An online parenting intervention to prevent affective disorders in high-risk adolescents: the PIPA trial protocol

BACKGROUND

Adolescent depression can place a young person at high risk of recurrence and a range of psychosocial and vocational impairments in adult life, highlighting the importance of early recognition and prevention. Parents/carers are well placed to notice changes in their child's emotional wellbeing which may indicate risk, and there is increasing evidence that modifiable factors exist within the family system that may help reduce the risk of depression and anxiety in an adolescent. A randomised controlled trial (RCT) of the online personalised 'Partners in Parenting' programme developed in Australia, focused on improving parenting skills, knowledge and awareness, showed that it helped reduce depressive symptoms in adolescents who had elevated symptom levels at baseline. We have adapted this programme and will conduct an RCT in a UK setting.

METHODS

In total, 433 family dyads (parents/carers and children aged 11-15) will be recruited through schools, social media and parenting/family groups in the UK. Following completion of screening measures of their adolescent's depressive symptoms, parents/carers of those with elevated scores will be randomised to receive either the online personalised parenting programme or a series of online factsheets about adolescent development and wellbeing. The primary objective will be to test whether the personalised parenting intervention reduces depressive symptoms in adolescents deemed at high risk, using the parent-reported Short Mood & Feelings Questionnaire. Follow-up assessments will be undertaken at 6 and 15 months and a process evaluation will examine context, implementation and impact of the intervention. An economic evaluation will also be incorporated with cost-effectiveness of the parenting intervention expressed in terms of incremental cost per quality-adjusted life year gained.

DISCUSSION

Half of mental health problems emerge before mid-adolescence and approximately three-quarters by mid-20s, highlighting the need for effective preventative strategies. However, few early interventions are family focused and delivered online. We aim to conduct a National Institute for Health and Care Research (NIHR) funded RCT of the online personalised 'Partners in Parenting' programme, proven effective in Australia, targeting adolescents at risk of depression to evaluate its effectiveness, cost-effectiveness and usability in a UK setting. TRIAL REGISTRATION {2A}: ISRCTN63358736 . Registered 18 September 2019.

Perceived negative attitude of others predicts transition to psychosis in patients at risk of psychosis

Aim

Our previous study (Salokangas et al., 2009) suggested that the subjective experience of negative attitude of others (NAO) towards oneself is an early indicator of psychotic development. The aim of this prospective follow-up study was to test this hypothesis.

Methods

A total of 55 young psychiatric outpatients assessed as being at current risk of psychosis (CROP) were followed for up to 60 months and rates of transition to psychosis (TTP) identified. CROP was assessed employing the Bonn Scale for assessment of basic symptoms (Schultze-Lutter and Klosterkötter, 2002) and the Structured Interview for prodromal symptoms (Miller et al., 2002). TTP was defined by a psychotic episode lasting for more than one week. Associations between NAO at baseline and TTP were analyzed by a Cox regression survival analysis.

Results

Eight (14.5%) TTP were identified: four (57.1%) within seven NAO patients and four (8.7%) within forty-six non-NAO patients. In the multivariate Cox regression analysis, NAO at baseline significantly (P = 0.007) predicted TTP.

Conclusion

The prospective follow-up results support our hypothesis that subjective experience of NAO is an early indicator of psychotic in development.

The impact of emotional acknowledgement and self-esteem on resilience to family dysfunction

Introduction

Family dysfunction can test the resilience of adolescents, specifically those from single parent families and those attending schools in more socio-economically challenged areas.

Objectives

To determine what factors are associated with resilience for those from single parent families or attend schools in more socio-economically challenged areas.

Aims

To examine the role of emotional regulation and self-esteem as putative resilience factors in the context of single parents status and socioeconomic disadvantage.

Methods

Secondary school pupils from single and dual parent families aged 13 to 15 answered questionnaires at three time points on: emotional regulation, self-esteem, depression and anxiety. A total of 434 pupils took part at time 1, 574 at time 2, and 467 at time 3. The secondary schools were categorised into more and less disadvantaged schools.

Results

Positive self-esteem [F(1.205) = 54.568, P = 0.000; F(1.157) = 35.582, P = 0.000] and emotional regulation [F(1.205) = 46.925, P = 0.000; F(1.157) = 16.583, P = 0.000] were both associated with resilience against depression in adolescents from single parent families. Positive self-esteem [F(1,75) = 102.629, P = 0.000; F(1.355) = 60.555, P = 0.000] and emotional regulation [F(1.60) = 34.813, P = 0.000; F(1.73) = 36.891, P = 0.000] were both associated with resilience against depression in adolescents attending more socio-economically challenged areas.

Conclusions

This research suggests that adolescent resilience against depression may be promoted by improving self-esteem and emotional regulation. Therefore, future interventions could focus on boosting these resilience factors. Further resilience research could include emotional regulation and self-esteem as protective factors for resilience in adolescent mental health. As these variables have been identified, they can help find more pieces to the complex puzzle of resilience.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The impact of the transition from primary school to secondary school on young adolescents

Introduction

Previous research suggests that adult anxiety disorders begin in adolescence and the transition from primary school to secondary school is the first challenge many young adolescents face, which could test their resilience for the first time.

