Understanding the social costs of psychosis: the experience of adults affected by psychosis identified within the second Australian National Survey of Psychosis

Social network structure as a biopsychosocial suicide prevention target for young people at clinical high-risk for psychosis

Young people who are at clinical high-risk for psychosis experience suicidal thoughts and behaviors at a greater rate than young people in the general population. However, no suicide prevention interventions have been specifically designed for or tested with this group of young people. To address this gap, we need to identify and leverage malleable potential intervention targets that can be measured at multiple levels of analysis. Here, we argue that social network structure, or the pattern of relationships in which a person is embedded, offers one potential target for intervention. We first provide a select review of what is currently known about social network structure and suicide risk, social network disruption among people at clinical high-risk for psychosis, and inflammatory processes as a potential underlying metric of social bond disruption. We then propose opportunities to advance suicide prevention research focused on young people at clinical high-risk for psychosis, with an eye toward establishing a foundation for future interventions that can account for biological, psychological, and social domains.

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.

The temporal association between social isolation, distress, and psychotic experiences in individuals at clinical high-risk for psychosis

BACKGROUND

Psychotic experiences (PEs) and social isolation (SI) seem related during early stages of psychosis, but the temporal dynamics between the two are not clear. Literature so far suggests a self-perpetuating cycle wherein momentary increases in PEs lead to social withdrawal, which, subsequently, triggers PEs at a next point in time, especially when SI is associated with increased distress. The current study investigated the daily-life temporal associations between SI and PEs, as well as the role of SI-related and general affective distress in individuals at clinical high risk (CHR) for psychosis.

METHODS

We used experience sampling methodology in a sample of 137 CHR participants. We analyzed the association between SI, PEs, and distress using time-lagged linear mixed-effects models.

RESULTS

SI did not predict next-moment fluctuations in PEs, or vice versa. Furthermore, although SI-related distress was not predictive of subsequent PEs, general affective distress during SI was a robust predictor of next-moment PEs.

CONCLUSIONS

Our results suggest that SI and PEs are not directly related on a moment-to-moment level, but a negative emotional state when alone does contribute to the risk of PEs. These findings highlight the role of affective wellbeing during early-stage psychosis development.

Attributions of Loneliness-Life Story Interviews with Older Mental Health Service Users

There is growing evidence on the prevalence and impact of loneliness, particularly among older people. However, much less is known about the personal origins of loneliness and how it persists, or not, over an individual's life course. This study aimed to increase understanding of the personal experiences of loneliness among older adults across the life course. Central to this study was giving voice to the participants and allowing them to define loneliness, what it meant to them, and how it affected them throughout their lives. This qualitative study employed 18 life story interviews with older adults attending a mental health service. We explored their personal experiences of loneliness and the situations and factors associated with loneliness across the life course. We identified three distinct typologies of loneliness: those who experienced (1) chronic loneliness since childhood, (2) chronic loneliness after a life-changing event in midlife, and (3) loneliness which remained situational/transitional, never becoming chronic. This study found the seeds of chronic life course loneliness are often determined in childhood. Early detection and intervention may prevent situational loneliness from becoming chronic. More research is needed from a life course approach to help understand and address the causes and consequences of loneliness.

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.

Analyzing Two Decades of Literature on Experiences of Familial Mental Illness Stigma in Four Advanced Countries (2000-2020)

BACKGROUND

Mental illness-related stigma does not only emanate from the public but also within families of persons with mental illnesses. Familial mental illness stigma implies family members perpetuating stigma against their loved ones with mental illnesses.

AIMS

The aim of this review was to analyze the empirical literature on experiences of familial mental illness stigma in four countries.

METHODS

Using seven databases, we reviewed 133 empirical studies with 26 meeting the inclusion criteria. Each of the 26 studies spoke to various forms of familial mental illness stigma that potentially impact the self-esteem and self-worth of the affected person.

RESULTS

Findings from this review show the existence of familial mental illness stigma in high-income countries, highlighting the need for evidence-based policies to safeguard affected persons at the family level. Close relatives stigmatizing their loved ones due to mental illnesses have contributed to the concealment of mental illness diagnoses within families, which often results in poor prognoses.

CONCLUSIONS

Family members' understanding of mental illnesses is key in confronting the stigma associated with mental disorders in our communities, but this is contingent on continuous comprehensive familial program and education. Constant social support from community services and family members is essential in the recovery of persons with mental illnesses. This underscores the need for a stigma-free environment at all levels of society to ensure all-inclusiveness which calls for a comprehensive strategy that targets policy changes, public education, and media representations of mental health-related problems.

The Role of Acceptance in Everyday Loneliness Among Adults with Serious Mental Illness

There is a high prevalence of loneliness among adults with serious mental illness (SMI) with most research focusing on stable contributing factors. This study sought to identify the role of dispositional loneliness and internalized stigma, as well as the momentary feelings of acceptance on experiential loneliness among adults with SMI. Data were collected using ecological momentary assessment via smart phones, and 89 adults with a SMI were included. Hierarchical linear modeling was used to identify the role of dispositional and experience factors in experiential loneliness. Findings indicated that (a) dispositional internalized stigma, (b) being at home, (c) being alone and, (d) a cross-level interaction between dispositional loneliness and feelings of acceptance best fit the data. The relationship of acceptance to experiential loneliness was strongest among the most lonely. Supporting people with SMI to develop social connections contributing to their relational value may enhance feelings of acceptance and reduce loneliness.

Loneliness is associated with mentalizing and emotion recognition abilities in schizophrenia, but only in a cluster of patients with social cognitive deficits

OBJECTIVE

Loneliness is a concern for patients with schizophrenia. However, the correlates of loneliness in patients with schizophrenia are unclear; thus, the aim of the study is to investigate neuro- and social cognitive mechanisms associated with loneliness in individuals with schizophrenia.

METHOD

Data from clinical, neurocognitive, and social cognitive assessments were pooled from two cross-national samples (Poland/USA) to examine potential predictors of loneliness in 147 patients with schizophrenia and 103 healthy controls overall. Furthermore, the relationship between social cognition and loneliness was explored in clusters of patients with schizophrenia differing in social cognitive capacity.

RESULTS

Patients reported higher levels of loneliness than healthy controls. Loneliness was linked to increased negative and affective symptoms in patients. A negative association between loneliness and mentalizing and emotion recognition abilities was found in the patients with social-cognitive impairments, but not in those who performed at normative levels.

CONCLUSIONS

We have elucidated a novel mechanism which may explain previous inconsistent findings regarding the correlates of loneliness in individuals with schizophrenia.

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.

Temporal Interactions Between Social Motivation and Behavior In Daily Life Among Individuals at Clinical High-Risk for Psychosis

BACKGROUND AND HYPOTHESES

Poor social functioning is common among individuals at clinical high-risk (CHR) for psychosis and is associated with greater likelihood of conversion. Unfortunately, processes contributing to social impairment are unclear, making social functioning difficult to improve via treatment. The current study examined whether abnormalities in social functioning result from aberrant temporal interactions between social motivation and behavior.

STUDY DESIGN

Participants included 105 individuals at CHR and 62 healthy controls (CN) who completed 6 days of ecological momentary assessment. Multilevel models examined time-lagged interactions between social behavior and motivation.

