Tim Bradshaw

AN INVESTIGATION INTO THE PSYCHOMETRIC PROPERTIES OF THE COGNITIVE THERAPY SCALE FOR PSYCHOSIS (CTS-Psy)

Recent research suggests that cognitive-behaviour therapy (CBT) can significantly improve outcomes for patients with severe mental health problems. However, there are no tools specifically designed to assess competence in delivering CBT to psychotic patients. This study investigates the psychometric properties of the Cognitive Therapy Scale for Psychosis (the CTS-Psy) for assessing the quality of CBT with psychotic patients. Inter-rater reliability of trained raters using the CTS-Psy was investigated using taped therapy of trainees engaged in a CBT oriented psychosis training course. Validity was investigated in relation to examining the degree to which the scale could be used to assess a range of therapist ability and patient severity and by assessing the degree to which the CTS-Psy could pick up changes in skill acquisition during the training course over a 9-month period. The CTS-Psy demonstrated excellent inter-rater reliability and good validity in relation to it being able to rate all standards of therapy and all types of patient sessions in the sample studied. In addition, the scale was sensitive to changes in clinical skills during a training course and could discriminate between those who had received training and those who had not.

Evolving role of mental health nurses in the physical health care of people with serious mental health illness

Life expectancy in members of the general population has steadily improved in most countries since 1960. However, during the same period, the life expectancy of people with serious mental illness (SMI) has actually reduced. The majority of premature deaths result from natural causes, such as coronary heart disease. Obesity, a key risk factor for heart disease in this client group, might be caused both by unhealthy lifestyle behaviours and the side-effects of antipsychotic medication. Mental health nurses (MHN) nurses have an important role to play in improving the physical health of people with SMI. Evidence, however, suggests that they are often ambivalent about this role, and might perceive themselves as being inadequately trained and lacking in confidence. In this paper, we will argue that MHN need to re-evaluate their practice and recognize that the provision of physical health care is as important as other roles they occupy in relation to the care of people with SMI. We will also consider examples of best practice in physical health care, and discuss how these might be adopted by MHN and other professionals, in order to begin to improve services and to reduce health inequalities in this client group.

Life Skills Training in Schizophrenia

Rehabilitation approaches incorporating life skills training are widely employed in the treatment of individuals with schizophrenia. However, whether such approaches are effective is unknown (Nicol et al 2003). This pilot study assessed the effectiveness of a life skills training intervention for people with a diagnosis of schizophrenia, facilitated by occupational therapists working in community mental health teams. Seventeen clients with a diagnosis of schizophrenia and a life skill deficit or deficits were recruited from two National Health Service trusts and participated in up to 12 sessions of life skills training, based upon a treatment manual written specifically for the study. The intervention was facilitated by eight occupational therapists who received training in life skills therapy. A pre-intervention and post-intervention experimental design was used to assess the effectiveness of the programme, with measures of psychiatric symptoms and social functioning being conducted by an independent assessor who was naïve to the intervention being used. For the 13 participants who completed the life skills intervention, participation was found to reduce negative symptoms and overall levels of general psychopathology, although this was not reflected in social functioning. Indeed, a statistically non-significant deterioration in social functioning was found upon completion of the intervention. This uncontrolled study does not allow definitive evaluation of the value of life skills training in schizophrenia, but it does provide justification for a larger-scale controlled trial of a manual based approach to life skills training with this client group.

