A systematic review of users experiences of using digital interventions within psychosis: a thematic synthesis of qualitative research.

PURPOSE: Although the development of digital mental health support for people with psychosis has been increasing, the development and opportunities to access this have been more limited compared to other mental health conditions. Qualitative research exploring the experiences of using digital interventions amongst people with psychosis is even less well developed; however, such research is crucial in capturing the experiences of using digital interventions to ensure they are meeting the needs of people with psychosis. This paper aimed to synthesise qualitative data related to the experiences of people with psychosis who have used digital interventions. METHODS: A systematic literature search was conducted of articles published between 1992 and October 2023 using PubMed, MBase, PsycINFO, & OVID Medline. Two reviewers independently reviewed and screened 268 papers. Papers that met inclusion criteria were quality assessed using The Critical Appraisal Skills Programme (CASP) qualitative studies checklist. The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist was used to guide the structure of the report. RESULTS: A thematic synthesis of 19 studies revealed six overarching themes which related to different aspects and features of the digital interventions: participants' relationship with technology; the accessibility of the interventions; how the interventions could impact on individuals' awareness and management of mental health; enhanced communication and relationships; and opportunities for reflection. CONCLUSIONS: Benefits of using digital interventions are discussed. Areas for development and improvements are highlighted. Finally, recommendations for stakeholders who develop and implement digital interventions for psychosis are made.

Exploring stigma, shame, and safety behaviours in social anxiety and paranoia amongst people diagnosed with schizophrenia.

BACKGROUND: Social anxiety and paranoia are connected by a shared suspicion framework. Based on cognitive-behavioural approaches, there is evidence for treating social anxiety and psychosis. However, mechanisms underlying the relationship between social anxiety and paranoia remain unclear. AIMS: To investigate mediators between social anxiety and paranoia in schizophrenia such as negative social appraisals (i.e. stigma or shame; Hypothesis 1), and safety behaviours (i.e. anxious avoidance or in situ safety behaviours; Hypothesis 2). METHOD: A cross-sectional study was conducted among Asian out-patients with schizophrenia (January-April 2020). Data on social anxiety, paranoia, depression, shame, stigma, anxious avoidance, and in situ behaviours were collected. Associations between social anxiety and paranoia were investigated using linear regressions. Mediation analysis via 10,000 bias-corrected bootstrap samples with 95% confidence intervals (CI) was used to test the indirect effects (ab) of mediators. RESULTS: Participants (n=113, 59.3% male) with a mean age of 44.2 years were recruited. A linear relationship between social anxiety and paranoia was found. In multiple mediation analyses (co-varying for depression), stigma and shame (Hypothesis 1) did not show any significant indirect effects with ab=.004 (95%CI=-.013, .031) and -.003 (-.023, .017), respectively, whereas in situ behaviours (Hypothesis 2) showed a significant effect with ab=.110 (.038, .201) through the social anxiety-paranoia relationship. CONCLUSIONS: Social anxiety and paranoia are positively correlated. In situ safety behaviours fully mediated the social anxiety and paranoia relationship. Targeted interventions focusing on safety behaviours could help reduce paranoia in psychosis. Symptom severity should be measured to help characterise the participants' characteristics.

Using EMPOWER in daily life: a qualitative investigation of implementation experiences.

