Loneliness in psychosis: A practical review and critique for clinicians

Place-Based FACT: Treatment Outcomes and Patients' Experience with Integrated Neighborhood-Based Care

Locating specialized mental healthcare services in the neighborhood of people with severe mental illnesses (SMI) has been suggested as a way of improving treatment outcomes by increasing patient engagement and integration with the local care landscape. The current mixed methods study aimed to examine patient experience and treatment outcomes in three Flexible Assertive Community Treatment (FACT) teams that relocated to the neighborhood they served, compared to seven teams that continued to provide FACT as usual from a central office. Routine Outcome Measurement (ROM) and care use data were analyzed to compare change in treatment outcomes for patients in place-based FACT (n = 255) and FACT as usual (n = 833). Additionally, retrospective in-depth interviews were conducted with twenty patients about their experience with place-based FACT. Quantitative analysis showed mental health admission days decreased more in place-based than FACT as usual, although this difference was small. Both groups showed improved quality of life, psychosocial functioning, and symptomatic remission rates, and decreased unmet and overall needs for care. There was no change over time in met needs for care, employment, and daily activities. Qualitative analysis showed that patients experienced place-based FACT as more accessible, a better safety net, a more personal approach, better integrated with other forms of care, involving their social network, and embedded in their neighborhood and daily environment. This study showed that location and integration matter to patients, and the long term impact of place-based FACT on treatment outcomes should be explored.

How does loneliness interact with positive, negative and depressive symptoms of psychosis? New insights from a longitudinal therapy process study

Cross-sectional research suggests an association between loneliness and psychotic symptoms, but the causal direction of this association is still unclear. Even though loneliness has been proposed as a potential treatment target to improve psychotherapy for psychosis, not much is known about its role in the treatment process. In this study, we re-analyzed data from a therapy process study to investigate the temporal dynamics between loneliness and psychotic symptoms throughout therapy and to explore whether state-of-the-art CBT for psychosis (CBTp) decreases loneliness. Over the course of up to 45 weekly sessions of CBTp, 57 patients reported their feelings of loneliness and current positive, negative and depressive symptom levels at each session. Multilevel regression revealed a reduction in all symptoms over time, but no reduction in loneliness. Time-lagged multilevel regression showed that loneliness predicted subsequent negative and depressive symptoms, whereas positive symptom levels predicted subsequent loneliness. Thus, changes in loneliness seem to be both cause and consequence of psychotic symptom changes. These findings highlight the importance of loneliness as a treatment target, particularly in patients with negative symptoms and depression. Future research should address loneliness-specific interventions as an augmentation of state-of-the-art CBTp.

Modelling the longitudinal dynamics of paranoia in psychosis: A temporal network analysis over 20 years

BACKGROUND

Paranoia is a key feature of psychosis that can be highly debilitating. Theories of paranoia mostly interface with short-scale or cross-sectional data models, leaving the longitudinal course of paranoia underspecified.

METHODS

We develop an empirical characterisation of two aspects of paranoia - persecutory and referential delusions - in individuals with psychosis over 20 years. We examine delusional dynamics by applying a Graphical Vector Autoregression Model to data collected from the Chicago Follow-up Study (n = 135 with a range of psychosis-spectrum diagnoses). We adjusted for age, sex, IQ, and antipsychotic use.

RESULTS

We found that referential and persecutory delusions are central themes, supported by other primary delusions, and are strongly autoregressive - the presence of referential and persecutory delusions is predictive of their future occurrence. In a second analysis we demonstrate that social factors influence the severity of referential, but not persecutory, delusions.

IMPLICATIONS

We suggest that persecutory delusions represent central, resistant states in the cognitive landscape, whereas referential beliefs are more flexible, offering an important window of opportunity for intervention. Our data models can be collated with prior biological, computational, and social work to contribute toward a more complete theory of paranoia and provide more time-dependent evidence for optimal treatment targets.

Associations between social engagement, internalizing symptoms, and delusional ideation in the general population

BACKGROUND

Delusions are a hallmark feature of psychotic disorders and lead to significant clinical and functional impairment. Internalizing symptoms-such as symptoms of depression, anxiety, and trauma exposure-are commonly cited to be related to delusions and delusional ideation and are often associated with deficits in social functioning. While emerging studies are investigating the impact of low social engagement on psychotic-like experiences, little work has examined the relationship between social engagement, internalizing symptoms, and delusional ideation, specifically.

METHODS

Using general population data from the Nathan Kline Institute-Rockland (NKI-Rockland) database (N = 526), we examined the relationships between self-reported delusional ideation, internalizing symptoms, and social engagement and tested four indirect effect models to understand how these factors interrelate.

