Evaluating cognitive analytic therapy within a primary care psychological therapy service.

OBJECTIVES: Cognitive analytic therapy (CAT) is used within UK mental health settings as a treatment for transdiagnostic complex psychological presentations. However, it is not routinely offered by the NHS Talking Therapies, for anxiety and depression (NHS Talking Therapies) programme which provides psychological treatments for common mental health difficulties. We aimed to evaluate the outcomes of providing CAT treatment to patients presenting with depression and/or anxiety, within the context of relational difficulties, adverse childhood experience or difficulty managing emotions, returning for further psychological treatment within NHS Talking Therapies. METHODS: This was a pragmatic, real-world evaluation, involving routinely collected self-report measures of depression and anxiety, to examine the treatment outcomes of NHS Talking Therapies patients offered CAT over an 18-month period. Quantitative validated measures of depression and anxiety were administered at the beginning and end of CAT treatment, and at follow up. Within-group change in depression and anxiety scores were examined statistically, and rates of reliable improvement and recovery calculated. RESULTS: Statistically significant decreases in depression and anxiety scores were observed during the CAT active treatment phase. The recovery rate was 46.4%, and 71.4% of patients showed a reliable improvement post-treatment. Positive outcomes continued to be observed at follow-up, with a recovery rate of 50% and a reliable improvement rate of 79.4%. CONCLUSIONS: CAT shows promise as a treatment option for NHS Talking Therapies patients re-presenting with depression and/or anxiety. More research is required to determine if CAT should be offered more widely within NHS Talking Therapies services.

A qualitative process evaluation of social recovery therapy for enhancement of social recovery in first-episode psychosis (SUPEREDEN3).

BACKGROUND: Many individuals with first-episode psychosis experience severe and persistent social disability despite receiving specialist early intervention. The SUPEREDEN3 trial assessed whether augmenting early intervention in psychosis services with Social Recovery Therapy (SRT) would lead to better social recovery. AIMS: A qualitative process evaluation was conducted to explore implementation and mechanisms of SRT impact from the perspective of SUPEREDEN3 participants. METHOD: A subsample of SUPEREDEN3 trial participants (n = 19) took part in semi-structured interviews, which were transcribed verbatim and analysed thematically. Trial participants were early intervention service users aged 16-35 years with severe and persistent social disability. Both SRT plus early intervention and early intervention alone arm participants were interviewed to facilitate better understanding of the context in which SRT was delivered and to aid identification of mechanisms specific to SRT. RESULTS: The six themes identified were used to generate an explanatory model of SRT's enhancement of social recovery. Participant experiences highlight the importance of the therapist cultivating increased self-understanding and assertively encouraging clients to face feared situations in a way that is perceived as supportive, while managing ongoing symptoms. The sense of achievement generated by reaching targets linked to personally meaningful goals promotes increased self-agency, and generates hope and optimism. CONCLUSIONS: The findings suggest potentially important processes through which social recovery was enhanced in this trial, which will be valuable in ensuring the benefits observed can be replicated. Participant accounts provide hope that, with the right support, even clients who have persistent symptoms and the most severe disability can make a good social recovery.

Self-evaluation as an active ingredient in the experience and treatment of adolescent depression; an integrated scoping review with expert advisory input.

