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Background The availability of multidisciplinary care for the management of chronic pain is uncommon outside specialist clinics. The present study aims to determine the physical intervention use of patients participating in an online psychological pain management program and whether exposure to physical interventions in these patients alters treatment outcomes compared with patients who do not access physical interventions. Methods Data were obtained from 2 previously published randomized controlled trials of an online psychological pain management program. Physical intervention exposure (categories: none, 1–3 sessions, 4+ sessions) was assessed at baseline, after treatment, and at 3-month follow-up. Primary outcomes included depression, anxiety, pain intensity, and pain-related disability. Generalized estimating equation models were used to compare treatment outcomes among those with different physical intervention frequencies and periods of exposure. We assessed whether changes in primary outcomes differed (moderated) by the period and category of physical intervention exposure. Results Of the patients (n  = 1074) who completed the baseline questionnaire across both randomized controlled trials, 470 (44%) reported physical intervention use at baseline, 383 (38%) reported physical intervention use after treatment, and 363 (42%) reported physical intervention use at 3-month follow-up. On average, there were moderate–large reductions from baseline to after treatment with respect to all outcomes (Cohen's d  = 0.36–0.82). For all outcomes, the interaction of time by physical intervention exposure was statistically nonsignificant. Conclusion A substantial proportion of patients who participated in a psychologically informed pain management program were establishing, continuing, or stopping additional physical interventions. The frequency of and period of exposure to physical interventions did not appear to moderate treatment outcomes. Clinical trial registration Australian and New Zealand Clinical Trials Registry (ACTRN12613000252718 and ACTRN12615001003561). The website for registration information is https://www.anzctr.org.au [ABSTRACT FROM AUTHOR]

BackgroundMethodsResultsDiscussionA service evaluation of the feasibility and acceptability of a six-session compassion focused therapy (CFT) group for outpatients with psychosis was conducted.Fourteen groups were run across two services, with different facilitators following the same protocol. One hundred and nine clients were recruited, of whom 80 completed groups, and 71–76 completed measures of key social processes targeted by CFT.Overall attendance and satisfaction ratings were good. A thematic analysis of feedback suggested a range of therapeutic benefits. A mixed-effects model with maximum likelihood estimation, incorporating random effects at two hierarchical levels, showed significant improvements in pre-post measures of social safeness (p < .001, effect size .53) and self-compassion (p = .002, effect size .50), but changes in perceived social rank were only at trend level (p = .087, effect size .21).These findings indicate that CFT groups are feasible and acceptable for outpatients with psychosis, and that it is possible to effectively target, in six-weeks, some of the key processes central to CFT. The next step will be to replicate these findings using a more robust methodology, and further research is needed to determine the impact of CFT groups on other outcomes (e.g. distress, well-being, symptoms, and valued goals) and whether impact is maintained over time. [ABSTRACT FROM AUTHOR]

Purpose: There are discrepancies in mental health treatment outcomes between ethnic groups, which may differ between genders. NHS Talking Therapies for anxiety and depression provide evidence-based psychological therapies for common mental disorders. This study examines the intersection between ethnicity and gender as factors associated with psychological treatment outcomes. Aims were to explore by gender: (1) differences in psychological treatment outcomes for minoritized ethnic people compared to White-British people, (2) whether differences are observed when controlling for clinical and socio-demographic factors associated with outcomes, and (3) whether organization-level factors moderate differences in outcomes between ethnic groups. Methods: Patient data from eight NHS Talking Therapies for anxiety and depression services (n = 98,063) was used to explore associations between ethnicity and outcomes, using logistic regression. Stratified subsamples were used to separately explore factors associated with outcomes for males and females. Results: In adjusted analyses, Asian (OR = 0.82 [95% CI 0.78; 0.87], p <.001, 'Other' (OR = 0.79 [95%CI 0.72–0.87], p <.001) and White-other (0.93 [95%CI 0.89–0.97], p <.001) ethnic groups were less likely to reliably recover than White-British people. Asian (OR = 1.48 [95% CI 1.35–1.62], p <.001), Mixed (OR = 1.18 [95% CI 1.05–1.34], p =.008), 'Other' (OR = 1.60 [95% CI 1.38–1.84], p <.001) and White-other (OR = 1.18 [95% CI 1.09–1.28], p <.001) groups were more likely to experience a reliable deterioration in symptoms. Poorer outcomes for these groups were consistent across genders. There was some evidence of interactions between ethnic groups and organization-level factors impacting outcomes, but findings were limited. Conclusions: Across genders, Asian, 'Other' and White-other groups experienced worse treatment outcomes across several measures in adjusted models. Reducing waiting times or offering more treatment sessions might lead to increased engagement and reduced drop-out for some patient groups. [ABSTRACT FROM AUTHOR]

Introduction: Although there have been qualitative meta-syntheses on experiences of eating disorders treatments, there is a paucity of syntheses specifically examining the perspectives and experiences of eating disorders treatments (ED) in East Asia (EA). Such synthesis could facilitate a better understanding of culture-specific perspectives and experiences. This review complements a quantitative scoping review published on ED treatments in EA (Yim & Schmidt, 2023), where most interventions reviewed focused on cognitive behavioural therapy (CBT) and internet interventions. The present meta-synthesis summarises stakeholders' views on treatments and to synthesise clinical and research recommendations. Method: A systematic search of five databases and a citation search were conducted to identify relevant studies and data were analysed using thematic synthesis. Out of the 301 studies found, a total of 12 papers were included in the analysis. Results: A diverse range of treatments, such as family therapy, paediatric/psychiatric inpatient care, CBT, and counselling, were discussed. Three overarching themes were identified: Delineating Physical and Psychological Recovery; 'I am not alone in this battle'; and Barriers to Change. The themes further delve into the various obstacles to recovery, including financial concerns and limited access to professionals and services. Culture-specific factors include family obligations and promoting family harmony. Balancing interdependence and independence from one's family, as well as understanding family body ideals versus broader societal body ideals, are important considerations in ED interventions. Discussion: Some themes paralleled other qualitative syntheses, highlighting improved family relationships, perceived authoritarianism in treatments, and financial barriers. The review extends beyond the previous findings, revealing nuanced factors like family roles, cultural values, and norms. Clinical recommendations include incorporating family context in treatment and considering cultural influences on body image ideals. Capacity building through telemedicine and increased training is essential for advancing ED treatment in East Asia. Continued research is needed to better understand and treat people affected by ED in EA. Plain English Summary: Research on eating disorders (EDs) treatment mainly focuses on Western countries, with little exploration of experiences in East Asia. To fill this gap, we reviewed 12 studies on the perspectives of individuals, families and clinicians regarding EDs treatments in East Asia. Our synthesis identified three main themes: Physical and Psychological Recovery: Effective treatment needs to address both physical and mental aspects of recovery. Finding Support – 'I am not alone in this battle': Many individuals find strength in knowing they are not alone. Barriers to Change: Obstacles like financial difficulties, limited EDs knowledge from professionals, and cultural factors can hinder recovery. Cultural-specific factors such as family obligations and maintaining family harmony can impact on treatment motivation and effectiveness. Balancing family's wishes/ interdependence and personal aspirations/ independence can also be a challenge. Our findings highlight the need for culturally sensitive treatments. Expanding telemedicine and increasing provider training can also help overcome treatment barriers. In conclusion, understanding cultural and contextual factors is essential for developing effective support systems and improving ED treatment outcomes in East Asia. [ABSTRACT FROM AUTHOR]

BackgroundGeriatric depression is a common psychiatric problem among older adults. Animal-assisted interventions （AAI） can aid in the treatment of psychiatric disorders， but their effectiveness in geriatric depression remains controversial.ObjectiveTo provide an overview of the current research on AAI in alleviating geriatric depression， in order to provide references for developing AAI programs for this population.MethodsBased on Arksey's scoping review method， a comprehensive literature search was conducted on April 16， 2023. The databases searched included China Knowledge Network， VIP， Wanfang Medical Network， China Biomedical Literature Database， Web of Science， PubMed， CINAHL， Cochrane Library and Embase. The search aimed to collect studies related to AAI and geriatric depression from the inception of each database until April 15， 2023. Two trained researchers independently screened the literature and extracted data on basic information.ResultsA total of 13 studies were included in the final review. AAI settings included nursing homes， hospitals， communities， day care centers and residences. Interventions involved touching and naming the animals， verbally interacting with the animals， playing games with the animals， communicating with the therapists and learning to care for the animals. AAI was found to improve social interaction and communication abilities， bring positive emotional experiences and enhance life satisfaction in geriatric depression. However， its effect on cognitive function improvement was inconclusive.ConclusionAAI can potentially alleviate negative mood and depressive symptoms in geriatric depression. ［Funded by National Natural Science Foundation of China （number， 82001444）］

Abstract Introduction Although there have been qualitative meta-syntheses on experiences of eating disorders treatments, there is a paucity of syntheses specifically examining the perspectives and experiences of eating disorders treatments (ED) in East Asia (EA). Such synthesis could facilitate a better understanding of culture-specific perspectives and experiences. This review complements a quantitative scoping review published on ED treatments in EA (Yim & Schmidt, 2023), where most interventions reviewed focused on cognitive behavioural therapy (CBT) and internet interventions. The present meta-synthesis summarises stakeholders’ views on treatments and to synthesise clinical and research recommendations. Method A systematic search of five databases and a citation search were conducted to identify relevant studies and data were analysed using thematic synthesis. Out of the 301 studies found, a total of 12 papers were included in the analysis. Results A diverse range of treatments, such as family therapy, paediatric/psychiatric inpatient care, CBT, and counselling, were discussed. Three overarching themes were identified: Delineating Physical and Psychological Recovery; ‘I am not alone in this battle’; and Barriers to Change. The themes further delve into the various obstacles to recovery, including financial concerns and limited access to professionals and services. Culture-specific factors include family obligations and promoting family harmony. Balancing interdependence and independence from one’s family, as well as understanding family body ideals versus broader societal body ideals, are important considerations in ED interventions. Discussion Some themes paralleled other qualitative syntheses, highlighting improved family relationships, perceived authoritarianism in treatments, and financial barriers. The review extends beyond the previous findings, revealing nuanced factors like family roles, cultural values, and norms. Clinical recommendations include incorporating family context in treatment and considering cultural influences on body image ideals. Capacity building through telemedicine and increased training is essential for advancing ED treatment in East Asia. Continued research is needed to better understand and treat people affected by ED in EA.