RESULTS

Delusional ideation was significantly associated with both increased internalizing symptoms (r = 0.41, p < 0.001) and lower social engagement (r = - 0.14, p = 0.001). Within aspects of social engagement, perceived emotional support showed the strongest relationship with delusional ideation (r = - 0.17, p < 0.001). Lower social engagement was also significantly associated with increased internalizing symptoms (r = - 0.29, p < 0.001). Cross-sectional models suggest that internalizing symptoms have a significant indirect effect on the association between delusional ideation and social engagement.

CONCLUSIONS

These findings reveal that elevated delusional ideation in the general population is associated with lower social engagement. Elevated internalizing symptoms appear to play a critical role in reducing engagement, possibly exacerbating delusional thinking. Future work should examine the causal and temporal relationships between these factors.

Loneliness in the Daily Lives of People With Mood and Psychotic Disorders

BACKGROUND AND HYPOTHESIS

Loneliness, the subjective experience of feeling alone, is associated with physical and psychological impairments. While there is an extensive literature linking loneliness to psychopathology, limited work has examined loneliness in daily life in those with serious mental illness. We hypothesized that trait and momentary loneliness would be transdiagnostic and relate to symptoms and measures of daily functioning.

STUDY DESIGN

The current study utilized ecological momentary assessment and passive sensing to examine loneliness in those with schizophrenia (N = 59), bipolar disorder (N = 61), unipolar depression (N = 60), remitted unipolar depression (N = 51), and nonclinical comparisons (N = 82) to examine relationships of both trait and momentary loneliness to symptoms and social functioning in daily life.

STUDY RESULTS

Findings suggest that both trait and momentary loneliness are higher in those with psychopathology (F(4,284) = 28.00, P < .001, ηp2 = 0.27), and that loneliness significantly relates to social functioning beyond negative symptoms and depression (β = -0.44, t = 6.40, P < .001). Furthermore, passive sensing measures showed that greater movement (β = -0.56, t = -3.29, P = .02) and phone calls (β = -0.22, t = 12.79, P = .04), but not text messaging, were specifically related to decreased loneliness in daily life. Individuals higher in trait loneliness show stronger relationships between momentary loneliness and social context and emotions in everyday life.

CONCLUSIONS

These findings provide further evidence pointing to the importance of loneliness transdiagnostically and its strong relation to social functioning. Furthermore, we show that passive sensing technology can be used to measure behaviors related to loneliness in daily life that may point to potential treatment implications or early detection markers of loneliness.

Interpersonal distance in schizophrenia: A systematic review

BACKGROUND AND HYPOTHESIS

Schizophrenia is often associated with severe difficulties in social functioning, resulting in increased isolation and subsequent loneliness. Interpersonal distance - the amount of space around an individual's body during social interaction - can signal such difficulties. However, little is known about how individuals with schizophrenia regulate their interpersonal distance during social encounters. Summarizing the current empirical findings of interpersonal distance regulation in schizophrenia can bring novel perspectives for understanding interpersonal difficulties observed in this clinical population.

STUDY DESIGN

This systematic review examined empirical studies indexed in Web of Science and PubMed based on a-priori-defined criteria. 1164 studies were screened with the final review consisting of 14 studies. They together included 1145 adult participants, of whom 668 were diagnosed with schizophrenia or psychotic disorder.

STUDY RESULTS

The studies clearly showed that patients maintain greater interpersonal distances than do controls. Furthermore, a larger distance was linked to more severe positive and negative symptoms. More specifically, the link to symptoms was more pronounced when patients were being approached by someone else during interactions. On a neurobiological level, the increased activity and functional connectivity of the dorsal inferior parietal sulcus and increased subjective state-dependent stress are further indicated as being potentially related to increase interpersonal distancing in schizophrenia.

CONCLUSIONS

We provided information about the aberrant modulation of interpersonal distance in schizophrenia. Studies showed substantial heterogeneity in tasks used to measure interpersonal distance. Future studies should look at links to social functioning, underlying neurobiology, and neuroendocrinal regulation of interpersonal space in schizophrenia.

