational, single-centre cohort study with an independent control group matched for age and sex aimed at investigating the significance of cholinergic activity in patients with schizophrenia: study protocol of the CLASH-study

INTRODUCTION

Alterations in the cholinergic metabolism may cause various clinical symptoms of schizophrenia. In addition to the 'monoamine hypothesis,' neuroinflammation is also discussed as a cause of schizophrenia. To date, there has been no evidence of alterations in the central cholinergic transmitter balance in patients with schizophrenia under clinical conditions. By contrast, studies in critically ill patients have established the measurement of acetylcholinesterase activity as a suitable surrogate parameter of central cholinergic transmitter balance/possible pathophysiological changes. Butyrylcholinesterase activity has been established as a parameter indicating possible (neuro)inflammatory processes. Both parameters can now be measured using a point-of-care approach. Therefore, the primary objective of this study is to investigate whether acetylcholinesterase and butyrylcholinesterase activity differs in patients with various forms of schizophrenia. Secondary objectives address the possible association between acetylcholinesterase and butyrylcholinesterase activity and (1) schizophrenic symptoms using the Positive and Negative Syndrome Scale, (2) the quantity of antipsychotics taken and (3) the duration of illness.

METHODS AND ANALYSIS

The study is designed as a prospective, observational cohort study with one independent control group. It is being carried out at the Department of Psychiatry and Psychotherapy III, Ulm University Hospital, Germany. Patient enrolment started in October 2020, and the anticipated end of the study is in January 2022. The enrolment period was set from October 2020 to December 2021 (extension required due to SARS-CoV-2 pandemic). The sample size is calculated at 50 patients in each group. Esterase activity is measured on hospital admission (acute symptomatology) and after referral to a postacute ward over a period of three consecutive days. The matched control group will be created after reaching 50 patients with schizophrenia. This will be followed by a comprehensive statistical analysis of the data set.

ETHICS AND DISSEMINATION

The study was registered prospectively in the German Clinical Trials Register (DRKS-ID: DRKS00023143,URL: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023143) after approval by the ethics committee of the University of Ulm, Germany Trial Code No. 280/20.

TRIAL REGISTRATION NUMBER

DRKS00023143; Pre-results.

Physical comorbidity and use of healthcare services in people with schizophrenia: protocol for a systematic review

INTRODUCTION

People with schizophrenia die about 15-20 years earlier than the general population. A constellation of factors contributes to this gap in life expectancy: side effects of psychotropic drugs, unhealthy lifestyles (inactivity, unhealthy diet) and inequality in the provision of healthcare services. This is a topic of main importance, which requires constant update and synthesis of the literature. The aim of this review is to explore the evidence of physical comorbidity and use of healthcare services in people with schizophrenia.

METHODS AND ANALYSIS

We will conduct a systematic literature search in the databases PubMed/MEDLINE, EMBASE, Scopus, Web of Science, PsycINFO and Cochrane Library, Proquest Health Research Premium Collection, in order to identify studies that answer to our research question: Are patients with schizophrenia different from the non-psychiatric population in terms of physical comorbidity and use of healthcare services? Two authors will independently review the studies and extract the data.

ETHICS AND DISSEMINATION

This study does not include human or animal subjects. Thus, ethics considerations are not applicable. Dissemination plans include publications in peer-reviewed journals and discussion of results in psychiatric congresses.

PROSPERO REGISTRATION NUMBER

CRD42020139972.

Effectiveness and cost-effectiveness of a structured social coaching intervention for people with psychosis (SCENE): protocol for a randomised controlled trial

INTRODUCTION

People with psychosis tend to have smaller social networks than both people in the general population and other people with long-term health conditions. Small social networks are associated with poor quality of life. Preliminary evidence suggests that coaching patients to increase their social contacts may be effective. In this study, we assessed whether structured social coaching improves the quality of life of patients with psychosis (primary outcome) compared with an active control group, receiving information on local social activities.

