The subjective experience and phenomenology of depression following first episode psychosis: a qualitative study using photo-elicitation

A mixed-methods review and meta-synthesis of fears of recurrence and progression in people with mental health conditions

A fear that one's physical illness will recur or worsen has received substantial research attention over the past decade, most notably as fear of cancer recurrence. Indeed, such fear is known to be associated with poorer quality of life, adjustment, and psychopathology. However, fear of a recurrence or progression (FORP) of mental health conditions has received comparatively little study. The present review aimed to, 1) systematically review quantitative research on FORP in mental health regarding its association with age, gender, quality of life, mental health outcomes, and health behaviours, and 2) meta-synthesize qualitative research related to FORP to construct a transdiagnostic model. A qualitative meta-synthesis of 19 studies identified four subthemes underlying FORP (fear of symptoms, loss of progress, fear of death, and traumatic experiences). The three themes related to FORP were: inability to trust oneself, hypervigilance, and a low-risk low-reward lifestyle which was comprised of three subthemes (limiting relationships, limiting life goals, and fear of changing treatment). A quantitative systematic review of 15 studies found that FORP was strongly associated with worse quality of life, and greater depression, anxiety, psychotic symptoms, and medication adherence, but was not associated with age or gender. Hence, FORP can be understood transdiagnostically, and is generally associated with poorer mental health outcomes but may also predict adaptive health behaviours, such as appropriate medication adherence.

A case of postpsychotic depression improved by switching antipsychotic monotherapy

AIM

Postpsychotic depression is challenging to differentiate, yet it is clinically frequent, puts patients at risk for suicide, and affects their mental capacity. Treatment with antipsychotics for postpsychotic depression is desirable; however, there is no consensus on which antipsychotics are optimal.

CASE PRESENTATION

We report the case of a young male patient with schizophrenia in his 20s who developed postpsychotic depression, including despair, overwhelming loss, humiliation, and suicidal ideation during treatment with paliperidone. As a result, we switched his medication to lurasidone, which relieved his depressive symptoms without any symptom relapse and his social functioning improved.

CONCLUSION

Postpsychotic depression has more psychic characteristics than behavioral. According to various international guidelines for the pharmacological treatment of schizophrenia, antipsychotics should be administered for depressive symptoms of schizophrenia. As evidenced in this case report, lurasidone may be a practical alternative for improving postpsychotic depression.

Treatment of post-psychotic depression in first-episode psychosis. A systematic review

BACKGROUND

Post-psychotic depression (PPD) after a FEP (first-episode psychosis) differs from other depressive symptoms in chronic schizophrenia in its aetiology, symptomatology, and prognostic implications. The objective was to search if any pharmacological or non-pharmacological interventions have proven to be effective on depressive symptoms after a FEP.

METHODS

for this systematic review we systematically searched and screened PubMed for articles published from August 1975 to October 15, 2020, with the terms: treatment AND first-episode psychosis OR post-psychotic OR post-schizophrenic AND depression.

RESULTS

we identified 139 articles of which 20 met the inclusion criteria. These interventions were then categorized into four subgroups (antipsychotics, antidepressants, psychological and miscellaneous).

LIMITATIONS

this review has several limitations. The reviewed studies were heterogeneous as to assessments, interventions, and samples; furthermore, only one study had PPD in FEP as its primary outcome.

CONCLUSIONS

to our knowledge, this is the first review of PPD in a FEP's treatment. PPD continues to be a diagnostic and therapeutic challenge. The available evidence for the use of treatment whether pharmacological or non-pharmacological is limited. However, certain approaches such as online therapy and treatment with n-3 polyunsaturated fatty acids (PUFA) show promising results. It could be of interest for future studies to focus not only on the treatment of PPD but also on the diagnostic heterogeneity of the sample and the adaptation of the content of the intervention to the individual.

From co-morbidity to transdiagnostic potential and novel immunotherapies for psychosis

One of my first placements in psychiatry training was with the early intervention in psychosis services in Birmingham, in the late 1990's. It was in this context that I became aware of the frequency and importance of affective co- modbidity and lack of diagnostic certianty in early stages of develping severe mental illness. This challenged the established dichotomy between affective and non-affective severe mental illnesses, and has driven my work and thinking ever since- including that embracing the presence of affective symptoms in schizophrenia may open the door for new treatments. Understanding affective dysfunction as a potential intrisic component of developing psychotic disorders has also shown the potential for transdiagnostic symptoms with shared underlying biological processess, including immune dysfunction, related to remission and functional outcomes. Currently my work focuses on targeting the immune system to improve recovery in clinical trials, and further mechanistic studies that reach beyond traditional diagnostic catagories.

Fear of relapse in schizophrenia: a mixed-methods systematic review

INTRODUCTION

Fears of relapse in people diagnosed with schizophrenia have long been recognised as an impediment to recovery and wellbeing. However, the extent of the empirical basis for the fear of relapse concept is unclear. A systematic review is required to collate available evidence and define future research directions.

METHODS

A pre-registered systematic search (PROSPERO CRD42020196964) of four databases (PubMED, MEDLINE-Ovid, PsycINFO-Ovid, and Cochrane Central Register of Controlled Trials) was conducted from their inception to 05/04/2021.

RESULTS

We found nine eligible studies. Five were quantitative (4 descriptive and 1 randomised controlled trial), and four were qualitative. The available quantitative evidence suggests that fear of relapse may have concurrent positive relationships with depression (r = 0.72) and suicide ideation (r = 0.48), and negative relationship with self-esteem (r = 0.67). Qualitative synthesis suggests that fear of relapse is a complex phenomenon with behavioural and emotional components which has both direct and indirect effects on wellbeing.

CONCLUSIONS

Evidence in this area is limited and research with explicit service user and carer involvement is urgently needed to develop new and/or refine existing measurement tools, and to measure wellbeing rather than psychopathology. Nonetheless, clinicians should be aware that fear of relapse exists and appears to be positively associated with depression and suicide ideation, and negatively associated with self-esteem. Fear of relapse can include fears of losing personal autonomy and/or social/occupational functioning. It appears to impact carers as well as those diagnosed with schizophrenia.

Mirtazapine in schizophrenia - an undeservedly overlooked option?

