An analysis of real-time suicidal ideation and its relationship with retrospective reports among young people with borderline personality disorder

INTRODUCTION

This study aimed to analyze the real-time variability of suicidal ideation intensity and the relationship between real-time and retrospective reports of suicidal ideation made on the Beck Scale for Suicidal Ideation (BSS), among young people with borderline personality disorder (BPD).

METHODS

Young people (15-25-year olds) with BPD (N = 46), recruited from two government-funded mental health services, rated the intensity of their suicidal ideation six times per day for 7 days before completing the BSS.

RESULTS

For 70% of participants, suicidal ideation changed in intensity approximately five times across the week, both within and between days. BSS ratings were most highly correlated with the highest real-time ratings of suicidal ideation. However, this was not significantly different from the relationship between the BSS and both the average and most recent ratings. Median ratings of suicidal ideation intensity were higher on the BSS compared with an equivalent question asked in real time.

CONCLUSION

Findings suggest that young people with BPD experience high levels of fluctuation in their intensity of suicidal ideation across a week and that retrospective reports of suicidal ideation might be more reflective of the most intense experience of suicidal ideation across the week.

MDMA-assisted psychotherapy for post-traumatic stress disorder: The devil is in the detail

Recent years have seen escalating media, public and scientific interest in psychedelic medicine. Australia and New Zealand have been late to this research; however, in the past 2 years, rapid developments suggest that this is changing. Here, we argue for the need to critically review existing evidence in this field to guide future directions. We focus on (±)3,4-methylenedioxymethamphetamine-assisted psychotherapy for post-traumatic stress disorder, currently the most advanced area of clinical psychedelic research. Food and Drug Administration approval of this approach is likely in 2023, based on a series of promising findings. We provide a detailed overview of Phase 2 and 3 studies published to date. We identify several concerns related to this body of evidence, including methodological/design limitations and broader factors - such as robust involvement of advocacy groups in research and reliance on non-government financing leading to simplistic public messaging - that compound the methodological issues identified. We propose steps for future improvement, including the need for large, high-quality, independent efficacy trials with design enhancements, effectiveness trials and for researchers to consider their own engagement with media and public messaging around these modalities. We argue that, notwithstanding promising findings to date, rigorous and dispassionate science is needed to move the field forward and safeguard the welfare of participants.

Ill-defined: Concepts of mental health and illness are becoming broader, looser, and more benign

OBJECTIVES

We argue that mental health-related concepts have become degraded within professional circles and in the wider community. We identify three trends: concept creep, the rise of broad umbrella concepts (e.g. distress and trauma), and the conflation of mental health with well-being, which marginalises serious mental illness. We speculate on the causes of these trends, including cultural shifts towards greater sensitivity to harm and the rise of wellness industries. Contributing factors within psychiatry include overdiagnosis, dimensional models and transdiagnostic perspectives.

CONCLUSIONS

These trends may lead to inflated demands on services from those at the milder end of the psychopathological spectrum. We set out seven measures that mental health professionals can take to resist trends towards broad concepts of mental illness and limit some of their adverse consequences.

Immunocompromised children and young people are at no increased risk of severe COVID-19

OBJECTIVES

We aimed to prospectively describe the incidence and clinical spectrum of SARS-CoV-2 infection in immunocompromised paediatric patients in the UK.

METHODS

From March 2020 to 2021 weekly questionnaires were sent to immunocompromised paediatric patients or their parents. Information, including symptom presentation and SARS-CoV-2 PCR test results, was collected from 1527 participants from 46 hospitals. Cross-sectional serology was investigated in February and March 2021.

RESULTS

Until the end of September 2020, no cases were reported. From September 28th 2020 to March 2021 a total of 38 PCR-detected SARS-CoV-2 infections were reported. Of these, four children were admitted to hospital but none had acute severe COVID-19. Increasing age in association with immunodeficiency increased reporting of SARS-CoV-2 infection. Worsening of fever, cough, and sore throat were associated with participants reporting SARS-CoV-2 infection. Serology data included 452 unvaccinated participants. In those reporting prior positive SARS-CoV-2 PCR, there were detectable antibodies in 9 of 18 (50%). In those with no prior report of infection, antibodies were detected in 32 of 434 (7•4%).

CONCLUSIONS

This study shows SARS-CoV-2 infections have occurred in immunocompromised children and young people with no increased risk of severe disease. No children died.

Personality disorder increases risk of low quality of life among women with mental state disorders

BACKGROUND

Limited data are available examining the relationship between mental state disorders (mood, anxiety, substance use, eating disorders), their co-occurrence with personality disorder (PD), and quality of life among women. We aimed to investigate these relationships in a sample of women from the community.

METHOD

Women from the Geelong Osteoporosis Study (n = 717) were administered the Structured Clinical Interview for DSM-IV (SCID-I/NP and SCID-II) and the World Health Organisation Quality of Life scale (WHOQOL-BREF). Weight and height were measured and lifestyle and demographic factors were self-reported. Logistic regression models (odds ratios with 95% confidence intervals) were undertaken to investigate associations among groups (mental state disorders, co-occurring mental state disorders with PD, and controls) and the WHOQOL-BREF domains (physical, psychological, social, and environmental health) while testing for potential confounding.

RESULTS

Results indicated that mental state disorders were associated with increased risk of low quality of life in physical, psychological, social, but not environmental domains, compared to controls. This risk was increased among women with co-occurring PD across all domains compared to both controls and those with mental state disorders.

CONCLUSION

These findings add evidence suggesting poor quality of life is experienced by those with mental state disorders, and that this is worsened by the experience of co-occurring PD.

INdividual Vocational and Educational Support Trial (INVEST) for young people with borderline personality disorder: study protocol for a randomised controlled trial

Background

The clinical onset of borderline personality disorder (BPD) usually occurs in young people (aged 12–25 years) and commonly leads to difficulty achieving and maintaining vocational (education and/or employment) engagement. While current psychosocial interventions lead to improvements in psychopathology, they have little effect upon functioning. Individual Placement and Support (IPS) is a client-driven model that assists individuals with severe mental illness to engage with education and/or employment appropriate to their personal goals, and that provides ongoing support to maintain this engagement. The objective of the INdividual Vocational and Educational Support Trial (INVEST) is to evaluate the effectiveness of adding IPS to an evidence-based early intervention programme for BPD, with the aim of improving vocational outcomes.

