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Coronado-Montoya S, Abdel-Baki A, Crockford D, Côté J, Dubreucq S, Dyachenko A, Fischer B, Lecomte T, L’Heureux S, Ouellet-Plamondon C, Roy MA, Tibbo P, Villeneuve M, Jutras-Aswad D. Preferences of Young Adults With Psychosis for Cannabis-Focused Harm Reduction Interventions: A Cross-Sectional Study: Préférences des jeunes adultes souffrant de psychose pour les interventions de réduction des méfaits axées sur le cannabis : une étude transversale. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2024; 69:524-535. [PMID: 38571478 PMCID: PMC11168346 DOI: 10.1177/07067437241242395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVES Cannabis use is common in people with early-phase psychosis (EP) and is associated with worse treatment outcomes. Few targeted interventions for cannabis use behaviour in this population exist, most focusing on abstinence, none focusing on harm reduction. Many people with EP will not seek treatment for their cannabis use with current therapeutic options. Understanding preferences for cannabis-focused harm reduction interventions may be key to improving outcomes. This study aimed to determine preferences of young adults with EP who use cannabis for cannabis-focused harm reduction interventions. METHODS Eighty-nine young adults across Canada with EP interested in reducing cannabis-related harms were recruited. An online questionnaire combining conventional survey methodology and two unique discrete choice experiments (DCEs) was administered. One DCE focused on attributes of core harm reduction interventions (DCE 1) and the second on attributes of boosters (DCE 2). We analysed these using mixed ranked-ordered logistic regression models. Preference questions using conventional survey methodology were analysed using summary statistics. RESULTS Preferred characteristics for cannabis-focused harm reduction interventions (DCE 1) were: shorter sessions (60 min vs. 10 min, odds ratio (OR): 0.72; P < 0.001); less frequent sessions (daily vs. monthly, OR: 0.68; P < 0.001); shorter interventions (3 months vs. 1 month, OR: 0.80; P < 0.01); technology-based interventions (vs. in-person, OR: 1.17; P < 0.05). Preferences for post-intervention boosters (DCE 2) included opting into boosters (vs. opting out, OR: 3.53; P < 0.001) and having shorter boosters (3 months vs. 1 month, OR: 0.79; P < 0.01). Nearly half of the participants preferred to reduce cannabis use as a principal intervention goal (vs. using in less harmful ways or avoiding risky situations). CONCLUSIONS Further research is required to see if technology-based harm reduction interventions for cannabis featuring these preferences translate into greater engagement and improved outcomes in EP patients.
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Affiliation(s)
- Stephanie Coronado-Montoya
- Department of Psychiatry and Addiction, Université de Montréal, Montréal, Canada
- Research Centre, Centre Hospitalier de l’Université de Montréal, Montréal, Canada
| | - Amal Abdel-Baki
- Department of Psychiatry and Addiction, Université de Montréal, Montréal, Canada
- Research Centre, Centre Hospitalier de l’Université de Montréal, Montréal, Canada
- Department of Psychiatry, Centre Hospitalier de l’Université de Montréal, Montréal, Canada
| | - David Crockford
- Department of Psychiatry, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - José Côté
- Research Centre, Centre Hospitalier de l’Université de Montréal, Montréal, Canada
- Faculty of Nursing, Université de Montréal, Montréal, Canada
| | - Simon Dubreucq
- Department of Psychiatry and Addiction, Université de Montréal, Montréal, Canada
- Research Centre, Centre Hospitalier de l’Université de Montréal, Montréal, Canada
| | - Alina Dyachenko
- Research Centre, Centre Hospitalier de l’Université de Montréal, Montréal, Canada
| | - Benedikt Fischer
- Centre for Applied Research in Addiction and Mental Health, Simon Fraser University, Vancouver, Canada
- Research & Graduate Studies Division, University of the Fraser Valley, Abbotsford, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
- School of Population Health, University of Auckland, Auckland, New Zealand
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Tania Lecomte
- Department of Psychology, University of Montréal, Montréal, Canada
- Centre de Recherche de l’Institut Universitaire en Santé Mentale de Montréal, Montréal, Canada
| | - Sophie L’Heureux
- Clinique Notre-Dame des Victoires, Institut Universitaire en Santé Mentale, Centre Intégré Universitaire de Soins et Services Sociaux de la Capitale Nationale, Québec, Canada
- Department of Psychiatry and Neurosciences, Laval University, Québec, Canada
| | - Clairélaine Ouellet-Plamondon
- Department of Psychiatry and Addiction, Université de Montréal, Montréal, Canada