STUDY RESULTS

CHR and CN did not differ in social motivation; however, CHR were less likely to interact with family and coworkers and more likely to engage in interactions via phone and text/social media. Autocorrelations indicated that social behavior and motivation were generally consistent across time in CHR and CN groups. Time-lagged analyses indicated that both groups had an increase in social motivation across time when they were alone and a decrease in social motivation across time when they were with others. However, the relative decrease when with others and increase when alone were less robust in CHR than CN, particularly for in-person interactions. Social motivation at time t did not differentially impact social partner or modality at time t+1 in the groups.

CONCLUSIONS

Findings suggest that social behavior and motivation have different temporal interactions in CHR and CN. Psychosocial interventions may benefit from targeting the frequency of social behavior with specific partners and modalities to change social motivation.

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.

Mobile health in the specific management of first-episode psychosis: a systematic literature review

Purpose

The purpose of this systematic literature review is to assess the therapeutic efficacy of mobile health methods in the management of patients with first-episode psychosis (FEP).

Method

The participants are patients with FEP. The interventions are smartphone applications. The studies assess the preliminary efficacy of various types of application.

Results

One study found that monitoring symptoms minimized relapses, visits to A&E and hospital admissions, while one study showed a decrease in positive psychotic symptoms. One study found an improvement in anxiety symptoms and two studies noted an improvement in psychotic symptoms. One study demonstrated its efficacy in helping participants return to studying and employment and one study reported improved motivation.

Conclusion

The studies suggest that mobile applications have potential value in the management of young patients with FEP through the use of various assessment and intervention tools. This systematic review has several limitations due to the lack of randomized controlled studies available in the literature.

Too Close for Comfort: Stigma by Association in Family Members Who Live with Relatives with Mental Illness

Stigma by association is described in qualitative research of family members who have relatives diagnosed with mental illness, depicting their sense of public shame for having these relationship ties. However, there have been relatively few empirical studies thus far, in part due to the isolation of family members affecting research recruitment. In order to address this gap, an online survey was administered to 124 family members, comparing those who live in the same home with their ill relative (n = 81) and those who do not (n = 43). A remarkable incidence of one in three family members reported experiencing stigma by association. Those living with an ill relative reported comparatively higher levels of stigma by association using an adapted questionnaire measure. Both groups experienced loneliness (moderate levels), but importantly, the cohabiting relatives perceived themselves as lacking support from friends and other family members. Correlational analyses revealed that those with heightened stigma by association reported heightened anti-mattering: that is, feeling that other people treat them as if they are insignificant and invisible. Anti-mattering was also associated with more loneliness and reduced social support. Our discussion focuses on the theme that family members who actually live with mentally ill relatives experience heightened social isolation that is under-recognized due to public stigma concerns, compounded by feeling their own lives do not matter to others. Public health implications are considered for the stigmatized family members who appear to be particularly marginalized.

Prevalence of loneliness and its correlates among patients with schizophrenia

BACKGROUND

There are limited data on loneliness and its correlates in patients with schizophrenia.

OBJECTIVE

To evaluate prevalence and correlates of loneliness in patients with schizophrenia, currently in clinical remission.

METHODOLOGY

A total of 160 patients of schizophrenia in clinical remission were assessed on UCLA Loneliness Scale, Positive and Negative syndrome scale, Calgary Depression Scale for Schizophrenia (CDSS), Internalized Stigma of Mental Illness Scale, Rosenberg Self-esteem Scale, Brief COPE, Beck's Hopelessness Scale, Brief Dyadic Scale of Expressed Emotions, and Self-report Quality of Life Measure.

RESULTS

The mean age of the study sample was 34.99 (SD = 9.13) years. The prevalence of loneliness in the study sample was 80%, with mean total UCLA-loneliness scale score of 30.04 (16.9).Compared to participants without loneliness, those with loneliness had had higher CDSS score, had poor quality of life, lower self-esteem, experienced higher level of stigma, more often used maladaptive coping strategies such as self-blaming and reported a higher level of hopelessness. In the correlation analysis, higher level of loneliness was associated higher severity of depression, higher level of stigma (except for stigma resistance) and discrimination, poorer quality of life, lower self-esteem, perception of a higher level of expressed emotions, higher use of maladaptive coping in the domains of behavioral disengagement, and self-blaming, and a higher level of hopelessness. In regression analysis, the maximum variance of loneliness was explained by quality of life score (29%), followed by hopelessness score (8.8%) and discrimination score (2%).

CONCLUSION

There is a high prevalence of loneliness in patients with schizophrenia, and there is a need to routinely evaluate the patients of schizophrenia for loneliness and address the same.

Depression Mediates the Relationships between Hallucinations, Delusions, and Social Isolation in First-Episode Psychosis

Social isolation is common among individuals with schizophrenia spectrum and other psychotic disorders. Research indicates that social isolation relates to poorer mental health outcomes, depression, and negative symptoms, with less known about its relationship with positive symptoms. This study examined depression as a mediator in the relationships between positive symptoms (i.e., hallucinations and delusions) and social isolation among an early treatment phase sample in the United States. Data were obtained from the Recovery After an Initial Schizophrenia Episode project of the National Institute of Mental Health's Early Treatment Program. Participants (N = 404) included adults between ages 15 and 40 in a first episode of psychosis. Data were analyzed using structural equation modeling in Mplus (Version 8). The study showed that delusions (b = .095, SE = 0.04, p < .05) and hallucinations (b = .076, SE = 0.03, p < .01) were directly related to depression, and that both delusions (b = .129, SE = 0.06, p < .05) and depression (b = .254, SE = 0.09, p < .05) were directly related to social isolation. Findings of this study determined that depression functioned as a mediator in the relationships between positive symptoms and social isolation. Targeting psychosis symptomatology and depression in treatment, improving social skills and social support networks, and considering the role of stigma in social isolation are of great importance in the prevention of poorer mental health outcomes.

Early Maladaptive Schemas and Mental Disorders in Adulthood: a Systematic Review and Meta-analysis

Early maladaptive schemas (EMSs) are broad and pervasive themes regarding oneself and one’s relationships with others originating from adverse childhood experiences. Although the concept of EMSs was initially developed for the treatment of personality disorders, the associations of EMSs with a variety of other mental disorders have been investigated. The goal of the present study was to summarize and analyze the EMSs-disorder associations in studies in which patients with specific psychiatric diagnoses were compared to healthy controls. Of the 28 studies that met the inclusion criteria, 27 were included in a meta-analysis. Across diagnoses, all EMSs were elevated in the clinical groups. The largest effect sizes were observed for the social isolation, the negativity/pessimism, the defectiveness/shame, and social undesirability schemas. Depression (n = 8), borderline personality disorder (n = 5), and obsessive–compulsive disorder (n = 5) were the most frequently studied mental disorders. Heterogeneity between studies was high. Results suggest that mental disorders are not characterized by specific EMSs.

Loneliness, positive, negative and disorganised Schizotypy before and during the COVID-19 pandemic

Loneliness is common in psychosis and occurs along a continuum. Here we investigate inter-relationships between loneliness, three-dimensional schizotypy, and depressive symptoms before and during the COVID-19 pandemic.

The sample included 507 university students (48.3% participated before and 51.7% during the COVID-19 pandemic) who completed the Multidimensional Schizotypy Scale-Brief, the Counseling Center Assessment of Psychological Symptoms depression scale and the University of California, Los Angeles Loneliness Scale. Schizotypy and depression scores were regressed onto loneliness individually and in multiple regressions.

