A systematic review and meta-analysis of studies exploring prevalence of non-specific anxiety in undergraduate university students.

BACKGROUND: Anxiety is a common mental health problem in the general population, and is associated with functional impairment and negative impacts upon quality of life. There has been increased concern about university students' mental health in recent years, with a wide range of non-specific anxiety rates reported worldwide in undergraduate university students. We aimed to explore prevalence of non-specific anxiety in undergraduate university student populations. METHODS: Four databases were searched to identify studies published between 1980 and 2020 which investigated prevalence of non-specific anxiety in undergraduate university students. Each study's quality was appraised using a checklist. Sub-analyses were undertaken reflecting outcome measure utilized, course of study, location of study, and whether study was before or during the COVID-19 pandemic. RESULTS: A total of 89 studies - representing approx. 130,090 students-met inclusion criteria. Eighty-three were included in meta-analysis, calculating a weighted mean prevalence of 39.65% (95% CI: 35.72%-43.58%) for non-specific anxiety. Prevalence from diagnostic interview studies ranged from 0.3%-20.8% 12-month prevalence. Prevalence varied by outcome measure used to assess non-specific anxiety, the type of course studied by sample, and by study location. In half the studies, being female was associated with being more likely to have higher non-specific anxiety scores and/or screening above thresholds. Few of the included studies met all quality appraisal criteria. CONCLUSION: The results suggest that approximately a third of undergraduate students are experiencing elevated levels of non-specific anxiety. Results from sub-analyses have identified some methodological issues that need consideration in appraising prevalence in this population.

A Systematic Review of the Effects of Urban Living on Suicidality and Self-Harm in the UK and Ireland.

We conducted a systematic review to answer the following: (a) Is there any evidence to support increased prevalence of suicidality and self-harm (i.e. self-harm or suicidality) in urban versus rural environments? (b) What aspects of the urban environment pose risk for suicidality and self-harm? Thirty-five studies met our criteria. Our findings reflect a mixed picture, but with a tendency for urban living to be associated with an increased risk of suicidality and self-harm over rural living, particularly for those living in deprived areas. Further research should focus on the clustering and additive effects of risk and protective factors for suicidality and self-harm in urban environments.

A cross-sectional study of auditory verbal hallucinations experienced by people with a diagnosis of borderline personality disorder.

BACKGROUND: The presence of auditory verbal hallucinations (AVHs) does not currently feature in the main diagnostic criteria for borderline personality disorder (BPD). However, there is accumulating evidence that a high proportion of BPD patients report longstanding and frequent AVHs which constitute a significant risk factor for suicide plans and attempts, and hospitalization. AIM: This study addressed questions about the validity and phenomenology of AVHs in the context of BPD. The longer-term aim is to facilitate the development and translation of treatment approaches to address the unmet need of this population. METHOD: This was a cross-sectional study, combining phenomenological and psychological assessments administered in person and online. We explored the experiences of 48 patients with a diagnosis of BPD who were hearing AVHs. RESULTS: Participants gave 'consistent' reports on the measure of AVH phenomenology, suggesting that these experiences were legitimate. Similar to AVHs in a psychosis context, AVHs were experienced as distressing and appraised as persecutory. AVHs were found to be weakly associated with BPD symptoms. AVHs were also rated highly as a treatment priority by the majority of participants. CONCLUSION: The findings suggest that AVH is a legitimate and distressing symptom of BPD and a treatment priority for some patients. The relative independence of AVHs from other BPD symptoms and emotional states suggests that psychological treatment may need to be targeted specifically at the symptom of AVHs. This treatment could be adapted from cognitive behaviour therapy, the psychological intervention that is recommended for the treatment of AVHs in the context of psychosis.

Pilot evaluation of a brief training video aimed at reducing mental health stigma amongst emergency first responders (the ENHANcE II study).