BACKGROUND: Digital self-management tools blended with clinical triage and peer support have the potential to improve access to early warning signs (EWS) based relapse prevention in schizophrenia care. However, the implementation of digital interventions in psychosis can be poor. Traditionally, research focused on understanding how people implement interventions has focused on the perspectives of mental health staff. Digital interventions are becoming more commonly used by patients within the context of daily life, which means there is a need to understand implementation from the perspectives of patients and carers. METHODS: Semi-structured one-on-one interviews with 16 patients who had access to the EMPOWER digital self-management intervention during their participation in a feasibility trial, six mental health staff members who supported the patients and were enrolled in the trial, and one carer participant. Interviews focused on understanding implementation, including barriers and facilitators. Data were coded using thematic analysis. RESULTS: The intervention was well implemented, and EMPOWER was typically perceived positively by patients, mental health staff and the carer we spoke to. However, some patients reported negative views and reported ideas for intervention improvement. Patients reported valuing that the app afforded them access to things like information or increased social contact from peer support workers that went above and beyond that offered in routine care. Patients seemed motivated to continue implementing EMPOWER in daily life when they perceived it was creating positive change to their wellbeing, but seemed less motivated if this did not occur. Mental health staff and carer views suggest they developed increased confidence patients could self-manage and valued using the fact that people they support were using the EMPOWER intervention to open up conversations about self-management and wellbeing. CONCLUSIONS: The findings from this study suggest peer worker supported digital self-management like EMPOWER has the potential to be implemented. Further evaluations of these interventions are warranted, and conducting qualitative research on the feasibility gives insight into implementation barriers and facilitators, improving the likelihood of interventions being usable. In particular, the views of patients who demonstrated low usage levels would be valuable.

General and age-specific fertility rates in non-affective psychosis: population-based analysis of Scottish women.

PURPOSE: Women diagnosed with non-affective psychosis have a lower general fertility rate (GFR) and age-specific fertility rate (ASFR) than women in the general population. Contemporary data on GFR in this group remain limited, despite substantive changes in prescribing and management. We calculated contemporary estimates of the GFR and ASFR for women diagnosed with non-affective psychosis compared with the general population of women without this diagnosis. METHODS: A population-based design combined routinely collected historical maternity and psychiatric data from two representative areas of Scotland. Women were included from the NHS Grampian or Greater Glasgow and Clyde areas and were aged 15-44 between 2005 and 2013 inclusive. The 'exposed' group had a diagnosis of non-affective psychosis (ICD-10 F20-F29) and was compared to the general population of 'unexposed' women in the same geographical areas. RESULTS: Annual GFR between 2005 and 2013 for women with non-affective psychosis varied from 9.6 to 21.3 live births/1000 women per year in the exposed cohort and 52.7 to 57.8 live births/1000 women per year in the unexposed cohort, a rate ratio (RR) of 0.28 [p < 0.001; 95% CI (0.24, 0.32)]. ASFR for all 5-year age groups was lower in the exposed cohort than amongst unexposed women. CONCLUSION: We highlight continued low fertility rates in women with a diagnosis of non-affective psychosis, despite widespread availability of prolactin-sparing atypical antipsychotics. Accurate estimation of fertility rates remains crucial in developing needs-matched perinatal care for these women. Methodological improvements using routine datasets to investigate perinatal mental health are also urgently needed.

A case series study of compassion-focused therapy for distressing experiences in psychosis.

OBJECTIVES: Compassion-focused therapy (CFT) is an evolution-informed biopsychosocial approach that seeks to cultivate attachment and care motivational systems and their psychophysiological regulators. These can counteract some of the harmful effects of social threat, inferiority, shame, self-criticism and depression, which are common in people with psychosis and undermine their well-being, social trust and ability to feel safe. This study aimed to test the acceptability of a novel manualized individual CFT intervention for psychosis (CFTp). DESIGN: A non-concurrent, multiple-baseline, case series design, with three phases: baseline, intervention and follow-up. METHODS: The 26-session CFTp intervention was provided for a sample of eight people with distressing psychotic experiences and a psychosis-related diagnosis. The study aimed to assess acceptability of CFTp and to test clinically reliable improvements while receiving the intervention, compared to a baseline period. RESULTS: Seven of eight participants completed the therapy, and clinically reliable improvements were found at both the single-case and group level of analysis. At the single-case level, over half the participants showed improvements in depression (5/7), stress (5/7), distress (5/7), anxiety (4/7) and voices (3/5). One participant showed a deterioration in anxiety (1/7) and dissociation (1/7). At the group level (n = 7), there were significant improvements in depression, stress, distress, voices and delusions. The improvements in voices, delusions and distress were sustained at 6- to 8-week follow-up, but depression and stress dropped slightly to trend-level improvements. CONCLUSIONS: CFTp is a feasible and acceptable intervention for psychosis, and further investigation is warranted with a randomized controlled trial.

