The impact of reduced routine community mental healthcare on people from minority ethnic groups during the COVID-19 pandemic: qualitative study of stakeholder perspectives.

BACKGROUND: Enduring ethnic inequalities exist in mental healthcare. The COVID-19 pandemic has widened these. AIMS: To explore stakeholder perspectives on how the COVID-19 pandemic has increased ethnic inequalities in mental healthcare. METHOD: A qualitative interview study of four areas in England with 34 patients, 15 carers and 39 mental health professionals from National Health Service (NHS) and community organisations (July 2021 to July 2022). Framework analysis was used to develop a logic model of inter-relationships between pre-pandemic barriers and COVID-19 impacts. RESULTS: Impacts were largely similar across sites, with some small variations (e.g. positive service impacts of higher ethnic diversity in area 2). Pre-pandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model, leading to poor communication, disengagement and alienation. During the pandemic remote service delivery, closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers, fuelling prejudice and division, and increasing mistrust in services. Some minority ethnic patients reported positive developments, experiencing empowerment through self-determination and creative activities. CONCLUSIONS: During the COVID-19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services. However, there has been a reduction in the availability of group-specific NHS and third-sector services in the community, exacerbating pre-existing barriers. As these developments are likely to have long-term consequences for minority ethnic groups' engagement with mental healthcare, they need to be addressed as a priority by the NHS and its partners.

Working with suicidal mothers during the perinatal period: a reflexive thematic analysis study with mental health professionals.

BACKGROUND: Suicide is the leading cause of death in mothers postpartum and one of the most common causes of death during pregnancy. Mental health professionals who work in perinatal services can offer insights into the factors they perceive as being linked to mothers' suicidal ideation and behaviour, support offered to mothers and improvements to current practices. We aimed to explore the experiences and perceptions of perinatal mental health professionals who have worked with suicidal mothers during the perinatal period. METHOD: Semi-structured interviews were conducted face-to-face or via telephone with mental health professionals working in perinatal mental health inpatient or community services across England. Data were analysed using reflexive thematic analysis. RESULTS: From the professionals' (n = 15) accounts three main themes were developed from their interview data. The first, factors linked to suicidal ideation and behaviour, overarched two sub-themes: (1.1) the mother's context and (1.2) what the baby represents and what this means for the mother. These sub-themes described factors that professionals assessed or deemed contributory in relation to suicidal ideation and behaviour when a mother was under their care. The second main theme, communicating about and identifying suicidal ideation and behaviour, which outlined how professionals enquired about, and perceived, different suicidal experiences, encapsulated two sub-themes: (2.1) how to talk about suicide and (2.2) types of suicidal ideation and attempts. The third main theme, reducing suicidal ideation through changing how a mother views her baby and herself, focused on how professionals supported mothers to reframe the ways in which they viewed their babies and in turn themselves to reduce suicidal ideation. CONCLUSION: Professionals highlighted many factors that should be considered when responding to a mother's risk of suicide during the perinatal period, such as the support around her, whether the pregnancy was planned and what the baby represented for the mother. Professionals' narratives stressed the importance of adopting a tailored approach to discussing suicidal experiences with mothers to encourage disclosure. Our findings also identified psychological factors that professionals perceived as being linked to suicidal outcomes for mothers, such as self-efficacy; these factors should be investigated further.

Prevalence and correlates of perinatal depression.

PURPOSE: This systematic review of systematic reviews aims to provide the first global picture of the prevalence and correlates of perinatal depression, and to explore the commonalities and discrepancies of the literature. METHODS: Seven databases were searched from inception until April 2022. Full-text screening and data extraction were performed independently by two researchers and the AMSTAR tool was used to assess the methodological quality. RESULTS: 128 systematic reviews were included in the analysis. Mean overall prevalence of perinatal depression, antenatal depression and postnatal depression was 26.3%, 28.5% and 27.6%, respectively. Mean prevalence was significantly higher (27.4%; SD = 12.6) in studies using self-reported measures compared with structured interviews (17.0%, SD = 4.5; d = 1.0) and among potentially vulnerable populations (32.5%; SD = 16.7, e.g. HIV-infected African women) compared to the general population (24.5%; SD = 8.1; d = 0.6). Personal history of mental illness, experiencing stressful life events, lack of social support, lifetime history of abuse, marital conflicts, maternity blues, child care stress, chronic physical health conditions, preeclampsia, gestational diabetes mellitus, being exposed to second-hand smoke and sleep disturbance were among the major correlates of perinatal depression. CONCLUSION: Although the included systematic reviews were all of medium-high quality, improvements in the quality of primary research in this area should be encouraged. The standardisation of perinatal depression assessment, diagnosis and measurement, the implementation of longitudinal designs in studies, inclusions of samples that better represent the population and better control of potentially confounding variables are encouraged.