Objectives

To examine students’ anxiety scores before and after their transition, and what protective and risk factors are present during this challenge.

Aims

To determine how the transition can impact anxiety in children, and if protective factors can help decrease the disruption that the transition can cause.

Methods

One hundred and eighty-four pupils completed questionnaires in their last term of primary school and during the first term of secondary school. At time 1: the attachment, school membership, and bullying and victimization measures were compared with pupils’ anxiety scores, along with whether their friends or siblings will be attending the same secondary school as them. These analyses will also be conducted once the pupils start secondary school, at time 2.

Results

Secure attachment was associated with lower anxiety and transition anxiety (F(2.56) = 7.255, P = .002; F(2.52) = 19.245, P = .000; F(2.181) = 10.181, P = .000; F(2.53) = 20.545, P = .000). School membership was associated with lower transition anxiety (F(2.181) = 4.151, P = .017; F(2.181) = 3.632, P = .028). Low victimisation was also associated with low anxiety and transition anxiety (F(2.181) = 14.024, P = .000; F(2.181) = 14.529, P = .000; F(2.181) = 9.381, P = .000).

Conclusions

These preliminary results suggest that attachment, school membership and victimisation all impact on pupils anxiety before they transition to secondary school. Therefore, schools could work together to increase school membership and decrease victimisation, particularly for pupils who they suspect will struggle with the transition.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Short-term outcome of substance-induced psychotic disorder in a large UK first episode psychosis cohort

OBJECTIVE

The incidence and outcome of first-episode substance-induced psychotic disorder (SIPD) are unclear. The study aimed to compare the 1-year outcomes of those given a SIPD diagnosis by clinicians compared to other psychosis diagnoses in a first-episode cohort.

METHOD

Data were from a large (n = 1027) cohort of first-episode psychosis (FEP) patients admitted to early intervention services in the UK (National EDEN). Diagnosis, including that of SIPD, was made by treating psychiatrists at baseline using ICD10 criteria. Details on symptoms, functioning, quality of life, relapse and recovery were available at baseline and 12 months.

RESULTS

There were 67 cases of SIPD (6.5% of the cohort). At baseline, SIPD patients were no different to other psychoses on symptoms, functioning and quality of life. At 12 months, there was no difference in SIPD and other psychoses on functioning, quality of life or relapse and recovery rates. Levels of psychotic and general symptomatology were similar but depressive symptoms were higher in the SIPD group.

CONCLUSIONS

First-episode psychosis patients with a diagnosis of SIPD do not appear to have better outcomes than those with other primary psychotic diagnoses. The higher levels of depressive symptoms may be a specific marker in these patients.

Pilot randomised trial of a brief intervention for comorbid substance misuse in psychiatric in-patient settings

OBJECTIVE

This proof of principle study evaluated the effectiveness and feasibility of a brief motivational intervention, delivered in mental health in-patient settings, to improve engagement in treatment for drug and alcohol misuse.

METHOD

A randomised controlled trial using concealed randomisation, blind, independent assessment of outcome at 3 months. Participants were 59 new adult admissions, to six acute mental health hospital units in one UK mental health service, with schizophrenia related or bipolar disorder diagnoses, users of community mental health services and also misusing alcohol and/or drugs. Participants were randomised to Brief Integrated Motivational Intervention (BIMI) with Treatment As Usual (TAU), or TAU alone. The BIMI took place over a 2-week period and encouraged participants to explore substance use and its impact on mental health.

RESULTS

Fifty-nine in-patients (BIMI n = 30; TAU n = 29) were randomised, the BIMI was associated with a 63% relative odds increase in the primary outcome engagement in treatment [OR 1.63 (95% CI 1.01-2.65; P = 0.047)], at 3 months. Qualitative interviews with staff and participants indicated that the BIMI was both feasible and acceptable.

CONCLUSION

Mental health hospital admissions present an opportunity for brief motivational interventions focussed on substance misuse and can lead to improvements in engagement.

Negative cognition, affect, metacognition and dimensions of paranoia in people at ultra-high risk of psychosis: a multi-level modelling analysis

BACKGROUND

Paranoia is one of the commonest symptoms of psychosis but has rarely been studied in a population at risk of developing psychosis. Based on existing theoretical models, including the proposed distinction between ‘poor me’ and ‘bad me’ paranoia, we aimed to test specific predictions about associations between negative cognition, metacognitive beliefs and negative emotions and paranoid ideation and the belief that persecution is deserved (deservedness).

METHOD

We used data from 117 participants from the Early Detection and Intervention Evaluation for people at risk of psychosis (EDIE-2) trial of cognitive–behaviour therapy, comparing them with samples of psychiatric in-patients and healthy students from a previous study. Multi-level modelling was utilized to examine predictors of both paranoia and deservedness, with post-hoc planned comparisons conducted to test whether person-level predictor variables were associated differentially with paranoia or with deservedness.