Characterising cognitive heterogeneity in individuals at clinical high-risk for psychosis: a cluster analysis with clinical and functional outcome prediction.

Schizophrenia is characterised by cognitive impairments that are already present during early stages, including in the clinical high-risk for psychosis (CHR-P) state and first-episode psychosis (FEP). Moreover, data suggest the presence of distinct cognitive subtypes during early-stage psychosis, with evidence for spared vs. impaired cognitive profiles that may be differentially associated with symptomatic and functional outcomes. Using cluster analysis, we sought to determine whether cognitive subgroups were associated with clinical and functional outcomes in CHR-P individuals. Data were available for 146 CHR-P participants of whom 122 completed a 6- and/or 12-month follow-up; 15 FEP participants; 47 participants not fulfilling CHR-P criteria (CHR-Ns); and 53 healthy controls (HCs). We performed hierarchical cluster analysis on principal components derived from neurocognitive and social cognitive measures. Within the CHR-P group, clusters were compared on clinical and functional variables and examined for associations with global functioning, persistent attenuated psychotic symptoms and transition to psychosis. Two discrete cognitive subgroups emerged across all participants: 45.9% of CHR-P individuals were cognitively impaired compared to 93.3% of FEP, 29.8% of CHR-N and 30.2% of HC participants. Cognitively impaired CHR-P participants also had significantly poorer functioning at baseline and follow-up than their cognitively spared counterparts. Specifically, cluster membership predicted functional but not clinical outcome. Our findings support the existence of distinct cognitive subgroups in CHR-P individuals that are associated with functional outcomes, with implications for early intervention and the understanding of underlying developmental processes.

Fear of relapse in schizophrenia: a mixed-methods systematic review.

INTRODUCTION: Fears of relapse in people diagnosed with schizophrenia have long been recognised as an impediment to recovery and wellbeing. However, the extent of the empirical basis for the fear of relapse concept is unclear. A systematic review is required to collate available evidence and define future research directions. METHODS: A pre-registered systematic search (PROSPERO CRD42020196964) of four databases (PubMED, MEDLINE-Ovid, PsycINFO-Ovid, and Cochrane Central Register of Controlled Trials) was conducted from their inception to 05/04/2021. RESULTS: We found nine eligible studies. Five were quantitative (4 descriptive and 1 randomised controlled trial), and four were qualitative. The available quantitative evidence suggests that fear of relapse may have concurrent positive relationships with depression (r = 0.72) and suicide ideation (r = 0.48), and negative relationship with self-esteem (r = 0.67). Qualitative synthesis suggests that fear of relapse is a complex phenomenon with behavioural and emotional components which has both direct and indirect effects on wellbeing. CONCLUSIONS: Evidence in this area is limited and research with explicit service user and carer involvement is urgently needed to develop new and/or refine existing measurement tools, and to measure wellbeing rather than psychopathology. Nonetheless, clinicians should be aware that fear of relapse exists and appears to be positively associated with depression and suicide ideation, and negatively associated with self-esteem. Fear of relapse can include fears of losing personal autonomy and/or social/occupational functioning. It appears to impact carers as well as those diagnosed with schizophrenia.

Digital Interventions for Psychological Well-being in University Students: Systematic Review and Meta-analysis.

BACKGROUND: Life at university provides important opportunities for personal growth; however, this developmental phase also coincides with the peak period of risk for the onset of mental health disorders. In addition, specific university lifestyle factors, including impaired sleep and academic and financial stress, are known to exacerbate psychological distress in students. As a result, university students have been identified as a vulnerable population who often experience significant barriers to accessing psychological treatment. Digital psychological interventions are emerging as a promising solution for this population, but their effectiveness remains unclear. OBJECTIVE: This systematic review and meta-analysis aimed to assess digital interventions targeting psychological well-being among university students. METHODS: Database searches were conducted on December 2, 2021, via Embase, MEDLINE, PsycINFO, and Web of Science. RESULTS: A total of 13 eligible studies were identified, 10 (77%) of which were included in the meta-analysis. Mean pre-post effect sizes indicated that such interventions led to small and significant improvement in psychological well-being (Hedges g=0.32, 95% CI 0.23-0.4; P<.001). These effects remained, albeit smaller, when studies that included a wait-list control group were excluded (Hedges g=0.22, 95% CI 0.08-0.35; P=.002). An analysis of acceptance and commitment therapy approaches revealed small and significant effects (k=6; Hedges g=0.35, 95% CI 0.25-0.45; P<.001). CONCLUSIONS: Digital psychological interventions hold considerable promise for university students, although features that optimize service delivery and outcomes require further assessment. TRIAL REGISTRATION: PROSPERO CRD42020196654; https:/www.crd.york.ac.uk/prospero/display_record.php?RecordID=196654.

