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Measurement of adverse effects of psychological therapy is inconsistent due to ambiguity about the concept. The perspective of people undertaking psychological therapy (that is, experts by experience) has largely been overlooked. This study will investigate whether there is consensus between the opinions of professionals and experts by experience. The Delphi method was used. In Round 1 thematic analysis was used to analyse qualitative responses. Wilcoxon rank‐sum tests were used to examine group differences in Rounds 2 and 3. The study protocol was prospectively registered, reference osf.io/f9wp7. Fifty‐one professionals and 51 experts by experience generated 147 potential adverse effects in Round 1, across 9 themes; including 'therapy amplifies problem', 'emotional lability' and 'sense of self'. Each item was rated for overall consensus in Rounds 2 (n = 62) and 3 (n = 63). Thirty‐eight items were rated as essential, very important or important to include on a list of potential adverse effects. A further 12 items were rated as important by the expert by experience group only. Professionals were more conservative in their ratings. There appeared to be consensus between professionals and experts by experience on what to include in a list of adverse effects of psychological therapy (the EDAPT), including novel adverse effects which have not been previously considered. Further research is required to understand which adverse effects are necessary, unnecessary, or indeed harmful to psychotherapy outcomes. [ABSTRACT FROM AUTHOR]

Objectives: Cognitive Analytic Therapy (CAT) is an effective psychological intervention for several different mental health conditions. However, whether it is acceptable, safe, and beneficial for people with psychosis remains unclear, as is the feasibility of providing and evaluating it within a research context. The aim of this study was to begin to address these questions and to obtain for the first time a rich and detailed understanding of the experience of receiving CAT for psychosis. Design: A mixed‐methods case series design. Method: Seven individuals who experienced non‐affective psychosis received CAT. They completed assessments at the start of CAT, 16 weeks, and 28 weeks post‐baseline. Qualitative interviews were completed with four individuals following completion of or withdrawal from therapy. Results: Six participants attended at least four sessions of therapy and four went on to complete therapy. There were no serious adverse events, and self‐reported adverse experiences were minimal. Qualitative interviews suggested CAT is acceptable and provided a way to understand and work therapeutically with psychosis. There was limited evidence of change in psychotic symptoms, but improvement in perceived recovery and personality integration was observed. Conclusions: The results suggest that CAT is a safe and acceptable intervention for psychosis. Personality integration, perceived recovery, and functioning are relevant outcomes for future evaluations of CAT for psychosis. Practitioner points: It is feasible to conduct research evaluating CAT for people with psychosis.Within this case series, CAT appears acceptable and safe to individuals with psychosis.Within this case series, clients reported that CAT was a positive and helpful experience.There is a mixed picture with regard to secondary outcomes, but the design and aims of this case series limit conclusion that can be drawn from this data. [ABSTRACT FROM AUTHOR]

Objectives: Acute psychiatric inpatient wards are characterized by minimal provision of therapeutic activities and high readmission rates. Implementation of a comprehensive inpatient psychological intervention service has been recommended to overcome these problems; however, whether this is feasible or effective remains unclear. Methods: This non‐randomized parallel cluster feasibility trial examined the feasibility of delivering and evaluating cross‐diagnostic psychologically informed acute psychiatric care the Edinburgh‐Acute Psychological Inpatient Therapy Service (EDAPTS) and gathered preliminary clinical outcome data. Patients able to consent and complete questionnaires were recruited from two adult acute wards (i.e., clusters) and received either EDAPTS plus TAU or TAU. Results: Between October 2015 and October 2016, 96 inpatients were recruited. Findings suggested that there were good data completion rates for several clinical outcomes, that several EDAPTS components were successfully delivered, and that some initial effects appeared to favour the intervention, depending on outcome. However, difficulties relating to the recruitment process were also identified, as well as problems relating to adequate delivery of group therapies, participant engagement in some intervention components, and data completion at follow‐up. Conclusion: These issues, and the feasibility of randomization and rater‐blinding, have important implications for the design of future trials. Overall, this study provides an important insight into the challenges and complexities of developing and evaluating a comprehensive psychological intervention service in an acute psychiatric setting. Practitioner points: Individual therapy sessions can be delivered in the acute environment.The EDAPTS intervention showed some promise on outcomes of distress and self‐efficacy.Delivery of nurse‐led groups was challenging and may need to be embedded into routine clinical practice to increase intervention and outcome reach.More parameters, for example, randomization at cluster level, should be tested before progressing to an adequately powered, single‐blind, definitive cluster RCT. [ABSTRACT FROM AUTHOR]

