Experiences of Help-Seeking for Severe Mental Health Problems in Young Pakistani Women: A Preliminary Qualitative Study.

Almost three quarters of mental illnesses start by the age of 25, yet youth (18-25-year-olds) are often underrepresented in U.K. services. This is particularly true for those of ethnic minorities. In this study, we aimed to understand how young Pakistani women and their parents make decisions to seek help for severe mental health problems, and the barriers and facilitators to accessing professional help. Young Pakistani women with experience of severe mental health problems and their parents were recruited from a community sample. Semi-structured interviews were conducted with six young people and two parents. Data were analyzed using reflexive thematic analysis. Pakistani culture and its interplay with British culture strongly influenced the decisions and ability of young Pakistani women and their parents to help-seek, largely through the role of stigma. Low mental health literacy, stigma, and a lack of culturally informed services were identified as the most common barriers to accessing care. These barriers fed into the internalized stigma these young women experienced which, through fear of damaged reputation and personal prejudices, posed further barriers to seeking help. Participants highlighted recommendations for both individual-level (e.g., increased education and awareness) and service-level (e.g., greater choice over care) change to facilitate accessibility of professional help. Young Pakistani women face multiple culturally related challenges to accessing care for severe mental health problems at both the individual- and service-level. Novel suggestions to address these challenges, such as including youth peer support workers in services, may facilitate more inclusive and accessible services.

Understanding unusual sensory experiences: a randomised experimental study of a school-based intervention for adolescents.

BACKGROUND: One in ten young people experience unusual sensory experiences (USE), such as hallucinations. From a cognitive perspective, the appraisal of USE determines the impact of these experiences. Negative appraisal, as well as other psychological processes (e.g. thinking flexibility, maladaptive schemas, anxiety/depression), is associated with more distress. Our aim was to (a) develop a universal single-session school-based intervention on USE for adolescents and (b) evaluate the effect of the intervention on appraisals of and help seeking intentions for USE. METHODS: A randomised controlled experimental design with a one-month follow-up was used to test the effectiveness of the intervention in one school. Students (n = 223) aged 12-13 were randomised by class to a single-session intervention on USE or a control intervention (generic mental wellbeing). Participants completed measures of appraisals of and help-seeking intentions for USE at pre- and postintervention and at one-month follow-up. They also completed measures of schemas, thinking flexibility and anxiety/depression at preintervention. RESULTS: Overall, 190 adolescents completed the main outcome measures at all three points. The intervention on USE led to a significant (p < .05) increase of positive appraisals of USE compared with the control, with effects sustained at one-month follow-up. The intervention on USE did not lead to significantly greater help-seeking intentions for USE (p = .26). Adolescents' schemas were associated with appraisals and slow thinking and anxiety/depressive symptoms with help-seeking behaviour for USE. CONCLUSIONS: A single-session universal school-based intervention shows promise by improving appraisals of USE. Further research is required across different school populations.

Unravelling the complex interactions between self-awareness, cognitive change, and mood at 6-months post-stroke using the Y-shaped model.

We investigated the relationships between cognitive change following stroke, awareness of cognitive impairments, and mood to further understanding of change processes influencing psychological outcomes post-stroke in line with the "Y-shaped" process model. Patients (n = 143; Mage = 73 years, SD = 13.73; 74 males) were assessed at 3-weeks (T1) and 6-months (T2) post-stroke and had completed the Oxford Cognitive Screen (T1 and T2), the Cognitive Failures Questionnaire (CFQ; T2), and the Hospital Anxiety and Depression Scale (HADS; T2). An ANCOVA controlling for disability relating to activities of daily living (ADL) revealed that awareness of cognitive impairment was significantly lower in participants with moderate-severe cognitive impairment. Regression analysis indicated that greater awareness of cognitive impairment and reduced independence in ADL were associated with greater emotional distress at T2. Cognitive improvement was associated with lower emotional distressat T2. Contrary to the awareness hypothesis, moderation analyses suggest that this effect was largest for those most cognitively impaired at T1. Findings emphasize the importance of monitoring stroke patients' capacity to be self-aware when assessing and formulating long-term post-stroke distress and have potential implications for improving long-term emotional status in those most cognitively impaired post-stroke, e.g., through psychoeducation, cognitive rehabilitation, and emotional support.

Sociodemographic characteristics associated with parenthood amongst patients with a psychotic diagnosis: a cross-sectional study using patient clinical records.