BACKGROUND: First responders (i.e. police and ambulance staff) have increasingly become part of the mental health care system, often being the first port of call for those experiencing a crisis. Despite their frequent involvement in supporting those with mental health problems, there is evidence that mental health stigma is high amongst first responders. AIMS: The aim of the present study was to evaluate a brief training video aimed at reducing mental health stigma amongst first responders. METHODS: First responders watched a training video based on the cognitive behavioural model of mental health stigma, and involved contributions from people with lived experience, and first responders. Measures of mental health stigma were collected before and after viewing the training. RESULTS: The training video produced small but significant improvements in mental health stigma, and these effects did not differ between police and ambulance staff. We were unable to determine what psychological constructs mediated this change in stigma. The feedback on the training video was generally positive, but also indicated some key areas for future development. CONCLUSIONS: The present study provides encouraging evidence that levels of mental health stigma can be improved using a resource-light training intervention.

Predictors of UK postgraduate researcher attendance behaviours and mental health-related attrition intention.

High rates of postgraduate researchers (PGRs) terminate their studies early. This attrition can have detrimental personal consequences, and results in a loss of productivity, and research and innovation for the higher education sector and society as a whole. PGRs are vulnerable to the experience of mental health problems; a factor that appears to be increasing attrition amongst students in the UK. However, investigation of the determinants of problems with PGRs' attendance and influencing intention to discontinue their studies is rare. Here, we consider the relative predictive validity of a set of putative predictors (mental health symptoms, demographic, occupational, psychological, social, and relational) of attendance behaviours (absenteeism, presenteeism, mental health-related intermission) and early attrition intention amongst UK PGRs. Depression, anxiety, and suicidality predicted attendance behaviours and greater attrition intention. Individual demographic and occupational factors predicted all outcomes. Psychological, social and relational factors had less predictive validity, although individual variables in these conceptual clusters did significantly predict some outcomes. Our results suggest that interventions to reduce high rates of mental health problems are likely to improve attendance behaviours, and reduce the extent to which PGRs intermit or consider ending their PhD studies for mental health-related reasons. Initiatives designed to improve supervisory relationships and reduce loneliness may also reduce absenteeism, intermission and attrition intention.

Demographic predictors of wellbeing in Carers of people with psychosis: secondary analysis of trial data.

BACKGROUND: Carers of people with psychosis are at a greater risk of physical and mental health problems compared to the general population. Yet, not all carers will experience a decline in health. This predicament has provided the rationale for research studies exploring what factors predict poor wellbeing in carers of people with psychosis. Our study builds on previous research by testing the predictive value of demographic variables on carer wellbeing within a single regression model. METHODS: To achieve this aim, we conducted secondary analysis on two trial data sets that were merged and recoded for the purposes of this study. RESULTS: Contrary to our hypotheses, only carer gender and age predicted carer wellbeing; with lower levels of carer wellbeing being associated with being female or younger (aged under 50). However, the final regression model explained only 11% of the total variance. CONCLUSIONS: Suggestions for future research are discussed in light of the limitations inherent in secondary analysis studies. Further research is needed where sample sizes are sufficient to explore the interactive and additive impact of other predictor variables.

Preventing family transmission of anxiety: Feasibility RCT of a brief intervention for parents.