Sleep disturbance may impact response to psychological treatment for depression. Understanding how sleep disturbance changes during the course of psychological treatment, and identifying the risk factors for sleep disturbance response may inform clinical decision-making. This analysis included 18,915 patients receiving high-intensity psychological therapy for depression from one of eight London-based Improving Access to Psychological Therapies (IAPT) services between 2011 and 2020. Distinct trajectories of change in sleep disturbance were identified using growth mixture modelling. The study also investigated associations between identified trajectory classes, pre-treatment patient characteristics, and eventual treatment outcomes from combined PHQ-9 and GAD-7 metrics used by the services. Six distinct trajectories of sleep disturbance were identified: two demonstrated improvement, while one showed initial deterioration and the other three groups displayed only limited change in sleep disturbance, each with varying baseline sleep disturbance. Associations with trajectory class membership were found based on: gender, ethnicity, employment status, psychotropic medication use, long-term health condition status, severity of depressive symptoms, and functional impairment. Groups that showed improvement in sleep had the best eventual outcomes from depression treatment, followed by groups that consistently slept well. Single item on sleep disturbance used, no data on treatment adherence. These findings reveal heterogeneity in the course of sleep disturbance during psychological treatment for depression. Closer monitoring of changes in sleep disturbance during treatment might inform treatment planning. This includes decisions about when to incorporate sleep management interventions, and whether to change or augment therapy with interventions to reduce sleep disturbance. • Six distinct sleep disturbance trajectories found in initial 12 treatment sessions • Improving sleep disturbance trajectories related to better endpoint outcomes • Unimproved or worsening sleep disturbance associated with worse outcomes • Unemployment, worse social function, & Asian identity linked to sleep deterioration • Being female, unemployed, medicated, or long-term conditions risks non-improvement [ABSTRACT FROM AUTHOR]

Incarceration is a popular method of dealing with violent offenders. However, incarceration does not rehabilitate many violent offenders and often increases recidivism, which suggests a need for different interventions. Because public opinion has an important influence on the criminal justice system, we compared attitudes toward two alternative interventions and incarceration. These alternative interventions were brain-based treatments (i.e. neuronormalization) and psychological therapies. In two experiments, participants were randomly assigned to one of these three interventions and answered questions about their use with violent offenders in general and two severely violent cases: a domestic violence homicide offender and a child sex offender. For violent offenders in general, participants were more positive toward neuronormalization and psychological therapies than incarceration. However, when evaluating the two severely violent cases, participants were most positive toward incarceration. These findings highlight that people were generally amenable to alternative treatments for violent offenders, but these attitudes flipped in favor of incarceration when confronted with serious individual cases of violence. Our findings suggest that disseminating evidence for the effectiveness of alternative treatments may eventually lead to positive attitudes and policy change. Doing so could simultaneously lead to lower rates of incarceration and recidivism and create safer communities. [ABSTRACT FROM AUTHOR]

Background: Gold-standard approaches for chronic tinnitus involve hearing amplification measures and psychological therapy, where applicable. Whilst schema therapy is accumulating evidence as a transdiagnostically useful treatment framework, its applicability for patients with chronic tinnitus has not yet been examined. The present study (a) explores latent dimensions of psychological distress in a sample of chronic tinnitus patients, and (b) examines whether the schema mode model might explain these dimensions - thus constituting a potentially helpful conceptualization and treatment framework. Methods: N = 696 patients with chronic tinnitus completed the Tinnitus Questionnaire, Tinnitus Handicap Inventory, Hospital Anxiety and Depression Scale, Perceived Stress Questionnaire and ICD-10 Symptom Rating. As criterion, patients further completed the Schema Mode Inventory (SMI-r) - which assesses psychological constructs linked to negative self-beliefs ("parent modes"), primary emotions resulting from unmet psychological needs ("child modes"), and secondary emotional or behavioral attempts to reinstate or maintain psychological equilibrium ("coping modes"). A varimax-rotated principal axis factor analysis grouped the primary item pool. Factor scale scores were then correlated with the SMI-r. Results: A three-factor solution explained 37.4% of variance and represented 78% of the included items. Following item content examination, the factors represented (1) General emotional distress, (2) Tinnitus-attributed emotional distress, and (3) Socio-audiological impairment. Factors 1|2 correlated highly (r = 0.70), Factors 2|3 moderately (r = 0.62). Linked to the schema mode model, Factor 1 correlated highly with the "vulnerable child" (r = 0.78), and moderately with the "parent", "angry child", and "detached protector" modes (0.53 < r < 0.65). Factor 2 correlated moderately with the "vulnerable child" (r = 0.53). Factor 3 was largely uncorrelated with SMI-r scores - although a low correlation with the "detached protector" warrants further examination. Conclusion: "General" and "tinnitus-attributed" emotional distress correlate highly - warranting holistic (not symptom-specific) psychological case conceptualization and treatment planning. Viewed from a schema mode perspective, the "vulnerable child" explains substantial variance across both dimensions. Consequently, autobiographically anchored, unmet emotional needs and emotional detachment constitute key treatment targets. Socialaudiological impairment should be multimodally conceptualised and treated with hearing aids and psychological support measures, as applicable. [ABSTRACT FROM AUTHOR]

Background Geriatric depression is a common psychiatric problem among older adults. Animal-assisted interventions (AAI) can aid in the treatment of psychiatric disorders, but their effectiveness in geriatric depression remains controversial. Objective To provide an overview of the current research on AAI in alleviating geriatric depression, in order to provide references for developing AAI programs for this population. Methods Based on Arksey's scoping review method, a comprehensive literature search was conducted on April 16, 2023. The databases searched included China Knowledge Network, VIP, Wanfang Medical Network, China Biomedical Literature Database, Web of Science, PubMed, CINAHL, Cochrane Library and Embase. The search aimed to collect studies related to AAI and geriatric depression from the inception of each database until April 15, 2023. Two trained researchers independently screened the literature and extracted data on basic information. Results A total of 13 studies were included in the final review. AAI settings included nursing homes, hospitals, communities, day care centers and residences. Interventions involved touching and naming the animals, verbally interacting with the animals, playing games with the animals, communicating with the therapists and learning to care for the animals. AAI was found to improve social interaction and communication abilities, bring positive emotional experiences and enhance life satisfaction in geriatric depression. However, its effect on cognitive function improvement was inconclusive. Conclusion AAI can potentially alleviate negative mood and depressive symptoms in geriatric depression. [ABSTRACT FROM AUTHOR]

During the COVID-19 pandemic, telehealth delivery of psychological care services expanded to meet the needs of people with cancer. This study examined psychologists' attitudes toward using telehealth during the pandemic peak in a tertiary oncology hospital. Semi-structured interviews were conducted with ten psychologists who used telehealth to deliver psychological services. Thematic analysis was conducted to identify themes in the interview data. Themes identified: (1) increased uptake and attendance of psychology sessions was due to greater accessibility of services; (2) clinicians reported ease of communication and building of rapport when using telehealth; and (3) clinicians perceived differences in the psychotherapeutic process when sessions were delivered via telehealth compared to in-person. Clinicians expressed high satisfaction with delivering telehealth psychological support for oncology patients. Implications for Psychosocial Providers: Oncology services that are considering developing or expanding a telehealth psychology service can facilitate this by ensuring a reliable technological platform and providing training and/or support to staff and patients. Clinicians should also use their clinical judgment to decide if a patient is appropriate for telehealth-delivered psychological care or if a mix of modalities is more ideal. [ABSTRACT FROM AUTHOR]

• Seizure-related measures are commonly used outcomes in psychological intervention trials in patients with FDS. • Our meta-analysis suggests that psychological treatment is associated with improvements in seizure-related outcomes in patients with FDS with a moderate effect size (d = 0.53). • Approximately two in three patients maintain improvement in their seizures at follow-up, while two in five continue to demonstrate seizure freedom. • Analyses revealed that a reduction rather than cessation of FDS frequency is more likely following psychological therapy. • Research is required to identify how best to standardise methods, in particular the examination and reporting of seizure measurements. Psychological interventions are the most recommended treatment for functional/dissociative seizures (FDS); however, there is ongoing uncertainty about their effectiveness on seizure outcomes. This systematic review and meta-analysis synthesises the available data. In February 2023, we completed a systematic search of four electronic databases. We described the range of seizure-related outcomes captured, used meta-analytic methods to analyse data collected during treatment and follow-up; and explored sources of heterogeneity between outcomes. Overall, 44 relevant studies were identified involving 1,300 patients. Most were categorised as being at high (39.5 %) or medium (41.9 %) risk of bias. Seizure frequency was examined in all but one study; seizure intensity, severity or bothersomeness in ten; and seizure duration and cluster in one study each. Meta-analyses could be performed on seizure freedom and seizure reduction. A pooled estimate for seizure freedom at the end of treatment was 40 %, while for follow-up it was 36 %. Pooled rates for ≥50 % improvement in seizure frequency were 66 % and 75 %. None of the included moderator variables for seizure freedom were significant. At the group level, seizure frequency improved during the treatment phase with a moderate pooled effect size (d = 0.53). FDS frequency reduced by a median of 6.5 seizures per month. There was also evidence of improvement of the other (non-frequency) seizure-related measures with psychological therapy, but data were insufficient for meta-analysis. The findings of this study complement a previous meta-analysis describing psychological treatment-associated improvements in non-seizure-related outcomes. Further research on the most appropriate FDS-severity measure is needed. [ABSTRACT FROM AUTHOR]