BACKGROUND: Negative self-perceptions is one of the most common symptoms of depression in young people, and has been found to be strongly associated with severity of depression symptoms. Psychological treatments for adolescent depression are only moderately effective. Understanding the role and importance of these self-perceptions may help to inform and improve treatments. The aim of this review was to examine self-evaluation as a characteristic of adolescent depression, and as an active ingredient in treatment for adolescent depression. METHODS: We conducted a scoping review which included quantitative and qualitative studies of any design that reported on self-evaluation as a characteristic of, or focus of treatment for, adolescent depression. Participants were required to be 11-24 years and experiencing elevated symptoms of depression or a diagnosis. We also met with 14 expert advisory groups of young people with lived experience, clinicians, and researchers, for their input. Findings from 46 peer-reviewed research studies are presented alongside views of 64 expert advisors, to identify what is known and what is missing in the literature. RESULTS: Three overarching topics were identified following the review and reflections from advisors: 1) What does it look like? 2) Where does it come from? and 3) How can we change it? The literature identified that young people view themselves more negatively and less positively when depressed, however expert advisors explained that view of self is complex and varies for each individual. Literature identified preliminary evidence of a bidirectional relationship between self-evaluation and depression, however, advisors raised questions regarding the influences and mechanisms involved, such as being influenced by the social environment, and by the cognitive capacity of the individual. Finally, there was a consensus from the literature and expert advisors that self-evaluation can improve across treatment. However, research literature was limited, with only 11 identified studies covering a diverse range of interventions and self-evaluation measures. Various barriers and facilitators to working on self-evaluation in treatment were highlighted by advisors, as well as suggestions for treatment approaches. CONCLUSIONS: Findings indicate the importance of self-evaluation in adolescent depression, but highlight the need for more research on which treatments and treatment components are most effective in changing self-evaluation.

Low-intensity sleep intervention in a youth mental health service: a case series analysis.

BACKGROUND: There is increasing evidence of a strong association between sleep and mental health in both adolescents and adults. CBT for insomnia is being applied to good effect with adults with mental health difficulties but there are few studies examining its applicability to adolescents within mental health services. METHOD: We carried out a case series analysis (n = 15) looking at the feasibility, accessibility and impact of a low-intensity sleep intervention for young people (14-25 years) being seen by a secondary care Youth Mental Health team in the UK. The intervention was based on cognitive behavioural therapy for insomnia (CBTi) and acceptance and commitment therapy (ACT) approaches and involved six individual sessions delivered on a weekly basis by a graduate psychologist. Routine outcome measures were used to monitor insomnia, psychological distress and functioning with assessments at baseline, session 3, session 6 and at 4 weeks after end of intervention. All participants scored in the clinical range for insomnia at the start of the study. RESULTS: High uptake, attendance and measure completion rates were observed. Large effect sizes were observed for insomnia, psychological distress and functioning. Twelve of the fifteen participants (80%) no longer scored above threshold for insomnia at follow-up. All seven under-18s no longer met threshold for clinical 'caseness' on the Revised Child Anxiety and Depression Scale (RCADS) at follow-up. DISCUSSION: The findings suggest that the intervention was well accepted by young people and feasible to apply within a secondary care setting. Strong effect sizes are encouraging but are probably inflated by the small sample size, uncontrolled design and unblinded assessments.

Review: Delivering mental health support within schools and colleges - a thematic synthesis of barriers and facilitators to implementation of indicated psychological interventions for adolescents.

BACKGROUND: Increasing the role of schools and colleges in the provision of mental health services for young people has the potential to improve early intervention and access to treatment. We aimed to understand what factors influence the successful implementation of indicated psychological interventions within schools and colleges to help guide increased provision of mental health support within education settings. METHODS: Systematic search for studies that have reported barriers or facilitators to the implementation of indicated interventions for adolescent emotional disorders delivered within schools and further education/sixth form colleges (CRD42018102830). Databases searched were EMBASE, MEDLINE, PsycINFO, CINAHL, British Nursing Index, ASSIA, ERIC and British Education Index. A thematic synthesis of factors reported to impact implementation was conducted. RESULTS: Two thousand five hundred and sixty-nine records and 177 full texts were screened. Fifty studies were identified for inclusion, all of which were of school-based interventions. Eleven analytic themes were developed encompassing intervention characteristics, organisational capacity, training and technical assistance, provider characteristics and community-level factors. Findings indicate the need to select appropriate interventions, consider logistical challenges of the school context and provide training and supervision to enable staff to deliver interventions with fidelity. However, structural and environmental support is required for these facilitators to have the greatest impact on successful implementation. CONCLUSIONS: Implementing indicated school-based mental health interventions is challenging. Those involved in planning school-based mental health initiatives must be alert to the impact of factors on multiple interacting levels. There is a lack of research on implementing mental health support within further education and sixth form colleges. KEY PRACTITIONER MESSAGE: Increased utilisation of schools and colleges as a setting for early intervention has been proposed as a means of improving access to mental health treatment, but successful implementation of mental health interventions within educational settings is challenging. Based on a synthesis of current evidence, we recommend that young people and education professionals should be involved in the selection of school-based interventions to ensure they are acceptable and practical to deliver within the logistical constraints of the school environment. Those delivering interventions within schools, as well as staff involved in identifying young people who might benefit from these interventions, must receive high-quality ongoing training and support. Senior school leaders play an important role in championing mental health interventions and developing a school culture that prioritises mental well-being. Health and education policy should be designed to promote a cross-sector focus on the emotional health of young people. There is a lack of evidence on the implementation of indicated psychological interventions within sixth form and further education colleges.