OBJECTIVES: Children of anxious parents are at high risk of anxiety disorders themselves. The evidence suggests that this is due to environmental rather than genetic factors. However, we currently do little to reduce this risk of transmission. There is evidence that supporting parenting in those with mental health difficulties can ameliorate this risk. Therefore, the objective of this study was to test the feasibility of a new one-session, group-based, preventive parenting intervention for parents with anxiety disorders. DESIGN: Feasibility Randomized Controlled Trial. METHODS: A total of 100 parents with anxiety disorders, recruited from adult mental health services in England (and child aged 3-9 years), were randomized to receive the new intervention (a 1-day, group workshop), or to treatment as usual. Children's anxiety disorder and anxiety symptoms were assessed to 12 months by outcome assessors who were blind to group allocation. Exploratory analyses were conducted on an intention to treat basis, as far as possible. RESULTS: A total of 51 participants were randomized to the intervention condition and 49 to the control condition (82% and 80% followed to 12 months, respectively). The attendance rate was 59%, and the intervention was highly acceptable to parents who received it. The RCT was feasible, and 12-month follow-up attrition rates were low. Children whose parents were in the control condition were 16.5% more likely to have an anxiety disorder at follow-up than those in the intervention group. No adverse events were reported. CONCLUSIONS: An inexpensive, light-touch, psycho-educational intervention may be useful in breaking the intergenerational cycle of transmission of anxiety disorders. A substantive trial is warranted. PRACTITIONER POINTS: Anxiety disorders run in families, but we currently do little to help anxious parents to raise confident children. A brief group workshop was highly acceptable to such parents and was very inexpensive to run. Children of parents who took part in the brief intervention were 16.5% less likely to have an anxiety disorder, 1 year later, than children whose parents were in the control group. This was a feasibility study, and while it showed that both the intervention and the research were feasible, the study needs replicating with a much larger sample. Many parents faced barriers to attending the workshop, and future efforts should focus on widening accessibility. We were unable to obtain sufficient self-report data from children, so the outcomes are based on parent report only.

Understanding clinician attitudes towards implementation of guided self-help cognitive behaviour therapy for those who hear distressing voices: using factor analysis to test normalisation process theory.

BACKGROUND: The Normalisation Process Theory (NPT) has been used to understand the implementation of physical health care interventions. The current study aims to apply the NPT model to a secondary mental health context, and test the model using exploratory factor analysis. This study will consider the implementation of a brief cognitive behaviour therapy for psychosis (CBTp) intervention. METHODS: Mental health clinicians were asked to complete a NPT-based questionnaire on the implementation of a brief CBTp intervention. All clinicians had experience of either working with the target client group or were able to deliver psychological therapies. In total, 201 clinicians completed the questionnaire. RESULTS: The results of the exploratory factor analysis found partial support for the NPT model, as three of the NPT factors were extracted: (1) coherence, (2) cognitive participation, and (3) reflexive monitoring. We did not find support for the fourth NPT factor (collective action). All scales showed strong internal consistency. Secondary analysis of these factors showed clinicians to generally support the implementation of the brief CBTp intervention. CONCLUSIONS: This study provides strong evidence for the validity of the three NPT factors extracted. Further research is needed to determine whether participants' level of seniority moderates factor extraction, whether this factor structure can be generalised to other healthcare settings, and whether pre-implementation attitudes predict actual implementation outcomes.

Understanding Public Perceptions of Virtual Reality Psychological Therapy Using the Attitudes Towards Virtual Reality Therapy (AVRT) Scale: Mixed Methods Development Study.

BACKGROUND: Virtual reality (VR) psychological therapy has the potential to increase access to evidence-based mental health interventions by automating their delivery while maintaining outcomes. However, it is unclear whether these more automated therapies are acceptable to potential users of mental health services. OBJECTIVE: The main aim of this study was to develop a new, validated questionnaire to measure public perceptions of VR therapy (VRT) guided by a virtual coach. We also aimed to explore these perceptions in depth and test how aspects such as familiarity with VR and mental health are associated with these perceptions, using both quantitative and qualitative approaches. METHODS: We used a cross-sectional mixed methods design and conducted an exploratory factor analysis of a questionnaire that we developed, the Attitudes Towards Virtual Reality Therapy (AVRT) Scale, and a qualitative content analysis of the data collected through free-text responses during completion of the questionnaire. RESULTS: We received 295 responses and identified 4 factors within the AVRT Scale, including attitudes toward VRT, expectation of presence, preference for VRT, and cost-effectiveness. We found that being more familiar with VR was correlated with more positive attitudes toward VRT (factor 1), a higher expectation of presence (factor 2), a preference for VRT over face-to-face therapy (factor 3), and a belief that VRT is cost-effective (factor 4). Qualitative data supported the factors we identified and indicated that VRT is acceptable when delivered at home and guided by a virtual coach. CONCLUSIONS: This study is the first to validate a scale to explore attitudes toward VRT guided by a virtual coach. Our findings indicate that people are willing to try VRT, particularly because it offers increased access and choice, and that as VR becomes ubiquitous, they will also have positive attitudes toward VRT. Future research should further validate the AVRT Scale.