The cohorts did not differ in any of the schizotypy domains (all p > .29). Depressive symptoms (p = .05) and loneliness (p = .006) were higher during the pandemic than before. Across cohorts, loneliness was significantly associated with positive (β = 0.23, p < .001), negative (β = 0.44, p < .001), and disorganised schizotypy (β = 0.44, p < .001), and with depression (β = 0.72, p < .001). Schizotypy together explained a significant amount of variance in loneliness (R² = 0.26), with significant associations with positive (β = −0.09, p = .047), negative (β = 0.31, p < .001) and disorganised schizotypy (β = 0.34, p < .001). When depression was included (β = 0.69, p < .001), only positive (β = −0.09, p = .008) and negative schizotypy (β = 0.22, p < .001) significantly predicted loneliness.

When all schizotypy dimensions and depression were considered together, only negative schizotypy and depression significantly predicted loneliness. Loneliness and depressive symptoms were higher during the pandemic, but this did not relate to cohort differences in schizotypy.

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Loneliness is uniquely associated with negative schizotypy and depression, but not disorganised schizotypy.

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Certain aspects of positive schizotypy may protect against loneliness.

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Loneliness and depressive symptoms were higher in students during the COVID-19 pandemic than before.

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Cohorts of students assessed before and during the pandemic showed similar levels of schizotypy.

Face Your Fears: Virtual reality-based cognitive behavioral therapy (VR-CBT) versus standard CBT for paranoid ideations in patients with schizophrenia spectrum disorders: a randomized clinical trial

BACKGROUND

Schizophrenia spectrum disorders cause suffering for patients, relatives, and the surrounding society. Paranoid ideations, encompassing ideas of social reference and manifest persecutory delusions, are among the most frequent symptoms in this population and a cause of significant distress. Recent meta-analyses of cognitive behavioral therapy (CBT) for psychosis show small to moderate effect sizes in reducing paranoid ideations. Virtual reality-based CBT (VR-CBT) could improve therapy efficacy as exposure and behavioral experiments in VR can be optimized, individualized, and carried out in a safe environment. Few VR-CBT studies exist for paranoid ideations and there is a need for large-scale, methodologically rigorous trials.

METHODS

This study is a randomized, assessor-blinded parallel-groups multi-center superiority clinical trial, fulfilling the CONSORT criteria for non-pharmacological treatment. A total of 256 patients diagnosed with schizophrenia spectrum disorder, including schizotypal disorder (ICD-10 F20-29), will be allocated to either 10 sessions of symptom-specific CBT-VR plus treatment as usual-versus 10 sessions of standard symptom-specific CBT for paranoid ideations (CBT) plus treatment as usual. All participants will be assessed at baseline, treatment end (3 months post baseline), and then 9 months post baseline. A stratified block-randomization with concealed randomization sequence will be conducted. Independent assessors blinded to the treatment will evaluate the outcome. Analysis of outcome will be carried out with the intention to treat principles. The primary outcome is ideas of social reference measured with Green Paranoid Thought Scale Part A (GPTS-A) at the cessation of treatment at 3 months post baseline. Secondary outcomes are ideas of persecution (GPTS-B), Social Interaction Anxiety Scale (SIAS), Personal and Social Performance scale (PSP), Safety Behavior Questionnaire (SBQ), and CANTAB Emotion Recognition Task.

DISCUSSION

The trial will elucidate whether VR-CBT can enhance therapy efficacy for paranoid ideations. Additionally, Trial findings will provide evidence on the effectiveness and cost-effectiveness of VR-CBT for paranoid ideations that can guide the possible dissemination and implementation into clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04902066 . Initial release April 9th, 2021.

Recent findings on subjective well-being and physical, psychiatric, and social comorbidities in individuals with schizophrenia: A literature review

AIM

Care for people with schizophrenia is shifting the locus from long-stay mental hospitals to nonspecialized community-based settings. Knowledge on the care is not a sole property of psychiatric specialists. Community healthcare workers who do not specialize in psychiatry are recommended to learn more about schizophrenia. This review aimed to summarize recent findings on subjective well-being and physical, psychiatric, and social comorbidities in individuals with schizophrenia.

METHODS

A literature review was conducted. We retrieved findings from existing systematic reviews and meta-analyses as our preferred method. When data were not available, we referred to other types of studies.

RESULTS

As per our review, individuals with schizophrenia demonstrated poor subjective well-being, happiness, and life satisfaction despite individual differences. Pharmacotherapy caused weight gain and constipation, whereas race and hospitalization might affect weight reduction. Individuals with schizophrenia demonstrated poor oral health, a high prevalence of noncommunicable diseases, and unique eating behaviors. Depression, sleep disorders, smoking, and alcohol and drug consumption were frequently found in the individuals. Research findings regarding problematic internet and smartphone use and stress perception were limited. Low health literacy and neglect of preventable behaviors were frequently seen in individuals with schizophrenia. They tended to be less educated, poor, unemployed, unmarried/unattached, and had poor social cognition, resulting in little social support and a small social network.

CONCLUSION

Retrieving recent data, we confirmed that individuals with schizophrenia had poor subjective well-being and suffer from various physical, psychiatric, and social comorbidities.

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.

Social exclusion in psychotic disorders: An interactional processing model

Psychotic disorders are among the most highly stigmatized mental disorders, and individuals with psychosis experience significant exclusion from the community. Stigma reduction programs have done little to reduce social exclusion of individuals with psychosis, and there are significant limitations to the traditional stigma model as it applies to social exclusion. Herein, we present the Interactional Processing Model (IPM) of social exclusion towards individuals with psychosis. The IPM considers social exclusion to be the result of two interacting pathways with additional consideration for a feedback loop through which social exclusion sets in motion natural behavioural responses of individuals with psychosis that inadvertently perpetuates exclusion. The IPM considers initial social exclusion to be the result of an interaction between these two pathways. The first path aligns with the traditional stigma model and consists of the community becoming aware that an individual is diagnosed with a psychotic disorder and then excluding the individual based on pre-existing, generalized knowledge about the disorder. The second path to exclusion involves the observation of atypical behaviours from the individual, and generation of an individualized exclusion response. We provide initial empirical support for the IPM of social exclusion, outline testable hypotheses stemming from the model, and discuss implications for novel ways to consider both societal stigma reduction and personalized intervention.

