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BackgroundThere is some evidence of inequitable psychosis care provision by ethnicity. We investigated variations in the receipt of CBTp and family intervention across ethnic groups in Early Intervention in Psychosis (EIP) teams throughout England, where national policy mandates offering these interventions to all.MethodsWe included data on 29,610 service users from the National Clinical Audit of Psychosis (NCAP), collected between 2018 and 2021. We conducted mixed effects logistic regression to examine odds ratios of receiving an intervention (CBTp, family intervention, or either intervention) across 17 ethnic groups while accounting for the effect of years and variance between teams and adjusting for individual- (age, gender, occupational status) and team-level covariates (care-coordinator caseload and mental health inequalities strategies).FindingsCompared with White British people, every minoritized ethnic group, except those of mixed Asian-White and mixed Black African-White ethnicities, had lower adjusted odds of receiving CBTp (aOR 0·39, 95%CI 0·32-0·47 to 0·80, 0·64-1·00). People of Black African (0·61, 0·53-0·69), Black Caribbean (0·67, 0·56-0·81), non-African/Caribbean Black (0·63, 0·51-0·79), non-British/Irish White (0·73, 0·64-0·84), and of “any other” (0·66, 0·54-0·81) ethnicity also experienced lower adjusted odds of receiving family intervention.InterpretationPervasive inequalities in receiving CBTp for first episode psychosis exist for almost all minoritized ethnic groups, and family intervention for many groups. Investigating how these inequalities arise should be a research priority, allowing co-produced development and testing of approaches to address them.FundingIndependent research commissioned and funded by the National Institute for Health Research Policy Research Programme.

Background: The outcomes for a wide range of physical and mental health conditions can be influenced by the level of criticism and warmth in the family environment known in the literature as Expressed Emotion (EE). This finding is also true for individuals with an At-Risk Mental State (ARMS) for psychosis with individual’s perceptions of EE predicting transition to psychosis. While the original concept of EE incorporates both positive and negative aspects of relationships, most measures of EE and research focus on the negative aspects of relationships. Positive factors are also important and associated with improvements in functioning and reduced symptoms. However, the absence of a comprehensive, self-report measure of positive aspects of EE has hindered research in this area. Methods: This study aimed to investigate the reliability and validity of a new 10-item Service User Perceived Criticism and Warmth Questionnaire (SU-PCaW) based on the 2-item Perceived Criticism and 2-item Perceived Warmth questionnaires. Results: The measure was quick and easy to administer and had high internal consistency and reliability. Conclusion: This measure would aid services in screening families for therapy, be helpful in evaluating family intervention in groups such as the ARMS population and a useful measure for future research developments.

Background Young people with social disability and severe and complex mental health problems have poor outcomes, frequently struggling with treatment access and engagement. Outcomes may be improved by enhancing care and providing targeted psychological or psychosocial intervention. Aims We aimed to test the hypothesis that adding social recovery therapy (SRT) to enhanced standard care (ESC) would improve social recovery compared with ESC alone. Method A pragmatic, assessor-masked, randomised controlled trial (PRODIGY: ISRCTN47998710) was conducted in three UK centres. Participants (n = 270) were aged 16–25 years, with persistent social disability, defined as under 30 hours of structured activity per week, social impairment for at least 6 months and severe and complex mental health problems. Participants were randomised to ESC alone or SRT plus ESC. SRT was an individual psychosocial therapy delivered over 9 months. The primary outcome was time spent in structured activity 15 months post-randomisation. Results We randomised 132 participants to SRT plus ESC and 138 to ESC alone. Mean weekly hours in structured activity at 15 months increased by 11.1 h for SRT plus ESC (mean 22.4, s.d. = 21.4) and 16.6 h for ESC alone (mean 27.7, s.d. = 26.5). There was no significant difference between arms; treatment effect was −4.44 (95% CI −10.19 to 1.31, P = 0.13). Missingness was consistently greater in the ESC alone arm. Conclusions We found no evidence for the superiority of SRT as an adjunct to ESC. Participants in both arms made large, clinically significant improvements on all outcomes. When providing comprehensive evidence-based standard care, there are no additional gains by providing specialised SRT. Optimising standard care to ensure targeted delivery of existing interventions may further improve outcomes.

