The psychological impact of psychiatric admission: some preliminary findings

A systematic review of evidence-based aftercare for older adults following self-harm

OBJECTIVE

Self-harm is closely associated with suicide in older adults and may provide opportunity to intervene to prevent suicide. This study aimed to systematically review recent evidence for three components of aftercare for older adults: (1) referral pathways, (2) assessment tools and safety planning approaches and (3) engagement and intervention strategies.

METHODS

Databases PubMed, Medline, PsychINFO, Embase and CINAHL were searched from January 2010 to 10 July 2021 by two reviewers. Empirical studies reporting aftercare interventions for older adults (aged 60+) following self-harm (including with suicidal intent) were included. Full text of articles with abstracts meeting inclusion criteria were obtained and independently reviewed by three authors to determine final studies for review. Two reviewers extracted data and assessed level of evidence (Oxford) and quality ratings (Alberta Heritage Foundation for Medical Research Standard Quality Assessment Criteria for quantitative and Attree and Milton checklist for qualitative studies), working independently.

RESULTS

Twenty studies were reviewed (15 quantitative; 5 qualitative). Levels of evidence were low (3, 4), and quality ratings of quantitative studies variable, although qualitative studies rated highly. Most studies of referral pathways were observational and demonstrated marked variation with no clear guidelines or imperatives for community psychiatric follow-up. Of four screening tools evaluated, three were suicide-specific and one screened for depression. An evidence-informed approach to safety planning was described using cases. Strategies for aftercare engagement and intervention included two multifaceted approaches, psychotherapy and qualitative insights from older people who self-harmed, carers and clinicians. The qualitative studies identified targets for improved aftercare engagement, focused on individual context, experiences and needs.

CONCLUSION

Dedicated older-adult aftercare interventions with a multifaceted, assertive follow-up approach accompanied by systemic change show promise but require further evaluation. Research is needed to explore the utility of needs assessment compared to screening and evaluate efficacy of safety planning and psychotherapeutic approaches.

Psychiatric admission as a risk factor for posttraumatic stress disorder

Psychiatric hospitalization poses a risk for Posttraumatic Stress Disorder (PTSD), partly because of coercion. However, the role of legal status is less clear, while factors like insight, exposure to violence and affective disorders have not been addressed adequately. The present study aims at assessing PTSD rates after hospitalization and evaluating the potential role of these factors. 98 inpatients were assessed for PTSD, insight, main diagnosis, adverse events during hospitalization and legal status. Assessment took place at discharge (T1) and three months later (T2). Three months after discharge, 74.2% of patients with affective disorders met symptom-criteria for PTSD. Voluntarily hospitalized patients had more severe PTSD-symptoms. This relation vanished after controlling for affective disorders. The latter, as well as exposure to violence were the most significant risk factors at T2. Female gender, marital status (not married) and employment status (not employed), were additional risk factors at T1, while involuntary medication had a negative effect on PTSD-symptoms. Voluntarily hospitalized patients are more vulnerable to PTSD, due to higher rates of affective disorders. Females suffering from affective disorders who are not married and not employed should be monitored for PTSD symptoms during and after hospitalization, especially if exposed to violence.

Effectiveness of suicide prevention interventions: A systematic review and meta-analysis

OBJECTIVE

This study provides an estimate of the effect size of suicide prevention interventions and evaluates the possible synergistic effects of multilevel interventions.

METHOD

A systematic review and meta-analysis were conducted of controlled studies evaluating suicide prevention interventions versus control published between 2011 and 2017 in PubMed, PsycINFO, and Cochrane databases. Data extraction and risk of bias assessment according to ROBINS criteria were performed by independent assessors. Cohen's delta was calculated by a random meta-analysis on completed and attempted suicides as outcomes. Meta-regression explored a possible synergistic effect in multilevel interventions. PROSPERO ID number: CRD42018094373.