Methods/design

INVEST is a single-blind, parallel-groups, randomised controlled trial (RCT). The randomisation is stratified by gender and age and uses random permuted blocks. The interventions are 39 weeks of either IPS, or ‘usual vocational services’ (UVS). Participants will comprise 108 help-seeking young people (aged 15–25 years) with three or more DSM-5 BPD features and a desire to study or work, recruited from the Helping Young People Early (HYPE) early intervention programme for BPD at Orygen, in Melbourne, Australia. All participants will receive the HYPE intervention. After baseline assessment, staff who are blind to the intervention group allocation will conduct assessments at 13, 26, 39 and 52 weeks. At the 52-week primary endpoint, the primary outcome is the number of days in mainstream education/employment since baseline. Secondary outcomes include the cost-effectiveness of the intervention, quality of life, and BPD severity.

Discussion

Current treatments for BPD have little impact on vocational outcomes and enduring functional impairment is prevalent among this patient group. IPS is a targeted functional intervention, which has proven effective in improving vocational outcomes for adults and young people with psychotic disorders. This trial will investigate whether IPS is effective for improving vocational (employment and educational) outcomes among young people with subthreshold or full-syndrome BPD.

Trial registration

Australian New Zealand Clinical Trials Registry, ID: ACTRN12619001220156. 13 September 2019.

Personality disorder and functioning in major depressive disorder: a nested study within a randomized controlled trial

Objective:

This study aimed to determine if personality disorder (PD) predicted functional outcomes in patients with major depressive disorder (MDD).

Methods:

Data (n=71) from a double-blind, randomized, placebo-controlled 12-week trial assessing the efficacy of 200 mg/day adjunctive minocycline for MDD were examined. PD was measured using the Standardized Assessment of Personality Abbreviated Scale. Outcome measures included Clinical Global Impression – Improvement (CGI-I), Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), Social and Occupational Functioning Scale (SOFAS), and Range of Impaired Functioning (RIFT). Analysis of covariance was used to examine the impact of PD (dichotomized factor [≥ 3] or continuous measure) on the outcome measures-treatment group correlation.

Results:

PD was identified in 69% of the sample. After adjusting for age, sex, and baseline scores for each of the outcome measures, there was no significant difference between participants with and without PD on week 12 scores for any of the outcome measures (all p > 0.14).

Conclusion:

In this secondary analysis of a primary efficacy study, PD was a common comorbidity among those with MDD, but was not a significant predictor of functional outcomes. This study adds to the limited literature on PD in randomized controlled trials for MDD.

Clinical trial registration:

ACTRN12612000283875.

Developing and testing the F-SIM, a measure of social inclusion for people with mental illness

Social inclusion is an important contributor to good mental health and greater mental health outcomes for people with psychiatric disorders. A psychometrically-sound measure of social inclusion is required to facilitate progress in this area. The aim here was to report on preliminary findings from a novel, user-friendly measure of social inclusion that comprehensively assesses the construct. Preliminary testing of the Filia Social Inclusion Measure (F-SIM) was conducted with ninety participants (30 consumers; 30 family members/carers; 30 community members). Participants completed the self-report measure and a usability questionnaire. Preliminary findings demonstrated poorer social inclusion for people with mental illness compared to those without, with differences seen in each of five domains (housing and services, social functioning, occupational functioning, finances and health). Differences were also seen regarding family members or carers, with consistently poorer social inclusion than general community members observed. Participants reported the F-SIM as easy to use, and considered it to measure social inclusion well, indicating good face validity. The F-SIM demonstrates an ability to differentiate between groups. Implications for use and suggestions for future research are detailed. Following further psychometric assessment, the F-SIM will have wide applicability in clinical and research settings.

Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial

BACKGROUND

High unemployment is a hallmark of psychotic illness. Individual placement and support (IPS) may be effective at assisting the vocational recoveries of young people with first-episode psychosis (FEP).AimsTo examine the effectiveness of IPS at assisting young people with FEP to gain employment (Australian and Clinical Trials Registry ACTRN12608000094370).

METHOD

Young people with FEP (n = 146) who were interested in vocational recovery were randomised using computer-generated random permuted blocks on a 1:1 ratio to: (a) 6 months of IPS in addition to treatment as usual (TAU) or (b) TAU alone. Assessments were conducted at baseline, 6 months (end of intervention), 12 months and 18 months post-baseline by research assistants who were masked to the treatment allocations.

RESULTS

At the end of the intervention the IPS group had a significantly higher rate of having been employed (71.2%) than the TAU group (48.0%), odds ratio 3.40 (95% CI 1.17-9.91, z = 2.25, P = 0.025). However, this difference was not seen at 12- and 18-month follow-up points. There was no difference at any time point on educational outcomes.

CONCLUSIONS

This is the largest trial to our knowledge on the effectiveness of IPS in FEP. The IPS group achieved a very high employment rate during the 6 months of the intervention. However, the advantage of IPS was not maintained in the long term. This seems to be related more to an unusually high rate of employment being achieved in the control group rather than a gross reduction in employment among the IPS group.Declaration of interestNone.

What is social inclusion? A thematic analysis of professional opinion

OBJECTIVE

Social inclusion is increasingly recognized as an important contributor to positive mental health outcomes, particularly for people with mental illness. There is a lack of consensus regarding what it means to be socially included and what the key contributors to social inclusion may be. The aim of this investigation was to determine such key contributors, as identified by those with professional experience.

METHOD

A thematic analysis of literature regarding social inclusion was conducted to obtain the opinions of professionals regarding key contributors of social inclusion. Seventy-one pieces of literature were reviewed: peer-reviewed literature (academic literature regarding social inclusion in general [n = 25] and social inclusion and mental illness [n = 26]), and gray literature (organizational reports [n = 20]). Within- and between-groups analyses were performed to determine group differences and increase understanding of which contributors were deemed important consistently across groups.

RESULTS

A comprehensive list of 90 contributors to social inclusion and exclusion was compiled, categorized into 13 domains based on commonalities. Contributors related to employment and education, housing and neighborhood, and social activities and support were highly cited. Differences were observed between-groups regarding specificity of contributors, with organizational reports reporting more detailed contributors.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

A comprehensive and specific understanding of social inclusion was obtained. This improved understanding will allow for better measurement of social inclusion which will assist in evaluating programs and interventions, identifying areas of greatest need, and in planning services, policy and strategies to target specific contributors proven to improve social inclusion and subsequent mental health outcomes. (PsycINFO Database Record

Affective and cognitive theory of mind abilities in youth with borderline personality disorder or major depressive disorder

BACKGROUND

Theory of mind (ToM) is an important social cognitive ability that has been investigated in BPD, with inconsistent findings indicating impaired, comparable, and enhanced ToM in BPD. This study aimed to clarify and extend previous findings by investigating affective and cognitive ToM abilities in youth early in the course of BPD, by including a clinical comparison group of youth with major depressive disorder (MDD).