METHODS AND ANALYSIS

A structured social coaching intervention was developed based on the literature and refined through stakeholder involvement. It draws on principles from motivational interviewing, solution focused therapy and structured information giving. It is provided over a 6-month period and can be delivered by a range of different mental health professionals. Its effectiveness and cost-effectiveness are assessed in a randomised controlled trial, compared with an active control group, in which participants are given an information booklet on local social activities. Participants are aged 18 or over, have a primary diagnosis of a psychotic disorder (International Classification of Disease: F20-29) and capacity to provide informed consent. Participants are assessed at baseline and at 6, 12 and 18 months after individual randomisation. The primary outcome is quality of life at 6 months (Manchester Short Assessment of Quality of Life). We hypothesise that the effects on quality of life are mediated by an increase in social contacts. Secondary outcomes are symptoms, social situation and time spent in social activities. Costs and cost-effectiveness analyses will consider service use and health-related quality of life.

ETHICS AND DISSEMINATION

National Health Service REC London Hampstead (19/LO/0088) provided a favourable opinion. Findings will be disseminated through a website, social media, scientific papers and user-friendly reports, in collaboration with a lived experience advisory panel.

TRIAL REGISTRATION NUMBER

ISRCTN15815862.

Intimate partner violence among reproductive-age women with chronic mental illness attending a psychiatry outpatient department: cross-sectional facility-based study, Addis Ababa, Ethiopia

OBJECTIVE

To determine the prevalence of intimate partner violence (IPV), and associated factors, in reproductive-aged women attending psychiatric outpatient departments.

DESIGN

Cross-sectional facility-based study.

SETTING

Outpatient psychiatric clinics of public hospitals in Addis Ababa.

PARTICIPANTS

Reproductive aged women with chronic mental illness (CMI) who attended follow-up in psychiatric outpatient clinics.

PRIMARY AND SECONDARY OUTCOME MEASURES

The data were collected using a multi-culturally validated instrument from randomly sampled women with CMI. Multiple logistic regression was used to identify factors independently associated with IPV.

RESULT

Four hundred and twenty-two women who were attending the psychiatric outpatient clinics took part in the study. The majority of participants 62.0% (95% CI 56.1 to 68.8) experienced IPV at least once in their lifetime. The most common form of IPV experienced by women was emotional violence (60%; 95% CI 55.0 to 64.7). One hundred and eighty-six (44.1%; (95% CI 39.3 to 48.8)) respondents experienced physical or sexual violence during the last year. A history of divorce (Adjusted Odds Ratio [AOR]=5.64; 95% CI 2.75 to 11.56) and having a mental illness for more than 5 years (AOR=2.23; 95% CI 1.26 to 3.93) were associated with any form of IPV.

CONCLUSION

The high prevalence of IPV among women attending psychiatric outpatient services highlights the need to routinely inquire about IPV and develop effective strategies to prevent it among this vulnerable group.

Time trends in access to smoking cessation support for people with depression or severe mental illness: a cohort study in English primary care

OBJECTIVES

To investigate delivery of smoking cessation interventions, recorded quit attempts and successful quitting rates within primary care in smokers with depression or severe mental illness (SMI) compared with those without.

DESIGN

Longitudinal cohort study using primary healthcare records.

SETTING

English primary care.

PARTICIPANTS

882 849 patients registered with participating practices recorded as current smokers during 2007-2014, including three groups: (1) 13 078 with SMI, (2) 55 630 with no SMI but recent depression and (3) 814 141 with no SMI nor recent depression.

OUTCOMES

Recorded advice to quit smoking, referrals to smoking cessation services, prescriptions for smoking cessation medication, recorded quit attempts and changes of smoking status.

RESULTS

The majority (>70%) of smokers had recorded smoking cessation advice. This was consistently higher in those with SMI than the other cohorts of patients, although the gap greatly reduced in more recent years. Increases in smoking cessation advice over time were not accompanied by increases in recorded attempts to quit or changes of smoking status. Overall nicotine replacement therapy prescribing by general practitioners (GPs) was higher in those with SMI (10.1%) and depression (8.7%) than those without (5.9%), but a downward time trend was observed in all groups. Bupropion and varenicline prescribing was very low and lower for those with SMI. Few smokers (<5%) had referrals to stop smoking services, though this increased over time, but no significant differences were observed between those with and without mental health problems.