Quality of Life in Patients with Chronic Psychotic Disorders: A Practical Model for Interventions in Romanian Mental Health Centers

Background and Objectives: Current psychiatric care is increasingly focusing on patients' quality of life (QoL). Research is still trying to determine the main factors which influence QoL. The present study aims to assess the QoL of patients with chronic psychotic-spectrum disorders, as well as its relation to symptomatology, functionality, adaptive behavior, and perceived level of recovery. Materials and Methods: The study included a sample of 78 patients with chronic psychosis. Symptomatology and illness severity were assessed with the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression Scale-Severity (CGI-S) scales, respectively. The Global Assessment of Functioning Scale (GAFS) and the Adaptive Behavior Assessment System II (ABAS-II)-Adult Form were used for the assessment of patients' functionality, and the Quality-of-Life Inventory (QOLI) scale was applied for the evaluation of QoL. Results: According to the CGI-Severity scale, 20.5% of the patients were borderline mentally ill, and 24.4% were mildly ill. The highest number of patients (34.6%) were moderately ill, while 14.1% and 2.6% were markedly ill and severely ill, respectively. Among the moderately ill patients, more than half (63%) were patients with schizophrenia, 18.5% were patients with delusional disorder, and 18.5% were patients with schizoaffective disorder. Most of the patients (43.6%) presented moderate functioning deficiency, while 38.5% of the patients presented severe deficiency, according to the GAFS score. When assessed with the ABAS, we observed that almost half of the patients (44.9%) showed an average functioning across skill areas in the conceptual, social, and practical domains. A percent of 67.9% of the patients presented an average QoL, while 15.4% and 12.8% showed a very low and low QoL. QoL was not influenced by the patients' symptomatology, gender, and education level. Having children, family support, better social and conceptual skills, and a higher perceived level of recovery was correlated with an increased QoL, hierarchical multiple regression R2 = 0.379, F(9, 68) = 2.616, and p = 0.012. Conclusions: Psychiatric interventions in psychosis should focus not only on symptoms' control, but also on improving social and family support, as well as adaptive skills to increase the patients' QoL.

Demographic and Clinical Factors Related to Severe COVID-19 Infection and Mortality in Patients With Schizophrenia

We aimed to explore the prevalence and determinants of severe COVID-19 disease and mortality in patients with schizophrenia in this study. We conducted a retrospective observational study of 1620 patients with schizophrenia. Of the 1620 patients, 52 (3.2%) tested positive for SARS-CoV-19. Among SARS-CoV-2-positive patients, 40 patients were hospitalized, and 17 patients required intensive care unit admission due to COVID-19 (76.9% and 32.7%, respectively). Severe COVID-19 disease was noted in 17 patients (32.7%) requiring intubation. In the logistic regression analysis, antipsychotic dose, and comorbidity score were independently associated with a greater risk of severe COVID-19 disease in patients with schizophrenia. Our study suggests that factors such as age, sex, comorbidities, and a daily antipsychotic dose may have effects on the poor outcome of SARS-CoV-2 disease in schizophrenia patients. In addition, the current findings propose that mortality may be associated with an older age, comorbidity score, and a longer duration of psychiatric disease among the SARS-CoV-2-positive patients with schizophrenia. However, the findings of our study should be verified in prospective and larger sample studies.

Behavioral Interventions to Reduce Cardiovascular Risk Among People with Severe Mental Disorder

Cardiovascular disease (CVD) is the leading cause of death among people with severe mental disorder (SMD). CVD risk factors occur at the individual, health system, and socio-environmental levels and contribute not only to high rates of CVD but also to worsening mental health. While acknowledging this wider context, this review focuses on behavioral interventions for seven CVD risk behaviors-smoking, physical inactivity, excessive alcohol consumption, low fruit and vegetable intake, inadequate sleep, poor social participation, and poor medication adherence-that are common among people with SMD. We survey recent meta-reviews of the literature and then review additional key studies to provide clinical recommendations for behavioral interventions to reduce CVD risk among people with SMD. A transdiagnostic psychological approach from the start of mental health treatment, drawing upon multidisciplinary expertise to address multiple risk behaviors, is recommended. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

The experience of psychosis and recovery from consumers' perspectives: An integrative literature review

WHAT IS KNOWN ON THE SUBJECT?: Since the first decade of this century, few qualitative studies and literature reviews have reported consumers' experiences of psychosis and recovery. The findings from these studies need further exploration. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: New insights into consumers' experiences of psychosis were generated. Additionally, understanding of consumers' conceptions and experiences of recovery were reported. Consumers' insights into the enablers and barriers to recovery that they encountered were also identified. Gaps in the literature remain, particularly those related to the effects of gender and culture on consumers' experiences of and recovery from psychosis. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses' understanding of consumers' perspectives and experiences of psychosis is vital to enhancing the quality of mental health nursing when caring for people living with psychosis. To support user-based recovery, mental health nurses need to incorporate person-centred approaches and reduce their preferencing of medical understandings of recovery.

ABSTRACT

INTRODUCTION: Psychosis is a distressing disorder. Consumers' perspectives about their experiences of psychosis and recovery are essential aspects of mental health nursing.

AIMS

To review contemporary evidence related to consumers' experiences of and recovery from psychosis.

METHOD

An integrative review was the method used; six databases were systematically searched. Of the 157 articles screened, 14 met the inclusion criteria and were assessed for quality using Joanna Briggs Institute Appraisal tools. Data were compared, classified and integrated.

RESULTS

Findings revealed that consumers' experiences of psychosis included issues with self-expression and language, psychosocial problems and stigma. Also, consumers' experiences associated with their recovery were reported, and this included their perspectives on the enablers and barriers that they encountered.

DISCUSSION

Consumer's experiences of and recovery from psychosis provide an essential basis for managing and working with people experiencing psychosis. Further research identifying the potential effects of gender and culture into consumers' lived experiences is required.

IMPLICATIONS FOR PRACTICE

Exploring the experience of someone with psychosis will help nurses to understand the impacts of this condition. This understanding can guide nurses to apply recovery-oriented practices. Specific aspects of psychosis experience, including gender and culture, should inform nurses' practices towards recovery.

Dynamic and progressive changes in thalamic functional connectivity over the first five years of psychosis

The early stage of psychosis (ESP) is a critical period where effective intervention has the most favorable impact on outcomes. Thalamic connectivity abnormalities have been consistently found in psychosis, and are associated with clinical symptoms and cognitive deficits. However, most studies consider ESP patients as a homogeneous population and fail to take the duration of illness into account. In this study, we aimed to capture the progression of thalamic connectivity changes over the first five years of psychosis. Resting-state functional MRI scans were collected from 156 ESP patients (44 with longitudinal data) and 82 healthy controls (24 with longitudinal data). We first performed a case-control analysis comparing thalamic connectivity with 13 networks in the cortex and cerebellum. Next, we modelled the shape (flat, linear, curvilinear) of thalamic connectivity trajectories by comparing flexible non-linear versus linear models. We then tested the significance of the duration of illness and diagnosis in trajectories that changed over time. Connectivity changed over the ESP period between the thalamus and default mode network (DMN) and fronto-parietal network (FPN) nodes in both the cortex and cerebellum. Three models followed a curvilinear trajectory (early increase followed by a subsequent decrease), while thalamo-cerebellar FPN connectivity followed a linear trajectory of steady reductions over time, indicating different rates of change. Finally, diagnosis significantly predicted thalamic connectivity. Thalamo-cortical and thalamo-cerebellar connectivity change in a dynamic fashion during the ESP period. A better understanding of these changes may provide insights into the compensatory and progressive changes in functional connectivity in the early stages of illness.

Loneliness and psychotic experiences among US university students: Findings from the Healthy Minds Study 2020

Loneliness and psychotic experiences (PEs) are common in university students. Despite this, little information is available on the association between loneliness and PEs in this population. In the present study, we studied 30,529 individuals from the Fall semester cohort of the 2020 Healthy Minds Study, a cross-sectional, web-based survey examining mental health and related factors in undergraduate and graduate students aged 18 years or older. Multivariable logistic regression analyses were used to evaluate associations between loneliness (exposure) and PEs (outcome). Loneliness was significantly associated with increased odds of any PEs (odds ratio, 1.32; 95% CI, 1.29-1.36), adjusting for age, gender identity, race/ethnicity, sexual orientation, and international student status. This relationship was consistent across the subtypes of PEs, i.e., delusions (odds ratio, 1.32; 95% CI, 1.29-1.36) and hallucinations (odds ratio, 1.27; 95% CI, 1.21-1.34), adjusting for the same covariates. We found that loneliness is consistently associated with PEs across different subtypes in a university population sample. Future studies may consider testing whether interventions to reduce loneliness among young adults and university students can have an impact on PEs.