METHODS

Female participants aged 15-24 years diagnosed with BPD (n = 41) or MDD (n = 37) completed the Reading the Mind in the Eyes Test (RMET) and Happé's Cartoon Task, measures of affective and cognitive dimensions of ToM, respectively.

RESULTS

The BPD group performed significantly worse than the MDD group on the affective ToM task, even after controlling for age, intelligence and depressive symptoms. Results for cognitive ToM were not significantly different.

CONCLUSIONS

Finding of poorer performance on a measure of affective ToM, in BPD youth, relative to youth with MDD early in the course of BPD suggest a developmental failure of sociocognitive abilities needed for mentalising and which are theorised as giving rise to core features of BPD. Future research should employ more naturalistic paradigms to study social cognition and should assess individuals even earlier in the course of BPD.

The prevalence, age distribution and comorbidity of personality disorders in Australian women

OBJECTIVE

We aimed to describe the prevalence and age distribution of personality disorders and their comorbidity with other psychiatric disorders in an age-stratified sample of Australian women aged ⩾25 years.

METHODS

Individual personality disorders (paranoid, schizoid, schizotypal, histrionic, narcissistic, borderline, antisocial, avoidant, dependent, obsessive-compulsive), lifetime mood, anxiety, eating and substance misuse disorders were diagnosed utilising validated semi-structured clinical interviews (Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition and Structured Clinical Interview for DSM-IV Axis II Personality Disorders). The prevalence of personality disorders and Clusters were determined from the study population ( n = 768), and standardised to the Australian population using the 2011 Australian Bureau of Statistics census data. Prevalence by age and the association with mood, anxiety, eating and substance misuse disorders was also examined.

RESULTS

The overall prevalence of personality disorders in women was 21.8% (95% confidence interval [CI]: 18.7, 24.9). Cluster C personality disorders (17.5%, 95% CI: 16.0, 18.9) were more common than Cluster A (5.3%, 95% CI: 3.5, 7.0) and Cluster B personality disorders (3.2%, 95% CI: 1.8, 4.6). Of the individual personality disorders, obsessive-compulsive (10.3%, 95% CI: 8.0, 12.6), avoidant (9.3%, 95% CI: 7.1, 11.5), paranoid (3.9%, 95% CI: 3.1, 4.7) and borderline (2.7%, 95% CI: 1.4, 4.0) were among the most prevalent. The prevalence of other personality disorders was low (⩽1.7%). Being younger (25-34 years) was predictive of having any personality disorder (odds ratio: 2.36, 95% CI: 1.18, 4.74), as was being middle-aged (odds ratio: 2.41, 95% CI: 1.23, 4.72). Among the strongest predictors of having any personality disorder was having a lifetime history of psychiatric disorders (odds ratio: 4.29, 95% CI: 2.90, 6.33). Mood and anxiety disorders were the most common comorbid lifetime psychiatric disorders.

CONCLUSIONS

Approximately one in five women was identified with a personality disorder, emphasising that personality disorders are relatively common in the population. A more thorough understanding of the distribution of personality disorders and psychiatric comorbidity in the general population is crucial to assist allocation of health care resources to individuals living with these disorders.

Tangible Self-Consequation and Arithmetical Problem-Solving: An Exploratory Comparison of Four Strategies

In an exploratory investigation, 25 volunteer postgraduate students were exposed to a control and four self-consequation conditions of positive and negative reward and positive and negative punishment. The experimental tasks were arithmetic problems matched for difficulty. Generally, the results indicated that, when subjects were operating under the two self-reward conditions whereby they self-reinforced correct responses, they attempted more items and produced more correct responses. Conversely, as predicted, participants in the two self-punishment conditions were more accurate.

Delusional infestation: the case for improved mental state testing

OBJECTIVES

Delusional infestation may present as a primary disorder or secondary to another disorder (e.g. schizophrenia). In this report we focus on the issue of inadequacies in mental state examinations leading to diagnostic uncertainty.

METHODS

Case studies were identified for this review through searching the academic databases MedLine, PSYCInfo and PubMed. We developed a template that contained 36 headings and independently examined each case study report. Our percentage agreement for the first 42 case studies we reviewed was 91%.

RESULTS

We identified diagnostic uncertainty due to inadequacies in the reporting of mental state examinations.

CONCLUSIONS

Clinicians need to provide mental state information to an adequate standard that would allow confirmation of a diagnosis of delusions of infestation or exclude other possibilities.

Does the Perceived Value of Consequation Affect Performance Outcomes? A Laboratory Investigation

25 postgraduate students were exposed to a control and 4 self-consequation conditions in a Latin square design. The experimental tasks were arithmetic problems matched for difficulty. Following each experimental condition, participants responded to a questionnaire to ascertain subjective differences in perceived valence of the particular type of consequation. This procedure yielded two groups designated as ‘adequate’ or ‘inadequate’ within each condition. Results of post hoc comparisons gave no predictable pattern between contrasted groups within conditions despite predicted between-condition differences. Factors other than perceived incentive valence of the consequences were responsible for the predicted differences between the self-consequation conditions.

Some Effects of Feedback Alone and Four Types of Self-Consequation on Selected Measures of Problem Solving

This paper examines the relative efficacy of five self-management strategies on four measures of arithmetical problem-solving performance. Four of the self-management contingencies, namely, positive and negative self-reward and positive and negative self-punishment, involved the self-presentation of a tangible consequence, whereas for the fifth or self-recording group the consequence was in the form of veridical feedback and more covert or cognitive in nature. A sixth group served as a control ( n — 84). Analyses of data indicated that the self-reward groups completed significantly more items than the comparison groups. But when accuracy (errors) was the measure of interest, the self-punishment groups were superior. Essentially, these results replicated the data of an earlier exploratory study.

Long-term follow-up of all-cause and unnatural death in young people with first-episode psychosis

OBJECTIVE

To determine mortality-related estimates and causes of death in young people with first-episode psychosis (FEP), and to identify baseline predictors of mortality.

METHOD

Mortality outcomes in 723 young people presenting to an early psychosis service were prospectively ascertained up to 20 years. Predictors of all-cause and unnatural death were investigated using survival techniques.

RESULTS

Forty-nine participants died by study end. Most deaths (n=41) occurred within 10 years of service entry. All-cause mortality was 5.5% at 10 years, rising to 8.0% after 20 years. Unnatural death rates at 10 and 20 years were 5.0% and 5.9%, respectively. Three risk factors consistently predicted all-cause mortality and unnatural deaths.