RESULTS

Our sample of at-risk mental state participants was not as paranoid, but reported higher levels of ‘bad-me’ deservedness, compared with psychiatric in-patients. We found several predictors of paranoia and deservedness. Negative beliefs about self were related to deservedness but not paranoia, whereas negative beliefs about others were positively related to paranoia but negatively with deservedness. Both depression and negative metacognitive beliefs about paranoid thinking were specifically related to paranoia but not deservedness.

CONCLUSIONS

This study provides evidence for the role of negative cognition, metacognition and negative affect in the development of paranoid beliefs, which has implications for psychological interventions and our understanding of psychosis.

Insight, duration of untreated psychosis and attachment in first-episode psychosis: prospective study of psychiatric recovery over 12-month follow-up

BACKGROUND

Increasing evidence shows attachment security influences symptom expression and adaptation in people diagnosed with schizophrenia and other psychoses.

AIMS

To describe the distribution of secure and insecure attachment in a cohort of individuals with first-episode psychosis, and to explore the relationship between attachment security and recovery from positive and negative symptoms in the first 12 months.

METHOD

The study was a prospective 12-month cohort study. The role of attachment, duration of untreated psychosis (DUP), baseline symptoms and insight in predicting and mediating recovery from symptoms was investigated using multiple regression analysis and path analysis.

RESULTS

Of the 79 participants, 54 completed the Adult Attachment Interview (AAI): 37 (68.5%) were classified as insecure, of which 26 (48.1%) were insecure/dismissing and 11 (20.4%) insecure preoccupied. Both DUP and insight predicted recovery from positive symptoms at 12 months. Attachment security, DUP and insight predicted recovery from negative symptoms at 12 months.

CONCLUSIONS

Attachment is an important construct contributing to understanding and development of interventions promoting recovery following first-episode psychosis.

Short-term functional outcome and premorbid adjustment in clinical high-risk patients. Results of the EPOS project

PURPOSE

In patients with schizophrenia, premorbid psychosocial adjustment is an important predictor of functional outcome. We studied functional outcome in young clinical high-risk (CHR) patients and how this was predicted by their childhood to adolescence premorbid adjustment.

METHODS

In all, 245 young help-seeking CHR patients were assessed with the Premorbid Adjustment Scale, the Structured Interview for Prodromal Syndromes (SIPS) and the Schizophrenia Proneness Instrument (SPI-A). The SIPS assesses positive, negative, disorganised, general symptoms, and the Global Assessment of Functioning (GAF), the SPI-A self-experienced basic symptoms; they were carried out at baseline, at 9-month and 18-month follow-up. Transitions to psychosis were identified. In the hierarchical linear model, associations between premorbid adjustment, background data, symptoms, transitions to psychosis and GAF scores were analysed.

RESULTS

During the 18-month follow-up, GAF scores improved significantly, and the proportion of patients with poor functioning decreased from 74% to 37%. Poor premorbid adjustment, single marital status, poor work status, and symptoms were associated with low baseline GAF scores. Low GAF scores were predicted by poor premorbid adjustment, negative, positive and basic symptoms, and poor baseline work status. The association between premorbid adjustment and follow-up GAF scores remained significant, even when baseline GAF and transition to psychosis were included in the model.

CONCLUSION

A great majority of help-seeking CHR patients suffer from deficits in their functioning. In CHR patients, premorbid psychosocial adjustment, baseline positive, negative, basic symptoms and poor working/schooling situation predict poor short-term functional outcome. These aspects should be taken into account when acute intervention and long-term rehabilitation for improving outcome in CHR patients are carried out.

A systematic review and meta-regression analysis of aggression during the first episode of psychosis

OBJECTIVE

The First Episode of Psychosis (FEP) represents a period of heightened risk for aggression. However, it is not known whether this risk is significantly altered following contact with mental health services.

METHOD

Meta-analytic methods were used to estimate pooled prevalence of 'any' and 'serious' aggression during FEP, while meta-regression analyses were conducted to explore reasons for heterogeneity between studies.

RESULTS

Fifteen studies comprising 3, 294 FEP subjects were analysed. Pooled prevalence of 'any aggression' before service contact was 28% (95% CI: 22-34) and following contact 31% (95% CI: 20-42). Pooled prevalence of 'serious aggression' was 16% (95% CI: 11-20) before service contact and 13% (95% CI: 6-20) following contact. Four studies reporting repeated assessments within the same cohort revealed that aggression rates did not significantly differ post and pre service contact: Odds Ratios for any aggression: 1.18 (95% CI: 0.46-2.99) and serious aggression: 0.61 (95% CI: 0.31-1.21).

CONCLUSION

Rates of aggression are high during FEP, both before and following initial service contact, and seem not to alter following contact. This conclusion remains tentative due to considerable heterogeneity between studies and a lack of prospective cohort studies.

Prediction of psychosis in clinical high-risk patients by the Schizotypal Personality Questionnaire. Results of the EPOS project

OBJECTIVE

Schizotypal features indicate proneness to psychosis in the general population. It is also possible that they increase transition to psychosis (TTP) among clinical high-risk patients (CHR). Our aim was to investigate whether schizotypal features predict TTP in CHR patients.

