Jo Hodgekins

Cognitive behaviour therapy for improving social recovery in psychosis: a report from the ISREP MRC Trial Platform study (Improving Social Recovery in Early Psychosis)

BACKGROUND This study reports on a preliminary evaluation of a cognitive behavioural intervention to improve social recovery among young people in the early stages of psychosis showing persistent signs of poor social functioning and unemployment. The study was a single-blind randomized controlled trial (RCT) with two arms, 35 participants receiving cognitive behaviour therapy (CBT) plus treatment as usual (TAU), and 42 participants receiving TAU alone. Participants were assessed at baseline and post-treatment. METHOD Seventy-seven participants were recruited from secondary mental health teams after presenting with a history of unemployment and poor social outcome. The cognitive behavioural intervention was delivered over a 9-month period with a mean of 12 sessions. The primary outcomes were weekly hours spent in constructive economic and structured activity. A range of secondary and tertiary outcomes were also assessed. RESULTS Intention-to-treat analysis on the combined affective and non-affective psychosis sample showed no significant impact of treatment on primary or secondary outcomes. However, analysis of interactions by diagnostic subgroup was significant for secondary symptomatic outcomes on the Positive and Negative Syndrome Scale (PANSS) [F(1, 69)=3.99, p=0.05]. Subsequent exploratory analyses within diagnostic subgroups revealed clinically important and significant improvements in weekly hours in constructive and structured activity and PANSS scores among people with non-affective psychosis. CONCLUSIONS The primary study comparison provided no clear evidence for the benefit of CBT in a combined sample of patients. However, planned analyses with diagnostic subgroups showed important benefits for CBT among people with non-affective psychosis who have social recovery problems. These promising results need to be independently replicated in a larger, multi-centre RCT.

Can targeted early intervention improve functional recovery in psychosis? A historical control evaluation of the effectiveness of different models of early intervention service provision in Norfolk 1998-2007.

Aims: This paper assesses the impact of different models of early intervention (EI) service provision on functional recovery and inpatient hospital admission. The study compares the outcome of a comprehensive EI team with a partial model (community mental health team (CMHT) plus specialist support) and traditional care (generic CMHT) over a 10‐year period.

Comparing time use in individuals at different stages of psychosis and a non-clinical comparison group

Social functioning difficulties are a common and disabling feature of psychosis and have also been identified in the prodromal phase. However, debate exists about how such difficulties should be defined and measured. Time spent in structured activity has previously been linked to increased psychological wellbeing in non-clinical samples and may provide a useful way of assessing social functioning in clinical settings. The current study compared hours in structured activity, assessed with the Time Use Survey, in three clinical groups at different stages of psychosis: individuals with at-risk mental states (N=199), individuals with first-episode psychosis (N=878), and individuals with delayed social recovery following the remission of psychotic symptoms (N=77). Time use in the three clinical groups was also compared with norms from an age-matched non-clinical group (N=5686) recruited for the Office for National Statistics UK 2000 Time Use Survey. Cutoff scores for defining social disability and recovery were examined. All three clinical groups spent significantly fewer hours per week in structured activity than individuals in the non-clinical group. Reduced activity levels were observed before the onset of psychosis in individuals with at-risk mental states. Additional reductions in activity were observed in the first-episode psychosis and delayed recovery groups compared to the at-risk mental state group. Assessing time spent in structured activity provides a useful way to assess social disability and recovery across the spectrum of psychosis.

Measuring the benefits of treatment for psychosis: validity and responsiveness of the EQ–5D

BACKGROUND The UK National Institute for Health and Clinical Excellence (NICE) has recommended that cost-effectiveness analysis includes the EQ-5D; however, this is often not implemented in the area of mental health. AIMS To assess the appropriateness of using the EQ-5D to measure improvements in mental health. METHOD Seventy-seven participants with psychosis were rated according to the EQ-5D and seven measures of mental health at both pre- and post-intervention. To assess construct validity we compared the (pre-intervention) mean EQ-5D scores for those with milder and more severe scores, according to each of the seven measures. To assess responsiveness we estimated the mean EQ-5D change score for those who improved (post-intervention), according to each of the measures. RESULTS The mean EQ-5D score was more favourable for both those with milder scores (mean difference: 0.044 to 0.301) and for those who improved post-intervention (mean change: 0.029 to 0.117). CONCLUSIONS This suggests the EQ-5D should be considered for use in future cost-effectiveness studies in the area of mental health.

Cognitive behaviour therapy for improving social recovery in psychosis: Cost-effectiveness analysis

A randomised trial was conducted in order to estimate the clinical and cost-effectiveness of social recovery orientated cognitive behavioural therapy (SRCBT) for people diagnosed with psychosis, compared to case management alone (CMA). The mean incremental health and social care cost, and the mean incremental quality adjusted life year (QALY) gain, of SRCBT was calculated over the 9 month intervention period. The cost-effectiveness of SCRBT was in turn estimated, and considered in relation to the cost-effectiveness threshold of 20000 UK pounds per QALY. The level of uncertainty associated with that decision was estimated by calculating the cost-effectiveness acceptability curve for SRCBT. N=35 received SRCBT and N=42 received CMA. The mean incremental cost was estimated to be 668 UK pounds, and the mean incremental QALY gain 0.035. SRCBT was estimated to be cost-effective as it had a cost per QALY of 18844 UK pounds, which was more favourable than the assumed cost-effectiveness threshold of 20000 UK pounds per QALY. At that threshold the probability of being cost-effective was however estimated to be 54.3% according to the CEAC, suggesting that further research may be warranted in order to reduce the level of uncertainty associated with the decision as to whether SRCBT is cost-effective.