CONCLUSIONS

There was no evidence of consistent inequalities in access to GP-delivered smoking cessation interventions for people with mental health conditions. Smoking cessation advice was widely reported as taking place in all groups. In order to address the widening gap in smoking prevalence in those with poor mental health compared with those without, the emphasis should be on addressing the quality of advice and support given.

Cross-sectional study comparing cognitive function in treatment responsive versus treatment non-responsive schizophrenia: evidence from the STRATA study

BACKGROUND

70%-84% of individuals with antipsychotic treatment resistance show non-response from the first episode. Emerging cross-sectional evidence comparing cognitive profiles in treatment resistant schizophrenia to treatment-responsive schizophrenia has indicated that verbal memory and language functions may be more impaired in treatment resistance. We sought to confirm this finding by comparing cognitive performance between antipsychotic non-responders (NR) and responders (R) using a brief cognitive battery for schizophrenia, with a primary focus on verbal tasks compared against other measures of cognition.

DESIGN

Cross-sectional.

SETTING

This cross-sectional study recruited antipsychotic treatment R and antipsychotic NR across four UK sites. Cognitive performance was assessed using the Brief Assessment of Cognition in Schizophrenia (BACS).

PARTICIPANTS

One hundred and six participants aged 18-65 years with a diagnosis of schizophrenia or schizophreniform disorder were recruited according to their treatment response, with 52 NR and 54 R cases.

OUTCOMES

Composite and subscale scores of cognitive performance on the BACS. Group (R vs NR) differences in cognitive scores were investigated using univariable and multivariable linear regressions adjusted for age, gender and illness duration.

RESULTS

Univariable regression models observed no significant differences between R and NR groups on any measure of the BACS, including verbal memory (ß=-1.99, 95% CI -6.63 to 2.66, p=0.398) and verbal fluency (ß=1.23, 95% CI -2.46 to 4.91, p=0.510). This pattern of findings was consistent in multivariable models.

CONCLUSIONS

The lack of group difference in cognition in our sample is likely due to a lack of clinical distinction between our groups. Future investigations should aim to use machine learning methods using longitudinal first episode samples to identify responder subtypes within schizophrenia, and how cognitive factors may interact within this.

TRAIL REGISTRATION NUMBER

REC: 15/LO/0038.

Antipsychotic use in pregnancy and risk of attention/deficit-hyperactivity disorder and autism spectrum disorder: a Nordic cohort study

Background

Antipsychotics are increasingly used among women of childbearing age and during pregnancy.

Objective

To determine whether children exposed to antipsychotics in utero are at increased risk of attention-deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD), accounting for maternal diagnoses of bipolar, psychotic and other psychiatric disorders.

Design

Population-based cohort study, including a sibling analysis.

Setting

Nationwide data on all pregnant women and their live-born singletons in Denmark (1997-2017), Finland (1996-2016), Iceland (2004-2017), Norway (2004-2017), and Sweden (2006-2016).

Participants

4 324 086 children were eligible for inclusion to the study cohort.

Intervention

Antipsychotic exposure in utero, assessed by pregnancy trimester, type of antipsychotic, and varying patterns of use.

Main outcome measures

Non-mutually exclusive diagnoses of ADHD and ASD. We used Cox proportional hazard models to calculate hazard ratios (HRs) controlling for maternal psychiatric disorders and other potential confounding factors.

Findings

Among 4 324 086 singleton births, 15 466 (0.4%) were exposed to antipsychotics in utero. During a median follow-up of 10 years, we identified 72 257 children with ADHD and 38 674 children with ASD. Unadjusted HRs were raised for both outcomes but shifted substantially towards the null after adjustment; 1.10 (95%CI 1.00 to 1.27) for ADHD and 1.12 (0.97 to 1.29) for ASD. Adjusted HRs remained consistent by trimester of exposure and type of antipsychotic. Comparing in utero exposure with pre-pregnancy use yielded HRs of 0.74 (0.62 to 0.87) for ADHD and 0.88 (0.70 to 1.10) for ASD. Sibling analyses yielded HRs of 1.14 (0.79 to 1.64) for ADHD and 1.34 (0.75 to 2.39) for ASD.

Discussion

Our findings suggest little or no increased risk of child ADHD or ASD after in utero exposure to antipsychotics.