Practitioner Review: Effectiveness of indicated school-based interventions for adolescent depression and anxiety - a meta-analytic review.

BACKGROUND: Interest in delivering psychological interventions within schools to facilitate early intervention is increasing. However, most reviews have focused on universal or preventative programmes rather than interventions designed to decrease existing symptoms of depression or anxiety. This paper aims to provide a meta-analytic review of randomised controlled trials of indicated psychological interventions for young people aged 10-19 with elevated symptoms of depression and/or anxiety. METHODS: Eight electronic databases were systematically searched from inception to April 2019 for eligible trials. Study quality was assessed using two scales designed to evaluate psychotherapy intervention trials. Random effects meta-analyses were conducted separately for trials that recruited participants based on symptoms of depression and based on symptoms of anxiety. RESULTS: Data from 45 trials were analysed. Most interventions studied used cognitive and behavioural strategies. Few studies met methodological quality criteria, but effect size was not associated with study quality. Indicated school-based interventions had a small effect on reducing depression symptoms (SMD = .34, 95% CI -0.48, -0.21) and a medium effect on reducing anxiety symptoms (SMD = -.49, 95% CI -0.79, -0.19) immediately postintervention. Subgroup analyses indicated that interventions delivered by internal school staff did not have significant effects on symptoms. Reductions in depression were maintained at short-term (≤6 months) but not medium (>6 months ≤ 12) or long-term (>12-month) follow-up. Reductions in anxiety symptoms were not maintained at any follow-up. CONCLUSIONS: Indicated school-based interventions are effective at reducing symptoms of depression and anxiety in adolescents immediately postintervention but there is little evidence that these reductions are maintained. Interventions delivered by school staff are not supported by the current evidence base. Further high-quality randomised controlled trials incorporating assessment of longer-term outcomes are needed to justify increased investment in school-based interventions for adolescent depression and anxiety.

Evaluation of a non-diagnostic 'Psychology of Emotions' group intervention within a UK youth IAPT service: a mixed-methods approach.

BACKGROUND: A novel CBT-based intervention, tailored for young people, was developed in response to concerns about traditional diagnostically based approaches. Psychology of Emotions workshops use a normative approach to emotional difficulty instead of a diagnostic framework. AIMS: To evaluate the acceptability and efficacy of Psychology of Emotions workshops within an IAPT service for young people aged 16-25 years. METHOD: This was a mixed-methods study, evaluating routinely collected self-report measures of depression and anxiety, and qualitative feedback forms. The main outcomes were rates of attendance, change in symptom severity, and participant views of the intervention. RESULTS: From January to September 2016, 595 young people were invited to attend the Psychology of Emotions workshops, of whom 350 (58.8%) attended at least one session. Young people who attended all six sessions (8.1%) experienced significant reductions in self-reported anxiety (d = .72) and depression (d = .58) and 35.5% were classified as recovered at completion. Those who attended at least two sessions (41.3%) reported smaller but significant improvements in anxiety (d = .42) and depression (d = .45); 22.0% were classified as recovered at the last session attended. Participants provided largely positive feedback about the intervention. CONCLUSION: Psychology of Emotions is a promising treatment option, delivered outside of a diagnostic framework, for young people with mild to moderate mental health difficulties seen within IAPT services. Better understanding reasons for non-attendance might enable the intervention to be made accessible to more young people.