Background: Depression among young people is a global health problem due to its rising prevalence and negative physical and social outcomes. The prevalence of depression and the treatment gap among young people in Sub-Saharan Africa (SSA) is higher than global estimates. Most psychosocial interventions for adolescent and youth depression were developed in high-income countries and less is known about their effectiveness in SSA. Due to contextual differences, findings from High-Income Countries (HICs) are less applicable to SSA. Yet, no systematic review of psychosocial interventions for depression among young people in SSA has been conducted. Methods: A systematic literature search of four databases (Medline, Web of Science, PsycInfo, and Cochrane library) was conducted. Experimental studies published before May 2024 that evaluated the effect of psychosocial interventions on depressive symptoms among young people (aged 10–24 years) in SSA were included in the systematic review. Effect sizes (Hedge's g (g)) indicating differences between intervention and control groups were calculated using a random effects model. Results: Twenty-two eligible studies were identified for the systematic review, of which eighteen randomized control trials (RCTs) involving 2338 participants were included in the meta-analysis. The findings revealed that psychosocial interventions significantly reduced depressive symptoms (g = −1.55, 95% CI −2.48, −0.63), although heterogeneity was high (I2 = 98.8%). Subgroup analysis revealed that efficacy differed significantly by intervention type, with Cognitive Behavioural Therapy (9 studies) showing the strongest effect (g = −2.84, 95% CI −4.29; −1.38). While Wise Interventions (a form of positive psychology interventions; 2 studies) had a moderate effect (g = −0.46, 95% C.I −0.53, −0.39), Interpersonal Psychotherapy (2 studies; g = −0.08, 95% CI −1.05, 0.88) and Creative Psychological Interventions (3 studies; g = −0.29, 95% CI −1.38, 0.79) showed smaller, non-significant effects. Sensitivity analysis excluding studies at high risk of bias strengthened the effect size. Few studies assessed factors affecting intervention efficacy and showed mixed effects of age, gender, and adherence levels. Conclusion: Psychosocial interventions, particularly CBT, significantly reduced depressive symptoms among young people in SSA. However, it is crucial to acknowledge the high heterogeneity which likely stems from variations in study populations and intervention delivery modalities. This highlights the need for further research to identify the specific intervention components and delivery methods that work best for distinct subpopulations. Future research should also explore how long intervention effects are maintained and factors affecting efficacy. [ABSTRACT FROM AUTHOR]

Background: Service user involvement is imperative in the delivery of mental health services. However, a paucity of research has explored how individuals with a learning disability find waiting for therapy. Therefore, this project aimed to explore how service users accessing a community learning disability team experienced waiting for psychological therapy. Methods: Ten adults on a waiting list for psychological therapy in Yorkshire, UK completed a semistructured interview, which explored their experiences of being on the waiting list. Interviews were transcribed and analysed using thematic analysis. Findings: Five superordinate themes were drawn from the analysis. Participants recalled long waits for therapy, struggled waiting and were unsure when therapy would start. Relief and hopefulness were common when they were put forward for therapy. Difficulties reading and/or remembering letters were prominent. Keeping busy and support from others helped participants cope while waiting. Participants would have valued additional support including having someone on call, regular check‐ins and information on other appropriate services. Conclusions: This project led to a range of recommendations to inform a psychology waiting list standard operating procedure, service developments and improve the waiting list experience for service users. A future project exploring parent and carer experiences of the waiting list is warranted. Accessible summary: This project looked at the experiences of people with a learning disability when on a waiting list for psychological therapy with a community learning disability team.Ten adults on the waiting list for psychological therapy were interviewed and asked about their experiences.Most participants said that they had a long wait for therapy. Most people found waiting hard.Participants were relieved when they found out they were going to get help.This project led to recommendations to help improve the service. [ABSTRACT FROM AUTHOR]

Introduction: Visual hallucinations (VH) are more common than previously thought and are linked to higher levels of distress and disability in people with a psychotic illness. Despite this, scant attention has been given to VHs in the clinical literature, and the few therapy case series of cognitive behavioural therapy (CBT) published to date have not demonstrated reliable change. In other areas of clinical research, problematic mental imagery has been found to be more strongly related to negative affect in psychological disorders than negative linguistic thinking, and imagery focused techniques have commonly been found to improve the outcomes in CBT trials. Given VHs have many similarities with visual mental imagery and many of the distressing beliefs associated with VHs targeted in CBT are maintained by accompanying mental imagery (i.e., imaging a hallucinated figure attacking them), it seems plausible that an imagery‐focused approach to treating VHs may be most effective. Methods: The current study is a multiple baseline case series (N = 11) of a 10‐session imagery‐focused therapy for VH in a transdiagnostic sample. Results: The study had good attendance and feedback, no adverse events and only one [seemly unrelated] drop‐out, suggesting good feasibility, safety and acceptability. The majority of clients reported reduction on both full‐scale measures (administered at 3 baselines, midtherapy, posttherapy and 3‐month follow‐up) and weekly measures of VH severity and distress, ranging from medium to large effect sizes. Conclusions: The case series suggests that an imagery‐focused approach to treating VHs may be beneficial, with a recommendation for more rigorous clinical trials to follow. [ABSTRACT FROM AUTHOR]

