Suzanne L. K. Stewart

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.

The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule.

BACKGROUND Self-harm is a common reason for Emergency Department (ED) attendance. We aimed to develop a clinical tool to help identify patients at higher risk of repeat self-harm, or suicide, within 6 months of an ED self-harm presentation. METHOD The tool, the ReACT Self-Harm Rule, was derived using multicentre data from a prospective cohort study. Binary recursive partitioning was applied to data from two centres, and data from a separate centre were used to test the tool. There were 29 571 self-harm presentations to five hospital EDs between January 2003 and June 2007, involving 18 680 adults aged ⩾16 years. We estimated sensitivity, specificity and positive and negative predictive values to measure the performance of the tool. RESULTS A self-harm presentation was classified as higher risk if at least one of the following factors was present: recent self-harm (in the past year), living alone or homelessness, cutting as a method of harm and treatment for a current psychiatric disorder. The rule performed with 95% sensitivity [95% confidence interval (CI) 94-95] and 21% specificity (95% CI 21-22), and had a positive predictive value of 30% (95% CI 30-31) and a negative predictive value of 91% (95% CI 90-92) in the derivation centres; it identified 83/92 of all subsequent suicides. CONCLUSIONS The ReACT Self-Harm Rule might be used as a screening tool to inform the process of assessing self-harm presentations to ED. The four risk factors could also be used as an adjunct to in-depth psychosocial assessment to help guide risk formulation. The use of multicentre data helped to maximize the generalizability of the tool, but we need to further verify its external validity in other localities.

Early detection and intervention evaluation for people at high-risk of psychosis-2 (EDIE-2): Trial rationale, design and baseline characteristics.

Aims: Much research has begun to focus on the identification of people who are at high risk of developing psychosis, and clinical services have been initiated for this population. However, only a small number of studies have reported on the efficacy of interventions for preventing or delaying the onset of psychosis. The results of prior work suggest that cognitive therapy (CT) may be an effective, well‐tolerated treatment. We report on the rationale and design for a large‐scale, multi‐site randomized, controlled trial of CT for people who are assessed to be at high risk of psychosis because of either state or state‐plus‐trait risk factors.

Impact of cognitive therapy on internalised stigma in people with at-risk mental states

BACKGROUND Internalised stigma in young people meeting criteria for at-risk mental states (ARMS) has been highlighted as an important issue, and it has been suggested that provision of cognitive therapy may increase such stigma. AIMS To investigate the effects of cognitive therapy on internalised stigma using a secondary analysis of data from the EDIE-2 trial. METHOD Participants meeting criteria for ARMS were recruited as part of a multisite randomised controlled trial of cognitive therapy for prevention and amelioration of psychosis. Participants were assessed at baseline and at 6, 12, 18 and 24 months using measures of psychotic experiences, symptoms and internalised stigma. RESULTS Negative appraisals of experiences were significantly reduced in the group assigned to cognitive therapy (estimated difference at 12 months was -1.36 (95% CI -2.69 to -0.02), P = 0.047). There was no difference in social acceptability of experiences (estimated difference at 12 months was 0.46, 95% CI -0.05 to 0.98, P = 0.079). CONCLUSIONS These findings suggest that, rather than increasing internalised stigma, cognitive therapy decreases negative appraisals of unusual experiences in young people at risk of psychosis; as such, it is a non-stigmatising intervention for this population.

Internalized stigma, emotional dysfunction and unusual experiences in young people at risk of psychosis.

To investigate the relationship between internalized stigma, depression, social anxiety and unusual experiences in young people considered to be at risk of developing psychosis.

Negative cognition, affect, metacognition and dimensions of paranoia in people at ultra-high risk of psychosis: A multi-level modelling analysis

