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BackgroundDespite evidence for the general effectiveness of psychological therapies, there exists substantial heterogeneity in patient outcomes. We aimed to identify factors associated with baseline severity of depression and anxiety symptoms, rate of symptomatic change over the course of therapy, and symptomatic recovery in a primary mental health care setting.MethodsUsing data from a service evaluation involving 35 527 patients in England's psychological and wellbeing [Improving Access to Psychological Therapies (IAPT)] services, we applied latent growth models to explore which routinely-collected sociodemographic, clinical, and therapeutic variables were associated with baseline symptom severity and rate of symptomatic change. We used a multilevel logit model to determine variables associated with symptomatic recovery.ResultsBeing female, younger, more functionally impaired, and more socioeconomically disadvantaged was associated with higher baseline severity of both depression and anxiety symptoms. Being older, less functionally impaired, and having more severe baseline symptomatology was associated with more rapid improvement of both depression and anxiety symptoms (male gender and greater socioeconomic disadvantage were further associated with rate of change for depression only). Therapy intensity and appointment frequency seemed to have no correlation with rate of symptomatic improvement. Patients with lower baseline symptom severity, less functional impairment, and older age had a greater likelihood of achieving symptomatic recovery (as defined by IAPT criteria).ConclusionsWe must continue to investigate how best to tailor psychotherapeutic interventions to fit patients’ needs. Patients who begin therapy with more severe depression and/or anxiety symptoms and poorer functioning merit special attention, as these characteristics may negatively impact recovery.

Background: Immune mechanisms have been implicated in the pathogenesis of depression. Translocator protein (TSPO)–targeted positron emission tomography (PET) has been used to assess neuroinflammation in major depressive disorder. We aimed to 1) test the hypothesis of significant case-control differences in TSPO binding in the anterior cingulate cortex, prefrontal cortex, and insula regions; and 2) explore the relationship between cerebral TSPO binding and peripheral blood C-reactive protein (CRP) concentration. Methods: A total of 51 depressed subjects with Hamilton Depression Rating Scale score >13 (median 17; interquartile range, 16–22) and 25 healthy control subjects underwent dynamic brain 11C-PK11195 PET and peripheral blood immune marker characterization. Depressed subjects were divided into high CRP (>3 mg/L; n = 20) and low CRP (2 p = .09; F 1,71 = 6.97, p = .01), which was not influenced by body mass index. The case-control difference was greatest in the anterior cingulate cortex (d = 0.49; t 74 = 2.00, p = .03) and not significant in the prefrontal cortex or insula (d = 0.27 and d = 0.36, respectively). Following CRP stratification, significantly higher TSPO binding was observed in low-CRP depression compared with controls (d = 0.53; t 54 = 1.96, p = .03). These effect sizes are comparable to prior major depressive disorder case-control TSPO PET data. No significant correlations were observed between TSPO and CRP measures. Conclusions: Consistent with previous findings, there is a modest increase in TSPO binding in depressed patients compared with healthy control subjects. The lack of a significant correlation between brain TSPO binding and blood CRP concentration or body mass index poses questions about the interactions between central and peripheral immune responses in the pathogenesis of depression.

Objective: Many people with psychotic experiences do not develop psychotic disorders, yet those who seek help demonstrate high clinical complexity and poor outcomes. In this systematic review and meta-analysis, we evaluated the effectiveness and cost-effectiveness of psychological interventions for people with psychotic experiences. Method: We searched 13 databases for studies of psychological interventions for adults with psychotic experiences, but not psychotic disorders. Our outcomes were the proportion of participants remitting from psychotic experiences (primary); changes in positive and negative psychotic symptoms, depression, anxiety, functioning, distress, and quality of life; and economic outcomes (secondary). We analysed results using multilevel random-effects meta-analysis and narrative synthesis. Results: A total of 27 reports met inclusion criteria. In general, there was no strong evidence for the superiority of any one intervention. Five studies reported on our primary outcome, though only two reports provided randomised controlled trial evidence that psychological intervention (specifically, cognitive behavioural therapy) promoted remission from psychotic experiences. For secondary outcomes, we could only meta-analyse trials of cognitive behavioural therapy. We found that cognitive behavioural therapy was more effective than treatment as usual for reducing distress (pooled standardised mean difference: −0.24; 95% confidence interval = [−0.37, −0.10]), but no more effective than the control treatment for improving any other outcome. Individual reports indicated that cognitive behavioural therapy, mindfulness-based cognitive therapy, sleep cognitive behavioural therapy, systemic therapy, cognitive remediation therapy, and supportive treatments improved at least one clinical or functional outcome. Four reports included economic evaluations, which suggested cognitive behavioural therapy may be cost-effective compared with treatment as usual. Conclusion: Our meta-analytic findings were primarily null, with the exception that cognitive behavioural therapy may reduce the distress associated with psychotic experiences. Our analyses were limited by scarcity of studies, small samples and variable study quality. Several intervention frameworks showed preliminary evidence of positive outcomes; however, the paucity of consistent evidence for clinical and functional improvement highlights a need for further research into psychological treatments for psychotic experiences. PROSPERO protocol registration number: CRD42016033869

