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Objective. To further develop the Personal Beliefs about Illness Questionnaire (PBIQ), which reflects current constructs of social rank theory in relation to people experiencing psychosis. Method. Drawing on extensive clinical and research experience and after consultation with other mental health professionals and service users, 17 new items were added to 12 from the original 16 PBIQ questions. These made up five theoretical constructs (entrapment, loss, social marginalization, shame, and control). A total of 150 people who had just experienced a first episode of psychosis completed the newly devised PBIQ-R. To test the validity of its five subscales, a small sub-sample (N= 66) for whom follow-up data was available also completed measures of depression, insight, and other social rank appraisals. Results. All five subscales of the PBIQ-R were found to be reliable, valid, and sensitive to change. Conclusions. Although the PBIQ-R was not designed to produce an overall ‘personal beliefs about illness’ score, its five subscales provide a rapid and valid method to assess and measure common psychological reactions to a first episode of psychosis. It will have relevance for use in older, multiple episode samples although further validation may be needed.

BackgroundSocial anxiety disorder (SAD) is surprisingly prevalent among people with psychosis and exerts significant impact on social disability. The processes that underlie its development remain unclear. The aim of this study was to investigate the relationship between shame cognitions arising from a stigmatizing psychosis illness and perceived loss of social status in co-morbid SAD in psychosis.MethodThis was a cross-sectional study. A sample of individuals with SAD (with or without psychosis) was compared with a sample with psychosis only and healthy controls on shame proneness, shame cognitions linked to psychosis and perceived social status.ResultsShame proneness (p p p p p ConclusionsThese findings suggest that shame cognitions arising from a stigmatizing illness play a significant role in social anxiety in psychosis. Psychological interventions could be enhanced by taking into consideration these idiosyncratic shame appraisals when addressing symptoms of social anxiety and associated distress in psychosis. Further investigation into the content of shame cognitions and their role in motivating concealment of the stigmatized identity of being ‘ill’ is needed.

Objective: To examine whether abuse and dysfunctional parental affiliation in childhood are associated with voice appraisals of power and perceived expressed emotion, present-day shame cognitions, and depression and suicidal ideation. Method: Seventy-four voice-hearers participated. Depressive and suicidal status, childhood abuse and parental affiliation, shame cognitions and appraisals of voice power and perceived expressed emotion were assessed. Results: Overall, childhood emotional abuse was linked to greater voice power and lack of emotional support from parents was linked to lower support and affiliation with voices. Rejection from father and emotional abuse were the strongest and consistent predictors of internal and external shame cognitions. Depression was strongly correlated with parental emotional abuse. Conclusion: Our findings suggest that the voice/voice-hearer relationship operates as an emotional mirror reflecting elements of traumatic childhood affiliations, and that these affiliations are...

The use of cannabis during the early stage of psychosis has been linked with increased psychotic symptoms. This study aimed to examine the use of cannabis in the 12 months following a first-episode of psychosis (FEP) and the link with symptomatic course and outcome over 1 year post psychosis onset.One thousand twenty-seven FEP patients were recruited upon inception to specialized early intervention services (EIS) for psychosis in the United Kingdom. Participants completed assessments at baseline, 6 and 12 months.The results indicate that the use of cannabis was significantly associated with increased severity of psychotic symptoms, mania, depression and poorer psychosocial functioning. Continued use of cannabis following the FEP was associated with poorer outcome at 1 year for Positive and Negative Syndrome Scale total score, negative psychotic symptoms, depression and psychosocial functioning, an effect not explained by age, gender, duration of untreated psychosis, age of psychosis onset, ethnicity or other substance use.This is the largest cohort study of FEP patients receiving care within EIS. Cannabis use, particularly "continued use," was associated with poorer symptomatic and functional outcome during the FEP. The results highlight the need for effective and early intervention for cannabis use in FEP.

Considerable focus has been given to the interpersonal nature of the voice-hearing relationship and how appraisals about voices may be linked with distress and depression (the 'cognitive model'). Research hitherto has focused on appraisals of voice power, but the supportive and affiliative quality of voices, which may act to mitigate distress, is not understood. We explored appraisals of voices' power and emotional support to determine their significance in predicting depression and suicidal thought. We adapted the concept of expressed emotion (EE) and applied it to measure voice hearers' perception of the relationship with their voice(s). In a sample of 74 voice hearers, 55.4% were moderately depressed. Seventy-eight who rated their voices as high in both power and EE had a large and significant elevation in depression, suggesting that co-occurrence of these appraisals impacts on depression. Analysis of the relationship between power and EE revealed that many voices perceived as low in power were, nevertheless, perceived as high in EE. Those rating their voices as emotionally supportive showed the lowest levels of depression and suicidal thinking. These findings highlight the protective role that the supportive dimension of the voice/voice-hearer relationship may have.

Objective: Numerous studies have found a robust association between cannabis use and the onset of psychosis. Nevertheless, the relationship between cannabis use and the onset of early (or, in retrospect, prodromal) symptoms of psychosis remains unclear. The study focused on investigating the relationship between cannabis use and early and high-risk symptoms in subjects at clinical high risk for psychosis. Method: Prospective multicenter, naturalistic field study with an 18-month follow-up period in 245 help-seeking individuals clinically at high risk. The Composite International Diagnostic Interview was used to assess their cannabis use. Age at onset of high risk or certain early symptoms was assessed retrospectively with the Interview for the Retrospective Assessment of the Onset of Schizophrenia. Results: Younger age at onset of cannabis use or a cannabis use disorder was significantly related to younger age at onset of six symptoms (0.33 < rs < 0.83, 0.004 < P < 0.001). Onset of cannabis use preceded symptoms in most participants. Conclusion: Our results provide support that cannabis use plays an important role in the development of psychosis in vulnerable individuals. Cannabis use in early adolescence should be discouraged.