Duration of basic and attenuated-psychotic symptoms in individuals at clinical high risk for psychosis: pattern of symptom onset and effects of duration on functioning and cognition.

INTRODUCTION: Duration of risk symptoms (DUR) in people at clinical high risk for psychosis (CHR-P) has been related to poorer clinical outcomes, such as reduced functioning, but it is currently unclear how different symptoms emerge as well as their link with cognitive deficits. To address these questions, we examined the duration of basic symptoms (BS) and attenuated psychotic symptoms (APS) in a sample of CHR-P participants to test the hypothesis that BS precede the manifestation of APS. As a secondary objective, we investigated the relationship between DUR, functioning and neuropsychological deficits. METHODS: Data from 134 CHR-P participants were assessed with the Comprehensive Assessment of At-Risk Mental State and the Schizophrenia Proneness Interview, Adult Version. Global, role and social functioning and neurocognition were assessed and compared to a sample of healthy controls (n = 57). RESULTS: In CHR-P participants who reported both APS and BS, onset of BS and APS was not significantly related. When divided into short and long BS duration ( 8 years), CHR-P participants with a longer duration of BS showed evidence for an onset of BS preceding APS (n = 8, p = 0.003). However, in the short BS duration group, APS showed evidence of preceding BS (n = 56, p = 0.020). Finally, there were no significant effects of DUR on cognition or functioning measures. CONCLUSION: The present findings do not support the view that APS constitute a secondary phenomenon to BS. Moreover, our data could also not confirm that DUR has a significant effect on functioning and cognitive deficits. These findings are discussed in the context of current theories regarding emerging psychosis and the importance of DUR.

Mental Health Professionals' Positions in Relation to Advance Statements: A Foucauldian Discourse Analysis.

Advance Statements enable mental health patients to have their preferences considered in treatment decisions in the event of losing capacity, but their uptake is poor. This is for complex and often conflicting reasons and factors related to service user, clinician, and institutional priorities, which influence clinical practice. A Foucauldian discourse analysis approach was used to explore how 13 mental health clinicians positioned their role in relation to Advance Statements. Five positions emerged from the data: taking account of peoples' wishes, enabling people to have their say (to a point), we know what's best, firefighting with risk, and leverage and liability. Discursive practices demonstrated and reinforced power relations between patients, clinicians, and wider systems. These findings highlight the challenge of legitimizing the knowledge of patients and need for a cultural shift at a systems level, which recognizes the ways Advance Statements meet the needs of all stakeholders.

Neuropsychological deficits in participants at clinical high risk for psychosis recruited from the community: relationships to functioning and clinical symptoms.

BACKGROUND: The current study examined the pattern of neurocognitive impairments in a community-recruited sample of clinical high-risk (CHR) participants and established relationships with psychosocial functioning. METHODS: CHR-participants (n = 108), participants who did not fulfil CHR-criteria (CHR-negatives) (n = 42) as well as a group of healthy controls (HCs) (n = 55) were recruited. CHR-status was assessed using the Comprehensive Assessment of At-Risk Mental States (CAARMS) and the Schizophrenia Proneness Instrument, Adult Version (SPI-A). The Brief Assessment of Cognition in Schizophrenia Battery (BACS) as well as tests for emotion recognition, working memory and attention were administered. In addition, role and social functioning as well as premorbid adjustment were assessed. RESULTS: CHR-participants were significantly impaired on the Symbol-Coding and Token-Motor task and showed a reduction in total BACS-scores. Moreover, CHR-participants were characterised by prolonged response times (RTs) in emotion recognition as well as by reductions in both social and role functioning, GAF and premorbid adjustments compared with HCs. Neurocognitive impairments in emotion recognition accuracy, emotion recognition RT, processing speed and motor speed were associated with several aspects of functioning explaining between 4% and 12% of the variance. CONCLUSION: The current data obtained from a community sample of CHR-participants highlight the importance of dysfunctions in motor and processing speed and emotion recognition RT. Moreover, these deficits were found to be related to global, social and role functioning, suggesting that neurocognitive impairments are an important aspect of sub-threshold psychotic experiences and a possible target for therapeutic interventions.