The hydrology of the San Francisco Bay‐Delta estuary (the Delta) has been significantly modified over the past 150 years to serve a variety of human needs for water supply and food production, albeit with adverse ecological impacts. These adverse impacts, in concert with evolving societal values, have motivated change in the estuary's water management to promote ecosystem restoration goals while continuing to support human uses. Understanding historical flow patterns, as well as the environmental functions provided by these flow patterns, is critical to restoration planning. Building upon previous work on outflow trends from the Delta to San Francisco Bay, this paper evaluates historical trends in key interior Delta flows spanning nine decades (1922–2016) and presents an attribution of these trends to various anthropogenic drivers. We reconstructed historical time series records at four key locations in the interior of the Delta; these time series represent tidally‐averaged flows that are intensively managed and are of great importance to the beneficial uses of water in the region. We derived several scenario‐based flow time series at these same four locations to assist in attributing change to a variety of drivers, including reservoir and export pumping operations, in‐Delta barrier and gate operations, and upstream water diversions. Flow changes were measured relative to 1920‐level land use and water management conditions. We find the four interior Delta locations to have distinct seasonal flow trends and, in general, unique responses to various drivers of change. Our work highlights the complex nature of historical flow changes in a highly‐managed estuarine ecosystem, and the types of modifications that would be necessary to reverse these changes. [ABSTRACT FROM AUTHOR]

Objectives: The effectiveness of psychological therapies for those receiving acute adult mental health inpatient care remains unclear, partly because of the difficulty in conducting randomized controlled trials (RCTs) in this setting. The aim of this meta‐analysis was to synthesize evidence from all controlled trials of psychological therapy carried out with this group, to estimate its effects on a number of important outcomes and examine whether the presence of randomization and rater blinding moderated these estimates. Method: A systematic review and meta‐analysis of all controlled trials of psychological therapy delivered in acute inpatient settings was conducted, with a focus on psychotic symptoms, readmissions or emotional distress (anxiety and depression). Studies were identified through ASSIA, EMBASE, CINAHL, Cochrane, MEDLINE, and PsycINFO using a combination of the key terms ‘inpatient’, ‘psychological therapy’, and ‘acute’. No restriction was placed on diagnosis. The moderating effect of the use of assessor‐blind RCT methodology was examined via subgroup and sensitivity analyses. Results: Overall, psychological therapy was associated with small‐to‐moderate improvements in psychotic symptoms at end of therapy but the effect was smaller and not significant at follow‐up. Psychological therapy was also associated with reduced readmissions, depression, and anxiety. The use of single‐blind randomized controlled trial methodology was associated with significantly reduced benefits on psychotic symptoms and was also associated with reduced benefits on readmission and depression; however, these reductions were not statistically significant. Conclusions: The provision of psychological therapy to acute psychiatric inpatients is associated with improvements; however, the use of single‐blind RCT methodology was associated with reduced therapy‐attributable improvements. Whether this is a consequence of increased internal validity or reduced external validity is unclear. Trials with both high internal and external validity are now required to establish what type, format, and intensity of brief psychological therapy is required to achieve sustained benefits. Practitioner points: Clinical implications: This review provides the first meta‐analytical synthesis of brief psychological therapy delivered in acute psychiatric inpatient settings. This review suggests that brief psychological therapy may be associated with reduced emotional distress and readmissions. Limitations: The evidence in this review is of limited quality. The type, format, and intensity of brief psychological therapy required to achieve sustained benefits are yet to be established. [ABSTRACT FROM AUTHOR]