Background Cardiac rehabilitation improves health and quality of life and reduces risk of further cardiac events. Twenty-eight per cent of cardiac rehabilitation patients experience clinically significant anxiety and 19% suffer depression. Such patients are at greater risk of death, further cardiac events and poorer quality of life and use more health care, leading to higher NHS costs. The available psychological treatments for cardiac patients have small effects on anxiety and depression and quality of life; therefore, more effective treatments are needed. Research shows that a thinking style dominated by rumination and worry maintains anxiety and depression. A psychological intervention (metacognitive therapy) effectively reduces this style of thinking and alleviates depression and anxiety in mental health settings. The PATHWAY study evaluated two versions of metacognitive therapy applied in cardiac rehabilitation services. Objectives The primary aim was to improve psychological outcomes for cardiac rehabilitation patients. We evaluated two formats of metacognitive therapy: (1) a group-based face-to-face intervention delivered by cardiac rehabilitation staff (group-based metacognitive therapy) and (2) a paper-based, self-directed intervention (home-based metacognitive therapy). Each was compared with usual cardiac rehabilitation alone in separate randomised controlled trials. Design A randomised feasibility trial (work stream 1) and a full-scale randomised controlled trial (work stream 2) evaluated group-metacognitive therapy, while separate feasibility and full-scale trials (work stream 3 and work stream 3+, respectively) evaluated home-based metacognitive therapy. A cost-effectiveness analysis of group-metacognitive therapy was conducted, along with stated preference surveys and qualitative studies examining patient psychological needs and therapists’ perspectives on metacognitive therapy. Setting Seven NHS cardiac rehabilitation services across the north-west of England. Participants Adults aged ≥ 18 years who met cardiac rehabilitation eligibility criteria, scored ≥ 8 on depression or anxiety subscales of the Hospital Anxiety and Depression Scale, and were able to read, understand and complete questionnaires in English. Interventions Work stream 1 and work stream 2 – a 6-week group-metacognitive therapy intervention delivered by cardiac rehabilitation staff plus usual cardiac rehabilitation compared with usual cardiac rehabilitation alone. Group-metacognitive therapy was delivered once per week for 6 weeks, with each session lasting 90 minutes. Work stream 3 and work stream 3+ – home-based metacognitive therapy plus usual cardiac rehabilitation compared with usual cardiac rehabilitation alone. Home-metacognitive therapy was a paper-based manual that included six modules and two supportive telephone calls delivered by cardiac rehabilitation staff. Main outcome measures The Hospital Anxiety and Depression Scale total score at 4-month follow-up was the primary outcome in all trials. A range of secondary outcomes were also evaluated. Results Our qualitative study with 46 patients across three cardiac rehabilitation services suggested that cardiac rehabilitation patients’ psychological needs were not met by current approaches and that metacognitive therapy might offer an improved fit with their psychological symptoms. The internal pilot feasibility study (work stream 1; n = 54) demonstrated that a full-scale randomised controlled trial was feasible and acceptable and confirmed our sample size estimation. A subsequent full-scale, single-blind randomised controlled trial (work stream 2; n = 332) showed that adding group-based metacognitive therapy to cardiac rehabilitation was associated with statistically significant improvements on the Hospital Anxiety and Depression Scale (primary outcome) in anxiety and depression compared with cardiac rehabilitation alone at 4-month (adjusted mean difference −3.24, 95% confidence interval −4.67 to −1.81, p < 0.001; standardised mean difference 0.52) and 12-month follow-up (adjusted mean difference −2.19, 95% confidence interval −3.72 to −0.66, p = 0.005; standardised mean difference 0.33). The cost-effectiveness analysis suggested that group-metacognitive therapy was dominant, that it could be cost saving (net cost −£219, 95% confidence interval −£1446 to £1007) and health increasing (net quality-adjusted life-year 0.015, 95% confidence interval −0.015 to 0.045). However, confidence intervals were wide and overlapped zero, indicating high variability in the data and uncertainty in the estimates. A pilot feasibility trial (work stream 3; n = 108) supported a full-scale trial of home-metacognitive therapy and was extended (work stream 3+; n = 240). In the full trial, the adjusted mean difference on the Hospital and Anxiety and Depression Scale favoured the metacognitive therapy + cardiac rehabilitation arm (adjusted mean difference −2.64, 95% confidence interval −4.49 to −0.78, p = 0.005; standardised mean difference 0.38), with statistically significant greater improvements in anxiety and depression in home-metacognitive therapy plus cardiac rehabilitation than in cardiac rehabilitation alone at 4-month follow-up. A stated preference survey on clinic-delivered psychological therapy (not specific to metacognitive therapy) indicated a preference for including psychological therapy as part of cardiac rehabilitation. Participants favoured individual therapy, delivered by cardiac rehabilitation staff, with information provided prior to therapy and at a lower cost to the NHS. A pilot stated preference study focused on preferences for home- or clinic-based psychological therapy. Preferences were stronger for home-based therapy than for centre-based, but this was not statistically significant and participants highly valued receiving therapy and having reduced waiting times. Limitations Limitations include no control for additional contact as part of metacognitive therapy to estimate non-specific effects. Work stream 3+ did not include 12-month follow-up and therefore the long-term effects of home-based metacognitive therapy are unknown. The health economics analysis was limited by sample size and large amount of missing data in the final follow up. Findings from the qualitative study cannot necessarily be generalised. Conclusions Both group-based and home-based metacognitive therapy were associated with significantly greater reductions in anxiety and depression symptoms at 4 months, compared with cardiac rehabilitation alone. The results in group-based metacognitive therapy appeared to be stable over 12 months. Introducing metacognitive therapy into cardiac rehabilitation has the potential to improve mental health outcomes. Future work Future studies should evaluate the long-term effects of home-metacognitive therapy and the effect of metacognitive therapy against other treatments offered in cardiac rehabilitation. Given the uncertainty in the economic evaluation, further work is needed to determine the cost-effectiveness of metacognitive therapy. Trial registration Work stream 1/work stream 2: NCT02420431 and ISRCTN74643496; work stream 3: NCT03129282; work stream 3+: NCT03999359. The trial is registered with clinicaltrials.gov NCT03999359. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-1211-20011) and is published in full in Programme Grants for Applied Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information. Plain language summary Depression and anxiety are common among cardiac rehabilitation patients. Cardiac patients with anxiety and depression are at greater risk of death, further cardiac events and poorer quality of life and use more health care, leading to higher NHS costs. Current talking-based therapies have small effects on anxiety and depression in patients with cardiovascular disease. It is important that more effective treatments for mental health are added to cardiac rehabilitation. We applied two versions of a recent treatment called metacognitive therapy in cardiac rehabilitation: a group version and a home-based (self-help) paper-based manual. The programme had three work streams conducted across seven NHS trusts. In work stream 1, we ran a pilot trial showing that adding group-metacognitive therapy to cardiac rehabilitation was feasible and acceptable A full-scale trial (work stream 2) followed, and this showed that adding group-metacognitive therapy to cardiac rehabilitation was associated with greater improvement in anxiety and depression than cardiac rehabilitation alone. In work stream 3, we created a home-based version of metacognitive therapy and ran a feasibility trial, which was extended to a full-scale trial and showed that home-metacognitive therapy plus cardiac rehabilitation was associated with improved anxiety and depression outcomes compared with cardiac rehabilitation alone. Interview studies of patients’ needs, treatment preferences and reactions to treatment were included, and our patient and public involvement group advised the research team throughout the trial. The originator of metacognitive therapy, Adrian Wells, was the chief investigator of the study and is the director of the Metacognitive Therapy Institute. He has funding for the study ‘Implementing Group Metacognitive Therapy in Cardiac Rehabilitation Services (PATHWAY-Beacons; NIHR29567)’ as chief investigator. To maintain objectivity along with the trial statistician and research assistants he did not know patient treatment allocation, data were managed by a separate clinical trials unit and a plan for analysis was devised before analysis took place. Project oversight and monitoring were undertaken by an independent Trial Steering Committee. Scientific summary Background Cardiac rehabilitation (CR) aims to improve heart disease patients’ health and quality of life and reduce the risk of further cardiac events: 28% of cardiac patients have clinically significant anxiety and 19% have depression. Such patients are at greater risk of death, further cardiac events and poorer quality of life and use more health care, leading to higher NHS costs. Available psychological treatments for patients with heart disease have small effects on improving anxiety, depression and quality of life. Therefore, more effective treatments for depression and anxiety need to be explored and made available in CR services. Research in mental health contexts shows that a style of thinking dominated by rumination and worry maintains distress. A psychological intervention [metacognitive therapy (MCT)] reduces this style of thinking and alleviates depression and anxiety. The PATHWAY study evaluated two versions of MCT applied in heart disease patients attending CR: (1) a 6-week intervention delivered face to face in a group setting by CR staff (group-based MCT) and (2) a paper-based, six-module, self-directed intervention (home-based MCT). Objectives The primary aim is to improve access to more effective psychological interventions for the range of heart disease patients attending CR services. The specific objectives were to: conduct a pilot randomised controlled trial (RCT) of group-based MCT (Group-MCT) to evaluate the acceptability and feasibility of delivering the intervention to CR patients who have symptoms of anxiety and depression establish evidence of the effectiveness and cost-effectiveness of Group-MCT in CR in a full-scale RCT produce a rigorous, well-specified Group-MCT package develop a home-based metacognitive intervention (Home-MCT) for CR patients with depression and/or anxiety establish the feasibility and acceptability of integrating Home-MCT into the CR pathway in a pilot RCT establish provisional evidence of the effectiveness and cost-effectiveness of Home-MCT develop a protocol and manual for Home-MCT to inform a full-scale RCT conduct a full-scale RCT evaluating the effectiveness of Home-MCT. Methods We conducted a randomised controlled pilot trial and a full-scale RCT comparing usual CR alone against CR plus group-based MCT [work stream (WS) 1 and WS2; n = 332)]. We also conducted a randomised controlled pilot trial and a full-scale RCT of home-based metacognitive therapy (WS3 and WS3+; n = 240). All trials included integrated qualitative (n = 52) and economic evaluations (n = 339; stated preference survey). Participants A total of seven NHS trusts that provided a routine CR service participated in the research, with the number of participants and specific sites varying by trial. Work streams 1 and 2 explored the acceptability and effectiveness of Group-MCT integrated into usual CR in hospital settings, whereas WS3 and WS3+ explored the acceptability and effectiveness of Home-MCT integrated into usual CR in hospital and community settings. Work stream 1 recruited participants from three NHS trusts in north-west England. Participant recruitment for WS2 took place in five NHS trusts across north-west England. WS3 and WS3+ patients were recruited from CR services at five NHS hospital trusts across north-west England. Participating CR patients in all trials had to score ≥ 8 on the anxiety and/or depression subscale of the Hospital Anxiety and Depression Scale (HADS), be aged ≥ 18 years and meet the British Association for Cardiovascular Prevention and Rehabilitation criteria for attending CR. Participants were randomly allocated in a one-to-one ratio to receive either MCT plus usual CR or usual CR only using a randomisation procedure that balanced the trial arms with respect to gender, HADS scores and trial sites. Interventions Group-MCT: a 6-week manualised MCT intervention delivered face to face in a group setting. Therapists were CR staff who were not mental health specialists (e.g. clinical psychologists) but were trained to deliver the intervention. The intervention was developed by Adrian Wells based on the metacognitive model of psychological disorder and uses effective metacognitive therapy methods tested in mental health settings. Home-MCT: a paper-based, self-directed MCT intervention consisting of six modules in a treatment manual following a structure and content like that of the group-based MCT intervention. Adrian Wells provided pre-trial training for staff but was not involved in the ongoing supervision of staff delivering the intervention to maintain blinding and objectivity. Outcome measures The primary outcome was HADS total score at 4 months, with HADS total scores at 12 months as a secondary outcome (WS1 and WS2, i.e. Group-MCT only). Other secondary outcomes were the separate HADS anxiety and depression subscales, traumatic stress symptoms, and psychological mechanisms including metacognitive beliefs and repetitive negative thinking. For both interventions, qualitative interviews were conducted to assess patients’ emotional experiences and needs following cardiac events, and their understanding and experience of MCT. In Group-MCT, practitioners were interviewed to understand their experience of delivering the intervention and their understanding of patients’ responses to it and patients’ emotional needs. Statistical analysis For the pilot studies, statistical analysis was principally descriptive. We assessed the acceptability of adding Group-MCT and Home-MCT to usual CR regarding rates of recruitment into the study, attrition by the primary end point, and numbers of MCT and CR modules/sessions completed. The feasibility of conducting a full RCT was assessed against the completion of follow-up questionnaires, adequate variability in the outcome measures, and re-estimation of the required sample size based on pilot study findings. Therapist adherence to the Group-MCT treatment protocol was also assessed. The full-scale RCTs of Group-MCT and Home-MCT were designed to detect a standardised mean difference (SMD) between trial arms of 0.4 in HADS total score at 4-month follow-up with 90% power, based on effect sizes reported for other psychological interventions for depression. Analysis was conducted following a prespecified plan detailing the analytic models, primary and secondary outcomes, choice of covariates, sensitivity analyses, and all other key aspects of the analysis. The primary analyses used intention-to-treat principles. To reduce bias, data from the trial were managed by a separate clinical trials unit and locked prior to analysis. The chief investigator (AW), trial statisticians and research assistants were kept unaware of patient treatment allocation throughout the programme and the analyses followed a prespecified plan. Cost-effectiveness analysis For Group-MCT only, a within-trial cost-effectiveness analysis with a 12-month time horizon compared the cost-effectiveness of MCT plus usual CR with that of CR alone, from a UK health and social care perspective. Key measures included health status (measured using the EuroQol-5 Dimensions, five-level) and self-reported health and social care use. Total costs and quality-adjusted life-years (QALYs) were calculated for the trial follow-up. Missing values were addressed using multiple imputation. The primary outcome was the incremental cost-effectiveness ratio. Regression analysis was used to estimate net costs and net QALYs, and 10,000 bootstrapped pairs of net costs and QALYs were generated to inform the probability of cost-effectiveness. For the home-based MCT pilot study, a simple between-group comparison of the available economic data (health status and NHS and social care costs), using summary statistics, was performed. Two stated preference studies (using discrete choice experiment designs), one focused on Group-MCT and the other on Home-MCT, were conducted to explore patient preferences for the delivery of psychological therapy in CR. Participants were asked to choose between two hypothetical interventions, described using five attributes. The cost to the NHS was used to estimate willingness to pay for aspects of intervention delivery. Results Group-MCT Fifty-two CR patients were consented to the pilot trial of Group-MCT + CR versus CR alone, of whom 23 were randomly allocated to Group-MCT + CR and 29 to CR. The trial recruited to target, and > 70% of participants completed the 4-month follow-up questionnaire. More than half of the patients in both arms attended at least six CR sessions, and 57% of Group-MCT participants completed an a priori defined minimal dose of the intervention likely to produce the benefit of at least four of the six MCT sessions. The addition of MCT to rehabilitation did not negatively impact on CR attendance, and we observed high therapist adherence to the protocol. The trial concluded that Group-MCT is an acceptable and feasible intervention to deliver in CR services. The Trial Steering Committee and NIHR as funder agreed to support the progression to a full-scale RCT of the Group-MCT intervention. No substantive changes were required to the trial procedures; therefore, the pilot and full RCT samples were pooled for final analysis. A total of 332 patients (including 52 from the pilot trial) consented to the full-scale RCT of Group-MCT + CR versus CR alone, with 163 randomly allocated to Group-MCT + CR and 169 randomly allocated to CR alone; 81% returned data at 4-month follow-up. The adjusted group difference on the primary outcome of HADS total score at 4 months significantly favoured Group-MCT + CR [–3.24, 95% confidence interval (CI) –4.67 to –1.81, p < 0.001; SMD 0.52], as did the difference at the 12-month secondary outcome point (–2.19, 95% CI –3.72 to –0.66, p < 0.01; SMD 0.33). Patients in the Group-MCT + CR arm also had lower mean HADS anxiety and depression subscale scores at 4 months (p < 0.001). Differences in anxiety remained statistically significant at 12 months (p < 0.01), but those in depression did not (p = 0.065). Most of the other secondary outcomes also favoured the MCT intervention. Attendance at CR sessions did not differ between trial arms. Over 60% of Group-MCT + CR participants attended four or more of the six MCT intervention sessions. However, Group-MCT did not appeal to some patients, with 40 (25%) of the 163 patients randomised to receive MCT attending no MCT intervention sessions. Home-MCT One hundred and eight CR patients consented to the pilot trial of Home-MCT, with 54 randomised to Home-MCT + CR and 54 randomised to CR alone. The trial recruited to target, with 96% of CR only and 83% of Home-MCT + CR participants completing 4-month follow-up measures. Forty-four per cent of patients in the MCT arm completed a minimally effective dose of more than four out of six modules. Exit questionnaire ratings were good. However, views about telephone support were mixed and the quality of calls was rated low. Home-MCT appeared to be acceptable and feasible to deliver in CR services. The Trial Steering Committee and NIHR as funder agreed to support the progression to a full-scale RCT of the Home-MCT intervention. We submitted a no-additional-cost variation to contract (VTC) on 29 January 2019 to progress WS3 to a full-scale RCT (WS3+). The VTC was awarded on 12 March 2019. No substantive changes were required to the trial procedures; therefore, the pilot sample was pooled with the sample from the full RCT in final analysis. A total of 240 patients (including 108 from the pilot trial) were consented to the full-scale RCT of Home-MCT, with 118 randomly allocated to Home-MCT + CR and 122 randomly allocated to CR alone; 89% returned 4-month follow-up data. The adjusted group difference on the primary outcome of HADS total score at 4 months significantly favoured the MCT + CR arm (−2.64, 95% CI −4.49 to −0.78, p = 0.005; SMD 0.38). Patients in the MCT + CR arm also reported significantly lower mean HADS anxiety and depression scores (p < 0.05). Most other secondary outcomes also favoured the MCT intervention. Attendance at CR sessions did not differ between the trial arms. Over 70% of participants in the Home-MCT arm completed more than four MCT modules, but the intervention did not appeal to some patients; 21 participants (18%) withdrew or were not contactable at 4 months, compared with only one in the CR-alone arm. An investigation of the impact of differential attrition on the findings using last-observation-carried-forward resulted in no changes in statistical significance for the primary outcome and most of the secondary outcomes. In the primary cost-effectiveness analysis, the Group-MCT intervention was dominant, that is cost saving (net cost −219, 95% CI −£1446 to £1007) and health increasing (net QALY 0.015, 95% CI −0.015 to 0.045). However, the CIs are wide and overlap zero, indicating a high level of variability in the data and uncertainty in the estimates. Stated preference research indicated a preference for the inclusion of psychological therapy as part of a programme of CR. Conclusions There is not currently a standardised approach for psychological interventions in CR, and interventions can vary. There is a preference for the inclusion of psychological therapy in rehabilitation. Group-based MCT and Home-MCT were associated with significantly better anxiety and depression outcomes when added to CR compared with CR alone. The implications for health care are (1) MCT could be provided as part of the menu of approaches used in CR and (2) patients could be given the option to choose between group-based or home-based treatment to increase access. The recommendations for future research are (1) implementation studies that assess barriers to and enablers of roll-out in the NHS, (2) studies of longer-term outcomes of home-based MCT and (3) an evaluation of MCT against alternative therapies. Trial registration Work stream 1/work stream 2: NCT02420431 and ISRCTN74643496; work stream 3: NCT03129282; work stream 3+: NCT03999359. The trial is registered with clinicaltrials.gov NCT03999359. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: RP-PG-1211-20011) and is published in full in Programme Grants for Applied Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information.