RESULTS

The search yielded 16 controlled studies with a total of 252,932 participants. The meta-analysis was performed in 15 studies with 29,071 participants. A significant effect was found for suicide prevention interventions on completed suicides (d = -0.535, 95% CI -0.898; -0.171, p = .004) and on suicide attempts (d = -0.449, 95% CI -0.618; -0.280, p < .001). Regarding the synergistic effect of multilevel interventions, meta-regression showed a significantly higher effect related to the number of levels of the intervention (p = .032).

CONCLUSIONS

Suicide prevention interventions are effective in preventing completed and attempted suicides and should be widely implemented. Further research should focus on multilevel interventions due to their greater effects and synergistic potential. Further research is also needed into risk appraisal for completed versus attempted suicide, as the preferred intervention strategy differs with regard to both outcomes.

The experiences of inpatient nursing staff caring for young people with early psychosis

BACKGROUND

Early intervention services aim to improve outcomes for people with first episode psychosis and, where possible, to prevent psychiatric hospital admission. When hospitalisation does occur, inpatient staff are required to support patients and families who may be less familiar with services, uncertain about possible outcomes, and may be experiencing a psychiatric hospital for the first time.

AIMS

Our study aimed to understand the process of hospitalisation in early psychosis, from the perspective of inpatient nursing staff. We were particularly interested in their experiences of working with younger people in the context of adult psychiatric wards.

METHODS

Nine inpatient nursing staff took part in semi-structured interviews, which were transcribed and then analysed using interpretative phenomenological analysis.

RESULTS

Five themes are outlined: 'it's all new and it's all learning'; the threatening, unpredictable environment; care and conflict within the intergenerational relationship; motivation and hope; and coping and self-preservation.

CONCLUSIONS

The phenomenological focus of our approach throws the relational component of psychiatric nursing into sharp relief. We reflect on the implications for organisations, staff, families and young people. We suggest that the conventional mode of delivering acute psychiatric inpatient care is not likely to support the best relational and therapeutic outcomes.

Our Sunshine place: A collective narrative and reflection on the experiences of a mental health crisis leading to an admission to a psychiatric inpatient unit

Acute mental health inpatient units are complex environments where tensions between clinical and personal recovery can be amplified. The focus for mental health staff is often centred on providing clinical care, whereas from the patient perspective, the admission can represent a profound existential crisis. There are very few user-led accounts of their experiences of psychiatric inpatient unit. This project was developed in the traditions of Analytic Auto-Ethnography, a research methodology which provides a systematic process to reflect on our own experience while still producing trustworthy findings. Through this process, a collective narrative and critical reflection of a group of over 20 individuals with experiences of either providing or receiving care in an acute psychiatric inpatient unit was developed. The narrative developed shows that for some the hospital admission was a time of healing; for others, the inpatient unit represented an alien and unsafe environment, which accentuated the strangeness of the experiences of mental ill health. Common themes among the group were that of an overarching need to make sense of what happened leading up to the admissions and to come to terms with the potential impact of the illness on identity and future. This journey can be best described as a process of healing and moving towards 'wholeness'. Safety, connection, autonomy and control were identified as factors which either facilitated or hindered the process of successfully integrating the various experiences.

Relationship between attachment style and symptom severity across the psychosis spectrum: A meta-analysis

There is growing evidence for the role of attachment in psychosis, however, to date there has been no quantitative review of the prevalence of insecure attachment in psychosis. The current study sought to systematically appraise studies investigating the prevalence of insecure attachment and the association with psychosis-spectrum experiences using meta-analytic techniques. A systematic search of studies carried out between January 1980 and 30th November 2015 found 25 papers eligible for inclusion. The meta-analysis showed that the prevalence of insecure attachment style was significantly higher in individuals with psychosis (76%) than in non-clinical samples (38%), with fearful attachment being the most prevalent. Across the continuum, there was a small but significant relationship between positive symptom severity and insecure attachment and a significant relationship between negative symptom severity and insecure attachment in the non-clinical analysis. This relationship was not found in the clinical group. The prevalence of insecure attachment appears to be high in psychosis, however, the relationship between symptom severity and attachment is small. Attachment theory may provide greater understanding of the development of positive symptoms than previously thought, however, research needs to include more at-risk samples and longitudinal research to fully understand the dynamics of this relationship.