CONCLUSION

A substantial proportion of excess mortality was due to non-suicide unnatural death, and, later, natural deaths. This suggests that mental health services should expand their current focus on suicide to incorporate strategies to prevent accidental death and promote healthier lifestyles.

Psychosocial influences on glycemic control in women with pre-existing diabetes preparing for pregnancy

OBJECTIVE

The purpose of this study was to identify psychosocial factors associated with glycemic control in a sample of adult women with type 1 or type 2 diabetes mellitus preparing for pregnancy.

METHODS

This was a cross-sectional study. Participants comprised a subsample (n=38) of a larger study investigating predictors of prepregnancy care uptake in women with pre-existing diabetes. Participants were recruited from the diabetes and pregnancy clinics at 2 major hospitals and completed self-report questionnaires on personality, coping style, social support and knowledge of diabetes and pregnancy. The main outcome was glycemic control using glycated hemoglobin (A1C) as the outcome of interest.

RESULTS

The sample was divided into good (n=20) vs. poor (n=18) glycemic control based on their A1C at entry to the study. Univariate tests indicated no differences between the 2 groups on any of the variables except that the good control group were better educated. Hierarchical multiple regression analysis revealed that problem-focused coping and higher education remained significantly associated with better glycemic control when controlling for potential confounds.

CONCLUSIONS

Providing women with enhanced prepregnancy diabetes education with a particular emphasis on problem-solving and coping skills may enable them to take more proactive approaches to challenges they face in managing their diabetes. That in turn can improve glycemic control at the critical period.

Social relationships and quality of life moderate distress associated with delusional ideation

PURPOSE

In a previous study, individuals who followed a particular new religious movement (NRM) reported significantly less distress even though they reported similar levels of delusional ideation when compared with individuals diagnosed with psychotic disorders. Protective factors such as social relationship quality and quality of life (QOL) were hypothesized to explain attenuated distress associated with delusional ideation.

METHODS

NRM individuals (n = 29), individuals diagnosed with psychotic disorders (n = 25), and control individuals (n = 63) were recruited. Psychotic symptoms, delusion-proneness, and facets of social relationships quality and QOL were examined across group. Potential moderators of the relationship between group membership and distress were further examined in multiple regression models.

RESULTS

NRM participants reported more social relationships that were of higher quality (as demonstrated by more crisis supports, unique and overlap supports, more helpful supports and more reciprocated supports) than individuals with psychotic disorders. NRM participants also reported significantly higher QOL than individuals with psychotic disorders. Furthermore, NRM participants reported more distinct and less reciprocated supports, and significantly higher psychological, environmental, and total QOL, when compared with control participants. The relationship between group membership, delusional ideation, and distress was moderated by relationship reciprocity as well as by total QOL.

CONCLUSIONS

Findings highlight the importance of establishing healthy reciprocal social relationships and improving QOL in people diagnosed with psychotic disorders, as these factors may act as a buffer against distress associated with delusional beliefs.

The relative contribution of neurocognition and social cognition to 6-month vocational outcomes following Individual Placement and Support in first-episode psychosis

AIMS

To examine whether baseline neurocognition and social cognition predict vocational outcomes over 6 months in patients with first-episode psychosis (FEP) enrolled in a randomised controlled trial of Individual Placement and Support (IPS) versus treatment as usual (TAU).

METHODS

135 FEP participants (IPS n=69; TAU n=66) completed a comprehensive neurocognitive and social cognitive battery. Principal axis factor analysis using PROMAX rotation was used to determine the underlying cognitive structure of the battery. Setwise (hierarchical) logistic and multivariate linear regressions were used to examine predictors of: (a) enrolment in education and employment; and (b) hours of employment over 6 months. Neurocognition and social cognition factors were entered into the models after accounting for premorbid IQ, baseline functioning and treatment group.

RESULTS

Six cognitive factors were extracted: (i) social cognition; (ii) information processing speed; (iii) verbal learning and memory; (iv) attention and working memory; (v) visual organisation and memory; and (vi) verbal comprehension. Enrolment in education over 6 months was predicted by enrolment in education at baseline (p=.002) and poorer visual organisation and memory (p=.024). Employment over 6 months was predicted by employment at baseline (p=.041) and receiving IPS (p=.020). Better visual organisation and memory predicted total hours of paid work over 6 months (p<.001).

CONCLUSIONS

Visual organisation and memory predicted the enrolment in education and duration of employment, after accounting for premorbid IQ, baseline functioning and treatment. Social cognition did not contribute to the prediction of vocational outcomes. Neurocognitive interventions may enhance employment duration in FEP.

An investigation of psycho-social factors associated with the uptake of pre-pregnancy care in Australian women with type 1 and type 2 diabetes

Pre-pregnancy care (PPC) reduces adverse pregnancy outcomes for women with pre-existing diabetes. Yet, despite the compelling case for PPC, participation rates remain poor. The reasons for poor participation are as yet unclear. The aim of this study was to further our understanding of the factors-associated PPC uptake, particularly attitudes and beliefs towards PPC using models of health behaviour: The Health Belief Model, Social Cognitive Theory, and Theory of Reasoned Action. Participants comprised 123 women with type 1 and 2 diabetes attending outpatient clinics for diabetes and pregnancy, who completed questionnaires. Logistic regression analysis indicated that after adjusting for socio-demographic factors, exposure to a greater number of cues was a significant predictor of PPC participation (odds ratio [OR]: 1.93; 95% confidence interval [95% CI]: 1.13-3.28). Other significant predictors of PPC uptake were older age (OR: 1.13; 95% CI: 1.01-1.26) and not having children (OR: 3.93; 95% CI: 1.28-12.06). The findings from this study support initiatives to provide cues to PPC for women with diabetes to enhance PPC uptake. Further, some groups such as younger women as well as women with children may possibly be considered for the focus of more vigorous intervention efforts.

Tobacco smoking predicts depression and poorer quality of life in heart disease

Background

We report on the prospective association between smoking and depression and health-related quality of life (HRQOL) in patients with coronary artery disease (CAD).

Methods

Prospective study of 193 patients with assessment of depression occurring 3-, 6- and 9- months (T1, 2, and 3, respectively) following discharge from hospital for a cardiac event. HRQOL was assessed at T3. T1 depression was assessed by clinical interview; T2 and T3 depression was assessed by self-report. Smoking at time of cardiac event was assessed by self-report. Multivariate analyses controlled for known demographic, psychosocial and clinical correlates of depression.