What does recovery mean to young people with mental health difficulties? - "It's not this magical unspoken thing, it's just recovery".

Background: There is extensive literature documenting the nature of recovery in mental health in adult populations, but there is very little exploring its nature and meaning for young people.Aims: To gain a detailed understanding from the perspective of young people about the concept of recovery in young people's mental health.Method: Semi structured interviews were conducted with 23 young people. Interviews were transcribed verbatim and analysed using thematic analysis.Results: Themes emerging from the interviews included young people's dynamic conceptualisations of recovery, awareness of others views of recovery, polarised goals of recovery, and facilitators and barriers of recovery.Conclusions: To be relevant for young people, the mental health recovery model must incorporate individual needs, developmental considerations and fluctuations in goals. It must also be embedded within the young person's ecological system such as family, friends and school, and be focussed around an explicit and collaborative recovery discussion with the young person.

Assessing social recovery of vulnerable youth in global mental health settings: a pilot study of clinical research tools in Malaysia.

BACKGROUND: A social recovery approach to youth mental health focuses on increasing the time spent in valuable and meaningful structured activities, with a view to preventing enduring mental health problems and social disability. In Malaysia, access to mental health care is particularly limited and little research has focused on identifying young people at risk of serious socially disabling mental health problems such as psychosis. We provide preliminary evidence for the feasibility and acceptability of core social recovery assessment tools in a Malaysian context, comparing the experiential process of engaging young Malaysian participants in social recovery assessments with prior accounts from a UK sample. METHODS: Nine vulnerable young people from low-income backgrounds were recruited from a non-government social enterprise and partner organisations in Peninsular Malaysia. Participants completed a battery of social recovery assessment tools (including time use, unusual experiences, self-schematic beliefs and values). Time for completion and completion rates were used as indices of feasibility. Acceptability was examined using qualitative interviews in which participants were asked to reflect on the experience of completing the assessment tools. Following a deductive approach, the themes were examined for fit with previous UK qualitative accounts of social recovery assessments. RESULTS: Feasibility was indicated by relatively efficient completion time and high completion rates. Qualitative interviews highlighted the perceived benefits of social recovery assessments, such as providing psychoeducation, aiding in self-reflection and stimulating goal setting, in line with findings from UK youth samples. CONCLUSIONS: We provide preliminary evidence for the feasibility and acceptability of social recovery assessment tools in a low-resource context, comparing the experiential process of engaging young Malaysian participants in social recovery assessments with prior accounts from a UK sample. We also suggest that respondents may derive some personal and psychoeducational benefits from participating in assessments (e.g. of their time use and mental health) within a social recovery framework.

Barriers and facilitators in the implementation of youth and young adult models of mental health care.

AIM: It is increasingly recognised that traditional models of mental health (MH) care, with a service transition at age 18 years, may not reflect best practice. The literature supports a move towards youth and young adult focused models of MH care, for young people up to the age of 25, which specifically cater to the unique psychosocial and developmental needs of this population. This service evaluation aimed to explore the facilitators and barriers to the implementation of youth models of MH care across England (UK). METHODS: Six services participated in separate focus groups pertaining to their experience of implementing youth models of MH care. The interview guide for the focus groups was informed by the Consolidated Framework for Implementation Research (CFIR) and explored barriers and facilitators to implementation and sustainment. The focus groups were recorded, transcribed verbatim and analysed thematically. RESULTS: Seven key themes relevant to the implementation of youth models of MH care were identified: a clear rationale for doing things differently, for young people by young people, "building those relationships is key", service identity development, resource and infrastructure, leadership at multiple levels, and valuing and developing staff. CONCLUSIONS: The findings suggest effective communication and leadership, co-production and cross system collaboration contribute to successful implementation of youth models of MH care. The findings will be of interest to those involved in informing and supporting successful implementation and delivery of youth models of mental health care at local and national levels.