Paul French takes a look at Chiang Yee’s work during World War Two. Chiang’s various contributions to war-related propaganda speak both of his position in British society at the time and his attempts to draw parallels between the twin struggles of Britain and China against the Axis powers. Chiang’s The Silent Traveller in War Time (1939) sought to portray British resolution in the face of war. Critically, as argued by French, it also serves as an early example of propaganda work, documenting the wartime experience of solidarity, laughter in the face of adversity, and the ‘Blitz spirit’ under the threat of gas attacks and evacuation.

Background Much of the psychosocial care people receive after major incidents and disasters is informal and is provided by families, friends, peer groups and wider social networks. Terrorist attacks have increased in recent years. Therefore, there is a need to better understand and facilitate the informal social support given to survivors. Aims We addressed three questions. First, what is the nature of any informal support-seeking and provision for people who experienced the 2017 Manchester Arena terrorist attack? Second, who provided support, and what makes it helpful? Third, to what extent do support groups based on shared experience of the attack operate as springboards to recovery? Method Semi-structured interviews were carried out with a purposive sample of 18 physically non-injured survivors of the Manchester Arena bombing, registered at the NHS Manchester Resilience Hub. Interview transcripts were thematically analysed. Results Participants often felt constrained from sharing their feelings with friends and families, who were perceived as unable to understand their experiences. They described a variety of forms of helpful informal social support, including social validation, which was a feature of support provided by others based on shared experience. For many participants, accessing groups based on shared experience was an important factor in their coping and recovery, and was a springboard to personal growth. Conclusions We recommend that people who respond to survivors’ psychosocial and mental healthcare needs after emergencies and major incidents should facilitate interventions for survivors and their social networks that maximise the benefits of shared experience and social validation.

Background: There are longstanding concerns regarding physical health inequalities for people with psychotic disorders. In recent years concerted efforts have been made to address these. \ud Aims: To examine whether recent national initiatives in England have led to improvements in the physical health of people with schizophrenia and related psychoses. \ud Methods: Secondary analysis of data from multiple rounds of a national audit of services for people with psychosis, conducted over a 9-year period. Proportions of patients in ‘good health’ according to seven discrete measures, and one composite measure derived from national standards, were compared between each round of the audit. \ud Results: The proportion of patients in overall ‘good health’ under the care of ‘Early Intervention in Psychosis’ (EIP) teams increased between 2014 and 2019 (OR=4.65, 95% CI 3.32 to 6.52, P

Aim A large proportion of individuals with an at‐risk mental state (ARMS) live at home and are supported by their families. Recommended treatment includes family intervention (FI), and therefore, understanding relationships between individuals with an ARMS and their family members is key. This study aimed to provide a more holistic exploration of relationships within families of individuals with an ARMS by reporting the perceived impact of the condition on other family members including sibling and romantic relationships. Method Fourteen semi‐structured interviews with family members were analysed using thematic analysis. Results Parents wanted to maintain a safe family environment for all family members. This can result in spending less time with siblings who impacted on siblings' relationships with the service user and other family members. Romantic relationships were negatively impacted when there was unclear communication between the couple, as well as the partner's response and understanding of the ARMS condition. Clear communication across sibling and romantic relationships facilitated helpful family/carer's behaviour and understanding of the individuals' mental distress. Conclusion FI should explore and support families with changes in sibling and romantic relationships. More research is needed to understand siblings' perspectives in families with individuals experiencing an ARMS and to develop resources to support partners and families in changes within their sexual and romantic relationships.