Understanding and improving the experience of claiming social security for mental health problems in the west of Scotland: A participatory social welfare study.

A growing body of literature links claimant interactions with the UK social security system and negative psychological consequences. Psychologists for social change developed a framework to outline proposed mechanisms of psychological impact from austerity. This codesigned study aimed to make an informed comment on areas of dis(agreement) between the Austerity Ailments framework and how people claiming for mental health problems describe their own experiences. In line with the participatory social welfare design of the study, qualitative analysis was performed by both claimants and academics. The overall findings indicate that existing framework mostly captured claimant experiences. However, some aspects of the claimant experience (particularly social aspects) were not well captured. Claimants were keen to utilise this study as an opportunity to gather claimant ideas on how to improve the system. Therefore, we report their suggestions that may be useful for those designing and improving social welfare systems.

Antenatal caregiving representations and perinatal behavior in mothers with severe lifetime psychopathology.

Psychopathology poses a risk for optimal parenting. The current study explored antenatal caregiving representations as markers for later risk of nonoptimal maternal behavior among mothers with severe mental illness. Sixty-five mothers diagnosed with psychosis, bipolar disorder, depression (psychopathology group), and nonclinical controls participated in a longitudinal study from pregnancy to 16 weeks after birth. Mental health diagnoses and caregiving representations were assessed during pregnancy. Maternal behavior was assessed during the 5-min recovery phase of the still-face paradigm at 16 weeks. Mothers with psychopathology reported significantly higher levels of "heightened" caregiving representations (i.e., separation anxiety from the child) than did controls. The only significant diagnostic group difference in perinatal maternal behavior was that mothers diagnosed with depression exhibited more overriding-intrusive behavior than did nonclinical control mothers. Regression modeling results showed that antenatal caregiving representations of "role reversal" predicted significantly lower levels of sensitivity and higher levels of overriding-intrusive behavior independent of the effect of psychopathology. The findings can be interpreted in the context of representational transformation to motherhood during pregnancy. The results provide preliminary evidence for the potential of a new questionnaire measure of caregiving representations as a screening instrument for antenatal representational risk.

La sicopatología presenta un riesgo para la crianza óptima. El presente estudio exploró las representaciones antenatales de la prestación de cuidado como señales para un posterior riesgo de conducta materna no óptima entre madres con una enfermedad mental severa. Sesenta y cinco madres con diagnosis de sicosis, trastorno bipolar, depresión (grupo de sicopatología), así como madres en el grupo control no clínico participaron en un estudio longitudinal desde el embarazo hasta 16 semanas después del nacimiento. Se evaluaron los diagnósticos de salud mental y las representaciones de la prestación de cuidado durante el embarazo. La conducta materna fue evaluada durante la fase de cinco minutos de recuperación del paradigma de la Cara Inmóvil a las 16 semanas. Las madres con sicopatología reportaron niveles significativamente más altos de representaciones "agudizadas" de la prestación de cuidado (v.g. ansiedad de estar separadas de su niño) que las madres del grupo de control. La única significativa diferencia de grupo de diagnóstico en cuanto a la conducta materna perinatal fue que las madres con diagnosis de depresión presentaron una conducta predominantemente más intrusa que las madres del grupo de control no clínico. Los resultados del uso de modelos de regresión mostraron que las representaciones antenatales de la prestación de cuidado en cuanto al 'cambio de roles' predijeron niveles significativamente más bajos de sensibilidad y niveles más altos de conductas predominantemente intrusas, independiente del efecto de la sicopatología. Se pueden interpretar los resultados en el contexto de la transformación de representación hacia la maternidad durante el embarazo. Los resultados aportan evidencia preliminar para la posibilidad de una nueva medida de cuestionario sobre las representaciones de la prestación de cuidado como instrumento de detección del riesgo de la representación antenatal.

