Sophie Parker

Early detection and intervention evaluation for people at risk of psychosis: multisite randomised controlled trial

Objective To determine whether cognitive therapy is effective in preventing the worsening of emerging psychotic symptoms experienced by help seeking young people deemed to be at risk for serious conditions such as schizophrenia. Design Multisite single blind randomised controlled trial. Setting Diverse services at five UK sites. Participants 288 participants aged 14-35 years (mean 20.74, SD 4.34 years) at high risk of psychosis: 144 were assigned to cognitive therapy plus monitoring of mental state and 144 to monitoring of mental state only. Participants were followed-up for a minimum of 12 months and a maximum of 24 months. Intervention Cognitive therapy (up to 26 (mean 9.1) sessions over six months) plus monitoring of mental state compared with monitoring of mental state only. Main outcome measures Primary outcome was scores on the comprehensive assessment of at risk mental states (CAARMS), which provides a dichotomous transition to psychosis score and ordinal scores for severity of psychotic symptoms and distress. Secondary outcomes included emotional dysfunction and quality of life. Results Transition to psychosis based on intention to treat was analysed using discrete time survival models. Overall, the prevalence of transition was lower than expected (23/288; 8%), with no significant difference between the two groups (proportional odds ratio 0.73, 95% confidence interval 0.32 to 1.68). Changes in severity of symptoms and distress, as well as secondary outcomes, were analysed using random effects regression (analysis of covariance) adjusted for site and baseline symptoms. Distress from psychotic symptoms did not differ (estimated difference at 12 months −3.00, 95% confidence interval −6.95 to 0.94) but their severity was significantly reduced in the group assigned to cognitive therapy (estimated between group effect size at 12 months −3.67, −6.71 to −0.64, P=0.018). Conclusions Cognitive therapy plus monitoring did not significantly reduce transition to psychosis or symptom related distress but reduced the severity of psychotic symptoms in young people at high risk. Most participants in both groups improved over time. The results have important implications for the at risk mental state concept. Trial registration Current Controlled Trials ISRCTN56283883.

Psychological factors in people at ultra-high risk of psychosis: comparisons with non-patients and associations with symptoms.

BACKGROUND There have been recent advances in the ability to identify people at high risk of developing psychosis. This has led to interest in the possibility of preventing the development of psychosis and provides the opportunity to investigate psychological mechanisms that may confer vulnerability to psychosis. METHOD Fifty-eight patients at ultra-high risk of developing a first episode of psychosis were compared with 56 non-patients matched for age and occupational status on measures of meta-cognition, schizotypal traits, dysfunctional attitudes and distress. RESULTS Analyses of covariance revealed that people at high risk of developing psychosis scored higher on measures of cognitive vulnerability, including negative meta-cognitive beliefs, beliefs about rejection and criticism from others, and discrepancies in self-perception, schizotypal traits and general mental distress. Correlational analyses revealed that negative meta-cognitive beliefs, dysfunctional attitudes and beliefs about rejection and criticism from others were positively associated with several dimensions of symptomatology in at-risk mental states (ARMS) patients. CONCLUSIONS Cognitive and personality factors appear to characterize people at high-risk of developing psychosis and are associated with their distressing experiences. The clinical implications of these findings are discussed.

Prevalence of suicide risk factors in people at ultra-high risk of developing psychosis: a service audit

Background: Little data is available on the prevalence of suicide risk factors in people at ultra‐high risk (UHR) of developing psychosis.

Metacognitive therapy in people with a schizophrenia spectrum diagnosis and medication resistant symptoms: A feasibility study

BACKGROUND AND OBJECTIVES Cognitive behaviour therapy (CBT) for psychosis has been shown to be effective, but there are recent suggestions that it is less efficacious than initially thought. Metacognitive therapy (MCT), which focuses on metacognitive mechanisms, has led to positive results in other disorders, but has yet to be evaluated in people with schizophrenia spectrum diagnoses. This study evaluates the feasibility of MCT for people with psychotic disorders. METHODS Ten participants with schizophrenia spectrum disorders received up to 12 sessions of MCT in an open trial. Outcomes included psychiatric symptoms measured using the PANSS, at baseline, 9 months (end of treatment) and at 12 months (follow-up), as well as dimensions of hallucinations and delusions, emotional dysfunction, self-rated recovery, social functioning and metacognitive beliefs. RESULTS T-tests and Wilcoxons signed ranks tests revealed significant beneficial effects on several outcomes at end-of-treatment and follow-up. Cohens d effect sizes were moderate to large (for PANSS total, d = 1.0 at end of treatment; d = 0.95 at follow-up). A response rate analysis found 50% and 40% of participants achieved at least a 25% reduction in PANSS total scores by end of therapy and follow-up, respectively. Exploratory analyses revealed that metacognitive beliefs significantly changed over treatment and follow-up periods. LIMITATIONS This study had no control group and was not randomised; therefore, it is likely that effect sizes were inflated. CONCLUSIONS This study provides preliminary evidence that MCT is a feasible treatment for people with psychosis. An adequately powered randomised controlled trial is warranted.