Mirtazapine has often been prescribed as add-on treatment for schizophrenia in patients with suboptimal response to conventional treatments. In this review, we evaluate the existing evidence for efficacy and effectiveness of add-on mirtazapine in schizophrenia and reappraise the practical and theoretical aspects of mirtazapine-antipsychotic combinations. In randomized controlled trials (RCTs), mirtazapine demonstrated favourable effects on negative and cognitive (although plausibly not depressive) symptoms, with no risk of psychotic exacerbation. Mirtazapine also may have a desirable effect on antipsychotic-induced sexual dysfunction, but seems not to alleviate extrapyramidal symptoms, at least if combined with second-generation antipsychotics. It is noteworthy that all published RCTs have been underpowered and relatively short in duration. In the only large pragmatic effectiveness study that provided analyses by add-on antidepressant, only mirtazapine was associated with both decreased rate of hospital admissions and number of in-patient days. Mirtazapine hardly affects the pharmacokinetics of antipsychotics. However, possible pharmacodynamic interactions (sedation and metabolic offence) should be borne in mind. The observed desired clinical effects of mirtazapine may be due to its specific receptor-blocking properties. Alternative theoretical explanations include its possible neuroprotective effect. Further well-designed RCTs and real-world effectiveness studies are needed to determine whether add-on mirtazapine should be recommended for difficult-to-treat schizophrenia.

Beyond instrumental support: Mobile application use by family caregivers of persons living with dementia

In recent years, there has been a rapid increase in technology use in dementia caregiving, particularly the use of mobile applications (apps) which are highly accessible, cost-effective and intuitive. Yet, little is known about the experiences of family caregivers of persons living with dementia who use apps to support caregiving activities. This is of particular concern given that limited understandings of the user experience in designing technology have often led to end-users experiencing barriers in technology adoption and use. Using a qualitative descriptive approach, the purpose of the study was to explore the experiences of family caregivers of persons living with dementia on using apps in their caregiving roles. A purposive sample of five family caregivers in Ontario, Canada participated in two interviews each, with the second interview informed by photo-elicitation methods. Thematic analysis of the collected data revealed a central overarching theme, Connecting to support through apps in my, your and our lives, which explicated how apps played an important role in the lives of the caregiver, the care recipient and both together as a dyad. Three core themes also emerged: Adapting apps to meet individual needs of the dyad, Minimising the impact of the condition on the person and the family and Determining the effectiveness of apps. The findings highlighted that the value of apps extends beyond their mere functionality and their ability to help with care provision as they are also able to promote richer interpersonal connections, enhance personhood and sustain family routines. This research advances our understanding of the impact of app use in caregiving and provides direction for future research, policy, education, practice and app development.

The specific phenotype of depression in recent onset schizophrenia spectrum disorders: A symptom profile and network comparison to recent onset major depressive disorder without psychotic features

The specific phenotype of depression in recent-onset schizophrenia spectrum disorders (SSD) and its relation to non-psychotic depression is unknown. Symptom profile and network analysis are complementary statistical techniques that may provide important insights into the presentation and relative importance of individual symptoms that give rise to depression. The aim of the current study was to characterise the profile and network of depressive symptoms in SSD and compare it to individuals with major depressive disorder (MDD) without psychotic features. This study involved analysis of baseline data pertaining to 109 individuals with comorbid SSD and depression and 283 with MDD without psychotic features. Study cohorts were the Psychosis Recent Onset GRoningen Survey (PROGR-S) and Youth Depression Alleviation (YoDA) trials, respectively. Profile and network analyses revealed that SSD and MDD differed in the profile and relative importance of individual depressive symptoms. While reported sadness was the primary hallmark of depression in both SSD and MDD, individuals with depression in SSD were more likely to sleep more, and have lower lassitude and pessimism. While sadness had great importance in MDD and SSD, in SSD but not MDD lassitude, sleep, appetite, concentration difficulties, and inability to feel were important in the network of depressive symptoms. The specific phenotype of depression might be different in SSD compared to MDD. Symptom inequivalence or underlying functional mechanisms in SSD might result in depression in SSD that is similar to MDD with atypical features.

Post-Psychotic Depression: An Updated Review of the Term and Clinical Implications

BACKGROUND

Post-psychotic depression (PPD) is an important and frequent clinical phenomenon featuring controversial complexity in its nosological and aetiopathogenic cataloguing.

OBJECTIVES

The main objective of this research was to review the published literature on PPD. The second objective was to indicate its clinical importance, either comorbid or as an entity of its own. To answer these questions, a historical review of the term is made and a search about the clinical, evolutionary, predisposal, and prognostic variables that characterize the PPD.

METHODS

The international recommendations were followed according to the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses (PRISMA). The databases used were Web of Science and PubMed, with the deadline for the inclusion of articles in November 2019. The MeSH used were the following: "post" AND "psych *" AND "psich" AND "depr."

RESULTS

The search resulted in 64 articles. Only 19 of these met the pre-specified inclusion criteria and were finally included in the review. One article found that reading this literature was added due to its relevance. Despite its high prevalence (around 30%), there is little research about the term PPD. Nevertheless, results show data to improve the description of the syndrome, revealing differential characteristics from other depressive symptoms in chronic psychosis due to its clinical implications.

CONCLUSIONS

Coinciding with the latest classification manuals that do not include the term, there appears to be an abandonment of its use despite its high prevalence. Data suggest that PPD is a nosological entity different from a secondary effect to antipsychotics, the negative symptoms of psychosis, and other clinical disorders that combine psychotic and depressive symptoms such as bipolar disorder, schizoaffective disorder, or depression with psychotic symptoms. PPD also has differential characteristics concerning further depressive symptoms, especially important clinical implications such as higher suicide risk and poorer quality of life.

An early intervention for adolescent depression targeting emotional mental images and memory specificity: a process evaluation

We have evaluated a novel early intervention for adolescent depression (age 16-18) in a feasibility randomised controlled trial. This nested process evaluation aimed to understand how this complex intervention worked. We sought to understand participants' views and experiences of receiving and interacting with the intervention to evaluate whether the underpinning theoretical basis of the intervention is justified and whether it contributes to valued outcomes for participants. Twelve participants were invited to take part in semi-structured interviews. Framework analysis was employed to identify important aspects of adolescents' experiences. The active ingredients identified by participants were consistent with and extended our understanding of the theoretical basis of the intervention. Four principle themes were identified: understanding how memory works and being able to remember memories in more detail; processing negative experiences and letting go; imagining positive future events; and understanding and being kinder to myself. The outcomes of the intervention were valued by participants. Six principle themes were identified: improving mood and well-being; reducing impact of negative memories; motivation and goal-directed behaviour; overcoming avoidance and rumination; relationships, communication and being open; and self-understanding and acceptance. A simplified logic model is also proposed to connect the intervention components, active ingredients, and valued outcomes. The findings provide an in-depth understanding of how participants interacted with the intervention and what they derived from it. For example, the findings establish processing negative experiences as a core intervention component, extend it to include letting go of these memories, and highlight that reducing the impact of negative memories is valued by participants. This richer understanding guides further intervention development and future implementation.