Clinical implications

Results regarding child neurodevelopment are reassuring for women who need antipsychotics during pregnancy.

'Care co-ordinator in my pocket': a feasibility study of mobile assessment and therapy for psychosis (TechCare)

OBJECTIVES

The aim of the project was to examine the acceptability and feasibility of a mobile phone application-based intervention 'TechCare', for individuals with psychosis in the North West of England. The main objectives were to determine whether appropriate individuals could be identified and recruited to the study and whether the TechCare App would be an acceptable intervention for individuals with psychosis.

METHODS

This was a mixed methods feasibility study, consisting of a test-run and feasibility evaluation of the TechCare App intervention.

SETTING

Early Intervention Services (EIS) for psychosis, within an NHS Trust in the North West of England.

PARTICIPANTS

Sixteen participants (test-run n=4, feasibility study n=12) aged between 18 and 65 years recruited from the East, Central and North Lancashire EIS.

INTERVENTION

A 6-week intervention, with the TechCare App assessing participants' symptoms and responses in real-time and providing a personalised-guided self-help-based psychological intervention based on the principles of Cognitive Behaviorual Therapy (CBT).

RESULTS

A total of 83.33% (n=10) of participants completed the 6-week feasibility study, with 70% of completers achieving the set compliance threshold of ≥33% engagement with the TechCare App system. Analysis of the qualitative data suggested that participants held the view that the TechCare was both an acceptable and feasible means of delivering interventions in real-time.

CONCLUSION

Innovative digital clinical technologies, such as the TechCare App, have the potential to increase access to psychological interventions, reduce health inequality and promote self-management with a real-time intervention, through enabling access to mental health resources in a stigma-free, evidence-based and time-independent manner.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT02439619.

Weight change, cardio-metabolic risk factors and cardiovascular incidence in people with serious mental illness: protocol of a population-based cohort study in the UK from 1998 to 2020

INTRODUCTION

People with serious mental illness (SMI), which includes people with diagnoses of schizophrenia spectrum and bipolar disorders, face significant health inequality. This includes a life expectancy reduced by 15-20 years mostly due to premature cardiovascular disease (CVD) compared with the general population. Excess weight gain and related comorbidities are preventable risk factors for CVD. To improve the understanding and management of CVD in people with SMI, we will examine the association between SMI and: (1) weight change; (2) cardio-metabolic risk factors for CVD; and (3) incidence of and mortality from CVD. We will also (4) examine the incidence of referral to weight management services for people with SMI compared with people without SMI.

METHODS AND ANALYSIS

In this retrospective cohort study, we will link general practice records from the UK Clinical Practice Research Datalink Aurum database. We will establish a cohort of patients diagnosed with SMI between 1998 and 2020 who are matched with up to four controls on age, sex, general practice and calendar year. We will use multivariable mixed-effects linear regression models and Cox proportional hazard models with sequential adjustment for potential confounders identified by separate directed acyclic graphs.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Independent Scientific Advisory Committee for Medicines and Healthcare products Regulatory Agency database research. The results will be published in a peer-reviewed journal.

Guidelines to understand and compute the number needed to treat

OBJECTIVE

We aim to explain the unadjusted, adjusted and marginal number needed to treat (NNT) and provide software for clinicians to compute them.

METHODS

The NNT is an efficacy index that is commonly used in randomised clinical trials. The NNT is the average number of patients needed to treat to obtain one successful outcome (ie, response) due to treatment. We developed the nntcalc R package for desktop use and extended it to a user-friendly web application. We provided users with a user-friendly step-by-step guide. The application calculates the NNT for various models with and without explanatory variables. The implemented models for the adjusted NNT are linear regression and analysis of variance (ANOVA), logistic regression, Kaplan-Meier and Cox regression. If no explanatory variables are available, one can compute the unadjusted Laupacis et al's NNT, Kraemer and Kupfer's NNT and the Furukawa and Leucht's NNT. All NNT estimators are computed with their associated appropriate 95% confidence intervals. All calculations are in R and are replicable.

RESULTS

The application provides the user with an easy-to-use web application to compute the NNT in different settings and models. We illustrate the use of the application from examples in schizophrenia research based on the Positive and Negative Syndrome Scale. The application is available from https://nntcalc.iem.technion.ac.il. The output is given in a journal compatible text format, which users can copy and paste or download in a comma-separated values format.

