An internet-based intervention for people with psychosis (EviBaS): study protocol for a randomized controlled trial

Randomised controlled trial on the effect of video-conference cognitive behavioural therapy for patients with schizophrenia: a study protocol

INTRODUCTION

Cognitive behavioural therapy for psychosis (CBTp) has demonstrated effectiveness in reducing positive symptoms, improving depression, enhancing coping skills and increasing awareness of illness. However, compared with cognitive behavioural therapy for depression and anxiety, the spread of CBTp in clinical practice is minimal. The present study designed a randomised controlled trial (RCT) research protocol to evaluate whether real-time remote video-conference CBTp (vCBTp) could facilitate access to psychosocial interventions and effectively improve symptoms compared with usual care (UC) for patients with schizophrenia.

METHODS AND ANALYSIS

This exploratory RCT will consist of two parallel groups (vCBTp+UC and UC alone) of 12 participants (n=24) diagnosed with schizophrenia, schizoaffective disorder or paranoid disorder, who remain symptomatic following pharmacotherapy. Seven 50-min weekly vCBTp interventions will be administered to test efficacy. The primary outcome will be the positive and negative syndrome scale score at week 8. The secondary outcome will be the Beck Cognitive Insight Scale to assess insight, the Patient Health Questionnaire-9 to assess depression, the Generalised Anxiety Disorder-7 to assess anxiety, the 5-level EuroQol 5-dimensional questionnaire to assess quality of life and the Impact of Event Scale-Revised to assess subjective distress about a specific stressful life event. We will take all measurements at 0 weeks (baseline) and at 8 weeks (post-intervention), and apply intention-to-treat analysis.

ETHICS AND DISSEMINATION

We will conduct this study in the outpatient department of Cognitive Behavioral Therapy Center at Chiba University Hospital. Further, all participants will be informed of the study and will be asked to sign consent forms. We will report according to the Consolidated Standards of Reporting Trials.

TRIAL REGISTRATION NUMBER

UMIN000043396.

Statistical analysis plans for two randomised controlled trials of the Narrative Experiences Online (NEON) Intervention: impact of receiving recorded mental health recovery narratives on quality of life in people experiencing psychosis (NEON) and people experiencing non-psychosis mental health problems (NEON-O)

BACKGROUND

Mental health recovery narratives are a first-hand account of an individual's recovery from mental health distress, access to narratives can aid recovery. The NEON Intervention is a web-application providing access to a managed collection of narratives. We present the statistical analysis plan for assessing the effectiveness of the NEON Intervention in improving quality of life at 1-year post-randomisation. We pay particular focus on the statistical challenges encountered due to the online nature of this trial.

METHODS AND DESIGN

The NEON Intervention is assessed in two trial populations, one for people with experience of psychosis in the last 5 years, and mental health distress in the last six months (NEON Trial) and one for people with experience of non-psychosis mental health problems (NEON-O Trial). Both NEON trials are two-arm randomised controlled superiority trials comparing the effectiveness of the NEON Intervention with usual care. The target sample size is 684 randomised participants for NEON and 994 for NEON-O. Participants were randomised centrally in a 1:1 ratio.

RESULTS

The primary outcome is the mean score of subjective items on the Manchester Short Assessment of Quality-of-Life questionnaire (MANSA) at 52 weeks. Secondary outcomes are scores from the Herth Hope Index, Mental Health Confidence Scale, Meaning of Life questionnaire, CORE-10 questionnaire and Euroqol 5-Dimension 5-Level (EQ-5D-5L).

CONCLUSION

This manuscript is the statistical analysis plan (SAP) for the NEON trials. Any post hoc analysis, such as those requested by journal reviewers will be clearly labelled as such in the final trial reporting. Trial registration Both trials were prospectively registered. NEON Trial: ISRCTN11152837, registered on 13 August 2018. NEON-O Trial: ISRCTN63197153, registered on 9 January 2020.

'You are trying to teach us to think more slowly!': Adapting Metacognitive Training for the acute care setting-A case report

Psychological group interventions for the acute inpatient care setting are scarce. Whereas Metacognitive Training for patients with Psychosis (MCT) provides a widely accessible, easy-to-implement intervention for patients with mild to moderate symptoms, it is less adequate for the acute care setting with respect to length and density of information. We present the adaptation process and the resulting adaptation of MCT, MCT-Acute, for the acute inpatient care setting. We report the case of a first patient, NK, who participated in MCT-Acute during her mandated stay on the locked acute ward due to an exacerbation of schizophrenia. NK participated in MCT-Acute 12 times, evaluated the training overall as positive and reported that she used exercises she had learned during training to improve her mood. She also described changing her behaviour in everyday life to think more slowly and make less hasty decisions, which is a central topic discussed in MCT and MCT-Acute. Conducting an adapted version of MCT in the acute care setting is feasible, and the present case report suggests that MCT-Acute may be a useful complement to a multidisciplinary treatment plan to stabilize patients with severe mental illness in acute inpatient care.