BACKGROUND Paranoia is one of the commonest symptoms of psychosis but has rarely been studied in a population at risk of developing psychosis. Based on existing theoretical models, including the proposed distinction between ‘poor me’ and ‘bad me’ paranoia, we aimed to test specific predictions about associations between negative cognition, metacognitive beliefs and negative emotions and paranoid ideation and the belief that persecution is deserved (deservedness). METHOD We used data from 117 participants from the Early Detection and Intervention Evaluation for people at risk of psychosis (EDIE-2) trial of cognitive–behaviour therapy, comparing them with samples of psychiatric in-patients and healthy students from a previous study. Multi-level modelling was utilized to examine predictors of both paranoia and deservedness, with post-hoc planned comparisons conducted to test whether person-level predictor variables were associated differentially with paranoia or with deservedness. RESULTS Our sample of at-risk mental state participants was not as paranoid, but reported higher levels of ‘bad-me’ deservedness, compared with psychiatric in-patients. We found several predictors of paranoia and deservedness. Negative beliefs about self were related to deservedness but not paranoia, whereas negative beliefs about others were positively related to paranoia but negatively with deservedness. Both depression and negative metacognitive beliefs about paranoid thinking were specifically related to paranoia but not deservedness. CONCLUSIONS This study provides evidence for the role of negative cognition, metacognition and negative affect in the development of paranoid beliefs, which has implications for psychological interventions and our understanding of psychosis.

Risk factors associated with repetition of self-harm in black and minority ethnic (BME) groups: A multi-centre cohort study

BACKGROUND Little information is available to inform clinical assessments on risk of self-harm repetition in ethnic minority groups. METHODS In a prospective cohort study, using data collected from six hospitals in England for self-harm presentations occurring between 2000 and 2007, we investigated risk factors for repeat self-harm in South Asian and Black people in comparison to Whites. RESULTS During the study period, 751 South Asian, 468 Black and 15,705 White people presented with self-harm in the study centres. Repeat self-harm occurred in 4379 individuals, which included 229 suicides (with eight of these fatalities being in the ethnic minority groups). The risk ratios for repetition in the South Asian and Black groups compared to the White group were 0.6, 95% CI 0.5-0.7 and 0.7, 95% CI 0.5-0.8, respectively. Risk factors for repetition were similar across all three groups, although excess risk versus Whites was seen in Black people presenting with mental health symptoms, and South Asian people reporting alcohol use and not having a partner. Additional modelling of repeat self-harm count data showed that alcohol misuse was especially strongly linked with multiple repetitions in both BME groups. LIMITATIONS Ethnicity was not recorded in a third of cases which may introduce selection bias. Differences may exist due to cultural diversity within the broad ethnic groups. CONCLUSION Known social and psychological features that infer risk were present in South Asian and Black people who repeated self-harm. Clinical assessment in these ethnic groups should ensure recognition and treatment of mental illness and alcohol misuse.

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.

The relationship between theory of mind and insight in psychosis: Evidence for specificity

We predicted that mentalizing relates to social aspects of insight in psychosis. Thirty participants experiencing psychosis and presenting poor to moderate insight undertook a false belief picture sequencing task with control sequences. We used an improved scoring system that accounted simultaneously for speed and accuracy of mentalizing. While mentalizing was not significantly related to global insight, “awareness of psychosis”, “re‐labelling symptoms as abnormal”, or “understanding need for treatment”, it was positively related to the influence of the opinions of unspecified “others” on insight. Participants were insightful in predicting their doctor’s opinion, but this was unrelated to mentalizing. Intact social knowledge about doctors, rather than mentalizing, may be used to understand the doctor’s opinion. However, mentalizing is needed to incorporate others’ opinions about psychosis into one’s own insight, as the perspectives of unspecified “others” would likely vary more than that of medical professionals. The results suggest that medical professionals should be careful to distinguish simple recognition of their views from genuine insight.

Mental state references in psychosis: A pilot study of prompted implicit mentalising during dialogue and its relationship with social functioning

Introduction. Few studies of psychosis have examined dialogue-based implicit mentalising even though this is likely to reflect the skills required in everyday life better than more typical mentalising tasks. Using a semistructured dialogue task, we predicted that a psychosis sample would be impaired in “prompted” online mentalising (i.e., the frequency and variety of mental and emotional state words as well as references to own mental state) and that performance would relate to social functioning. Methods. Eighteen adults with psychosis and nine healthy adults were each recorded during four semistructured dialogues, which were transcribed, coded, scored, and quantitatively analysed. The patients also completed a measure of social functioning. Results. Compared to controls, the psychosis participants referred to others’ mental and emotional states significantly less and with a lower variety of words. These findings were all large effects with sufficient observed power. There was no significant difference in references to own mental state. The relationships between mentalising and social functioning were mostly modest. Conclusions. Although prompted implicit mentalising is impoverished in psychosis, self-knowledge appears to be intact. Simulation-based mentalising may be spared in the context of impoverished theory-based mentalising. Also, implicit mentalising contributes to social functioning, corroborating the results of previous work.