METHODS

In the EPOS (European Prediction of Psychosis Study) project, 245 young help-seeking CHR patients were prospectively followed for 18 months and their TTP was identified. At baseline, subjects were assessed with the Schizotypal Personality Questionnaire (SPQ). Associations between SPQ items and its subscales with the TTP were analysed in Cox regression analysis.

RESULTS

The SPQ subscales and items describing ideas of reference and lack of close interpersonal relationships were found to correlate significantly with TTP. The co-occurrence of these features doubled the risk of TTP.

CONCLUSIONS

Presence of ideas of reference and lack of close interpersonal relations increase the risk of full-blown psychosis among CHR patients. This co-occurrence makes the risk of psychosis very high.

The Strauss and Carpenter Prognostic Scale in subjects clinically at high risk of psychosis

OBJECTIVE

To investigate the predictive value of the Strauss and Carpenter Prognostic Scale (SCPS) for transition to a first psychotic episode in subjects clinically at high risk (CHR) of psychosis.

METHOD

Two hundred and forty-four CHR subjects participating in the European Prediction of Psychosis Study were assessed with the SCPS, an instrument that has been shown to predict outcome in patients with schizophrenia reliably.

RESULTS

At 18-month follow-up, 37 participants had made the transition to psychosis. The SCPS total score was predictive of a first psychotic episode (P < 0.0001). SCPS items that remained as independent predictors in the Cox proportional hazard model were as follows: most usual quality of useful work in the past year (P = 0.006), quality of social relations (P = 0.006), presence of thought disorder, delusions or hallucinations in the past year (P = 0.001) and reported severity of subjective distress in past month (P = 0.003).

CONCLUSION

The SCPS could make a valuable contribution to a more accurate prediction of psychosis in CHR subjects as a second-step tool. SCPS items assessing quality of useful work and social relations, positive symptoms and subjective distress have predictive value for transition. Further research should focus on investigating whether targeted early interventions directed at the predictive domains may improve outcomes.

Social anxiety disorder and shame cognitions in psychosis

BACKGROUND

Social anxiety disorder (SAD) is surprisingly prevalent among people with psychosis and exerts significant impact on social disability. The processes that underlie its development remain unclear. The aim of this study was to investigate the relationship between shame cognitions arising from a stigmatizing psychosis illness and perceived loss of social status in co-morbid SAD in psychosis.

METHOD

This was a cross-sectional study. A sample of individuals with SAD (with or without psychosis) was compared with a sample with psychosis only and healthy controls on shame proneness, shame cognitions linked to psychosis and perceived social status.

RESULTS

Shame proneness (p < 0.01) and loss of social status (p < 0.01) were significantly elevated in those with SAD (with or without psychosis) compared to those with psychosis only and healthy controls. Individuals with psychosis and social anxiety expressed significantly greater levels of shame (p < 0.05), rejection (p < 0.01) and appraisals of entrapment (p < 0.01) linked to their diagnosis and associated stigma, compared to those without social anxiety.

CONCLUSIONS

These findings suggest that shame cognitions arising from a stigmatizing illness play a significant role in social anxiety in psychosis. Psychological interventions could be enhanced by taking into consideration these idiosyncratic shame appraisals when addressing symptoms of social anxiety and associated distress in psychosis. Further investigation into the content of shame cognitions and their role in motivating concealment of the stigmatized identity of being 'ill' is needed.

Cannabis use and age at onset of symptoms in subjects at clinical high risk for psychosis

OBJECTIVE

Numerous studies have found a robust association between cannabis use and the onset of psychosis. Nevertheless, the relationship between cannabis use and the onset of early (or, in retrospect, prodromal) symptoms of psychosis remains unclear. The study focused on investigating the relationship between cannabis use and early and high-risk symptoms in subjects at clinical high risk for psychosis.

METHOD

Prospective multicenter, naturalistic field study with an 18-month follow-up period in 245 help-seeking individuals clinically at high risk. The Composite International Diagnostic Interview was used to assess their cannabis use. Age at onset of high risk or certain early symptoms was assessed retrospectively with the Interview for the Retrospective Assessment of the Onset of Schizophrenia.

RESULTS

Younger age at onset of cannabis use or a cannabis use disorder was significantly related to younger age at onset of six symptoms (0.33 < r(s) < 0.83, 0.004 < P < 0.001). Onset of cannabis use preceded symptoms in most participants.

CONCLUSION

Our results provide support that cannabis use plays an important role in the development of psychosis in vulnerable individuals. Cannabis use in early adolescence should be discouraged.

Physical illnesses, developmental risk factors and psychiatric diagnoses among subjects at risk of psychosis

Background

Subjects with psychoses have significantly increased rates of physical illnesses, but the nature of the relationship remains largely unknown.

Material and methods

The present study is part of the European Prediction of Psychosis Study (EPOS). Data were collected from 245 help-seeking individuals from six European centers (age 16–35) who met criteria for ultra-high risk of psychosis criteria. This paper seeks to investigate self-reported physical ill health and its associations with psychiatric symptoms and disorders, risk factors, and onset of psychosis during 48 months of follow-up.

