Acceptability and experience of a smartphone symptom monitoring app for people with psychosis in China (YouXin): a qualitative study.

BACKGROUND: Access to high-quality mental healthcare remains challenging for people with psychosis globally, including China. Smartphone-based symptom monitoring has the potential to support scalable mental healthcare. However, no such tool, until now, has been developed and evaluated for people with psychosis in China. This study investigated the acceptability and the experience of using a symptom self-monitoring smartphone app (YouXin) specifically developed for people with psychosis in China. METHODS: Semi-structured interviews were conducted with 10 participants with psychosis to explore the acceptability of YouXin. Participants were recruited from the non-randomised feasibility study that tested the validity, feasibility, acceptability and safety of the YouXin app. Data analysis was guided by the theoretical framework of acceptability. RESULTS: Most participants felt the app was acceptable and easy to use, and no unbearable burdens or opportunity costs were reported. Participants found completing the self-monitoring app rewarding and experienced a sense of achievement. Privacy and data security were not major concerns for participants, largely due to trust in their treating hospital around data protection. Participants found the app easy to use and attributed this to the training provided at the beginning of the study. A few participants said they had built some form of relationship with the app and would miss the app when the study finished. CONCLUSIONS: The YouXin app is acceptable for symptom self-monitoring in people with experience of psychosis in China. Participants gained greater insights about their symptoms by using the YouXin app. As we only collected retrospective acceptability in this study, future studies are warranted to assess hypothetical acceptability before the commencement of study to provide a more comprehensive understanding of implementation.

Experiences of a digital health intervention for young people exposed to technology assisted sexual abuse: a qualitative study.

BACKGROUND: There is growing evidence that Technology Assisted Sexual Abuse (TASA) represents a serious problem for large numbers of children. To date, there are very few evidence-based interventions available to young people (YP) after they have been exposed to this form of abuse, and access to support services remains a challenge. Digital tools such as smartphones have the potential to increase access to mental health support and may provide an opportunity for YP to both manage their distress and reduce the possibility of further victimization. The current study explores the acceptability of a digital health intervention (DHI; the i-Minds app) which is a theory-driven, co-produced, mentalization-based DHI designed for YP aged 12-18 who have experienced TASA. METHODS: Semi-structured interviews were conducted with 15 YP recruited through Child and Adolescent Mental Health Services, a Sexual Assault Referral Centre and an e-therapy provider who had access to the i-Minds app as part of a feasibility clinical trial. Interviews focused on the acceptability and usability of i-Minds and were coded to themes based on the Acceptability of Healthcare Interventions framework. RESULTS: All participants found the i-Minds app acceptable. Many aspects of the app were seen as enjoyable and useful in helping YP understand their abuse, manage feelings, and change behavior. The app was seen as usable and easy to navigate, but for some participants the level of text was problematic and aspects of the content was, at times, emotionally distressing at times. CONCLUSIONS: The i-Minds app is useful in the management of TASA and helping change some risk-related vulnerabilities. The app was designed, developed and evaluated with YP who had experienced TASA and this may account for the high levels of acceptability seen. TRIAL REGISTRATION: The trial was registered on the ISRCTN registry on the 12/04/2022 as i-Minds: a digital intervention for young people exposed to online sexual abuse (ISRCTN43130832).

The key components of a clinical psychology formulation: A consensus study.

OBJECTIVE: Psychological formulation is a key competency for clinical psychologists. However, there is a lack of consensus regarding the key components and processes of formulation that are hypothesized to contribute to poor reliability of formulations. The aim of this study was to develop consensus on the essential components of a formulation to inform training for clinical psychologists and best practice guidelines. METHODS: A Delphi methodology was used. Items were generated from the literature and discussed and refined with a panel of experts (n = 10). In round one, 110 clinical psychologists in the United Kingdom rated the importance of components of formulation via an online questionnaire. Criteria for consensus were applied and statements were rerated in round two if consensus was not achieved. RESULTS: Consensus was achieved on 30 items, with 18 statements regarding components of a formulation and 12 statements regarding formulation process. Items that clinicians agreed upon emphasized the importance of integrating sociocultural, biological, strengths and personal meaning alongside well-established theoretical frameworks. Consensus was not reached on 20 items, including whether a formulation should be parsimonious or adhere to a model. CONCLUSION: Our findings provide mixed evidence regarding consensus on the key components of formulation. There was an agreement that formulation should be client-led and incorporate strengths and sociocultural factors. Further research should explore client perspectives on the key components of formulation and how these compare to the clinicians' perspectives.