A brief transdiagnostic group (the take control course) compared to individual low-intensity CBT for depression and anxiety: a randomized non-inferiority trial.

Few studies have examined brief transdiagnostic groups. The Take Control Course (TCC) was developed for patients with mild to moderate common mental health problems. We examined whether TCC is non-inferior to individual low-intensity cognitive behaviour therapy (CBT) in a single-blind individually randomised parallel non-inferiority trial. The primary outcomes were depression (PHQ9) and anxiety (GAD7) at 6-month follow-up (primary outcome point) and 12-month follow-up. The non-inferiority margin that we set, based on previous trials, corresponds to approximately 3 points on the PHQ9 and approximately 2.5 points on the GAD7. Intention-to-treat (ITT) and per-protocol (PP) analyses of 6-month data of 156 randomised patients indicated that TCC was non-inferior to individual low-intensity CBT on anxiety (ITT Coefficient = 0.24; 95% CI: -1.45 to 1.92; d = 0.04; p = .79), and depression (ITT Coefficient = 0.82; 95% CI: -1.06 to 2.69; d = 0.14; p = .39) outcomes, and functioning (ITT Coefficient = 0.69; 95% CI: -2.56 to 3.94; d = 0.08; p = .68). The findings at 12 months were inconclusive and require further testing. This randomised trial provides preliminary support that TCC is not less effective than short-term individual CBT within Improving Access to Psychological Therapies (IAPT) services.

What makes a perinatal woman suicidal? A grounded theory study.

BACKGROUND: Suicide is a leading cause of maternal death during pregnancy and up to a year after birth. Psychological and psychosocial risk factors for maternal suicide ideation and behaviour have been identified but do not account for why mothers begin to experience suicidal thoughts. Qualitative research offers a way of identifying what might drive mothers to initially consider suicide and then go on to act on such thoughts; crucial for the development of assessments to identify, and interventions to target, maternal suicide ideation and behaviour. We aimed to develop a grounded theory outlining what makes women think about suicide and/or engage in suicidal behaviour during pregnancy and the first 12 months following birth? METHOD: Semi-structured interviews were conducted with 12 mothers in the UK who had suicidal thoughts during pregnancy and/or the first year following birth. A constructivist approach to grounded theory was adopted which guided the data collection and analysis processes. RESULTS: We developed a model outlining the theorised process of psychological factors that culminates in mothers experiencing suicidal thoughts and then making a suicide attempt during the perinatal period. The process was initiated when mothers felt attacked by motherhood which led to feeling like a failure, self-identifying as a "bad mother" and subsequent appraisals of entrapment and/or defeat. When nothing resolved the distress and as mothers collated reasons for why they perceived they needed to die, suicidal behaviour became a viable and appealing option. We theorised that mothers might make a suicide attempt when they entered a state of intense "darkness" brought on by a trigger, followed by a temporary lapse in the conflict between the desire to live and desire to die and an opportunity to attempt. CONCLUSIONS: Participants stressed the rapid onset of suicidal thoughts. We suggest that healthcare professionals enquire about the mother's feelings towards the baby and of isolation, how she views herself as a mother, feelings of entrapment and defeat during routine contacts to aid identification and prevention of suicidal ideation/behaviour. Suggested interventions to prevent suicidal thoughts and behaviour include helping women manage their expectations for pregnancy and the postpartum period.

A cluster randomised controlled trial of a ward-based intervention to improve access to psychologically-informed care and psychological therapy for mental health in-patients.