PURPOSE: Estimates of parenthood in individuals with psychosis range from 27 to 63%. This number has likely increased due to the introduction of newer anti-psychotics and shorter hospital stays. The problems of psychosis can affect patients' capacity to offer the consistent, responsive care required for healthy child development. The following research questions were assessed: (1) what proportion of these patients have their children correctly recorded in their clinical notes, (2) what proportion of patients in secondary care with a psychotic diagnosis have children, and (3) what sociodemographic characteristics are associated with parenthood in this population. METHODS: This study used CRIS (Clinical Record Interactive Search) to search for patients with a diagnosis of non-affective or affective psychosis (F20-29, F31.2 or F31.5) within a UK NHS Trust. A binomial regression model was fitted to identify the variables associated with parenthood. RESULTS: Fewer than half of the parents in the sample had their children recorded in the correct field in their clinical notes. Of 5173 patients with psychosis, 2006 (38.8%) were parents. Characteristics associated with parenthood included being female, older age, higher socioeconomic status, renting or owning, having ever been married, being unemployed, not being White (British) and not having a diagnosis of schizophrenia. CONCLUSION: Over one-third of patients with psychosis were parents, and the study indicates that not all NHS Trusts are recording dependants accurately. Many variables were strongly associated with parenthood and these findings may help target interventions for this population.

Parenting and psychosis: An experience sampling methodology study investigating the inter-relationship between stress from parenting and positive psychotic symptoms.

OBJECTIVES: There is a strong association between stress and psychotic symptoms, and this study examined the bidirectional nature of this relationship in parents with psychosis, with negative affect as a mediator and a range of other psychosocial factors included as covariates. It also examined whether stress from parenting had a larger impact on psychosis than non-parenting stress. DESIGN: The study used a within-participants repeated measures design, using experience sampling methodology (ESM). ESM is a self-report surveying technique completed over an intensive longitudinal period. Participants completed six surveys a day, for 10 days. METHODS: Thirty-five participants with psychosis who were a parent to a child between the ages of 2 and 16 took part. Study phones alerted participants to complete surveys by beeping at semi-random intervals over 10 days. Multi-level modelling was used with surveys at Level-1 and participants at Level-2. Predictor variables were time-lagged in order to infer directionality. RESULTS: Parenting stress was found to predict psychotic symptoms, and this relationship was mediated by negative affect. The reverse direction was also confirmed. Few of the additional psychosocial factors were found to have a significant impact on the models' estimations. Parenting stress was not found to have a larger impact on psychosis than other sources of stress. CONCLUSIONS: This study provides further evidence of the bidirectional relationship between stress and psychosis in the context of parenting. Further research should explore if parenting stress plays a unique role in predicting psychotic symptoms by comparing parents and non-parents with psychosis.

Parenting interventions for people with schizophrenia or related serious mental illness.

BACKGROUND: Around a third of people with schizophrenia or related serious mental illness will be a parent. Both the parents and the children in this population are at increased risk of adverse outcomes due to parental mental illness. Parenting interventions are known to improve parenting skills and decrease child disruptive behaviour. This systematic review aimed to synthesise the evidence base for parenting interventions designed specifically for parents who have schizophrenia or related serious mental illness. OBJECTIVES: To assess the effects of parenting interventions for people with schizophrenia or related serious mental illness. SEARCH METHODS: On 10 February 2021 we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on the following: Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.Gov, Embase, International Standard Randomised Controlled Trial Number (ISRCTN), MEDLINE, PsycINFO, PubMed, and the World Health Organization International Clinical Trials Registry Platform. SELECTION CRITERIA: Eligible studies were randomised controlled trials (RCTs) that compared parenting interventions with a control condition for people with schizophrenia or related serious mental illness with a child between the ages of 0 and 18 years. DATA COLLECTION AND ANALYSIS: We independently inspected citations, selected studies, extracted data and appraised study quality. We assessed risk of bias for included studies. MAIN RESULTS: We only included one trial (n = 50), and it was not possible to extract any data because the authors did not provide any means and standard deviations for our outcomes of interest; they only reported whether outcomes were significant or not at the 0.05 level. Three domains of the trial were rated as having a high risk of bias. AUTHORS' CONCLUSIONS: The only included trial provided inconclusive evidence. There is insufficient evidence to make recommendations to people with schizophrenia (or related serious mental illness) or clinicians, or for policy changes. Although there is no RCT evidence, parenting interventions for people with schizophrenia or related serious mental illness have been developed. Future research should test these in RCTs in order to improve the evidence base for this population.