Digital tools to support mental health: a survey study in psychosis.

BACKGROUND: There is a notable a gap between promising research findings and implementation of digital health tools. Understanding and addressing barriers to use is key to widespread implementation. METHODS: A survey was administered to a self-selecting sample in-person (n = 157) or online (n = 58), with questions examining: i) ownership and usage rates of digital devices among people with psychosis; ii) interest in using technology to engage with mental health services; and iii) facilitators of and barriers to using digital tools in a mental healthcare context. RESULTS: Device ownership: Virtually all participants owned a mobile phone (95%) or smartphone (90%), with Android phones slightly more prevalent than iPhones. Only a minority owned a fitness tracker (15%) or smartwatch (13%). Device ownership was significantly lower in unemployed people and those without secondary education. Device cost and paranoid ideation were barriers to ownership. Technology and mental health services: Most participants (88%) said they would willingly try a mental health app. Symptom monitoring apps were most popular, then appointment reminders and medication reminders. Half the sample would prefer an app alongside face-to-face support; the other half preferred remote support or no other mental health support. Facilitators: Participants thought using a mental health app could increase their understanding of psychosis generally, and of their own symptoms. They valued the flexibility of digital tools in enabling access to support anywhere, anytime. Barriers: Prominent barriers to using mental health apps were forgetting, lack of motivation, security concerns, and concerns it would replace face-to-face care. Overall participants reported no substantial effects of technology on their mental health, although a quarter said using a phone worsened paranoid ideation. A third used technology more when psychotic symptoms were higher, whereas a third used it less. Around half used technology more when experiencing low mood. CONCLUSIONS: Our findings suggest rapidly increasing device ownership among people with psychosis, mirroring patterns in the general population. Smartphones appear appropriate for delivering internet-enabled support for psychosis. However, for a sub-group of people with psychosis, the sometimes complex interaction between technology and mental health may act as a barrier to engagement, alongside more prosaic factors such as forgetting.

A systematic review of measures of adult disorganized attachment.

BACKGROUND: Disorganized attachment has been identified as an important factor in the development and maintenance of mental health problems. Further research is required to understand the mechanism by which this attachment pattern predisposes individuals to develop, and maintain, personal and social difficulties and mental health problems utilizing valid and reliable measurement tools. The assessment of adult disorganized attachment is therefore important for both applied psychologists and researchers. METHOD: We conducted a systematic review using the COSMIN guidelines to identify and critically appraise instruments which measure adult disorganized attachment. A systematic database search was performed using MEDLINE, EMBASE, Web of Science, PsychInfo and CINHAL in accordance with PRISMA guidelines. RESULTS: Database searching provided 5757 results, with 18 measures identified across 27 eligible papers which were critically evaluated. Measurement properties were promising for the Childhood Disorganization and Role Reversal Scale, Psychological Treatment Inventory-Attachment Styles Scale, Attachment Style Questionnaire - Short Form and the Adult Attachment Interview. However, overall, due to inconsistent quality of methodology and reporting of results, it is challenging to reach sufficient conclusions and suggestions regarding the best instrument to use to measure adult disorganized attachment. CONCLUSION: The Childhood Disorganization and Role Reversal Scale, Psychological Treatment Inventory-Attachment Styles Scale. Attachment Style Questionnaire-Short-Form and Adult Attachment Interview are the best available measures of disorganized attachment in adulthood. This review highlights the need for further psychometric testing of existing measures, or development of new instruments, grounded in sound methodology.

Conceptualizing the digital therapeutic alliance in the context of fully automated mental health apps: A thematic analysis.