Insight and the number of completed modules predict a reduction of positive symptoms in an Internet-based intervention for people with psychosis

Emerging evidence suggests that Internet-based interventions for people with psychosis (ICBTp) are feasible and efficacious. However, predictors of adherence and treatment outcomes are largely unknown. To narrow this research gap, we conducted secondary analyses on data from a randomized controlled trial, which evaluated an eight-week ICBTp intervention targeting topics, such as voice hearing, mindfulness, and others. In n = 100 participants with psychosis, we aimed at identifying sociodemographic, psychopathological, and treatment-related predictor variables of post-treatment symptoms and adherence (i.e., at least four completed modules). We followed a two-stage approach. First, we conducted regression analyses to examine the effect of single candidate predictors on post-treatment symptoms as well as adherence. Subsequently, we selected variables that met a significance threshold of p < .1 and entered them into linear and logistic multiple regression models. Whereas no variable was able to predict adherence, the number of completed modules was negatively associated with self-reported delusion severity at post-treatment. Additionally, higher pre-treatment insight predicted fewer hallucinations after treatment. Because this was one of the first studies to investigate predictors in ICBTp, more research is needed to customize future interventions to the needs of users.

Psychiatry in the Digital Age: A Blessing or a Curse?

Social distancing and the shortage of healthcare professionals during the COVID-19 pandemic, the impact of population aging on the healthcare system, as well as the rapid pace of digital innovation are catalyzing the development and implementation of new technologies and digital services in psychiatry. Is this transformation a blessing or a curse for psychiatry? To answer this question, we conducted a literature review covering a broad range of new technologies and eHealth services, including telepsychiatry; computer-, internet-, and app-based cognitive behavioral therapy; virtual reality; digital applied games; a digital medicine system; omics; neuroimaging; machine learning; precision psychiatry; clinical decision support; electronic health records; physician charting; digital language translators; and online mental health resources for patients. We found that eHealth services provide effective, scalable, and cost-efficient options for the treatment of people with limited or no access to mental health care. This review highlights innovative technologies spearheading the way to more effective and safer treatments. We identified artificially intelligent tools that relieve physicians from routine tasks, allowing them to focus on collaborative doctor-patient relationships. The transformation of traditional clinics into digital ones is outlined, and the challenges associated with the successful deployment of digitalization in psychiatry are highlighted.

Thought Suppression in Primary Psychotic Disorders and Substance/Medication Induced Psychotic Disorder

Introduction: First episode-psychosis (FEP) represents a stressful/traumatic event for patients. To our knowledge, no study to date has investigated thought suppression involved in FEP in a Romanian population. Our objective was to investigate thought suppression occurring during FEP within primary psychotic disorders (PPD) and substance/medication induced psychotic disorders (SMIPD). Further, we examined the relationship between thought suppression and negative automatic thoughts within PPD and SMIPD. Methods: The study included 30 participants (17 females) with PPD and 25 participants (10 females) with SMIPD. Psychological scales were administered to assess psychotic symptoms and negative automatic thoughts, along a psychiatric clinical interview and a biochemical drug test. Results: Participants in the PPD group reported higher thought suppression compared to SMIPD group. For the PPD group, results showed a positive correlation between thought suppression and automatic thoughts. For the SMIPD group, results also showed a positive correlation between thought suppression and automatic thoughts. Conclusions: Patients with PPD rely more on thought suppression, as opposed to SMIPD patients. Thought suppression may be viewed as an unhealthy reaction to FEP, which is associated with the experience of negative automatic thoughts and might be especially problematic in patients with PPD. Cognitive behavioral therapy is recommended to decrease thought suppression and improve patients’ functioning.

Sleep problems and worrying precede psychotic symptoms during an online intervention for psychosis

OBJECTIVE

Experience sampling assessments (multiple assessments per day for approximately one week) indicate that positive symptoms fluctuate over time in psychosis. Precursors, such as sleep problems or worrying, predict these fluctuations. To date, it remains unclear whether the same precursors predict symptom variability also during treatment in an online intervention for psychosis, using assessments lying temporally further apart.