AIMS: Much research has begun to focus on the identification of people who are at high risk of developing psychosis, and clinical services have been initiated for this population. However, only a small number of studies have reported on the efficacy of interventions for preventing or delaying the onset of psychosis. The results of prior work suggest that cognitive therapy (CT) may be an effective, well-tolerated treatment. We report on the rationale and design for a large-scale, multi-site randomized, controlled trial of CT for people who are assessed to be at high risk of psychosis because of either state or state-plus-trait risk factors. METHODS: The study employs a single-blind design in which all participants receive frequent mental-state monitoring, which will efficiently detect transition to psychosis, and half are randomized to weekly sessions of CT for up to 6 months. Participants will be followed-up for a minimum of 12 months and to a maximum of 2 years. RESULTS: We report the characteristics of the final sample at baseline (n=288). CONCLUSIONS: Our study aimed to expand the currently limited evidence base for best practice in interventions for individuals at high risk of psychosis.

Background Whilst Early Intervention Services (EIS) are the ‘gold standard’ treatment for young people with psychosis, in a recent study of over 1000 First Episode Psychosis (FEP) cases, 66% of individuals were experiencing a high level of poor functioning, despite receiving care under EIS for a period of 12 months (Hodgekins et al., 2015). This highlights the need to develop new interventions to target functional impairments in FEP. A specialised Social Recovery Cognitive Behavioural Therapy (SRCBT) has been developed which aims to address the underlying factors impeding social recovery, and has shown to be effective at improving structured activity in individuals with established illness and FEP (Fowler et al., 2013). Identifying the factors that contribute to functional change will ensure that targeted psychosocial therapies are being delivered appropriately. Impaired social cognition (SC) and neurocognition (NC) are closely related to poor functioning in psychosis. Exploration of SC and NC pre- and post-intervention will therefore be important to test underlying mechanisms of functional change, and identify individuals who are more likely to benefit from the specialized SRCBT. Methods This study ran alongside a multi-site proof of concept trial of SRCBT, for individuals with FEP experiencing social disability. Participants (M age = 25 years) had less than 30 hours a week of structured activity before entering the trial. At baseline, 123 participants completed a battery of SC and NC assessments. 59 participants were randomly allocated to the therapy group (SRCBT + EIS), and 64 were randomly allocated to the standard care group (care from an EIS alone). Participants completed a follow-up assessment at 9 months on the same cognitive battery, and a further assessment of their structured activity. The assessors were blind to group allocation. A small sub-sample of participants (N=6) allocated to the SRCBT group underwent functional magnetic resonance imaging (fMRI) scanning pre- and post- SRCBT, to explore any changes in the social brain regions following successful intervention. Results Regression analyses showed that SC was a significant predictor of treatment response (i.e. improved structured activity). Specifically, those who had better social knowledge at baseline were most likely to benefit from the SRCBT (Wald χ2 = 4.073; p = .044), accounting for 16% of the overall variance. To further illustrate this, individuals scoring in the top quartile for social knowledge achieved an additional 11 hours on average of structured activity post-intervention. Furthermore, in the group that underwent fMRI scanning pre- and post - intervention, there were increased activations in the social brain regions, namely the temporo-parietal junction (TPJ), which became more refined and localized by follow-up. There was also a trend for increased signal intensity in the TPJ, with increased structured activity post-SRCBT. Although this was not significant (r = .455; p = .365), there was a moderate strength relationship Discussion No studies to-date have examined predictors of treatment response to a CBT intervention targeting functional impairment in FEP. These findings have implications for practice where remediation of SC may improve the efficacy of the SRCBT, particularly for individuals who have poorer social knowledge. This study is also the first to provide preliminary insights into a functional brain network associated with improved structured activity in psychosis; however, replication of these findings in a larger sample is needed.

Background: Despite remission being the primary objective following the first episode of schizophrenia, clinically stabilized patients nevertheless relapse. Aim: To assess the extent and fluctuation of low-level psychotic symptoms in patients who are in remission after first-episode schizophrenia and consider whether this is equivalent to symptomatology experienced by those at ‘ultra high risk’ (UHR) of developing first-episode psychosis. Methods: We examined the phenomenological characteristics of 11 patients who fulfilled international remission criteria using the Structured Interview for Prodromal Symptoms and compared this cohort with an UHR sample. Results: Remitted patients were experiencing attenuated positive symptoms (73%) and brief limited intermittent psychotic symptoms (18%), features that were similarly prevalent in the UHR group. There was no significant fluctuation in these low-level symptoms over the course of four interviews. Conclusions: Although further research is required in this novel field, such features could form the building blocks for better prediction of psychotic relapse.

There are few evaluated psychological interventions or theoretical approaches which are specifically aimed at reducing problems related to adjustment and adaptation following a first episode of psychosis. The present study tests the efficacy of a form of CBT (Cognitive Recovery Intervention; CRI) in reducing trauma, depression and low self esteem following a first episode of psychosis, in a single-blind randomised controlled trial. A total of 66 patients who had recently experienced a first episode of psychosis were randomly assigned to CRI or treatment as usual (TAU) and followed up at 6 and 12 months. People receiving CRI tended to have lower levels of post-intervention trauma symptoms and demonstrated greater improvement than those receiving TAU alone. This was especially the case at 6 months for those with high pre-treatment levels of trauma. There was, however, no advantage for the CRI group with regards to reduced depression or improved self esteem. In conclusion, CRI appears to be an effective intervention to help young people adapt to the traumatic aspects of a first episode of psychosis although further evaluation in a larger study is warranted.