Fully automated mental health apps provide a promising opportunity for increasing access to mental health care and resources. Given this opportunity, continued research into the utility and effectiveness of mental health apps is crucial. Therapeutic alliance (TA) refers to the relationship between a client and a healthcare professional, and has been shown to be an important predictor of clinical outcomes in face-to-face therapy. Given the significance of TA in traditional therapy, it is important to explore whether the notion of a digital therapeutic alliance (DTA) in the context of fully automated mental health apps also plays an important role in clinical outcomes. Current evidence shows that the conceptualization of DTA in the context of fully automated mental health apps can be potentially different to TA in face-to-face therapy. Thus, a new DTA conceptual model is necessary for comprehensively understanding the mechanisms underpinning DTA for fully automated mental health apps. To the best of our knowledge, this is the first study that qualitatively explored the dimensions of a DTA in the context of fully automated mental health apps. We conducted interviews with 20 users of mental health apps to explore the key dimensions comprising DTA in the context of fully automated mental health apps. We found that although conceptualizations of DTA and TA have shared dimensions, flexibility and emotional experiences are unique domains in DTA. On the other hand, although agreement on goals between a therapist and a client is important in face to face therapy, we found that users can have an alliance with an app without a goal. The importance of goal needs further investigations.

Exploring engagement with the CBT-informed Actissist smartphone application for early psychosis.

BACKGROUND: Individuals with psychosis report favourable attitudes towards psychological interventions delivered via smartphone apps. Evidence for acceptability, safety, feasibility and efficacy is promising but in-depth reporting of app engagement in trials is sparse. AIMS: To examine how people with psychosis engaged with the cognitive behaviour therapy (CBT)-informed Actissist app over a 12-week intervention period, and to examine factors associated with app engagement. METHODS: Secondary data from participants in the intervention arm (n = 24) of a proof-of-concept randomised controlled trial of the Actissist app were analysed. The app prompted participants to engage with app-based CBT-informed material in five domains (voices, socialization, cannabis use, paranoia, perceived criticism) at pseudo-random intervals (three notifications per day, six days per week). Participants could self-initiate use any time. App use was financially incentivised. RESULTS: Participants responded to 47% of app notifications. Most app engagements (87%) were app-initiated rather than self-initiated. Participants engaged most with the voices domain, then paranoia. Age and employment status were significantly associated with overall app engagement. CONCLUSION: Individuals with psychosis engaged well with Actissist, particularly with areas focussing on voice-hearing and paranoia. App-generated reminders successfully prompted app engagement. As financial incentives may have increased app engagement, future studies of non-incentivized engagement in larger samples are needed.

Leaf surface traits contributing to wettability, water interception and uptake of above-ground water sources in shrubs of Patagonian arid ecosystems.

BACKGROUND AND AIMS: The ecohydrological significance of leaf wetting due to atmospheric water in arid and semiarid ecosystems is not well understood. In these environments, the inputs of precipitation or dew formation resulting in leaf wetting have positive effects on plant functioning. However, its impact on plant water relations may depend on the degree of leaf surface wettability. In this study we evaluated leaf wettability and other leaf traits and its effects on foliar water uptake and canopy interception in plant species of a Patagonian steppe. We also studied how leaf traits affecting wettability vary seasonally from growing to dry season. METHODS: Contact angle of a water droplet with the leaf surface, water adhesion, droplet retention angle, stomatal density, cuticular conductance, canopy interception and maximum foliar water uptake were determined in six dominant shrub species. KEY RESULTS: All species increased leaf wettability during the dry season and most species were considered highly wettable. The leaf surface had very high capacity to store and retain water. We found a negative correlation between foliar water uptake and leaf hydrophilia. CONCLUSIONS: Despite the diversity of life forms, including cushion shrubs and tall shrubs, as well as phenological variability, all species converged in similar seasonal changes in leaf traits that favour wettability. Intercepted water by crowns and the extremely high capacity of retention of droplets on leaf surfaces can have a significant impact on eco-hydrological process in water limited ecosystems where most of water sources during the growing and the dry season may be small rainfall events or dew, which do not always increase soil water availability.

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.

Fluctuations in proximity seeking and paranoia.

OBJECTIVES: This study aimed to investigate associations between proximity seeking, stress and paranoia in the context of daily life, and whether these relationships are moderated by trait attachment styles. METHODS: Sixty non-clinical participants completed 3423 assessments of state stress, proximity seeking and paranoia over a 6-day period using an experience sampling method. Multilevel linear regression was performed to evaluate relationships between variables. RESULTS: The post-hoc analysis showed antecedent events subjectively appraised as very unpleasant or very pleasant predicted greater levels of momentary proximity seeking at the subsequent timepoint. Greater stress predicted greater subsequent shifts or variability in proximity seeking. Changes in proximity seeking were not associated with momentary paranoia. However, for individuals with an avoidant attachment style, greater shifts in proximity seeking resulted in greater subsequent reports of paranoia. CONCLUSIONS: These findings suggest that, in daily life, the attachment system may become active in response to stress. For those with an avoidant attachment style, an active attachment system may exacerbate paranoid thoughts possibly due to the activation of attachment-related beliefs that one should be fearful of unavailable others and instead rely on one's autonomy to regulate affect. These findings highlight the need to consider attachment in the assessment and formulation of paranoia.