This study explored participant-reported facilitators and barriers to learning and implementation from a 2-day training in psychological assessment and intervention skills for cancer staff, involving deliberate practice and supervision. Twenty-six semi-structured interviews were analysed using thematic analysis leading to four meta-themes: perceived practicality of training, impact of training: practice and its effects, implementation transfer processes and supervision engagement. Analysis identified a learning process to implementation: observation and practice of techniques during training facilitated participant learning; personal use and relevance of training content encouraged reflection, which enabled selection of appropriate tools for clinical practice; gains in commitment and confidence to use techniques supported participants to adapt clinical consultations, and supervision further facilitated implementation. Changing practice increased confidence, sense of achievement and engagement with participants' own wellbeing. Interactive training, deliberate practice and continuous learning were facilitators to implementation whilst time constraint and low confidence in using techniques in remote consultations were barriers. [ABSTRACT FROM AUTHOR]

Aphasia, a communication disability commonly caused by stroke, can profoundly affect a person's mood and identity. We explored the experiences of stroke survivors with aphasia and depression who received a modified cognitive behavioral therapy (CBT)-based psychological intervention. The therapy is manualized with a flexible treatment protocol, including 10 individually based therapy sessions (+2 booster sessions) either via telehealth or in person. Six participants with chronic aphasia (60% of the total sample) participated in in-depth interviews that were analyzed using reflexive thematic analysis. Two core themes were derived from the data: the first theme, helpful elements of therapy—doing enjoyable activities, new ways of thinking, problem solving, working with the experienced therapist, and using telehealth; and the second theme, making progress—mood, communication, acceptance of the 'new me', and improving relationships. All participants found the therapy to be helpful in managing mood problems with various elements being beneficial depending on the individual, highlighting the importance of tailoring the intervention. Therefore, delivering modified CBT to individuals with aphasia is likely to be acceptable both in person and through telehealth. Further evaluation of the intervention and its impact on mood would be beneficial. [ABSTRACT FROM AUTHOR]

Background: Almost no research has been published reporting on evaluations of the effectiveness of psychological interventions for people with severe to profound intellectual disabilities and depression. This paper describes the development and initial feasibility testing of an adapted Behavioural Activation therapy (BeatIt2) for this population. Method: Phase 1 of the study examined participant recruitment and willingness to be randomised in the context of a planned Randomised Controlled Trial (RCT). Phase 2 examined the feasibility of delivering the intervention. Results: Twenty adults with a severe or profound intellectual disability and clinically significant depression were recruited to Phase 1 of the study. In Phase 2, there was 100% participant retention for those recruited to the study at 6‐month follow‐up. The BeatIt2 therapy was reported to be acceptable for participants. Conclusion: COVID disruption meant that it was not possible to complete the planned feasibility RCT. The positive findings suggest that additional evaluation of BeatIt2 is warranted. [ABSTRACT FROM AUTHOR]

Background: People with severe to profound intellectual disabilities experience similar or higher levels of depression than those with more mild intellectual disabilities. Yet, there is an absence of evidence about how to adapt existing psychological therapies for this population. Method: A behavioural activation intervention (BeatIt) for people with mild to moderate intellectual disabilities was adapted for people with severe to profound intellectual disabilities and depression. Key considerations include: (i) beginning with a more in‐depth assessment process; (ii) including the person in session activities and developing a relationship with them; (iii) formulation and the use of film to document the link between activity and mood; and (iv) addressing barriers to change at an individual and inter‐personal level and considering how the carer could support the person's engagement in activity. Results: Successfully adapting BeatIt represents a first step towards gathering evidence about the effectiveness of behavioural activation for people with severe to profound intellectual disabilities. [ABSTRACT FROM AUTHOR]