Aims: This study aimed to explore the attitudes of staff working within mental health settings toward cannabis in general and cannabis use in individuals with severe mental-health problems. Method: Twenty members of staff working within community mental health teams in Birmingham, UK, were interviewed using qualitative research methods. The overarching themes within the staff accounts are described and the interrelationship between themes explored. Findings: Staff use an ‘individualized’ approach when working with cannabis-using clients dependent on a number of key components, including the positive and negative effects of use, wider evidence base, client vulnerability, engagement, professional and personal views and harm reduction. It is suggested that any approach staff may take toward cannabis use at any one time is greatly dependent upon the above factors and these factors are highly client specific. Conclusions: The findings may help to explain why interventions aimed at reducing substance use in peo...

Background: Cocaine/crack-cocaine use is associated with a number of negative outcomes in people with mental health problems. Aims: To explore the extent of use in individuals with severe mental health problems and impact of client use on mental health service staff. Method: Following Graham et al. (2001), care coordinators within community mental health teams in Birmingham, UK completed a prevalence survey of cocaine/crack-cocaine use in clients on their current caseload to determine the extent of use. Findings were compared to those of Graham et al. Interviews with staff explored the impact of cocaine/crack-cocaine on client outcome and effects on staff within the teams under study. Results: An increase in cocaine/crack-cocaine use is reported (from 5.6% to 11.5% over 8 years). Interview data indicate that despite this increase, staff declare themselves more competent and confident in dealing with cocaine/crack-cocaine use. Conclusions: We propose that the integration of substance use treatment within m...

Objectives: Previous research indicates that beliefs about voice power and omnipotence are associated with distress, depression, and compliance. The present study investigates whether acting on voices to mitigate perceived threat, in a broader sense than compliance, is driven by delusional beliefs, as the Chadwick, Birchwood, and Trower cognitive-behavioural model of voices would suggest. The role of safety behaviours in maintaining beliefs about voice omnipotence and distress is also examined. Design: A cross-sectional investigation of 30 individuals with current experience of auditory verbal hallucinations was conducted. Method: Participants were assessed on self-report measures of voice topography, voice-related threat and distress, safety behaviour use, beliefs about voices, and depression and anxiety. Results: Three sources of threat were identified: physical harm, shame, and loss of control. Twenty-six individuals had recently used safety behaviours, believing them to be effective in threat reduction. The degree of safety behaviour use and voice-related distress were associated with voice omnipotence beliefs; mood or voice characteristics did not account for this relationship. The association of safety behaviours with increased distress was mediated by beliefs about voice omnipotence. Conclusions: Acting on voices can be conceptualized as a form of safety seeking, associated with maintaining beliefs about voice omnipotence and distress.

Partnership working between health and the voluntary and community sector has become an increasing political priority. This paper describes and explores the extent and patterns of partnership working between health and the voluntary and community sector in the context of Early Intervention Services for young people with a first episode of psychosis. Data were collected from 12 Early Intervention Services and through semistructured interviews with 47 voluntary and community sector leads and 42 commissioners across the West Midlands of England. Most partnerships were described as ad hoc and informal in nature although four formal partnerships between Early Intervention Services and voluntary and community sector organizations had been established. Shared agendas, the ability to refer clients onto an organization that could provide a service they could not and shared training facilitated partnership working in this context. Barriers to closer working included differences in culture such as managing risk, the time required to make and maintain relationships and recognition of the advantages of remaining a small and autonomous organization. The four more formal partnerships were also built on the organizations' experience of working together informally, in one case through a specific pilot project. The voluntary and community organizations involved were also branches of larger national organizations for whom finding sustainable funding was less of an issue. In theoretical terms, eight Early Intervention Service: voluntary and community sector partnerships were at a stage of 'pre-partnership collaboration', three at 'partnership creation and consolidation' and one at 'partnership programme delivery'. The empirical data viewed through the lens of the partnership life-cycle model could help early intervention services, and voluntary and community sector professionals better understand where they are, why they are there and the conditions needed to realise the full potential of partnership working.

This is the second of two papers that present a small, randomized control trial of cognitive behavioural therapy (CBT) within a group setting for the treatment of auditory hallucinations. In the previous paper, a method was described for an eight-session CBT group. Assessments were undertaken measuring control, power, frequency, and symptoms of distress and anxiety on commencement and on completion of the group. This second paper details the experience of the group and reports on the outcomes of the assessment measures. The study concludes that group CBT was helpful in the treatment of auditory hallucinations.

Understanding how adolescents perceive mental illness is important for clinicians wishing to improve engagement, and for the development of educational programmes and health-behaviour directed policies. The current research aimed to develop a preliminary model of how adolescents perceive mental illness and construct their understanding of mental health.Forty-six participants aged 11-18 from six schools in Birmingham, UK, took part in one of 12 group interviews.A thematic analysis highlighted a dual perception of mental illness. Adolescents discussed stereotypes and extreme examples of illness, but also displayed an insightful understanding of mental distress which had developed through participants' own experiences. Participants attempted to reconcile and negotiate these conflicting perceptions by creating distinctions between concepts of 'craziness' and 'normality', and reported experiencing negative emotions relating to both perceptions of illness.The findings suggest that once media stereotypes have been acknowledged, adolescents demonstrate a relatively sophisticated understanding of mental illness, although one which differed at times from the diagnostic medical model of mental illness. Focusing on individual symptoms, prevalence rates and prior contact adolescents have had with individuals with mental illnesses provides a framework to discuss mental health and ill-health with adolescents.