Bespoke smoking cessation for people with severe mental ill health (SCIMITAR): a pilot randomised controlled trial

BACKGROUND People with severe mental ill health are three times more likely to smoke but typically do not access conventional smoking cessation services, contributing to widening health inequalities and reduced life expectancy. We aimed to pilot an intervention targeted at smokers with severe mental ill health and to test methods of recruitment, randomisation, and follow up before implementing a full trial. METHODS The Smoking Cessation Intervention for Severe Mental Ill Health Trial (SCIMITAR) is a pilot randomised controlled trial of a smoking cessation strategy designed specifically for people with severe mental ill health, to be delivered by mental health nurses and consisting of behavioural support and drugs, compared with a conventional smoking cessation service (ie, usual care). Adults (aged 18 years or older) with bipolar disorder or schizophrenia, who were current smokers, were recruited from NHS primary care and mental health settings in the UK (York, Scarborough, Hull, and Manchester). Eligible participants were randomly allocated to either usual care (control group) or usual care plus the bespoke smoking cessation strategy (intervention group). Randomisation was done via a central telephone system, with computer-generated random numbers. We could not mask participants, family doctors, and researchers to the treatment allocation. Our primary outcome was smoking status at 12 months, verified by carbon monoxide measurements or self-report. Only participants who provided an exhaled CO measurement or self-reported their smoking status at 12 months were included in the primary analysis. The trial is registered at ISRCTN.com, number ISRCTN79497236. FINDINGS Of 97 people recruited to the pilot study, 51 were randomly allocated to the control group and 46 were assigned to the intervention group. Participants engaged well with the bespoke smoking cessation strategy, but no individuals assigned to usual care accessed NHS smoking cessation services. At 12 months, 35 (69%) controls and 33 (72%) people assigned to the intervention group provided a CO measurement or self-reported their smoking status. Smoking cessation was highest among individuals who received the bespoke intervention (12/33 [36%] vs 8/35 [23%]; adjusted odds ratio 2·9, 95% CI 0·8-10·5). INTERPRETATION We have shown the feasibility of recruiting and randomising people with severe mental ill health in a trial of this nature. The level of engagement with a bespoke smoking cessation strategy was higher than with a conventional approach. The effectiveness and safety of a smoking cessation programme designed particularly for people with severe mental ill health should be tested in a fully powered randomised controlled trial. FUNDING National Institute of Health Research Health Technology Assessment Programme.

Music therapy for service users with dementia: a critical review of the literature

Dementia is an organic mental health problem that has been estimated to affect over 23 million people worldwide. With increasing life expectancy in most countries, it has been estimated that the prevalence of dementia will continue to significantly increase in the next two decades. Dementia leads to cognitive impairments most notably short-term memory loss and impairments in functioning and quality of life (QOL). National policy in the UK advocates the importance of early diagnosis, treatment and social inclusion in maintaining a good QOL. First-line treatment options often involve drug therapies aimed at slowing down the progression of the illness and antipsychotic medication to address challenging behaviours. To date, research into non-pharmacological interventions has been limited. In this manuscript, we review the literature that has reported evaluations of the effects of music therapy, a non-pharmacological intervention. The results of six studies reviewed suggest that music therapy may have potential benefits in reducing anxiety, depression and agitated behaviour displayed by elderly people with dementia as well as improving cognitive functioning and QOL. Furthermore, music therapy is a safe and low-cost intervention that could potentially be offered by mental health nurses and other carers working in residential settings.

The development and evaluation of a complex health education intervention for adults with a diagnosis of schizophrenia

Life expectancy in adults with schizophrenia is reduced by approximately 15 years compared with others in the population. Two thirds of premature deaths result from natural causes triggered by unhealthy lifestyles and the side-effects of antipsychotic medication. There is a need to develop and evaluate health education interventions for people with this diagnosis. In this paper we describe how with reference to the UK Medical Research Councils complex interventions framework we developed and evaluated a health education intervention designed specifically for adults with schizophrenia. The study was completed in three separate but interrelated phases: (1) theoretical work was undertaken to identify the components of effective health education interventions; (2) this information was synthesized to develop the intervention; and (3) the intervention was tested in an open exploratory trial which used mixed methods to evaluate the feasibility, acceptability and potential effect of the intervention. 45 service users were referred, 39 attended the groups and 65% attended at least half of the sessions. Participants reported significant increases in their consumption of fruit and vegetables and levels of physical activity. Results suggest that this model of health education is feasible and acceptable for this population and that it shows promise in supporting health-related behaviour changes.