Regulatory goals for the California Delta attempt to restore natural ecosystems through various water management efforts. Defining management criteria for restoration is challenging, given that the earliest data describing the hydrology of the region follow many decades of change associated with agricultural development, channel modification, and flood control. This study explores the hydrology of the 1850–1920 period by synthesizing new reconstructed precipitation, basin inflows, land use change, and levee construction time series, in a semidistributed hydrologic model. The model demonstrated that it is impossible to simultaneously reproduce estimated historical flood extents, frequencies, and durations given contemporary topography. Bounding cases were constructed to span potential water budget partitioning and suggest that the state of this region by the 1920s was hydrologically similar to that of the natural regime (i.e., flow experienced was depressed due to drought, but within the bounds of variability of the natural Delta system), partly due to the flow augmentation provided by flood control infrastructure and enhanced channel conveyance. The model suggests that levee construction, rather than land use change, had the greatest impact on Delta hydrology. This and other reconstructions, however, suggest that decreases in annual Delta outflows accelerated after 1920. Future efforts to reconstruct Delta hydrology should focus on improving information about the historical topography and channel geometry of the Central Valley river network, with a view to refining understanding of the natural and historical flood regime. Plain Language Summary: The California Delta is a nexus of conflict between environmental, agriculture, and urban water interests. Current management approaches mandate restoration of the Delta ecosystems, yet appropriate hydrologic restoration targets are unclear. The earliest reliable flow records date to the 1920s, by which time the Delta watersheds had experienced many decades of land cover, flood control, and other changes. The impact of these changes on the measured flows is unclear. We reconstructed rainfall, basin inflows, land use and flood levy histories, and modeled 1850–1920 Delta outflows. The effect of human‐induced changes on annual Delta outflow ranged from a 40% increase in flow from 1850‐1920 depending on the assumed characteristics of the natural flood regime. We could not model a historical flood regime that matched reported peak flooded areas, typical flood durations, and the contemporary watershed topography. Regardless, the results indicate that annual Delta outflows in the 1920s were not depressed relative to natural conditions and that flood levee construction had the most important human impact on flow in the 1850–1920 period. Future work is needed to characterize the historical flood regime in the Central Valley watersheds and reduce the uncertainty surrounding the change in Delta Outflows in the 1850–1920 period. Key Points: Effects of human intervention on the California Delta outflows are unknown, but important for defining flow restoration targetsReconstructed outflows indicate minimal declines to substantial increases in Delta outflow attributable to human action from 1850 to 1920Historic flood regime is the key uncertainty; further understanding of topographic change and historical flood extent is needed [ABSTRACT FROM AUTHOR]

Background Previous meta-analyses have only found small correlations ( r = .10 to r = .19) between therapeutic alliance and clinical outcomes in samples of adolescents receiving psychological therapy. Although study-level variables have been found to moderate this, little is known about the impact of therapist variability. The present meta-analysis aimed to address this gap by using patient-therapist ratio as a moderator variable. Methods Contrary to previous reviews of adolescent alliance, individual effect sizes were extracted using a preregistered conceptual hierarchy. Controlling for treatment-level confounds, a random effects meta-analysis assessed the moderating effect of patient-therapist ratio on the alliance-outcome relationship in predefined single-predictor and multipredictor meta-regressions. Results The alliance-outcome relationship was found to be larger than previously thought ( k = 28, N = 2,911, r = .29, 95% Confidence Interval 0.21, 0.37; p < .0001, I 2 = 80%). When study samples exceeding the adolescent 12-19 age range were removed, the correlation rose ( k = 15, N = 1,797, r = .34, 95% Confidence Interval 0.23, 0.45; p < .0001, I 2 = 83%). In contrast to research with adults, patient-therapist ratio did not moderate this relationship in either single-predictor ( p = .26) or multi-predictor ( p = .22) models. Conclusions The alliance-outcome relationship for adolescents was larger than previously thought, and comparable to estimates in adult samples. The failure of patient-therapist ratio to moderate its strength, however, challenges the hypothesis that variability in therapist characteristics is an important determinant of the alliance-outcome effect in this age group. [ABSTRACT FROM AUTHOR]