Approximately 80 000 children and young people in the UK suffer from depression, but many are untreated because of poor identification of early warning signs and risk factors.This study aimed to derive and to investigate discrimination characteristics of a prediction model for a first recorded diagnosis of depression in young people aged 15-24 years.This study used a matched case-control method using electronic primary care records. Stepwise conditional logistic regression modelling investigated 42 potential predictors including symptoms, co-morbidities, social factors and drug and alcohol misuse.Of the socio-economic and symptomatic predictors identified, the strongest associations were with depression symptoms and other psychological conditions. School problems and social services involvement were prominent predictors in men aged 15-18 years, work stress in women aged 19-24 years.Our model is a first step in the development of a predictive model identifying early warning signs of depression in young people in primary care.

Aims\ud To investigate trajectories of negative symptoms during the first 12 months of treatment for first episode psychosis (FEP), their predictors and relationship to social recovery.\ud \ud Method\ud 1006 participants were followed up for 12 months following acceptance into Early Intervention in Psychosis services. Negative symptom trajectories were modelled using latent class growth analysis (LCGA) and predictors of trajectories examined using multinomial regression. Social recovery trajectories – also modelled using LCGA – of members of each negative symptom trajectory were ascertained and the relationship between negative symptom and social recovery trajectories examined.\ud \ud Results\ud Four negative symptom trajectories were identified: Minimal Decreasing (63.9%), Mild Stable (13.5%), High Decreasing (17.1%) and High Stable (5.4%). Male gender and family history of non-affective psychosis predicted stably high negative symptoms. Poor premorbid adolescent adjustment, family history of non-affective psychosis and baseline depression predicted initially high but decreasing negative symptoms. Members of the Mild Stable, High Stable and High Decreasing classes were more likely to experience stably low functioning than the Minimal Decreasing class.\ud \ud Conclusions\ud Distinct negative symptom trajectories are evident in FEP. Only a small subgroup present with persistently high levels of negative symptoms. A substantial proportion of FEP patients with elevated negative symptoms at baseline will achieve remission of these symptoms within 12 months. However, elevated negative symptoms at baseline, whether or not they remit, are associated with poor social recovery, suggesting targeted interventions for service users with elevated baseline negative symptoms may help improve functional outcomes.

BackgroundParanoia is one of the commonest symptoms of psychosis but has rarely been studied in a population at risk of developing psychosis. Based on existing theoretical models, including the proposed distinction between ‘poor me’ and ‘bad me’ paranoia, we aimed to test specific predictions about associations between negative cognition, metacognitive beliefs and negative emotions and paranoid ideation and the belief that persecution is deserved (deservedness).MethodWe used data from 117 participants from the Early Detection and Intervention Evaluation for people at risk of psychosis (EDIE-2) trial of cognitive–behaviour therapy, comparing them with samples of psychiatric in-patients and healthy students from a previous study. Multi-level modelling was utilized to examine predictors of both paranoia and deservedness, withpost-hocplanned comparisons conducted to test whether person-level predictor variables were associated differentially with paranoia or with deservedness.ResultsOur sample of at-risk mental state participants was not as paranoid, but reported higher levels of ‘bad-me’ deservedness, compared with psychiatric in-patients. We found several predictors of paranoia and deservedness. Negative beliefs about self were related to deservedness but not paranoia, whereas negative beliefs about others were positively related to paranoia but negatively with deservedness. Both depression and negative metacognitive beliefs about paranoid thinking were specifically related to paranoia but not deservedness.ConclusionsThis study provides evidence for the role of negative cognition, metacognition and negative affect in the development of paranoid beliefs, which has implications for psychological interventions and our understanding of psychosis.

Objective\ud This proof of principle study evaluated the effectiveness and feasibility of a brief motivational intervention, delivered in mental health in-patient settings, to improve engagement in treatment for drug and alcohol misuse.\ud \ud Method\ud A randomised controlled trial using concealed randomisation, blind, independent assessment of outcome at 3 months. Participants were 59 new adult admissions, to six acute mental health hospital units in one UK mental health service, with schizophrenia related or bipolar disorder diagnoses, users of community mental health services and also misusing alcohol and/or drugs. Participants were randomised to Brief Integrated Motivational Intervention (BIMI) with Treatment As Usual (TAU), or TAU alone. The BIMI took place over a 2-week period and encouraged participants to explore substance use and its impact on mental health.\ud \ud Results\ud Fifty-nine in-patients (BIMI n = 30; TAU n = 29) were randomised, the BIMI was associated with a 63% relative odds increase in the primary outcome engagement in treatment [OR 1.63 (95% CI 1.01–2.65; P = 0.047)], at 3 months. Qualitative interviews with staff and participants indicated that the BIMI was both feasible and acceptable.\ud \ud Conclusion\ud Mental health hospital admissions present an opportunity for brief motivational interventions focussed on substance misuse and can lead to improvements in engagement.

Outcomes for individuals with psychosis remain far from acceptable. Recently, prominent psychiatrists have called for an improved understanding of the impact of social contexts, and how social contexts might influence the development and maintenance of mental health problems. A key social context for individuals with psychosis is the therapeutic relationship. As part of a trial of joint crisis planning in England, this qualitative study aimed to determine the mechanism through which joint crisis planning might affect the therapeutic relationship. Results suggest that routine processes in mental health care are affected by policy and organizational requirements for risk mitigation—aspects that undermine person-centered approaches. In contrast, strong therapeutic relationships are characterized by individualized care and reliable and respectful treatment. The Joint Crisis Plan intervention partially succeeded in reducing contextual influences on routine role enactments, facilitating the demonstration of respect and improving the therapeutic relationship.