Loneliness among people with severe mental illness during the COVID-19 pandemic: Results from a linked UK population cohort study

AIM/GOAL/PURPOSE

Population surveys underrepresent people with severe mental ill health. This paper aims to use multiple regression analyses to explore perceived social support, loneliness and factor associations from self-report survey data collected during the Covid-19 pandemic in a sample of individuals with severe mental ill health.

DESIGN/METHODOLOGY/APPROACH

We sampled an already existing cohort of people with severe mental ill health. Researchers contacted participants by phone or by post to invite them to take part in a survey about how the pandemic restrictions had impacted health, Covid-19 experiences, perceived social support, employment and loneliness. Loneliness was measured by the three item UCLA loneliness scale.

FINDINGS

In the pandemic sub-cohort, 367 adults with a severe mental ill health diagnosis completed a remote survey. 29-34% of participants reported being lonely. Loneliness was associated with being younger in age (adjusted OR = -.98, p = .02), living alone (adjusted OR = 2.04, p = .01), high levels of social and economic deprivation (adjusted OR = 2.49, p = .04), and lower perceived social support (B = -5.86, p < .001). Living alone was associated with lower perceived social support. Being lonely was associated with a self-reported deterioration in mental health during the pandemic (adjusted OR = 3.46, 95%CI 2.03-5.91).

PRACTICAL IMPLICATIONS

Intervention strategies to tackle loneliness in the severe mental ill health population are needed. Further research is needed to follow-up the severe mental ill health population after pandemic restrictions are lifted to understand perceived social support and loneliness trends.

ORIGINALITY

Loneliness was a substantial problem for the severe mental ill health population before the Covid-19 pandemic but there is limited evidence to understand perceived social support and loneliness trends during the pandemic.

Loneliness among people with severe mental illness during the COVID-19 pandemic: Results from a linked UK population cohort study

AIM/GOAL/PURPOSE

Population surveys underrepresent people with severe mental ill health. This paper aims to use multiple regression analyses to explore perceived social support, loneliness and factor associations from self-report survey data collected during the Covid-19 pandemic in a sample of individuals with severe mental ill health.

DESIGN/METHODOLOGY/APPROACH

We sampled an already existing cohort of people with severe mental ill health. Researchers contacted participants by phone or by post to invite them to take part in a survey about how the pandemic restrictions had impacted health, Covid-19 experiences, perceived social support, employment and loneliness. Loneliness was measured by the three item UCLA loneliness scale.

FINDINGS

In the pandemic sub-cohort, 367 adults with a severe mental ill health diagnosis completed a remote survey. 29-34% of participants reported being lonely. Loneliness was associated with being younger in age (adjusted OR = -.98, p = .02), living alone (adjusted OR = 2.04, p = .01), high levels of social and economic deprivation (adjusted OR = 2.49, p = .04), and lower perceived social support (B = -5.86, p < .001). Living alone was associated with lower perceived social support. Being lonely was associated with a self-reported deterioration in mental health during the pandemic (adjusted OR = 3.46, 95%CI 2.03-5.91).

PRACTICAL IMPLICATIONS

Intervention strategies to tackle loneliness in the severe mental ill health population are needed. Further research is needed to follow-up the severe mental ill health population after pandemic restrictions are lifted to understand perceived social support and loneliness trends.

ORIGINALITY

Loneliness was a substantial problem for the severe mental ill health population before the Covid-19 pandemic but there is limited evidence to understand perceived social support and loneliness trends during the pandemic.

Self-reported needs of people living with psychotic disorders: Results from the Australian national psychosis survey

Person-centered care is a collaborative approach to health care. To provide effective, person-centered care to people living with severe mental illness, it is necessary to understand how people view their own needs. The Perceived Need for Care Questionnaire (PNCQ) was used in the Australian National Survey of High Impact Psychosis (SHIP) to deepen understanding and evaluate, at a population level, the needs of Australian adults living with psychotic illness. SHIP participants were 1,825 adults, aged 18-65 years, living with psychotic illness and in contact with public specialized mental health services across Australia in 2010. The survey package included demographic and clinical items, and various scales including the PNCQ appraising a comprehensive range of life domains. Logistic regressions measured the impact that various demographic, clinical and psychosocial independent variables (e.g., loneliness, health-related quality of life, disability, accommodation type) had on the likelihood of inadequately met PNCQ domain-related need. Over two-thirds of people living with psychosis reported at least two areas of unmet need for care despite most being in contact with mental health services. Work or using one's time and socializing, counseling, and self-care domains had the largest proportion of inadequately met needs (range between 49 and 57%). Feelings of loneliness and/or social isolation were significantly associated with unmet needs across all PNCQ domains, except for financial needs. Health-related quality of life was significantly associated with unmet needs across all domains, except for housing needs. Disability was significantly associated with unmet social, occupation (work or time use), housing and medication-related needs. Consumers view their needs for care as unmet across many life areas despite being in contact with mental health services. Loneliness, unmet psychosocial needs, and health-related quality of life appear strongly interconnected and warrant greater attention in the delivery of person-centered care for people living with psychosis. Support to address social, work or time use and housing related needs among people living with psychosis appears less well targeted toward those with disability. Results underscore the link between quality of life, recovery and needs. These inter-relationships should be considered in mental health services research and evaluation.

Cariprazine's Potential in Improving Social Dysfunction in Patients With Schizophrenia: A Perspective

Social dysfunction is one of the most debilitating aspects of schizophrenia. Treatment of this complex phenomenon, constituted by negative, cognitive, and affective symptoms, has been difficult with the available pharmacological agents, hence it represents an unmet medical need. Cariprazine, a novel, third-generation antipsychotic with a unique mechanism of action has been proven to sufficiently alleviate negative, cognitive, and affective symptoms of schizophrenia. These characteristics make this compound a valid candidate for addressing social dysfunction too. In this perspective, we argue that cariprazine can be viewed as a "socializing drug" that has the ability to improve the patient's functionality and ultimately their quality of life. Data from animal research, clinical trials, an observational study, and patient cases are provided.

Hallucinations and Other Psychotic Symptoms in Patients with Borderline Personality Disorder

BACKGROUND

Psychotic symptoms in BPD are not uncommon, and they are diverse and phenomenologically similar to those in schizophrenia spectrum disorders. Despite their prevalence in BPD patients, knowledge about the characteristics and severity of hallucinations is limited, especially in modalities other than auditory.

AIM

This review summarises the causes, phenomenology, severity, and treatment options of hallucinations and other psychotic symptoms in BPD.

METHODS

The PubMed database was used with the following key terms: "borderline personality disorder" and 'hallucinations' and "psychotic symptoms". Articles were selected between January 1990 and May 2021. The primary keyword search yielded a total of 545 papers, of which 102 articles met the inclusion criteria and were fully screened. Papers from the primary source reference lists were also screened, assessed for eligibility, and then added to the primary documents where appropriate (n = 143). After the relevance assessment, 102 papers were included in the review. We included adult and adolescent studies to gather more recent reviews on this topic.