Delivering a sleep intervention across a youth mental health service using non-expert practitioners: A service evaluation.

AIMS: Poor sleep is highly prevalent in young people and increases risk of mental health difficulties, yet access to sleep interventions remains limited. This paper evaluates the use of a sleep intervention delivered by non-expert practitioners in a secondary care youth mental health service. METHOD: Assistant psychologists were trained to deliver a six-session 1:1 cognitive-behavioural sleep intervention adapted for use with young people with mental health difficulties. A within-subject design assessed clinical outcomes relating to sleep (Insomnia Severity Index), psychological distress and personal goals (Goal Based Outcome Measures) at four time points. RESULTS: High referral, intervention take-up (82.82%) and completion (70%) rates were reported, together with high baseline levels of insomnia (Insomnia Severity Index mean 20.47, SD 3.68) and poor sleep efficiency (56.36%, SD 17.23). Fifty-six young people (average age 19.2 years, SD 3.25) were included in the outcome analysis. Statistically and clinically significant improvements were seen across all outcome measures, with 68% no longer meeting clinical threshold (ISI ≥15) for insomnia at endpoint. CONCLUSIONS: This study demonstrates exceptionally high levels of clinical need and engagement with a sleep intervention adapted specifically for young people with mental health difficulties. Whilst limited by the uncontrolled design, large improvements in insomnia and psychological distress support its effectiveness and utility in clinical settings. More robust implementation and evaluation is warranted in broader youth mental health services to promote earlier access.

Doing research in non-specialist mental health services for children and young people: lessons learnt from a process evaluation of the ICALM (Interpersonal Counselling for Adolescent Low Mood) feasibility randomised controlled trial.

BACKGROUND: The rising prevalence of adolescent mild depression in the UK and the paucity of evidence-based interventions in non-specialist sectors where most cases present, creates an urgent need for early psychological interventions. Randomised controlled trials (RCTs) are considered the gold standard for obtaining unbiased estimates of intervention effectiveness. However, the complexity of mental health settings poses great challenges for effectiveness evaluations. This paper reports learning from an embedded process evaluation of the ICALM RCT which tested the feasibility of delivering Interpersonal Counselling for Adolescents (IPC-A) plus Treatment as Usual (TAU) versus TAU only for adolescent (age 12-18) mild depression by non-qualified mental health professionals in non-specialist sectors. METHODS: A qualitative mixed methods process evaluation, drawing on Bronfenbrenner's socioecological model to investigate key influences on trial delivery across macro-(e.g. policy), meso-(e.g. service characteristics) and micro-(e.g. on-site trial processes) contextual levels. Data collection methods included 9 site questionnaires, 4 observations of team meetings, policy documents, and 18 interviews with stakeholders including therapists, heads of service and managers. Thematic analysis focused on understanding how contextual features shaped trial implementation. RESULTS: The ICALM trial concluded in 2022 having only randomised 14 out of the target 60 young people. At a macro-level, trial delivery was impacted by the COVID-19 pandemic, with services reporting a sharp increase in cases of (social) anxiety over low mood, and backlogs at central referral points which prolonged waiting times for mild cases (e.g. low mood). An interaction between high demand and lack of capacity at a meso-service level led to low prioritisation of trial activities at a micro-level. Unfamiliarity with research processes (e.g. randomisation) and variation in TAU support also accentuated the complexities of conducting an RCT in this setting. CONCLUSIONS: Conducting a RCT of IPC-A in non-specialist services is not feasible in the current context. Failure to conduct effectiveness trials in this setting has clinical implications, potentially resulting in escalation of mild mental health problems. Research done in this setting should adopt pragmatic and innovative recruitment and engagement approaches (e.g. creating new referral pathways) and consider alternative trial designs, e.g. cluster, stepped-wedge or non-controlled studies using complex systems approaches to embrace contextual complexity. TRIAL REGISTRATION: ISRCTN registry, ISRCTN82180413. Registered on 31 December 2019.