Results

Smoking at the time of index cardiac event increased the likelihood of being diagnosed with Major Depressive Disorder (MDD) at T1 by 4.30 [95% CI, 1.12-16.46; p < .05]. The likelihood of receiving a diagnosis of minor depression, dysthymia or MDD as a combined group was increased by 8.03 [95% CI, 2.35-27.46; p < .01]. Smoking did not reliably predict depression at T2 or T3 and did not reliably predict persistent depression. Smoking increased the likelihood of being classified as depressed according to study criteria at least once during the study period by 5.19 [95% CI, 1.51-17.82; p < .01]. Smoking independently predicted worse mental HRQOL.

Conclusions

The findings support a role for smoking as an independent predictor of depression in CAD patients, particularly in the first 3 months post-cardiac event. The well-established imperative to encourage smoking cessation in these patients is augmented and the findings may add to the evidence for smoking cessation campaigns in the primary prevention of depression.

Predictors of vocational recovery among young people with first-episode psychosis: findings from a randomized controlled trial

OBJECTIVE

The current study sought to examine demographic and clinical predictors of vocational recovery among young people with first-episode psychosis who participated in a randomized controlled trial (RCT) investigating the effectiveness of the supported employment model among this population.

METHOD

Our original RCT compared Individual Placement and Support + treatment as usual (n = 20) with treatment as usual alone (n = 21) (Killackey, Jackson, & McGorry, 2008). A series of logistic regression analyses were conducted to assess the predictive power of demographic and clinical factors on the vocational recovery of young people with first-episode psychosis.

RESULTS

Vocational recovery (defined as securing a position in competitive employment or attending a course of education at any point during the 6-month follow-up period) was predicted by participating in the vocational intervention (OR = 14.17, p = .001), having never been married (compared to those married/de facto: OR = 6.56, p = .044), and the instrumental role functioning subscale from the Quality of Life scale (OR = 1.21, p = .037). When considered together, only treatment group remained significant: Participants randomized to the vocational intervention were 16.26 times more likely to obtain work or study during the follow-up period compared to participants randomized to treatment as usual.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

It is critical that vocational services are introduced as part of an evidence-based, multidisciplinary approach in routine clinical care at early psychosis services. Further replication of these findings is indicated with a larger sample, particularly with the addition of cognitive training interventions to further improve vocational outcomes for young people with first-episode psychosis.

Source monitoring and proneness to auditory-verbal hallucinations: a signal detection analysis

INTRODUCTION

It has been suggested that a bias to misattribute self-generated thoughts to a nonself source underlies the experience of auditory-verbal hallucinations (AVH). We tested this hypothesis with healthy participants prone or not prone to AVH.

METHOD

Participants (N=133) were presented with 96 words for subsequent recognition (half positively, half negatively valenced). For self-generated trials, participants generated a sentence containing the word. For other-generated trials, participants heard a prerecorded sentence containing the word. At test, studied words were re-presented visually, intermixed with 96 matched lures. Participants indicated the study status (old or new) and source (self or other) for each item. Sensitivity and bias measures were derived for item and source memory using signal detection theory. The 20 participants scoring highest on questions relating to AVH from the revised Launay-Slade Hallucination Scale formed the high-AVH group and the 20 scoring lowest formed the low-AVH group.

RESULTS

ANOVAs revealed no significant differences between the two participant groups in sensitivity or bias of source memory, regardless of item valence. There was a trend for the sensitivity of item memory to be lower in the high-AVH group, compared with the low-AVH group. The bias of item memory was not significantly different between groups.

CONCLUSIONS

Although we found no evidence that source-monitoring problems underlie the experience of AVHs in the general population, we recommend that signal detection measures be applied in future investigations of source monitoring in at-risk and clinical populations.

Hearing voices inside and outside the head: spatial source monitoring in participants prone to auditory hallucinations

INTRODUCTION

Previous studies of source monitoring and auditory hallucinations (AH) have often conflated spatial source (internal-external) with source agency (self-other). Other studies have used suboptimal manipulations of auditory space (e.g., imagine saying vs. saying aloud). We avoided these problems by presenting experimenter-generated stimuli over headphones in the voice of another person so that the location of the voice sounded either internal or external to the participant's head.

METHODS

Participants (N=121) studied 96 words and indicated for each whether it was presented internally or externally (online spatial source monitoring). At test, studied words were presented visually, intermixed randomly with 96 unstudied words. Participants indicated whether each item was old or new (item memory) and whether it was presented internally or externally during study (spatial source memory). Independent measures of memory accuracy and response bias were derived for online source monitoring, item memory and source memory using signal detection theory. Performance on these measures was compared between two groups of 30 participants who scored low or high on a measure of AH proneness.

RESULTS

ANOVAs revealed no differences between the high- and low-AH groups in online spatial source monitoring, item memory, or spatial source memory.

CONCLUSIONS

We found no evidence that proneness to AH in a sample of healthy volunteers was related to any of the measures of spatial source monitoring performance. We recommend that the methods introduced be applied to future investigations of spatial source monitoring with patient groups and with individuals at-risk for psychosis.

Psychometric properties of a scale to measure investment in the sick role: the Illness Cognitions Scale

RATIONALE, AIMS AND OBJECTIVES

A person's beliefs about their illness may contribute to recovery and prognosis. Some degree of acceptance of illness and its impact is necessary to integrate the presence of a chronic disorder into one's lifestyle and adhere to necessary components of illness management; however, some individuals can become 'stuck' and have difficulty adjusting out of the sick role. Inventories exist to measure illness cognitions, attitudes and behaviours as they relate to hypochondria and psychosomatic illness, but there is no extant measure of sick role inertia. We describe the psychometric properties of a new scale, the Illness Cognitions Scale (ICS), a metric of investment in the sick role.

METHODS

The ICS was administered to 97 individuals with bipolar or schizoaffective disorder, and the psychometric properties of the scale measured. Dimensionality was assessed using Principal Components Analysis with Oblimin rotation.

RESULTS

The scale has a strong internal consistency, with a Cronbach's alpha of 0.858. Results of a factor analysis suggested the presence of one main factor, with three other smaller, related sub-factors, capturing aspects of maladaptive illness beliefs.

CONCLUSION

The ICS is a 17-item, internally validated scale measuring difficulty adjusting out of the sick role. The scale predominantly measures a single construct. Further research on external validity of the ICS is required as well as determination of the clinical significance and patient acceptability of the scale.