Background: \ud Early warning signs monitoring by service users with schizophrenia has shown promise in preventing relapse but the quality of evidence is low. We aimed to establish the feasibility of undertaking a definitive randomised controlled trial to determine the effectiveness of a blended digital intervention for relapse prevention in schizophrenia.\ud \ud Methods: \ud This multicentre, feasibility, cluster randomised controlled trial aimed to compare Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery (EMPOWER) with treatment as usual in community mental health services (CMHS) in Glasgow and Melbourne. CMHS were the unit of randomisation, selected on the basis of those that probably had five or more care coordinators willing to participate. Participants were eligible if they were older than 16 years, had a schizophrenia or related diagnosis confirmed via case records, were able to provide informed consent, had contact with CMHS, and had had a relapse within the previous 2 years. Participants were randomised within stratified clusters to EMPOWER or to continue their usual approach to care. EMPOWER blended a smartphone for active monitoring of early warning signs with peer support to promote self-management and clinical triage to promote access to relapse prevention. Main outcomes were feasibility, acceptability, usability, and safety, which was assessed through face-to-face interviews. App usage was assessed via the smartphone and self-report. Primary end point was 12 months. Participants, research assistants and other team members involved in delivering the intervention were not masked to treatment conditions. Assessment of relapse was done by an independent adjudication panel masked to randomisation group. The study is registered at ISRCTN (99559262).\ud \ud Findings: \ud We identified and randomised eight CMHS (six in Glasgow and two in Melbourne) comprising 47 care coordinators. We recruited 86 service users between Jan 19 and Aug 8, 2018; 73 were randomised (42 [58%] to EMPOWER and 31 [42%] to treatment as usual). There were 37 (51%) men and 36 (49%) women. At 12 months, main outcomes were collected for 32 (76%) of service users in the EMPOWER group and 30 (97%) of service users in the treatment as usual group. Of those randomised to EMPOWER, 30 (71%) met our a priori criterion of more than 33% adherence to daily monitoring that assumed feasibility. Median time to discontinuation of these participants was 31·5 weeks (SD 14·5). There were 29 adverse events in the EMPOWER group and 25 adverse events in the treatment as usual group. There were 13 app-related adverse events, affecting 11 people, one of which was serious. Fear of relapse was lower in the EMPOWER group than in the treatment as usual group at 12 months (mean difference –7·53 (95% CI –14·45 to 0·60; Cohen's d –0·53).\ud \ud Interpretation: \ud A trial of digital technology to monitor early warning signs blended with peer support and clinical triage to detect and prevent relapse appears to be feasible, safe, and acceptable. A further main trial is merited.\ud \ud Funding: \ud UK National Institute for Health Research Health Technology Assessment programme and the Australian National Health and Medical Research Council.

Aim: The authors compare two approaches to assessment of the quality of early psychosis intervention services, the National Clinical Audit of Psychosis used in the United Kingdom and the First Episode Psychosis Services Fidelity Scale used in North America and Europe. \ud Methods: We compare the two approaches on the source of standards, measurement type, data collection, time requirements, resources used, scoring and reliability. Finally, we review their strengths and limitations.\ud Results: Both measures are based on standards derived from the same research evidence base. Both methods rely on data from health records and administrative data. The audit is supplemented with user survey data, the fidelity scale with clinician interviews. The audit appears to require less time. The audit is based on quality indicators rated as present or absent which yields a statistical benchmark. The Fidelity Scale is based on quality indicators that are rated on a five-point scale yielding a standards-based measure. The two methods cover similar core service components, but the FEPS-FS has a broader coverage of team functioning. The National audit also collects data on the user experience directly from patients. The fidelity scale has achieved good to excellent inter-rater reliability, the reliability of the audit has not been tested. \ud Conclusions: Both methods deliver reliable and useful measures of quality of care. The NCAP works in the context of a single provider health system, the FEPS-FS works in a more variable health system. Comparing the two systems in the field would support international comparison of standards of care.