Background Psychotic experiences (PE) may co-occur with common mental disorders (CMD), such as depression and anxiety. However, we know very little about the prevalence of and recovery from PE in primary mental health care settings, such as the Improving Access to Psychological Therapies (IAPT) services in the UK National Health Service (NHS), where most CMD are treated. Methods We used the Community Assessment of Psychic Experiences - Positive 15-item Scale (CAPE-P15) to determine the prevalence of PE in patients receiving treatment from IAPT services. Patient-reported measures of depression (PHQ-9) and anxiety (GAD-7) are routinely collected and establish recovery in IAPT services. We studied recovery rates according to the absence and presence of PE. Multi-group growth models estimated improvement trajectories for each group. Results A total of 2,042 patients with CMD completed the CAPE-P15. The mean age was 39.8. The overall prevalence of PE was 29.68%. The recovery rate was 27.43% compared to 62.08% for those without PE. Although patients with or without PE shared similar improvement trajectories, the initial severity of patients with PE impeded their likelihood of recovery. Limitations We mirrored routine data collection in IAPT services, including self-report questionnaires that may affect valid reporting of symptoms. Missing data in the calculation of improvement trajectories may reduce generalisability. Conclusions At least one in four patients receiving treatment from IAPT services in primary care experience CMD and PE. This significant group of people experience a lower recovery rate, with adverse implications not only for them but also for efficiency of services.

Psychotic experiences (PE) co-occur with depression and anxiety, and indicate severity of general mental distress. Identifying PE in primary care mental health settings may facilitate access to evidence-based interventions. The Community Assessment of Psychic Experiences - Positive 15-items Scale (CAPE-P15) has shown promise in detecting those at ultra-high risk of developing psychosis. Based on a sample of 1131 individuals with common mental disorder we propose high-sensitivity thresholds of the CAPE-P15 to broaden its application across clinical settings.

Background: Many people with psychotic experiences who seek help do not develop psychotic disorders, yet still demonstrate higher clinical complexity, suboptimal treatment response, and poor clinical and functional outcomes. Methods: We searched thirteen databases for studies concerning psychological interventions for adults with psychotic experiences, but not psychotic disorders. Our outcomes were the proportion of participants remitting/recovering from psychotic experiences (primary); changes in positive and negative psychotic symptoms, depression, anxiety, functioning, distress, or quality of life; and economic outcomes (secondary). We analysed results using random-effects meta-analysis and narrative synthesis. Findings: Twenty-seven reports from 21 studies met inclusion criteria. Five reported the proportion of participants remitting from psychotic experiences. Non-meta-analytic evidence suggested that cognitive behavioural therapy (CBT) may promote symptomatic recovery. For secondary outcomes, CBT demonstrated effectiveness over treatment as usual (TAU) and supportive treatments (ST) in improving distress (pooled standardised mean difference: -0.23 [-0.36 to -0.10]), but no other outcome. Individual reports indicated that CBT, mindfulness, sleep CBT, systemic therapy, cognitive remediation therapy, and supportive treatments improved some clinical and/or functional outcomes. Only four reports, using data from two studies, included economic evaluations, which suggested CBT may be cost-effective compared with TAU. Interpretation: Initial evidence suggests that CBT may promote recovery from psychotic experiences and reduce associated distress, although scarcity of studies, small sample sizes, and variable study quality limit our ability to make definitive conclusions. The paucity of consistent evidence for improving other non-psychotic clinical and functional outcomes highlights a need for further research into psychological treatments for this population. Funding: This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Reference Number RP-PG-0616-20003). Declaration of Interest: The authors declare no competing interests. Ethical Approval: Not applicable.