Longitudinal association of social isolation and loneliness with physical function among in-patients living with schizophrenia

WHAT IS KNOWN ON THE SUBJECT?: People living with schizophrenia have reduced physical function and are more likely to experience loneliness than those without condition. Low physical function is associated with greater loneliness in people with psychosis. However, it is unclear whether social isolation and loneliness contribute to impaired physical function in this population. Loneliness is linked to an increased risk of physical function impairment among older individuals, but research on patients living with schizophrenia is limited. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This study is the first to evaluate the longitudinal association of social isolation and loneliness with physical function among inpatients living with schizophrenia. It showed that more than one third of the participants experienced a decline in physical function over a 2-year period. Loneliness, rather than social isolation, was associated with an increase in physical function impairment over 2 years among inpatients living with schizophrenia. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Healthcare professionals should recognize loneliness as a potential risk factor for impaired physical function among inpatients diagnosed with schizophrenia. It is recommended that people living with schizophrenia are assessed for loneliness and that interventions are offered to alleviate their feelings of loneliness. Implementing interventions to reduce loneliness may help improve physical function and overall quality of life for individuals living with schizophrenia.

ABSTRACT

INTRODUCTION: Patients living with schizophrenia often experience low physical function, which is associated with negative health outcomes. Therefore, investigating the risk factors for physical function is crucial in this population.

AIM

This study examined the longitudinal association of social isolation and loneliness with physical function among inpatients living with schizophrenia.

METHODS

Physical function was assessed using measures of activities daily living (ADL), instrumental activities daily living (IADL) and the combination scores of ADL/IADL. Social isolation was indexed with five types of social connection and loneliness was measured using UCLA Loneliness Scale.

RESULTS

Social isolation was not associated with the measures of physical function over 2 years. Loneliness exhibited an association with IADL and ADL/IADL at follow-up, after adjustment for baseline levels of the outcomes. These associations remained when both social isolation and loneliness were simultaneously entered into the model.

DISCUSSION

Loneliness, rather than social isolation, was associated with increased physical function impairment over 2 years among inpatients living with schizophrenia.

IMPLICATIONS FOR PRACTICE

Healthcare professionals should consider loneliness as a potential risk factor for impaired physical function. It would be beneficial to assess patients for loneliness and implement interventions to reduce feelings of loneliness.

An exploration of loneliness experienced by people living with mental illness and the impact on their recovery journey: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: There is evidence that social isolation and loneliness is more prevalent in people living with mental illness than in the general population. People living with mental illness frequently experience stigma, discrimination, rejection, repeated psychiatric admissions, low self-esteem, low self-efficacy, and increased symptoms of paranoia, depression, and anxiety. There is evidence of common interventions that can be used to improve loneliness and social isolation such as psychosocial skills training and cognitive group therapy. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper offers a comprehensive assessment of the evidence between mental illness, loneliness, and recovery. The results suggest that people living with mental illness experience elevated levels of social isolation and loneliness leading to poor recovery and quality of life. Social deprivation, social integration and romantic loneliness are related to loneliness, poor recovery, and reduced quality of life. A sense of belonging, ability to trust and hope are important aspects of improved loneliness, quality of life and recovery. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The existing culture in mental health nursing practice needs to be examined to address loneliness in people living with mental illness and its impact on recovery. Existing tools to research loneliness do not consider dimensions in loneliness experience as reflected in the literature. Practice needs to demonstrate an integrated approach to recovery, optimal service delivery and augmentation of evidence-based clinical practice to improve individual's loneliness, social circumstances, and relationships. Practice needs to demonstrate nursing knowledge in caring for people living with mental illness experiencing loneliness. Further longitudinal research is required to clearly understand the relationship between loneliness, mental illness, and recovery.

ABSTRACT

INTRODUCTION: To our knowledge, there are no previous reviews on the impact of loneliness experienced by people aged 18-65, who are living with mental illness and their recovery experience.

AIM/QUESTION

To explore the experience and impact of loneliness in people living with mental illness during recovery.

METHOD

An integrative review.

RESULTS

A total of 17 papers met the inclusion criteria. The search was conducted using four electronic databases: MEDLINE, CINAHL, Scopus and PsycINFO. Across these 17 papers, participants were most commonly, diagnosed with schizophrenia or psychotic disorders and recruited from community mental health services.

DISCUSSION

The review revealed loneliness to be substantial in people living with mental illness and that loneliness affected their recovery, and their quality of life. The review identified many factors that contribute to loneliness including unemployment, financial strain, social deprivation, group housing, internalized stigma and mental illness symptoms. Individual factors such as social/community integration and social network size as well as an inability to trust, a sense of not belonging, hopelessness and lack of romance were also evident. Interventions targeting social functioning skills and social connectedness were found to improve social isolation and loneliness.