The study explored the extent to which a sample of clinical psychologists in Early Intervention Psychosis (EIP) services routinely investigated trauma with clients. A novel vignette-semi-structured telephone interview approach was used. To avoid limiting conceptualisations of these phenomena, for example, by solely considering trauma as a contributory or aetiological factor in psychosis, the study was designed to allow wider exploration of relationships and other key factors. The majority of the sample reported routine investigation of severe adversity, abuse, or trauma (AAT) with clients, assuming broad definitions. Assessment procedures were collaborative and client-led. An appropriate context was deemed necessary before trauma was explored, including engagement and a psychologically safe environment. The overall findings highlighted explicit investigation of, broadly defined, trauma-related issues within heterogeneous approaches to working with psychosis. While trauma was one key factor, links with psychosis were complex in practice. Participants appeared to operate within a more complex understanding of psychosis than researchers may sometimes be willing to promote. [ABSTRACT FROM AUTHOR]

This paper summarizes the results of the Improving Mood with Psychoanalytic and Cognitive Therapies (IMPACT) study and its implications for psychological treatment of adolescents with moderate to severe unipolar major depression. IMPACT was a pragmatic, superiority, randomized controlled trial conducted in the United Kingdom, which compared the clinical and cost-effectiveness of short-term psychoanalytic therapy (STPP), cognitive−behavioral therapy (CBT), and a brief psychosocial intervention (BPI) in reducing depression symptoms in 465 adolescents with unipolar major depression, aged 11 to 17 years. Although this was a clinically heterogeneous group of adolescents, some symptoms (eg, sleep and concentration difficulties, irritability/anger) were common and disabling. The trial reported no significant difference among the 3 treatments in reducing depression symptoms. One year after treatment, 84% of participants showed improvement in depressive symptoms (<50% of baseline symptoms) and improved psychosocial functioning, achieving this through different symptom reduction trajectories. Although participants attended fewer treatment sessions than planned, the 3 treatments were delivered with fidelity to their respective models. Ending treatment without therapist agreement occurred in 37% of cases. This was not associated with outcomes by treatment group. Adolescents emphasized the importance of the therapeutic relationship in all 3 treatments. Results suggest that although most adolescents respond to time-limited, structured psychological therapy, subgroups of depressed adolescents are likely to need additional treatment or support. These include adolescents who live in complex circumstances and/or who believe that their needs are not met in therapy, some who stop treatment early, and the 16% to 18% of adolescents who do not respond to treatment. Improving Mood and Preventing Relapse With Psychoanalytic Psychotherapy and Cognitive Behaviour Therapy; https://www.isrctn.com ; ISRCTN83033550. [ABSTRACT FROM AUTHOR]

Policies such as The Perinatal Mental Health Care Pathways document (2018) state mothers and birthing people experiencing psychological difficulties should have timely access to evidence-based psychological therapies. However, psychological distress often goes unidentified in racialised minority women and birthing people who have poorer experiences and outcomes within perinatal contexts compared to White women. Whilst limited research has focused on this within the perinatal period, there is greater recognition concerning how culturally sensitive practices can facilitate equity in care outcomes. This service evaluation aimed to explore racialised minority women's experiences of psychological intervention within a Perinatal and a Maternal Mental Health Service to evaluate service provision and inform service development. Semi-structured interviews with eight women who accessed psychological intervention were analysed using thematic analysis. Two superordinate themes were constructed, with findings suggesting participants had mostly positive experiences of psychological intervention. Cornerstones of therapeutic engagement comprised six subthemes: empathy, flexibility, the utility of psychological approaches, acknowledging family and community systems, points of difference and cultural context as a 'spotlight'. This theme encapsulated psychological therapist's relational and interventional approaches alongside participant preferences which influenced intervention experiences. Therapists were generally experienced as empathic and flexible although some participants desired greater flexibility relating to various practical aspects. Psychological approaches were experienced as beneficial although some wanted greater exploration of childhood trauma and found trauma-focused CBT emotionally demanding. Most participants preferred female therapists due to various socio-cultural reasons and felt systemic factors and their cultural context were acknowledged which enhanced the therapeutic relationship and outcomes where relevant with the inverse also apparent. History repeating itself comprised three subthemes (lack of representation, mistrust of the system and disorientation in help-seeking). This reflected mainly Black participants' negative healthcare experiences and structural racism. Therapeutic and organisational implications are discussed. [ABSTRACT FROM AUTHOR]

Dysfunctional mental imagery is integral to the maintenance of many psychological disorders and is typically associated with stronger affective and behavioural responses than verbal cognitions. This finding extends itself to the high prevalence of suicidal mental imagery in disorders such as depression and bipolar disorder. Imagery Rescripting is a therapy approach which has been found to effectively reduce dysfunctional mental images across various mental health conditions. Thus, Imagery Rescripting of suicidal mental imagery may be effective at reducing such cognitions and ultimately associated risk. However, this remains an unexplored area within the treatment literature. This paper puts out an urgent call for clinical research to evaluate the effectiveness of such a treatment intervention, and to assist, we propose and describe a clinical approach to this to stimulate further thought and research. There are also many research questions of clinical relevance that must be explored in this field of work, which we put forward and consider in this commentary piece. What is already known about this topic: Mental imagery is a form of cognition that generates stronger emotional responses compared to verbal-linguistic thinking and is integral to the maintenance of most psychological disorders. Cognitive Behavioural Therapy (CBT) approaches are typically more effective when mental imagery techniques – such as Imagery Rescripting (ImRs) – are incorporated to target intrusive, distressing mental imagery. Mental images of suicide (comprised of both flash-back and/or flash-forward mental images) are more distressing, realistic and promote suicidal behaviours more than verbal thoughts, and are common in disorders such as depression and bipolar disorder. What this topic adds: Urgent clinical research is needed to evaluate the effectiveness of ImRs at reducing intrusive suicidal mental images, and thus related risk, and this paper proposes and describes an approach for researchers to use as a framework. There are several clinical research considerations to be made when examining ImRs of suicidal mental images, including around the delivery and safety of the intervention. More research is needed to clarify the above clinical considerations, and to further understand change mechanisms, to learn the most safe and effective ImRs approach. If ImRs is found to be effective at reducing suicidal images in upcoming clinical trials, it is strongly recommended clinicians receive adequate training and ongoing clinical supervision from an experienced practitioner given the complexities around this approach. [ABSTRACT FROM AUTHOR]

Key summary points: Aim: Review undertaken to identify and explore suitable strategies and interventions for managing or reducing the impact of pain for community-dwelling older people with frailty from the evidence in a broader population. Findings: Thirty-one randomised controlled trials (RCTs) that collectively evaluated 16 pain management programmes and 17 psychological therapies were identified. The common mechanisms of change proposed in the studies were enhancing self-efficacy, using positive psychological skills or refocusing attention to improve responses to pain, and practising physical exercises to improve physiological well-being and reduce restrictions from pain. Message: All the evaluated interventions appeared to show potential benefits to older people that may be transferable to those with frailty. Purpose: Persistent pain is common in older people and people living with frailty. Pain or the impact of pain on everyday life is potentially modifiable. We sought to map research evidence and information from randomised controlled trials (RCTs) of pain management programmes and psychological therapies targeting community-dwelling older people, and explore appropriate strategies and interventions for managing or reducing the negative impact of pain for older people, particularly those with frailty. Method: A mapping review of pain management programmes and psychological therapies for community-dwelling older people living with chronic pain. We searched for systematic reviews of randomised controlled trials and for individual randomised controlled trials and extracted data from eligible studies. Results: Searches resulted in 3419 systematic review records and 746 RCT records from which there were 33 eligible interventions identified in 31 eligible RCTs (48 reports). Broad aims of the interventions were to: improve physical, psychological, or social functioning; adjust the effects or sensation of pain psychologically; enhance self-care with self-management skills or knowledge. Common mechanisms of change proposed were self-efficacy enhanced by self-management tasks and skills, using positive psychological skills or refocusing attention to improve responses to pain, and practising physical exercises to improve physiological well-being and reduce restrictions from pain. Content of interventions included: skills training and activity management, education, and physical exercise. Interventions were delivered in person or remotely to individuals or in groups, typically in 1–2 sessions weekly over 5–12 weeks. Conclusion: All the evaluated interventions appeared to show potential to provide some benefits to older people. None of the included studies assessed frailty. However, some of the included interventions appear appropriate for community-dwelling older people living with both frailty and pain. [ABSTRACT FROM AUTHOR]

This document is an editorial published in the journal Frontiers in Psychiatry that discusses the topic of schizophrenia and the ongoing research efforts to understand and treat the disorder. The editorial emphasizes the diverse nature of schizophrenia and its relationship with other psychiatric disorders. It highlights the importance of identifying factors that can aid in accurate diagnosis and appropriate treatment. The document also mentions several reviews that explore non-pharmacological treatment options, such as virtual reality and cognitive remediation therapy, as well as alternative pharmacological treatments like palmitoylethanolamide (PEA). The editorial concludes by mentioning other reviews that investigate the symptoms and comorbidities of schizophrenia. Overall, the document suggests that a comprehensive and integrated approach to schizophrenia treatment is necessary, and further research is needed in areas that have received less attention. [Extracted from the article]

Background: There have been several reports of inequalities for ethnic minoritised service users across National Health Service mental health services in the United Kingdom. This research aims to explore the perspectives and experiences of young people from ethnic minoritised groups accessing psychological therapy in a National Specialist Child and Adolescent Mental Health Service in England. Method: Semi-structured interviews were conducted to investigate how young people perceived their ethnicity and how it was considered during psychological therapy. Nine young people were interviewed, and a thematic analysis was conducted. Results: Qualitative analysis revealed five themes: (1) adolescence, ethnicity, and identity; (2) ethnicity as a meaningful part of the therapeutic intervention; (3) therapeutic alliance to facilitate dialogue; (4) aversion to ethnicity exploration; and (5) treading lightly: a fine line between sensitive and overly cautious. Conclusions: The study illustrated the complexity of considering ethnicity in therapy due to conflicting views and preferences and the need for further research. [ABSTRACT FROM AUTHOR]