The role of attachment and dissociation in the relationship between childhood interpersonal trauma and negative symptoms in psychosis.

Negative symptoms have an adverse impact on quality of life and functioning in psychosis. Service users with psychosis have identified negative symptoms as a priority for their recovery. Despite this, there is a lack of effective and targeted psychological interventions for negative symptoms and their underlying mechanisms remain poorly understood. Childhood trauma is a robust risk factor for positive symptoms in psychosis, but the association with negative symptoms is less well established. Our aim was to examine the association between childhood interpersonal trauma and negative symptoms and the psychological mediators of this relationship. Two hundred and forty participants experiencing psychosis completed validated self-report measures of childhood trauma, attachment, dissociation, compartmentalization, and symptoms. Mediation analyses showed that disorganized attachment and dissociative experiences mediated the association between childhood trauma and negative symptoms, when analysed individually and in a combined model. Models adjusted for age and positive and depressive symptoms. Avoidant attachment and compartmentalization were independently associated with negative symptoms but not childhood trauma and thus were not significant mediators. Childhood trauma was not independently associated with negative symptoms. This paper is the first to present empirical data to support a model implicating attachment and dissociation as important psychological processes in the link between childhood trauma and negative symptoms. These exploratory findings suggest that it may be beneficial to consider these relationships in trauma-informed formulations and interventions. Further longitudinal research is required to establish causality and test theoretical models of mechanisms in the pathway to negative symptoms.

Digital mental health in China: a systematic review.

Mental health problems are highly prevalent in China; however, China's mental health services lack resources to deliver high-quality care to people in need. Digital mental health is a promising solution to this short-fall in view of the population's digital literacy. In this review, we aim to: (i) investigate the effectiveness, acceptability, usability, and safety of digital health technologies (DHTs) for people with mental health problems in China; (ii) critically appraise the literature; and (iii) make recommendations for future research directions. The databases MEDLINE, PsycINFO, EMBASE, Web of Science, CNKI, WANFANG, and VIP were systemically searched for English and Chinese language articles evaluating DHTs for people with mental health problems in mainland China. Eligible studies were systematically reviewed. The heterogeneity of studies included precluded a meta-analysis. In total, 39 articles were retrieved, reporting on 32 DHTs for various mental health problems. Compared with the digital mental health field in the West, the Chinese studies targeted schizophrenia and substance use disorder more often and investigated social anxiety mediated by shame and culturally specific variants, DHTs were rarely developed in a co-production approach, and methodology quality was less rigorous. To our knowledge, this is the first systematic review focused on digital mental health in the Chinese context including studies published in both English and the Chinese language. DHTs were acceptable and usable among Chinese people with mental health problems in general, similar to findings from the West. Due to heterogeneity across studies and a paucity of robust control trial research, conclusions about the efficacy of DHTs are lacking.

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.

The Team Formulation Quality Rating Scale (TFQS): development and evaluation.

BACKGROUND: Team formulation is a core skill in mental health care, but there is currently no valid tool for assessing the quality of this process. AIM: The aim of this study was to design and evaluate a new scale, the Team Formulation Quality Scale (TFQS), which assesses both structure and content. METHODS: Experts were asked to assess the relevance and clarity of each item on the TFQS to measure its content and face validity. Two experienced Clinical Psychologists rated eight audio recorded team formulation sessions and the scores were used to assess the internal consistency and inter-rater reliability of the TFQS. RESULTS: The TFQS demonstrated good content and face validity as experts agreed all twenty-three items were relevant to measuring the quality of team formulation and rated it as understandable and comprehensive. The overall internal consistency of the TFQS was good (alpha = 0.718). The inter-rater reliability of the TFQS was consistent with individual case formulation quality measures (ICC = 0.600). CONCLUSIONS: We have developed the first scale to measure the quality of team formulation. The TFQS showed good validity and is a reliable tool that can be used in training, clinical practice and research related to team formulations.

Foliar water uptake in arid ecosystems: seasonal variability and ecophysiological consequences.