Posttraumatic Reactions to Psychosis: A Qualitative Analysis

The current study aimed to evaluate the potentially traumatic aspects of psychotic symptoms and psychiatric treatment of psychosis using qualitative methods. Participants included 63 people with first episode psychosis or multiple psychotic episodes recruited from an inpatient psychiatric unit and an urban state psychiatric hospital in the North East region of the United States. Quasi-structured interviews were used to explore those aspects of symptoms and treatment that were perceived as traumatic Emotional reactions to the most traumatic aspect of symptoms and treatment, during and after the event, were also examined. Participants described a number of traumatogenic aspects of psychotic symptoms, including frightening hallucinations; suicidal thought/attempts, thoughts/attempts to hurt others; paranoia/delusions and bizarre/disorganized behavior or catatonia. Traumatic aspects of psychosis elicited emotions including anger, sadness and confusion, anxiety, and numbness at the time of event. Furthermore, many participants found aspects of treatment to be traumatic, including: being forced to stay in the hospital for a long time; experiencing upsetting side-effects; coercive treatments, including involuntary hospitalization, use of restraints, and forced medication; being exposed to aggressive patients; and mistreatment by professionals. These experiences elicited emotions of anger, sadness, distrust, and a sense of helplessness. Study findings suggest that the experiences both of psychotic symptoms and psychiatric treatment, potentially traumatic, can be a powerful barrier to engaging people in mental health services and facilitating recovery. Clinical implications were discussed.

Exploring compulsory admission experiences of adults with psychosis in the UK using Grounded Theory

BACKGROUND

There is a paucity of research into the experience of compulsory admissions under the Mental Health Act (MHA) 1983/2007, particularly for adults with psychosis, yet this diagnostic group reportedly account for the largest proportion of compulsory admissions.

AIMS

This UK-based study's objective was to explore the compulsory admission experiences (under the MHA 1983/2007) of service users with psychosis, and to identify key characteristics of these experiences.

DESIGN

The qualitative method "Grounded Theory" (Glaser & Strauss, 1967) was employed as it worked inductively from the data. Seventeen participants (eight service users with psychosis, nine psychiatrists) were interviewed.

RESULTS

Five higher-order categories and 47 categories were identified and are displayed in a model entitled "A disturbing journey to and from detention".

CONCLUSION

This small-scale qualitative study achieved its objectives, exploring compulsory admission experiences (under the MHA 1983/2007) of service users with psychosis in England, and identified key characteristics of these experiences. Service and clinical implications are highlighted, with scope for further research.

On the Brink of Genuinely Collaborative Care: Experience-Based Co-Design in Mental Health

Inpatient mental health services in the United Kingdom are currently dissatisfactory for service-users and staff. For young people with psychosis, being hospitalized is often distressing, and can lead to disengagement with mental health services. This article describes how we took three qualitative research studies about hospitalization in early psychosis (exploring the perspectives of service-users, parents, and staff) and translated them into service improvements developed in collaboration with a range of stakeholders, including service-users, carers, community and inpatient staff, and management. We used an adapted form of experience-based co-design (EBCD), a participatory action-research method for collaboratively improving health care services. The use of EBCD is still relatively novel in mental health settings, and we discuss how we adapted the methodology, and some of the implications of using EBCD with vulnerable populations in complex services. We reflect on both the disappointments and successes and give some recommendations for future research and methodological development.

A qualitative investigation into the relationships between social factors and suicidal thoughts and acts experienced by people with a bipolar disorder diagnosis

BACKGROUND

The prevalence rate of completed suicide in bipolar disorder is estimated to be as high as 19%. Social factors or influences, such as stigmatisation and family conflict, contribute to the development of suicidal ideation in clinical and non-clinical populations. Yet, there is a lack of studies examining suicidality from a psychosocial perspective in people who experience bipolar disorder.