RESULTS

Hallucinations are significantly prevalent in BPD, mainly auditory, similar to schizophrenia spectrum disorders. The relationship between hallucinations and depression, anxiety, suicidality, schizotypy, and loneliness in BPD has been discovered but requires more research. Studies for treatment options for hallucinations in BPD are lacking.

CONCLUSION

Recognition of psychotic symptoms in patients with BPD as distinguished psychopathological phenomena instead of diminishing and overlooking them is essential in the clinical assessment and can be useful in predicting complications during treatment. More focused research in this area is needed.

Loneliness among people with severe mental illness during the COVID-19 pandemic: Results from a linked UK population cohort study

AIM/GOAL/PURPOSE

Population surveys underrepresent people with severe mental ill health. This paper aims to use multiple regression analyses to explore perceived social support, loneliness and factor associations from self-report survey data collected during the Covid-19 pandemic in a sample of individuals with severe mental ill health.

DESIGN/METHODOLOGY/APPROACH

We sampled an already existing cohort of people with severe mental ill health. Researchers contacted participants by phone or by post to invite them to take part in a survey about how the pandemic restrictions had impacted health, Covid-19 experiences, perceived social support, employment and loneliness. Loneliness was measured by the three item UCLA loneliness scale.

FINDINGS

In the pandemic sub-cohort, 367 adults with a severe mental ill health diagnosis completed a remote survey. 29-34% of participants reported being lonely. Loneliness was associated with being younger in age (adjusted OR = -.98, p = .02), living alone (adjusted OR = 2.04, p = .01), high levels of social and economic deprivation (adjusted OR = 2.49, p = .04), and lower perceived social support (B = -5.86, p < .001). Living alone was associated with lower perceived social support. Being lonely was associated with a self-reported deterioration in mental health during the pandemic (adjusted OR = 3.46, 95%CI 2.03-5.91).

PRACTICAL IMPLICATIONS

Intervention strategies to tackle loneliness in the severe mental ill health population are needed. Further research is needed to follow-up the severe mental ill health population after pandemic restrictions are lifted to understand perceived social support and loneliness trends.

ORIGINALITY

Loneliness was a substantial problem for the severe mental ill health population before the Covid-19 pandemic but there is limited evidence to understand perceived social support and loneliness trends during the pandemic.

Post-traumatic growth in psychosis: a systematic review and narrative synthesis

BACKGROUND AND OBJECTIVE

People with psychosis report experiences of highly traumatic events. Positive change or post-traumatic growth (PTG) can occur as a result of traumatic experiences. Yet there is limited attention on PTG in psychosis, possibly due to the negative impact of psychotic symptoms on functioning and quality of life. The aim of this review was to identify significant correlates and mediators of PTG in psychosis, and to develop a conceptual framework synthesising facilitators of PTG in psychosis.

METHOD

Ten electronic databases were searched in seven languages, and five journals and grey literature were searched in English. Quantitative studies were eligible if examining correlates, mediators, or the temporal relationship between PTG and one or more variables. Qualitative studies were eligible if describing PTG arising from experiences of psychosis. Findings from quantitative papers were grouped by analysis method, with significant correlates, mediators, and temporal relationships descriptively reported upon. Narrative synthesis was conducted on findings in qualitative papers.

RESULTS

Thirty-seven papers were included. Significant correlates and mediators of PTG were identified. Mediators of PTG in psychosis included meaning in life, coping self-efficacy, core beliefs, and self-reported recovery. No studies describing the temporal relationship between PTG and psychosis were identified. The narrative synthesis identified seven facilitators of PTG in psychosis: Personal identity and strength, Receiving support, Opportunities and possibilities, Strategies for coping, Perspective shift, Emotional experience, and Relationships, giving the acronym PROSPER.

CONCLUSIONS

Individuals with psychosis can be supported to grow from traumatic experiences. Clinicians can support PTG through the provision of trauma-informed care that supports positively valued identity changes. For researchers, the findings provide an evidence-based theoretical framework for conceptualising PTG, which can be validated through longitudinal cohort studies and underpin the development of new clinical interventions.

The cross-lagged relationship between loneliness, social support, and psychotic-like experiences in young adults

BACKGROUND

Individuals with psychotic disorders often report feelings of loneliness, fewer social contacts and less satisfaction with their social support prior to diagnosis. However, temporal relationships between these variables remain unclear. The primary aim of this study was to examine whether subjective and objective social factors predict, or are predicted by, psychotic-like experiences (PLEs) in healthy young adults.

METHODS

196 undergraduates completed baseline and 3-month follow-up assessments for PLEs, loneliness, social support size, and satisfaction. Cross-lagged panel models were conducted to investigate the temporal relationships between these variables.

RESULTS

Higher loneliness scores, fewer social contacts, and being less satisfied with social support at both time points were significantly associated with higher endorsement of PLEs. Furthermore, after controlling for baseline levels, cross-lagged analyses revealed that individuals who reported feeling more lonely and having less social support at baseline, predicted higher PLEs three months later but not vice versa. No cross-lagged effect was found between the satisfaction of social support and PLEs.

CONCLUSION

The study highlights the significant relationships between loneliness, social support and PLEs. Higher levels of loneliness and smaller social support networks predicted future PLEs. These findings need to be given full consideration in future clinical practice and intervention for young adults with PLEs.

The Influence of Health Literacy and Social Support on Loneliness Among Patients With Severe Mental Illness in Rural Southwest China

Loneliness is an important risk factor for poor health outcomes among adults, especially among those with severe mental illnesses (SMIs). Existing research has shown that adults with SMIs often lack health literacy, which contributes to more restricted social networks and low levels of social support. The objective of this cross-sectional study was to examine the influence of health literacy and social support on the loneliness of patients with SMI in rural Southwest China. We recruited 300 patients with SMI in rural Southwest China between December, 2017 to May, 2018 via a multi-stage stratified random sampling approach. We used structural equation modeling (SEM) test the hypothesized relationships among the variables of the 270 patients who completed the survey. Results of the SEM showed that health literacy was both directly and indirectly associated with loneliness, with social support playing a mediating role. These findings suggest psychoeducation for SMI patients, and their informal caregivers, may offer beneficial effects toward reducing loneliness in this vulnerable population. Further, social support is another potential target for intervention development for improving patient outcomes.

Psychosocial interventions for people with a first episode psychosis: between tradition and innovation

PURPOSE OF REVIEW

Assessing recent evidence on psychosocial interventions for people with first episode psychosis (FEP).

RECENT FINDINGS

Family interventions (FI) reduce relapse rates, whilst cognitive behavioural therapy (CBT) shows a moderate effect in improving positive psychotic symptoms. Vocational interventions (VI) appear to be worthy of implementation within early intervention for psychosis (EIP) teams, but it is still unclear what is the most cost-effective strategy for their delivery. Promising interventions, which need more careful evaluation, focus on substance misuse, physical health comorbidities, improvement of social participation, peer support and the potential of new technologies.