- Research Centre, Centre Hospitalier de l’Université de Montréal, Montréal, Canada
- Department of Psychiatry, Centre Hospitalier de l’Université de Montréal, Montréal, Canada
| | - Marc-André Roy
- Department of Psychiatry and Neurosciences, Laval University, Québec, Canada
- Centre de Recherche de l’Institut Universitaire en Santé Mentale de Québec, Québec, Canada
- Centre de Recherche CERVO, Québec, Canada
| | - Philip Tibbo
- Department of Psychiatry, Dalhousie University, Halifax, Canada
| | - Marie Villeneuve
- Department of Psychiatry and Addiction, Université de Montréal, Montréal, Canada
| | - Didier Jutras-Aswad
- Department of Psychiatry and Addiction, Université de Montréal, Montréal, Canada
- Research Centre, Centre Hospitalier de l’Université de Montréal, Montréal, Canada
- Department of Psychiatry, Centre Hospitalier de l’Université de Montréal, Montréal, Canada
- University Institute on Addictions, Montréal, Canada
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Mayer SF, Corcoran C, Kennedy L, Leucht S, Bighelli I. Cognitive behavioural therapy added to standard care for first-episode and recent-onset psychosis. Cochrane Database Syst Rev 2024; 3:CD015331. [PMID: 38470162 PMCID: PMC10929366 DOI: 10.1002/14651858.cd015331.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) can be effective in the general population of people with schizophrenia. It is still unclear whether CBT can be effectively used in the population of people with a first-episode or recent-onset psychosis. OBJECTIVES To assess the effects of adding cognitive behavioural therapy to standard care for people with a first-episode or recent-onset psychosis. SEARCH METHODS We conducted a systematic search on 6 March 2022 in the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, ISRCTN, and WHO ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing CBT added to standard care vs standard care in first-episode or recent-onset psychosis, in patients of any age. DATA COLLECTION AND ANALYSIS Two review authors (amongst SFM, CC, LK and IB) independently screened references for inclusion, extracted data from eligible studies and assessed the risk of bias using RoB2. Study authors were contacted for missing data and additional information. Our primary outcome was general mental state measured on a validated rating scale. Secondary outcomes included other specific measures of mental state, global state, relapse, admission to hospital, functioning, leaving the study early, cognition, quality of life, satisfaction with care, self-injurious or aggressive behaviour, adverse events, and mortality. MAIN RESULTS We included 28 studies, of which 26 provided data on 2407 participants (average age 24 years). The mean sample size in the included studies was 92 participants (ranging from 19 to 444) and duration ranged between 26 and 52 weeks. When looking at the results at combined time points (mainly up to one year after start of the intervention), CBT added to standard care was associated with a greater reduction in overall symptoms of schizophrenia (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.47 to -0.08, 20 RCTs, n = 1508, I2 = 68%, substantial heterogeneity, low certainty of the evidence), and also with a greater reduction in positive (SMD -0.22, 95% CI -0.38 to -0.06, 22 RCTs, n = 1565, I² = 52%, moderate heterogeneity), negative (SMD -0.20, 95% CI -0.30 to -0.11, 22 RCTs, n = 1651, I² = 0%) and depressive symptoms (SMD -0.13, 95% CI -0.24 to -0.01, 18 RCTs, n = 1182, I² = 0%) than control. CBT added to standard care was also associated with a greater improvement in the global state (SMD -0.34, 95% CI -0.67 to -0.01, 4 RCTs, n = 329, I² = 47%, moderate heterogeneity) and in functioning (SMD -0.23, 95% CI -0.42 to -0.05, 18 RCTs, n = 1241, I² = 53%, moderate heterogeneity, moderate certainty of the evidence) than control. We did not find a difference between CBT added to standard care and control in terms of number of participants with relapse (relative risk (RR) 0.82, 95% CI 0.57 to 1.18, 7 RCTs, n = 693, I² = 48%, low certainty of the evidence), leaving the study early for any reason (RR 0.87, 95% CI 0.72 to 1.05, 25 RCTs, n = 2242, I² = 12%, moderate certainty of the evidence), adverse events (RR 1.29, 95% CI 0.85 to 1.97, 1 RCT, n = 43, very low certainty of the evidence) and the other investigated outcomes. AUTHORS' CONCLUSIONS This review synthesised the latest evidence on CBT added to standard care for people with a first-episode or recent-onset psychosis. The evidence identified by this review suggests that people with a first-episode or recent-onset psychosis may benefit from CBT additionally to standard care for multiple outcomes (overall, positive, negative and depressive symptoms of schizophrenia, global state and functioning). Future studies should better define this population, for which often heterogeneous definitions are used.