Young people with social disability and non-psychotic severe and complex mental health problems are an important group. Without intervention, their social problems can persist and have large economic and personal costs. Thus, more effective evidence-based interventions are needed. Social recovery therapy is an individual therapy incorporating cognitive-behavioural techniques to increase structured activity as guided by the participant's goals.This trial aimed to test whether or not social recovery therapy provided as an adjunct to enhanced standard care over 9 months is superior to enhanced standard care alone. Enhanced standard care aimed to provide an optimal combination of existing evidence-based interventions.A pragmatic, single-blind, superiority randomised controlled trial was conducted in three UK centres: Sussex, Manchester and East Anglia. Participants were aged 16-25 years with persistent social disability, defined as 30 hours per week of structured activity with social impairment for at least 6 months. Additionally, participants had severe and complex mental health problems, defined as at-risk mental states for psychosis or non-psychotic severe and complex mental health problems indicated by a Global Assessment of Functioning score ≤ 50 persisting for ≥ 6 months. Two hundred and seventy participants were randomised 1 : 1 to either enhanced standard care plus social recovery therapy or enhanced standard care alone. The primary outcome was weekly hours spent in structured activity at 15 months post randomisation. Secondary outcomes included subthreshold psychotic, negative and mood symptoms. Outcomes were collected at 9 and 15 months post randomisation, with maintenance assessed at 24 months.The addition of social recovery therapy did not significantly increase weekly hours in structured activity at 15 months (primary outcome treatment effect -4.44, 95% confidence interval -10.19 to 1.31). We found no evidence of significant differences between conditions in secondary outcomes at 15 months: Social Anxiety Interaction Scale treatment effect -0.45, 95% confidence interval -4.84 to 3.95; Beck Depression Inventory-II treatment effect -0.32, 95% confidence interval -4.06 to 3.42; Comprehensive Assessment of At-Risk Mental States symptom severity 0.29, 95% confidence interval -4.35 to 4.94; or distress treatment effect 4.09, 95% confidence interval -3.52 to 11.70. Greater Comprehensive Assessment of At-Risk Mental States for psychosis scores reflect greater symptom severity. We found no evidence of significant differences at 9 or 24 months. Social recovery therapy was not estimated to be cost-effective. The key limitation was that missingness of data was consistently greater in the enhanced standard care-alone arm (9% primary outcome and 15% secondary outcome missingness of data) than in the social recovery therapy plus enhanced standard care arm (4% primary outcome and 9% secondary outcome missingness of data) at 15 months.We found no evidence for the clinical superiority or cost-effectiveness of social recovery therapy as an adjunct to enhanced standard care. Both arms made large improvements in primary and secondary outcomes. Enhanced standard care included a comprehensive combination of evidence-based pharmacological, psychotherapeutic and psychosocial interventions. Some results favoured enhanced standard care but the majority were not statistically significant. Future work should identify factors associated with the optimal delivery of the combinations of interventions that underpin better outcomes in this often-neglected clinical group.Current Controlled Trials ISRCTN47998710.This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inYoung people with social disability and non-psychotic severe and complex mental health problems are an important group. Their problems are often long-standing and they often have difficulty doing ‘structured activity’, such as work, sports and leisure activities (e.g. going shopping or to the cinema). They often avoid such activities because of anxiety or low mood. Other barriers may include financial and practical issues, and stigma from activity providers. Non-participation in structured activity increases the risk that mental health problems will continue and prevent these young people from reaching meaningful goals. We tested whether or not social recovery therapy might help. This is a talking and activity therapy, in which young people (participants) work individually with a social recovery therapy therapist. Social recovery therapy aims to help participants identify what activities they would like to do, practise spending more time doing them, and work through barriers to maintaining increased activity. By improving structured activity, young people feel more hopeful and better able to manage their symptoms. However, social recovery therapy has never been evaluated properly using the best research methods. The best way to evaluate treatments like this is a randomised controlled trial in which participants are allocated by chance, like tossing a coin, to have the new therapy or not to have the therapy. Both groups are followed up for a period to see if the new therapy works. We tested social recovery therapy in this way. We also tested whether or not it was cost-effective. We recruited 270 16- to 25-year-old participants in Sussex, East Anglia and Manchester. Participants had non-psychotic severe and complex mental health problems (not psychosis) and were doing 30 hours of structured activity per week at the start of the study. All participants had enhanced standard care. This involved standard NHS treatment plus a full assessment and feedback from the study team, and a best practice guide to local support services that encouraged the best provision of standard evidence-based interventions. Half of the participants were randomly allocated to have social recovery therapy in addition to enhanced standard care over 9 months. All participants were invited to assessments 9, 15 and 24 months later. Therapists recorded the tasks and activities undertaken with participants. We asked both participants and therapists what they thought of the trial and the social recovery therapy. We found no evidence that adding social recovery therapy improved outcomes. Participants in both arms made large and clinically worthwhile improvements in structured activity and mental health outcomes. If anything, there was some evidence that people allocated to enhanced standard care improved more than those allocated to social recovery therapy plus enhanced standard care. The differences were small, however, and could have occurred by chance.