Results

In multivariate analysis, lifetime panic disorder (OR = 2.43, 95%CI: 1.03–5.73), known complications during pregnancy and delivery (OR = 2.81, 95%CI: 1.10–7.15), female gender (OR = 2.88, 95%CI: 1.16–7.17), family history of psychosis (OR = 3.08, 95%CI: 1.18–8.07), and having a relationship (OR = 3.44, 95%CI: 1.33–8.94) were significantly associated with self-reported physician-diagnosed illness. In the Cox proportional hazard model we found no significant differences between those who had undergone a transition to psychosis and those who had not.

Conclusions

The physical health of patients defined to be at ultra-high risk of psychosis seems to be commonly impaired and associated with female gender, marital status, complications during pregnancy and birth, lifetime panic disorder, and genetic risk of psychosis.

Course of psychopathology in the at-risk mental state - outcomes beyond transition to psychosis

Introduction

Research on at-risk states of psychosis has mainly aimed to predict conversion. Yet as a considerable number of patients does not to progress to this outcome during the investigated observation periods, the course of these non-converters (NC) is of major interest, particularly with regard to preventive interventions and treatment.

Aims

To analyze the psychopathological and functional in 18-month non-converters.

Methods

Data were derived from the prospective multicenter European Prediction of Psychosis Study with an 18-month follow-up period. Participants had to fulfill ultra-high risk criteria and/or the COGDIS criterion, which is based on a set of cognitive basic symptoms. Psychopathology was assessed with the Structure Interview for Prodromal Syndromes (SIPS), including the Global Assessment of Functioning Scale (GAF) and a short version of the Schizophrenia Proneness Instrument (SPI-A).

Results

All total and subscale scores improved significantly during follow-up. However, a more detailed analysis revealed that a considerable part of the patients showed no improvement or even a worsening of psychopathology and function.

Conclusions

Our first analysis of course on non-converters shows that a high proportion of patients improved. In the light of results from retrospective studies, however, this improvement has to be interpreted with caution, as the observation period does not allow to determine the proportion of outpost syndromes, i.e. precursors of a later prodrome. Furthermore, a considerable portion of our sample worsened functionally and/or symptomatically. With regard to retrospective schizophrenia related results, very long observation periods may be needed to characterize the patterns of course in subpsychotic syndromes.

Subjective quality of life and its changes in patients at-risk for psychosis results of the EPOS study

Objectives

In the European Prediction of Psychosis Study (EPOS) a large sample of young patients at high risk of psychosis (HR) were examined and their conversion rate to psychosis during 18 months follow-up was estimated. This presentation describes quality of life (QoL) and its changes in patients at risk of psychosis who did or did not convert to psychosis.

Methods

In all, 245 young HR patients were recruited and followed for 9 and 18 months. Risk of psychosis was defined by occurrence of basic symptoms (BS), attenuated psychotic symptoms (ATP), brief, limited or intermittent psychotic symptoms (BLIPS) or familial risk plus reduced functioning (FR-RF). QoL was assessed at baseline and at 9 and 18 months’ follow-ups, and analysed in the HR-patients who converted (HR-P; n = 40) or did not converted to psychosis (HR-NP; n = 205).

Results

There were no differences in the course of QoL between the HR-P and HR-NP patients. Of the inclusion criteria, only BS associated with poor QoL at baseline. Among HR-NP subjects, depressive symptoms associated with QoL at baseline and predicted poor QoL at 9 and 18 month follow-ups.

Conclusions

QoL of the HR-NP patients is as poor as that of the HR-P. From the QoL point of view, all HR patients require intensive treatment intervention from the first contact on. Especially, depressive disorders need to be treated vigorously.

Treating prolactinoma and psychosis: medication and cognitive behavioural therapy

The patient in this case report had two severe medical conditions that require oppositional treatment: prolactinoma and psychosis. A prolactinoma is a benign tumour of the pituitary gland that produces prolactin. Dopamine agonist medication is the first-line treatment in patients with prolactinoma. The psychotic symptoms started after a dosage increase of a dopamine D2-receptor agonist. Several antipsychotic medications were tried with and without the dopamine D2-receptor agonist, but severe command hallucinations remained. Cognitive behavioural therapy (CBT) was added which reduced the impact of the hallucinations to a great extent, indicating that CBT can have an additional positive effect in prolactinoma patients with psychosis that shows incomplete recovery after antipsychotic medication. Future research should be aimed at the severe and prolonged side effects of dopamine agonists in the treatment of prolactinoma patients with multiple risk factors for a psychotic decompensation.

[Early signs and symptoms before the psychotic onset. A study on the Duration of Untreated Illness (DUI) in a sample of patients with diagnosis of "non-affective psychotic disorders"]

AIMS

The aims of the study are to evaluate, in the Italian context, the presence and clinical features of early prodromal symptoms before the psychotic onset and, most of all, the duration of the period between the first onset of any psychiatric symptom and the psychotic onset (Duration of Untreated Illness).

