Eleanor Longden

Empirical evidence about recovery and mental health

BackgroundTwo discourses exist in mental health research and practice. The first focuses on the limitations associated with disability arising from mental disorder. The second focuses on the possibilities for living well with mental health problems.DiscussionThis article was prompted by a review to inform disability policy. We identify seven findings from this review: recovery is best judged by experts or using standardised assessment; few people with mental health problems recover; if a person no longer meets criteria for a mental illness, they are in remission; diagnosis is a robust basis for characterising groups and predicting need; treatment and other supports are important factors for improving outcome; the barriers to receiving effective treatment are availability, financing and client awareness; and the impact of mental illness, in particular schizophrenia, is entirely negative. We selectively review a wider range of evidence which challenge these findings, including the changing understanding of recovery, national mental health policies, systematic review methodology and undertainty, epidemiological evidence about recovery rates, reasoning biased due to assumptions about mental illness being an illness like any other, the contested nature of schizophrenia, the social construction of diagnoses, alternative explanations for psychosis experiences including the role of trauma, diagnostic over-shadowing, stigma, the technological paradigm, the treatment gap, social determinants of mental ill-health, the prevalence of voice-hearing in the general population, and the sometimes positive impact of psychosis experience in relation to perspective and purpose.ConclusionWe propose an alternative seven messages which are both empirically defensible and more helpful to mental health stakeholders: Recovery is best judged by the person living with the experience; Many people with mental health problems recover; If a person no longer meets criteria for a mental illness, they are not ill; Diagnosis is not a robust foundation; Treatment is one route among many to recovery; Some people choose not to use mental health services; and the impact of mental health problems is mixed.

Auditory verbal hallucinations in schizophrenia and post-traumatic stress disorder: common phenomenology, common cause, common interventions?

Auditory verbal hallucinations (AVH: ‘hearing voices’) are found in both schizophrenia and post-traumatic stress disorder (PTSD). In this paper we first demonstrate that AVH in these two diagnoses share a qualitatively similar phenomenology. We then show that the presence of AVH in schizophrenia is often associated with earlier exposure to traumatic/emotionally overwhelming events, as it is by definition in PTSD. We next argue that the content of AVH relates to earlier traumatic events in a similar way in both PTSD and schizophrenia, most commonly having direct or indirect thematic links to emotionally overwhelming events, rather than being direct re-experiencing. We then propose, following cognitive models of PTSD, that the reconstructive nature of memory may be able to account for the nature of these associations between trauma and AVH content, as may threat-hypervigilance and the individual’s personal goals. We conclude that a notable subset of people diagnosed with schizophrenia with AVH are having phenomenologically and aetiologically identical experiences to PTSD patients who hear voices. As such we propose that the iron curtain between AVH in PTSD (often termed ‘dissociative AVH’) and AVH in schizophrenia (so-called ‘psychotic AVH’) needs to be torn down, as these are often the same experience. One implication of this is that these trauma-related AVH require a common trans-diagnostic treatment strategy. Whilst antipsychotics are already increasingly being used to treat AVH in PTSD, we argue for the centrality of trauma-based interventions for trauma-based AVH in both PTSD and in people diagnosed with schizophrenia.

Childhood adversity and psychosis: generalised or specific effects?

Background. This study examines relationships between childhood adversity and the presence of characteristic symptoms of schizophrenia. It was hypothesised that total adversity exposures would be significantly higher in individuals exhibiting these symptoms relative to patients without. Recent proposals that differential associations exist between specific psychotic symptoms and specific adversities was also tested, namely: sexual abuse and hallucinations, physical abuse and delusions, and fostering/adoption and delusions. Method. Data were collected through auditing 251 randomly selected medical records, drawn from adult patients in New Zealand community mental health centres. Information was extracted on presence and subtype of psychotic symptoms and exposure to ten types of childhood adversity, including five types of abuse and neglect. Results. Adversity exposure was significantly higher in patients experiencing hallucinations in general, voice hearing, command hallucinations, visions, delusions in general, paranoid delusions and negative symptoms than in patients without these symptoms. There was no difference in adversity exposure in patients with and without tactile/olfactory hallucinations, grandiose delusions or thought disorder. Indication of a dose–response relationship was detected, in that total number of adversities significantly predicted total number of psychotic symptoms. Although fostering/adoption was associated with paranoid delusions, the hypothesised specificity between sexual abuse and hallucinations, and physical abuse and delusions, was not found. The two adversities showing the largest number of associations with psychotic symptoms were poverty and being fostered/adopted. Conclusions. The current data are consistent with a model of global and cumulative adversity, in which multiple exposures may intensify psychosis risk beyond the impact of single events. Implications for clinical intervention are discussed.

Trauma, dissociation, attachment and neuroscience: A new paradigm for understanding severe mental distress.

A new and profoundly important paradigm for understanding overwhelming emotional pain has emerged over the last few years, with the potential to change the way we conceptualize human suffering across the whole spectrum of mental health difficulties. It is a strongly evidence-based synthesis of findings from trauma studies, attachment theory and neuroscience, which offers new hope for recovery. It also presents a powerful challenge to biomedical model psychiatry in that it is based on scientific evidence that substantiates and attests to what many individuals with first-hand experience of mental health problems have always known — that the bad things that happen to you can drive you mad. In this article we will summarize the key findings and reflect on the implications for current practice.