BACKGROUND: There is good evidence that psychological interventions improve patient well-being and independent living, but patients on acute mental health wards often do not have access to evidence-based psychological therapies which are strongly advised by NICE guidance for severe mental health problems. The overall aim of this programme of work is to increase patient access to psychological therapies on acute mental health inpatient wards. Stage one of the programme (which is complete) aimed to identify barriers and facilitators to delivering therapy in these settings through a large qualitative study. The key output of stage one was an intervention protocol that is designed to be delivered on acute wards to increase patient access to psychologically-informed care and therapy. Stage two of the programme aims to test the effects of the intervention on patient wellbeing and serious incidents on the ward (primary outcomes), patient social functioning and symptoms, staff burnout, ward atmosphere from staff and patient perspectives and cost effectiveness of the intervention (secondary outcomes). METHODS: The study is a single blind, pragmatic, cluster randomised controlled trial and will recruit thirty-four wards across England that will be randomised to receive the new intervention plus treatment as usual, or treatment as usual only. Primary and secondary outcomes will be assessed at baseline and 6-month and 9-month follow-ups, with serious incidents on the ward collected at an additional 3-month follow-up. DISCUSSION: The key output will be a potentially effective and cost-effective ward-based psychological intervention that increases patient access to psychological therapy in inpatient settings, is feasible to deliver in inpatient settings and is acceptable to patients. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT03950388. Registered 15th May 2019. https://clinicaltrials.gov/ct2/show/NCT03950388.

Trust and distrust: Identifying recruitment targets for ethnic minority blood donors.

BACKGROUND: We explore the role of trust, distrust, and the prevailing socio-political context to better understand why people from ethnic minority communities are less likely to be blood donors compared to people from White communities. Recruiting more ethnic minority donors will enhance representativeness, reduce inequality, and help meet the clinical need to increase the proportion of blood with Ro Kell antigen to treat Sickle Cell Disease (SCD). STUDY DESIGN AND METHODS: A 2 (donor-status: current donor; non-donors) by 4 (ethnicity: People from Asian, Black, Mixed and White ethnic backgrounds) quasi-experiment (N = 981) was conducted to examine perceptions of trust/distrust and their influence on willingness to donate blood, within the socio-political context of the Windrush scandal and Brexit. RESULTS: We identified five domains of trust ('National Health Service [NHS] and staff,' 'NHS Blood and Transplant,' 'outgroups,' 'individuals' and 'politics'), and a single domain of conditional distrust domain. Trust across all the domains was lower, and 'conditional distrust' higher for ethnic minorities. Trust in 'individuals' and 'NHSBT' predicted willingness to donate in non-donors from ethnic minorities and White non-donors, respectively. Concerns about the Windrush scandal were related to lower political trust. Viewing Brexit as 'positive for the UK' was related to lower trust across domains and reduced willingness to donate in White non-donors through its influence on reduced trust in NHSBT. CONCLUSION: Distinct domains of trust and distrust are identified, and targeting 'trust in others' through conditional cooperation is recommended as a strategy to increase donor numbers from ethnic minority communities.

Engagement with services in Black African and Caribbean people with psychosis: The role of social networks, illness perceptions, internalized stigma, and perceived discrimination.

OBJECTIVES: Research and policies in the United Kingdom have repeatedly highlighted the need to reduce ethnic disparities and improve engagement with mental health services among Black African and Caribbean people with psychosis. The aim of this study was to examine the role of social network characteristics and psychological factors in engagement with services in Black people with psychosis. METHODS: A cross-sectional study was conducted with 51 Black African and Caribbean adults with non-affective psychosis and currently receiving care from mental health services in England. Measures were completed to examine relationships between social networks, illness perceptions, perceived racial or ethnic discrimination in services, internalized stigma, and current engagement with services from service user and staff perspectives. RESULTS: Social network composition (ethnic homogeneity) moderately correlated with better service user and staff reported engagement. Greater perceived personal control over problems was associated with better staff reported engagement. Lower perceived ethnic or racial discrimination in services, and specific illness perceptions (higher perceived treatment control, greater self-identification with psychosis symptoms, more concern and greater emotional response related to problems) were associated with better service user reported engagement. Internalized stigma was not associated with service engagement. Multivariate regression analyses suggested that a more ethnically homogenous social network was the strongest predictor of better service user and staff reported engagement. CONCLUSIONS: Psychosocial interventions that target social networks, perceived ethnic and racial discrimination in services, and illness perceptions may facilitate better engagement and improve outcomes. Further longitudinal studies are required to examine causal mechanisms.