MATERIALS AND METHODS

The study was carried out on a sample of 296 inpatients with a diagnosis of "non-affective psychosis" enrolled in "Villa dei Fiori" inpatients Clinic in Rome. The retrospective analysis was developed using clinical records and clinical interview with patients and their parents. The evaluation of the psychotic onset and of DUI was assessed with the PANSS (Positive and Negative Symptoms Scale).

RESULTS

The mean DUI is 4.7 ± 4.4 years. We found a connection between DUI and early symptoms of psycosis: depressive symptoms (4.9; DS=5.0) were most frequently observed, followed by anxiety symptoms (5.1; DS=4.8), eating disorders (5.7; DS=3.0); obsessive symptoms (4.5; DS=3.6); social withdrawal (5.9; DS=4.9); psychotic like symptoms (2.6; DS=1.3). DUI resulted lower in psychotic like symptoms than in the depressive ones.

CONCLUSION

In Italy DUI turn out to be much longer than in other Country where do exists specialized services for early intervention. For this reason seem to be necessary to explore the opportunity to develop also in Italy specialized services for adolescents and young adults at risk and at their psychotic onset.

The evolution of depression and suicidality in first episode psychosis

OBJECTIVE

To have a clearer understanding of the ebb and flow of depression and suicidal thinking in the early phase of psychosis, whether these events are predictable and how they relate to the early course of psychotic symptoms.

METHOD

Ninety-two patients with first episode psychosis (FEP) completed measures of depression, including prodromal depression, self-harm and duration of untreated psychosis. Follow-up took place over 12 months.

RESULTS

Depression occurred in 80% of patients at one or more phases of FEP; a combination of depression and suicidal thinking was present in 63%. Depression in the prodromal phase was the most significant predictor of future depression and acts of self-harm.

CONCLUSION

Depression early in the emergence of a psychosis is fundamental to the development of future depression and suicidal thinking. Efforts to predict and reduce depression and deliberate self-harm in psychosis may need to target this early phase to reduce later risk.

the ‘schizophrenia Postdrome’: A Study of Low-level Positive Symptoms after Remission of First Episode Schizophrenia

Background:

Despite remission being the primary objective following the first episode of schizophrenia, clinically stabilised patients are rarely studied.

Aims:

To assess the extent and fluctuation of low-level positive symptoms in patients who are in remission following their first episode of schizophrenia, and consider whether symptoms displayed are similar to those exhibited in the prodromal population.

Methods:

Eleven patients who had recovered for at least six months following one episode of schizophrenia and subsequently fulfilled remission criteria were interviewed four times over the course of three months. Interviews were based on the Structured Interview of Prodromal Symptoms (SIPS), an in-depth assessment of low-level symptoms that is widely used in the prodromal group. Data was compared to equivalent results from the prodromal population (with data provided by the local ED:IT service).

Results:

Over the course of the interviews 73% of participants displayed attenuated positive symptoms, predominantly unusual thought content and suspiciousness. 18% experienced brief limited intermittent psychotic symptoms (BLIPS). Analysis with Friedman's test revealed no significant fluctuation in positive symptoms, indicating that they are stable over time. Furthermore, the symptoms exhibited in the sample were closely comparable to those in the prodromal group in the ED:IT service.

Conclusions:

The majority of patients in remission are experiencing a form of ‘postdrome’, which appears to be an enduring state. the presence of these symptoms may put patients at an increased risk of relapse. Larger-scale research is required to follow-up this novel preliminary study.

Declaration of interest:

None.

The critical period

Aim:

Evidence from long-term follow-up studies of schizophrenia and from the ‘new epidemiology’ of psychoses has forced us to rewrite the textbooks and challenge accepted wisdom. In this paper I aim to review the concept of my ‘Critical Period’ in the long-term trajectory of schizophrenia.

Method:

I will review long-term follow-up studies of first episode psychosis.

Results:

Studies suggest that:a.

Conclusion:

This picture presents a fresh take on my concept of the ‘critical period’ with implications for public health and prevention.

Early intervention in psychotic relapse

In spite of advances in neuroleptic treatment, relapse of positive symptoms continues to punctuate the course of schizophrenia. In this paper the conceptual and empirical basis for early intervention in the process of psychotic relapse as a preventative manoeuvre is evaluated. The predictive efficacy of early, 'prodromal' signs, their nature, and the utility of early detection and intervention strategies are reviewed. There is strong evidence that relapse is preceded by early signs, but the classical (medical) concept of prodrome is inadequate to explain the findings. The early detection and treatment of early signs appears to confer protection from relapse, but the active ingredients of the pharmacological and psychological based treatment studies are as yet unclear and suggest important avenues for future research.

Drug and alcohol problems amongst individuals with severe mental health problems in an inner city area of the UK

BACKGROUND

The extent and impact of drug and alcohol use among those with severe mental health problems has been well documented in the US. However, little is known of the nature of this problem in the UK, particularly in community treatment settings. This paper outlines findings from a large-scale survey conducted across community-based Mental Health and Substance Misuse services, which aimed to ascertain the prevalence of drug and alcohol problems among those with severe mental health problems.

