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Background: People with severe mental illness (e.g. psychosis, bipolar disorder) experience poor oral health compared to the general population as shown by more decayed, missing and filled teeth and a higher prevalence of periodontal disease. Attending dental services allows treatment of oral health problems and support for prevention. However, people with severe mental illness face multiple barriers to attending routine dental appointments and often struggle to access care. Link work interventions use non-clinical support staff to afford vulnerable populations the capacity, opportunity, and motivation to navigate use of services. The authors have co-developed with service users a link work intervention for supporting people with severe mental illness to access routine dental appointments. The Mouth Matters in Mental Health Study aims to explore the feasibility and acceptability of this intervention within the context of a feasibility randomised controlled trial (RCT) measuring outcomes related to the recruitment of participants, completion of assessments, and adherence to the intervention. The trial will closely monitor the safety of the intervention and trial procedures. Methods: A feasibility RCT with 1:1 allocation to two arms: treatment as usual (control) or treatment as usual plus a link work intervention (treatment). The intervention consists of six sessions with a link worker over 9 months. Participants will be adults with severe mental illness receiving clinical input from secondary care mental health service and who have not attended a planned dental appointment in the past 3 years. Assessments will take place at baseline and after 9 months. The target recruitment total is 84 participants from across three NHS Trusts. A subset of participants and key stakeholders will complete qualitative interviews to explore the acceptability of the intervention and trial procedures. Discussion: The link work intervention aims to improve dental access and reduce oral hea

Background: Research into bipolar disorder (BD) has primarily focused upon clinical recovery (CR), i.e. symptom reduction, and overlooked personally meaningful recovery outcomes emphasized by service users. Personal recovery (PR) has been a major focus in the formulation of mental health policies and guidelines, and yet, research into factors influencing PR in BD is in its infancy. Methods: This study compared psychological associates of concurrent PR and CR, and determined psychological factors in PR prospectively at 6 months. Results: 107 participants completed baseline assessments, of whom 84% completed follow-up at 6 months. Controlling for potential confounders, multiple linear and ordinal regression models showed that some psychological factors underpinned both CR and PR at baseline: worse PR and CR outcomes were associated with higher negative self-dispositional appraisals and dysfunctional attitudes. Better PR, but worse CR ([hypo]mania related) were associated with higher adaptive coping. Additionally, better PR (but not CR) was associated with higher concurrent risk taking at baseline and predicted at follow-up by higher levels of baseline rumination. Better CR ([hypo]mania related), but not PR, was associated with lower impulsivity, but higher BAS processes. Limitations: Psychological and clinical factors were not measured at follow up and may have changed over time. Participants were a convenience sample. Conclusions: Understanding psychological factors driving recovery in BD is essential for refining the conceptual framework of PR, and informing psychological models and related interventions for BD. The identified differences in psychological factors highlight the importance of more individualised, PR focused therapeutic approaches.

BACKGROUND: Carers of people with psychosis are at a greater risk of physical and mental health problems compared to the general population. Yet, not all carers will experience a decline in health. This predicament has provided the rationale for research studies exploring what factors predict poor wellbeing in carers of people with psychosis. Our study builds on previous research by testing the predictive value of demographic variables on carer wellbeing within a single regression model. METHODS: To achieve this aim, we conducted secondary analysis on two trial data sets that were merged and recoded for the purposes of this study. RESULTS: Contrary to our hypotheses, only carer gender and age predicted carer wellbeing; with lower levels of carer wellbeing being associated with being female or younger (aged under 50). However, the final regression model explained only 11% of the total variance. CONCLUSIONS: Suggestions for future research are discussed in light of the limitations inherent in secondary analysis studies. Further research is needed where sample sizes are sufficient to explore the interactive and additive impact of other predictor variables.

