Miriam Fornells-Ambrojo

The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis

Abstract Objective To evaluate the effectiveness of a service for early psychosis. Design Randomised controlled clinical trial. Setting Community mental health teams in one London borough. Participants 144 people aged 16-40 years presenting to mental health services for the first or second time with non-organic, non-affective psychosis. Interventions Assertive outreach with evidence based biopsychosocial interventions (specialised care group) and standard care (control group) delivered by community mental health teams. Primary outcome measures Rates of relapse and readmission to hospital. Results Compared with patients in the standard care group, those in the specialised care group were less likely to relapse (odds ratio 0.46, 95% confidence interval 0.22 to 0.97), were readmitted fewer times (β 0.39, 0.10 to 0.68), and were less likely to drop out of the study (odds ratio 0.35, 0.15 to 0.81). When rates were adjusted for sex, previous psychotic episode, and ethnicity, the difference in relapse was no longer significant (odds ratio 0.55, 0.24 to 1.26); only total number of readmissions (β 0.36, 0.04 to 0.66) and dropout rates (β 0.28, 0.12 to 0.73) remained significant. Conclusions Limited evidence shows that a team delivering specialised care for patients with early psychosis is superior to standard care for maintaining contact with professionals and for reducing readmissions to hospital. No firm conclusions can, however, be drawn owing to the modest sample size.

Virtual reality and persecutory delusions : Safety and feasibility

OBJECTIVE Virtual reality (VR) has begun to be used to research the key psychotic symptom of paranoia. The initial studies have been with non-clinical individuals and individuals at high risk of psychosis. The next step is to develop the technology for the understanding and treatment of clinical delusions. Therefore the present study investigated the acceptability and safety of using VR with individuals with current persecutory delusions. Further, it set out to determine whether patients feel immersed in a VR social environment and, consequently, experience paranoid thoughts. METHOD Twenty individuals with persecutory delusions and twenty non-clinical individuals spent 4 min in a VR underground train containing neutral characters. Levels of simulator sickness, distress, sense of presence, and persecutory ideation about the computer characters were measured. A one-week follow-up was conducted to check longer-term side effects. RESULTS The VR experience did not raise levels of anxiety or symptoms of simulator sickness. No side effects were reported at the follow-up. There was a considerable degree of presence in the VR scenario for all participants. A high proportion of the persecutory delusions group (65%) had persecutory thinking about the computer characters, although this rate was not significantly higher than the non-clinical group. CONCLUSIONS The study indicates that brief experiences in VR are safe and acceptable to people with psychosis. Further, patients with paranoia can feel engaged in VR scenes and experience persecutory thoughts. Exposure to social situations using VR has the potential to be incorporated into cognitive behavioural interventions for paranoia.

Remission and relapse in psychosis: operational definitions based on case-note data.

BACKGROUND In psychosis, the prime indicator of outcome has been relapse, but hospital readmission can no longer be used for this purpose. Researchers now require methods for assessing relapse that are objective, blind, reliable and valid. We describe the reliability and validity of such a technique using case-notes. METHOD Information from routine clinical notes of participants in the Lambeth Early Onset (LEO) study (less all references that would unblind the assessor) were recorded on a form divided into 1-month sections. Operational definitions of remission and relapse enabled clinicians to identify remissions and relapses blindly from the summary information. We calculated reliability regarding both the fact and the timing of remission and relapse. PANSS ratings at 6 and 18 months provided a measure of validity. RESULTS The kappa value for the identification of remission by individuals ranged from 0.64 to 0.82, while that for consensus between paired raters was 0.56. The corresponding values for relapse were 0.57-0.59 and 0.71. Intra-class correlations for time to remission and to relapse were very high. Raters guessed correctly whether the participants came from the intervention or control group on 60-75% of occasions. Independent PANSS ratings were strongly related to the remission/relapse status of participants. CONCLUSIONS The reliability of the technique described here was moderate to good, its validity was good, and it provides a useful and timely addition to methods of evaluating remission and relapse in psychosis. On the basis of our experience, we recommend consensus rather than individual ratings.