METHOD

Semi-structured interviews were used to collect qualitative data from 20 participants with bipolar disorder. The interview focused on the effects of social factors upon participants׳ experiences of suicidality (suicidal thoughts, feelings or behaviours). A thematic analysis was used to understand the data.

RESULTS

Social or interpersonal factors which participants identified as protective against suicidality included, 'the impact of suicide on others' and, 'reflecting on positive social experiences'. Social factors which triggered suicidal thoughts included, 'negative social experiences' and, 'not being understood or acknowledged'. Social factors which worsened suicidal thoughts or facilitated suicidal behaviour were, 'feeling burdensome,' and 'reinforcing negative self-appraisals'.

LIMITATIONS

Some participants had not experienced suicidal thoughts for many years and were recalling experiences which had taken place over ten years ago. The accuracy and reliability of these memories must therefore be taken into consideration when interpreting the results.

CONCLUSIONS

The themes help to enhance current understanding of the ways in which social factors affect suicidality in people who experience bipolar disorder. These results highlight the importance of considering the social context in which suicidality is experienced and incorporating strategies to buffer against the effects of negative social experiences in psychological interventions which target suicide risk in bipolar disorder.

The experiential impact of hospitalisation in early psychosis: service-user accounts of inpatient environments

Early Intervention in Psychosis services aim to keep young people out of hospital, but this is not always possible. This research used in-depth interviews to explore the experience of hospitalisation amongst young people with psychosis. Findings describe fear and confusion at admission, conflicting experiences of the inpatient unit as both safe and containing, and unsafe and chaotic, and the difficult process of maintaining identity in light of the admission. We discuss the need to move from construing psychiatric hospitals as places for 'passive seclusion', to developing more permeable and welcoming environments that can play an active role in recovery.

Perceived stops to suicidal thoughts, plans, and actions in persons experiencing psychosis

BACKGROUND

Suicide has been conceived as involving a continuum, whereby suicidal plans and acts emerge from thoughts about suicide. Suicide prevention strategies need to determine whether different responses are needed at these points on the continuum.

AIMS

This study investigates factors that were perceived to counter suicidal ideation, plans, and acts.

METHOD

The 36 participants, all of whom had had experiences of psychosis and some level of suicidality, were presented with a vignette describing a protagonist with psychotic symptoms. They were asked to indicate what would counter the suicidal thoughts, plans, and acts of the protagonist described in the vignette. Qualitative techniques were first used to code these free responses into themes/categories. Correspondence analysis was then applied to the frequency of responses in each of these categories.

RESULTS

Social support was identified as a strong counter to suicidal ideation but not as a counter to suicidal plans or acts. Help from health professionals was strongly related to the cessation of suicidal plans as were the opinions of the protagonist's children. Changing cognitions and strengthening psychological resources were more weakly associated with the cessation of suicidal ideation and plans. The protagonist's children were considered potentially helpful in addressing suicidal acts.

CONCLUSION

These results suggest that both overlapping and nonoverlapping factors need to be considered in understanding suicide prevention, dependent on whether individuals are thinking about, planning, or attempting suicide.

Distress, trauma, and recovery: adjustment to first episode psychosis

OBJECTIVE

To understand the experiences that people with early psychosis are adjusting to and their perceived barriers to recovery.

METHOD

Semi-structured interviews were conducted with eight participants. Grounded Theory was applied to the design and analysis. Sampling and coding ceased when saturation of the data was reached. Respondent validation was sought from participants.

RESULTS

A theoretical model was developed using Strauss and Corbin's (1998) framework. A core category of distress was elicited, which was evident in all participants' accounts of their recovery. Overall six main categories were identified and it was proposed that individuals were adjusting to the distress of past experiences, uncertainty, a challenged identity, being in a psychiatric system, the reaction of others and social disadvantage.

CONCLUSIONS

Recovery from the distress and trauma of early psychosis does not simply involve adjustment to and recovery from a single experience or set of symptoms. The results are discussed in relation to trauma, developmental, and social inequality frameworks. Specific implications for clinical practice include incorporating the findings within formulations, developing interventions that focus on trauma, identity, and uncertainty as well as addressing the social and systemic issues identified.