'Diabetes doesn't matter as long as we're keeping traditions alive': a qualitative study exploring the knowledge and awareness of Type 2 diabetes and related risk factors amongst the young Punjabi Sikh population in the UK.

Objectives: It is well known that Sikhs are at an increased risk of Type 2 Diabetes (T2DM) due to a genetic predisposition. High level of education is associated with lower incidence of T2DM. Young Sikhs are well educated compared to other South Asian sub-groups. Despite this, T2DM rates remain high in Sikhs. The uptake of preventative services is also low within Sikhs. At present, no research has been conducted with the young Punjabi Sikh population on diabetes awareness in the UK. To address this gap, this study explores the knowledge and awareness of T2DM and related modifiable risk factors in the UK Punjabi Sikh community. Views surrounding T2DM health-seeking behaviours are also explored.Design: A qualitative design comprising of 1-to-1 semi-structured interviews was adopted. Thirteen Punjabi Sikh participants between the ages of 18-30 took part. Participants were recruited through a Sikh temple and University of Manchester Sikh Society using purposive and snowball sampling in West Yorkshire and North West England. Data were analysed using inductive thematic analysis taking a critical realist stance.Results: Three themes were identified: (1) Perceptions of the causes of T2DM, (2) Perceptions of factors impacting physical activity and diet, and (3) Attitudes towards health-seeking behaviours.Conclusions: The findings show that although well educated, participants overlooked physical activity as contributing factor towards T2DM onset. Additionally, gender and cultural norms influenced physical activity and diet, as these are passed through generations to preserve the collectivist Sikh culture. Exploration of health seeking behaviours also found young Punjabi Sikhs perceived the internet to be the preferred tool to seek T2DM information. These findings hold implications for health professionals, as the information and preventative services provided to Sikhs can be tailored to be culturally appropriate and in line with cultural and gender norms, such as bhangra dancing for physical activity.

Associations between attachment, therapeutic alliance, and engagement in black people with psychosis living in the UK.

BACKGROUND: Compared to other ethnic groups in the UK, Black people have the highest rates of psychosis. This may partly be explained by both assessment bias and structural racism. Mental health services often find it difficult to develop therapeutic relationships with Black people with psychosis. Attachment theory posits that the quality of previous caregiving experiences influence current interpersonal functioning and emotional regulation. In this study, we applied the theory to improve the understanding of therapeutic relationships with people with psychosis. AIMS: This is the first study to examine associations between attachment difficulties, therapeutic alliance, and service engagement in a Black sample with psychosis. METHOD: Fifty-one participants completed self-report measures of attachment and alliance. Staff completed measures of alliance and service engagement. RESULTS: Higher attachment avoidance was related to poorer alliance ratings. These significant findings were not upheld in a regression model controlling for total symptom scores and perceived ethnic/racial discrimination in services. Attachment anxiety was generally not associated with alliance ratings. Neither attachment anxiety nor attachment avoidance was significantly associated with service engagement. CONCLUSIONS: Staff should be supported to better understand the needs of service users with avoidant attachment behaviours and to develop mutually-agreed treatment goals and therapeutic bonds.

Treatment of maternal depression in low-income women: A feasibility study from Kilifi, Kenya.