IMPLICATIONS FOR PRACTICE

It is vital for mental health nursing practice to employ an approach integrating physical health as well as social recovery needs, optimal service delivery and augmentation of evidence-based clinical practice to improve loneliness, recovery, and quality of life.

Health and Social Case Management for the Inclusion of People Living with a Schizophrenic Disorder: The PASSVers Experience

The way the social protection system in France is organized frequently leads to coordination difficulties between the social and healthcare sectors. A health and social program has been implemented in a French medical-psychological center to optimize the coherence of the pathway for people living with schizophrenia. This study evaluated the way users and professionals perceive this program so as to assess the relevance of double case management. Semi-structured interviews were conducted with users (N = 21) and professionals (N = 11) of this program and then analyzed with Alceste software. The results highlight the overall satisfaction of the participants with the program, and the double case management was shown to be beneficial in supporting people living with schizophrenia in their life project. These results indicate that this program enabled the emergence of a collective empowerment, which could assist with the recovery process of schizophrenia.

Digital health literacy and digital engagement for people with severe mental ill health across the course of the COVID-19 pandemic in England

BACKGROUND

An unprecedented acceleration in digital mental health services happened during the COVID-19 pandemic. However, people with severe mental ill health (SMI) might be at risk of digital exclusion, partly because of a lack of digital skills, such as digital health literacy. The study seeks to examine how the use of the Internet has changed during the pandemic for people with SMI, and explore digital exclusion, symptomatic/health related barriers to internet engagement, and digital health literacy.

METHODS

Over the period from July 2020 to February 2022, n = 177 people with an SMI diagnosis (psychosis-spectrum disorder or bipolar affective disorder) in England completed three surveys providing sociodemographic information and answering questions regarding their health, use of the Internet, and digital health literacy.

RESULTS

42.5% of participants reported experiences of digital exclusion. Cochrane-Q analysis showed that there was significantly more use of the Internet at the last two assessments (80.8%, and 82.2%) compared to that at the beginning of the pandemic (65.8%; ps < 0.001). Although 34.2% of participants reported that their digital skills had improved during the pandemic, 54.4% still rated their Internet knowledge as being fair or worse than fair. Concentration difficulties (62.6%) and depression (56.1%) were among the most frequently reported symptomatic barriers to use the Internet. The sample was found to have generally moderate levels of digital health literacy (M = 26.0, SD = 9.6). Multiple regression analysis showed that higher literacy was associated with having outstanding/good self-reported knowledge of the Internet (ES = 6.00; 95% CI: 3.18-8.82; p < .001), a diagnosis of bipolar disorder (compared to psychosis spectrum disorder - ES = 5.14; 95% CI: 2.47-7.81; p < .001), and being female (ES = 3.18; 95% CI: 0.59-5.76; p = .016).

CONCLUSIONS

These findings underline the need for training and support among people with SMI to increase digital skills, facilitate digital engagement, and reduce digital engagement, as well as offering non-digital engagement options to service users with SMI.

Social Withdrawal, Loneliness, and Health in Schizophrenia: Psychological and Neural Mechanisms

BACKGROUND AND HYPOTHESIS

Some of the most debilitating aspects of schizophrenia and other serious mental illnesses (SMI) are the impairments in social perception, motivation, and behavior that frequently accompany these conditions. These impairments may ultimately lead to chronic social disconnection (ie, social withdrawal, objective isolation, and perceived social isolation or loneliness), which may contribute to the poor cardiometabolic health and early mortality commonly observed in SMI. However, the psychological and neurobiological mechanisms underlying relationships between impairments in social perception and motivation and social isolation and loneliness in SMI remain incompletely understood.

STUDY DESIGN

A narrative, selective review of studies on social withdrawal, isolation, loneliness, and health in SMI.

STUDY RESULTS

We describe some of what is known and hypothesized about the psychological and neurobiological mechanisms of social disconnection in the general population, and how these mechanisms may contribute to social isolation and loneliness, and their consequences, in individuals with SMI.

CONCLUSIONS

A synthesis of evolutionary and cognitive theories with the "social homeostasis" model of social isolation and loneliness represents one testable framework for understanding the dynamic cognitive and biological correlates, as well as the health consequences, of social disconnection in SMI. The development of such an understanding may provide the basis for novel approaches for preventing or treating both functional disability and poor physical health that diminish the quality and length of life for many individuals with these conditions.

Do loneliness and social exclusion breed paranoia? An experience sampling investigation across the psychosis continuum

Background

The role of loneliness and social exclusion in the development of paranoia is largely unexplored. Negative affect may mediate potential associations between these factors. We investigated the temporal relationships of daily-life loneliness, felt social exclusion, negative affect, and paranoia across the psychosis continuum.