Background: A reduced availability of resources has hampered the implementation of family work in psychosis. Web-based support programs have the potential to increase access to high-quality, standardized resources. This pilot study tested the Norwegian version of the Relatives Education and Coping Toolkit (REACT), a web-based United Kingdom National Health Service program in combination with phone-based support by trained family therapists. Objective: We investigated how the program was perceived by its users and identified the facilitators and barriers to its clinical implementation. Methods: Relatives of people with psychosis were offered access to REACT and to weekly family therapist support (with 1 of 2 trained family therapists) for 26 weeks. Level of distress and level of expressed emotion data were collected at baseline and after 26 weeks using the Family Questionnaire and the Relatives Stress Scale. Both family therapists and a subset of the relatives were interviewed about their experiences after completing the program. Results: During the program, relatives (n=19) had a median of 8 (range 4-11) consultations with the family therapists. Postintervention, there was a significant reduction in stress and in expressed emotions in the relatives of people with psychosis. Interviews with the relatives (n=7) and the family therapists (n=2) indicated the following themes as important-the intervention turned knowledge into action; the intervention strengthened the feeling of being involved and taken seriously by the health services; and management support and the ability for self-referral were important, while lack of reimbursement and clinician resistance to technology were barriers to implementation. Conclusions: The service was found to offer a valued clinical benefit; however, strategies that aim to engage clinicians and increase organizational support toward new technology need to be developed. © Kristin Lie Romm, Liv Nilsen, Kristine Gjermundsen, Marit Holter

BACKGROUND: Relatives caring for people with severe mental health problems find information and emotional support hard to access. Online support for self-management offers a potential solution. OBJECTIVE: The objective was to determine the clinical effectiveness and cost-effectiveness of an online supported self-management tool for relatives: the Relatives' Education And Coping Toolkit (REACT). DESIGN AND SETTING: This was a primarily online (UK), single-blind, randomised controlled trial, comparing REACT plus a resource directory and treatment as usual with the resource directory and treatment as usual only, by measuring user distress and other well-being measures at baseline and at 12 and 24 weeks. PARTICIPANTS: A total of 800 relatives of people with severe mental health problems across the UK took part; relatives who were aged ≥ 16 years, were experiencing high levels of distress, had access to the internet and were actively seeking help were recruited. INTERVENTION: REACT comprised 12 psychoeducation modules, peer support through a group forum, confidential messaging and a comprehensive resource directory of national support. Trained relatives moderated the forum and responded to messages. MAIN OUTCOME MEASURE: The main outcome was the level of participants' distress, as measured by the General Health Questionnaire-28 items. RESULTS: Various online and offline strategies, including social media, directed potential participants to the website. Participants were randomised to one of two arms: REACT plus the resource directory (n = 399) or the resource directory only (n = 401). Retention at 24 weeks was 75% (REACT arm, n = 292; resource directory-only arm, n = 307). The mean scores for the General Health Questionnaire-28 items reduced substantially across both arms over 24 weeks, from 40.2 (standard deviation 14.3) to 30.5 (standard deviation 15.6), with no significant difference between arms (mean difference -1.39, 95% confidence interval -3.60 to 0.83; p = 0.22)

Background: A reduced availability of resources has hampered the implementation of family work in psychosis. Web-based support programs have the potential to increase access to high-quality, standardized resources. This pilot study tested the Norwegian version of the Relatives Education and Coping Toolkit (REACT), a web-based United Kingdom National Health Service program in combination with phone-based support by trained family therapists. Objective: We investigated how the program was perceived by its users and identified the facilitators and barriers to its clinical implementation. Methods: Relatives of people with psychosis were offered access to REACT and to weekly family therapist support (with 1 of 2 trained family therapists) for 26 weeks. Level of distress and level of expressed emotion data were collected at baseline and after 26 weeks using the Family Questionnaire and the Relatives Stress Scale. Both family therapists and a subset of the relatives were interviewed about their experiences after completing the program. Results: During the program, relatives (n=19) had a median of 8 (range 4-11) consultations with the family therapists. Postintervention, there was a significant reduction in stress and in expressed emotions in the relatives of people with psychosis. Interviews with the relatives (n=7) and the family therapists (n=2) indicated the following themes as important-the intervention turned knowledge into action; the intervention strengthened the feeling of being involved and taken seriously by the health services; and management support and the ability for self-referral were important, while lack of reimbursement and clinician resistance to technology were barriers to implementation. Conclusions: The service was found to offer a valued clinical benefit; however, strategies that aim to engage clinicians and increase organizational support toward new technology need to be developed. © Kristin Lie Romm, Liv Nilsen, Kristine Gjermundsen, Marit Holter