Is it time to change the approach of mental health stigma campaigns? An experimental investigation of the effect of campaign wording on stigma and help-seeking intentions.

INTRODUCTION: Mental health stigma causes a range of diverse and serious negative sequelae. Anti-stigma campaigns have largely aligned with medical theories and categorical approaches. Such campaigns have produced some improvements, but mental health stigma is still prevalent. The effect of alternative theoretical perspectives on mental health within anti-stigma campaigns has not been tested. Moreover, we do not know their effect on help-seeking intentions. METHODS: We conducted an online experimental pre-post study comparing the effects of two anti-stigma campaign posters on mental health stigma and help-seeking intentions. One poster adhered to the medical, categorical approach to mental health, whereas the other poster portrayed mental health problems in line with a non-categorical, continuous perspective. RESULTS: After controlling for familiarity with the campaign poster, country of residence and pre-test scores, we found no significant between-group differences in terms of help-seeking intentions and all stigma attitudes except for danger-related beliefs. That is, those who viewed the non-categorical poster reported an increased perception that people with mental health problems are dangerous. DISCUSSION: Our largely null findings may suggest the equivalence of these posters on stigma and help-seeking intentions but may also reflect the brevity of the intervention. Our findings concerning danger beliefs may reflect a Type I error, the complexities of stigma models, or the adverse effects of increased perceived contact. Further research is needed to test the effects of differing mental health paradigms on stigma and help-seeking intentions over a longer duration.

Creating a hierarchy of mental health stigma: testing the effect of psychiatric diagnosis on stigma.

BACKGROUND: Levels of mental health stigma experienced can vary as a function of the presenting mental health problem (e.g. diagnosis and symptoms). However, these studies are limited because they exclusively use pairwise comparisons. A more comprehensive examination of diagnosis-specific stigma is needed. AIMS: The aim of our study was to determine how levels of mental health stigma vary in relation to a number of psychiatric diagnoses, and identify what attributions predict levels of diagnosis-specific stigma. METHOD: We conducted an online survey with members of the public. Participants were assessed in terms of how much stigma they had, and their attributions toward, nine different case vignettes, each describing a different mental health diagnosis. RESULTS: We recruited 665 participants. After controlling for social desirability bias and key demographic variables, we found that mental health stigma varied in relation to psychiatric diagnosis. Schizophrenia and antisocial personality disorder were the most stigmatised diagnoses, and depression, generalised anxiety disorder and obsessive-compulsive disorder were the least stigmatised diagnoses. No single attribution predicted stigma across diagnoses, but fear was the most consistent predictor. CONCLUSIONS: Assessing mental health stigma as a single concept masks significant between-diagnosis variability. Anti-stigma campaigns are likely to be most successful if they target fearful attributions.

The cognitive-phenomenological assessment of delusions and hallucinations at the early intervention in psychosis service stage: The results of a quality improvement project.

