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BackgroundCommand hallucinations are a distressing and high-risk group of symptoms that have long been recognised but little understood, with few effective treatments. In line with our recent research, we propose that the development of an effective cognitive therapy for command hallucinations (CTCH) would be enhanced by applying insights from social rank theory.AimsWe tested the efficacy of CTCH in reducing beliefs about the power of voices and thereby compliance, in a single-blind, randomised controlled trial.MethodA total of 38 patients with command hallucinations, with which they had recently complied with serious consequences, were allocated randomly to CTCH or treatment as usual and followed up at 6 months and 12 months.ResultsLarge and significant reductions in compliance behaviour were obtained favouring the cognitive therapy group (effect size=1.1). Improvements were also observed in the CTCH but not the control group in degree of conviction in the power and superiority of the voices and the need to comply, and in levels of distress and depression. No change in voice topography (frequency, loudness, content) was observed. The differences were maintained at 12 months' follow-up.ConclusionsThe results support the efficacy of cognitive therapy for CTCH.

BackgroundStudies have consistently found that many individuals with first-episode psychosis experience significant delays before receiving treatment. Current research investigating treatment delays has focused on the relationship between demographic factors and duration of untreated psychosis (DUP). However, treatment-seeking behaviours in this group have not been investigated.AimsTo examine psychological processes that influence the decision-making process to contact primary care, in individuals with emerging psychosis.MethodThe influence of coping style, health locus of control and past health help-seeking behaviour on DUP was investigated in clients with a first episode of psychosis. This involved scrutiny of general practitioner (GP) records in an average of 6 years before the first treatment.ResultsShorter DUP was associated with more frequent GP attendance in the 6 years before the onset of psychosis and lower health threat avoidant coping scores.ConclusionsPatients with short DUP have a history of higher contact with their GP and, as a group, tend not to avoid health threats. The study underlines the importance of engaging young people and their families with primary care as one of a series of strategies to reduce DUP.

BackgroundIn 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).AimsWe apply our cognitive framework to PPD and chart the appraisal of self and psychosis and their link with the later emergence of PPD.MethodPatients 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.ResultsBefore 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.ConclusionsDepression 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.

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

Background We consider the evidence for the proposition that the early phase of psychosis (including the period of untreated psychosis) is a critical period' in which (a) long-term outcome is predictable, and (b) biological, psychological and psychosocial influences are developing and show maximum plasticity.Method First-episode prospective studies, predictors of outcome and the genesis of patients' key appraisals of their psychosis are reviewed.Results The data support the notion of the ‘plateau effect’, first coined by Tom McGlashan, which suggested that where deterioration occurs, it does so aggressively in the first 2-3 years; and that critical psychosocial influences, including family and psychological reactions to psychosis and psychiatric services, develop during this period.Conclusions The early phase of psychosis presents important opportunities for secondary prevention. We outline a prototype of intervention appropriate to the critical period. The data challenge the widely held assumption that first-episode psychosis is a benign illness posing little risk.

BackgroundThe application of cognitive therapy (CT) to psychosis is currently being developed in the UK. This paper reports a trial of CT in acute psychosis with the objective of hastening the resolution of positive symptoms and reducing residual symptoms.MethodOf 117 patients with acute non-affective psychosis, 69 satisfied inclusion criteria and 40 proceeded to stratified randomisation. The experimental intervention involving individual and group CT was compared with a group receiving matched hours of therapist input providing structured activities and informal support; routine pharmacotherapy was provided by clinicians blind to group allocation. Patients were monitored weekly using self-report and mental state assessments during admission and over the subsequent nine months.ResultsBoth groups showed a decline in positive symptoms but this was more marked in the CT group (P < 0.001). At 9 months 5% of the CT group, v. 56% of the control group, showed moderate or severe residual symptoms.ConclusionCT appears to be a potent adjunct to pharmacotherapy and standard care for acute psychosis. Issues concerning internal and external validity of the study and opportunities for further research are discussed.

Emotional dysfunction and schizophrenia have long been uncomfortable bedfellows. It was Bleuler who first argued that problems of affect lie at the heart of schizophrenia and that the symptoms we all focus on — the hallucinations and delusions — are merely ‘accessory’ and common to many

Considerable advances have been made in the family management of schizophrenia but there remains a major challenge for the psychiatric services to integrate these innovations into clinical practice. A number of important issues need to be considered in developing routine clinical services: the problem of engaging families in a therapeutic programme; the utility of the concept of ‘expressed emotion’; and procedures for clinical practice. The latter include the needs of low-EE families; maintaining quality of intervention in a clinical context; responding to the multiplicity of needs of the patient and family; and integrating family interventions with ongoing rehabilitation practice. A model of service provision is described.

SummaryIt is now known that the onset of severe and recurring mental health problems begins for the most part before the age of 25: this provides a clear focus for preventive strategies and public mental health that are a feature of many health policy frameworks. The present distinction between child and adolescent mental health services and adult services at 16 or 18 does not fit easily with these data and the now well-documented problems of transition suggest that a fundamental review of services for young people is overdue. This supplement provides an overview of the epidemiological, conceptual and service structures for young people with emergent and existing mental health problems, and asks the question, ‘How should we design services for young people to promote prevention and service engagement, and to improve outcomes?’

SummarySome 20 trials of cognitive-behavioural therapy (CBT) for psychosis have re-established psychotherapy as a credible treatment for psychosis. However, it is not without its detractors and problems, including uncertainty about the nature of its active ingredients. We believe that the way forward is to abandon the neuroleptic metaphor of CBT for psychosis and to develop targeted interventions that are informed by the growing understanding of the interface between emotion and psychosis.

A schizophrenic patient whose severe level of auditory hallucinations had proved refractory to neuroleptic medication was given two treatment techniques derived from Green's theory that hallucinations represent verbal activity in the non-dominant hemisphere. Voice activity was markedly reduced in frequency and severity over a six-month period, and led to general improvements in interpersonal functioning. There was evidence for independent and additive effects of the two techniques.