Mental health professionals' experiences of working with parents with psychosis and their families: a qualitative study.

BACKGROUND: Healthcare service users who are parents with psychosis form part of the caseload of most community mental health teams. Mental health professionals can experience uncertainty about how to work with and ask about the children of these parents, and often report difficulties when collaborating with other agencies. This study focused on professionals' experiences of working with parents with psychosis and their families to gain an understanding of these parents' needs from a service-level perspective, and to identify barriers that professionals may experience in meeting those needs. METHODS: Qualitative focus groups were conducted with four to eight mental health professionals per group. Data were analysed using reflexive thematic analysis. JR familiarised herself with the transcripts and then coded each salient unit within the text. Themes were then identified and discussed amongst all authors until there was agreement. RESULTS: We developed two overarching themes: 1) Diversity of need in parents with psychosis and 2) Role boundaries. The first explored mental health professionals' perceived range of experiences that parents with psychosis and their families have, and the range of potential effects of parental psychosis on a child. The second theme described how some mental health professionals emphasised the importance of supporting service users in terms of their parenting status and others felt it was more critical to treat the person's symptomatic expression. This theme also included issues with communication both with their service users and with other agencies. CONCLUSIONS: Mental health professionals identified that the needs of parents with psychosis were diverse and reflected significant variation in the experiences of service users. Mental health professionals across different types of team (early intervention and community mental health) expressed contrasting viewpoints about how achievable it was to respond to a service user's parenting status in an adult mental health setting. Future research should aim to determine where training is needed to enhance mental health professionals' ability to work holistically with families in an adult mental health setting, and how to enhance collaboration with other agencies.

Effect of mammographic screening from age 40 years on breast cancer mortality (UK Age trial): final results of a randomised, controlled trial.

BACKGROUND: The appropriate age range for breast cancer screening remains a matter of debate. We aimed to estimate the effect of mammographic screening at ages 40-48 years on breast cancer mortality. METHODS: We did a randomised, controlled trial involving 23 breast screening units across Great Britain. We randomly assigned women aged 39-41 years, using individual randomisation, stratified by general practice, in a 1:2 ratio, to yearly mammographic screening from the year of inclusion in the trial up to and including the calendar year that they reached age 48 years (intervention group), or to standard care of no screening until the invitation to their first National Health Service Breast Screening Programme (NHSBSP) screen at approximately age 50 years (control group). Women in the intervention group were recruited by postal invitation. Women in the control group were unaware of the study. The primary endpoint was mortality from breast cancers (with breast cancer coded as the underlying cause of death) diagnosed during the intervention period, before the participant's first NHSBSP screen. To study the timing of the mortality effect, we analysed the results in different follow-up periods. Women were included in the primary comparison regardless of compliance with randomisation status (intention-to-treat analysis). This Article reports on long-term follow-up analysis. The trial is registered with the ISRCTN registry, ISRCTN24647151. FINDINGS: 160 921 women were recruited between Oct 14, 1990, and Sept 24, 1997. 53 883 women (33·5%) were randomly assigned to the intervention group and 106 953 (66·5%) to the control group. Between randomisation and Feb 28, 2017, women were followed up for a median of 22·8 years (IQR 21·8-24·0). We observed a significant reduction in breast cancer mortality at 10 years of follow-up, with 83 breast cancer deaths in the intervention group versus 219 in the control group (relative rate [RR] 0·75 [95% CI 0·58-0·97]; p=0·029). No significant reduction was observed thereafter, with 126 deaths versus 255 deaths occurring after more than 10 years of follow-up (RR 0·98 [0·79-1·22]; p=0·86). INTERPRETATION: Yearly mammography before age 50 years, commencing at age 40 or 41 years, was associated with a relative reduction in breast cancer mortality, which was attenuated after 10 years, although the absolute reduction remained constant. Reducing the lower age limit for screening from 50 to 40 years could potentially reduce breast cancer mortality. FUNDING: National Institute for Health Research Health Technology Assessment programme.

Group acceptance and commitment therapy for patients and caregivers in psychosis services: Feasibility of training and a preliminary randomized controlled evaluation.