CONCLUSION

This application will help researchers and clinicians assess the efficacy of treatment and consequently improve the quality and accuracy of decisions.

Occupational therapy interventions for adults with severe mental illness: a scoping review

OBJECTIVE

To identify the occupational therapy (OT) interventions in adults with severe mental illness (SMI) most investigated in intervention studies and to describe their characteristics.

DESIGN

Scoping review.

DATA SOURCES

On 17 January 2020, we searched the following electronic databases: MEDLINE, Scopus, Web of Science and EMBASE. We also performed a manual search of TESEO doctoral thesis database and of the journals indexed in the first quartile of OT according to the SCImago Journal Rank. We updated our search on 10 March 2021, performing a complementary search on ProQuest database and repeating the search in all sources. The terms included in the search strategy were: schizophrenia, schizotypal personality, delusional, schizoaffective, psychotic, bipolar, major depression, obsessive-compulsive, severe mental, OT and intervention.

STUDY SELECTION

The study screening was peer-reviewed. Inclusion criteria were: (1) OT intervention studies in SMI: experimental, randomised, non-randomised and pilot/exploratory studies; (2) adult population with SMI: schizophrenia, schizotypal personality disorder, delusional disorder, obsessive-compulsive disorder, schizoaffective disorder, psychotic disorder, bipolar disorder, major depressive disorder; (3) OT identified as a discipline involved in the intervention; (4) English or Spanish language and (5) studies with full text available.

RESULTS

Thirty-five studies met the inclusion criteria. OT interventions were classified in psychosocial, psychoeducational, cognitive and exercise interventions. The most used OT intervention was psychosocial intervention.

CONCLUSION

Psychosocial intervention was the most investigated OT intervention in SMI, followed by psychoeducational, cognitive and exercise interventions. These interventions are usually group interventions in patients with schizophrenia, performed by a multidisciplinary team (in which an occupational therapist collaborates), with 2-3 weekly 60 min sessions and a duration of 3-6 months.

Evaluating the utility of digital phenotyping to predict health outcomes in schizophrenia: protocol for the HOPE-S observational study

INTRODUCTION

The course of schizophrenia illness is characterised by recurrent relapses which are associated with adverse clinical outcomes such as treatment-resistance, functional and cognitive decline. Early identification is essential and relapse prevention remains a primary treatment goal for long-term management of schizophrenia. With the ubiquity of devices such as smartphones, objective digital biomarkers can be harnessed and may offer alternative means for symptom monitoring and relapse prediction. The acceptability of digital sensors (smartphone and wrist-wearable device) and the association between the captured digital data with clinical and health outcomes in individuals with schizophrenia will be examined.

METHODS AND ANALYSIS

In this study, we aim to recruit 100 individuals with schizophrenia spectrum disorders who are recently discharged from the Institute of Mental Health (IMH), Singapore. Participants are followed up for 6 months, where digital, clinical, cognitive and functioning data are collected while health utilisation data are obtained at the 6 month and 1 year timepoint from study enrolment. Associations between digital, clinical and health outcomes data will be examined. A data-driven machine learning approach will be used to develop prediction algorithms to detect clinically significant outcomes. Study findings will inform the design, data collection procedures and protocol of future interventional randomised controlled trial, testing the effectiveness of digital phenotyping in clinical management of individuals with schizophrenia spectrum disorders.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the National Healthcare Group (NHG) Domain Specific Review Board (DSRB Reference no.: 2019/00720). The results will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT04230590.

Patients' and psychiatrists' perspectives on clozapine treatment-a scoping review protocol

INTRODUCTION

The atypical antipsychotic clozapine has shown superior efficacy compared with other antipsychotics and is the gold standard for treating otherwise treatment resistant schizophrenia. However, multiple studies have found that clozapine is underutilised in most parts of the world. A few reviews of literature addressing barriers to clozapine prescribing have been conducted. While there is some variation in the literature included in these reviews, a common feature of the studies included is that they primarily focus on clinical staff's attitudes and perceived barriers for prescribing. Studies of patient perspectives are only sparsely included. A preliminary literature search revealed though, that additional literature on the subject exists, including literature on patient perspectives. It is therefore difficult to conclude if the formerly synthesised literature is representative of current evidence or if the topic has been adequately investigated to inform clinical practice. A scoping review is warranted in order to map and synthesise primary literature on patients' and psychiatrists' perspectives on clozapine treatment, and to identify gaps for future research.