An exploratory randomized controlled study of a healthy living intervention in early intervention services for psychosis: the INTERvention to encourage ACTivity, improve diet, and reduce weight gain (INTERACT) study.

BACKGROUND People with psychosis often experience weight gain, which places them at risk of cardiovascular disease, diabetes, and early death. OBJECTIVE To determine the uptake, adherence, and clinical effectiveness of a healthy living intervention designed to reduce weight gain. METHOD An exploratory randomized controlled trial, comparing the intervention with treatment as usual (TAU) in 2 early intervention services for psychosis in England. DSM-IV classification was the diagnostic criteria used to assign the psychiatric diagnoses. The primary outcome was change in body mass index (BMI) from baseline to 12-month follow-up. The study was conducted between February 2009 and October 2012. RESULTS 105 service users, with a BMI of ≥ 25 (≥ 24 in South Asians), were randomized to intervention (n = 54) or TAU (n = 51) after stratification by recent commencement of antipsychotic medication. Ninety-three service users (89%) were followed up at 12 months. Between-group difference in change in BMI was not significant (effect size = 0.11). The effect of the intervention was larger (effect size = 0.54, not significant) in 15 intervention (28%) and 10 TAU (20%) participants who were taking olanzapine or clozapine at randomization. CONCLUSIONS The healthy living intervention did not show a significant difference in BMI reduction compared to the TAU group. TRIAL REGISTRATION www.isrctn.org identifier: ISRCTN22581937.

An evaluation of the outcomes of psychosocial intervention training for qualified and unqualified nursing staff working in a low-secure mental health unit

Psychosocial intervention (PSI) training results in enhanced knowledge, more positive attitudes, increased confidence and lower levels of clinical burnout for qualified mental health professionals and better outcomes for service users who they work with. This paper describes an evaluation of a PSI training course for qualified and unqualified nurses working in a low-secure unit. Forty-two staff (21 qualified) were randomly allocated to an experimental training group or a waiting list control group. Knowledge, attitudes and burnout were assessed before and after the training. In addition, a random sample of 44 care plans written by the qualified nurses were audited before and after to examine evidence of implementation of PSI in practice. Qualified and unqualified nurses in the experimental group showed significant improvements in knowledge and attitudes compared with the control group. Care plans showed a significant increase in the implementation of PSI. The only significant change in burnout was a reduction in depersonalization for qualified nurses in the experimental group. The PSI training may result in improvements in knowledge, attitude and practice in qualified and unqualified nurses working with severely mentally ill patients in low-secure settings, but in this study the training did not incur protection against burnout.

Obesity and Serious Mental Ill Health: A Critical Review of the Literature

Individuals who experience serious mental ill health such as schizophrenia are more likely to be overweight or obese than others in the general population. This high prevalence of obesity and other associated metabolic disturbances, such as type 2 diabetes and cardiovascular disease, contribute to a reduced life expectancy of up to 25 years. Several reasons have been proposed for high levels of obesity including a shared biological vulnerability between serious mental ill health and abnormal metabolic processes, potentially compounded by unhealthy lifestyles. However, emerging evidence suggests that the most significant cause of weight gain is the metabolic side effects of antipsychotic medication, usual treatment for people with serious mental ill health. In this paper we review the prevalence of obesity in people with serious mental ill health, explore the contribution that antipsychotic medication may make to weight gain and discuss the implications of this data for future research and the practice of mental health and other professionals.

Monitoring of physical health in services for young people at ultra-high risk of psychosis.

People with schizophrenia have poor physical health and high rates of premature mortality. Risk factors for later cardiovascular disease are present from an early stage, and recording of these factors is recommended in first‐episode services. However, it is unclear whether cardiometabolic risk factors are monitored prior to first‐episode psychosis.