Road to full recovery: longitudinal relationship between symptomatic remission and psychosocial recovery in first-episode psychosis over 7.5 years

BACKGROUND

In recent years there has been increasing interest in functional recovery in the early phase of schizophrenia. Concurrently, new remission criteria have been proposed and several studies have examined their clinical relevance for prediction of functional outcome in first-episode psychosis (FEP). However, the longitudinal interrelationship between full functional recovery (FFR) and symptom remission has not yet been investigated. This study sought to: (1) examine the relationships between FFR and symptom remission in FEP over 7.5 years; (2) test two different models of the interaction between both variables.

METHOD

Altogether, 209 FEP patients treated at a specialized early psychosis service were assessed at baseline, 8 months, 14 months and 7.5 years to determine their remission of positive and negative symptoms and functional recovery. Multivariate logistic regression and path analysis were employed to test the hypothesized relationships between symptom remission and FFR.

RESULTS

Remission of both positive and negative symptoms at 8-month follow-up predicted functional recovery at 14-month follow-up, but had limited value for the prediction of FFR at 7.5 years. Functional recovery at 14-month follow-up significantly predicted both FFR and remission of negative symptoms at 7.5 years, irrespective of whether remission criteria were simultaneously met. The association remained significant after controlling for baseline prognostic indicators.

CONCLUSIONS

These findings provided support for the hypothesis that early functional and vocational recovery plays a pivotal role in preventing the development of chronic negative symptoms and disability. This underlines the need for interventions that specifically address early psychosocial recovery.

Social perspective coordination in youth with borderline personality pathology

This study investigated social perspective coordination (SPC) in youth (15-24-year-olds) with first-presentation borderline personality disorder (BPD). SPC is defined as the capacity to differentiate and integrate the perspective of the self with the perspectives of others (Selman, Beardslee, Schultz, Krupa, & Podorefsky, 1986). Two groups: patients with full or sub-syndromal BPD (n = 30) and patients with major depressive disorder (MDD; n = 30) completed measures of SPC derived from the interpersonal negotiation strategies (INS) model (Selman et al., 1986). Compared with the MDD group, the BPD group responded to all vignettes with significantly lower SPC scores and SPC was a significant predictor of BPD status over and above self-reported, personality factors (Neuroticism and Agreeableness), attachment disturbance and functional impairment. These findings suggest that disturbances in social cognition are an important characteristic of individuals with BPD pathology. These difficulties extended beyond attachment contexts and were not limited to situations involving BPD-related themes of abandonment, deprivations or mistrust/abuse.

Childhood trauma increases the risk of post-traumatic stress disorder in response to first-episode psychosis

OBJECTIVE

To investigate the relationship between childhood trauma, post-traumatic stress symptoms due to the experience of childhood trauma, and post-traumatic stress symptoms due to the experience of psychosis.

METHOD

The current study assessed childhood trauma and post-traumatic stress disorder (PTSD) symptoms as a result of both childhood trauma and psychosis using the Impact of Events Scale - Revised, in a group of 36 people with first-episode psychosis.

RESULTS

Reported rates of clinical level post-psychotic PTSD symptoms, childhood trauma and childhood trauma-related clinical level PTSD symptoms were 47% (95% CI 31-64%), 64% (95% CI 48-80%) and 39% (95% CI 23-55%), respectively. Reporting childhood trauma increased the risk of developing post-psychosis PTSD 27-fold (95% CI 2.96-253.80, p = 0.01). Having childhood trauma-related PTSD increased the risk of developing post-psychosis PTSD 20-fold (95% CI 3.38-123.25, p = 0.01). These risks were not explained by illness factors such as duration of untreated psychosis, age of onset or severity of psychotic symptoms. Those without post-psychotic PTSD symptoms at clinical levels were unlikely to report childhood trauma (6%; 95% CI 3-8%).

CONCLUSIONS

These results suggest the cognitive, social and biological consequences of childhood trauma can prevent effective recovery from the trauma of acute first-episode psychosis resulting in post-psychotic PTSD. Treatment strategies for post-psychotic PTSD must address childhood trauma and related PTSD.

Patient predictors of symptom and functional outcome following cognitive behaviour therapy or befriending in first-episode psychosis

BACKGROUND

Cognitive behaviour therapy (CBT) is an effective treatment for many, but not all, individuals with psychosis. An important goal is identifying individuals more likely to benefit from CBT to ensure appropriate delivery. The current study aimed to examine patient-related predictors of symptom and functional outcome following CBT and Befriending in first-episode psychosis (FEP).

METHOD

Our original randomized controlled trial compared 14 weeks of CBT (n=31) and Befriending (n=31) in FEP (Jackson et al. 2008). A series of regressions were conducted separately for each group to examine demographic, cognitive, symptoms/illness and functioning variables in predicting positive symptoms (BPRS Psychotic), negative symptoms (SANS Total) and functioning (SOFAS) at 1-year follow-up.

RESULTS

In the CBT group, higher baseline functioning (SOFAS) predicted lower levels of positive symptoms (R(2)=0.19; p=0.023), higher educational achievement and lower levels of avolition symptoms (SANS Avolition) predicted lower levels of total negative symptoms (R(2)=0.38; p=0.003), and working/studying at baseline predicted higher functional outcome (R(2)=0.35; p=0.004) at 1 year. In the Befriending group, premorbid adjustment (PAS Average) was the only variable that predicted 1-year positive symptom (R(2)=0.26; p=0.010), negative symptom (R(2)=0.35; p=0.016) and functional (R(2)=0.48; p=0.002) outcome.

CONCLUSIONS

FEP individuals with higher baseline functioning may benefit more from CBT than those with poorer functioning. Individuals with functional difficulties may benefit from alternative treatments initially, such as supported education or employment.

Selective attention to threat bias in delusion-prone individuals

The study examined the selective attention to threat bias in delusion-prone individuals recruited from New Religious Movements (NRMs). Twenty-seven delusion-prone NRM individuals were compared with 25 individuals with psychotic disorders and 63 non-delusion-prone individuals on a Stroop task, together with psychotic and delusion proneness measures. NRM individuals showed significantly lower levels of selective attention to threat bias compared with individuals with psychotic disorders but not with non-delusion-prone individuals. Selective attention to threat bias was also not correlated with distress associated with delusional ideation. These findings may be specific to delusion-prone NRM individuals. The absence of the selective attention to threat bias may be related to levels of safety and security among members of NRMs.