La psychopathologie pose un risque pour le parentage optimal. Cette étude a exploré les représentations de soin anténatal en tant que marqueurs de risque ultérieur de comportement maternel non-optimal chez les mères atteintes d'une maladie mentale sérieuse. Soixante-cinq mères ayant été diagnostiquées avec une psychose, un trouble maniaco-dépressif, une dépression (groupe psychopathologie) et des contrôles non-cliniques ont participé à une étude longitudinale de la grossesse à 16 semaines après la naissance. Les diagnostics de santé mentale et les représentations de soin ont été évaluées durant la grossesse. Le comportement maternel a été évalué durant la phase de récupération de cinq minutes du paradigme de Visage Immobile à 16 semaines. Les mères avec une psychopathologie ont fait état de niveaux bien plus élevés de représentations 'accrues' de soin (anxiété de séparation d'avec l'enfant) que les contrôles. La seule différence importante de diagnostic de groupe dans le comportement maternel périnatal était que les mères diagnostiquées avec une dépression ont fait preuve de plus de comportement prépondérant-intrusif que les mères du groupe de contrôle non-clinique. Les résultats du modèle de régression ont montré que les représentations anténatales de soin de 'l'inversion des rôles' ont prédit des niveaux de sensibilité bien plus bas et des niveaux de comportement prépondérant-intrusif bien plus élevés quel que soit l'effet de la psychopathologie. Les résultats peuvent être interprétés dans le contexte de la transformation représentationnelle de la maternité durant la grossesse. Les résultats offrent des preuves préliminaires quant au potentiel d'un nouveau questionnaire comme mesure de représentations de soin en tant qu'instrument de dépistage du risque représentationnel anténatal.

Hair cortisol in the perinatal period mediates associations between maternal adversity and disrupted maternal interaction in early infancy.

Existing literature points to the possibility that cortisol could be one link between maternal adversity and poorer parenting quality, but most studies have examined salivary cortisol concentrations rather than hair cortisol concentrations. The current study examined hair cortisol concentration (HCC) during the third trimester of pregnancy as a mediator between maternal adversity indicators (childhood abuse, severe mental illness, symptomatic functioning) and maternal caregiving behavior at 4 months postpartum. Forty-four women participated in the study: 30 with severe mental disorders, and 14 nonclinical controls. HCC was assessed during the third trimester of pregnancy (HCC-P) and at 4 months postpartum (HCC-4M). Sexual, physical, and emotional abuse were assessed by the Adverse Childhood Experiences Study Questionnaire. Maternal disrupted interaction was reliably coded from mother-infant video interactions during a Still-Face Procedure. Mediation models indicated that maternal HCC-P and HCC-4M mediated associations between maternal psychopathology (severe mental illness, symptomatic functioning) and maternal disrupted interaction at 4 months. Maternal HCC at 4 months also mediated associations between experienced childhood abuse and overall disrupted interaction. Our findings indicate that HCC may be a potential early biomarker for future caregiving challenges among mothers with severe mental illness and histories of childhood abuse.

Developing a Hypothetical Implementation Framework of Expectations for Monitoring Early Signs of Psychosis Relapse Using a Mobile App: Qualitative Study.