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Affiliation(s)
- Susanna Franziska Mayer
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, TUM School of Medicine and Health, Technical University of Munich, München, Germany
| | | | - Liam Kennedy
- Department of Old Age Psychiatry, Carew House, St Vincent's Hospital, Dublin, Ireland
| | - Stefan Leucht
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, TUM School of Medicine and Health, Technical University of Munich, München, Germany
- German Center for Mental Health (DZPG), Munich, Germany
| | - Irene Bighelli
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, TUM School of Medicine and Health, Technical University of Munich, München, Germany
- German Center for Mental Health (DZPG), Munich, Germany
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Bighelli I, Çıray O, Salahuddin NH, Leucht S. Cognitive behavioural therapy without medication for schizophrenia. Cochrane Database Syst Rev 2024; 2:CD015332. [PMID: 38323679 PMCID: PMC10848293 DOI: 10.1002/14651858.cd015332.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) can be effective in people with schizophrenia when provided in combination with antipsychotic medication. It remains unclear whether CBT could be safely and effectively offered in the absence of concomitant antipsychotic therapy. OBJECTIVES To investigate the effects of CBT for schizophrenia when administered without concomitant pharmacological treatment with antipsychotics. SEARCH METHODS We conducted a systematic search on 6 March 2022 in the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, and WHO ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) in people with schizophrenia comparing CBT without antipsychotics to standard care, standard care without antipsychotics, or the combination of CBT and antipsychotics. DATA COLLECTION AND ANALYSIS Two review authors independently screened references for inclusion, extracted data from eligible studies, and assessed risk of bias using Cochrane's RoB 2 tool. We contacted study authors for missing data and additional information. Our primary outcome was general mental state measured with a validated rating scale. Key secondary outcomes were specific symptoms of schizophrenia, relapse, service use, number of participants leaving the study early, functioning, quality of life, and number of participants actually receiving antipsychotics during the trial. We also assessed behaviour, adverse effects, and mortality. MAIN RESULTS We included 4 studies providing data for 300 participants (average age 21.94 years). The mean sample size was 75 participants (range 61 to 90 participants). Study duration was between 26 and 39 weeks for the intervention period and 26 to 104 weeks for the follow-up period. Three studies employed a blind rater, while one study was triple-blind. All analyses included data from a maximum of three studies. The certainty of the evidence was low or very low for all outcomes. For the primary outcome overall symptoms of schizophrenia, results showed a difference favouring CBT without antipsychotics when compared to no specific treatment at long term (> 1 year mean difference measured with the Positive and Negative Syndrome Scale (PANSS MD) -14.77, 95% confidence interval (CI) -27.75 to -1.79, 1 RCT, n = 34). There was no difference between CBT without antipsychotics compared with antipsychotics (up to 12 months PANSS MD 3.38, 95% CI -2.38 to 9.14, 2 RCTs, n = 63) (very low-certainty evidence) or compared with CBT in combination with antipsychotics (up to 12 months standardised mean difference (SMD) 0.30, 95% CI -0.06 to 0.65, 3 RCTs, n = 125). Compared with no specific treatment, CBT without antipsychotics was associated with a reduction in overall symptoms (as described above) and negative symptoms (PANSS negative MD -4.06, 95% CI -7.50 to -0.62, 1 RCT, n = 34) at longer than 12 months. It was also associated with a lower duration of hospital stay (number of days in hospital MD -22.45, 95% CI -28.82 to -16.08, 1 RCT, n = 74) and better functioning (Personal and Social Performance Scale MD -12.42, 95% CI -22.75 to -2.09, 1 RCT, n = 40, low-certainty evidence) at up to 12 months. We did not find a difference between CBT and antipsychotics in any of the investigated outcomes, with the exception of adverse events measured with the Antipsychotic Non-Neurological Side-Effects Rating Scale (ANNSERS) at both 6 and 12 months (MD -4.94, 95% CI -8.60 to -1.28, 2 RCTs, n = 48; MD -6.96, 95% CI -11.55 to -2.37, 2 RCTs, n = 42). CBT without antipsychotics was less effective than CBT combined with antipsychotics in reducing positive symptoms at up to 12 months (SMD 0.40, 95% CI 0.05 to 0.76, 3 RCTs, n = 126). CBT without antipsychotics was associated with a