Method

Seventy-five participants, including 29 individuals with a diagnosis of non-affective psychosis, 20 first-degree relatives, and 26 controls used an Experience Sampling Method (ESM) app to capture the fluctuations in loneliness, feelings of social exclusion, paranoia, and negative affect across a 1-week period. Data were analysed with multilevel regression analyses.

Results

In all groups, loneliness and feelings of social exclusion were independent predictors of paranoia over time (b = 0.05, p < .001 and b = 0.04, p < .05, respectively). Negative affect predicted paranoia (b = 0.17, p < .001) and partially mediated the associations between loneliness, social exclusion, and paranoia. It also predicted loneliness (b = 0.15, p < .0001), but not social exclusion (b = 0.04, p = .21) over time. Paranoia predicted social exclusion over time, with more pronounced effects in controls (b = 0.43) than patients (b = 0.19; relatives: b = 0.17); but not loneliness (b = 0.08, p = .16).

Conclusion

Paranoia and negative affect worsen in all groups following feelings of loneliness and social exclusion. This highlights the importance of a sense of belonging and being included for mental well-being. Loneliness, feeling socially excluded, and negative affect were independent predictors of paranoid thinking, suggesting they represent useful targets in its treatment.

Facing the pandemic and lockdown: an insight on mental health from a longitudinal study using diaries

We conducted a longitudinal online study to examine attenuated psychotic symptoms (APS) over time in a sample of locked-down individuals. We used (i) questionnaires and (ii) the automatic analysis of the emotional content of narratives. Participants (N = 162) were recruited to complete an online survey 4 times between March and June 2020 (T1, T2, T3, T4). T1 completion coincided with the beginning of the lockdown, and T4 with the pandemic trough. Depression, anxiety, and stress were assessed with the DASS-42 and APS with the PQ-16. Psychosocial data such as the feeling of loneliness and social network size were also collected. The participants wrote daily narratives during the lockdown period. Anxiety and APS were the highest at T1 and decreased over time. APS and APS-associated distress were correlated with the DASS-42 at all times. APS arose acutely at the beginning of the pandemic, despite participants being socio-economically advantaged, and were related with negative emotions.

A network analysis on the relationship between loneliness and schizotypy

BACKGROUND

Schizotypy is a multidimensional personality trait related to the heightened risk for the development of schizophrenia spectrum disorders. While it has been suggested that loneliness may be associated with schizotypy in general, whether it relates to the specific schizotypal traits differentially remains unknown. Besides, as loneliness often co-occurs with depression and anxiety, it is important to delineate its relationship with schizotypy in consideration of these co-occurring emotional disturbances.

METHODS

A demographically diverse sample of young people was obtained from multiple sources. The validated sample consisted of 2089 participants (68.4% female, age range: 18-30). The structural relationship between loneliness and schizotypy was modelled using a network analytic approach. The Gaussian graphical model with loneliness and nine schizotypal traits as nodes was first estimated without, and then with adjustment for the levels of depressive and anxiety symptoms. Edges were estimated as unique associations between nodes.

RESULTS

'Suspiciousness', 'odd beliefs or magical thinking', 'no close friends', 'constricted affect' and 'excessive social anxiety' were linked to loneliness directly. Loneliness was found to be more strongly associated with 'suspiciousness' and 'no close friends' than other schizotypal traits. After adjustment for the levels of depressive and anxiety symptoms, the above direct edges remained robust.

LIMITATIONS

The use of cross-sectional data indicated only undirected associations between variables.

CONCLUSIONS

Loneliness was more strongly linked to some schizotypal traits than others, with the relationships maintaining above and beyond the effects of anxiety and depression. These findings warrant further investigation of the specific relationships between loneliness and individual schizotypal traits.

Loneliness in Autism and Its Association with Anxiety and Depression: A Systematic Review with Meta-Analyses

Objectives

This systematic review aimed to quantify differences in loneliness levels between autistic and neurotypical samples and investigate the association between loneliness and mental health in autistic individuals.

Methods

Three meta-analyses were conducted. Studies were methodologically appraised using established tools.

Results

Overall, 39 studies were included. The majority of these achieved moderate methodological quality ratings. The primary meta-analysis (N = 23) found autistic samples reported higher loneliness compared with neurotypical samples (Hedges’ g = .89). The meta-analyses on the associations between loneliness and anxiety (N = 14) and depression (N = 11) in autistic samples found significant pooled correlations (r = .29 and r = .48, respectively).