BackgroundMental health policy makers require evidence-based information to optimise effective care provision based on local need, but tools are unavailable.AimsTo develop and validate a population-level prediction model for need for early intervention in psychosis (EIP) care for first-episode psychosis (FEP) in England up to 2025, based on epidemiological evidence and demographic projections.MethodWe used Bayesian Poisson regression to model small-area-level variation in FEP incidence for people aged 16–64 years. We compared six candidate models, validated against observed National Health Service FEP data in 2017. Our best-fitting model predicted annual incidence case-loads for EIP services in England up to 2025, for probable FEP, treatment in EIP services, initial assessment by EIP services and referral to EIP services for ‘suspected psychosis’. Forecasts were stratified by gender, age and ethnicity, at national and Clinical Commissioning Group levels.ResultsA model with age, gender, ethnicity, small-area-level deprivation, social fragmentation and regional cannabis use provided best fit to observed new FEP cases at national and Clinical Commissioning Group levels in 2017 (predicted 8112, 95% CI 7623–8597; observed 8038, difference of 74 [0.92%]). By 2025, the model forecasted 11 067 new treated cases per annum (95% CI 10 383–11 740). For every 10 new treated cases, 21 and 23 people would be assessed by and referred to EIP services for suspected psychosis, respectively.ConclusionsOur evidence-based methodology provides an accurate, validated tool to inform clinical provision of EIP services about future population need for care, based on local variation of major social determinants of psychosis.

Purpose Biallelic hypomorphic variants in PPA2, encoding the mitochondrial inorganic pyrophosphatase 2 protein, have been recently identified in individuals presenting with sudden cardiac death, occasionally triggered by alcohol intake or a viral infection. Here we report 20 new families harboring PPA2 variants. Methods Synthesis of clinical and molecular data concerning 34 individuals harboring five previously reported PPA2 variants and 12 novel variants, 11 of which were functionally characterized. Results Among the 34 individuals, only 6 remain alive. Twenty-three died before the age of 2 years while five died between 14 and 16 years. Within these 28 cases, 15 died of sudden cardiac arrest and 13 of acute heart failure. One case was diagnosed prenatally with cardiomyopathy. Four teenagers drank alcohol before sudden cardiac arrest. Progressive neurological signs were observed in 2/6 surviving individuals. For 11 variants, recombinant PPA2 enzyme activities were significantly decreased and sensitive to temperature, compared to wild-type PPA2 enzyme activity. Conclusion We expand the clinical and mutational spectrum associated with PPA2 dysfunction. Heart failure and sudden cardiac arrest occur at various ages with inter- and intrafamilial phenotypic variability, and presentation can include progressive neurological disease. Alcohol intake can trigger cardiac arrest and should be strictly avoided.

Purpose The purpose of this paper is to provide an exploration of Recovery Academy influences upon employment and service use amongst individuals with lived experience of mental health difficulties. Design/methodology/approach The study utilised a questionnaire design over a nine-month period. Participants’ baseline and follow-up data were analysed to explore the influence of course attendance upon employment and service use. Findings At follow-up, there was a significant association between participants attending Recovery Academy courses and paid or self-employment (p Research limitations/implications Further research is required to explore the cost-effectiveness of the Recovery Academy. As participants were all enroled onto the Recovery Academy findings may not be generalisable to other Recovery Colleges. There is a need for more robust research such as a randomised controlled trial (RCT) to evaluate multiple Recovery Colleges and establish definitive conclusions as to their economic implications. Social implications There may be value in the Recovery Academy as a gateway to employment, speaking to the transformative powers of Recovery Colleges. The Recovery Academy may serve as a vehicle to support service users to obtain paid or self-employment, and thus promote community reintegration. Originality/value This paper offers an important contribution to the Recovery College literature, which remains limited in evaluative evidence, particularly regarding associated economic factors, such as employment and service use.