BACKGROUND The link between depression and paranoia has long been discussed in psychiatric literature. Because the causality of this association is difficult to study in patients with full-blown psychosis, we aimed to investigate how clinical depression relates to the presence and occurrence of paranoid symptoms in clinical high-risk (CHR) patients. METHODS In all, 245 young help-seeking CHR patients were assessed for suspiciousness and paranoid symptoms with the structured interview for prodromal syndromes at baseline, 9- and 18-month follow-up. At baseline, clinical diagnoses were assessed by the Structured Clinical Interview for DSM-IV, childhood adversities by the Trauma and Distress Scale, trait-like suspiciousness by the Schizotypal Personality Questionnaire, and anxiety and depressiveness by the Positive and Negative Syndrome Scale. RESULTS At baseline, 54.3 % of CHR patients reported at least moderate paranoid symptoms. At 9- and 18-month follow-ups, the corresponding figures were 28.3 and 24.4 %. Depressive, obsessive-compulsive and somatoform disorders, emotional and sexual abuse, and anxiety and suspiciousness associated with paranoid symptoms. In multivariate modelling, depressive and obsessive-compulsive disorders, sexual abuse, and anxiety predicted persistence of paranoid symptoms. CONCLUSION Depressive disorder was one of the major clinical factors predicting persistence of paranoid symptoms in CHR patients. In addition, obsessive-compulsive disorder, childhood sexual abuse, and anxiety associated with paranoia. Effective pharmacological and psychotherapeutic treatment of these disorders and anxiety may reduce paranoid symptoms in CHR patients.

Background:\ud Studies demonstrate ethnic variations in pathways to care during first episode psychosis (FEP). There are no extant studies, however, that have statistically examined the influence of culturally mediated illness attributions on these variations.\ud \ud Methods:\ud We conducted an observational study of 123 (45 White; 35 Black; 43 Asian) patients recruited over a two-year period from an Early Intervention Service (EIS) in Birmingham, UK. Sociodemographic factors (age; sex; education; country of birth; religious practice; marital status; living alone), duration of untreated psychosis (DUP), service contacts (general practitioner; emergency services; faith-based; compulsory detention; criminal justice) and illness attributions (“individual;” “natural;” “social;” “supernatural;” “no attribution”) were assessed.\ud \ud Results:\ud Ethnic groups did not differ in DUP (p = 0.86). Asian patients were more likely to report supernatural illness attributions in comparison to White (Odds Ratio: 4.02; 95 % Confidence Intervals: 1.52, 10.62) and Black (OR: 3.48; 95 % CI: 1.25, 9.67) patients. In logistic regressions controlling for confounders and illness attributions, Black (OR: 14.00; 95 % CI: 1.30, 151.11) and Asian (OR: 13.29; 95 % CI: 1.26, 140.47) patients were more likely to consult faith-based institutions than White patients. Black patients were more likely to be compulsorily detained than White patients (OR: 4.56; 95 % CI: 1.40, 14.85).\ud \ud Conclusion:\ud Illness attributions and sociodemographic confounders do not fully explain the ethnic tendency to seek out faith-based institutions. While Asian and Black patients are more likely to seek help from faith-based organisations, this does not appear to lead to a delay in contact with mental health services.

INTRODUCTION: This paper describes the development and implementation of an educational intervention to help general practitioners (GPs) recognise young people with first episode psychosis. METHOD: The Medical Research Council complex interventions framework was used to guide the development of the intervention. The theoretical phase included a literature review of previous educational interventions in primary care and consideration of the literature on attitude formation and change, and the relationship between attitudes and behaviour. The modelling phase included focus groups with GPs and service users, and a training needs analysis questionnaire administered to GPs. The 2-stage intervention consisted of a video featuring role-plays of primary care consultations, GP-led discussion and discussion with early intervention service users. The acceptability and utility of the educational programme was evaluated using a 5-point Likert scale questionnaire administered at the end of each session. RESULTS: General practitioners from each of the 39 intervention practices participated in the initial session and from 27 practices in the booster session. Information about symptoms and signs of first episode psychosis was the most valued aspect of the initial session. The booster session was also well received, with GPs valuing the opportunity to gain insight into first episode psychosis from users. CONCLUSIONS: This paper adds a pragmatic description to the literature on the development of educational interventions in primary care. The Medical Research Council framework helped to identify and clarify component parts of the intervention and how the active components may relate to the expected outcome of behaviour change.

The role of 3 personality dimensions (i.e., dependency, self-criticism, and efficacy) in recovery from an acute and severe psychosis was examined. Conceptualizing psychosis as involving difficulties in establishing psychological boundaries, the authors hypothesized that dependency has a greater disruptive effect on recovery than self-criticism. Results of a reanalysis of longitudinal data (N = 76) of people with schizophrenia spectrum disorders during recovery from acute psychosis were consistent with this hypothesis: Dependency predicted depressive and negative symptoms, and, under low efficacy, perceived loss of independence and insight into the presence of the illness. These findings elucidate the central role of interpersonal relatedness as a foundation for self-definition in recovery from psychosis.

Command hallucinations (CH) have recently become the focus of research into positive symptoms of schizophrenia. The importance of CH has become clear for theoretical and practical reasons, because CH are regarded as potentially the most dangerous symptoms of schizophrenia. The aim is to critically review research that has attempted to better understand CH and develop theories that may predict behavior and shape psychological treatments. This review draws together, presents, and critically discusses the current disparate body of literature produced (1990-2000) considering compliance with CH. The literature can be grouped broadly into three overlapping classes. (1) Studies testing for a relationship between CH and compliance. (2) Studies considering factors associated with acting on CH (mediating variables). (3) Studies that look for a relationship between CH and dangerous behavior. The body of literature is in its infancy and marred by methodological difficulties. Researchers have asked differing questions about different samples while hoping to provide similar answers. While acknowledging difficulties in interpreting the literature, themes do emerge. The weight of the evidence is that some individuals who hear commands will act on them. However, some studies show no link or only a weak link and although methodological errors account for some of the inconsistent results, there are also clearly individual differences. The relationship between command and action is more complex than many researchers have assumed. One conjecture is that the relationship is established via psychological processes or mediating variables which include beliefs about the voice and content of instruction. Prediction of compliance with commands is of further interest when dangerous behavior results. It is postulated that the issue of dangerousness is subject to the same mediating variables as other commands. It is clear however, that CH are not sufficient to produce action in isolation and that psychological processes mediate the process.

