Evaluating end of treatment care of young people with cancer.

BACKGROUND: Existing literature implies there may be gaps in post-treatment support for young people with cancer. This service evaluation explored the needs and experiences of young people when ending cancer treatment in a UK children's hospital to inform service provisions. METHODS: Semi-structured interviews were conducted with nine young people, aged 13-18 years, who had finished active cancer treatment and were receiving follow-up care. The data was analysed using thematic analysis. RESULTS: Four main themes were developed: being in the dark (i.e. limited awareness of what happens when treatment ends); separation from the hospital (i.e. the loss of valued support from staff); consequences of cancer (i.e. managing ongoing psychological and physical effects); and getting back to normal life (i.e. shifting from hospital to everyday life). CONCLUSIONS: Recommendations for improving clinical practice were made. Greater preparedness for ending treatment could be achieved by clearly setting out ongoing care arrangements, providing resource packs, having opportunities to mark the end of treatment, and offering peer support. To identify specific post-treatment needs, there should be an end of treatment multidisciplinary review and space for young people to share how they are feeling in follow-up medical appointments.

Automated virtual reality cognitive therapy versus virtual reality mental relaxation therapy for the treatment of persistent persecutory delusions in patients with psychosis (THRIVE): a parallel-group, single-blind, randomised controlled trial in England with mediation analyses.

BACKGROUND: Persecutory delusions are a major psychiatric problem that often do not respond sufficiently to standard pharmacological or psychological treatments. We developed a new brief automated virtual reality (VR) cognitive treatment that has the potential to be used easily in clinical services. We aimed to compare VR cognitive therapy with an alternative VR therapy (mental relaxation), with an emphasis on understanding potential mechanisms of action. METHODS: THRIVE was a parallel-group, single-blind, randomised controlled trial across four UK National Health Service trusts in England. Participants were included if they were aged 16 years or older, had a persistent (at least 3 months) persecutory delusion held with at least 50% conviction, reported feeling threatened when outside with other people, and had a primary diagnosis from the referring clinical team of a non-affective psychotic disorder. We randomly assigned (1:1) patients to either THRIVE VR cognitive therapy or VR mental relaxation, using a permuted blocks algorithm with randomly varying block size, stratified by severity of delusion. Usual care continued for all participants. Each VR therapy was provided in four sessions over approximately 4 weeks, supported by an assistant psychologist or clinical psychologist. Trial assessors were masked to group allocation. Outcomes were assessed at 0, 2 (therapy mid-point), 4 (primary endpoint, end of treatment), 8, 16, and 24 weeks. The primary outcome was persecutory delusion conviction, assessed by the Psychotic Symptoms Rating Scale (PSYRATS; rated 0-100%). Outcome analyses were done in the intention-to-treat population. We assessed the treatment credibility and expectancy of the interventions and the two mechanisms (defence behaviours and safety beliefs) that the cognitive intervention was designed to target. This trial is prospectively registered with the ISRCTN registry, ISRCTN12497310. FINDINGS: From Sept 21, 2018, to May 13, 2021 (with a pause due to COVID-19 pandemic restrictions from March 16, 2020, to Sept 14, 2020), we recruited 80 participants with persistent persecutory delusions (49 [61%] men, 31 [39%] women, with a mean age of 40 years [SD 13, range 18-73], 64 [80%] White, six [8%] Black, one [1%] Indian, three [4%] Pakistani, and six [8%] other race or ethnicity). We randomly assigned 39 (49%) participants assigned to VR cognitive therapy and 41 (51%) participants to VR mental relaxation. 33 (85%) participants who were assigned to VR cognitive therapy attended all four sessions, and 35 (85%) participants assigned to VR mental relaxation attended all four sessions. We found no significant differences between the two VR interventions in participant ratings of treatment credibility (adjusted mean difference -1·55 [95% CI -3·68 to 0·58]; p=0·15) and outcome expectancy (-0·91 [-3·42 to 1·61]; p=0·47). 77 (96%) participants provided follow-up data at the primary timepoint. Compared with VR mental relaxation, VR cognitive therapy did not lead to a greater improvement in persecutory delusions (adjusted mean difference -2·16 [-12·77 to 8·44]; p=0·69). Compared with VR mental relaxation, VR cognitive therapy did not lead to a greater reduction in use of defence behaviours (adjusted mean difference -0·71 [-4·21 to 2·79]; p=0·69) or a greater increase in belief in safety (-5·89 [-16·83 to 5·05]; p=0·29). There were 17 serious adverse events unrelated to the trial (ten events in seven participants in the VR cognitive therapy group and seven events in five participants in the VR mental relaxation group). INTERPRETATION: The two VR interventions performed similarly, despite the fact that they had been designed to affect different mechanisms. Both interventions had high uptake rates and were associated with large improvements in persecutory delusions but it cannot be determined that the treatments accounted for the change. Immersive technologies hold promise for the treatment of severe mental health problems. However, their use will likely benefit from experimental research on the application of different therapeutic techniques and the effects on a range of potential mechanisms of action. FUNDING: Medical Research Council Developmental Pathway Funding Scheme and National Institute for Health and Care Research Oxford Health Biomedical Research Centre.

The lived experience of adolescent depression: A systematic review and meta-aggregation.