METHODS AND ANALYSIS

The electronic databases Cochrane Library, CINAHL, Web of Science, Psychinfo, MEDLINE and EMBASE will be searched for relevant publications, supplied with searches of Google scholar, The Networked Digital Library of Theses and Dissertations and OpenGrey. Citation tracking of selected studies will furthermore be undertaken. Two researchers will independently screen and extract data. Data will be collated to provide a descriptive summary of the literature, along with a qualitative content analysis of key findings. Identified gaps in research will be accompanied by recommendations for future investigations.

ETHICS AND DISSEMINATION

Findings will be disseminated through a peer-reviewed journal and conference presentations. The scoping review does not require ethics approval.

Comparison of three different exercise training modalities (aerobic, strength and mixed) in patients with schizophrenia: study protocol for a multicentre randomised wait-list controlled trial

INTRODUCTION

Numerous studies support the practice of different physical exercise modalities as an effective treatment to address the problems associated with schizophrenia, reporting that they result in improvements in patient symptoms and quality of life. Given the lack of studies comparing different types of training in controlled environments, the aim of this proposed study will be to compare the effects of three physical exercise programmes (strength, aerobic and mixed) on the symptoms, body composition, level of physical activity and health-related quality of life of patients with schizophrenia.

METHODS AND ANALYSIS

A multicentre, single-blinded (evaluator), randomised, wait-list controlled (ratio 2:2:2:1) trial will be conducted with 105 patients recruited from different psychosocial care centres. The participants will be randomised into three 16-week training groups comprising 48 sessions lasting 1 hour each, or to the wait-list control group. The training groups will complete aerobic, strength or mixed (aerobic+strength) training. The participants will be assessed before, immediately after and 6 months after the end of the intervention. The patients in the wait-list control group (n=15) will receive one of the three trainings immediately after the intervention. The study variables will include positive, negative and general symptomology (Positive and Negative Syndrome Scale) as the primary outcome; as secondary outcome: body composition (by assessing body mass index, body fat mass and waist circumference), physical activity levels (International Physical Activity Questionnaire-Short Form) and quality of life (abbreviated WHO Quality of Life questionnaire).

ETHICS AND DISSEMINATION

This study was approved by the ethics committees for Biomedical Research at the CEU Cardenal Herrera University of Valencia, Spain (CEI18/215). Participants will be fully informed of the purpose and procedures of the study, and written informed consent will be obtained. The results from this study will be published in peer-reviewed journals and presented in scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04987151.

PLAN-e-PSY, a mobile application to improve case management and patient's functioning in first episode psychosis: protocol for an open-label, multicentre, superiority, randomised controlled trial

INTRODUCTION

The prognosis of first episode psychosis (FEP), which is a severe disorder, can be notably impaired by patients' disengagement from healthcare providers. Coordinated specialty care with case management is now considered as the gold standard in this population, but there are still challenges for engagement with subsequent functional impairments. Youth-friendly and patient-centred clinical approaches are sought to improve engagement in patients with FEP. Mobile applications are widely used by young people, including patients with FEP, and can increase the youth friendliness of clinical tools. We hypothesise that a co-designed mobile application used during case management can improve functioning in patients with FEP as compared with usual case management practices.

METHODS AND ANALYSIS

A mobile case management application for planning and monitoring individualised care objectives will be co-designed with patients, caregivers and health professionals in a recovery-oriented approach. The application will be compared with usual case management practices in a multicentre, two-arm and parallel groups clinical trial. Patients will be recruited by specialised FEP teams. Impact on functioning will be assessed using the Personal and Social Performance Scale; the variation between baseline and 12 months in each group (control and active) will be the primary outcome.