Service user experiences of a novel in-reach rehabilitation and recovery service for people with profound and enduring mental health needs

This article provides an organizational case study using exploratory qualitative and visual research methods. We address the research question: What are the experiences of service users who use a novel in-reach rehabilitation and recovery service for people with severe and enduring mental health needs? Fifteen purposefully sampled service users were recruited from across a Service that is novel in embedding community sectors within inpatient provision. The sample reflects approximately the demographic of the Service and comprises: 10 men, 5 women; 12 white British, 3 ethnic minority; aged 18-60 years; and across inpatient care and supported community living. Photo-elicitation was used to enrich data collection through lightly structured interviews focused on the images brought by participants. Interview transcripts were analysed using interpretative phenomenological analysis. Analysis indicates that participants oriented towards four 'meta-questions': What does mental well-being mean to you? What difficulties have you encountered? What do you appreciate about the Service? What do you need for change to occur? We also identified six themes which told the story of a journey. The journey begins with challenge and moves towards making connections with others. Here, power dynamics are often experienced and addressed in the development of a greater sense of independence. This then provides opportunities for raised awareness around possibilities of recovery and a new-found hope. Our three main conclusions are all relevant to clinical practice: service users (a) place great importance on building relationships; (b) aspire to make informed choices throughout their recovery journey; and (c) desire greater transparency regarding treatment options.

Utilizing Instagram Data to Identify Usage Patterns Associated With Schizophrenia Spectrum Disorders

Background and Objectives: Prior research has successfully identified linguistic and behavioral patterns associated with schizophrenia spectrum disorders (SSD) from user generated social media activity. Few studies, however, have explored the potential for image analysis to inform psychiatric care for individuals with SSD. Given the popularity of image-based platforms, such as Instagram, investigating user generated image data could further strengthen associations between social media activity and behavioral health. Methods: We collected 11,947 Instagram posts across 68 participants (mean age = 23.6; 59% male) with schizophrenia spectrum disorders (SSD; n = 34) and healthy volunteers (HV; n = 34). We extracted image features including color composition, aspect ratio, and number of faces depicted. Additionally, we considered social connections and behavioral features. We explored differences in usage patterns between SSD and HV participants. Results: Individuals with SSD posted images with lower saturation (p = 0.033) and lower colorfulness (p = 0.005) compared to HVs, as well as images showing fewer faces on average (SSD = 1.5, HV = 2.4, p < 0.001). Further, individuals with SSD demonstrated a lower ratio of followers to following compared to HV participants (p = 0.025). Conclusion: Differences in uploaded images and user activity on Instagram were identified in individuals with SSD. These differences highlight potential digital biomarkers of SSD from Instagram data.

Application of Interpersonal and Social Rhythm Therapy (IPSRT) for Depression Associated With Schizophrenia Spectrum Disorders

People with schizophrenia spectrum disorders frequently experience depression, yet depressive symptoms are often unaddressed. The authors propose that interpersonal and social rhythm therapy (IPSRT) may be effective for individuals with these disorders who experience depression. IPSRT is a manualized, evidence-based treatment for bipolar disorders. It combines the core elements of interpersonal psychotherapy for unipolar depression with social rhythm therapy to target disrupted social rhythms. The authors highlight evidence for the potential utility of IPSRT to treat patients with schizophrenia spectrum disorders and present a case example. IPSRT is one promising therapy that could fill a treatment gap for people with schizophrenia spectrum disorders by addressing depressive symptoms. Future work should build on this rationale and case example to design and implement a randomized controlled trial of IPSRT for treatment of schizophrenia spectrum disorders and evaluate needed modifications.

Women in a situation of homelessness and violence: a single-case study using the photo-elicitation technique

Background

Violence against women places them in a vulnerable position with regard to homelessness. Although sometimes invisible, women’s homelessness is a complex reality shrouded in dramatic biographies that should be sensitively addressed to avoid revictimization.

Methods

With the aim of understanding the chaotic discourse of homeless women’s experiences of violence, a qualitative single-case study was conducted using the photo-elicitation technique. Data were analyzed in accordance with grounded theory.

Results

The participant’s discourse could be summarized in the following categories: “Living in a spiral of violence”, “Confronting vulnerability and violence”, “Being a strong woman”, “New family networks”, “Re-building mother–child relationships”, and “Nurturing spiritual wellbeing”.

Conclusions

Supporting homelessness women requires an approach that focuses on the prevention of re-victimization and the consequences of violence in terms of physical and mental health. Shelters are spaces of care for recovery and represent referential elements for the re-construction of self.

Pilot study of a group worry intervention for recent onset psychosis

Worry is common among individuals with psychosis and has been found to be a causal factor in the development of paranoia. Previous research has shown that a cognitive behavioural therapy protocol targeting worry helps to reduce persecutory delusions and associated distress in a population experiencing longstanding psychotic symptoms. However, there has yet to be a published adaptation of the protocol for individuals experiencing a recent onset of psychosis. The current study aims to examine the feasibility of adapting the worry intervention for recent onset psychosis in a group setting. Six young adults with a recent onset of psychosis, aged 18–32 years, participated in a pilot study of an 8-week group intervention covering cognitive behavioural strategies for managing worry, including worry periods, worry postponement techniques, mindfulness and relaxation, and problem solving. Pre- and post-intervention data were collected on worry, anxiety, depressive symptoms, psychotic symptoms, and perceived recovery from psychosis. In addition, qualitative feedback from group members was gathered during a post-intervention focus group. Feasibility of the group appeared promising, despite high participant attrition. All components of the intervention were successfully implemented, and group members provided positive feedback regarding acceptability of the group. Contrary to prediction, there was not a consistent decrease in worry from pre- to post-intervention. Findings from secondary symptom measures were mixed and may have been related to participants’ subjective experience of the group. Specifically, participants who experienced high levels of group cohesion seemed to benefit more from the intervention.

Key learning aims

(1)

The influence of romantic relationships on mental wellbeing for people who experience psychosis: A systematic review

PURPOSE

Whilst it is generally accepted that supportive relationships facilitate recovery from psychosis, much less is known about the role of romantic relationships in people with psychosis. This review aimed to synthesise quantitative literature regarding the impact of romantic relationships on the mental health and general wellbeing of people who experience psychosis.

METHOD

A systematic review of electronic databases (PsychINFO, PubMed, Web of Science) was carried out using search terms relating to psychosis and romantic relationships. Papers were selected for inclusion by independent reviewers. Quality assessment was completed and a narrative synthesis produced.

RESULTS

Fifty-eight studies reporting the association between romantic relationships and psychotic symptoms, depression, posttraumatic stress disorder, suicidality, quality of life, satisfaction with life and self-esteem were included. Results were mixed but indicated having a romantic partner may be associated with reduced positive and negative symptoms of psychosis, but increased depressive symptoms. Tentative explanations for these findings, such as functioning prior to onset of psychosis, social support and relationship quality are explored.

CONCLUSION

Findings highlight the importance of this often-overlooked area in clinical practice. Studies with robust design, which specifically aim to understand the relationship between romantic relationships and wellbeing for people who experience psychosis are needed.