AIM: Clinical assessments are vital for gaining an understanding of a patients' presenting problem. A priority for Early Intervention in Psychosis Service staff is understanding and supporting their patients' experiences of hallucinations and/or delusions. We aimed to identify what cognitive-phenomenology dimensions of hallucinations and delusions EIPS staff were assessing with their patients. METHODS: We developed a brief checklist of cognitive-phenomenological dimensions of hallucinations and delusions called the Lived Experience Symptom Survey (LESS) based on relevant literature. As part of a Quality Improvement Project, we reviewed the health records of a sub-sample of EIPS patients using the LESS identifying whether each dimension was present or absent. RESULTS: We found that all patients had been asked about the content of their hallucinations and/or delusions, and the majority had been asked about the valence of this content. Despite patients having experienced psychosis for almost 2 years on average, less than half of patients were asked about the potential or actual harm associated with these symptoms. All other cognitive-phenomenological dimensions were assessed inconsistently. CONCLUSIONS: The assessment of hallucination and delusions in our EIPS was inconsistent and incomprehensive. These findings require replication in other EIPS' but may point to a need for guidelines and training around how to conduct a thorough assessment of hallucinations and delusions for current and future EIPS staff. Improved assessment of these symptoms will aid the development of risk assessments and treatment plans.

Caring for Carers (C4C): Results from a feasibility randomised controlled trial of positive written disclosure for older adult carers of people with psychosis.

BACKGROUND: Older adult carers of people who experience psychosis are at increased risk of developing physical and mental health problems due to the compounding factors of supporting their care-recipient and the health changes associated with ageing. Effective interventions exist but can be difficult to access and maintain prolonged engagement. Self-directed writing therapies, frequently referred to as Written Emotional Disclosure (WED), might be a suitable alternative intervention to improve the wellbeing of carers. METHODS: This study aimed to determine the feasibility (recruitment, retention and primary outcome completion) and acceptability of a specific WED intervention known as Positive Written Disclosure (PWD). Informal carers of people with psychosis were randomised to PWD, neutral writing or no writing. Quantitative outcomes including positive and negative affect, carer wellbeing, quality of life, depression, anxiety, stress, self-efficacy, leisure time satisfaction as well as health care utilisation were collected at baseline, 1-, 3-, and 6-month assessments. Qualitative feedback was also collected via questionnaire and semi-structured interviews from those randomised to either writing group. RESULTS: We successfully met our progression criteria, recruiting to target and within timeframes whilst attaining 97% retention and 84% primary outcome data completed at 6 months. Carers randomised to the positive writing group described the intervention as enabling them to have a more positive attitude and focus on activities for themselves. Both writing groups described their tasks as providing distraction from caring responsibilities. However, some carers found the narrow positive emotion focus challenging. CONCLUSIONS: PWD is a feasible and acceptable intervention for older adult carers of people with psychosis within a community setting. Further refinement of the writing protocol to include choice in type of emotion disclosed in addition to screening for some level of need may be required in future trials to reduce floor/ceiling effects of outcomes which may explain the lack of change observed.

Do carers of adolescents at first episode psychosis have distinctive psychological needs? A pilot exploration.

BACKGROUND: Carers of patients experiencing first episode psychosis (FEP) are at an increased risk of mental and physical health problems themselves. However, little is known about how the psychological needs of carers may differ between those caring for an adolescent versus an adult who has FEP. AIMS: This pilot study aimed to explore any differences in the psychological needs of carers caring for adolescents versus adults with FEP. METHODS: We surveyed 254 carers of 198 FEP patients (34 carers of adolescents of 24 FEP adolescent patients). Carers completed self-report measures of anxiety, depression, burnout, subjective burden, coping, and key illness beliefs. The sample was divided according to whether the patient was under (adolescent) or over (adult) age 18, and analysed using mixed model logistic regressions. RESULTS: Compared to the carers of adult patients, carers of adolescents were more than twice as likely (12% vs. 30%) to experience overall burnout syndrome (all three domains), and to develop it much quicker (19.4 vs. 10.1 months). They were also more likely to adopt behavioural disengagement avoidance as a form of coping. However, there was no difference between carers in terms of anxiety, depression, beliefs and subjective burden. For carers of adolescents, burnout was independently predicted by: a negative belief about the consequences of psychosis for the adolescent patient and an incoherent understanding of the patient's mental health. CONCLUSIONS: If our findings can be replicated in a larger sample, then Rapid-Onset-Burnout-Syndrome (ROBS) is a particular problem in carers of adolescents at FEP, suggesting a need for routine screening and possible prophylactic intervention. Carers of adolescent's use of behavioural escape coping maybe also require early intervention. Theoretically, consideration could be given to the development of an adolescent sub-branch to the cognitive model of caregiving.