BACKGROUND: Relatives caring for people with severe mental health problems find information and emotional support hard to access. Online support for self-management offers a potential solution. OBJECTIVE: The objective was to determine the clinical effectiveness and cost-effectiveness of an online supported self-management tool for relatives: the Relatives' Education And Coping Toolkit (REACT). DESIGN AND SETTING: This was a primarily online (UK), single-blind, randomised controlled trial, comparing REACT plus a resource directory and treatment as usual with the resource directory and treatment as usual only, by measuring user distress and other well-being measures at baseline and at 12 and 24 weeks. PARTICIPANTS: A total of 800 relatives of people with severe mental health problems across the UK took part; relatives who were aged ≥ 16 years, were experiencing high levels of distress, had access to the internet and were actively seeking help were recruited. INTERVENTION: REACT comprised 12 psychoeducation modules, peer support through a group forum, confidential messaging and a comprehensive resource directory of national support. Trained relatives moderated the forum and responded to messages. MAIN OUTCOME MEASURE: The main outcome was the level of participants' distress, as measured by the General Health Questionnaire-28 items. RESULTS: Various online and offline strategies, including social media, directed potential participants to the website. Participants were randomised to one of two arms: REACT plus the resource directory (n = 399) or the resource directory only (n = 401). Retention at 24 weeks was 75% (REACT arm, n = 292; resource directory-only arm, n = 307). The mean scores for the General Health Questionnaire-28 items reduced substantially across both arms over 24 weeks, from 40.2 (standard deviation 14.3) to 30.5 (standard deviation 15.6), with no significant difference between arms (mean difference -1.39, 95% confidence interval -3.60 to 0.83; p = 0.22)

BACKGROUND: The development of digital health interventions (DHIs) for severe mental health problems is fast-paced. Researchers are beginning to consult service users to inform DHIs; however, much of this involvement has been limited to feedback on specific interventions post-DHI development. This study had two aims: 1. explore service user views towards DHIs for severe mental health problems; and 2. make recommendations for specific content within DHIs based on service user needs and suggestions. METHODS: Qualitative interviews with eighteen people with severe mental health problems focussed on two domains: 1) views about DHIs for severe mental health problems; and 2) ideas for future DHI content and design features. Data were analysed thematically. RESULTS: Participants responses were captured in five key themes: 1) DHIs could be empowering tools that instigate reflection and change; 2) society is already divided; DHIs will further increase this divide; 3) considerations must be made about who has access to DHI data and how this data may be used; 4) DHIs should not be delivered without other support options; and 5) DHIs should provide a positive, fun, practical and interactive method for self-management. CONCLUSIONS: Participants found DHIs acceptable due to the empowering nature of self-management and ability to take ownership of their own healthcare needs. However, concerns included the potential for digital exclusion, privacy and confidentiality and fears about DHIs being used to replace other mental health services. Service users want tools to help them self-manage their mental health, but also provide positive and recovery-focussed content that can be used in conjunction with other support options.

Objective An evidence‐base is emerging indicating detrimental and beneficial effects of social media. Little is known about the impact of social media use on people who experience psychosis. Method Forty‐four participants with and without psychosis completed 1084 assessments of social media use, perceived social rank, mood, self‐esteem and paranoia over a 6‐day period using an experience sampling method (ESM). Results Social media use predicted low mood, but did not predict self‐esteem and paranoia. Posting about feelings and venting on social media predicted low mood and self‐esteem and high paranoia, whilst posting about daily activities predicted increases in positive affect and self‐esteem and viewing social media newsfeeds predicted reductions in negative affect and paranoia. Perceptions of low social rank when using social media predicted low mood and self‐esteem and high paranoia. The impact of social media use did not differ between participants with and without psychosis; although, experiencing psychosis moderated the relationship between venting and negative affect. Social media use frequency was lower in people with psychosis. Conclusion Findings show the potential detrimental impact of social media use for people with and without psychosis. Despite few between‐group differences, overall negative psychological consequences highlight the need to consider use in clinical practice.