Attachment styles and affect regulation among outpatients with schizophrenia: relationships to symptomatology and emotional distress

OBJECTIVES

Using the model of activation and dynamics of the attachment system (Shaver & Mikulincer, 2002) and dynamic stress-vulnerability models of psychosis (Ingmar & Luxton, 2005) as the analytical frameworks, the authors tested the hypothesis that the insecure attachment styles are differentially associated with the severity of psychopathological symptoms and emotional distress among outpatients with International Classification of Diseases, Tenth edition (ICD-10) diagnosis of schizophrenia.

METHODS

 Attachment styles were identified using the Relationship Questionnaire (Bartholomew & Horowitz, 1991) among 100 outpatients with an ICD-10 schizophrenia diagnosis. Current symptom severity was measured by the Positive and Negative Syndromes Scale (Kay, Fiszbein, & Opler, 1987) and emotional distress by the General Health Questionnaire (Goldberg & Williams, 1988). Univariate and multivariate analyses were performed to test the hypotheses.

RESULTS

 The preoccupied and fearful-avoidant attachment patterns were associated with higher scores of psychotic (delusions, suspiciousness/persecution, and hallucinatory behaviour) and affective (anxiety, tension, guilt feeling, and depression) symptoms, whereas the dismissing-avoidant style was associated with only anxiety. All the insecure attachment styles were associated with elevated emotional distress.

CONCLUSIONS

The findings support the hypothesis of a predisposing role of the preoccupied and fearful-avoidant styles in psychotic symptom formation and call for cognitive interpersonal interventions geared to reduce symptom and emotional distress severity.

PTSD symptoms associated with the experiences of psychosis and hospitalisation: a review of the literature

There is evidence of high rates of PTSD in people with psychosis, but the influence that symptoms or hospitalisation have on PTSD in individuals with psychosis is less clear. This paper reviewed studies investigating the prevalence of PTSD induced as a result of the experience of psychosis and hospitalisation and factors that might influence its development. The review included 24 studies, published between 1980 and 2011. Studies showed high levels of PTSD resulting from the trauma of symptoms and/or hospitalisation, with prevalence rates for actual PTSD resulting from these traumas varying from 11% to 67%. In line with studies of PTSD related to other traumatic events, there were inconsistent associations between PTSD and severity of positive and negative symptoms, but there were consistent associations between affective symptoms and PTSD. There were also inconsistent associations between hospital experiences and PTSD. Consistent with the general PTSD literature, there was some evidence that psychosis-related PTSD was associated with trauma history. There was also some emerging evidence that psychological variables, such as appraisals and coping style may influence psychosis-related PTSD. The review highlights the need for further research into psychological mechanisms that could increase vulnerability to psychosis-related PTSD and treatment approaches.

Prevalence of suicide risk factors in people at ultra-high risk of developing psychosis: a service audit

BACKGROUND

Little data is available on the prevalence of suicide risk factors in people at ultra-high risk (UHR) of developing psychosis.

AIM

The aim of this study was to provide an estimate of the cross-sectional prevalence of possible suicide risk factors in those attending a routine clinical service for people at UHR of developing psychosis.

METHODS

For all patients in treatment (n=34) over a 4-week period, levels of suicidal ideation and depression upon entry to the service were assessed by auditing intake scores on the Beck Depression Inventory, second edition. Level of engagement with services, social isolation, substance and alcohol misuse, ready access to means, current suicidal ideation, previous suicide attempts, current or previous self-harm, expressions of concern from others, depression, agitation, hopelessness, worthlessness, suspiciousness and fears of mental disintegration were all assessed by case note review and interview with the treating clinician.

RESULTS

There was a high prevalence of at least mild suicidal ideation (58.8%, n=20) and severe depressed mood (47%, n=16) in this client group at point of entry to the service. Seven people (20.6%) had engaged in serious self-harm (including attempted suicide) during the time they were in contact with the service. Forty-seven per cent (n=16) reported at least 27 suicide attempts between them; the mean number of attempts being 1.69 (standard deviation=1.08).