BACKGROUND: Relapse is a common experience for people diagnosed with psychosis, which is associated with increased service costs and profound personal and familial distress. EMPOWER (Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery) is a peer worker-supported digital intervention that aims to enable service users to self-monitor their mental health with the aim of encouraging self-management and the shared use of personal data to promote relapse prevention. Digital interventions have not been widely used in relapse prevention and, therefore, little is currently known about their likely implementation-both within trials and beyond. OBJECTIVE: Seeking the perspectives of all relevant stakeholder groups is recommended in developing theories about implementation because this can reveal important group differences in understandings and assumptions about whether and for whom the intervention is expected to work. However, the majority of intervention implementation research has been retrospective. This study aimed to discover and theoretically frame implementation expectations in advance of testing and synthesize these data into a framework. METHODS: To develop a hypothetical implementation framework, 149 mental health professionals, carers, and people diagnosed with psychosis participated in 25 focus groups in both Australia and the United Kingdom. An interview schedule informed by the normalization process theory was used to explore stakeholders' expectations about the implementation of the EMPOWER intervention. Data were analyzed using thematic analysis and then theoretically framed using the Medical Research Council guidelines for understanding the implementation of complex interventions. RESULTS: All groups expected that EMPOWER could be successfully implemented if the intervention generated data that were meaningful to mental health staff, carers, and service users within their unique roles. However, there were key differences between staff, carers, and service users about what facilitators and barriers that stakeholders believe exist for intervention implementation in both the cluster randomized controlled trial stage and beyond. For example, service user expectations mostly clustered around subjective user experiences, whereas staff and carers spoke more about the impact upon staff interactions with service users. CONCLUSIONS: A hypothetical implementation framework synthesized from stakeholder implementation expectations provides an opportunity to compare actual implementation data gathered during an ongoing clinical trial, giving valuable insights into the accuracy of these stakeholders' previous expectations. This is among the first studies to assess and record implementation expectations for a newly developed digital intervention for psychosis in advance of testing in a clinical trial. TRIAL REGISTRATION: ISRCTN Registry ISRCTN99559262; http://www.isrctn.com/ISRCTN99559262.

Self-compassion, self-forgiveness, suicidal ideation, and self-harm: A systematic review.

Self-compassion has been implicated in the aetiology and course of mental health with evidence suggesting an association between greater self-compassion and lower emotional distress. However, our understanding of the nature and extent of the relationship between self-compassion and self-harm (self-injury regardless of suicidal intent) or suicidal ideation remains unclear. This review, therefore, aimed to critically evaluate the extant literature investigating this relationship. To do so, a systematic search, including terms synonymous with self-compassion, was conducted on three main psychological and medical databases (Web of Science, PsycINFO, and Medline). Only studies investigating self-compassion or self-forgiveness and self-harm or suicidal ideation were found to be relevant to the review. Eighteen studies were included in the final narrative synthesis. Heterogeneity of studies was high, and the majority of studies were quantitative and cross-sectional (n = 16) in design. All studies reported significant associations between higher levels of self-forgiveness or self-compassion and lower levels of self-harm or suicidal ideation. Several studies suggested that self-compassion or self-forgiveness may weaken the relationship between negative life events and self-harm. In conclusion, this review highlights the potential importance of self-compassion in the aetiology of suicidal thoughts and self-harm. We discuss the clinical and research implications.

Antenatal caregiving representations among expectant mothers with severe mental illness: a cross-sectional study.

Objective: The study explores predictors of antenatal caregiving representations among mothers with a history of severe mental illness (SMI). Background: Attachment research has demonstrated that multifactorial assessment of antenatal caregiving representations predicts later maternal behaviour and child attachment. However, the field lacks research among clinical groups. Knowledge of factors influencing caregiving representations during pregnancy can contribute to our understanding of caregiving risk among SMI-mothers and inform intervention decisions. Method: The current study is a cross-sectional subsample of the WARM study. Participants were 65 Danish or Scottish pregnant women with a history of either schizophrenia, bipolar disorder, moderate-severe depression, or non-clinical controls. Caregiving representations, adverse childhood experiences, social support and current symptom severity were assessed during pregnancy. Results: Symptom severity was associated with more non-optimal caregiving representations expecting less parental enjoyment, more difficulties separating from the child, and more feelings of caregiving helplessness. Lack of social support and adverse childhood experiences served as independent predictors of caregiving representations. Parental mental illness during own childhood predicted role reversed expectations. Conclusion: Antenatal caregiving representations can be assessed with a time-efficient self-report measure that assesses caregiving as a multidimensional construct. Prenatal treatment planning should target individual difficulties in undertaking transformation of the caregiving system.