Conclusions

This review highlights numerous limitations within current autism and loneliness research. Nevertheless, loneliness in autism merits targeted clinical and research attention.

Cardiovascular disease risk in people with severe mental disorders: an update and call for action

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is a major cause of premature death in people with severe mental disorders (SMDs). This review provides an update on the level of CVD mortality and morbidity, as well as the socioeconomic, psychosocial and genetic factors associated with the comorbidity, and offer directions for improved interventions to reduce CVD in SMDs.

RECENT FINDINGS

The level of CVD mortality and morbidity has sustained high in people with SMDs during the past decades, but the causal mechanism must be further elucidated. Psychosocial and socioeconomic challenges are frequent in SMDs as well as in CVD. Further, recent studies have revealed genetic variants jointly associated with SMDs, CVD risk and social factors. These findings highlight the need for more targeted interventions, prediction tools and psychosocial approaches to comorbid CVD in SMDs.

SUMMARY

The level of CVD comorbidity remains high in SMDs, indicating that most people with SMDs have not benefitted from recent medical advances. A complex interplay between genetic and social vulnerability to CVD, which differs across subgroups of patients, seems to be involved. Further research is required to meet the urgent need for earlier, more efficient intervention approaches and preventive strategies for comorbid CVD in SMD.

A pilot choral intervention in individuals with schizophrenia-spectrum conditions; Singing away loneliness

Social disconnection is associated with poor outcome and long-term disability in individuals with schizophrenia-spectrum conditions (SCZ) but social isolation is not typically a target for treatment. Singing together has long been shown to promote unique group cohesion and improve sense of well-being across the lifespan. Accordingly, we devised a novel choral intervention to examine the potential efficacy of this low-burden social intervention strategy designed to reduce loneliness in SCZ. Seventeen SCZ participated in a weekly, 1-hr choir group for 8 weeks. At pre- and post-intervention, we examined symptoms, loneliness, stress, and face recognition. Choral intervention led to significant reductions in scores for loneliness, the Brief Psychiatric Rating Scale (BPRS) and the Beck Depression Inventory-II (BDI-II). No significant changes were observed in scores for the Scale for the Assessment of Negative Symptoms (SANS), the Scale for the Assessment of Positive Symptoms (SAPS), face recognition, or the Perceived Stress Scale (PSS). Diminished loneliness was inversely correlated with the number of sessions attended. Participants judged the choir intervention to be acceptable and enjoyable. Reduced loneliness and symptom improvement after 8 weeks of intervention in SCZ suggest that choral intervention presents an enjoyable and low-burden opportunity to collaborate in a group setting for isolated individuals and thus may serve as a beneficial adjunct in a multi-arm intervention strategy for alleviating symptom distress and loneliness.

Lived experience of loneliness in psychosis: A qualitative approach

BACKGROUND

Loneliness impedes recovery from mental illness. Despite increased interest in loneliness in psychosis, qualitative methods are underused in clinical research on this topic.

AIMS

We used qualitative interviews to explore loneliness among persons with schizophrenia spectrum disorders (SSDs). We examined which aspects of living with psychosis were associated with the experience of loneliness, including symptomatology, social relationships, and disruptions in school/work.

METHODS

Sixteen participants diagnosed with SSDs engaged in semi-structured, qualitative interviews about loneliness. Participants commented on current activities and social relationships, including their perceptions of the quantity, quality and types of relationships. Important demographic and clinical information was acquired through communication with participants and/or through medical record review. Thematic analysis was used to examine interview content.

RESULTS

Our analyses revealed four key topic areas and several sub-themes related to loneliness across participants, including aspects of the physical environment (e.g. financial limitations), social context (e.g. lacking a romantic partner), and psychological functioning (e.g. psychotic/symptoms) that impact lonely feelings. Participants commented on coping strategies to manage loneliness and provided suggestions for possible interventions.

CONCLUSIONS

Persons diagnosed with SSDs report significant and impactful feelings of loneliness. This study highlights the need for novel and effective treatments targeting loneliness in this population.