Background: People with bipolar disorder (BD) experience parenting challenges associated with mood fluctuations. This talk describes the development and evaluation of a novel web- based self- management approach (Integrated Bipolar Parenting Intervention; IBPI) to support parents with BD developed with individuals with lived experience of bipolar disorder. Methods: IBPI content and structure was developed in collaboration with service users coordinated by a service user grant holder. Parents with BD with children aged 3- 10 years randomised to IBPI plus treatment as usual (TAU) or waitlist control (WL). IBPI offered 16 weeks access to interactive self- management information concerning BD and parenting issues. The trial was designed to access feasibility and acceptability as well as provide initial indications of potential benefits of IBPI. Feasibility was through recruitment, retention and web usage. Clinical outcomes were assessed at baseline, 16, 24, 36 and 48 weeks. A nested qualitative study was conducted focusing on participant experiences of the IBPI intervention. Results: The intervention and trial design were both feasible and acceptable. 97 participants were recruited with 90% retention to final follow- up. 77% of IBPI participants accessed the website. Child behaviour, parenting sense of competence and parenting stress improved significantly in IBPI compared to WL to end of intervention, sustained to 48 weeks. Qualitative feedback indicated participants’ valued this approach and made suggestions for further improvements. Conclusions: Developing an online self- management support for parents with BD is feasible, with promising improvements in parenting and child behaviour outcomes. A definitive clinical and cost- effectiveness trial is required.

Background: People with bipolar disorder (BD) experience parenting challenges associated with mood fluctuations. This talk describes the development and evaluation of a novel web- based self- management approach (Integrated Bipolar Parenting Intervention; IBPI) to support parents with BD developed with individuals with lived experience of bipolar disorder. Methods: IBPI content and structure was developed in collaboration with service users coordinated by a service user grant holder. Parents with BD with children aged 3- 10 years randomised to IBPI plus treatment as usual (TAU) or waitlist control (WL). IBPI offered 16 weeks access to interactive self- management information concerning BD and parenting issues. The trial was designed to access feasibility and acceptability as well as provide initial indications of potential benefits of IBPI. Feasibility was through recruitment, retention and web usage. Clinical outcomes were assessed at baseline, 16, 24, 36 and 48 weeks. A nested qualitative study was conducted focusing on participant experiences of the IBPI intervention. Results: The intervention and trial design were both feasible and acceptable. 97 participants were recruited with 90% retention to final follow- up. 77% of IBPI participants accessed the website. Child behaviour, parenting sense of competence and parenting stress improved significantly in IBPI compared to WL to end of intervention, sustained to 48 weeks. Qualitative feedback indicated participants’ valued this approach and made suggestions for further improvements. Conclusions: Developing an online self- management support for parents with BD is feasible, with promising improvements in parenting and child behaviour outcomes. A definitive clinical and cost- effectiveness trial is required.

BACKGROUND: Despite the rapid growth in the sophistication of research on bipolar disorder (BD), the field faces challenges in improving quality of life (QoL) and symptom outcomes, adapting treatments for marginalized communities, and disseminating research insights into real-world practice. Community-based participatory research (CBPR)-research that is conducted as a partnership between researchers and community members-has helped address similar gaps in other health conditions. This paper aims to improve awareness of the potential benefits of CBPR in BD research. METHODS: This paper is a product of the International Society for Bipolar Disorders (ISBD) Taskforce on Community Engagement which includes academic researchers, healthcare providers, people with lived experience of BD, and stakeholders from BD community agencies. Illustrative examples of CBPR in action are provided from two established centres that specialize in community engagement in BD research: the Collaborative RESearch Team to study psychosocial issues in BD (CREST.BD) in Canada, and the Spectrum Centre for Mental Health Research in the United Kingdom. RESULTS AND DISCUSSION: We describe the philosophy of CBPR and then introduce four core research areas the BD community has prioritized for research: new treatment approaches, more comprehensive outcome assessments, tackling stigma, and enhanced understanding of positive outcomes. We then describe ways in which CBPR is ideal for advancing each of these research areas and provide specific examples of ways that CBPR has already been successfully applied in these areas. We end by noting potential challenges and mitigation strategies in the application of CBPR in BD research. CONCLUSIONS: We believe that CBPR approaches have significant potential value for the BD research community. The observations and concerns of people with BD, their family members, and supports clearly represent a rich source of information. CBPR approaches provide a collaborative, e