'Very hit and miss': an interpretive phenomenological analysis of ambulance service care for young people experiencing mental health crisis.

Introduction: The ambulance service provides vital front line mental healthcare for young people in crisis, but there is a lack of evidence to guide best practice in this area. The lived experiences of service users can offer important insights to guide service development, therefore we carried out a qualitative evaluation of care provided by the ambulance service to young people experiencing a mental health-related emergency. Methods: Ten participants aged 16-25 years who had used the ambulance service due to a mental health crisis within the past 2 years were interviewed about their experiences and view of the care they received. Interviews were transcribed verbatim and interpretative phenomenological analysis used to explore participants' individual narratives and identify recurrent themes. Results: A theme of inconsistent quality of care was evident in all participants' accounts. Contributing to this superordinate theme were six recurrent themes: positive qualities of individual ambulance clinicians, ambivalence about seeking care, the importance of retaining agency, need for mental health training for ambulance clinicians, need for inter-service collaboration and favourable comparison of the ambulance service to other services. Conclusions: We identified some examples of good practice, including person-centred care, respect for patient autonomy and attending to physical health needs. However, our findings suggest the quality of ambulance service mental healthcare is not yet sufficiently consistent. In the absence of mandatory high-quality mental health training and evidence-based protocols, the quality of care appears largely dependent on the qualities and experience of individual ambulance clinicians.

Interpersonal counselling for adolescent depression delivered by youth mental health workers without core professional training: a feasibility randomised controlled trial study protocol.

BACKGROUND: Depression is a common health problem during adolescence and is associated with adverse academic, social and health outcomes. To meet the demand for treatment for adolescent depression, there is a need for evidence-based interventions suitable for delivery outside of specialist Child and Adolescent Mental Health Services (CAMHS). Interpersonal Counselling for Adolescents (IPC-A) is a brief manualised intervention for adolescent depression suitable for delivery by staff who are not qualified health professionals following participation in a brief training course. While initial piloting within Local Authority services has generated promising results, the effectiveness and cost-effectiveness of IPC-A has yet to be established. This study aims to assess the feasibility of a randomised controlled trial (RCT), evaluating the effectiveness and cost-effectiveness of IPC-A delivered by staff without core professional training in comparison to current provision. METHOD: Feasibility RCT with process evaluation using ethnographic methodology. Eligible young people (n = 60) will be randomised in a 1:1 ratio to receive either IPC-A or treatment as usual (TAU). Participants will be assessed pre-randomisation (baseline) and followed up at 5, 10 and 23 weeks post-randomisation. A parallel process evaluation will generate understanding of intervention implementation across services and explore the acceptability of the intervention from the perspective of young people and other key stakeholders. PARTICIPANTS: Young people aged 12-18 years presenting to non-specialist services with symptoms of depression. Youth workers, young people and stakeholders will participate in the process evaluation. DISCUSSION: The need for effective and accessible interventions for young people with mild/sub-threshold depression who, in most cases, do not meet the threshold for mainstream mental health services is long overdue. The primary output of this feasibility trial will be the design of the subsequent full-scale trial. If the results of the current study indicate that this would be feasible, we intend to progress to a multi-site, assessor-blind, superiority RCT of the effectiveness and cost-effectiveness of IPC-A in comparison to TAU for adolescents presenting to non-specialist services with depressive symptoms. If satisfactory solutions to any problems encountered cannot be identified, alternative research designs will be considered. If proven effective, an IPC-A training programme could be implemented. TRIAL REGISTRY: ISRCTN registry, ISRCTN82180413 , Registered 31 December 2019.

Views of young people in Malaysia on mental health, help-seeking and unusual psychological experiences.