Social motivation and behavior in first-episode psychosis: Unique contributions to social quality of life and social functioning

Social functioning is diminished among people early in the course of psychotic illnesses, and is likely influenced by the negative symptoms that accompany these disorders, including changes in motivation and experience of pleasure. Though social impairments have a deleterious impact on functioning, socialization is a multifaceted behavior and little is known about how the various aspects may influence social functioning and social quality of life among people with first-episode psychosis. In the present study, we investigated the associations of specific aspects of social motivation and behavior with social functioning and social quality of life in a group of 54 young people (aged 15 to 35) with first-episode psychosis. Though different aspects of social motivation and behavior correlated positively with one another, social motivation for peer interactions was uniquely associated with social functioning and social quality of life - including when a broad measure of negative symptoms was considered within the same model. When these same associations were examined longitudinally, social motivation for peer interactions again emerged as a unique predictor of change in social functioning over 6 months. Our results suggest that the unique contribution of aspects of social motivation has implications for treatment, including the importance of developmentally-informed interventions to improve peer socialization in youth and young adults with psychosis.

"COVID-19 spreads round the planet, and so do paranoid thoughts". A qualitative investigation into personal experiences of psychosis during the COVID-19 pandemic

The COVID-19 pandemic is likely to affect people who have had previous experiences of psychosis - either positively or negatively. A research gap exists in looking at qualitative experiences of the pandemic. In the present study, we address the research gap in those who self-identified as having psychosis via Reddit discussion forum posts, collecting data from a popular online community. Sixty-five posts were analysed using inductive thematic analysis. Five overarching themes were identifie; declining mental health, changed psychosis experiences, personal coping experiences, social connectedness and disconnectedness, and COVID-19 as a metaphor. The data show that there are varied experiences associated with the pandemic. People who have experiences of psychosis do not only have vulnerabilities but may also perceive themselves as having strengths that allow them to cope better.

Use of the Internet and Digital Devices Among People With Severe Mental Ill Health During the COVID-19 Pandemic Restrictions

Background: Restrictions due to the COVID-19 pandemic have led to everyday reliance on digitalisation of life, including access to health care services. People with severe mental ill health (SMI-e.g., bipolar or psychosis spectrum disorders) are at greater risk for digital exclusion and it is unknown to what extent they adapted to online service delivery. This study explored use of the Internet and digital devices during the pandemic restrictions and its association with physical and mental health changes. Methods: Three hundred sixty seven adults with an SMI diagnosis completed a survey (online or offline) and provided information on access to Internet connexion and devices, internet knowledge, online activities, and barriers to using the Internet. They also self-reported changes in mental and physical health since the beginning of the pandemic restrictions. Results: During the pandemic restrictions 61.6% were limited or non-users of the Internet. The majority had access to the Internet and digital devices but around half reported knowledge deficits. Most common activities were accessing information and entertainment (88.9%), staying in touch with friends and families (84.8%), and purchasing goods (other than food) (84.3%). Most common barriers were finding the Internet "not interesting" (28.3%) or "too difficult" (27.9%), as well as "security concerns" (22.1-24.3%). Using the Internet "a lot" (vs. "just a bit or not at all") during the pandemic was associated with younger age (18-30: Adj ORs 4.76; 31-45: 6.39; Ps < 0.001; vs. 66+), having a diagnosis of bipolar disorder (compared to psychosis; Adj OR = 3.88, P < 0.001), or reporting a decline in mental health (compared to no decline; Adj OR = 1.92, P = 0.01). Conclusion: Most people with SMI were limited or non-users of the Internet during the pandemic, which seems to be mainly attributable to lack of interest and skills, rather than lack of devices or connectivity. Older adults with psychosis should be the focus of interventions to support digital engagement in people with SMI.

Young adults' dynamic relationships with their families in early psychosis: Identifying relational strengths and supporting relational agency

OBJECTIVES

Most existing research on the family context of psychosis focuses on the 'burden' of caring for people experiencing psychosis. This research is the first to ask young people experiencing early psychosis to 'map' and describe their experiences and understandings of their family relationships, and how they have related to their psychosis and recovery.

DESIGN

The research took an inductive, multimodal hermeneutic-phenomenological approach (Boden, Larkin & Iyer, 2019, Qual. Res. Psychology, 16, 218-236; Boden & Larkin, 2020, A handbook of visual methods in psychology, 358-375).

METHOD

Ten young adults (18-23), under the care of early intervention in psychosis services in the UK, participated in an innovative relational mapping interview (Boden, Larkin & Iyer, 2018), which invited participants to draw a subjective 'map' of their important relationships. This visual methodology enables subtle, complex, ambivalent, and ambiguous aspects of the participants' experiences to be explored.

RESULTS

Findings explore the participants' accounts of how they love, protect, and care for their families; how they wrestle with family ties as they mature; and their feelings about talking about their mental health with loved ones, which was typically very difficult.