Purpose The purpose of this paper is to reflect upon experiences of measuring the influences of the Recovery Academy within Greater Manchester Mental Health (GMMH) NHS Foundation Trust amongst a student population of health professionals. This paper aims to present considerations for future quantitative research surrounding the efficacy of Recovery Colleges such as the Recovery Academy. Design/methodology/approach This paper utilised baseline data collected from health professionals as part of a quantitative evaluation of the Recovery Academy. The paper discusses challenges experienced in measuring change amongst this student population within GMMH. Findings Health professionals reported positive attitudes towards recovery at baseline presenting challenges in measuring attitudinal change associated with the Recovery Academy. The experiences of conducting research amongst health professionals within GMMH offers insights into the selection and use of self-report measures in Recovery College research; the representativeness of health professional student populations; and models of course attendance within Recovery Colleges. Originality/value The existing literature specific to Recovery College influences upon health professionals remains predominantly qualitative and anecdotal. It is important to gather empirical evidence regarding Recovery Colleges to establish their ability to re-orientate health professionals around principles of recovery. This paper therefore offers considerations for future researchers aiming to gather empirical evidence which may facilitate quantitative evaluations of Recovery Colleges such as the Recovery Academy amongst staff populations.

Background Many people who have common mental disorders, such as depression and anxiety, also have some psychotic experiences. These experiences are associated with higher clinical complexity, poor treatment response, and negative clinical outcomes. Psychological interventions have the potential to improve outcomes for people with psychotic experiences. The aims of this systematic review are to (1) synthesise the evidence on the effectiveness and cost-effectiveness of psychological interventions to reduce psychotic experiences and their associated distress and (2) identify key components of effective interventions. Methods Our search strategy will combine terms for (1) psychological interventions, (2) psychotic experiences, and (3) symptoms associated with psychotic experiences. We will search the following online databases: MEDLINE, Embase, PsycINFO, all Cochrane databases, British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Management Information Consortium (HMIC), Education Resources Information Center (ERIC), and EconLit. Our primary outcome is the proportion of people who recovered or remitted from psychotic experiences after the intervention. Our secondary outcomes are changes in positive psychotic symptoms, negative psychotic symptoms, depression, anxiety, functioning (including social, occupational, and academic), quality of life, and cost-effectiveness. Two independent reviewers will judge each study against pre-specified inclusion and exclusion criteria and will extract study characteristics, outcome data, and intervention components. Risk of bias and methodological quality will be assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies and the Drummond Checklist. Results will be synthesised using random-effects meta-analysis and narrative synthesis. Discussion The identification of effective psychological interventions and of specific components associated with intervention effectiveness will augment existing evidence that can inform the development of a new, tailored intervention to improve outcomes related to psychotic symptoms, anxiety and depression, distress, functioning, and quality of life. Systematic review registration PROSPERO CRD42016033869

Background Early Intervention in Psychosis (EIP) services improve health outcomes for young people with psychosis in the medium–long term, but 25% of young people disengage in the first 12 months with costs to their mental health, families, society and the NHS. This study will evaluate the effectiveness, cost-effectiveness and implementation of a team-based motivational Early Youth Engagement (EYE-2) intervention. Method The study design is a cluster randomised controlled trial (RCT) with economic evaluation, comparing the EYE-2 intervention + standardised EIP service to standardised EIP service alone, with randomisation at the team level. A process evaluation will evaluate the delivery of the intervention qualitatively and quantitatively across contexts. The setting is 20 EIP teams in 5 sites: Manchester, South London, East Anglia, Thames Valley and Hampshire. Participants are young people (14–35 years) with first episode psychosis, and EIP staff. The intervention is the team-based motivational engagement (EYE-2) intervention, delivered alongside standardised EIP services, and supported by additional training, website, booklets and social groups. The comparator is the standardised EIP service. Both interventions are delivered by EIP clinicians. The primary outcome is time to disengagement (time in days from date of allocation to care coordinator to date of last contact following refusal to engage with EIP service, or lack of response to EIP contact for a consecutive 3-month period). Secondary outcomes include mental and physical health, deaths, social and occupational function, recovery, satisfaction and service use at 6, 12, 18 and 24 months. A 12-month within-trial economic evaluation will investigate cost-effectiveness from a societal perspective and from an NHS perspective. Discussion The trial will provide the first test of an engagement intervention in standardised care, with the potential for significant impact on the mental health and wellbeing of young people and their families, and economic benefits for services. The intervention will be highly scalable, supported by the toolkit including manuals, commissioning guide, training and resources, adapted to meet the needs of the diverse EIP population, and based on an in-depth process evaluation. Trial registration ISRCTN 51629746 prospectively registered 7th May 2019. Date assigned 10th May 2019.