The psychometric validity of the Montgomery-Åsberg Depression Rating Scale (MADRS) in recent onset schizophrenia spectrum disorders

Earlier recognition and accurate assessment of depressive symptoms is important to improving outcomes in individuals with recent-onset schizophrenia spectrum disorders (termed SSD hereafter)-regardless of whether positive psychotic symptoms are present or have resolved. The Montgomery-Åsberg Depression Rating Scale (MADRS) is frequently used to assess depressive symptoms in SSD, but no study has examined the psychometric validity of MADRS scores in individuals exclusively with SSD and sub-grouped by those with and without positive psychotic symptoms. This study involved baseline data from the Psychosis Recent Onset GRoningen Survey (PROGR-S). Measures used were: MADRS, depressive and negative subscales of Positive and Negative Syndrome Scale (PANSS_D, PANSS_N), and Schedules for Clinical Assessment in Neuropsychiatry (SCAN). The MADRS total score had sufficient concurrent validity with PANSS_D (evidence by ρ≥0.70), and insufficient divergent validity with PANSS_N (evidenced by ρ ≥0.30), in the full cohort and when sub-grouped by positive psychotic symptoms. In symptom networks, divergent communities comprising either MADRS or PANSS_N items were found, except the MADRS item inability to feel overlapped with PANSS_N items. The most divergent MADRS items were sadness, pessimism, and suicidal thoughts. The MADRS total score had sufficient predictive validity for determining caseness for MDD based on SCAN, but the optimal cut-off differed in those with and without positive psychotic symptoms (MADRS≥18 versus MADRS≥11). The MADRS has sufficient validity for assessing depressive symptoms in SSD. Since scores might depend upon symptoms of SSD, MADRS≥11 and the presence of sadness, pessimism, or suicidal ideation might be the best indicator of MDD in SSD.

How to Include Patients' Perspectives in the Study of the Mind: A Review of Studies on Depression

Depression has been widely studied by researchers from different fields, but its causes, and mechanism of action are still not clear. A difficulty emerges from the shifting from objective diagnosis or analysis to exploration of subjective feelings and experiences that influence the individuals' expression, communication and coping in facing depression. The integration of the experiential dimension of the first-person in studies on depression-and related methodological recommendations-are needed to improve the validity and generalizability of research findings. It will allow the development of timely and effective actions of care. Starting from providing a summary of the literature on theoretical assumptions and considerations for the study of the mind, with particular attention to the experiential dimension of patients with depression (aim #1 and #2), this contribution is aimed to provide practical suggestions for the design of research able to incorporate first- and third-person accounts (aim #3). It is also aimed to review qualified phenomenological methods for the acquisition and interpretation of experiential data in patients with depression (aim #4). Recognizing the first-person perspective in the study of depression is a major step toward a better understanding and treatment of this disorder. Theoretical constructs and technique suggestions that result from this review offer a valid starting point for the inclusion of the experiential dimension to common third-person research in the study of the mind.

The big picture of recovery: a systematic review on the evidence of photography-based methods in researching recovery from mental distress

Background: In the context of a growing body of literature on incorporating visual media in researching well-being and mental health, this systematic review examined the evidence of using photography-based research methods in exploring recovery from mental distress, their outcomes, but also limitations and challenges encountered by researchers.Methodology: Six cross-disciplinary electronic databases (CINAHL, MEDLINE, Web of Science, Scopus, PsycINFO, Arts & Humanities) were systematically searched resulting in a total of 15 qualitative and mixed-methods studies included in a thematic synthesis.Results: Photo-elicitation and photovoice were identified as the main photographic methods employed in recovery research along with less common, but nonetheless creative, techniques. Four key themes were identified through thematic analysis in photography-based recovery studies: enhanced understanding, collaboration and empowerment, situatedness, and storytelling. The results of this review revealed photography as a valuable methodological tool with potential to contribute to conceptualising recovery from the stance of research participants, but also facilitate and support their recovery processes.Conclusions: Recovery research can benefit from the use of photographic methods that are widely accessible, versatile, and interactive. They may offer mental health researchers alternative ways to explore individuals' perspective on recovery in ways that are creative, empowering, and supportive of their recovery.

Antidepressive Effect of Antipsychotics in the Treatment of Schizophrenia: Meta-Regression Analysis of Randomized Placebo-Controlled Trials

BACKGROUND

Antipsychotics improve the positive symptoms of schizophrenia. However, little is known about the extent of antidepressive effects of antipsychotics and their correlation with effects on other symptom domains in schizophrenia. The aim was to investigate whether antidepressive effects of antipsychotics have a significant correlation with the effects on specific symptom domains of schizophrenia.

METHODS

Electronic databases were searched to identify eligible studies that reported antidepressive effects of antipsychotics for the treatment of adult patients with schizophrenia in double-blind, randomized placebo-controlled trials (RCTs). Mean change from baseline in depressive symptoms was meta-analyzed, and the correlation with the effects on other symptom domains was examined through meta-regression analysis.

RESULTS

Thirty-five RCTs (13 890 patients) were included in this meta-analysis. Overall, antipsychotics showed greater efficacy than placebo in reducing depressive symptoms, with small to medium effect sizes (standardized mean difference = -0.27, 95% confidence interval -0.32 to -0.22, P < .001). All the antipsychotics, except for chlorpromazine, haloperidol, and ziprasidone, were associated with significantly greater decreases in depressive symptoms compared with placebo (standardized mean difference = -0.19 to -0.40). A higher antidepressive effect was significantly correlated with a higher improvement in Positive and Negative Syndrome Scale/Brief Psychiatric Rating Scale total, positive, and negative, and Positive and Negative Syndrome Scale-general psychopathology symptoms (β = .618, P < .001; β = .476, P < .001; β = .689, P < .001; β = .603, P < .001, respectively).

CONCLUSIONS

Second-generation antipsychotics (except for ziprasidone) were associated with small to medium effects sizes on improvement in depressive symptoms among adult patients with schizophrenia. The antidepressive effect of antipsychotics was significantly correlated with improvement in other symptom domains, with the highest correlation observed for improvement in negative symptoms.

PROSPERO REGISTRATION NUMBER

CRD42019133015.

Why Is Airline Food Always Dreadful? Analysis of Factors Influencing Passengers’ Food Wasting Behaviour

Food waste is emerging as a global issue and has been recognised in the Sustainable Development Goals with a specific target to halve per capita global food waste at consumer levels and reduce food losses by 2030. Research on food waste has been neglected particularly in the aviation sector. The International Air Transport Association reported that 5.7 million tonnes of cabin waste was generated on airlines, up to 80.5% of which was leftover food and beverages. The exploration of passengers’ food wasting aims to provide insights for tackling the airline food waste problem. To address this issue, this research investigated the in-flight catering experience of 19 passengers from 21 full-service flights. Qualitative research techniques have been applied to analyse passengers’ food-wasting behaviour by collecting participant-produced photographs and completed questionnaires concerning food-related behaviour. This research identified key factors associated with passengers’ food wasting behaviour by adopting Design for Sustainable Behaviour approaches. Four types of factors were found to influence onboard passenger waste, these were normative, habitual, intentional and situational factors. This research indicates that behavioural change interventions need to incorporate the power of social norms to prevent food waste.