Background: Relatives of people with bipolar disorder report that services do not meet their own needs, despite clinical recommendations for the development of care plans for relatives, provision of information regarding their statutory entitlements, and formal involvement in decision making meetings. Further, there is now conclusive evidence highlighting the benefits of relatives' involvement in improving outcomes for service users, relatives, and the health system as a whole. This qualitative study explored the views of relatives of people with bipolar disorder, service users and healthcare professionals regarding the barriers and the facilitators to relatives' involvement in care. Methods: Thirty five people were interviewed (12 relatives, 11 service users and 12 healthcare professionals). Audio recordings were transcribed verbatim and common themes in participants' narratives emerged using framework analysis. Results: Participants' accounts confirmed the existence of opportunities for relatives to be involved. These, however, were limited and not always accessible. There were three factors identified that influenced accessibility namely: pre-existing worldviews, the quality of relationships and of communication between those involved, and specific structural impediments. Discussion: These themes are understood as intertwined and dependent on one another. People's thoughts, beliefs, attitudes, cultural identifications and worldviews often underlie the ways by which they communicate and the quality of their relationship. These, however, need to be conceptualised within operational frameworks and policy agendas in health settings that often limit bipolar relatives' accessibility to opportunities for being more formally involved. Conclusions: Involving relatives leads to clear benefits for relatives, service users, healthcare professionals, and the health system as a whole. Successful involvement of relatives, however, depends on a complex network of processes and i

Background Relapse prevention for bipolar disorder increases time to relapse but is not available in routine practice. Aims To determine the feasibility and effectiveness of training community mental health teams (CMHTS) to deliver enhanced relapse prevention. Method in a cluster randomised controlled trial, CMHT workers were allocated to receive 12h training in enhanced relapse prevention to offer to people with bipolar disorder or to continue giving treatment as usual. The primary outcome was time to relapse and the secondary outcome was functioning. Results Twenty-three CMHTs and 96 service users took part. Compared with treatment as usual, enhanced relapse prevention increased median time to the next bipolar episode by 8.5 weeks (hazard ratio 0.79, 95% CI 0.45-1.38). Social and occupational functioning improved with the intervention (regression coefficient 0.68, 95% CI 0.05-1.32). The clustering effect was negligible but imprecise (intracluster correlation coefficient 0.0001, 95% CI 0.0000-0.5142). Conclusions Training care coordinators to offer enhanced relapse prevention for bipolar disorder may be a feasible effective treatment. Large-scale cluster trials are needed.

This study tests whether the same dimensions that have been shown to be relevant to cognitive understanding of physical health problems may also be applied validly to severe mental health problems such as schizophrenia. 22 people with a diagnosis of schizophrenia, and 18 of their relatives, were asked open-ended questions about their understanding of schizophrenia. The responses were recorded and were sorted into common sense dimensions. Construct validity for the use of the dimensions assessed by the most recently updated Illness Perception Questionnaire (IPQ-R) was examined. The results suggest that the dimensions of the IPQ-R are present in people's understanding of schizophrenia. Copyright © 2005 John Wiley & Sons, Ltd.

A number of recent studies have shown that individual cognitive-behaviour therapy can be effective in reducing the severity of psychotic symptoms in chronic treatment resistant schizophrenia. In addition, cognitive-behaviourally oriented family interventions have been shown to significantly reduce relapse in similar populations. However, the application of either individual or family CBT approaches has not been evaluated in people who have a psychotic illness and who also have intellectual disabilities. This paper describes how individual and family CBT for psychosis has been modified for people with a mild learning disability who have a diagnosis of schizophrenia and illustrates its use with five case studies. Copyright (C) 2004 John Wiley Sons, Ltd.