lower number of participants experiencing at least one adverse event in comparison with CBT combined with antipsychotics at up to 12 months (risk ratio 0.36, 95% CI 0.17 to 0.80, 1 RCT, n = 39, low-certainty evidence). AUTHORS' CONCLUSIONS This review is the first attempt to systematically synthesise the evidence about CBT delivered without medication to people with schizophrenia. The limited number of studies and low to very low certainty of the evidence prevented any strong conclusions. An important limitation in the available studies was that participants in the CBT without medication group (about 35% on average) received antipsychotic treatment, highlighting the challenges of this approach. Further high-quality RCTs are needed to provide additional data on the feasibility and efficacy of CBT without antipsychotics.
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Affiliation(s)
- Irene Bighelli
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Germany
- German Center for Mental Health (DZPG), Munich, Germany
| | - Oğulcan Çıray
- Child and Adolescent Psychiatry Department, Mardin State Hospital Child and Adolescent Psychiatry Department, Mardin, Turkey
| | - Nurul Husna Salahuddin
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Stefan Leucht
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Germany
- German Center for Mental Health (DZPG), Munich, Germany
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Sunshine A, McClellan J. Practitioner Review: Psychosis in children and adolescents. J Child Psychol Psychiatry 2023; 64:980-988. [PMID: 36878476 PMCID: PMC10501332 DOI: 10.1111/jcpp.13777] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 03/08/2023]
Abstract
Psychotic symptoms, including hallucinations, delusions, and disorganized thinking and behaviors, are the hallmarks of schizophrenia; but may also present in the context of other psychiatric and medical conditions. Many children and adolescents describe psychotic-like experiences, which can be associated with other types of psychopathology and past experiences (e.g., trauma, substance use, and suicidality). However, most youth reporting such experiences do not have, nor will ever develop, schizophrenia or another psychotic disorder. Accurate assessment is critical because these different presentations have different diagnostic and treatment implications. For this review, we focus primarily on the diagnosis and treatment of early onset schizophrenia. In addition, we review the development of community-based first-episode psychosis programming, and the importance of early intervention and coordinated care.
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Affiliation(s)
- Anna Sunshine
- Department of Psychiatry, University of Washington, Seattle, WA, USA
| | - Jon McClellan
- Department of Psychiatry, University of Washington, Seattle, WA, USA
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Pattnaik JI, Panda UK, Chandran S, Padhy S, Ravan JR. Treatment resistant psychosis in children and adolescents and clozapine: Nuances. Front Psychiatry 2023; 14:1014540. [PMID: 36911129 PMCID: PMC9998521 DOI: 10.3389/fpsyt.2023.1014540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/25/2023] [Indexed: 03/14/2023] Open
Abstract
With proliferation in research on high-risk psychosis spectrum diseases, it is crucial to distinguish a prodrome or psychosis-like episode in children and adolescents from true psychosis. The limited role of psychopharmacology in such circumstances is well-documented, underlining the difficulties in diagnosing treatment resistance. To add to the confusion is emerging data on the head-to-head comparison trials for treatment-resistant and treatment-refractory schizophrenia. Clozapine, the gold-standard drug for resistant schizophrenia and other psychotic psychopathology, lacks FDA or manufacturer guidelines for use in the pediatric population. Possibly due to developmental pharmacokinetic (PK) considerations, clozapine-related side effects are more commonly seen in children than adults. Despite evidence of an increased risk for seizures and hematological problems in children, clozapine is widely used off-label. Clozapine reduces the severity of resistant childhood schizophrenia, aggression, suicidality, and severe non-psychotic illness. There is inconsistent prescribing, administration, and monitoring of clozapine, and limited database evidence-backed guidelines. Despite the overwhelming efficacy, problems remain regarding unambiguous indications of use and risk-benefits assessments. This article reviews the nuances in the diagnosis of treatment resistance psychosis in childhood and adolescents and its management, in particular highlighting the evidence base for clozapine in this population group.