METHODS

Participants completed brief intermediate online self-report assessments on their computers (up to every 7 days during a 2-month waiting period and up to twice every 6 days during a 2-month intervention period) within a randomized controlled trial. We monitored the course of paranoia, auditory verbal hallucinations, and their theory-driven precursors worrying, negative affect, self-esteem, self-reported cognitive biases, and quality of sleep in n = 124 participants (M = 10.32 assessments per participant; SD = 6.07). We tested group differences regarding the course of the composite of precursors, group differences regarding the effect of the composite on subsequent momentary psychotic symptoms, and the effect of each individual precursor on subsequent psychotic symptoms, using (lagged) linear mixed models.

RESULTS

The course composite precursors over time and their lagged effect on subsequent momentary psychotic symptoms did not differ between groups. During the intervention, increased worrying and decreased quality of sleep preceded heightened momentary psychotic symptoms.

CONCLUSION

The regression-based design does not allow drawing causal conclusions. However, worrying and sleep problems likely represent underlying mechanisms of psychotic symptom variability during online psychosis treatment, indicating that experience sampling findings from everyday life generalize to interventions with assessments lying several days apart.

PRACTITIONER POINTS

Worrying and sleep problems represent important mechanisms of symptom fluctuations during an online intervention for people with psychosis. Our findings further support the notion that worrying and sleep problems are important treatment targets in psychological interventions for people with psychosis. Momentary levels of worrying and quality of sleep can signal subsequent fluctuations of psychotic symptom severity so practitioners should monitor these variables during treatment. Worrying seems to predict subsequent paranoia specifically during treatment whereas quality of sleep predicts both paranoia and auditory verbal hallucinations.

www.psychopap.com : améliorer l’accès à la psychothérapie par le transfert des connaissances aux patients et aux futurs thérapeutes

La psychothérapie est un traitement efficace pour plusieurs troubles mentaux. Elle est, toutefois, peu accessible pour différentes raisons, dont son coût, la façon de l’offrir et la disponibilité locale des thérapeutes. Par ailleurs, l’accès à la formation en psychothérapie pour les futurs thérapeutes peut être compliqué par différents facteurs incluant le manque de ressources adaptées à différents contextes de pratique et la difficulté à obtenir une supervision. Dans ce contexte, un site web offrant des documents d’autothérapie aux patients, des miniguides de formation dans différents types de psychothérapies basées sur des données probantes, des suggestions d’articles et livres phares, des capsules vidéo expliquant les principes sous-tendant différents modèles théoriques et démontrant des techniques de psychothérapie, pourrait bénéficier autant aux patients qu’aux psychothérapeutes débutants.

L’Hôpital en santé mentale Albert-Prévost (HSMAP), impliqué dès ses origines dans la formation et la pratique de la psychothérapie, conçoit un tel outil pour célébrer son centenaire, le site www.psychopap.com. Le présent article propose de décrire la genèse et le déploiement de ce projet de transmission de connaissances en psychothérapie en décrivant d’abord le contexte et l’implication des membres de l’HSMAP dans l’enseignement de la psychothérapie puis une brève recension des écrits concernant l’autothérapie pour les troubles mentaux, l’utilisation des ordinateurs/Internet pour l’enseignement de la psychothérapie et comment ces données ont été appliquées dans la création de www.psychopap.com.

Prolonged rather than hasty decision-making in schizophrenia using the box task. Must we rethink the jumping to conclusions account of paranoia?

Jumping to conclusions (JTC) is the best established cognitive bias in schizophrenia and is increasingly targeted in interventions aimed to improve positive symptoms. To address shortcomings of the standard measure to capture JTC, the beads task, we developed a new variant-the box task-which was subsequently validated in people with elevated psychotic-like experiences. For the first time, the box task was administered in a sample of individuals with manifest schizophrenia. We hypothesized that patients with schizophrenia would display an elevated JTC bias relative to controls.

METHOD

We recruited a large sample of 101 patients with schizophrenia and matched them to an online sample recruited from the general population. In the box task, participants must decide which of two kinds of colored balls are presented more often. Participants are told that the task may end prematurely, and that task performance will be counted as an error if no decision had been made before that point. The primary measure was the number of draws to decision (DTD), where fewer DTD corresponds to greater JTC.

RESULTS

In contrast to expectations, participants with schizophrenia showed significantly higher DTD (i.e., reduced JTC). Consistent with our previous findings, patients also displayed a lowered decision threshold compared to controls. Response confidence for the final decision was lower in patients and correlated with self-esteem and positive symptoms. While there was evidence that previous knowledge of the box task lowered DTD, exclusion of participants with experience on the box task did not substantially change results.