CONCLUSION

Suicide risk was high in this small sample of people at UHR of developing psychosis. Controlled research with larger samples and better methodology is urgently required to inform legal, ethical and scientific debates surrounding this group.

Post-traumatic reactions to psychosis in people with multiple psychotic episodes

Psychotic symptoms, coercive interventions, and other negative treatment experiences have been found to lead to posttraumatic stress disorder (PTSD) symptoms. However, prior research has not examined the importance of the DSM-IV A1 (perception of threat) and A2 (negative emotion at time of event) criteria for a traumatic event due to a psychotic episode. To address this question, 50 clients with a history of multiple episodes of psychosis were interviewed to identify distressing experiences related to past episodes, with PTSD assessed (including A1/A2 criteria) related to those events, and other psychiatric symptoms, psychosocial functioning, and coping style. Participants reported intense distress related to psychotic symptoms (66%), treatment experiences (25%), and their combination (8%), with 69% meeting symptom criteria for PTSD (excluding A1/A2 criteria), and 31% meeting full diagnostic criteria for PTSD (including A1/A2 criteria). Clients meeting symptom criteria for PTSD, as well as those meeting full diagnostic criteria for PTSD were similar, with both groups reporting more severe symptoms and distress, and more problems in daily functioning, than clients with fewer or no PTSD symptoms. The results are similar to a previous study of PTSD in persons with recent onset of psychosis (Mueser et al., 2010), and suggest that individuals with PTSD symptoms related to psychosis and coercive treatment may benefit from interventions designed to help them integrate their experiences into their lives and reduce PTSD symptoms, regardless of whether the triggering event(s) meet DSM-IV A1/A2 criteria for a traumatic event.

Identifying potential predictors of traumatic reactions to psychotic episodes

OBJECTIVES

The experience of a psychotic episode can sometimes lead to post-traumatic stress disorder (PTSD) symptoms. The objective of the research was to identify candidate predictors of such negative reactions for future prospective study. We examined six predictors identified from the PTSD and psychosis literatures in a retrospective study: a history of previous trauma, a history of previous episodes of psychosis, perceived helplessness and uncontrollability at the time of the index psychotic episode, the content of persecutory delusions at episode and the perceived presence of crisis support after the psychotic episode.

DESIGN

The design was a cross-sectional self-report and interview study of people with recently remitted symptoms of psychosis.

METHOD

36 individuals with delusions and hallucinations that had remitted in the past year were assessed for the presence of PTSD symptoms in reaction to their most recent psychotic episode. Measures of the potential predictors were also taken at this point and associations with PTSD symptoms tested.

RESULTS

61% of the individuals with remitted positive symptoms had a reaction to their psychotic episode that was potentially severe enough to receive a PTSD diagnosis. Higher levels of PTSD symptoms were associated with all six predictors tested.

CONCLUSIONS

The study provides further evidence that negative reactions to psychotic episodes are relatively common. Clinicians may wish to assess for such symptoms. The study extended these findings by identifying a number of candidate psychological predictors of PTSD reactions such as perceptions of uncontrollability and absence of support. Prospective longitudinal studies are required to test the causal significance of these factors. More broadly, the findings indicate that traumatic stress in response to intra-psychic events such as delusions can be understood in similar ways to traumatic stress arising from physical traumas such as disasters.

Postpsychotic posttraumatic stress disorder: associations with fear of recurrence and intolerance of uncertainty

Experiencing psychosis can be sufficiently distressing to precipitate symptoms of postpsychotic posttraumatic stress disorder (PP-PTSD). The current research sought to investigate potential associations that PP-PTSD had with the Fear of Recurrence Scale and the Intolerance of Uncertainty Scale. Twenty-seven individuals diagnosed with DSM-IV Schizophrenia and adjudged to be distressed by their experience of psychosis were recruited by referral to the study. The Clinician Administered PTSD Scale was used to assess participants for PP-PTSD. Clinical rating scales (PANSS, HADS, and IES-R) and measures assessing appraisals of paranoia and hallucinatory voices (BAPS and IVI) were also employed. The prevalence rate of PP-PTSD in the sample was 37%. PP-PTSD caseness was associated with being fearful about psychosis recurring, being intolerant of uncertainty, and making negative appraisals of paranoia. Logistical regression analyses indicated that fear of recurrence was a significant predictor of PP-PTSD caseness. The implications of these results for understanding how fear and worry processes might influence emotional adaptation following psychosis are discussed.