The Youth Mental Health Risk and Resilience Study (YouR-Study).

BACKGROUND: The transition from adolescence to adulthood is associated with the emergence of psychosis and other mental health problems, highlighting the importance of this developmental period for the understanding of developing psychopathology and individual differences in risk and resilience. The Youth Mental Health Risk and Resilience Study (YouR-Study) aims to identify neurobiological mechanisms and predictors of psychosis-risk with a state-of-the-art neuroimaging approach (Magnetoencephalography, Magnetic Resonance Spectroscopy, Magnetic Resonance Imaging) in combination with core psychological processes, such as affect regulation and attachment, that have been implicated in the development and maintenance of severe mental health problems. METHODS/DESIGN: One hundred participants meeting clinical high-risk criteria (CHR) for psychosis through the Comprehensive Assessment of At-Risk Mental State and Schizophrenia Proneness Instrument, Adult Version, in the age range from 16 to 35 years of age will be recruited. Mental-state monitoring up to a total of 2 years will be implemented to detect transition to psychosis. In addition, a sample of n = 40 help-seeking participants will be recruited who do not meet CHR-criteria, a group of n = 50 healthy control participants and a sample of n = 25 patients with first-episode psychosis. MEG-activity will be obtained during auditory and visual tasks to examine neural oscillations and event-related fields. In addition, we will obtain estimates of GABA and Glutamate levels through Magnetic Resonance Spectroscopy (MRS) to examine relationships between neural synchrony and excitatory-inhibition (E/I) balance parameters. Neuroimaging will be complemented by detailed neuropsychological assessments as well as psychological measures investigating the impact of childhood abuse, attachment experiences and affect regulation. DISCUSSION: The YouR-study could potentially provide important insights into the neurobiological mechanisms that confer risk for psychosis as well as biomarkers for early diagnosis of severe mental health problems. Moreover, we expect novel data related to the contribution of affect regulation and attachment-processes in the development of mental health problems, leading to an integrative model of early stage psychosis and the factors underlying risk and resilience of emerging psychopathology.

Design and protocol for the Focusing on Clozapine Unresponsive Symptoms (FOCUS) trial: a randomised controlled trial.

BACKGROUND: For around a third of people with a diagnosis of schizophrenia, the condition proves to respond poorly to treatment with many typical and atypical antipsychotics. This is commonly referred to as treatment-resistant schizophrenia. Clozapine is the only antipsychotic with convincing efficacy for people whose symptoms are considered treatment-resistant to antipsychotic medication. However, 30-40 % of such conditions will have an insufficient response to the drug. Cognitive behavioural therapy has been shown to be an effective treatment for schizophrenia when delivered in combination with antipsychotic medication, with several meta-analyses showing robust support for this approach. However, the evidence for the effectiveness of cognitive behavioural therapy for people with a schizophrenia diagnosis whose symptoms are treatment-resistant to antipsychotic medication is limited. There is a clinical and economic need to evaluate treatments to improve outcomes for people with such conditions. METHODS/DESIGN: A parallel group, prospective randomised, open, blinded evaluation of outcomes design will be used to compare a standardised cognitive behavioural therapy intervention added to treatment as usual versus treatment as usual alone (the comparator group) for individuals with a diagnosis of schizophrenia for whom an adequate trial of clozapine has either not been possible due to tolerability problems or was not associated with a sufficient therapeutic response. The trial will be conducted across five sites in the United Kingdom. DISCUSSION: The recruitment target of 485 was achieved, with a final recruitment total of 487. This trial is the largest definitive, pragmatic clinical and cost-effectiveness trial of cognitive behavioural therapy for people with schizophrenia whose symptoms have failed to show an adequate response to clozapine treatment. Using a prognostic risk model, baseline information will be used to explore whether there are identifiable subgroups for which the treatment effect is greatest. TRIAL REGISTRATION: Current Controlled Trials ISRCTN99672552 . Registered 29(th) November 2012.