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.

One of the challenges for services in the UK has been how best to meet the needs of those people who experience severe mental health problems and use drugs and alcohol problematically. It is now well-documented in the international literature that the coexistence of severe mental health and substance misuse problems are common (e.g. Regier et al, 1990; Krausz et al, 1996; Menezes et al, 1996; Fowler et al, 1998; Mueser et al, 2000; Graham et al, 2001) and often correlated with a number of adverse outcomes (Smith & Hucker, 1994; Johnson, 1997; Mueser et al, 2000). Integrated treatment approaches developed in the USA for this client group (e.g. Drake & Wallach, 2000; Drake et al, 2001), and although they offer much food for thought and some direction, they could not be wholly imported and implemented in the UK because of significant differences in the contextual factors that guide service provision in the two countries. The challenge in the UK has been to develop effective services that fit with the unique community-based treatment approaches for substance misuse problems and mental health that have developed and historically offered separately and in parallel.

Command hallucinations (CH) are a distressing and high-risk group of symptoms that have long been recognized but little understood, with few effective treatments. Research shows that cognitive behavior therapy (CBT) is a promising treatment for hallucinations in general and therefore has a potential role in the treatment of CH. We propose that the development of an effective CBT for CH would be enhanced by a theory specific to this uniquely problematic symptom. In this article we describe and apply such a theory from evolutionary psychology, namely social rank theory, and review recent evidence for its application to hallucinations in general. Second, we present a treatment protocol developed in accordance with the principles of the theory specifically for CH, and describe an illustrative case. Finally, we outline the design and methodology of a new, randomized, controlled trial currently being undertaken to test the efficacy of the treatment. Further developments both in the protocol and in its evaluation are discussed.

The development of psychosis is often described as a process that goes through different linear stages such as a premorbid and a prodromal phase, with the onset of psychosis as the end state. In this article we elaborate a hierarchical model in which psychosis is understood at different levels of abstraction: we differentiate an etiological, a descriptive, and a therapeutical level, and finally a level of understanding. We regard coping as a special psychological process that starts when symptoms of psychosis first emerge (often many years before treatment is initiated) and continues throughout therapy. In patients who do not respond very well to standard treatment (approximately 15-20% of all patients who suffer from schizophrenia), coping strategies are probably some of the most important long-term prognostic factors. Two cognitive-oriented treatment programs are described: the German model for possible pre-psychosis and the UK tradition for treatment of chronic psychotic symptoms (nonresponders). We conclude that psychological treatment that focuses on coping strategies might be of help both in possible pre-psychotic stages and in nonresponders.

The cognitive model of auditory hallucinations considers voices as involuntary thoughts that are attributed to an external source. Misattribution of internal events to an external source is a well-documented major information-processing bias that characterizes hallucinating patients (Brebion et al., 2000). Emotions increase the bias to external attribution even further (Morrison et al., 1997). Patients who start to experience hearing voices will also construct a set of beliefs about them—who they are and whether they are willing to help him or that they pursue to punish or destroy him. Beliefs of “malevolent” intent and power of the voices are considered to trigger anxiety and depression (Chadwick and Birchwood, 1994). Anxiety could be the result of beliefs about the voices and, at the same time, facilitate the recurrence of auditory hallucinations and thus be a perpetuating factor. Based on these beliefs, the patient will engage with the voices or show resistance. Chadwick and Birchwood (1994) demonstrated that malevolent voices evoked anxiety and were resisted, whereas benevolent voices were engaged. The beliefs about voices’ identity and meaning were not always linked to the voice content; these beliefs seem to be constructed by the patient in an attempt to make sense of the voices. A patient with negative voice content and a belief of benevolent intent may hear a voice saying: “You are lousy, stupid! I told you not to do this before.” The patient believes the voice is harsh, but will help him in the end. These data were confirmed in a study by Birchwood and Chadwick (1997); however, Close and Garety (1998) found that beliefs about omnipotence (67%) and omniscience (73%) were not present in all patients, and none of the patients had beliefs at odds with content. The authors suggest that the voice experience in itself is enough to provoke negative affect within participants, even when the content is benevolent. Thus, it is still unclear what the relative contribution of negative voice content versus (malevolent) beliefs about voices is. The measurement of voice content could be the key to the disparity in findings between the original study by Chadwick and Birchwood (1994) and the study by Close and Garety (1998). Both studies seem to rate the content at face value, without definitions or an indication of the accuracy of the ratings. The present study will improve the assessment of the voice content by using two raters to independently assess voice content. Only the data of patients with voice content that was confirmed by both raters entered the analyses, providing a better opportunity to clearly disentangle the contribution of voice content and voice belief to distress by using multivariate analysts.

Using the lessons gained from implementing the St Vincent Declaration for Diabetes (1990), this declaration details general goals, 5 years targets, performance and outcome measures for the detection and management of early psychosis. Its successful implementation requires integrated partnerships working locally, nationally and internationally to: • educate and raise awareness about psychosis; • plan, deliver and audit care; • promote recovery and social inclusion; • promote and apply research. General goals: • timely access to evidence-based interventions sensitive to age, gender and culture; • a ‘recovery’ paradigm; • eliminating stigma and ensuring rights to citizenship and social inclusion. Five-year targets: • a workforce (resourced for skills, leadership and manpower) which delivers comprehensive EI programmes; • greater consumer independance, self sufficiency and socialequity; • greater consumer service satisfaction; • raised awareness among the general population and care professionals; • developed centres of excellence for research and training performance and outcome measures which: – monitor: DUP, relapse rates, legal detention use, police involvement, suicide/untoward death; – audit: pathways into care personal, social, educational and vocational outcomes consumer and carer satisfaction.