METHOD

An assessment instrument was completed by keyworkers for each of their clients, which included mental health diagnosis and an adapted version of the Clinician Rating Scales for Alcohol and Drug Use.

RESULTS

From a sample of 3079 clients across services, 1369 clients were identified with a severe mental illness diagnosis. According to their key-workers, 24% of these clients (324/1369) had used alcohol and/or drugs problematically during the past year. These individuals were most likely to have a diagnosis within the schizophrenia cluster, were mainly white males in their mid-30s, and tended to be located within Mental Health services in Assertive Outreach teams and to be higher utilisers of crises/emergency services.

CONCLUSIONS

It can be concluded that similar to other studies in inner city areas of the UK, problem substance use is common amongst those with severe mental health problems within Northern Birmingham.

An exploration of evolved mental mechanisms for dominant and subordinate behaviour in relation to auditory hallucinations in schizophrenia and critical thoughts in depression

BACKGROUND

Mental mechanisms have evolved to enable animals (and humans) to be able to function in various social roles. It is suggested that the nature and functions of the mental mechanisms that enable animals to act as a hostile-dominant or threatened-subordinate can be distinguished. It is further suggested these can be internally activated and 'play off' against each other, such that a person 'attacks' themselves and then responds to their own internal attacks with subordinate defences. Hence, a depressed person can submit, feel defeated, belittled, beaten down, or want to run away (escape) from their own self-attacking thoughts, while psychotic voice hearers can feel similarly to their hostile voices. Such internal interactions may relate to depression in both psychotic voice hearers and depressed people.

METHOD

A group of 66 voice hearers with a diagnosis of schizophrenia and 50 depressed patients were compared on a series of self-report questionnaires measuring the power of hostile self-directed thoughts/voices and the activation of defensive responses, especially fight/flight.

RESULTS

We present evidence that schizophrenic, malevolent voice hearers and self-critical depressed people experience their hostile, internally generated voices/thoughts as powerful, dominating and controlling (i.e. have typical characteristics of a hostile dominant). Moreover, these voices/thoughts activate evolved subordinate defences such as fight/flight and these are associated with depression in both depression and schizophrenia.

CONCLUSION

Conceptualizing aspects of depressed and psychotic thinking as relating to evolved mental mechanisms, which are role serving, but can internally play off against each other, may open new ways of investigating certain aspects of severe pathologies.

Cognitive approach to depression and suicidal thinking in psychosis. 1. Ontogeny of post-psychotic depression

BACKGROUND

Depression in schizophrenia is a rather neglected field of study, perhaps because of its confused nosological status. Three course patterns of depression in schizophrenia, including post-psychotic depression (PPD), are proposed.

AIMS

We chart the ontogeny of depression and psychotic symptoms from the acute psychotic episode over a 12-month period and test the validity of the proposed course patterns.

METHOD

One hundred and five patients with ICD-10 schizophrenia were followed up on five occasions over 12 months following the acute episode, taking measures of depression, positive symptoms, negative symptoms, neuroleptic exposure and side-effects.

RESULTS

Depression accompanied acute psychosis in 70% of cases and remitted in line with the psychosis; 36% developed PPD without a concomitant increase in psychotic symptoms.

CONCLUSIONS

The results provided support for the validity of two of the three course patterns of depression in schizophrenia, including PPD. Post-psychotic depression occurs de novo without concomitant change in positive or negative symptoms.

Cognitive approach to depression and suicidal thinking in psychosis. 2. Testing the validity of a social ranking model

BACKGROUND

In paper I we reported that depression in the acute stage remitted in line with the psychosis and that 36% of patients developed post-psychotic depression (PPD).

AIMS

We apply our cognitive framework to PPD and chart the appraisal of self and psychosis and their link with the later emergence of PPD.

METHOD

Patients with ICD-10 schizophrenia (n=105) were followed up over 12 months following the acute episode, taking measures of depression, working self-concept, cognitive vulnerability, insight and appraisals of psychosis.

RESULTS

Before developing PPD, these patients felt greater loss, humiliation and entrapment by their illness than those who relapsed or did not become depressed, and were more likely to see their future selves in 'lower status' roles. Upon becoming depressed, participants developed greater insight, lower self-esteem and a worsening of their appraisals of psychosis.

CONCLUSIONS

Depression in psychosis arises from the individual's appraisal of psychosis and its implications for his/her perceived social identity, position and 'group fit'. Patients developing PPD feel forced to accept a subordinate role without opportunity for escape. Implications for treatment are discussed.

Early intervention and sustaining the management of vulnerability

OBJECTIVE

The purpose of this article is to consider the issue of how long early intervention needs to be sustained to have a long-term impact on the course of psychosis.

METHOD

Factors relevant to the concept of secondary prevention in psychosis are discussed. The need for sustained intervention for long-term impact on psychosis is examined. Evidence concerning the length of time required for the maximal impact of early intervention services and interventions that have been demonstrated as effective in achieving long-term change is reviewed. The article discusses individuals of low and high vulnerability to schizophrenia and the interaction between this vulnerability and the length and type of treatment they require to change the deteriorating course of psychosis.