AIM: Mental health problems are prevalent among young people in Malaysia yet access to specialist mental health care is extremely limited. More context-specific research is needed to understand the factors affecting help-seeking in youth, when mental health problems typically have first onset. We aimed to explore the attitudes of vulnerable young Malaysians regarding mental health problems including unusual psychological experiences, help-seeking and mental health treatment. METHODS: In the present study, nine young people (aged 16-23 years) from low-income backgrounds participated in a semi-structured interview about their perspectives on mental health problems, unusual psychological experiences and help-seeking. RESULTS: Four themes were developed using thematic analysis. "Is it that they [have] family problems?" reflected participants' explanatory models of mental health problems. "Maybe in Malaysia" was concerned with perceptions of Malaysian culture as both encouraging of open sharing of problems and experiences, but also potentially stigmatizing. "You have to ask for help" emphasized the importance of mental health help-seeking despite potential stigma. "It depends on the person" addressed the challenges of engaging with psychological therapy. CONCLUSIONS: We conclude that young people in Malaysia may hold compassionate, non-stigmatizing views towards people experiencing mental health problems and a desire to increase their knowledge and understandings. Yet societal stigma is a perceived reputational risk that may affect mental health problem disclosure and help-seeking. We suggest that efforts to improve mental health literacy would be valued by young Malaysians and could support reduced stigma and earlier help-seeking.

A systematic review and meta-analysis on the prevalence of depression in children and adolescents after exposure to trauma.

BACKGROUND: Depression is often reported as co-occurring with post-traumatic stress disorder in children and adolescents, but its prevalence within trauma-exposed child and adolescent samples is not well understood. METHODS: Our meta-analyses addressed two questions: I. What is the prevalence of depression (either based on structured interview or cut-off on a self-report measure) in children and adolescents after exposure to trauma? II. Does trauma exposure increase the severity or rates of depression comparative to another comparison group of children and adolescents with milder exposure or no exposure to trauma? RESULTS: Fifty-six studies reported depression prevalence. A random effects meta-analysis suggested that 24.2% [95% CI 20.6-28.0] of children and adolescents exposed to a traumatic event met criteria for depression. Our second meta-analysis across 30 studies found that the effect of trauma exposure (relative to unexposed or less exposed children and adolescents) on depression scores was medium in size (d = 0.51, 95% CI 0.41-0.61). The odds of a diagnosis of depression were 2.6 times greater [95% CI 2.0-3.3] for children and adolescents exposed to trauma as compared to those unexposed or less exposed. Participants exposed to interpersonal violence (IPV) had a higher prevalence and level of depression compared with those exposed to non-IPV trauma. LIMITATIONS: Results should be interpreted with caution due to high levels of heterogeneity. CONCLUSION: Depression in trauma-exposed children and adolescents is a common response to trauma that is not solely reflective of pre-traumatic difficulties. Post-traumatic depression merits serious consideration in trauma-exposed children and adolescents.

The effect of non-pharmacological sleep interventions on depression symptoms: A meta-analysis of randomised controlled trials.

Poor sleep is a significant risk factor for depression across the lifespan and sleep problems have been hypothesised to contribute to the onset and maintenance of depression symptoms. However, sleep problems are usually not a direct target of interventions for depression. A range of non-pharmacological treatments can reduce sleep problems but it is unclear whether these interventions also reduce other depression symptoms. The aim of this review was to examine whether non-pharmacological interventions for sleep problems are effective in reducing symptoms of depression. We carried out a systematic search for randomised controlled trials of non-pharmacological sleep interventions that measured depression symptoms as an outcome. Forty-nine trials (n = 5908) were included in a random effects meta-analysis. The pooled standardised mean difference for depression symptoms after treatment for sleep problems was -0.45 (95% CI: -0.55,-0.36). The size of the effect on depression symptoms was moderated by the size of the effect on subjective sleep quality. In studies of participants with mental health problems, sleep interventions had a large effect on depression symptoms (d = -0.81, 95% CI: -1.13,-0.49). The findings indicate that non-pharmacological sleep interventions are effective in reducing the severity of depression, particularly in clinical populations. This suggests that non-pharmacological sleep interventions could be offered as a treatment for depression, potentially improving access to treatment.