The course of negative symptom in first episode psychosis and the relationship with social recovery

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

Social recovery therapy in combination with early intervention services for enhancement of social recovery in patients with first-episode psychosis (SUPEREDEN3): a single-blind, randomised controlled trial

Summary Background Provision of early intervention services has increased the rate of social recovery in patients with first-episode psychosis; however, many individuals have continuing severe and persistent problems with social functioning. We aimed to assess the efficacy of early intervention services augmented with social recovery therapy in patients with first-episode psychosis. The primary hypothesis was that social recovery therapy plus early intervention services would lead to improvements in social recovery. Methods We did this single-blind, phase 2, randomised controlled trial (SUPEREDEN3) at four specialist early intervention services in the UK. We included participants who were aged 16–35 years, had non-affective psychosis, had been clients of early intervention services for 12–30 months, and had persistent and severe social disability, defined as engagement in less than 30 h per week of structured activity. Participants were randomly assigned (1:1), via computer-generated randomisation with permuted blocks (sizes of four to six), to receive social recovery therapy plus early intervention services or early intervention services alone. Randomisation was stratified by sex and recruitment centre (Norfolk, Birmingham, Lancashire, and Sussex). By necessity, participants were not masked to group allocation, but allocation was concealed from outcome assessors. The primary outcome was time spent in structured activity at 9 months, as measured by the Time Use Survey. Analysis was by intention to treat. This trial is registered with ISRCTN, number ISRCTN61621571. Findings Between Oct 1, 2012, and June 20, 2014, we randomly assigned 155 participants to receive social recovery therapy plus early intervention services (n=76) or early intervention services alone (n=79); the intention-to-treat population comprised 154 patients. At 9 months, 143 (93%) participants had data for the primary outcome. Social recovery therapy plus early intervention services was associated with an increase in structured activity of 8·1 h (95% CI 2·5–13·6; p=0·0050) compared with early intervention services alone. No adverse events were deemed attributable to study therapy. Interpretation Our findings show a clinically important benefit of enhanced social recovery on structured activity in patients with first-episode psychosis who received social recovery therapy plus early intervention services. Social recovery therapy might be useful in improving functional outcomes in people with first-episode psychosis, particularly in individuals not motivated to engage in existing psychosocial interventions targeting functioning, or who have comorbid difficulties preventing them from doing so. Funding National Institute for Health Research.

Assessing Levels of Subthreshold Psychotic Symptoms in the Recovery Phase: the Schizotypal Symptoms Inventory (SSI)

Objective Subthreshold psychotic symptoms occurring during the recovery stages of psychosis may impede social functioning and precipitate relapse. Traditional assessment tools lack adequate sensitivity to assess such phenomena. The study aim was to develop a comprehensive self-report measure of residual psychotic symptoms. Method The psychometric properties of the Schizotypal Symptoms Inventory (SSI) were analysed in a sample of 808 students and a sample of 126 clinical cases recovering from psychosis. Levels of schizotypal symptoms were compared between the two groups. Results The SSI was shown to have good psychometric properties. The clinical sample had higher scores on all dimensions of the SSI than the non-clinical sample. Social anxiety symptoms were particularly prevalent in the recovery phase. Conclusions Individuals recovering from acute psychosis experience high levels of subthreshold psychotic symptoms which may impede long-term recovery. The SSI has robust psychometric properties and could be used to assess these phenomena.

Using a Semi-Structured Interview to Explore Imagery Experienced During Social Anxiety for Clients with a Diagnosis of Psychosis: An Exploratory Study Conducted Within an Early Intervention for Psychosis Service

BACKGROUND Social phobia frequently occurs as a comorbid condition, with high rates reported among people with psychosis. Little is known about the nature of social anxiety in this population or whether current psychological theories apply. AIMS This paper aims to develop and pilot a suitable measure to explore imagery experienced by participants with comorbid psychosis and social anxiety and to provide preliminary indications as to its nature. METHOD A semi-structured interview exploring imagery was used with seven participants (adapted from Hackmann, Surawy and Clark, 1998) and the results were analysed using qualitative template analysis. RESULTS Initial indications from this sample suggest that some participants experience typical social anxiety images, as identified by Hackmann et al. (1998). However, some experience images that appear more threatening, and may be related to residual psychotic paranoia. Image perspective was also explored: typical social anxiety images tended to be seen from an observer perspective, while those that may have been more related to psychosis tended to be seen from a field perspective. CONCLUSIONS This exploratory study has facilitated the careful adaptation and development of an imagery interview for use in this population and has suggested areas for further research and raised questions around clinical implications.

Young people's experiences of Social Recovery Cognitive Behavioural Therapy and treatment as usual in the PRODIGY trial

The PRODIGY trial is an ongoing randomized controlled trial of Social Recovery Cognitive Behavioural Therapy (SRCBT), a new intervention designed to improve social functioning in young people at risk of long‐term social disability due to severe and complex mental health problems. The aim of this qualitative sub‐study was to understand trial participants’ experiences of SRCBT and the control condition, treatment as usual.