AIMS OF THE STUDY: To test the feasibility and acceptability of a group psychosocial intervention called Learning Through Play (LTP) plus Culturally adapted Cognitive Behaviour Therapy (CaCBT) for depressed Kenyan mothers with children aged 0-36 months. METHODS USED TO CONDUCT THE STUDY: This study was a single-arm mixed methods feasibility study to test an integrated parenting intervention for postnatal depression in a low-income rural area of Fumbini village in Kilifi District of Kenya. Women between the ages of 18 and 45 years with children up to 3 years were screened for depression using the Patient Health Questionnaire (PHQ-9). Those scoring above 10 on PHQ-9 were interviewed using the Revised Clinical Interview Schedule (CIS-R) to confirm the diagnosis of depression. Assessments were carried out at baseline and at the end of the intervention (3 months), followed by qualitative interviews with 12 women. Qualitative interviews were analysed using thematic analysis from a socio-constructionist theoretical lens. RESULTS OF THE STUDY: The LTP Plus was both feasible and acceptable with high satisfaction among the participants. Qualitative results showed that the women perceived the intervention as beneficial in reducing the symptoms of depression, coping with stress and negative emotions. The results also indicated a reduction in scores on PHQ-9, GAD-7 with an increase in perceived social support, health-related quality of life and an improvement in mothers' knowledge about child development at the end of the intervention. CONCLUSIONS DRAWN FROM THE STUDY AND CLINICAL IMPLICATIONS: This study represents the first feasibility research on integrated parenting intervention in Kenya. The results indicated that culturally adapted LTP plus CaCBT is feasible and acceptable in a low-income setting of Kenya. There is now a need to study the clinical and cost-effectiveness of LTP plus CaCBT in an appropriately powered larger randomised control trial, with a longer follow-up period.

Exploring service user and family perspectives of a Culturally adapted Family Intervention (CaFI) for African-Caribbean people with psychosis: A qualitative study.

OBJECTIVES: In the UK, people of African-Caribbean background have the highest rates of psychosis and greatest inequity in mental health services of all ethnicities. National policies have highlighted the lack of evidence-based psychological interventions for this group. The aim of this study was to examine the acceptability of a novel Culturally adapted Family Intervention (CaFI) for African-Caribbean individuals diagnosed with non-affective psychosis and their relatives. DESIGN: A qualitative design. METHODS: Semi-structured interviews conducted with 22 service users and 12 family members following participation in CaFI. The interview topic guide included perceptions of the needs and benefits of CaFI; usefulness, cultural specificity and accessibility of CaFI therapy and supporting materials; content and delivering of CaFI sessions; views and experiences of working with CaFI therapists; and perceived barriers and facilitators to implementation. RESULTS: Deductive framework analysis identified three main themes for service users: perceived benefits, barriers and limitations, and delivery of the therapy. Four themes were identified for family members: perceived benefits, perceptions of therapists, delivery of therapy, and accessibility of therapy content, supporting materials, and cultural appropriateness. CONCLUSIONS: CaFI was found to be an acceptable intervention for African-Caribbean service users with psychosis and their relatives. Family interventions considering the needs of ethnic and cultural groups have the potential to improve the mental health care and experiences of service users and their families. PRACTITIONER POINTS: The Culturally adapted Family Intervention (CaFI) was viewed as acceptable to African-Caribbean service users with psychosis and their families. Through adapting interventions to be more culturally sensitive, it is possible to enhance the care of those who typically have poor engagement with mental health services. In-keeping with their ethos of individualized care delivery, mental health services should place more emphasis on being able to offer appropriate, culturally adapted interventions to their service users.

A study on the feasibility of delivering a psychologically informed ward-based intervention on an acute mental health ward.

Acute mental health inpatient wards have been criticized for being nontherapeutic. The study aimed to test the feasibility of delivering a psychologically informed intervention in these settings. This single-arm study evaluated the feasibility of clinical psychologists delivering a ward-based psychological service model over a 6-month period on two acute mental health wards. Data were gathered to assess trial design parameters and the feasibility of gathering patient/staff outcome data. Psychologists were able to deliver key elements of the intervention. Baseline staff and patient participant recruitment targets were met. However, there was significant patient attrition at follow-up, with incorrect contact details on discharge being the primary reason. Implementation of a ward-based psychological intervention appears feasible when implemented flexibly. It is feasible to recruit staff and patient participants and to collect staff outcome measures over a 6-month period. However, greater efforts need to be taken to trace patient movement following discharge.