What self-generated speech is externally misattributed in psychosis? Testing three cognitive models in a first-episode sample

BACKGROUND

External misattribution of internally generated speech has been implicated in several cognitive models of psychotic symptomatology as the process by which internal percepts become hallucinations. Different strands of research have suggested that a) information is externally misattributed irrespective of meaning, conferring a risk for hallucinations, b) negative or derogatory self-generated percepts are externally misattributed leading to persecutory hallucinations, and c) that, in some people who have experienced childhood trauma, post-traumatic intrusive memories of trauma are externally misattributed to become hallucinations.

METHODS

These strands of research were investigated with a group of people with first episode psychosis (n=44) and matched non-psychiatric controls (n=26) who completed psychopathology measures and underwent a source monitoring task using positive, neutral, negative and trauma words.

RESULTS

Those with hallucinations showed no external misattribution bias across all words, or specifically for negative words. Those with childhood trauma showed no externalising bias for trauma words. Those with hallucinations did show an externalising bias towards positive words.

CONCLUSIONS

The results suggest that external source monitoring bias may not be central to the cognitive processes underlying hallucinations early in the course of psychotic illness. The theory linking childhood trauma and external source misattribution was not supported.

Prediction of a single psychotic episode: a 7.5-year, prospective study in first-episode psychosis

BACKGROUND

Around 20% of patients who suffer from psychosis will experience a single psychotic episode (SPE), but relatively little is known about the characteristics and predictors for this group of patients. This study sought to: 1) characterise the subgroup of first-episode psychosis (FEP) patients who experienced a SPE over a 7.5-year follow-up; and 2) to identify significant predictors for this subgroup independent of potential confounders.

METHODS

A representative sample of 413 FEP patients treated at a specialist early psychosis service were assessed at baseline and followed-up for 7.5 years. Binary logistic regression models were employed to investigate univariate and adjusted associations between baseline predictors and experiencing a SPE. Results were adjusted for the influence of known prognostic factors for psychosis.

RESULTS

Follow-up data was available for 274 participants. Forty-six (16.5%) achieved clinical remission and experienced no recurrence over the follow-up period. Duration of untreated psychosis (DUP) shorter than 60 days (OR=3.89, p=0.007), more rapid response to antipsychotic treatment (OR=0.33, p=0.019) and no parental loss (OR=5.25, p=0.045) significantly predicted a SPE. The association remained significant after controlling for potential confounders.

CONCLUSIONS

Early treatment (within two months of onset of psychotic symptoms) and social support significantly reduce vulnerability to subsequent psychotic episodes. Future studies need to investigate the interplay between biological factors (i.e. sensitized dopaminergic system), environmental variables (i.e. exposure to trauma, stigma and discrimination), and psychological attributes (i.e. cognitive schemata) in order to elucidate the processes underlying the vulnerability to recurrent psychotic episodes.

The EPPIC follow-up study of first-episode psychosis: longer-term clinical and functional outcome 7 years after index admission

OBJECTIVE

To describe the longer-term clinical and functional outcome of a large, epidemiologic representative cohort of individuals experiencing a first episode of psychosis.

METHOD

A naturalistic, prospective follow-up of an epidemiologic sample of 723 consecutive first-episode psychosis patients, followed between January 1998 and April 2005, at a median of 7.4 years after initial presentation to the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia. EPPIC is a frontline public mental health early psychosis program, servicing a geographically defined catchment area with a population of about 800,000 people. The main outcome measures included the Brief Psychiatric Rating Scale, the Schedule for the Assessment of Negative Symptoms, the Beck Depression Inventory, the Global Assessment of Functioning Scale, the Social and Occupational Functioning Assessment Scale, the Quality of Life Scale, and the remission criteria developed by the Remission in Schizophrenia Working Group.

RESULTS

Follow-up information was collected on up to 90.0% (n = 651) of the baseline cohort of 723 participants, with 66.9% (n = 484) interviewed. In the last 2 years, 57% of individuals with schizophrenia/schizophreniform, 54% with schizoaffective disorder, 62% with affective psychosis, and 68% with other psychotic disorders reported some paid employment. Depending upon the criteria applied, symptomatic remission at follow-up was observed in 37%-59% of the cohort. Social/vocational recovery was observed in 31% of the cohort. Approximately a quarter achieved both symptomatic remission and social/vocational recovery.

CONCLUSION

The relatively positive outcomes are consistent with a beneficial effect of specialized early intervention programs; however it is premature to draw firm conclusions. There was no control group and there are many differences between the relevant comparison studies and the present one. Although difficult to conduct, large scale controlled health services research trials are required to definitively determine the impact and optimal duration of specialized early psychosis programs.

Early intervention for adolescents with borderline personality disorder: quasi-experimental comparison with treatment as usual

OBJECTIVE

The aim of the present study was to compare the effectiveness of specialized team-based early intervention for borderline personality disorder (BPD) with treatment as usual.

METHOD

In a quasi-experimental design, 32 outpatients who received historical treatment as usual (H-TAU) were compared with 78 participants from a recently published randomized controlled trial of cognitive analytic therapy (CAT; n = 41) versus manualized good clinical care (GCC; n = 37), conducted in a specialized early intervention service for BPD (the Helping Young People Early (HYPE) programme). All participants were 15-18-year-old outpatients who fulfilled 2-9 DSM-IV BPD criteria. It was predicted that, compared with H-TAU, HYPE + GCC and HYPE + CAT would show greater reductions in psychopathology and parasuicidal behaviour and greater improvement in global functioning over 24 months.

RESULTS

At 24 month follow up: (i) HYPE + CAT had lower standardized levels of, and a significantly faster standardized rate of improvement in, internalizing and externalizing psychopathology, compared with H-TAU; and (ii) HYPE + GCC had lower standardized levels of internalizing psychopathology and a faster rate of improvement in global functioning than H-TAU. HYPE + CAT yielded the greatest median improvement on the four continuous outcome measures over 24 months. No adverse effects were shown with any of the treatments.

CONCLUSIONS

Specialized early intervention for subsyndromal or full-syndrome BPD is more effective than TAU, with HYPE + CAT being the most effective intervention. Reform of existing services using the HYPE model might yield substantial improvements in patient outcomes.

Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: randomised controlled trial

BACKGROUND

No accepted intervention exists for borderline personality disorder presenting in adolescence.

AIMS

To compare the effectiveness of up to 24 sessions of cognitive analytic therapy (CAT) or manualised good clinical care (GCC) in addition to a comprehensive service model of care.

METHOD

In a randomised controlled trial, CAT and GCC were compared in out-patients aged 15-18 years who fulfilled two to nine of the DSM-IV criteria for borderline personality disorder. We predicted that, compared with the GCC group, the CAT group would show greater reductions in psychopathology and parasuicidal behaviour and greater improvement in global functioning over 24 months.