Enhancing mental health awareness in emergency services (the ENHANcE I project): cross-sectional survey on mental health stigma among emergency services staff.

BACKGROUND: The number of mental health-related 999 calls to emergency services has increased in recent years. However, emergency services staff have an unfavourable reputation when it comes to supporting people experiencing mental health problems. AIMS: To assess the levels of explicit and implicit mental health stigma among accident and emergency, ambulance and police staff, and draw comparisons with the general population. Additional analyses sought to identify which variables predict mental health stigma among emergency services staff. METHOD: A cross-sectional survey of 1837 participants, comprising four independent groups (accident and emergency, ambulance and police staff, and the general population). RESULTS: Levels of mental health stigma across all four groups were lower than those reported in recent surveys of the general population by the 'Time to Change' campaign. Within this study, explicit levels of mental health stigma were lower among the general population compared with emergency services staff. There was no difference between emergency service professions, nor were there any between-group differences in terms of implicit mental health stigma. The only consistent predictors of mental health stigma were attitudes and future behavioural intentions, whereby increased stigma was predicted by increased fear, reduced sympathy and greater intended discrimination. CONCLUSIONS: Our findings suggest that levels of mental health stigma have improved over time, but there is room for improvement in emergency services staff. Interventions to improve mental health stigma may be most effective if, in line with the cognitive-behavioural model of stigma, they target attitudes and behavioural intentions.

The Staff Views About Assessing Voices Questionnaire: Piloting a Novel Socratic Method of Evaluating and Training Multidisciplinary Staff's Cognitive Assessment of Patients' Distressing Voices.

Cognitive features of auditory hallucinations (voices) have important clinical significance and their assessment is vital for cognitive behavior therapy to be more widely deployed by multidisciplinary staff. Using a new Socratic instrument-The Staff Views About Assessing Voices Questionnaire (SVAVQ)-we surveyed a community inpatient rehabilitation multidisciplinary workforce's (N = 50) assessment and attitude toward asking cognitive questions about patients' voices. We found that there were many clinically important gaps in what staff asked about in relation to cognitive features of voices. We identified a range of beliefs the staff hold that may prevent assessment of voice cognitive features. However, after attending the Socratic SVAVQ interview, 84% of staff said they planned to ask patients more questions about cognitive features of patients' voices. Research could now test if other psychosis services neglect the assessment of important cognitive features of patients' voices and if staff Socratic questioning improves their cognitive assessments.

Understanding the mental health of doctoral researchers: a mixed methods systematic review with meta-analysis and meta-synthesis.

BACKGROUND: Data from studies with undergraduate and postgraduate taught students suggest that they are at an increased risk of having mental health problems, compared to the general population. By contrast, the literature on doctoral researchers (DRs) is far more disparate and unclear. There is a need to bring together current findings and identify what questions still need to be answered. METHODS: We conducted a mixed methods systematic review to summarise the research on doctoral researchers' (DRs) mental health. Our search revealed 52 articles that were included in this review. RESULTS: The results of our meta-analysis found that DRs reported significantly higher stress levels compared with population norm data. Using meta-analyses and meta-synthesis techniques, we found the risk factors with the strongest evidence base were isolation and identifying as female. Social support, viewing the PhD as a process, a positive student-supervisor relationship and engaging in self-care were the most well-established protective factors. CONCLUSIONS: We have identified a critical need for researchers to better coordinate data collection to aid future reviews and allow for clinically meaningful conclusions to be drawn. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration CRD42018092867.