SUMMARY

The first five years after the onset of psychotic symptoms are a 'critical period' in which psychosocial interventions can be particularly influential in determining prognosis. Traditional EIP interventions have different effectiveness profiles, i.e., FI reduce relapse rates, CBT has a moderate effectiveness on overall and positive symptoms and VI can improve educational and employment-related functioning. Newer interventions show promise on important targets for FEP treatment but require higher-quality evaluations. Decisions on which interventions to implement within EIP teams should be informed by high-quality evidence, but difficult choices will have to be made based on costs, professionals and technologies available, and local priorities.

Social Processes Associated With Health and Health Behaviors Linked to Early Mortality in People With a Diagnosis of a Serious Mental Illness

Individuals with serious mental illness (SMI) experience a 10- to 25-year reduced life expectancy compared with the general population. Early mortality for people with SMI has mainly been attributed to unhealthy behaviors (e.g., poor diet, sedentary lifestyle), which has led to the development of health promotion and self-management interventions specifically for people with SMI to promote health behavior change. Yet after decades of research, the mortality gap between people with SMI and the general population is increasing. To address this early mortality disparity for individuals with SMI, a new paradigm must be explored. In this article, we present the social processes impacting early mortality in people with SMI paradigm, which highlights the powerful role of social processes in shaping the health and health behaviors of people with SMI. This paradigm explores how loneliness, stigma (social and self), trauma, social exclusion, social isolation, and social norms are related to early mortality in people with SMI. This new paradigm is an important step in understanding and potentially addressing early mortality in people with SMI.

Horyzons USA: A moderated online social intervention for first episode psychosis

AIM

We evaluated the feasibility and acceptability of Horyzons, an online social media platform designed to facilitate relationship development among, and introduce therapeutic content to, first-episode psychosis (FEP) clients. We also evaluated whether participation in the platform was related to reduced loneliness, improved social integration and increased psychological well-being.

METHODS

Twenty-six participants diagnosed with a schizophrenia spectrum disorder were provided access to the moderated Horyzons platform for 12 weeks. During the intervention period, participants were encouraged to access therapeutic content and social components embedded within the site. Participants were recruited from three first-episode coordinated specialty care clinics in North Carolina and assessed at four time points: baseline, mid-treatment, post-treatment and 1-month follow-up.

RESULTS

Findings indicated that Horyzons was both feasible and very well tolerated, with a 92.3% retention rate and 79.2% of participants actively engaged in the platform. The most commonly identified personal strengths selected by Horyzons users were creativity (61.5%), curiosity (42.3%) and courage (38.5%). Feedback from participants indicated Horyzons could be improved by the development of a smartphone application, expanding the size of the Horyzons community and facilitating private messages between users. Preliminary results with engaged participants showed the greatest improvements in psychosis-related symptoms, followed by self-reported experience of negative emotions, depressive symptoms and loneliness.

CONCLUSIONS

This open trial found that Horyzons is both feasible and acceptable to FEP persons early in the course of illness living in the United States.

Why We Come: Clubhouse Members Seek Connection, Purpose and Meaning

Approximately 4.5% of U.S. adults live with a serious mental illness (SMI) (Substance Abuse and Mental Health Services Administration, 2018). Creating a place for people seeking structure, connection, and purpose following psychiatric hospitalization or for mental health recovery is difficult given several factors associated with illness trajectories, lack of community-based support programs, and reliance on traditional models of care. Using semi-structured interviews, the current study examined the reasons people attend community programs referred to as psychosocial "clubhouses." Interviews with 140 people across 10 clubhouse programs in one state were conducted. Qualitative analyses revealed that social connections and the need to reduce social isolation were driving forces for attending. Further, individuals noted that the "structure" of engaging in meaningful activities and roles was a main reason for participating. Authors discuss the continued need for community models that provide a "place" for all people to successfully engage and recover from psychiatric illnesses.

Are negative beliefs about psychosis associated with emotional distress in adults and young people with such experiences? A meta-analysis

OBJECTIVE

Emotional distress, including depression and anxiety, is commonly reported amongst individuals experiencing psychosis. The beliefs individuals hold about the meaning of their psychosis may explain the distress they experience. The current meta-analysis aimed to review the association between beliefs about psychosis experiences and emotional distress.

METHOD

Three electronic databases (PsycINFO, MEDLINE, and CINAHL) were searched using keywords and controlled vocabulary (e.g., Medical Subject Headings) from date of inception to August 2019. A total of 19 eligible papers were identified.

RESULTS

Our random-effects meta-analysis revealed that depression and anxiety held moderate association with psychosis beliefs, with perceptions concerning a lack of control over experiences having the strongest association with distress. Longitudinal studies suggest that negative beliefs at baseline are associated with depressive symptoms at follow-up.

CONCLUSIONS

The results suggest that the endorsement of negative beliefs about psychosis is associated with current level of depression and anxiety. The results are consistent with theories of emotional distress in psychosis. However, the small number of longitudinal papers limits what can be concluded about the direction or other temporal characteristics of these relationships. Therapies that target unhelpful beliefs about psychosis may beneficial.

PRACTITIONER POINTS

Negative beliefs about experiences of psychosis are associated with greater emotional distress such as depression and anxiety. Beliefs about a lack of control over experiences had the strongest association with distress. Interventions that aim to modify or prevent the formation of unhelpful beliefs about psychosis may be beneficial for this population.

Loneliness in early psychosis: a qualitative study exploring the views of mental health practitioners in early intervention services

BACKGROUND

Loneliness is an important public health problem with established adverse effects on physical and mental health. Although people with psychosis often experience high levels of loneliness, relatively little is known about the relationship between loneliness and early psychosis. Potential interventions to address loneliness might be easier to implement early in the illness when social networks and social skills may be more intact than at a later stage. We investigated the views of mental health practitioners about the context and causes of loneliness in people with early psychosis, and about potential interventions.

METHODS

Semi-structured face-to-face interviews were conducted with mental health practitioners (n = 20). Participants were purposively recruited from four early intervention services for first-episode psychosis in the UK. Interviews were transcribed verbatim and thematic analysis was conducted.

RESULTS

Participants believed that the majority of service users with early psychosis experience feelings of loneliness. They often saw socially isolated and disconnected clients and believed them to be lonely, but rarely discussed loneliness explicitly in clinical interactions. A combination of symptoms, stigma and negative sense of self were believed to underpin loneliness. Participants could not identify any specific current interventions delivered by their services for tackling loneliness, but thought some routinely provided interventions, including social groups and psychological treatments, could be helpful. They favoured making a wider range of loneliness interventions available and believed that community agencies beyond mental health services should be involved to make these effective and feasible to deliver. They suggested social participation interventions without an explicit mental health focus as potentially promising and valued a co-produced approach to intervention development.

CONCLUSIONS

This study suggests that loneliness is not routinely discussed in early intervention services, and a targeted strategy for tackling it is lacking. Co-produced, individualised community approaches, and interventions that target symptoms, stigma and negative self-schemas might be beneficial in alleviating loneliness for people with early psychosis. Empirical research is needed to develop and test such interventions.

Social connectedness in adults with mental disorders: ecological validation of a conceptual framework for novel complex interventions

BACKGROUND

Social connectedness interventions may improve the clinical outcomes and personal recovery of adults with mental disorders but many interventions lack a clear theory-base and show limited effectiveness.

AIM

To evaluate the validity of a newly developed conceptual framework (the CIVIC framework: Closeness, Identity, Valued relationships, Involvement and Cared for and accepted) to function as the theory-base for novel social connectedness-based mental health interventions.