Readability and quality of online eating disorder information-Are they sufficient? A systematic review evaluating websites on anorexia nervosa using DISCERN and Flesch Readability.

OBJECTIVE: Evaluate the quality and readability of United Kingdom-based websites on anorexia nervosa. METHOD: First-page search results of three search engines (with search term "anorexia nervosa") were consulted. Websites were excluded if they were pro-ana, duplications, advertisements, Wikipedia, nonwritten/video, invalid addresses, non-English, book links, articles/news pages, and discussion forums. Fifteen websites were evaluated on information quality using DISCERN, and on readability using the Flesch Reading Ease (FRE) Scale. Spearman's correlations between quality and readability were calculated. RESULTS: DISCERN-scores ranged from 34 to 71 (M = 49.27, SD = 9.16), representing "fair" information quality. FRE-scores ranged from 28 to 64 (M = 42.7, SD = 13.43), representing "difficult" readability. The Royal College of Psychiatrists website (https://www.rcpsych.ac.uk/) received the only "excellent" quality rating and was the only website that met the recommended reading level. The other websites' quality varied, and their reading levels ranged from fairly to very difficult. CONCLUSION: Website quality scores varied. Oftentimes, information about treatment risks and benefits was lacking, and texts were too complex. Website quality seals could prove beneficial, and web developers should use quality and readability measures to ensure information accessibility. Future research should utilize DISCERN and FRE to evaluate quality and readability of websites pertaining to other eating disorders too. Video abstract: https://www.youtube.com/watch?v=a9DKS7qISSA&feature=youtu.be.

Sources of Distress in First-Episode Psychosis: A Systematic Review and Qualitative Metasynthesis.

In this study, we aim to increase our understanding of the self-reported sources of distress among people who have experienced first-episode psychosis. Following a systematic literature search, 33 relevant studies containing first-person accounts of first-episode psychosis were identified, which were synthesized using thematic analysis. Two interrelated superordinate themes were identified: intrapersonal distress and interpersonal distress. Participants reported multiple, diverse, and multifaceted sources of distress across both themes. These were substantially different from those routinely recognized and targeted in clinical practice. This review suggests that practitioners who maintain a stance of genuine curiosity about the potential sources of distress for this population will be perceived as more helpful. The findings also highlight the importance of being service user-led when planning and delivering mental health care. Additional clinical and research implications are discussed.

Method of levels therapy for first-episode psychosis: The feasibility randomized controlled Next Level trial.

OBJECTIVE: We aimed to determine the feasibility and acceptability of Method of Levels (MOL) for people experiencing first-episode psychosis (FEP) to inform decision making about the therapy's suitability for further testing in a larger clinical trial. METHOD: A parallel group randomized controlled trial design was used. Participants (N = 36) were allocated to receive either treatment as usual (TAU) or TAU plus MOL. Recruitment and retention in the trial and the acceptability of the MOL intervention were the primary outcomes. RESULTS: The recruitment target was met within the planned time frame. Retention in the trial at final follow-up was 97%, substantially higher than the 80% threshold prespecified as a successful feasibility outcome. Participant feedback provided initial evidence of the acceptability of the study design and intervention for this population. CONCLUSION: Results support progressing to a larger trial of MOL for FEP. Recommendations for the design of future trials are provided.

Social networks and symptomatic and functional outcomes in schizophrenia: a systematic review and meta-analysis.