RESULTS

There is increasing evidence for the concept of a 'critical period' lasting up to 5 years after first presentation, during which the long-term level of vulnerability to relapse and disability may be determined.

CONCLUSIONS

For many highly vulnerable patients, early intervention must be sustained for a minimum of 3 years to prevent or limit the potential for early decline. A core unanswered question is whether effective early intervention prevents potential long-term disability or merely delays it.

Preventing the entrenchment of high expressed emotion in first episode psychosis: early developmental attachment pathways

OBJECTIVE

As part of a strategy to consider the options for preventing the developmental entrenchment of expressed emotion (EE), we examine the early ontogeny of EE in a first-episode sample of individuals with psychosis and its links with the process of adaptation to change.

METHODS

The key relatives of 50 first-episode psychosis patients from two locations were interviewed soon after patient referral and again 9 months later using measures of expressed emotion and loss.

RESULTS

The developmental pathways of components of expressed emotion, particularly criticism and emotional over-involvement, were independent despite having a similar effect on outcome for patients. Initially, high levels of emotional over-involvement were reduced by follow up, with 37% resolving into high criticism. Overall expressed emotion status changed in 28.2% of key relatives (all parental), predominantly from high to low. High emotional over-involvement and low criticism are associated with significantly high levels of perceived loss in relatives. The metamorphosis of emotional over-involvement to criticism was linked to a reduction in perceived loss.

CONCLUSIONS

Expressed emotion is not a stable index in relatives of first-episode psychosis samples. Appraisals of loss by relatives may be driving high emotional over-involvement with implications for family intervention programs. Attachment theory may help to explain some of the processes underlying resistance to change in some of the high-EE behaviours measured by expressed emotion.

The revised Beliefs About Voices Questionnaire (BAVQ-R)

BACKGROUND

We present a revised Beliefs About Voices Questionnaire (BAVQ-R), a self-report measure of patients' beliefs, emotions and behaviour about auditory hallucinations.

AIMS

To improve measurement of omnipotence, a pivotal concept in understanding auditory hallucinations, and elucidate links between beliefs about voices, anxiety and depression.

METHODS

Seventy-one participants with chronic auditory hallucinations completed the BAVQ-R, and 58 also completed the Hospital Anxiety and Depression Scale.

RESULTS

The mean Cronbach's alpha for the five sub-scales was 0.86 (range 0.74-0.88). The study supports hypotheses about links between beliefs, emotions and behaviour, and presents original data on how these relate to the new omnipotence sub-scale. Original data are also presented on connections with anxiety and depression.

CONCLUSIONS

The BAVQ-R is more reliable and sensitive to individual differences than the original version, and reliably measures omnipotence.

Cognitive therapy and recovery from acute psychosis: a controlled trial. 3. Five-year follow-up

BACKGROUND

This paper describes the 5-year outcome of a cohort of patients who had received a cognitive therapy intervention during an acute episode of non-affective psychosis.

METHOD

Thirty-four out of the original 40 patients who had taken part in a randomised controlled trial of a cognitive intervention were assessed, using standardised instruments completed at entry into the study. In the original trial, half the patients received a cognitive therapy programme (CT group) and the other half received recreational activities and support (ATY group).

RESULTS

At follow-up no significant differences in relapse rate, positive symptoms or insight between the groups were found, although the CT group did show significantly greater perceived 'Control over illness' than the ATY group. For individuals who had experienced a maximum of one relapse in the follow-up period, self-reported residual delusional beliefs and observer-rated hallucinations and delusions were significantly less in the CT than in the ATY group.

CONCLUSION

Cognitive therapy applied in the acute phase of a psychotic disorder can produce enduring and significant clinical benefits if experience of relapse can be minimised.

The power and omnipotence of voices: subordination and entrapment by voices and significant others

BACKGROUND

Cognitive therapy for psychotic symptoms often embraces self-evaluative beliefs (e.g. self-worth) but whether and how such beliefs are related to delusions remains uncertain. In previous research we demonstrated that distress arising from voices was linked to beliefs about voices and not voice content alone. In this study we examine whether the relationship with the voice is a paradigm of social relationships in general, using a new framework of social cognition, 'ranking' theory.

METHOD

In a sample of 59 voice hearers, measures of power and social rank difference between voice and voice hearer are taken in addition to parallel measures of power and rank in wider social relationships.

RESULTS

As predicted, subordination to voices was closely linked to subordination and marginalization in other social relationships. This was not the result of a mood-linked appraisal. Distress arising from voices was linked not to voice characteristics but social and interpersonal cognition.

CONCLUSION

This study suggests that the power imbalance between the individual and his persecutor(s) may have origins in an appraisal by the individual of his social rank and sense of group identification and belonging. The results also raise the possibility that the appraisal of voice frequency and volume are the result of the appraisal of voices' rank and power. Theoretical and novel treatment implications are discussed.