DISCUSSION

The study fits a growing body of experiments casting doubt on the generalizability of the JTC effect in schizophrenia across different tasks. While the study tentatively supports a liberal acceptance account of psychosis, caution is warranted and we recommend that research should explore and control for potentially important mediators (e.g., task difficulty, stress, test-taking attitudes).

Impact of receiving recorded mental health recovery narratives on quality of life in people experiencing psychosis, people experiencing other mental health problems and for informal carers: Narrative Experiences Online (NEON) study protocol for three randomised controlled trials

BACKGROUND

Mental health recovery narratives have been defined as first-person lived experience accounts of recovery from mental health problems which refer to events or actions over a period of time and which include elements of adversity or struggle, and also self-defined strengths, successes or survival. They are readily available in invariant recorded form, including text, audio or video. Previous studies have provided evidence that receiving recorded recovery narratives can provide benefits to recipients. This protocol describes three pragmatic trials that will be conducted by the Narrative Experiences Online (NEON) study using the NEON Intervention, a web application that delivers recorded recovery narratives to its users. The aim of the NEON Trial is to understand whether receiving online recorded recovery narratives through the NEON Intervention benefits people with experience of psychosis. The aim of the NEON-O and NEON-C trials is to evaluate the feasibility of conducting a definitive trial on the use of the NEON Intervention with people experiencing non-psychosis mental health problems and those who care for others experiencing mental health problems respectively.

METHODS

The NEON Trial will recruit 683 participants with experience of psychosis. The NEON-O Trial will recruit at least 100 participants with experience of non-psychosis mental health problems. The NEON-C Trial will recruit at least 100 participants with experience of caring for others who have experienced mental health problems. In all three trials, participants will be randomly allocated into one of two arms. Intervention arm participants will receive treatment as usual plus immediate access to the NEON Intervention for 1 year. Control arm participants will receive treatment as usual plus access to the NEON Intervention after 1 year. All participants will complete demographics and outcome measures at baseline, 1 week, 12 weeks and 52 weeks. For the NEON Trial, the primary outcome measure is the Manchester Short Assessment of Quality of Life at 52 weeks, and secondary outcome measures are the CORE-10, Herth Hope Index, Mental Health Confidence Scale and Meaning in Life Questionnaire. A cost-effectiveness analysis will be conducted using data collected through the EQ-5D-5 L and the Client Service Receipt Inventory.

DISCUSSION

NEON Trial analyses will establish both effectiveness and cost-effectiveness of the NEON Intervention for people with experience of psychosis, and hence inform future clinical recommendations for this population.

TRIAL REGISTRATION

All trials were prospectively registered with ISRCTN. NEON Trial: ISRCTN11152837 . Registered on 13 August 2018. NEON-C Trial: ISRCTN76355273 . Registered on 9 January 2020. NEON-O Trial: ISRCTN63197153 . Registered on 9 January 2020.

Mindfulness Mediates the Effect of a Psychological Online Intervention for Psychosis on Self-Reported Hallucinations: A Secondary Analysis of Voice Hearers From the EviBaS Trial

BACKGROUND

Psychological online interventions (POIs) could represent a promising approach to narrow the treatment gap in psychosis but it remains unclear whether improving mindfulness functions as a mechanism of change in POIs. For the present study, we examined if mindfulness mediates the effect of a comprehensive POI on distressing (auditory) hallucinations.

METHODS

We conducted a secondary analysis on voice hearers (n = 55) from a randomized controlled trial evaluating a POI for psychosis (EviBaS; trial registration NCT02974400, clinicaltrials.gov). The POI includes a module on mindfulness and we only considered POI participants in our analyses who completed the mindfulness module (n = 16).

RESULTS

Participants who completed the mindfulness module reported higher mindfulness (p = 0.015) and lower hallucinations (p = 0.001) at post assessment, compared to controls, but there was no effect on distress by voices (p = 0.598). Mindfulness mediated the POI's effect on hallucinations (b = -1.618, LLCI = -3.747, ULCI = -0.054) but not on distress by voices (b = -0.057, LLCI = -0.640, ULCI = 0.915).

LIMITATIONS AND DISCUSSION

Completion of the mindfulness module was not randomized. Hence, we cannot draw causal inferences. Even if we assumed causality, it remains unclear which contents of the POI could have resulted in increased mindfulness and reduced hallucinations, as participants completed other modules as well. In addition, confounding variables could explain the mediation and the sample size was small. Nonetheless, the overall pattern of results indicates that the POI is likely to improve mindfulness, and that increased mindfulness could partially explain the POI's efficacy.