The effect of a youth mental health service model on access to secondary mental healthcare for young people aged 14-25 years.

Aims and methodThe Norfolk Youth Service was created in 2012 in response to calls to redesign mental health services to better meet the needs of young people. The new service model transcends traditional boundaries by creating a single, 'youth friendly' service for young people aged 14-25 years. The aim of this study was to investigate the effect of the transition to this new model on patterns of referral, acceptance and service use. We analysed routinely collected data on young people aged 14-25 years referred for secondary mental healthcare in Norfolk before and after implementation of the youth mental health service. The number of referrals, their age and gender, proportion of referrals accepted and average number of service contacts per referral by age pre- and post-implementation were compared. RESULTS: Referrals increased by 68% following implementation of the new service model, but the proportion of referrals accepted fell by 27 percentage points. Before implementation of the youth service, there was a clear discrepancy between the peak age of referral and the age of those seen by services. Following implementation, service contacts were more equitable across ages, with no marked discontinuity at age 18 years.Clinical implicationsOur findings suggest that the transformation of services may have succeeded in reducing the 'cliff edge' in access to mental health services at the transition to adulthood. However, the sharp rise in referrals and reduction in the proportion of referrals accepted highlights the importance of considering possible unintended consequences of new service models.Declaration of interestsNone.

Lived experiences of negative symptoms in first-episode psychosis: A qualitative secondary analysis.

AIM: Exploring how negative symptoms are experienced and understood by individuals with lived experience of psychosis has the potential to offer insights into the complex psychosocial processes underlying negative symptom presentations. The aim of the current study was to investigate lived experiences of negative symptoms through secondary analysis of interviews conducted with individuals recovering from first-episode psychosis. METHOD: Transcripts of in-depth interviews with participants (n = 24) recruited from Early Intervention in Psychosis services were analysed thematically with a focus on participants' experiences and personal understandings of features corresponding to the negative symptoms construct. RESULTS: Descriptions of reductions in expression, motivation and sociability were common features of participants' accounts. Several participants described the experience of having difficulty interacting as like being a "zombie". Some participants experienced diminished capacity for emotion, thought or drive as underlying these experiences. However, participants typically attributed reductions in expression, motivation and sociability to medication side-effects, lack of confidence or active avoidance intended to protect them from rejection or ridicule, sometimes linked to internalized stigma. CONCLUSIONS: Personal accounts of experiences of reduced expression, motivation and sociability during first-episode psychosis highlight the personal meaningfulness and role of agency in these features, challenging the framing of negative symptoms as passive manifestations of diminished capacity.

Young people's experiences of Social Recovery Cognitive Behavioural Therapy and treatment as usual in the PRODIGY trial.

AIM: The PRODIGY trial is an ongoing randomized controlled trial of Social Recovery Cognitive Behavioural Therapy (SRCBT), a new intervention designed to improve social functioning in young people at risk of long-term social disability due to severe and complex mental health problems. The aim of this qualitative sub-study was to understand trial participants' experiences of SRCBT and the control condition, treatment as usual. METHODS: Trial participants were aged 16-25 years with socially disabling severe and complex mental health problems. A purposive sample of trial participants took part in in-depth qualitative interviews which were transcribed verbatim and analysed thematically. RESULTS: Participants from the SRCBT arm valued the relationship with their therapist, the flexibility of intervention delivery and the cognitive and behavioural techniques taught. They viewed SRCBT as challenging but worthwhile. Participants from the treatment as usual arm reported receiving little support, both prior to and during their participation in the trial. Participants from both arms valued opportunities to talk about their difficulties during trial participation. Increased activity was an important goal of participants from both arms and most expressed high motivation and little hopelessness. CONCLUSIONS: Currently available services do not meet the needs of some young people with socially disabling mental health problems. Motivation to change appears high at this early stage of disorder, supporting the potential value of intervening early to prevent longer term social disability. SRCBT was well accepted by participants and so is a promising intervention to meet this objective.