Background and objectives. Illness representations in physical health problems have been studied extensively using the Self-regulation Model (SRM) focusing on five dimensions of illness beliefs (identity, consequences, causes, timeline and control, or cure). Associations have been found between beliefs about illness and a range of health outcomes. This study aimed to examine models of depression, to assess whether the five dimensions of the SRM are relevant, to compare depression models with those for physical illness, and to examine the psychometric properties of the Illness Perception Questionnaire (IPQ) when used with depression. Design and method. A sample of 101 women either currently depressed or with a history of depression was asked to write about their experiences of physical sickness and depression. Their responses were analysed in terms of the dimensions of beliefs expressed and the two experiences were compared. The IPQ was also administered to assess the women's perceptions of depression. Results. The women used the same five dimensions of illness as identified in the SRM in describing both their experience of depression and physical sickness. There was evidence of some consistency across the models of the two illnesses in terms of their content and structure. The IPQ was a reliable measure for depressed experiences and discriminated between women who were currently depressed or not. Comparing the women's descriptions of their depression with their IPQ scores showed some relationships between their responses on the two different measures, at least for the consequences and cause dimensions. Conclusion. The SRM model and associated methodology may provide an appropriate framework to further explore illness 'representations in depression. Problems inherent in the study of illness models in depression including the influence of mood on the model are described. Applications of this research area to the understanding of treatment preferences and adherence to

A number of recent studies have shown that individual cognitive-behaviour therapy can be effective in reducing the severity of psychotic symptoms in chronic treatment resistant schizophrenia. In addition, cognitive-behaviourally oriented family interventions have been shown to significantly reduce relapse in similar populations. However, the application of either individual or family CBT approaches has not been evaluated in people who have a psychotic illness and who also have intellectual disabilities. This paper describes how individual and family CBT for psychosis has been modified for people with a mild learning disability who have a diagnosis of schizophrenia and illustrates its use with five case studies. Copyright (C) 2004 John Wiley Sons, Ltd.

The mechanisms contributing to the occurrence of auditory hallucinations have not been fully described, although many researchers agree that they may result from some type of misattributed cognitive event. A number of authors have shown that this misattribution may be influenced by 'top down' processes such as beliefs and expectations. This type of cognitive bias has also been implicated in other psychological disorders. One area of focus, particularly within the anxiety disorders, has been on metacognitive beliefs and their role in the occurrence and maintenance of symptoms. Metacognitive beliefs have not been widely investigated in psychosis and tools to investigate them have not been developed. In this study, a metacognitions questionnaire [MCQ; Cartwright-Hatton, S., & Wells, A. (1997). Journal of Anxiety Disorders, 11(3),279-296.] (previously used with anxiety disorders) was modified and used to assess metacognitive beliefs with schizophrenic patients. Metacognitive beliefs were compared between schizophrenic patients who were currently experiencing auditory hallucinations and schizophrenic patients who had never had hallucinations. A group of patients with anxiety disorders and a group of non-patients were used as controls. Hallucinating and non-hallucinating schizophrenics scored significantly higher than both the nonpatient group and the anxiety patient group on the amount. to which they believed their thoughts should be consistent with each other. Hallucinators and anxiety controls had significantly lower confidence in their cognitive processes than non-hallucinating schizophrenics and normal controls. The significance of these findings are discussed in relation to the literature on cognitive processes in hallucinations. (C) 2002 Elsevier Science Ltd. All rights reserved.

Background. Although carers' reactions to schizophrenic illness in a close family member may have important implications for the patient and for themselves, little is known of factors that influence the way carers. respond. In the area of physical health problems, people's models of their illness or illness representations have been found to be related to the ways they react and cope with their illness. This study examines the use of a modified form of the Illness Perception Questionnaire (IPQ) to investigate illness models in a sample of carets of schizophrenia patients. Methods. Forty-seven carets participated. The psychometric properties of the modified IPQ were examined, and a number of carer and patient outcomes were investigated in relation to carer scores on the illness identity, consequences, control-cure and timeline subscales of the modified IPQ. These outcomes included measures of carer distress and burden, expressed emotion dimensions, and patient functioning. Results. The modified IPQ was found to be a reliable measure of carers' perceptions of schizophrenia. Carer functioning, the patient-carer relationship and patient illness characteristics were associated with different dimensions of illness perceptions. Conclusions. The findings support the proposal that carer cognitive representations of the illness may have important implications for both carer and patient outcomes in schizophrenia.