Exercise as an intervention for first‐episode psychosis: a feasibility study

Exercise can improve psychiatric symptoms, neurocognitive functioning and physical health in schizophrenia. However, the effects in early psychosis have not been explored. This study aimed to assess the feasibility of an exercise intervention for early psychosis and to determine if it was associated with changes in physical and mental health.

Prevalence of violence risk factors in people at ultra-high risk of developing psychosis: a service audit: Audit of violence risk in a UHR group

Background: There is little data available on the prevalence of violence risk factors in people at ultra‐high risk of developing psychosis.

Identification of young people in the early stages of psychosis: validation of a checklist for use in primary care.

The study aims to establish the concordant validity of the Early Detection Primary Care Checklist (PCCL); a 20 item tool designed to help primary care practitioners identify young people in the early stages of psychosis. The checklist was completed by the referring practitioners of 176 young people referred to early detection teams across the UK. The concordant validity of the checklist was established by comparing screen results with a standardised psychiatric assessment for identifying young people who may be at a risk of developing psychosis (CAARMS). Preliminary analysis found that the simple checklist as originally conceived had excellent sensitivity (96%) but poor specificity (10%). Subsequent exploratory analysis led to the development of two better performing models for the combination of item responses to predict CAARMS outcomes. The first retained the use of all 20 checklist items and achieved sensitivity of 89% and specificity of 60%. The second retained six checklist items with p-values of 0.2 or above and achieved sensitivity of 88% and specificity of 47%. Although the initial checklist did not perform well as a screening tool the two models perform well in comparison to other, much longer, screening tools for this population. These tools are not intended as a diagnostic instrument; rather it has been designed as a bridge between primary care and specialist services and to build on the skills and knowledge already held by primary care practitioners. Following a consideration of the limitations of this study, the continued evaluation of the tools performance in practice is recommended.

Childhood adversity and social functioning in psychosis: Exploring clinical and cognitive mediators

Childhood adversity may increase risk of impaired social functioning across the continuum of psychosis. However, the pathways by which adversity dictates functional outcome remain underexplored. This study investigated the association between childhood adversity and social functioning, and the clinical and cognitive mediators of this relationship. Fifty-four clinical (20 chronic, 20 first episode, 14 at ultra-high risk) and 120 non-clinical participants completed standardised questionnaires, semi-structured interviews and tests of theory of mind ability. The authors used multiple group structural equation modelling to fit mediation models allowing for differential relationships between the clinical and non-clinical samples. When examining each pathway separately, depression, paranoia and anxious attachment mediated the effect of childhood adversity on social functioning. In a combined model, depression was the only significant mediating variable with greater adversity predicting lower mood across groups. Childhood adversity did not significantly predict theory of mind ability in any of the models. This is the first study to indicate that childhood adversity acts on social functioning by increasing levels of depression, suggesting a common mechanism across the spectrum of psychosis. Clinical interventions should target low mood in order to improve social functioning at all stages of psychotic disorder.

Psychopathology and affect dysregulation across the continuum of psychosis : a multiple comparison group study

There is evidence that psychotic‐like phenomena can be detected within the general population and that psychotic experiences lie on a continuum that also spans affective states. We aimed to investigate comparisons of a first‐episode psychosis group, an ‘at‐risk mental state group’ and a help‐seeking control group with non‐patients to explore whether affective states lie on a continuum of psychosis.

Cognitive behavioural therapy for thought disorder in psychosis

Abstract Clinicians are often sceptical about offering cognitive behavioural therapy (CBT) to individuals experiencing thought disorder. This view may result from perceived difficulties in clients being able to learn and better understand their experiences through verbal dialogue. However, it may also partly be due to the lack of clear guidance on how to address and work with these difficulties within therapy. This paper provides recommendations for delivering CBT in individuals experiencing thought disorder. It considers how clinicians might conduct their cognitive behavioural assessment, formulation, and intervention, targeting unhelpful appraisals and behaviour, and generating insight. The aim is to better disseminate the techniques sometimes applied in clinical practice.