Assessing and Reporting the Adverse Effects of Antipsychotic Medication: A Systematic Review of Clinical Studies, and Prospective, Retrospective, and Cross-Sectional Research.

ObjectiveAdverse effects (AEs) of antipsychotic medication have important implications for patients and prescribers in terms of well-being, treatment adherence, and quality of life. This review summarizes strategies for collecting and reporting AE data across a representative literature sample to ascertain their rigor and comprehensiveness. MethodsA PsycINFO search, following preferred reporting items for systematic reviews and meta-analyses statement guidelines, was conducted in English-language journals (1980 to July 2014) using the following search string: (antipsychotic* or neuroleptic*) and (subjective effect or subjective experience or subjective response or subjective mental alterations or subjective tolerability OR subjective well-being or patient perspective or self-rated effects or adverse effects or side effects). Of 7825 articles, 384 were retained that reported quantified results for AEs of typical or atypical antipsychotics among transdiagnostic adult, adolescent, and child populations. Information extracted included: types of AEs reported, how AEs were assessed, assessment duration, assessment of the global impact of antipsychotic consumption on subjective patient wellbeing, and conflict of interest due to industry sponsorship. ResultsNeurological, metabolic, and sedation-related cognitive effects were reported more systematically than affective, anticholinergic, autonomic, cutaneous, hormonal, miscellaneous, and nonsedative cognitive effects. The global impact of AEs on patient well-being was poorly assessed. Cross-sectional and prospective research designs yielded more comprehensive data about AE severity and prevalence than clinical or observational retrospective studies. ConclusionsThe detection and classification of AEs can be improved through the use of standardized assessment instruments and consideration of the global impact on subjective patient wellbeing. Observational research can supplement information from clinical trials to improve the ecological validity of AE data.

Shared Reading: assessing the intrinsic value of a literature-based health intervention

Public health strategies have placed increasing emphasis on psychosocial and arts-based strategies for promoting well-being. This study presents preliminary findings for a specific literary-based intervention, Shared Reading, which provides community-based spaces in which individuals can relate with both literature and one another. A 12-week crossover design was conducted with 16 participants to compare benefits associated with six sessions of Shared Reading versus a comparison social activity, Built Environment workshops. Data collected included quantitative self-report measures of psychological well-being, as well as transcript analysis of session recordings and individual video-assisted interviews. Qualitative findings indicated five intrinsic benefits associated with Shared Reading: liveness, creative inarticulacy, the emotional, the personal and the group (or collective identity construction). Quantitative data additionally showed that the intervention is associated with enhancement of a sense of ‘Purpose in Life’. Limitations of the study included the small sample size and ceiling effects created by generally high levels of psychological well-being at baseline. The therapeutic potential of reading groups is discussed, including the distinction between instrumental and intrinsic value within arts-and-health interventions.

Assessing the Impact and Effectiveness of Hearing Voices Network Self-Help Groups

The Hearing Voices Network (HVN) is an influential service-user led organisation that promotes self-help as an important aspect of recovery. This study presents the first systematic assessment of the impact and effectiveness of HVN self-help groups. A customized 45-item questionnaire, the Hearing Voices Groups Survey, was sent to 62 groups affiliated with the English HVN. 101 responses were received. Group attendance was credited with a range of positive emotional, social and clinical outcomes. Aspects that were particularly valued included: opportunities to meet other voice hearers, provision of support that was unavailable elsewhere, and the group being a safe and confidential place to discuss difficult issues. Participants perceived HVN groups to facilitate recovery processes and to be an important resource for helping them cope with their experiences. Mental health professionals can use their expertise to support the successful running of these groups.

An evaluation of shared reading groups for adults living with dementia: preliminary findings

Purpose – Although there is a growing evidence base for the value of psychosocial and arts-based strategies for enhancing well-being amongst adults living with dementia, relatively little attention has been paid to literature-based interventions. The purpose of this paper is to assess the impact of shared reading (SR) groups, a programme developed and implemented by The Reader Organisation, on quality of life for care home residents with mild/moderate dementia. Design/methodology/approach – In total, 31 individuals were recruited from four care homes, which were randomly assigned to either reading-waiting groups (three months reading, followed by three months no reading) or waiting-reading groups (three months no reading, followed by three months reading). Quality of life was assessed by the DEMQOL-Proxy and psychopathological symptoms were assessed by the Neuropsychiatric Inventory Questionnaire. Findings – Compared to the waiting condition, the positive effects of SR on quality of life were demonstrated at the commencement of the reading groups and were maintained once the activity ended. Low levels of baseline symptoms prevented analyses on whether the intervention impacted on the clinical signs of dementia. Research limitations/implications – Limitations included the small sample and lack of control for confounding variables. Originality/value – The therapeutic potential of reading groups is discussed as a positive and practical intervention for older adults living with dementia.