ETHICS AND DISSEMINATION

This study has been approved by the Inserm Institutional Review Board IRB00003888 (Comité d'évaluation éthique de l'INSERM, reference number 20-647). The results of the study will be published in a peer-reviewed journal and presented at national and international conferences. We will also communicate the results to patients and family representatives' associations. An optimised version of the application will be then disseminated through the French FEP network (Transition Network).

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT04657380.

Efficacy of positive psychotherapy in reducing negative and enhancing positive psychological outcomes: a meta-analysis of randomised controlled trials

OBJECTIVE

Positive psychotherapy (PPT) aims at increasing positive affect, meaning and engagement. We aimed to synthesise the available evidence on PPT efficacy.

DESIGN

We conducted a preregistered systematic literature search and meta-analysis of randomised controlled trials examining the efficacy of PPT for increasing positive (eg, satisfaction with life) or decreasing negative psychological outcomes (eg, depression).

DATA SOURCES

Medline, PsycINFO and Web of Science from 2006 (ie, inception of PPT) to February 2020 as well as related systematic reviews and meta-analyses.

RESULTS

We included 20 randomised controlled trial with a total of 1360 participants. Moderate effect sizes were found for increasing positive outcomes (g=-0.72, 95% CI: -1.31 to -0.14, k=10, numbers needed to treat (NNT)=2.55) and reducing negative outcomes (g=0.48, 95% CI: 0.18 to 0.78, k=8, NNT=3.76) when PPT was compared with waitlist control conditions at post-treatment assessment. When compared with active control conditions, PPT yielded large effect sizes for increasing positive outcomes (g=-0.92, 95% CI: -1.74 to -0.11, k=6, NNT=2.05) and reducing depression (g=0.94, 95% CI: 0.18 to 1.70, k=6, NNT=2.03) at post-treatment assessment. No significant differences in efficacy were found when compared with established treatments such as cognitive-behavioural therapy. Evidence was found to support an association between trial quality and effect sizes. For positive outcomes, higher trial quality was related to larger effect size. Whereas higher trial quality was associated with smaller effect size for depression. Follow-up assessments remained too scarce for most planned analyses.

CONCLUSIONS

Our findings support the short-term efficacy of PPT. However, results are to be regarded with due caution in the light of low number of trials. More high-quality trials that assess efficacy at follow-ups are needed to draw firmer conclusions on the long-term efficacy of PPT.

PROSPERO REGISTRATION NUMBER

CRD42020173567.

Exploring dementia family carers' self-initiated strategies in managing behavioural and psychological symptoms in dementia: a qualitative study

OBJECTIVES

Carer's self-initiated management strategies of behavioural and psychological symptoms of dementia (BPSD) can inform intervention development. These strategies are affected by cultural values. Little is known about non-Western dementia carers' BPSD management strategies. This study aimed to explore self-initiated strategies in managing BPSD adopted by Chinese carers.

DESIGN

Qualitative study using thematic framework method.

SETTING

Community setting in Hong Kong.

PARTICIPANTS

16 dementia carers with purposive sampling to include carers of different relationships to the people living with dementia (PLwD), education level and living arrangement.

RESULTS

Six overarching themes emerged from the data: (1) maintaining personhood in PLwD, (2) responding positively to BPSD, (3) explanation and bargaining, (4) responding negatively to BPSD, (5) controlling upsetting thoughts, and (6) getting respite care. Chinese carers treasured warm and supportive family relationships. They identified and minimised triggers to alleviate BPSD. Some carers struggled with care tasks and reacted with confrontation and avoidance. Changing attitudes and getting social and emotional support were described to manage carers' distress. Few self-care strategies including getting respite care were reported.

CONCLUSIONS

Carers' self-initiated strategies largely aligned with existing theoretical frameworks in BPSD management, such as person-centred approach, and echoed Asian culture, which advocates filial piety and supportive family relationships. While these cultural values encourage the engagement of people living with dementia in the normal process of family life, they may also prevent carers from taking time away from care. Interventions could support carers by enhancing their knowledge and skills in managing BPSD, providing social and emotional support, and providing guidance in self-care. Future cross-cultural research could explore factors contributing to how carers manage BPSD and how interventions could be culturally adapted to facilitate carers to apply learnt skills in daily practice and hence benefit the people living with dementia and carer population.