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.

The need for a measure of engagement with Community Mental Health Services has been identified. This article reports on the development and preliminary psychometric evaluation of a scale, Service Engagement Scale (SES), to measure engagement with community mental health services. Five Community Psychiatric Nurses completed the SES for 66 clients receiving Assertive Outreach services with an ICD-10 diagnosis of schizophrenia. Test-retest reliability of the subscale items and scale total is in the good to excellent range. Validity is supported by good internal consistency and by the criterion group method. Although preliminary psychometric results are promising, further psychometric study is necessary to evaluate the scale's factor structure. The SES appears to evaluate engagement with services, and may therefore be a useful tool to identify areas of concern with clients experiencing engagement difficulties.

PURPOSE:Recent legislation and guidance in England emphasises the importance of service user choice in care planning. However, it is not obvious how best to facilitate choices in care planning, and some clinicians are concerned that service users may make 'unwise' decisions. This study aimed to examine mental health service users' preferences and priorities in the event of a future mental health crisis or relapse.METHOD:Thematic analysis of 221 joint crisis plans (JCP) developed by service users and their clinical team as part of the CRIMSON randomised controlled trial. Participants had a diagnosis of a psychotic disorder, at least one psychiatric admission in the past 2 years, contact with a community mental health team, and complex care needs.RESULTS:Two major categories of preferences were identified: first the manner in which crisis care would be delivered; and second, specific treatment interventions. Most service users requested full involvement in decisions about their care, clear and consistent treatment plans, access to familiar clinicians who knew them well, and to be treated with respect and compassion. Some service users requested hospitalisation, but the majority preferred alternatives. The most frequently preferred intervention was care by a home treatment team. Just under half made a treatment refusal, the majority being for specific medications, alternatives were offered.CONCLUSIONS:Joint crisis planning resulted in service users making choices that were clinically reasonable. The technique employed by JCPs appeared to empower service users by engaging them in a productive dialogue with their clinicians.

As members of the recent National Institute for Health and Care Excellence (NICE) clinical guideline update for schizophrenia[1][1] (M.B. and D.S.), we read with interest the excellent meta-analysis of CBT for symptoms of schizophrenia by Jauhar et al .[2][2] The results are broadly in line with the

BackgroundResearch suggests that the way in which cognitive therapy is delivered is an important factor in determining outcomes. We test the hypotheses in which the development of a shared problem list, use of case formulation, homework tasks and active intervention strategies will act as process variables.MethodPresence of these components during therapy is taken from therapist notes. The direct and indirect effect of the intervention is estimated by an instrumental variable analysis.ResultsA significant decrease in the symptom score for case formulation (coefficient =–23, 95% CI –44 to –1.7, P = 0.036) and homework (coefficient =–0.26, 95% CI –0.51 to –0.001, P = 0.049) is found. Improvement with the inclusion of active change strategies is of borderline significance (coefficient =–0.23, 95% CI –0.47 to 0.005, P = 0.056).ConclusionsThere is a greater treatment effect if formulation and homework are involved in therapy. However, high correlation between components means that these may be indicators of overall treatment fidelity.

BackgroundIncreasing evidence shows attachment security influences symptom expression and adaptation in people diagnosed with schizophrenia and other psychoses.AimsTo describe the distribution of secure and insecure attachment in a cohort of individuals with first-episode psychosis, and to explore the relationship between attachment security and recovery from positive and negative symptoms in the first 12 months.MethodThe study was a prospective 12-month cohort study. The role of attachment, duration of untreated psychosis (DUP), baseline symptoms and insight in predicting and mediating recovery from symptoms was investigated using multiple regression analysis and path analysis.ResultsOf the 79 participants, 54 completed the Adult Attachment Interview (AAI): 37 (68.5%) were classified as insecure, of which 26 (48.1%) were insecure/dismissing and 11 (20.4%) insecure preoccupied. Both DUP and insight predicted recovery from positive symptoms at 12 months. Attachment security, DUP and insight predicted recovery from negative symptoms at 12 months.ConclusionsAttachment is an important construct contributing to understanding and development of interventions promoting recovery following first-episode psychosis.

Social anxiety is among the most prevalent and debilitating affective disturbances manifest in people with psychosis. It is usually accompanied by high levels of depression and leads to significant social disability, lower quality of life and poorer prognosis as it raises the possibility of an early relapse. Despite its elevated prevalence and severity in psychosis, social anxiety remains under-recognized and under-treated. Cognitive-behavioural therapy is recommended for the treatment of people with psychosis. However, its focus and evaluation has primarily revolved around the reduction of psychotic symptoms, and not for co-morbid affective disturbances such as social anxiety. There is lack of evidence on the clinical effectiveness and cost-effectiveness of cognitive-behavioural interventions for the treatment of social anxiety disorder in psychosis. Electronic databases will be systematically searched for randomised controlled trials and quasi-experimental studies investigating the effectiveness and cost-effectiveness of cognitive-behavioural interventions for the treatment of social anxiety disorder in people with psychosis. Grey literature will also be searched by screening trial registers. Only studies published in English will be included in the review. Date restrictions will not be applied. Eligible studies will have as the primary outcome social anxiety (continuous data) measured using any psychometrically validated scale both self-reported and clinician administered. Secondary outcomes will include general anxiety symptoms, distress, depression, positive and negative symptoms of schizophrenia, and quality of life measured using any psychometrically validated scale, both self-reported and clinician administered, and the cost of cognitive-behaviour therapy (CBT) intervention (with another treatment or treatment-as-usual). This review will provide an evidence synthesis of the effectiveness and cost-effectiveness of cognitive-behavioural interventions for the treatment of social anxiety disorder in people with psychosis. The review will identify the specific intervention components associated with effectiveness which will facilitate the translation of the existing evidence to the development of new, targeted interventions optimising these components. In doing so, this review will provide recommendations for the treatment of social anxiety and associated distress in psychosis and will further inform the development of future interventions in this area. PROSPERO registration number CRD42014009052 .