CONCLUSIONS

This paper advances understanding of recovery in psychosis through consideration of the importance of reciprocity, and the identification and nurturance of relational strengths. The capacity of a young person to withdraw or hold back when trying to protect others is understood as an example of relational agency. The possibility for extending strengths-based approaches and family work within the context of early intervention in psychosis services is discussed.

PRACTITIONER POINTS

Young adults experiencing early psychosis may benefit from support to identify their relational strengths and the opportunities they have for reciprocity within their family structures, where appropriate. Relational motivations may be important for a range of behaviours, including social withdrawal and non-communication. Services may benefit from exploring the young person's relational context and subjective meaning-making in regard to these actions. Young adults experiencing early psychosis may benefit from opportunities to make sense of their family dynamics and how this impacts on their recovery. Attachment-based and relationally oriented interventions that increase trust and openness, and reduce feelings of burdensomeness are likely to support family functioning as well as individual recovery.

Cross-cultural comparisons of psychosocial distress in the USA, South Korea, France, and Hong Kong during the initial phase of COVID-19

The COVID-19 crisis has resulted in disruption of everyday life worldwide but the impact and response to the pandemic have not been uniform. Many countries rapidly deployed physical-distancing mandates to curb the spread of the virus; others did not. Social distancing strategies are necessary to reduce the transmission of the virus but there may be unintended consequences. We examined psychological distress in four societies with distinct public health strategies (South Korea, Hong Kong, France and the United States) to identify common and region-specific factors that may contribute to mental health outcome during the pandemic. From March to July of 2020, a survey of demographics, general health, mental health, loneliness and social networks was conducted. Overall, younger age, greater concern for COVID, and more severe loneliness predicted worse psychological outcome but the magnitudes of these effects varied across the four regions. Objective measures of social isolation did not affect mental health. There were also notable differences in psychological outcome; Hong Kong, with very strict social distancing protocols plus ongoing political unrest, suffered the most drastic deterioration of mental health. To prepare for an impending mental health crisis, concerted efforts to reduce loneliness should be integrated into a comprehensive public health strategy.

Alarming levels of psychiatric symptoms and the role of loneliness during the COVID-19 epidemic: A case study of Hong Kong

Public health strategies to curb the spread of the coronavirus involve sheltering at home and social distancing are effective in reducing the transmission rate, but the unintended consequences of prolonged social isolation on mental health have not been investigated. We focused on Hong Kong for its very rapid and comprehensive response to the pandemic and strictly enacted social distancing protocols. Thus, Hong Kong is a model case for the population-wide practice of effective social distancing and provides an opportunity to examine the impact of loneliness on mental health during the COVID-19. We conducted an anonymous online survey of 432 residents in Hong Kong to examine psychological distress in the community. The results indicate a dire situation with respect to mental health. An astonishing 65.6% (95% C.I. = [60.6%, 70.4%]) of the respondents reported clinical levels of depression, anxiety, and/or stress. Moreover, 22.5% (95% C.I. = [18.2%, 27.2%]) of the respondents were showing signs of psychosis risk. Subjective feelings of loneliness, but not social network size, were associated with increased psychiatric symptoms. To mitigate the potential epidemic of mental illness in the near future, there is an urgent need to prepare clinicians, caregivers and stakeholders to focus on loneliness.

Loneliness and its association with health service utilization in people with a psychotic disorder

BACKGROUND

Loneliness is common in people with psychotic disorders and associated with reduced health and well-being. The relationship between loneliness in psychosis and health service use is unclear. This study examined whether loneliness predicts increased health care utilization in this population, independently of sociodemographics, health and functioning.

METHODS

We used cross-sectional data from the Second Australian National Survey of Psychosis. Loneliness was assessed using a single-item question, rated on a 4-point scale (not lonely; lonely occasionally; some friends but lonely for company; socially isolated and lonely). Health service use (past 12-months) was measured by the number of general practitioner (GP), emergency department (ED) and outpatient visits, inpatient admissions, and home visits by mental health professionals. Frequent hospital users comprised those in the top 15% of users of at least two services.

RESULTS

Negative binomial regression analysis showed that loneliness was associated with an increased number of GP visits, ED visits and inpatient admissions, only. Socially isolated and lonely survey participants were more than twice as likely (OR = 2.6) of being 'frequent users' compared to non-lonely responders. Following stringent adjustment for covariates, loneliness remained significantly associated with being a 'frequent user' and showed a non-significant trend to an increased number of GP visits and inpatient admissions.

CONCLUSIONS

Loneliness is a complex social and personal problem for people with psychosis, related to greater use of some health services. Better strategies for identifying and responding to loneliness in this population have the potential to increase well-being and contain health service utilization costs.