Making sense of 'consent' in a constrained environment

BACKGROUND

This project investigates patients' and practitioners' experiences and understandings of the consent process, as it is governed by the Mental Health Act in Great Britain.

AIMS

We aim to illuminate our respondents' experiences of the consent process, and to explore their attempts to make sense of that process.

METHOD

Semi-structured interviews with 5 Responsible Medical Officers, and 7 of their consenting adult patients, were conducted at a medium-secure psychiatric hospital. We approached the analysis from the perspective of Interpretative Phenomenological Analysis.

RESULTS

Our analysis begins with an account of some of the common phenomenological consequences of the consent process as our participants understand them, but then moves on to discuss some of the contextual constraints which are evident from their negotiation of these understandings.

CONCLUSIONS

We conclude by outlining a number of emergent issues relevant to the current development of new Mental Health legislation. These include: mechanisms to allow collaboration with user groups; a more consultative role for users in their own treatment decisions; formal training and support for those conducting competency assessments; and more flexible and transparent legislative frameworks.

Predictors of PTSD symptoms in response to psychosis and psychiatric admission

The experiences of psychosis and psychiatric admission have the potential to act as events precipitating posttraumatic stress disorder (PTSD) symptoms. Known risk factors for the development of PTSD symptoms in adults were identified. These included childhood trauma, current psychiatric symptoms, perceived coercion, and relationships with mental health service providers. These factors were analyzed to determine if they were important in the development of PTSD symptoms in response to psychosis and admission. We used a cross-sectional design with a sample of 47 participants recruited from a service in Northern Ireland who had experienced psychosis and been discharged from inpatient treatment within 12 months of data collection. The main outcome measure was the impact of events scale-revised. Data was subject to correlation analyses. A cut-off point of r = +/- 0.25 was used to select variables for inclusion in hierarchical regression analyses. Forty-five percent and 31% of the sample had moderate to severe PTSD symptoms related to psychosis and admission, respectively. The majority of participants identified positive symptoms and the first admission as the most distressing aspects of psychosis and admission. Childhood sexual and physical traumas were significant predictors of some PTSD symptoms. Strong association was found between current affective symptoms and PTSD symptoms. A reduced sense of availability of mental health service providers was also associated with PTSD symptoms and depression. Awareness of risk factors for the development of PTSD symptoms in response to admission and psychosis raises important issues for services and has implications for interventions provided.

A review of the role of adult attachment style in psychosis: Unexplored issues and questions for further research

Attachment styles reflect individual differences in beliefs about self and others, interpersonal functioning and affect regulation. We review and critically appraise studies suggesting higher levels of insecure attachment, and dismissing attachment in particular, in samples with psychosis compared to controls. We also review the role of social cognition, interpersonal factors, and affect regulation in the development and maintenance of psychosis, and specific symptoms associated with the diagnosis. We review studies showing that insecure attachment is associated with poorer interpersonal relationships and less integrative recovery styles and highlight how recent theories and empirical findings in the psychosis literature can be understood within the framework of attachment theory. In doing so, we argue that investigations of the nature of attachment styles in psychosis and how they relate to the cognitive, interpersonal and affective factors that have been implicated in psychosis will help develop theoretical knowledge in relation to the condition. We conclude by outlining the clinical implications of applying attachment theory to the understanding of psychosis and summarising the conceptual and methodological limitations of the theory which should be addressed, including the need for studies with longitudinal designs, larger, more representative samples, and more valid measures of assessing attachment styles in psychosis.

Developing psychological perspectives of suicidal behaviour and risk in people with a diagnosis of schizophrenia: We know they kill themselves but do we understand why?