Social networks, health and identity: exploring culturally embedded masculinity with the Pakistani community, West Midlands, UK

Background

Migrants from South Asia living in developed countries have an increased risk for developing cardiovascular disease (CVD), with limited research into underlying social causes.

Methods

We used social capital as an interpretive lens to undertake analysis of exploratory qualitative interviews with three generations of at-risk migrant Pakistani men from the West Midlands, UK. Perceptions of social networks, trust, and cultural norms associated with access to healthcare (support and information) were the primary area of exploration.

Results

Findings highlighted the role of social networks within religious or community spaces embedded as part of ethnic enclaves. Local Mosques and gyms remained key social spaces, where culturally specific gender differences played out within the context of a diaspora community, defined ways in which individuals navigated their social spheres and influenced members of their family and community on health and social behaviours.

Conclusions

There are generational and age-based differences in how members use locations to access and develop social support for particular lifestyle choices. The pursuit of a healthier lifestyle varies across the diverse migrant community, determined by social hierarchies and socio-cultural factors. Living close to similar others can limit exposure to novel lifestyle choices and efforts need to be made to promote wider integration between communities and variety of locations catering to health and lifestyle.

The phenomenology of auditory verbal hallucinations in emotionally unstable personality disorder and post-traumatic stress disorder

Objective:

To explore the phenomenology of auditory verbal hallucinations (AVHs) in a clinical sample of young people who have a ‘non-psychotic’ diagnosis.

Methods:

Ten participants aged 17–31 years with presentation of emotionally unstable personality disorder or post-traumatic stress disorder and frequent AVHs were recruited and participated in a qualitative study exploring their subjective experience of hearing voices. Photo-elicitation and ethnographic diaries were used to stimulate discussion in an otherwise unstructured walking interview.

Results:

‘Non-psychotic’ voices comprised auditory qualities such as volume and clarity. Participants commonly personified their voices, viewing them as distinct characters with which they could interact and form relationships. There appeared to be an intimate and unstable relationship between participant and voice, whereby voices changed according to the participants’ mood, insecurities, distress and circumstance. Equally, participants reacted to provocation by the voice, leading to changes in mood and circumstance through emotional and physical disturbances. In contrast to our previous qualitative work in psychosis, voice hearing was not experienced with a sense of imposition or control.

Conclusions:

This phenomenological research yielded in-depth and novel accounts of ‘non-psychotic’ voices which were intimately linked to emotional experience. In contrast to standard reports of voices in disorders such as schizophrenia, participants described a complex and bi-directional relationship with their voices. Many other features were in common with voice hearing in psychosis. Knowledge of the phenomenology of hallucinations in non-psychotic disorders has the potential to inform future more successful management strategies. This report gives preliminary evidence for future research.

The Psychopathology and Neuroanatomical Markers of Depression in Early Psychosis

Depression frequently occurs in first-episode psychosis (FEP) and predicts longer-term negative outcomes. It is possible that this depression is seen primarily in a distinct subgroup, which if identified could allow targeted treatments. We hypothesize that patients with recent-onset psychosis (ROP) and comorbid depression would be identifiable by symptoms and neuroanatomical features similar to those seen in recent-onset depression (ROD). Data were extracted from the multisite PRONIA study: 154 ROP patients (FEP within 3 months of treatment onset), of whom 83 were depressed (ROP+D) and 71 who were not depressed (ROP-D), 146 ROD patients, and 265 healthy controls (HC). Analyses included a (1) principal component analysis that established the similar symptom structure of depression in ROD and ROP+D, (2) supervised machine learning (ML) classification with repeated nested cross-validation based on depressive symptoms separating ROD vs ROP+D, which achieved a balanced accuracy (BAC) of 51%, and (3) neuroanatomical ML-based classification, using regions of interest generated from ROD subjects, which identified BAC of 50% (no better than chance) for separation of ROP+D vs ROP-D. We conclude that depression at a symptom level is broadly similar with or without psychosis status in recent-onset disorders; however, this is not driven by a separable depressed subgroup in FEP. Depression may be intrinsic to early stages of psychotic disorder, and thus treating depression could produce widespread benefit.

The association between insight and depressive symptoms in schizophrenia: Undirected and Bayesian network analyses

Background.

Greater levels of insight may be linked with depressive symptoms among patients with schizophrenia, however, it would be useful to characterize this association at symptom-level, in order to inform research on interventions.

Methods.

Data on depressive symptoms (Calgary Depression Scale for Schizophrenia) and insight (G12 item from the Positive and Negative Syndrome Scale) were obtained from 921 community-dwelling, clinically-stable individuals with a DSM-IV diagnosis of schizophrenia, recruited in a nationwide multicenter study. Network analysis was used to explore the most relevant connections between insight and depressive symptoms, including potential confounders in the model (neurocognitive and social-cognitive functioning, positive, negative and disorganization symptoms, extrapyramidal symptoms, hostility, internalized stigma, and perceived discrimination). Bayesian network analysis was used to estimate a directed acyclic graph (DAG) while investigating the most likely direction of the putative causal association between insight and depression.

Results.

After adjusting for confounders, better levels of insight were associated with greater self-depreciation, pathological guilt, morning depression and suicidal ideation. No difference in global network structure was detected for socioeconomic status, service engagement or illness severity. The DAG confirmed the presence of an association between greater insight and self-depreciation, suggesting the more probable causal direction was from insight to depressive symptoms.

Conclusions.

In schizophrenia, better levels of insight may cause self-depreciation and, possibly, other depressive symptoms. Person-centered and narrative psychotherapeutic approaches may be particularly fit to improve patient insight without dampening self-esteem.

Better insight seems associated with depressive symptoms in schizophrenia.

Network analyses were used to explore this association in a large sample.

Insight was associated with self-depreciation, guilt, and suicidal ideation.

Although cross-sectional, data suggest causal direction from insight to depression.

Rethinking Schizophrenia and Depression Comorbidity as One Psychiatric Disorder Entity: Evidence From Mouse Model

Schizophrenia is frequently accompanied by depressive symptoms, but the pathological mechanisms remain to be elucidated. In this study, we used chronic unpredicted mild stress plus MK801 injection to generate a mouse model of schizophrenia with depression, in which in vivo 2-photon calcium imaging and electrophysiological recordings were performed in conjunction with behavioral phenotyping. Compared to mice models with classical depression or to schizophrenia models, the animal models with schizophrenia and depression comorbidity presented worse psychotic and depressive symptoms. These behavioral deficits are associated with impaired neuronal calcium activities in the frontal cortex and thalamic nuclei. Moreover, in sharp contrast to classical models that have a satisfactory response to antipsychotic or antidepressant drugs, this novel schizophrenia with depression model is resilient to combined drug treatment in terms of behavioral and functional recovery. Taken together, these data indicate that schizophrenia with depression likely involves a unique pathophysiology that is different from schizophrenia or depression alone.