Barriers to recruiting and retaining psychosis carers: a case study on the lessons learned from the Caring for Caregivers (C4C) trial.

OBJECTIVE: Carers play an important role within the UK mental health system. Those carers who support persons with psychosis can experience a reduction in their own physical and mental health. As part of the Caring for Caregivers (C4C) trial, we piloted a writing intervention (Positive Written Disclosure) that has been shown to improve wellbeing in other populations. Although we reached our recruitment target, we encountered several barriers that made recruitment slower than anticipated. This paper synthesises the process data collected during the C4C trial that relates to the barriers to recruiting and retaining psychosis carers. RESULTS: We encountered four main carer-specific barriers to the recruitment and retention of participants in our study. These were: (1) poor relationship with mental health clinicians, (2) conflicting with the care recipient's (CR) needs, (3) lack of spare time, and (4) lack of services for mental health carers. The interventions to assist carers need to be informed by robust evidence and this requires trials that reach their recruitment targets. By sharing our practical experiences other researchers and clinicians can modify their practices to minimise recruitment difficulties and delay. Trial registration ISRCTN79116352. Retrospectively registered (before the final participant was recruited) on 23rd January 2017.

Guided self-help cognitive-behaviour Intervention for VoicEs (GiVE): Results from a pilot randomised controlled trial in a transdiagnostic sample.

BACKGROUND: Few patients have access to cognitive behaviour therapy for psychosis (CBTp) even though at least 16 sessions of CBTp is recommended in treatment guidelines. Briefer CBTp could improve access as the same number of therapists could see more patients. In addition, focusing on single psychotic symptoms, such as auditory hallucinations ('voices'), rather than on psychosis more broadly, may yield greater benefits. METHOD: This pilot RCT recruited 28 participants (with a range of diagnoses) from NHS mental health services who were distressed by hearing voices. The study compared an 8-session guided self-help CBT intervention for distressing voices with a wait-list control. Data were collected at baseline and at 12weeks with post-therapy assessments conducted blind to allocation. Voice-impact was the pre-determined primary outcome. Secondary outcomes were depression, anxiety, wellbeing and recovery. Mechanism measures were self-esteem, beliefs about self, beliefs about voices and voice-relating. RESULTS: Recruitment and retention was feasible with low study (3.6%) and therapy (14.3%) dropout. There were large, statistically significant between-group effects on the primary outcome of voice-impact (d=1.78; 95% CIs: 0.86-2.70), which exceeded the minimum clinically important difference. Large, statistically significant effects were found on a number of secondary and mechanism measures. CONCLUSIONS: Large effects on the pre-determined primary outcome of voice-impact are encouraging, and criteria for progressing to a definitive trial are met. Significant between-group effects on measures of self-esteem, negative beliefs about self and beliefs about voice omnipotence are consistent with these being mechanisms of change and this requires testing in a future trial.

Understanding the Barriers to Accessing Symptom-Specific Cognitive Behavior Therapy (CBT) for Distressing Voices: Reflecting on and Extending the Lessons Learnt From the CBT for Psychosis Literature.

The experience of hearing voices ('auditory hallucinations') can cause significant distress and disruption to quality of life for people with a psychosis diagnosis. Psychological therapy in the form of cognitive behavior therapy (CBT) for psychosis is recommended for the treatment of positive symptoms, including distressing voices, but is rarely available to patients in the United Kingdom. CBT for psychosis has recently evolved with the development of symptom-specific therapies that focus upon only one symptom of psychosis at a time. Preliminary findings from randomized controlled trials suggest that these symptom-specific therapies can be more effective for distressing voices than the use of broad CBT protocols, and have the potential to target voices trans-diagnostically. Whilst this literature is evolving, consideration must be given to the potential for a symptom-specific approach to overcome some of the barriers to delivery of evidence-based psychological therapies within clinical services. These barriers are discussed in relation to the United Kingdom mental health services, and we offer suggestions for future research to enhance our understanding of these barriers.