METHOD

Semi-structured interviews with adults with diagnostically heterogeneous mental disorders (n = 13) and mental health professionals (n = 9). Participants reported their social connectedness experiences, their views on the CIVIC framework and potential targets for new interventions. Sequential inductive and deductive thematic analyses were used. Data quality was assessed through respondent validation.

RESULTS

Both inductive and deductive analyses provided validation of the CIVIC framework. Additional themes of Stigma and Connectedness beyond social relationships were identified in the inductive analysis. Candidate interventions to target each CIVIC domain were identified.

CONCLUSIONS

The CIVIC framework demonstrates ecological validity and can therefore serve as the theory-base for the development of novel social connectedness-based interventions. This study indicates that interventions would be most effective when they incorporate evidence-based approaches which target each of the categories described by the CIVIC framework.

What gets in the way of social engagement in schizophrenia?

BACKGROUND

Social engagement-important for health and well-being-can be difficult for people with schizophrenia. Past research indicates that despite expressing interest in social interactions, people with schizophrenia report spending less time with others and feeling lonely. Social motivations and barriers may play an important role for understanding social engagement in schizophrenia.

AIM

To investigate how people with schizophrenia describe factors that impede and promote social engagement.

METHODS

We interviewed a community sample of people with (n = 35) and without (n = 27) schizophrenia or schizoaffective disorder about their social interactions with friends and family over the past week and planned social activities for the coming week. We reviewed the interview transcripts and developed a novel coding system to capture whether interactions occurred, who had initiated the contact, and frequency of reported social barriers (i.e., internal, conflict-based, logistical) and social motivations (i.e., instrumental, affiliative, obligation-based). We also assessed symptoms and functioning.

RESULTS

People with schizophrenia were less likely than people without schizophrenia to have spent time with friends [t (51.04) = 2.09, P = 0.042, d = 0.51)], but not family. People with schizophrenia reported more social barriers than people without schizophrenia [F (1, 60) = 10.55, P = 0.002, ηp2 = 0.15)] but did not differ in reported social motivations. Specifically, people with schizophrenia reported more internal [t (45.75) = 3.40, P = 0.001, d = 0.83)] and conflict-based [t (40.11) = 3.03, P = 0.004, d = 0.73)] barriers than people without schizophrenia. Social barriers and motivations were related to real-world social functioning for people with schizophrenia, such that more barriers were associated with more difficulty in close relationships (r = -0.37, P = 0.027) and more motivations were associated with better community functioning (r = 0.38, P = 0.024).

CONCLUSION

These findings highlight the importance of assessing first person accounts of social barriers and motivations to better understand social engagement in schizophrenia.

Polygenic overlap and shared genetic loci between loneliness, severe mental disorders, and cardiovascular disease risk factors suggest shared molecular mechanisms

Clinical and epidemiological evidence suggest that loneliness is associated with severe mental disorders (SMDs) and increases the risk of cardiovascular disease (CVD). However, the mechanisms underlying the relationship between loneliness, SMDs, and CVD risk factors remain unknown. Here we explored overlapping genetic architecture and genetic loci shared between SMDs, loneliness, and CVD risk factors. We analyzed large independent genome-wide association study data on schizophrenia (SCZ), bipolar disorder (BD), major depression (MD), loneliness and CVD risk factors using bivariate causal mixture mode (MiXeR), which estimates the total amount of shared variants, and conditional false discovery rate to evaluate overlap in specific loci. We observed substantial genetic overlap between SMDs, loneliness and CVD risk factors, beyond genetic correlation. We identified 149 loci jointly associated with loneliness and SMDs (MD n = 67, SCZ n = 54, and BD n = 28), and 55 distinct loci jointly associated with loneliness and CVD risk factors. A total of 153 novel loneliness loci were found. Most of the shared loci possessed concordant effect directions, suggesting that genetic risk for loneliness may increase the risk of both SMDs and CVD. Functional analyses of the shared loci implicated biological processes related to the brain, metabolic processes, chromatin and immune system. Altogether, the study revealed polygenic overlap between loneliness, SMDs and CVD risk factors, providing new insights into their shared genetic architecture and common genetic mechanisms.

Childhood maltreatment and social functioning in psychotic disorders: a systematic review protocol

Background: Childhood maltreatment (CM) is thought to play a key role in the etiology and course of psychotic disorders (PD). In addition, CM is related to neurobiological and clinical characteristics that can lead to poor social functioning. However, the extent to which CM and social functioning are directly associated in individuals with PD, is unclear. Therefore, we aim to systematically review the literature to provide an estimate on the strength of the association between CM and different domains of social functioning in PD and to summarize potential moderators and mediators of this association.Methods and analysis: To identify relevant studies, we will systematically search the following databases: Pubmed (Medline), PsycInfo, Embase, Web of Science (Core Collection), and Pilots (trauma), manually search reference lists and contact experts in the field. Studies will be included if they investigate and report on the association between CM (exposure) and social functioning (outcome) in adults with PD. Two independent reviewers will screen titles, abstracts and full texts according to eligibility criteria, perform data extraction and assess study quality according to a modified version of the Newcastle-Ottawa Scale.Analysis: Effect estimates will be pooled in a meta-analysis. Heterogeneity and publication bias will be assessed and the effects of potential moderators (genetic factors, type of diagnosis, duration of illness, type of CM and age at the time of CM exposure) will be analyzed using meta-regressions. Candidate moderators and mediators (neurocognition, cognitive schemas, comorbidities, stress sensitivity, attachment) will be also examined qualitatively.Ethics and dissemination: Because this review will make use of already published data, ethical approval will not be sought. This work has the potential to inform upcoming investigations on the association between the exposure to CM in PD and social functioning. PROSPERO registration number CRD42020175244.

The Intersection Between Childhood Trauma, the COVID-19 Pandemic, and Trauma-related and Psychotic Symptoms in People With Psychotic Disorders

Introduction

People with psychotic disorders may be disproportionately affected by the traumatic effects of the COVID-19 pandemic. Childhood trauma, which also increases vulnerability to subsequent stressors, is common in individuals with psychosis. In this study, we investigated the intersection of the pandemic, childhood trauma, and psychotic and trauma-related symptoms in individuals with psychotic disorders.

Methods

We administered a cross-sectional survey to 151 participants [47 schizophrenia (SZ), 53 psychotic bipolar disorder (BP)], 51 healthy control (HC)] during the COVID-19 pandemic. Participants were asked about exposure to the pandemic’s impacts, childhood trauma, and post-traumatic stress, dissociative, and psychotic symptoms.

Results

BP reported greater negative impacts to emotional health than SZ and HC and to non-COVID physical health than HC. SZ reported less impact on work and employment during the pandemic. There were no other group differences in pandemic-related adversities. We also found that cumulative exposure to the pandemic’s negative impacts was significantly associated with PTSD symptoms but not psychotic or dissociative symptoms. Moreover, the number of adversities an individual experienced during the pandemic was strongly associated with the cumulative number of traumatic experiences they had in childhood.

Discussion

Our results suggest that having a psychotic disorder does not, in and of itself, increase susceptibility to the pandemic’s negative impacts. Instead, we provide evidence of a graded relationship between cumulative exposure to the pandemic’s negative impacts and PTSD symptom severity, as well as a graded relationship between cumulative childhood traumatic experiences and the number pandemic adversities, across diagnoses.