PURPOSE: To conduct a systematic review and meta-analysis to examine the strength of associations between social network size and clinical and functional outcomes in schizophrenia. METHOD: Studies were identified from a systematic search of electronic databases (EMBASE, Medline, PsycINFO, and Web of Science) from January 1970 to June 2016. Eligible studies included peer-reviewed English language articles that examined associations between a quantitative measure of network size and symptomatic and/or functional outcome in schizophrenia-spectrum diagnoses. RESULTS: Our search yielded 16 studies with 1,929 participants. Meta-analyses using random effects models to calculate pooled effect sizes (Hedge's g) found that smaller social network size was moderately associated with more severe overall psychiatric symptoms (N = 5, n = 467, g = - 0.53, 95% confidence interval (CI) = - 0.875, - 0.184, p = 0.003) and negative symptoms (N = 8, n = 577, g = - 0.75, 95% CI = - 0.997, - 0.512, p = 0.000). Statistical heterogeneity was observed I2 = 63.04%; I2 = 35.75%,) which could not be explained by low-quality network measures or sample heterogeneity in sensitivity analyses. There was no effect for positive symptoms (N = 7, n = 405, g = - 0.19, 95% CI = 0.494, 0.110, p = 0.213) or social functioning (N = 3, n = 209, g = 0.36, 95% CI = - 0.078, 0.801, p = 0.107). Narrative synthesis suggested that larger network size was associated with improved global functioning, but findings for affective symptoms and quality of life were mixed. CONCLUSION: Psychosocial interventions which support individuals to build and maintain social networks may improve outcomes in schizophrenia. The review findings are cross-sectional and thus causal direction cannot be inferred. Further research is required to examine temporal associations between network characteristics and outcomes in schizophrenia and to test theoretical models relating to explanatory or mediating mechanisms.

An Assets-Based Approach to Co-Producing a Culturally Adapted Family Intervention (CaFI) with African Caribbeans Diagnosed with Schizophrenia and Their Families.

Objective: To determine how to improve the cultural appropriateness and acceptability of an extant evidence-based model of family intervention (FI), a form of 'talking treatment,' for use with African Caribbean service users diagnosed with schizophrenia and their families. Design: Community partnered participatory research (CPPR) using four focus groups comprising 31 key stakeholders. Setting: Community locations and National Health Service (NHS) mental health care settings in northwest England, UK. Participants: African Caribbean service users (n=10), family members, caregivers and advocates (n=14) and health care professionals (n=7). Results: According to participants, components of the extant model of FI were valid but required additional items (such as racism and discrimination and different models of mental health and illness) to improve cultural appropriateness. Additionally, emphasis was placed on developing a new ethos of delivery, which participants called 'shared learning.' This approach explicitly acknowledges that power imbalances are likely to be magnified where delivery of interventions involves White therapists and Black clients. In this context, therapists' cultural competence was regarded as fundamental for successful therapeutic engagement and outcomes. Conclusions: Despite being labelled 'hard-to-reach' by mainstream mental health services and under-represented in research, our experience suggests that, given the opportunity, members of the African Caribbean community were highly motivated to engage in all aspects of research. Participating in research related to schizophrenia, a highly stigmatized condition, suggests CPPR approaches might prove fruitful in developing interventions to address other health conditions that disproportionately affect members of this community.

Therapeutic alliance in psychological therapy for people with schizophrenia and related psychoses: A systematic review.

Therapeutic alliance is a key predictor of therapy outcomes. Alliance may be particularly pertinent for people with schizophrenia as this group often have a history of interpersonal trauma and relationship difficulties including difficult relationships with mental health staff. This review aimed to determine (a) the quality of therapeutic alliance between people with schizophrenia and their therapists; (b) whether alliance predicts therapeutic outcomes; and (c) variables associated with alliance. Databases were searched from inception up to April 2015. The search yielded 4,586 articles, resulting in 26 eligible studies, involving 18 independent samples. Weighted average client and therapist Working Alliance Inventory-Short Form total scores were 64.51 and 61.26, respectively. There was evidence that alliance predicts overall psychotic symptomatic outcomes and preliminary evidence for alliance predicting rehospitalization, medication use, and self-esteem outcomes. There was evidence for specific client-related factors being linked to different perspectives of alliance. For example, poorer insight and previous sexual abuse were associated with worse client-rated alliance, whereas baseline negative symptoms were associated with worse therapist-rated alliance. Therapist and therapy-related factors, including therapists' genuineness, trustworthiness, and empathy were associated with better client-rated alliance, whereas suitability for therapy, homework compliance, and attendance were associated with better therapist-rated alliance. Key clinical implications include the need to consider alliance from both client and therapist perspectives during therapy and training and supervision to enhance therapist qualities that foster good alliance. Future research requires longitudinal studies with larger samples that include pan-theoretical, well-validated alliance measures to determine causal predictor variables.