We will focus on cyber-addictions also considering the psychological and theological therapies in case: we will first make a survey of artificial intelligence and the way it impacts modern life; we will then describe nomophobia, Facebook depression included; we will finally refer to the manifold effects of digital media on sleep. [ABSTRACT FROM AUTHOR]

Purpose: The current review aimed to synthesise qualitative literature exploring adult refugees' and asylum seekers' experiences of individual psychological therapy. Methods: A comprehensive systematic search of the following databases led to the identification of eight studies for inclusion in this review: PsycINFO, PsycARTICLES, MEDLINE, EMBASE, CINAHL and Academic Search Ultimate. All selected studies used qualitative methodology to explore refugees' and asylum seekers' experiences of individual psychological therapy. Studies were appraised using an adapted version of the Critical Appraisal Skills Programme (CASP) Tool. The data from these selected studies were then synthesised using a meta‐ethnographic approach. Results: The synthesis of selected studies resulted in the development of five themes; (i) the importance of recognition and validation within therapy, (ii) building a human connection within the therapeutic relationship and the importance of cultural competency, (iii) revisiting trauma, managing difficult emotions from therapy and regaining hope, (iv) the value of practical interventions, (v) 'one should not wake up the djinns (demons)'—cultural stigma and accessing therapy. These themes illustrated the complexities of working therapeutically with asylum seekers and refugees and the vital role of building trust and safety within the therapeutic relationship prior to engagement in therapeutic work. The results also highlighted varied responses to engaging in trauma work ranging from participants finding the experience transformative to others finding it unhelpful, some participants preferred more practical interventions. Participants' cultural backgrounds and pre‐conceptions around therapy impacted on engagement and the therapist's cultural competency was a significant factor in therapeutic engagement. Conclusions: Working therapeutically with asylum seekers and refugees involves a number of factors for consideration. Forced migrants' socio‐political context was seen as central to their experiences of distress and recognition of these factors was imperative for positive therapeutic engagement. This review highlights a number of clinical implications to guide practitioners working therapeutically with this community. [ABSTRACT FROM AUTHOR]

Objective: There has been no review on eating disorder‐focused psychological interventions in East Asia. The aims of this systematic scoping review were to summarize existing and forthcoming studies and to synthesize the cultural adaptations and effectiveness of the interventions identified. Method: Five databases (PubMed, Embase, Global Health, Medline, PsychInfo) and seven trial registries were searched. Studies examining eating disorder (ED)‐focused psychological interventions in East Asia were included. Narrative synthesis was used for the analysis. Results: Eighteen published studies and 14 ongoing/completed but unpublished studies were included. Most published studies were uncontrolled and five were feasibility studies. Among the ongoing studies, 71% are randomized controlled trials. Cognitive therapies were the main approach used, including individual cognitive behavioral therapy (CBT), internet CBT, group CBT, guided self‐help, and cognitive remediation therapy. Cultural adaptations were mostly related to language, communication style and tailoring the dietary requirements to local diets. Interventions were shortened to increase acceptability and reduce financial and time burden to patients. Overall, studies showed good acceptability, completion rates and positive effects on ED symptoms (indicated by moderate to large effect sizes or statistical significance). Discussion: Studies were underpowered and uncontrolled, thus precluding meaningful interpretations of effectiveness to be made. However, the psychological interventions were acceptable and showed promise in delivery. Digital and group interventions seemed to be the most feasible given barriers in the local health systems. More controlled studies, as well as studies on children and adolescents, are needed in future. Public significance: This is the first systematic scoping review examining psychological interventions for eating disorders in East Asia. Research in eating disorders has largely focused on White people and in Western countries. This review will be helpful for clinicians and researchers to understand the current state of the field through a non‐Eurocentric lens, to identify gaps and plan future research. [ABSTRACT FROM AUTHOR]

Background: This study investigated the use of a Compassion‐Focused Therapy (CFT) group as a psychological intervention for a group of adults with an intellectual disability with a range of psychological issues. Method: Four clients attended the group, which was facilitated by three trainee Clinical Psychologists. The group consisted of 8 weekly sessions. Findings: Standardised outcome measures showed an increase in psychological well‐being and self‐compassion for all participants postintervention. Two participants showed an increase in psychological distress, while two participants reported decreases in this area. Scores on measures of self‐criticism fell for two participants, increased for one participant and showed no change for one participant. Qualitative interviews were conducted with postgroup with all group members (clients and facilitators). Thematic analysis identified two superordinate themes relating to the accessibility of the group content, and interpersonal aspects of the group. Conclusion: The results suggest that clients enjoyed and benefitted from the group. Challenges, such as lack of carer involvement, were identified, and recommendations for future CFT groups are made. Accessible Summary: Some people who find it hard to be kind to themselves can be helped by a therapy called Compassion‐Focused Therapy (CFT). Some studies show that CFT might help people with an intellectual disability.We ran a group to see if CFT helped people with intellectual disabilities to feel better and think kinder thoughts about themselves.We asked people what they thought about the group. We asked them to fill in some questionnaires to see if they felt better.The group seemed to help people. People with intellectual disabilities and people running the group enjoyed going to it.CFT might be a useful treatment for people with intellectual disabilities. [ABSTRACT FROM AUTHOR]

Background: Psychogenic nonepileptic seizures (PNES) are attacks that often look like epileptic seizures (ES). Unlike ES, PNES are not triggered by underlying neurological factors. PNES are relatively rare in the general population; however, their prevalence in people with learning disabilities is much higher—up to 10%. Individuals with PNES and learning disabilities often have psychiatric comorbidities, such as anxiety disorders, depression and posttraumatic stress disorder. There are currently no treatment guidelines for PNES in people with or without learning disabilities. However, talking therapies, such as cognitive‐behavioural therapy (CBT), are recommended. This study explores the effectiveness of CBT for the treatment of PNES in a woman (Susan) with PNES and learning disabilities. Methods: We used a single‐case experimental design (SCED) to investigate the effectiveness of CBT intervention. Specifically, the withdrawal (also known as ABA) design was applied. The patient's average PNES frequency, as well as idiosyncratic mood measure and standardised outcome measures for people with learning disabilities (Glasgow Anxiety Scale for People with an Intellectual Disability and Mini‐Maslow Assessment of Needs Scale‐Learning Disabilities), were used to assess the effectiveness of treatment. Findings: Results show that Susan's monthly PNES frequency reduced from phase A1 (assessment phase) to phase B (treatment phase), and this persisted to the follow‐up phase (phase A2). However, the reduction was not statistically significant. The intervention was associated with improvements in Susan's mood, anxiety and quality of life. Reduction of Susan's anxiety was clinically significant. Conclusions: This SCED study demonstrates that CBT might be associated with reduction of PNES frequency and improvements in general functioning in people with PNES and learning disabilities; however, further research, especially around confounding variables is needed. Accessible Summary: People sometimes experience episodes that look like epileptic seizures. Unlike epileptic seizures, these episodes are caused by psychological factors (such as stress). These are called 'psychogenic nonepileptic seizures' or PNES for short.We wanted to see if Cognitive Behaviour Therapy can help individuals with PNES and learning disabilities.We have written what we did with Susan (a woman with PNES and a learning disability) and how the therapy helped her.We met with Susan 15 times for therapy sessions.Susan reported fewer episodes of PNES after the therapy. The change in the number of episodes was not big. Following therapy, Susan also reported better mood and quality of life, and feeling less anxious. [ABSTRACT FROM AUTHOR]

Introduction: People with dementia have a high prevalence of psychological distress but are underserved with evidence‐based psychological interventions. To promote choice and improve clinical outcomes, there is a necessity to test different psychological intervention options for this population. Purpose: This study aimed to investigate the effectiveness and acceptability of acceptance and commitment therapy (ACT) for people with dementia, considering carer‐supported, remote delivery and necessary therapy adaptations. Methods: A hermeneutic single‐case efficacy design series was used to analyse the therapy process and change for three clients with dementia and psychological distress. A matrix of quantitative and qualitative data was collated ("rich case records") and subject to critical analyses by three independent psychotherapy experts ("judges") who identified change processes and determined the outcome for each client. Results: Adjudication concluded that one client made positive changes, specifically reliable reductions in psychological distress, which were largely attributable to ACT. Two clients remained unchanged. Discussion/Conclusion: Where change was achieved, the ACT‐specific processes of values, committed action and acceptance, in combination with non‐specific therapy factors, including a strong client–carer relationship, existing client interests and individualised therapy adaptations, were facilitative. Hence, ACT may be a feasible and effective vehicle for therapeutic change by helping carers to better meet the needs of their loved ones. Future research to optimise ACT delivery in this population may be beneficial. Furthermore, the assessment of carer factors (e.g., their psychological flexibility and the client–carer relationship) may strengthen the evidence base for systemic ACT use. [ABSTRACT FROM AUTHOR]

Research into psychological interventions for cancer patients has focused on the effectiveness of different treatment methods. Investigating common factors across treatments, such as qualities within the therapeutic relationship, has been neglected. This study explores cancer patients' experiences of moments of profound contact and engagement with their therapist, including any perceived impact. Semi-structured interviews were conducted with ten cancer patients. Eight participants reported having experienced moments of relational depth. Their transcripts were analyzed using thematic analysis. Five themes were identified: "Being physically and psychically vulnerable," "Being rescued from the waves," "Experiencing the calm after the storm," "More than a feeling," and "The therapist as 'a stranger and not a stranger'." Both novice and experienced practitioners should be aware of the potential power of moments of relational depth for cancer patients: to normalize patients' increased vulnerability and emotionality, and to manage breaks and endings with relational sensitivity. [ABSTRACT FROM AUTHOR]

Engager is a complex, collaborative, but flexible intervention providing psychological and practical support to male prison leavers with sentences of two years or less. Engager was not shown to be effective from an evaluation of standard outcome measures, although full delivery of the intervention was also not achieved. The success of interventions relies partly on how able individuals are to attend, so we used an exploratory analysis of the Engager evaluation data to investigate what factors impacted on the extent to which participants attended Engager sessions. The results showed that problems with alcohol at baseline have a positive relationship with subsequent attendance (i.e., predict greater engagement). This finding was somewhat unexpected. Several other factors were found not to be predictive of either increased or decreased attendance, including depression, anxiety and psychological distress. This is a potentially positive finding, in that Engager appears to overcome some barriers to engagement in those with more severe common mental health issues, rather than them engaging less. This is despite previous evidence of these factors reducing attendance for mental health and psychological support. Potential reasons for these findings and implications for future research are discussed.