People with a diagnosis of schizophrenia are at increased risk of suicidal behaviour yet little is understood of the psychological underpinnings of this vulnerability. The biopsychosocial 'Cry of Pain' model [Williams, J.M.G. (1997). Cry of pain. Harmondsworth: Penguin.] provides a broad framework from which to understand suicidal behaviour. However, the utility of the model in relation to suicide in schizophrenia has not yet been explored. This was the primary goal of this paper. Six components of the 'Cry of Pain' model were identified and evaluated with respect to whether they contributed to i. common transdiagnostic factors underlying suicide, ii. factors relating to co-morbid depression which account for suicidal behaviour, or iii. factors which are specific to schizophrenia and underlie suicide risk. The potential for applying the model to clinical management of suicide in schizophrenia is illustrated.

Switching antipsychotics: an updated review with a focus on quetiapine

Atypical antipsychotics offer broader efficacy and improved tolerability compared with conventional agents. Many patients currently treated with conventional antipsychotics continue to experience persistent symptoms or troublesome side effects and may benefit from a change to one of the newer atypical agents. There are also significant differences in the side-effect profiles of the atypicals, such that a switch from one atypical agent to another could offer advantages to many patients. Unfortunately, many clinicians remain uncertain about the switching process and are reluctant to initiate change. The aim of this review is to identify the indications for a switch in antipsychotic therapy with a focus on recent switching data for the atypical antipsychotic, quetiapine. The clinical aspects of quetiapine's receptor binding characteristics are reviewed including the implications of the low D(2) antagonist properties that make quetiapine the treatment of choice when EPS persists with other atypical antipsychotics. Practical guidelines are given for managing the process of changeover, for avoiding pitfalls and for maximizing the chances of a successful switch. For example, when managing the antipsychotic crossover, it is important to consider the psychological effects of switching arising from symptom and side-effect changes. Finally, advice is provided on the assessments necessary when evaluating the success of a change in therapy, together with guidance on the optimal duration of treatment trials.

[Group interventions for people with refractory psychosis]

Various types of group interventions exist for people with severe mental disorders such as schziophrenia. The content and theoretical backgrounds vary according to the therapeutic goals as well as the clientele targeted. This article describes three group interventions : 1) one aiming at improving self-esteem, 2) one aiming at improving competence through stress management, and 3) one aiming at diminushing distress linked to psychotic symptoms with cognitive behavior therapy. Details on how to conduct these three group interventions, as well as their clinical and theoretical relevance for individuals with refractory psychosis will be described.

Group CBT for Clients With a First Episode of Schizophrenia

This article describes the rationale for and the content of a 24-session group cognitive-behavioral therapy (CBT) tailored to the needs of individuals following a first episode of psychosis. The CBT group approach aims to increase coping with psychotic symptoms as well as help clients deal with other clinical realities such as low self-esteem, stress, anxiety, depression, suicide and substance abuse. Qualitative results, regarding process and satisfaction with treatment, are promising and suggest further investigation of this group intervention.

Changes in waiting-list patients over time: data on some commonly-used measures. Beware!

When samples of psychiatric patients are assessed on 2 occasions on state and trait measures, without any formal intervention having yet taken place, a mean change in scores towards less psychopathology is often observed. This re-test effect, which is a potential threat to the validity of longitudinal studies, has not been given serious attention by researchers using repeated administrations. The present study addressed this issue by examining re-test effects in 2 independent clinical samples with the Symptom Check List-90-Revised and other widely-used state and trait measures. Time intervals between intake and re-take were 3 months and 11-350 days (M = 93 days, median = 81 days). Results indicated that the re-test effect occurred for most of the measures. Where significant testing effects were observed, 54-72% of the patients had time 2 scores that were lower than the average time I scores. The importance and practical and scientific implications of the findings are discussed. Eleven hypotheses concerning the nature of the re-test effect are offered, including mood-congruent associative processing, natural coping mechanisms, self-monitoring hypothesis and response-shift.