Background Substance misuse in those with severe mental health problems is common and associated with poor engagement in treatment and treatment outcomes. Up to 44% of those admitted into psychiatric inpatient facilities have coexisting substance-misuse problems. However, this is not routinely addressed as part of their treatment plan. A mental health admission may present a window of opportunity for inpatients to reevaluate the impact of their substance use. This study will aim to evaluate the effectiveness of a targeted brief motivational intervention in improving engagement in treatment and to assess how feasible and acceptable this intervention is to inpatients and staff as a routine intervention. Methods/Design This randomized controlled trial will use concealed randomization; blind, independent assessment of outcome at 3 months; characterization of refusers and dropouts; and be analyzed according to the intention-to-treat principle. After baseline assessments, eligible participants will be randomized either to the Brief Integrated Motivational Intervention plus Treatment As Usual, or Treatment as Usual alone. Eligible participants will be those who are new admissions; >18 years; ICD-10 diagnosis of -schizophrenia or related disorder, bipolar affective disorder, recurrent depressive disorder, and DSM-IV diagnosis of substance abuse or dependence over the last 3 months. The primary outcome is engagement in treatment for substance misuse, and secondary outcomes include readiness to change substance misuse together with a cost-effectiveness analysis. Qualitative interviews with staff and participants will assess the acceptability of the intervention. Discussion This pilot randomized trial will provide the first robust evidence base for inpatient care of people with severe mental health problems and co-morbid substance misuse and provide the groundwork for confirmatory trials to evaluate a potentially feasible, cost-effective, and easy-to-implement treatment option that may be readily integrated into standard inpatient and community-based care. Trial registration ISRCTN43548483 Date of ISRCTN assignation: 4/17/2014.

Over recent years early intervention in psychosis has fired the imagination of clinicians and researchers, following the publication of several studies linking a long duration of psychosis prior to receiving treatment with a poor treatment outcome: a relationship that has been cogently argued to be independent of illness factors (e.g. Scully et al, 1997). Most influential was Wyatt's (1991) review of 22 studies, in which relatively similar groups of patients suffering from schizophrenia were, or were not, given antipsychotic medication early in the course of their illness. This pointed towards an improved long-term course in schizophrenia with early treatment.

Objective This study aimed to determine if the inception of Early Intervention Services (EISs) is followed by an improvement in the prompt treatment of people with first episode psychosis. Method A prospective cohort study of referrals to new and established EISs was conducted at 1, 2, 3, and 4 years after inception of new EIS. The study was conducted with 14 (seven new and seven established) secondary care EIS within geographically defined catchment areas in England between 2005 and 2009. Participants included 1027 consecutive referrals to EIS aged 14–35 with a first episode of psychosis. Duration of untreated psychosis (DUP) and number of participants treated adequately within 6 months of onset were the main outcome measures. Results A significant downward trend across yearly cohorts for DUP for new EIS (F1,549 = 8.4, p = 0.004) but not for established EIS (F1,429 = 1.7, p = 0.19) was observed. There was a significant upward trend across cohorts in the proportion of referrals treated within 6 months for new EIS (X2 = 8.0, df = 1, p = 0.005), but not for established EIS (X2 = 0.1, df = 1, p = 0.72). Conclusion The introduction of new EIS was followed by a reduction in DUP and an increase in the proportion of patients treated within 6 months of onset. These trends were not present in the catchment areas of established services where DUP was initially lower, suggesting that there was no general tendency for DUP to fall over time. Hence, the introduction of an EIS was followed by an improvement in the prompt and proper treatment of first episode psychosis.

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.

Relapse in schizophrenia remains common and cannot be entirely eliminated even by the best combination of biological and psychosocial interventions (Linszen et al, 1998). Relapse prevention is crucial as each relapse may result in the growth of residual symptoms (Shepherd et al, 1989) and accelerating social disablement (Hogarty et al, 1991). Many patients feel ‘entrapped’ by their illnesses, a factor highly correlated with depression (Birchwood et al, 1993), and have expressed a strong interest in learning to recognise and prevent impending psychotic relapse.

Objective The purpose of this article is to consider the issue of how long early intervention needs to be sustained to have a long-term impact on the course of psychosis. Method Factors relevant to the concept of secondary prevention in psychosis are discussed. The need for sustained intervention for long-term impact on psychosis is examined. Evidence concerning the length of time required for the maximal impact of early intervention services and interventions that have been demonstrated as effective in achieving long-term change is reviewed. The article discusses individuals of low and high vulnerability to schizophrenia and the interaction between this vulnerability and the length and type of treatment they require to change the deteriorating course of psychosis. Results There is increasing evidence for the concept of a ‘critical period’ lasting up to 5 years after first presentation, during which the long-term level of vulnerability to relapse and disability may be determined. Conclusions For many highly vulnerable patients, early intervention must be sustained for a minimum of 3 years to prevent or limit the potential for early decline. A core unanswered question is whether effective early intervention prevents potential long-term disability or merely delays it.