IntroductionCompassion focused therapy (CFT) is emerging as an effective psychological intervention to treat those experiencing mental health difficulties. CFT was adapted for women who are mothers during the perinatal period (from conception to 2 year postpartum). Although CFT is being delivered in NHS perinatal mental health services in the United Kingdom (UK), its current evidence-base for the treatment of women’s mental health problems is unclear. As part of this Mini Review, we aimed to identify the current findings relating to CFT for women in the perinatal period (with or without a mental health condition) in order to identify any associated future research and clinical implications.MethodA systematic search of two databases was undertaken. Included studies were required to meet the following criteria: (1) offered an intervention using CFT or perinatal CFT (P-CFT), (2) participants were women in the perinatal period, and (3) studies used a pre- and post-intervention study design. No language restrictions were used. A narrative synthesis was then conducted.ResultsFive studies, dating from 2018 to 2023, met the inclusion criteria. A total of 1,258 participants were included across those studies. Significant improvements in compassion-based outcomes (i.e., self-compassion, self-criticism/self-reassurance) were observed. However, these findings were primarily derived from non-clinical samples (n = 4) and could only be seen as preliminary.ConclusionAlthough these results are encouraging for mothers presenting with sub-clinical mental health symptoms, further research is clearly warranted to determine whether CFT/P-CFT may benefit mothers, including those presenting with more significant perinatal mental health difficulties.

Summary: Background: Alcohol use is the most important factor in determining the prognosis of patients with alcohol‐related cirrhosis and alcohol‐associated hepatitis. Aim: To conduct a systematic review of interventions for alcohol use disorder specific to patients with cirrhosis or alcohol‐associated hepatitis. Methods: We searched five databases between inception and November 2022. The primary outcomes were abstinence, hepatic decompensation and mortality. We included randomised and non‐randomised studies. Risk of bias was assessed using validated tools. Where possible, meta‐analysis was performed. Results: Twenty‐three studies met the inclusion criteria including six randomised trials and 17 non‐randomised studies of interventions. These included 104,298 patients with a mean/median age range from 44 to 65, of whom 75% were male. Interventions included psychological therapy, pharmacological therapies, specialist clinics, patient education and low alcohol drinks. Baclofen was the only intervention to demonstrate a statistically significant impact on the primary outcomes in a randomised trial (abstinence OR: 6.3, 95% CI: 2.4–16.1). Three non‐randomised studies reported reductions in episodes of hepatic decompensation that were significant in multivariate models. This was in response to psychological therapy, use of any pharmacotherapy, and use of any treatment. A meta‐analysis of non‐randomised studies that examined the impact of psychological therapies revealed statistically non‐significant improvements in abstinence (4 studies, OR: 1.87, 95% CI: 0.38–9.23) and mortality (4 studies, OR: 0.47, 95% CI: 0.12–1.77). Conclusions: Baclofen is the only intervention with randomised trial evidence for significant benefit in patients with cirrhosis. Non‐randomised studies also point to non‐pharmaceutical interventions possibly improving clinical outcomes. [ABSTRACT FROM AUTHOR]

Bibliotherapy is an important part of art therapy and many publications regarding bibliotherapy have been published in the past. However, there has none about the scientometric study to systematically analyze the development and emerging research trends on bibliotherapy. Therefore, we performed a scientometric investigation to describe trends of this theme. All publications related to bibliotherapy published from 1980 to 2020 were identified and selected from Science Citation Index Expanded, Social Sciences Citation Index, and Arts & Humanities Citation Index of Web of Science Core Collection. VOSviewer was used to create collaborative network plots of countries, institutions, and authors and to perform cluster analysis of keywords. A total of 703 articles were searched, and we retrieved the 100 most cited articles published by 146 institutions from 15 countries in 57 academic journals. The United States occupied a leading position in the field of bibliotherapy and Linköping University was the most productive institution. Journal of Consulting and Clinical Psychology was the most productive journal. Andersson G, Carlbring P, and Cuijpers P may have an important influence on bibliotherapy research. The applications in depression, anxiety, panic disorder, insomnia, and aphasia are the hot themes. This scientometric review provided a comprehensive understanding of the bibliotherapy research using quantitative and qualitative methods, which can provide references for researchers in the bibliotherapy field. As investigators continue to work, we look forward to the development of bibliotherapy efficacy and the implementation form and steps. [ABSTRACT FROM AUTHOR]

Objective: This study provides a preliminary report on the effectiveness of Specialist Supportive Clinical Management (SSCM) in a clinical case series of adults with anorexia nervosa, to supplement evidence of efficacy from controlled trials. Method: Body mass index (BMI), eating disorder symptoms, mood and anxiety were measured at the start and end of treatment for 42 adults who received SSCM in a community eating disorders service. Results: Significant improvements were observed on all outcome measures, with larger effect sizes for symptom change than BMI. Recovery rates appear similar to those in clinical trials. Discussion: The study offers preliminary support for the effectiveness of SSCM in routine settings and identifies several areas for further research. [ABSTRACT FROM AUTHOR]

Persistent, acute, chronic pain. The healthcare system must face a considerable challenge in addressing pain, which affects a large portion of patients. The therapies and protocols applied very often lack effectiveness for the patient, and the health system tries to find a solution that can adequately treat the pain. At the moment, we cannot reverse and definitively treat this major problem. The debate within the health system and outside it is permanent. [ABSTRACT FROM AUTHOR]

Objectives: Suicide is a leading cause of death worldwide. People experiencing psychosis are at increased risk of death by suicide. Talking therapies can alleviate suicidal thoughts, plans, and attempts. Therapies need to also be acceptable to recipients. The aim of this study was to investigate the views on psychological therapy for people experiencing psychosis and suicidality using the Theoretical Framework of Acceptability. Design: Qualitative interview study. Methods: Participants were recruited from a randomised controlled trial comparing suicide prevention psychological therapy with treatment as usual. Individuals had a diagnosis of non‐affective psychosis and experience of suicidal thoughts, plans and/or attempts. To assess the acceptability of the therapy, semi‐structured interviews were conducted with 20 participants randomised to receive therapy. Data were deductively analysed using an adaptation of the Theoretical Framework of Acceptability. Results: Interviews (Mean = 45 min) were conducted and audio recorded with 21 participants. Data were organised into six themes: 1. Affective attitude, 2. Burden, 3. Alliance, 4. Intervention coherence, 5. Perceived effectiveness, and 6. Self‐efficacy. There was no evidence of issues relating to domains of ethicality and opportunity costs associated with receiving therapy. Conclusions: Talking about suicide was difficult and, at times, distressing, but it was perceived to be useful for understanding experiences. To be acceptable, it is important for therapists to ensure that clients' understanding of therapy aligns with expectations of effectiveness and to invest in building strong therapeutic alliances. Future research will benefit from examining therapists' experiences of delivering therapy through different modes (e.g. online, telephone). [ABSTRACT FROM AUTHOR]

Background: Improving Access to Psychological Therapies (IAPT) is a primary care therapy service commissioned by England's National Health Service (NHS) for people with unipolar depression and anxiety-related disorders. Its scope does not extend to 'severe mental illness', including bipolar disorders (BD), but evidence suggests there is a high BD prevalence in ostensibly unipolar major depressive disorder (uMDD) samples. This study aimed to indicate the prevalence and characteristics of people with BD in a naturalistic cohort of IAPT patients. Methods: 371 participants were assessed before initiating therapy. Participants were categorised by indicated diagnoses: BD type-I (BD-I) or type-II (BD-II) as defined using a DSM diagnostic interview, bipolar spectrum (BSp, not meeting diagnostic criteria but exceeding BD screening thresholds), lifetime uMDD or other. Information about psychiatric history and co-morbidities was examined, along with symptoms before and after therapy. Results: 368 patients provided sufficient data to enable classification. 10% of participants were grouped as having BD-I, 20% BD-II, 40% BSp, 25% uMDD and 5% other. BD and uMDD participants had similar demographic characteristics, but patients meeting criteria for BD-I/BD-II had more complex psychiatric presentations. All three 'bipolar' groups had particularly high rates of anxiety disorders. IAPT therapy receipt was comparable between groups, as was therapy response (F 9704 = 1.113, p = 0.351). Conclusions: Notwithstanding the possibility that bipolar diathesis was overestimated, findings illustrate a high prevalence of BD in groups of people notionally with uMDD or anxiety. As well as improving the detection of BD, further substantive investigation is required to establish whether individuals affected by BD should be eligible for primary care psychological intervention. [ABSTRACT FROM AUTHOR]