Cancer/testis antigen (CTAg) expression is restricted to spermatogenic cells in an immune-privileged site within the testis. However, these proteins are expressed aberrantly by malignant cells and T-cell responses against CTAgs develop in many cancer patients. We investigated the prevalence, magnitude and phenotype of CTAg-specific T cells in the blood of patients with testicular germ cell tumors (TGCTs). CD8+ and CD4+ T-cell responses against MAGE-A family antigens were present in 44% (20/45) of patients' samples assayed by ex vivo IFN-γ ELISPOT. The presence of MAGE-specific CD8+ T cells was further determined following short-term in vitro expansion through the use of pMHC-I multimers containing known immunogenic peptides. Longitudinal analysis revealed that the frequency of MAGE-specific T cells decreased by 89% following orchidectomy suggesting that persistence of tumor antigen is required to sustain CTAg-specific T-cell immunity. Notably, this decrease correlated with a decline in the global effector/memory T-cell pool following treatment. Spontaneous T-cell immunity against CTAg proteins therefore develops in many patients with testicular cancer and may play an important role in the excellent clinical outcome of patients with this tumor subtype. [ABSTRACT FROM AUTHOR]

This paper explains observed trends in freshwater flow to the San Francisco Bay-Delta estuary as reported in a companion paper (Hutton, Rath, & Roy, 2017). We employ a historical hydrologic record spanning nine decades and define a set of idealized flow scenarios to identify drivers of change in delta outflow and consequent salinity regime. Flow changes are measured against a baseline scenario representing 1920-level land use and water management conditions. Additional scenarios are defined to represent the system absent state and federal water project reservoir and export operations, absent key non-project reservoir operations, and absent historicallyobserved sea level rise. These scenarios, in conjunction with the principle of superposition, are used to ascribe outflow and salinity trends to different anthropogenic and natural causes. We find that project and non-project water management are attributed similar responsibility for decreasing outflow trends in April and May and consequent increasing spring salinity trends. In contrast, we find that increasing July and August outflow trends (and lagged decreasing salinity trends) are attributed to flow contributions from project water management; these contributions more than fully attenuate impacts associated with non-project water management. [ABSTRACT FROM AUTHOR]

The San Francisco Bay-Delta estuary and its upstream watershed have been highly modified since exploration and settlement by Europeans in the mid-18th century. Although these hydrologic alterations supported the growth of California's economy to the eighth largest in the world, they have been accompanied by significant declines in native aquatic species and subsequent efforts to reverse these declines through flow management. To inform ongoing deliberations on management of freshwater flows to the estuary, we examined a recent nine-decade hydrologic record to evaluate seasonal and annual trends in reported Delta outflow. Statistically significant trends were observed in seasonal outflows, with decreasing trends observed in 4 months (February, April, May, and November) and increasing trends observed in 2 months (July and August). Trend significance in early-to-mid autumn (September and October) is ambiguous due to uncertainty associated with in-Delta agricultural water use. In spite of increasing water use over the period examined, we found no statistically significant annual trend in Delta outflow, a result likely due to large interannual variability. Linkages between outflow trends and changes in upstream flows and coincident developments such as reservoir construction and operation, out-of-basin imports and exports, and expansion of irrigated agriculture are discussed. To eliminate inter-annual variability as a factor, change attribution is explored using modelled flows and fixed climatology in a companion paper. [ABSTRACT FROM AUTHOR]

Objectives Negative beliefs about psychosis and other mental health difficulties may contribute to depression and distress in individuals with these experiences. The Personal Beliefs about Experience Questionnaire ( PBEQ) and Personal Beliefs about Illness Questionnaire ( PBIllQ) are two widely used measures of these beliefs. It is currently uncertain how the items on these measures map onto different underlying factors. This study therefore aimed to test the factor structure of these two measures. Methods Confirmatory factor analysis ( CFA) was used to test three alternative, pre-specified, factor structures for the PBIllQ and PBEQ in a sample of individuals diagnosed with bipolar disorder ( n = 202) and a sample of individuals with experien-ces of psychosis ( n = 362). Associations with depressive symptoms were also examined. Result A three-factor structure was supported for both measures, which included Negative Expectations/Appraisals ( NEA), Internal Shame/Defectiveness ( ISD) and External Shame ( ES) factors. The NEA and ISD subscales also had consistent independent associations with depressive symptoms. Conclusions The results suggest that the PBIllQ and PBEQ may capture three distinct sets of negative beliefs in individuals with psychosis or bipolar disorder and that these beliefs may have important consequences for subsequent difficulties in these populations such as depression. Both measures may be helpful in supporting assessment and formulation in clinical practice and in evaluating belief change in intervention trials. However, when used in these settings, the three subscales identified in this study may be the most valid way of calculating scores on these measures. Practitioner points Negative personal beliefs about the causes, meaning and consequences of psychosis and bipolar disorder are associated with greater distress and depression. Two related measures, the PBIllQ and PBEQ, have been developed to assess these beliefs., Our analyses suggest that scores on these questionnaires are best broken down into three subscales which capture perceptions of internal shame or defectiveness, general negative appraisals and perceptions of external shame., These subscales may capture key underlying sets of negative beliefs within individuals with psychosis or bipolar disorder, which in turn impact upon well-being, such as being associated with greater depression., These subscales can be used to aid assessment and formulation within clinical practice but may also provide a valuable means of assessing changes in negative beliefs following interventions. [ABSTRACT FROM AUTHOR]