RESULTS

Eighty-six patients were randomised and 78 (CAT n=41; GCC n=37) provided follow-up data. There was no significant difference between the outcomes of the treatment groups at 24 months on the pre-chosen measures but there was some evidence that patients allocated to CAT improved more rapidly. No adverse effect was shown with either treatment.

CONCLUSIONS

Both CAT and GCC are effective in reducing externalising psychopathology in teenagers with sub-syndromal or full-syndrome borderline [corrected] personality disorder. Larger studies are required to determine the specific value of CAT in this population.

Screening for borderline personality disorder in outpatient youth

Young people with borderline personality disorder (BPD) commonly seek help but often go unrecognized. Screening offers a means of identifying individuals for more detailed assessment for early intervention and for research.

AIMS

This study compared the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), Borderline Personality Questionnaire (BPQ), the BPD items from the International Personality Disorder Examination Screening Questionnaire and the BPD items from the Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II) Personality Questionnaire.

METHOD

101 outpatient youth (aged 15-25 years) completed the screening measures and were interviewed, blind to screening status, with the SCID-II BPD module. The screening measures were readministered two weeks later to assess test-retest reliability.

RESULTS

All four instruments performed similarly but the BPQ had the best mix of characteristics, with moderate sensitivity (0.68), the highest specificity (0.90), high negative predictive value (0.91) and moderate positive predictive value (0.65). Compared to the other three instruments, the BPQ had the highest overall diagnostic accuracy (0.85), a substantially higher kappa (0.57) with the criterion diagnosis, the highest test-retest reliability (ICC = 0.92) and the highest internal consistency (alpha = 0.92). The only clear difference to emerge in the Receiver Operator Curve (ROC) analysis was that the BPQ significantly outperformed the MSI (p = 0.05).

CONCLUSION

Screening for BPD in out-patient youth is feasible but is not a replacement for clinical diagnosis.

Vocational intervention in first-episode psychosis: individual placement and support v. treatment as usual

BACKGROUND

Unemployment is a major problem for people with first-episode psychosis and schizophrenia. This has repercussions for the economy, social functioning and illness prognosis.

AIMS

To examine whether a vocational intervention - individual placement and support (IPS) - which has been found to be beneficial in populations with chronic schizophrenia, was a useful intervention for those with first-episode psychosis.

METHOD

A total of 41 people with first-episode psychosis were randomised to receive either 6 months of IPS + treatment as usual (TAU) (n=20) or TAU alone (n=21).

RESULTS

The IPS group had significantly better outcomes on level of employment (13 v. 2, P<0.001), hours worked per week (median 38 v. 22.5, P=0.006), jobs acquired (23 v. 3) and longevity of employment (median 5 weeks v. 0, P=0.021). The IPS group also significantly reduced their reliance on welfare benefits.

CONCLUSIONS

Individual placement and support has good potential to address the problem of vocational outcome in people with first-episode psychosis. This has economic, social and health implications.

Childhood trauma and psychotic disorders: a systematic, critical review of the evidence

There is controversy over whether childhood trauma (CT) is a causal factor in the development of psychosis. This review aims to identify and critically analyze the association between CT and psychotic disorders. Studies investigating CT and psychotic disorder were identified by searches of electronic databases and manual searches of references lists, and 46 studies were identified. Forty studies had no control group, only psychiatric control groups, or unmatched, nonpopulation control groups and thus had methodologies that were inadequate to determine the relationship between CT and psychosis. Six studies used appropriate control groups. Three studies found an association between CT and psychosis, 2 found potentially real associations that failed to reach statistical significance, and 1 found no association, tentatively suggesting a relationship between CT and psychotic disorders. Several methodological problems were found in the studies in the review, including the highest quality studies, which limit the strength of the conclusions that can be drawn from them. These were lack of statistical power, lack of attention to moderating or mediating variables, the way in which CT was measured, and the use of cross-sectional research designs. These problems, some of which may be unavoidable in CT research, suggest the need for new and innovative methodologies in the investigation of CT and psychosis. Directions for further research are explored.

Acute-phase and 1-year follow-up results of a randomized controlled trial of CBT versus Befriending for first-episode psychosis: the ACE project

BACKGROUND

The ACE project involved 62 participants with a first episode of psychosis randomly assigned to either a cognitive behaviour therapy (CBT) intervention known as Active Cognitive Therapy for Early Psychosis (ACE) or a control condition known as Befriending. The study hypotheses were that: (1) treating participants with ACE in the acute phase would lead to faster reductions in positive and negative symptoms and more rapid improvement in functioning than Befriending; (2) these improvements in symptoms and functioning would be sustained at a 1-year follow-up; and (3) ACE would lead to fewer hospitalizations than Befriending as assessed at the 1-year follow-up.

METHOD

Two therapists treated the participants across both conditions. Participants could not receive any more than 20 sessions within 14 weeks. Participants were assessed by independent raters on four primary outcome measures of symptoms and functioning: at pretreatment, the middle of treatment, the end of treatment and at 1-year follow-up. An independent pair of raters assessed treatment integrity.

RESULTS

Both groups improved significantly over time. ACE significantly outperformed Befriending by improving functioning at mid-treatment, but it did not improve positive or negative symptoms. Past the mid-treatment assessment, Befriending caught up with the ACE group and there were no significant differences in any outcome measure and in hospital admissions at follow-up.

CONCLUSIONS

There is some preliminary evidence that ACE promotes better early recovery in functioning and this finding needs to be replicated in other independent research centres with larger samples.

Cognitive decline following psychosis onset: data from the PACE clinic

BACKGROUND

The origin of cognitive impairments in psychotic disorders is still unclear. Although some deficits are apparent prior to the onset of frank illness, it is unknown if they progress.

AIMS

To investigate whether cognitive function declined over the transition to psychosis in a group of ultra-high risk individuals.

METHOD

Participants consisted of two groups: controls (n=17) and individuals at ultra-high risk for development of psychosis (n=16). Seven of the latter group later developed psychosis. Neuropsychological testing was conducted at baseline and again after at least a 12-month interval.

RESULTS

Both the Visual Reproduction sub-test of the Wechsler Memory Scale-Revised and Trail-Making Test B showed a decline over the follow-up period that was specific to the group who became psychotic. In addition, both high-risk groups showed a decline in digit span performance. No other task showed significant change over time.

CONCLUSIONS

These preliminary data suggest that as psychosis develops there may be a specific decline in visual memory and attentional set-shifting, reflecting impairments in efficient organisation of visual stimuli. This may be caused by either the illness itself or treatment with antipsychotic medication.