Background Systematic reviews indicate that approximately one third of people with at-risk mental states for psychosis (ARMS) will transition to a psychotic disorder. Research in non-specialised services, such as primary care settings, has shown that far fewer make such a conversion. Nonetheless, psychotic experiences (PE) may also be linked to common mental disorders (CMD), particularly depression and anxiety, and still predict poor outcomes. Population studies modelling the co-occurrence of CMD and PE have found an underlying unitary psychopathological factor, with PE emerging towards its more severe end. We know little about the prevalence of and recovery from PE in primary mental health care, where most CMD are treated. One example of primary mental health care setting in England is the Improving Access to Psychological Therapies (IAPT) programme (https://www.england.nhs.uk/mental-health/adults/iapt/). The IAPT programme provides evidence-based psychological therapies for mild to moderate CMD across the UK National Health Service (NHS). IAPT services adhere to current diagnostic paradigms and, therefore, do not either measure or treat PE. We aimed to establish the prevalence of PE in a large sample of patients with CMD from the IAPT programme and compare recovery rates between patients with CMD and PE (CMD-P) and those without PE. Methods We used the Community Assessment of Psychic Experiences - Positive 15-item Scale (CAPE-P15) to determine the prevalence of PE in patients with CMD receiving treatment from IAPT services across England. We employed the CAPE-P15 threshold score of 1.47, which identifies individuals with ARMS, and also a lower threshold of 1.30, chosen as within one standard error of measurement, in order to explore threshold effects in the association between PE and recovery. Patient-reported measures of depression (PHQ-9) and anxiety (GAD-7) are routinely collected in IAPT services and determine ‘caseness’ before, during and after therapy. Using recovery rates (moving from ‘caseness’ to recovery) monitored nationally in the IAPT programme, we stratified patients according to the absence and presence of PE. Multi-group growth models estimated improvement trajectories for each group. Results 2,042 patients with CMD completed the CAPE-P15. The mean age was 39.8. The overall prevalence of CMD-P was 29.68% at CAPE-P15 threshold score for ARMS, i.e. 1.47, and 48.09% at threshold score 1.30. The overall recovery rate at threshold of 1.47 was 27.87% and 36.3% at 1.30. Recovery rates for those without PE were 58.92% and 62.43% for thresholds 1.47 and 1.30, respectively. Although patients with or without PE shared similar improvement trajectories, the initial severity of patients with CMD-P impeded their likelihood of recovery during treatment. Discussion At least one in four patients receiving treatment from IAPT services in primary care experience CMD-P. This significant group of people experience a lower recovery rate, with adverse implications not only for them but also for efficiency of services. Although recovery trajectories for this group showed improvement over therapy sessions, remittance of symptoms was insufficient to meet national IAPT standards of recovery. This patient group is not well-served by current interventions in primary care. This work forms part of a nation-wide NIHR research programme (TYPPEX; https://www.nihr.ac.uk/news/innovative-mental-health-study-launchesin-eastern-region) aiming to develop innovative therapies for people with CMD-P in primary care. Preliminary results related to feasibility and effectiveness of new therapeutic approaches will also be presented.

IntroductionSome people, who have common mental health disorders such as depression and anxiety, also have some psychotic experiences. These individuals may experience a treatment gap: their symptoms neither reach the increasingly high threshold for secondary care, nor do they receive full benefit from current interventions offered by the Improving Access to Psychological Therapies (IAPT) programme. The result may be poorer clinical and functional outcomes. A new talking therapy could potentially benefit this group. Informed by principles of coproduction, this study will seek the views of service users and staff to inform the design and development of such a therapy.Methods and analysisSemistructured interviews will be conducted with IAPT service users, therapists and managers based in three different geographical areas in England. Our sample will include (1) approximately 15 service users who will be receiving therapy or will have completed therapy at the time of recruitment, (2) approximately 15 service users who initiated treatment but withdrew, (3) approximately 15 therapists each with at least 4-month experience in a step-3 IAPT setting and (4) three IAPT managers. Data analysis will be based on the constant comparative method.Ethics and disseminationThe study has been approved by the London Harrow Research Ethics Committee (reference: 18/LO/0642), and all National Health Service Trusts have granted permissions to conduct the study. Findings will be published in peer-reviewed academic journals, and presented at academic conferences. We will also produce a ‘digest’ summary of the findings, which will be accessible, visual and freely available.

Purpose Early Intervention Psychosis [EIP] services have gained traction internationally, but are currently undergoing various forms of reconfiguration. In England, such services are now mandated to ensure 50% of accepted referrals commence care within 14 days, but no empirical evidence exists. We sought to estimate waiting times to EIP services in a large, representative epidemiological cohort in England, and investigate possible reasons for any variation. Methods We estimated median waiting time from referral to acceptance by EIP services and investigated whether this varied by clinical, demographic or neighbourhood-level factors, amongst 798 participants, 16–35 years old, presenting to six EIP services over 3.5 years in a defined catchment area serving 2.5 million people. We used parametric survival analysis to inspect variation in waiting times (in days). Results Median waiting time was 15 days (interquartile range 7–30), although this varied across services (p

Drawing on the lived experience of four members of Emergence, a service user-led organisation, this article debates the utility of the term ‘borderline personality disorder’, considers how therapeutic approaches might best address the difficulties associated with the diagnosis and specifically discusses the role art therapy might play in therapeutic processes. We critically engage with the complexities of being given a diagnosis of borderline personality disorder. We begin to demonstrate the transcendent possibilities of art therapy for people who struggle with a sense of identity, connection with others and the expression of often intense and polarised emotions, while remaining mindful of the complexities that art therapy may present.