Foliar water uptake (FWU) has been reported for different species across several ecosystems types. However, little attention has been given to arid ecosystems, where FWU during dew formation or small rain events could ameliorate water deficits. FWU and their effects on leaf water potential (ΨLeaf) were evaluated in grasses and shrubs exploring different soil water sources in a Patagonian steppe. Also, seasonal variability in FWU and the role of cell wall elasticity in determining the effects on ΨLeaf were assessed. Eleven small rain events (< 8 mm) and 45 days with dew formation were recorded during the study period. All species exhibited FWU after experimental wetting. There was a large variability in FWU across species, from 0.04 mmol m-2 s-1 in species with deep roots to 0.75 mmol m-2 s-1 in species with shallow roots. Species-specific mean FWU rates were positively correlated with mean transpiration rates. The increase in ΨLeaf after leaf wetting varied between 0.65 MPa and 1.67 MPa across species and seasons. The effects of FWU on ΨLeaf were inversely correlated with cell wall elasticity. FWU integrated over both seasons varied between 28 mol m-2 in species with deep roots to 361 mol m-2 in species with shallow roots. Taking into account the percentage of coverage of each species, accumulated FWU represented 1.6% of the total annual transpiration of grasses and shrubs in this ecosystem. Despite this low FWU integrated over time compared to transpiration, wetting leaves surfaces can help to avoid larger water deficit during the dry season.

The revised Psychosis Attachment Measure: Measuring disorganized attachment.

OBJECTIVES: The Psychosis Attachment Measure (PAM) is currently the most widely used and validated measure of attachment in psychosis. However, the PAM does not assess disorganized attachment, the type of attachment that has been most closely linked with vulnerability to psychosis. This study aimed to expand the PAM to capture the concept of disorganized attachment and to examine its psychometric properties in a psychosis sample. METHODS: Clinical and academic experts in the field of psychosis and service user representatives were asked to assess the comprehensiveness and comprehensibility of the pool of disorganized items. This process resulted in 12 items hypothesized to capture disorganized attachment that were included with the original items of the PAM. A sample of 144 individuals with either a self-reported diagnosis of, or treatment for, a psychosis-related condition completed a battery of online measures comprising the revised PAM, existing measures of adult disorganized attachment and constructs hypothesized to be conceptually related to disorganized attachment. RESULTS: An exploratory factor analysis was conducted with three factors retained; these were labelled anxious, avoidant and disorganized attachment. The factors displayed good internal consistency and test-retest reliability and the disorganized factor displayed good construct validity with related measures and constructs. CONCLUSIONS: These results provide preliminary evidence that the revised PAM captures the concept of disorganized attachment. However, confirmatory psychometric evaluation of the revised PAM is required, within a separate psychosis sample, to confirm its factor structure. The relationship between these results and the current literature, in addition to the clinical and research implications, are discussed. PRACTITIONER POINTS: We present an expanded version of the Psychosis Attachment Measure (PAM), revised to capture the concept of disorganised attachment in adulthood. This expanded measure showed good reliability and the new disorganized subscale demonstrated construct validity. These results provide preliminary evidence that disorganized attachment can be measured using a simple self-report measure with individuals with psychosis. Further research is required to confirm the structural dimensionality of the revised PAM within a new sample using confirmatory factor analysis. Following further psychometric validation the use of this measure has the potential to be expanded to other mental health conditions in which disorganized attachment has been implicated in the development and maintenance of difficulties, for example, trauma-related conditions and borderline personality disorder.

The relationship between insecure attachment and paranoia in psychosis: A systematic literature review.

OBJECTIVES: Paranoia is a key symptom in psychosis and associated with a range of poor outcomes. Earlier life experiences increase vulnerability to paranoid thinking, and attachment theory has been proposed as a key model in explaining this causal pathway. Previous reviews highlight evidence of associations between insecure attachment styles and overall severity of psychotic symptoms. Studies report on associations between insecure attachment and paranoia, but to date, this literature has not been adequately synthesized. The aim of the current review was to report the strength and consistency of associations between paranoia and insecure attachment across published studies, and provide systematic appraisal of study quality. METHOD: We carried out a systematic review of electronic databases using search terms to capture concepts of adult attachment, paranoia, and psychosis. We pre-registered the review protocol and followed PRISMA guidelines. RESULTS: Significant associations were reported in 11 out of 12 studies between an insecure attachment and paranoia, with associations remaining significant in studies that controlled for comorbid symptoms. The strongest, most commonly reported relationship was between an anxious attachment style and paranoia. CONCLUSIONS: The findings support the proposed role of attachment insecurity in the development and maintenance of paranoia in psychosis and highlight the need to address insecure attachment representations in the treatment of paranoia. PRACTITIONER POINTS: There is consistent evidence of associations between insecure attachment style and paranoia. Insecure anxious attachment is more consistently associated with paranoia than an insecure avoidant attachment. Associations between attachment and paranoia remain significant when key confounders are controlled for in the analyses. Interventions that address insecure attachment representations and promote a more secure attachment are likely to help reduce paranoia.