Opportunities and challenges in Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI): Evaluating the first operational year of the South London and Maudsley (SLaM) demonstration site for psychosis

Despite its demonstrated clinical and economic effectiveness, access to Cognitive Behavioural Therapy for psychosis (CBTp) in routine practice remains low. The UK National Health Service (NHS England) Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI) initiative aims to address this problem. We report 14-month outcomes for our psychosis demonstration site. Primary and secondary care and self-referrals were screened to check the suitability of the service for the person. Psychotic symptoms, distress, service use, functioning and satisfaction were measured before and after therapy, by trained assessors. User-defined wellbeing and goal-attainment were rated sessionally. Access to CBTp increased almost threefold (2011/12 accepted referrals/year n = 106; 2012/13, n = 300). The IAPT-SMI assessment protocol proved feasible and acceptable to service users, with paired primary outcomes for 97% of closed cases. Therapy completion (≥5 sessions) was high (83%) irrespective of ethnicity, age and gender. Preliminary pre-post outcomes showed clinical improvement and reduced service use, with medium/high effect sizes. User-rated satisfaction was high. We conclude that individual psychological interventions for people with psychosis can be successfully delivered in routine services using an IAPT approach. High completion rates for paired outcomes demonstrate good user experience, clinical improvement, and potential future cost savings.

Bad me paranoia in early psychosis: A relatively rare phenomenon

PURPOSE The aim of this study was to follow up Trower and Chadwicks (1995) proposal that there are two types of paranoia: poor me paranoia, in which the persecution is believed to be undeserved, and bad me paranoia, in which the persecution is seen as a deserved punishment. METHOD A cross-sectional design was used. A group of 40 participants with early psychosis, who were experiencing persecutory delusions, were assessed using a semi-structured interview on the content of their beliefs. RESULTS An extremely low rate of bad me paranoia was found in the sample of participants with early psychosis. CONCLUSIONS People with persecutory delusions who are in the initial stages of their illness do not tend to believe that they are being justifiably punished. Stigma and depression are put forward as tentative explanations of the development of this evaluative belief with time.

The effects of an Audio Visual Assisted Therapy Aid for Refractory auditory hallucinations (AVATAR therapy): study protocol for a randomised controlled trial

BackgroundPsychological interventions which adopt an explicitly interpersonal approach are a recent development in the treatment of distressing voices. AVATAR therapy is one such approach which creates a direct dialogue between a voice-hearer and a computerised representation of their persecutory voice (the avatar) through which the person may be supported to gain a sense of greater power and control. The main objective of the trial is to test the clinical efficacy of this therapy to reduce the frequency and severity of auditory verbal hallucinations (AVH). Secondary objectives of the study are to explore explanatory mechanisms of action and potential moderators, to carry out a qualitative evaluation of participants’ experience and to conduct an economic evaluation.Methods/DesignThe AVATAR randomised clinical trial will independently randomise 142 participants to receive either 7 sessions of AVATAR therapy or supportive counselling (SC). The study population will be individuals with schizophrenia spectrum and other psychotic disorders who report hearing persistent distressing voices, for more than 12 months, which are unresponsive or only partially responsive to antipsychotic medication. The main hypotheses are that, compared to SC, AVATAR therapy will reduce the frequency and severity of AVH and will also reduce the reported omnipotence and malevolence of these voices. Assessments will occur at 0 weeks (baseline), 12 weeks (post-intervention) and 24 weeks (follow-up), and will be carried out by blinded assessors. Both interventions will be delivered in a community-based mental health centre. Therapy competence and adherence will be monitored in both groups. Statistical analysis will follow the intention-to-treat principle and data will be analysed using a mixed (random) effects model at each post treatment time point separately. A formal mediation and moderator analysis using contemporary causal inference methods will be conducted as a secondary analysis. The trial is funded by the Welcome Trust (WT).DiscussionAVATAR therapy showed promising effects in a pilot study, but the efficacy of the approach needs to be examined in a larger randomised clinical trial before wider dissemination and implementation in mental health services.Trial registrationCurrent Controlled Trials ISRCTN: 65314790, registration date: 27 March 2013.

Do Family Interventions Improve Outcomes in Early Psychosis? A Systematic Review and Meta-Analysis