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Affiliation(s)
| | - Udit Kumar Panda
- Department of Psychiatry, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Suhas Chandran
- Child and Adolescent Psychiatry, St. Johns Medical College and Hospital, Bengaluru, India
| | - Susanta Padhy
- Department of Psychiatry, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
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Recovery-Focused Metacognitive Interpersonal Therapy (MIT) for Adolescents with First-Episode Psychosis. JOURNAL OF CONTEMPORARY PSYCHOTHERAPY 2022. [DOI: 10.1007/s10879-022-09569-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Langman-Levy A, Johns L, Palmier-Claus J, Sacadura C, Steele A, Larkin A, Murphy E, Bowe S, Morrison A. Adapting cognitive behavioural therapy for adolescents with psychosis: insights from the Managing Adolescent first episode in psychosis study (MAPS). PSYCHOSIS 2022; 15:28-43. [PMID: 36866165 PMCID: PMC9970186 DOI: 10.1080/17522439.2021.2001561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background Onset of psychosis commonly occurs in adolescence, and long-term prognosis can be poor. There is growing evidence, largely from adult cohorts, that Cognitive Behavioural Therapy for Psychosis (CBTp) and Family Interventions (FI) can play a role in managing symptoms and difficulties associated with psychosis. However, adolescents have distinct developmental needs that likely impact their engagement and response to talking therapy. There is limited guidance on adapting CBTp to meet the clinical needs of under-eighteens experiencing psychosis. Method This educational clinical practice article details learnings from therapists and supervisors working with young people (aged 14-18 years) with psychosis during the Managing Adolescent first-episode Psychosis: a feasibility Study (MAPS) randomised clinical treatment trial, supplemented by findings from nested qualitative interviews with young people receiving CBTp. Results Suggested are given for tailoring CBTp assessment, formulation and interventions to meet the developmental and clinical needs of adolescents with psychosis. Developmentally appropriate techniques and resources described. Conclusions Early indications from MAPS study indicate this developmentally tailored approach is an acceptable, safe and helpful treatment for young people with psychosis. Further research is needed to develop empirically grounded and evaluated CBTp for adolescents.
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Affiliation(s)
- Amy Langman-Levy
- Early Intervention in Psychosis Service, Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Louise Johns
- Early Intervention in Psychosis Service, Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford, UK,Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, UK,CONTACT Louise Johns Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford OX3 7JX, UK
| | - Jasper Palmier-Claus
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK,Research and Development Department, Lancashire and South Cumbria NHS Foundation Trust, Preston, UK
| | - Catarina Sacadura
- Research and Development Department, Sussex Partnership NHS Foundation Trust, Sussex, UK
| | - Ann Steele
- Research and Development Department, Sussex Partnership NHS Foundation Trust, Sussex, UK
| | - Amanda Larkin
- Psychosis Research Unit, Greater Manchester Health NHS Foundation Trust, Manchester, UK
| | - Elizabeth Murphy
- Psychosis Research Unit, Greater Manchester Health NHS Foundation Trust, Manchester, UK
| | - Samantha Bowe
- Psychosis Research Unit, Greater Manchester Health NHS Foundation Trust, Manchester, UK
| | - Anthony Morrison
- Psychosis Research Unit, Greater Manchester Health NHS Foundation Trust, Manchester, UK,Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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