The mediating role of depression in pathways linking positive and negative symptoms in schizophrenia. A longitudinal analysis using latent variable structural equation modelling

BACKGROUND

The interaction between positive, negative and depressive symptoms experienced by people with schizophrenia is complex. We used longitudinal data to test the hypothesis that depressive symptoms mediate the links between positive and negative symptoms.

METHODS

We analyzed data from the European Schizophrenia Cohort, randomly sampled from outpatient services in France, Germany and the UK (N = 1208). Initial measures were repeated after 6 and 12 months. Depressive symptoms were identified using the Calgary Depression Scale for Schizophrenia (CDSS), while positive and negative symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Latent variable structural equation modelling was used to investigate the mediating role of depression assessed at 6 months in relation to the longitudinal association between positive symptoms at baseline and negative symptoms at 12 months.

RESULTS

We found longitudinal associations between positive symptoms at baseline and negative symptoms at 12 months, as well as between both of these and CDSS levels at 6 months. However depression did not mediate the longitudinal association between PANSS scores; all the effect was direct.

CONCLUSIONS

Our findings are incompatible with a mediating function for depression on the pathway from positive to negative symptoms, at least on this timescale. The role of depression in schizophrenic disorders remains a challenge for categorical and hierarchical diagnostic systems alike. Future research should analyze specific domains of both depressive and negative symptoms (e.g. motivational and hedonic impairments). The clinical management of negative symptoms using antidepressant treatments may need to be reconsidered.

The Lived Experience of First-Episode Psychosis: A Systematic Review and Metasynthesis of Qualitative Studies

Both research and care have focused on first episodes of psychosis (FEPs) as a way to address the issue of early stages of schizophrenia and to reduce the duration of untreated psychosis. The objective of this study was to explore specifically the lived experience of FEP from the point of view of patients and their families by applying a metasynthetic approach, including a systematic review of the literature and analyses of qualitative studies on the subject. This metasynthesis follows thematic synthesis procedures. Four databases were systematically searched for qualitative studies reporting FEP from the patient or family's perspective. Article quality was assessed with the Critical Appraisal Skills Program. Thematic analysis was used to identify key themes and synthesize them. Thirty-eight articles were included, covering data from 554 participants (378 patients and 176 relatives). Three themes emerged from the analyses: (1) When and how does a FEP start? (2) What are its negative and positive aspects? (3) How do patients and families recount FEPs? Our results found important discrepancies between the experiences of patients and those of their families, especially regarding positive aspects. In light of the confusion reported by patients and notable in our results, we also discuss the gap between the name, FEP, and the lived experience of patients and family members in order to explore its practical implications.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Depressive psychopathology in first-episode schizophrenia spectrum disorders: a systematic review, meta-analysis and meta-regression

BACKGROUND

Despite knowing for many decades that depressive psychopathology is common in first-episode schizophrenia spectrum disorders (FES), there is limited knowledge regarding the extent and nature of such psychopathology (degree of comorbidity, caseness, severity) and its demographic, clinical, functional and treatment correlates. This study aimed to determine the pooled prevalence of depressive disorder and caseness, and the pooled mean severity of depressive symptoms, as well as the demographic, illness, functional and treatment correlates of depressive psychopathology in FES.

METHODS

This systematic review, meta-analysis and meta-regression was prospectively registered (CRD42018084856) and conducted in accordance with PRISMA and MOOSE guidelines.

RESULTS

Forty studies comprising 4041 participants were included. The pooled prevalence of depressive disorder and caseness was 26.0% (seven samples, N = 855, 95% CI 22.1-30.3) and 43.9% (11 samples, N = 1312, 95% CI 30.3-58.4), respectively. The pooled mean percentage of maximum depressive symptom severity was 25.1 (38 samples, N = 3180, 95% CI 21.49-28.68). Correlates of depressive psychopathology were also found.

CONCLUSIONS

At least one-quarter of individuals with FES will experience, and therefore require treatment for, a full-threshold depressive disorder. Nearly half will experience levels of depressive symptoms that are severe enough to warrant diagnostic investigation and therefore clinical intervention - regardless of whether they actually fulfil diagnostic criteria for a depressive disorder. Depressive psychopathology is prominent in FES, manifesting not only as superimposed comorbidity, but also as an inextricable symptom domain.

Post-psychotic depression: Paranoia and the damage done

To mitigate the often chronic course of schizophrenia and improve functional outcome, researchers are increasingly interested in prodromal states and psychological risk factors that may predict the outbreak of psychotic symptoms, but are also amenable to change. In recent years, depressive symptoms have been proposed as precursors of psychosis and some interventional studies indicate that the amelioration of depressive symptoms and depression-related thinking styles (e.g., worrying) improves positive symptoms, thereby "killing two birds with one stone". Yet, in a prior study, we were unable to find a strong specific predictive role of depression on paranoia over three years, which may have been due to the use of a nonclinical sample with minimal/mild symptom fluctuations. To address this further, in the present study we adopted a similar methodological approach but assessed a large patient sample with a schizophrenia spectrum disorder at three assessment points; baseline (N = 250), 6 weeks later (n = 207, 82.8% retention) and 6 months after baseline (n = 185, 74% retention). Using cross-lagged modeling, we assessed paranoia with the respective items from the Positive and Negative Syndrome Scale (PANSS) and the Psychosis Rating Scales (PSYRATS) delusions subscale. Depression was measured using the Patient Health Questionnaire-9 (PHQ-9) and the Calgary Depression Scale for Schizophrenia (CDSS). We could identify a significant pathway from depression to paranoia from baseline to post (negative association) but not from post to follow-up. Paranoia significantly predicted depressive symptoms for both intervals. Our findings do not refute claims that depression may precede or even predict psychosis, but such a linkage does not seem to be ubiquitous.