The relationship between attachment and functioning for people with serious mental illness: a systematic review.

AIMS: Functional impairment is a hallmark feature of severe mental health problems (SMI). Attachment theory is a key psychological theory of interpersonal functioning and difficulties in attachment are common in SMI and may help explain functioning problems in SMI. This systematic review aimed to synthesise and critically appraise existing literature exploring associations between adult attachment style and functioning in SMI samples. METHOD: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines we systematically searched five databases using strings of terms relating to both attachment and social functioning. Inclusion criteria were samples diagnosed with SMI and validated measure tools. RESULTS: Ten studies met inclusion criteria. Considerable heterogeneity was found across studies in relation to construct measurement, sample size, and gender distribution. However, as predicted there was some evidence to suggest that secure attachment is associated with better functioning, and insecure attachment (specifically anxious style) is associated with impairments in functioning. CONCLUSION: Findings highlight the importance of considering attachment in relation to functional outcome when working with people with SMI, particularly when assessing, formulating, and delivering psychological interventions.

Functional relationships between hydraulic traits and the timing of diurnal depression of photosynthesis.

The hydraulic coordination along the water transport pathway helps trees provide adequate water supply to the canopy, ensuring that water deficits are minimized and that stomata remain open for CO2 uptake. We evaluated the stem and leaf hydraulic coordination and the linkages between hydraulic traits and the timing of diurnal depression of photosynthesis across seven evergreen tree species in the southern Andes. There was a positive correlation between stem hydraulic conductivity (ks ) and leaf hydraulic conductance (KLeaf ) across species. All species had similar maximum photosynthetic rates (Amax ). The species with higher ks and KLeaf attained Amax in the morning, whereas the species with lower ks and KLeaf exhibited their Amax in the early afternoon concurrently with turgor loss. These latter species had very negative leaf water potentials, but far from the pressure at which the 88% of leaf hydraulic conductance is lost. Our results suggest that diurnal gas exchange dynamics may be determined by leaf hydraulic vulnerability such that a species more vulnerable to drought restrict water loss and carbon assimilation earlier than species less vulnerable. However, under stronger drought, species with earlier CO2 uptake depression may increase the risk of hydraulic failure, as their safety margins are relatively narrow.

Are family warmth and positive remarks related to outcomes in psychosis? A systematic review.

BACKGROUND: Affective attitudes and behaviours manifested within the family environment have been characterised as expressed emotion (EE). High EE environments have been robustly shown to put psychosis patients at a greater risk of relapse compared with low EE exposure. Positive EE dimensions (warmth; positive remarks) have received far less attention than negative EE dimensions such that EE has become synonymous with a negative family atmosphere; the predictive value of positive EE dimensions is largely ignored. A systematic review examining the relationship between positive family EE and outcomes in psychosis is needed. METHODS: A systematic search was conducted. Studies reporting bias and study quality were assessed. RESULTS: A total of 2368 studies were identified. Of these, 27 met eligibility criteria reporting outcomes including relapse, symptomatology, social functioning and life satisfaction. Relapse was the most commonly measured outcome. Stronger evidence emerged for the association between EE warmth and outcomes compared with EE positive remarks, with effects mostly evident in the early phase of psychosis. Evidence for protective effects of warmth on relapse was found up to 9 months follow-up. No effects were evident between positive remarks and relapse. Studies assessing symptom outcomes showed inconsistent findings. Evidence for an association with social functioning was evident, primarily in at risk mental states. Warmth and positive remarks predicted life satisfaction. CONCLUSIONS: The positive aspects of EE require further investigation with longitudinal research designs. Clinical interventions should focus not only on reducing negative aspects of EE but also foster warmth within families in the context of psychosis.