Family interventions for psychosis (FIp) are effective in reducing service user relapse and carer distress in people with schizophrenia-spectrum conditions. Several treatment and best practice guidelines recommend FIp for all people with schizophrenia. However, outcome findings in relation to early psychosis groups have been inconsistent. The current paper reports a systematic review and meta-analyses of articles that evaluated FIp in early psychosis with a clearly defined comparison group. A combination of electronic database searches (using PsychINFO, Medline, and CENTRAL), citation searches and hand searches of key journals and reviews was conducted. Peer-reviewed articles published in English from database inception to June 2016 were included. Methodological quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool (EPHPP). Seventeen papers from 14 studies met inclusion criteria for review, the overall quality of which was moderate. Meta-analytic synthesis showed that FIp improved service user functioning and reduced the likelihood of relapse by the end of treatment. Psychotic symptoms were significantly reduced in the FIp group at follow up, but this was not evident at end of treatment. In terms of FIp target mechanisms, carers receiving FIp were more likely to shift from high to low expressed emotion and less likely to report patient focused criticism or engage in conflict communication than carers randomized to standard care. Carer burden and well-being were improved by the end of treatment but gains were not sustained at follow up. FIp had no impact on carer emotional over-involvement. The findings indicate that FIp is an effective intervention for early psychosis service users and their relatives. However, further research is required to establish which key therapeutic components of FIp are most effective for whom, in addition to understanding the mechanisms by which FIp might affect positive change.

Attributional biases in paranoia: The development and validation of the Achievement and Relationships Attributions Task (ARAT)

Introduction. Attributional biases, in particular a tendency to blame other people for negative events, have been reported among people with persecutory delusions and in people in the general population with subclinical paranoia. However, existing attribution measures have some shortcomings. The present study therefore describes the development and validation of a new attribution measure: the Achievement and Relationships Attributions Task (ARAT). The ARAT assesses attributional style in a range of everyday life situations related to achievement and interpersonal events, and provides a context for attributions. Each scenario has three possible causes embedded within it: internal, personal-external, and situational-external. Methods. Three hundred and fifteen healthy volunteers completed the ARAT and measures of paranoia and depression. Results. A tendency to blame other people rather than themselves was associated with high trait paranoia and multidimensional aspects of paranoid beliefs. Depression was associated with a decreased tendency to internalise success. Conclusions. The ARAT is a valid measure of attributional style in relation to paranoid ideation in a nonclinical population and has good interrater reliability.

The effects of a brief CBT intervention, delivered by frontline mental health staff, to promote recovery in people with psychosis and comorbid anxiety or depression (the GOALS study): study protocol for a randomized controlled trial

BackgroundNICE guidance states that cognitive behavioural therapy (CBT) should be offered to all patients with psychosis. However, there is a need to improve access to therapeutic interventions. We aim to train frontline mental health staff to deliver brief, structured CBT-based therapies. We have developed and piloted a manualized intervention to support people with psychosis and anxious avoidance or depression to work towards a personal recovery goal.Methods/DesignThe ‘GOALS Study’ is a pilot randomized controlled trial comparing usual care plus an 8-week intervention with usual care alone. The key objective is to assess clinical feasibility (recruitment and randomization; compliance with the treatment manual; acceptability and satisfaction; progress towards goals). A secondary objective is a preliminary evaluation of efficacy. Sixty-six participants with a diagnosis of psychosis, plus symptoms of depression or anxiety will be recruited from adult mental health services. Those currently refusing medication, in receipt of CBT, or with a primary diagnosis of an organic mental health problem or substance dependency will be excluded. Following informed consent, randomization will be independent of the trial team, at a 50:50 ratio, at the level of the individual and stratified by main problem focus. Following randomization, participants allocated to the intervention group will begin the 8-week intervention with a local, trained member of staff, supervised by the study coordinator. Outcomes will be assessed blind to treatment condition at 0, 12 and 18 weeks post-randomization. The primary outcome measure for the efficacy analysis will be activity levels at 12 weeks. Secondary outcome measures include mood, psychotic symptoms, quality of life and clinical distress. A health economic analysis comparing service use in each condition will also be performed. Recruitment began in March, 2013 and is ongoing until December, 2014.DiscussionThis is the first trial of the GOALS intervention. The approach is brief and staff can be readily trained in its delivery: there is therefore potential to develop a cost-effective intervention that could be widely disseminated. If the trial proves clinically feasible and demonstrates preliminary evidence of efficacy, a large multi-site trial will be warranted.Trial registrationCurrent Controlled Trials ISRCTN: 73188383. http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=13538

Psychological impact of identifying character strengths in people with psychosis

A one group pre–post test design investigated the impact of identifying character strengths using the Values In Action Inventory of Strengths (VIA-IS) with individuals with early psychosis (N = 29). Post-test improvements in positive affect and cognitive performance were observed. Neither self-esteem nor self-efficacy improved. The technique appears feasible for use within early intervention services. Adverse consequences should be monitored and additional components considered to enhance benefits.