Predictors of treatment satisfaction in antipsychotic-naïve and previously medicated patients with acute-phase psychosis

Background: Treatment satisfaction predicts treatment adherence and long-term outcome for patients with psychosis. It is therefore important to understand the underpinnings of patient satisfaction in psychosis treatment for optimal treatment delivery. Aims: To examine the associations between satisfaction and level and change in positive symptoms, insight, depression and side effects of antipsychotics in previously medicated and antipsychotic-naïve patients. Method: Data derive from a randomised trial, with 226 respondents at baseline and 104 at follow-up. The measures were the positive subscale and insight item from the Positive and Negative Syndrome Scale, Calgary Depression Scale, the UKU Consumer Satisfaction Rating Scale, and the UKU side effects scale. Structural equation modelling was used to test the model. The full information maximum likelihood estimator used all available data. Results: In the sample of 226 patients, 67.3% were male and 44.2% were antipsychotic-naïve. The mean age was 34.1 years. For previously medicated patients, satisfaction was predicted by level of insight (b = -2.21, β = -0.42) and reduction in positive symptoms (b = -0.56, β = -0.39). For antipsychotic-naïve patients, satisfaction was predicted by level and change of insight (b = -2.21, β = -0.46), change in depression (b = -0.37, β = -0.26) and side effects (b = -0.15, β = -0.30). All predictors were significant at the 0.05 level. Conclusion: Reducing positive symptoms and side effects are important to enhance patient satisfaction. However, improving insight and reducing depression are more important in antipsychotic-naïve patients.

Does Depressive-Type Schizophrenia Exist? How Do We Prove It?: An Updated Review and Overview

Depressive symptoms can occur at any point in the duration of schizophrenia. However, we are unable to predict if or when depression will occur in schizophrenic patients. Simultaneously, the standard treatment of depression in schizophrenic patients is the combination of antidepressants and antipsychotics, which has been minimally effective for most patients. Based on several studies, we hypothesized the existence of depressive-type schizophrenia and reviewed the substantial evidence supporting the hypothesis of depressive-type schizophrenia. Simultaneously, we propose technical methods to explore the neuropathology of depressive-type schizophrenia in order to identify the disease during its early stages and to predict how patients will respond to the standard treatment strategies. We believe that the new classification of depressive-type schizophrenia will differentiate it from other forms of depression. In return, this will aid in the discovery of new therapeutic strategies for combatting this disease.

The relationship between negative symptoms and depression in schizophrenia: a systematic review

OBJECTIVE

To provide an update on the evidence base for the nature of the relationship between negative symptoms and depressive features in people with schizophrenia, and propose new models that reflect their complex relationship.

METHOD

A systematic review following PRISMA guidelines. A total of 2210 articles were identified from EMBASE, PsychInfo and MEDLINE, and further two articles were hand-searched from references. Twenty-seven met inclusion criteria and were included in the review.

RESULTS

In schizophrenia, primary evidence suggests symptoms of low mood, suicidal ideation and pessimism have more specificity for depression whereas alogia and blunted affect may have more specificity as negative symptoms. Anhedonia, anergia and avolition may be common to both.

CONCLUSION

It may be possible to further distinguish depressive features from negative symptoms in schizophrenia when detailed phenomenology is considered. However, in a proposed dimensional model, these two domains continue to share certain phenomena, highlighting their close relationship.

Treatment of depression in schizophrenia: systematic review and meta-analysis

BackgroundDepression in schizophrenia predicts poor outcomes, including suicide, yet the effectiveness of antidepressants for its treatment remains uncertain.AimsTo synthesise the evidence of the effectiveness of antidepressants for the treatment of depression in schizophrenia.MethodMultiple databases were searched and inclusion criteria included participants aged over 18 years with schizophrenia or related psychosis with a depressive episode. Papers were quality assessed used the Cochrane risk bias tool. Meta-analyses were performed for risk difference and standardised mean difference of all antidepressants, antidepressant class and individual antidepressant where sufficient studies allowed.ResultsA total of 26 moderate- to low-quality trials met inclusion criteria. In meta-analysis a significant risk difference was found in favour of antidepressant treatment, with a number needed to treat of 5 (95% CI 4-9). Studies using tools specifically designed to assess depression in schizophrenia showed a larger effect size. However, after sensitivity analysis standardised mean difference of all antidepressants did not show a statistically significant improvement in depression score at end-point, neither did any individual antidepressant class.ConclusionsAntidepressants may be effective for the treatment of depression in schizophrenia, however, the evidence is mixed and conclusions must be qualified by the small number of low- or moderate-quality studies. Further sufficiently powered, high-quality studies are needed.

Photoelicitation: a useful tool to investigate management of the vulnerability of homeless women

AIMS

The proposal of the manuscript is to provide a methodological reflection on the use of photo-elicitation as a data gathering strategy to explore vulnerability management among homeless women.

METHODS

A grounded theory study was carried out. Photo elicitation was one of the data gathering techniques used between February 2015 and February 2017. Five women were selected through intentional sampling. All of them were over 18 years old and residents in 4 shelters within the Madrid Care for the Homeless network. Participants used disposable cameras or mobile phones to record their experiences living in the shelters or on the street through photographs. An interview was conducted with each participant in order to explore the meaning of the photos after they were developed. Data analysis comprised, firstly, describing the obvious content of the photos and, secondly, comparing it with the latent content provided by participants during the interviews.

RESULTS

Only 3 women finished the task. Through data analysis some theoretical proposals were discovered, which contributed to a deeper knowledge of some previously established categories and subcategories such as: "The good professionals", "The safe places in the street" and "The threats in the street".

CONCLUSIONS

Photo-elicitation enabled an approach to participants' experiences with minimal imposition, allowing them much of the control over the data production. However, it is a demanding technique that requires deep reflection before its implementation, on the part of both participants and researchers.

Depression and Schizophrenia: Cause, Consequence, or Trans-diagnostic Issue?

The presence of depression in schizophrenia has been a challenge to the Kraepelinian dichotomy, with various attempts to save the fundamental distinction including evoking and refining diagnoses such as schizoaffective disorder. But the tectonic plates are shifting. Here we put forward a summary of recent evidence regarding the prevalence, importance, possible aetiological pathways and treatment challenges that recognizing depression in schizophrenia bring. Taken together we propose that depression is more than comorbidity and that increased effective therapeutic attention to mood symptoms will be needed to improve outcomes and to support prevention.

The "Insight Paradox" in Schizophrenia: Magnitude, Moderators and Mediators of the Association Between Insight and Depression

The so-called "insight paradox" posits that among patients with schizophrenia higher levels of insight are associated with increased levels of depression. Although different studies examined this issue, only few took in account potential confounders or factors that could influence this association. In a sample of clinically stable patients with schizophrenia, insight and depression were evaluated using the Scale to assess Unawareness of Mental Disorder and the Calgary Depression Scale for Schizophrenia. Other rating scales were used to assess the severity of psychotic symptoms, extrapyramidal symptoms, hopelessness, internalized stigma, self-esteem, and service engagement. Regression models were used to estimate the magnitude of the association between insight and depression while accounting for the role of confounders. Putative psychological and sociodemographic factors that could act as mediators and moderators were examined using the PROCESS macro. By accounting for the role of confounding factors, the strength of the association between insight into symptoms and depression increased from 13% to 25% explained covariance. Patients with lower socioeconomic status (F = 8.5, P = .04), more severe illness (F = 4.8, P = .03) and lower levels of service engagement (F = 4.7, P = .03) displayed the strongest association between insight and depression. Lastly, hopelessness, internalized stigma and perceived discrimination acted as significant mediators. The relationship between insight and depression should be considered a well established phenomenon among patients with schizophrenia: it seems stronger than previously reported especially among patients with lower socioeconomic status, severe illness and poor engagement with services. These findings may have relevant implications for the promotion of insight among patients with schizophrenia.