BACKGROUND: The under-detection of depression in adolescents suggests that a better understanding of its presentation may be needed. Conceptualizations of adolescent depression are largely the same as adult depression, with minimal consideration of developmental stage. Exploration of first-hand accounts could help to identify any unique features of adolescent depression. Therefore, this systematic review aimed to understand the lived experience of adolescents with depression to inform clinical practice. METHODS: The review was registered with PROSPERO (CRD42020198141). Databases (PsychINFO, CINAL, MEDLINE and EMBASE) were searched in March 2022 to identify peer-reviewed qualitative studies on first-hand experiences of adolescent depression. The Joanna Briggs Institute's qualitative data extraction tool and checklist for qualitative research were used to obtain study data and assess methodological quality of included papers. Meta-aggregation was the method of synthesis, whereby extracted themes from the papers were grouped according to shared meanings. RESULTS: Fifteen papers of mixed methodological quality were identified for inclusion from screening a total of 1,983 references. Studies were published between 2002 and 2021, spanned seven countries and included participants aged 11 to 22 years old. Aggregation of 56 themes resulted in 16 categories and 3 synthesized findings encompassing key aspects of adolescent depression: causes, symptoms and coping. Variability in adolescents' perspectives across these domains was evident. Some symptoms described, such as social disconnection and anger, are not listed in existing diagnostic criteria. CONCLUSIONS: Subjective experiences of depression among adolescents vary and may not entirely match diagnostic criteria. Awareness of this when assessing for depression may improve detection and help to ensure adolescents feel understood.

Individual differences in affective flexibility predict future anxiety and worry.

Deficits in cognitive flexibility have been associated with anxiety and worry, however few studies have assessed cognitive flexibility in the context of emotional stimuli (i.e. affective flexibility). The present study (n = 79) investigated whether individual differences in affective flexibility predict levels of trait anxiety and worry over a period of seven weeks. Affective flexibility was measured using a task-switching paradigm. Results showed that less efficient shifting of attention towards affective aspects of positive stimuli predicted higher anxiety over time. Additionally, more efficient shifting of attention away from affective towards non-affective aspects of negative stimuli predicted higher anxiety and worry over time. This latter finding may be understood by considering theoretical models and empirical evidence associating avoidance of negative information with increased anxiety. The effects were small and require replication in larger, representative samples, but they are an initial indication that anxiety may not be associated with general impairments in cognitive flexibility. Instead, our study emphasises the importance of breaking down cognitive flexibility into different components to investigate more nuanced relationships.

The weeks before 100 persecutory delusions: the presence of many potential contributory causal factors.

BACKGROUND: The period before the formation of a persecutory delusion may provide causal insights. Patient accounts are invaluable in informing this understanding. AIMS: To inform the understanding of delusion formation, we asked patients about the occurrence of potential causal factors - identified from a cognitive model - before delusion onset. METHOD: A total of 100 patients with persecutory delusions completed a checklist about their subjective experiences in the weeks before belief onset. The checklist included items concerning worry, images, low self-esteem, poor sleep, mood dysregulation, dissociation, manic-type symptoms, aberrant salience, hallucinations, substance use and stressors. Time to reach certainty in the delusion was also assessed. RESULTS: Most commonly it took patients several months to reach delusion certainty (n = 30), although other patients took a few weeks (n = 24), years (n = 21), knew instantly (n = 17) or took a few days (n = 6). The most frequent experiences occurring before delusion onset were: low self-confidence (n = 84); excessive worry (n = 80); not feeling like normal self (n = 77); difficulties concentrating (n = 77); going over problems again and again (n = 75); being very negative about the self (n = 75); images of bad things happening (n = 75); and sleep problems (n = 75). The average number of experiences occurring was high (mean 23.5, s.d. = 8.7). The experiences clustered into six main types, with patients reporting an average of 5.4 (s.d. = 1.0) different types. CONCLUSIONS: Patients report numerous different experiences in the period before full persecutory delusion onset that could be contributory causal factors, consistent with a complex multifactorial view of delusion occurrence. This study, however, relied on retrospective self-report and could not determine causality. DECLARATION OF INTEREST: None.

The comments of voices on the appearance of patients with psychosis: 'the voices tell me that I am ugly'.

BACKGROUND: There are high rates of obesity and low self-esteem in patients with psychosis. The occurrence of negative voice content directly about appearance is therefore plausible. Derogatory comments about appearance are likely to be distressing, increase depression and contribute to social withdrawal. AIMS: To systematically assess the occurrence of voice content regarding appearance and identify correlates. METHOD: Sixty patients experiencing verbal auditory hallucinations at least once a week in the context of non-affective psychosis completed a measure assessing positive and negative voice content about appearance. They also completed assessments about body image, self-esteem, psychiatric symptoms and well-being. RESULTS: Fifty-five (91.7%) participants reported hearing voices comment on their appearance. A total of 54 (90%) patients reported negative voice content about their appearance with 30 (50%) patients experienced negative appearance comments on a daily basis. The most common negative comment was 'the voices tell me that I am ugly' (n = 48, 80%). There were 39 (65%) patients who reported positive voice content on appearance. The most frequent positive comment was 'I look as nice as other people' (n = 26, 43.3%). Negative voice content about appearance was associated with body image concerns, paranoia, voice hearing severity, depression, worry, negative self-beliefs and safety-seeking behaviours. Positive appearance voice content was associated with greater body esteem and well-being and lower levels of depression and insomnia. CONCLUSIONS: Voice content about appearance is very common for patients seen in clinical services. Negative voice content may reflect - and subsequently reinforce - negative beliefs about one's appearance, low self-esteem, worry and paranoia. DECLARATION OF INTEREST: None.