Newton-Howes and Wood (published online, this journal, 8 Dec 2011) report the results of their systematic review and meta-analysis of clinical trials of cognitive-behavioural therapy ( CBT) for schizophrenia. They ran a random effects analysis of endpoint data from trials where participants were randomly allocated to receive either CBT or a control therapy, which could be inactive (e.g., befriending) or active (e.g., analytic supportive psychotherapy), found no difference between the groups and concluded 'it ( CBT) does not outperform supportive therapy in effecting change in phenomenology.' Such a conclusion is premature, if not unwarranted, for a number of reasons, including basic mistakes, lack of transparency, and failure to consider dose. [ABSTRACT FROM AUTHOR]

Background: There is little data available on the prevalence of violence risk factors in people at ultra-high risk of developing psychosis. Aim: The aim of this study was to provide an estimate of the cross-sectional prevalence of violence risk factors in those attending a routine clinical service for people at ultra-high risk of developing psychosis. Methods: The case notes of all 34 clients receiving treatment over a 4-week period were reviewed and all clinicians were interviewed. Information was gathered regarding gender, current violent ideation, history of violence (including convictions), expressions of concern from others, problems with alcohol or substance misuse, jealousy, suspiciousness, irritability, anger and relevant subthreshold psychotic symptoms. Information on protective factors, including treatment engagement, was also gathered. Results: Thirty-eight per cent ( n = 13) had a history of violent behaviour, 79.4% ( n = 27) were thought to be currently experiencing significant levels of suspiciousness and 47.1% ( n = 16) were thought to have problems with anger. Twenty-nine per cent ( n = 10) had previous known convictions for violence. Two-thirds ( n = 8) of those where risk of violence was identified were described as being engaged with treatment. Conclusion: There was a high prevalence of violence risk factors in this small sample. Further research with larger samples and better methodology is urgently required to investigate risk of violence in this group and determine the contribution, if any, of subclinical psychotic symptoms. [ABSTRACT FROM AUTHOR]

Background: Little data is available on the prevalence of suicide risk factors in people at ultra-high risk (UHR) of developing psychosis. Aim: The aim of this study was to provide an estimate of the cross-sectional prevalence of possible suicide risk factors in those attending a routine clinical service for people at UHR of developing psychosis. Methods: For all patients in treatment ( n = 34) over a 4-week period, levels of suicidal ideation and depression upon entry to the service were assessed by auditing intake scores on the Beck Depression Inventory, second edition. Level of engagement with services, social isolation, substance and alcohol misuse, ready access to means, current suicidal ideation, previous suicide attempts, current or previous self-harm, expressions of concern from others, depression, agitation, hopelessness, worthlessness, suspiciousness and fears of mental disintegration were all assessed by case note review and interview with the treating clinician. Results: There was a high prevalence of at least mild suicidal ideation (58.8%, n = 20) and severe depressed mood (47%, n = 16) in this client group at point of entry to the service. Seven people (20.6%) had engaged in serious self-harm (including attempted suicide) during the time they were in contact with the service. Forty-seven per cent ( n = 16) reported at least 27 suicide attempts between them; the mean number of attempts being 1.69 (standard deviation = 1.08). Conclusion: Suicide risk was high in this small sample of people at UHR of developing psychosis. Controlled research with larger samples and better methodology is urgently required to inform legal, ethical and scientific debates surrounding this group. [ABSTRACT FROM AUTHOR]