Metaphors of Distress: Photo-Elicitation Enhances a Discourse Analysis of Parents' Accounts

In research on sensitive topics, photo-elicitation can be a profound aid to data collection and interpretation processes. Photo-elicitation methods were used in this manner in a discourse analysis of parents' distress at least 6 months after preterm birth. After an initial interview, participants were asked to take digital photographs representing their distress and to return for a second interview to discuss the photographs. The elicited photo representations supported participants' engagement with their current or past distress and generated new meanings from the reappraisal of old photographs. Photo-elicitation demonstrated the embodiment of parents' distress in the child and the placement of distress in specific locations. Photographs of documents showed the power of the written word in generating and maintaining distress. Participants used existing photographs from their child's photo history to generate rich metaphors for their distress as parents. These findings have implications for enhancing interpretive health research by incorporating photo-elicitation methods.

Auditory verbal hallucinations in first-episode psychosis: a phenomenological investigation

BACKGROUND

In dimensional understanding of psychosis, auditory verbal hallucinations (AVH) are unitary phenomena present on a continuum from non-clinical voice hearing to severe mental illness. There is mixed evidence for this approach and a relative absence of research into subjective experience of AVH in early psychosis.

AIMS

To conduct primary research into the nature of subjective experience of AVH in first-episode psychosis.

METHOD

A phenomenological study using diary and photo-elicitation qualitative techniques investigating the subjective experience of AVH in 25 young people with first-episode psychosis.

RESULTS

AVH are characterised by: (a) entity, as though from a living being with complex social interchange; and (b) control, exerting authority with ability to influence. AVH are also received with passivity, often accompanied by sensation in other modalities.

CONCLUSIONS

A modern detailed phenomenological investigation, without presupposition, gives results that echo known descriptive psychopathology. However, novel findings also emerge that may be features of AVH in psychosis not currently captured with standardised measures.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Subjective distress in a representative sample of outpatients with psychotic disorders

BACKGROUND

The affective burden of psychotic disorder has been increasingly recognised. However, subjective reports of distress and its covariates, especially those related to service use, remain under-investigated in patients with psychosis.

METHODS

This study investigated subjective distress and its covariates in a representative sample of 401 outpatients with a confirmed diagnosis of psychotic disorders in Brazil. Distress was assessed using the corresponding domain of a standardised measure of need - the Camberwell Assessment of Need.

RESULTS

Distress was reported as a need by 165 (41%) patients, being met in 78 (20%) and unmet in 87 (22%). Hierarchical logistic regression showed that the presence of distress as a need was predicted by attendance at psychotherapy (OR=3.49, CI=1.62-7.53), presence of suicidal ideation (OR=2.89, CI=1.75-4.79), non-attendance at psychosocial rehabilitation (OR=2.84, CI=1.31-6.19), and higher psychopathology (OR=1.09, CI=1.06-1.12). An unmet need was predicted by family not accompanying patients to treatment (OR=2.60, CI=1.05-6.44) and higher psychopathology (OR=1.05, CI=1.02-1.09).

LIMITATION

The use of a cross-sectional design and a single questionnaire domain to evaluate distress are the main limitations.

CONCLUSIONS

Subjective distress is a common unmet need in psychosis, and can be treated. The main clinical implication is that subjective distress in psychosis may be impacted on by family engagement and psychosocial interventions.

Is good insight associated with depression among patients with schizophrenia? Systematic review and meta-analysis

Among patients with schizophrenia, better insight may be associated with depression, but the findings on this issue are mixed. We examined the association between insight and depression in schizophrenia by conducting a systematic review and meta-analysis. The meta-analysis was based on 59 correlational studies and showed that global clinical insight was associated weakly, but significantly with depression (effect size r=0.14), as were the insight into the mental disorder (r=0.14), insight into symptoms (r=0.14), and symptoms' attributions (r=0.17). Conversely, neither insight into the social consequences of the disorder nor into the need for treatment was associated with symptoms of depression. Better cognitive insight was significantly associated with higher levels of depression. The exploratory meta-regression showed that methodological factors (e.g. the instrument used to assess depression and the phase of the illness) can significantly influence the magnitude of the association between insight and depression. Moreover, results from longitudinal studies suggest that the relation between insight and depression might be stronger than what is observed at the cross-sectional level. Finally, internalized stigma, illness perception, recovery attitudes, ruminative style, and premorbid adjustment seem to be relevant moderators and/or mediators of the association between insight and depression. In conclusion, literature indicates that among patients with schizophrenia, better insight is associated with higher levels of depressive symptoms. Thus, interventions aimed at promoting patients' insight should take into account the clinical implications of these findings.

The 4th Schizophrenia International Research Society Conference, 5-9 April 2014, Florence, Italy: a summary of topics and trends

The 4th Schizophrenia International Research Society Conference was held in Florence, Italy, April 5-9, 2014 and this year had as its emphasis, "Fostering Collaboration in Schizophrenia Research". Student travel awardees served as rapporteurs for each oral session, summarized the important contributions of each session and then each report was integrated into a final summary of data discussed at the entire conference by topic. It is hoped that by combining data from different presentations, patterns of interest will emerge and thus lead to new progress for the future. In addition, the following report provides an overview of the conference for those who were present, but could not participate in all sessions, and those who did not have the opportunity to attend, but who would be interested in an update on current investigations ongoing in the field of schizophrenia research.

Depression in first episode psychosis: the role of subordination and shame

Depression in early psychosis is linked to poor outcome, relapse and risk of suicide, yet remains poorly understood. This article aims to examine the development of depression in acute and post psychotic phases of first episode psychosis (FEP), and its relationship to persecutors, voices, insight, and recovery. Data were gathered on 92 patients with acute FEP on depression course, severity and experience of positive symptoms, insight and appraisals of illness using validated semi-structured interviews and questionnaires. Measures were repeated at 12 months. Malevolent voices, use of safety behaviours and subordination to persecutors were associated with depression and suicidal behaviour in acute FEP. Loss, Shame, low level continuing positive symptoms and longer duration of untreated psychosis were associated with post psychotic depression. Negative appraisals remained stable despite recovery in other symptom domains. Thus, depression and risk in early psychosis may be propagated by the personal significance and content of positive symptoms experienced. When in recovery, low level symptoms, longer period of illness and negative appraisals are significant factors.