OBJECTIVE: Psychological interventions reduce the impact of psychosis, but widescale implementation is problematic. We tested the feasibility of group acceptance and commitment therapy for Psychosis (G-ACTp), delivered by frontline staff, and co-facilitated by service-user experts-by-experience (SU-EbyE), for service-users and informal caregivers (ISRCTN: 68540929). We estimated recruitment/retention rates and outcome variability for future evaluation. METHODS: Staff and SU-EbyE facilitators completed 1-day workshops, then delivered closely supervised G-ACTp, comprising four sessions (weeks 1-4) and two boosters (10 and 12 weeks). Participants recruited from adult community psychosis services were randomized to receive G-ACTp immediately or after 12 weeks, completing outcome assessments at 0, 4, and 12 weeks. Service-use/month was calculated for 1-year pre-randomization, weeks 0-12, and 5-year uncontrolled follow-up. RESULTS: Of 41 facilitators trained (29 staff, 12 SU-EbyE), 29 (71%; 17 staff, 12 SU-EbyE) delivered 18 G-ACTp courses. Participant refusal rates were low (9% of service-users [10/112]; 5% of caregivers [4/79]); 60% of those invited to participate attended ≥1 G-ACTp session (64% of service-users [39/61]; 56% of caregivers [35/63]). Randomization of facilitators and participants proved problematic and participant follow-up was incomplete (78% [66/85]; 82% of service-users [36/44]; 73% of caregivers [30/41]). Effect sizes ranged from very small to large mostly favouring treatment. Service-use reductions require cautious interpretation, as very few participants incurred costs. CONCLUSIONS: Implementation appears feasible for service-users; for caregivers, retention needs improving. Outcome variability indicated n = 100-300/arm followed up (α = 0.05, 90% power). Methodological limitations' mean replication is needed: identified sources of potential bias may be reduced in a cluster randomized design with sessional outcome completion. PRACTITIONER POINTS: Group acceptance and commitment therapy can be successfully adapted for people with psychosis and their caregivers. Implementation (training and delivery) is possible in routine community mental health care settings. Clinical and economic outcomes are promising, but replication is needed. Recommendations are made for future studies.

Why do patients with psychosis listen to and believe derogatory and threatening voices? 21 reasons given by patients.

BACKGROUND: Around two-thirds of patients with auditory hallucinations experience derogatory and threatening voices (DTVs). Understandably, when these voices are believed then common consequences can be depression, anxiety and suicidal ideation. There is a need for treatment targeted at promoting distance from such voice content. The first step in this treatment development is to understand why patients listen to and believe voices that are appraised as malevolent. AIMS: To learn from patients their reasons for listening to and believing DTVs. METHOD: Theoretical sampling was used to recruit 15 participants with non-affective psychosis from NHS services who heard daily DTVs. Data were obtained by semi-structured interviews and analysed using grounded theory. RESULTS: Six higher-order categories for why patients listen and/or believe voices were theorised. These were: (i) to understand the voices (e.g. what is their motive?); (ii) to be alert to the threat (e.g. prepared for what might happen); (iii) a normal instinct to rely on sensory information; (iv) the voices can be of people they know; (v) the DTVs use strategies (e.g. repetition) to capture attention; and (vi) patients feel so worn down it is hard to resist the voice experience (e.g. too mentally defeated to dismiss comments). In total, 21 reasons were identified, with all participants endorsing multiple reasons. CONCLUSIONS: The study generated a wide range of reasons why patients listen to and believe DTVs. Awareness of these reasons can help clinicians understand the patient experience and also identify targets in psychological intervention.

Changes in care costs associated with cognitive behavioural therapy for psychosis delivered in routine clinical practice.

Background: Schizophrenia spectrum disorders are long-term disabling conditions placing high economic demands on health services.Aim: To investigate whether cognitive behavioural therapy for psychosis (CBTp), delivered in a specialist psychological therapies service, was associated with a reduction in intensive care costs.Methods: Days using inpatient care and out of hours crisis support were recorded (N = 69). Costs associated with high intensity care use in the 12 months pre-referral were compared to during, and 12 months following cessation of therapy.Results: Despite the majority of participants incurring £0 at all time periods, costs of intensive mental health care more than halved with CBTp delivery, with a significant decrease during therapy, and at trend level after therapy (p = 0.07). Post hoc analysis revealed that offsetting the cost of therapy for those who utilised intensive care services at any time point (N = 18) resulted in therapy being cost neutral during therapy and cost effective (at trend level) 12 months following cessation of therapy.Conclusion: CBTp may reduce costs associated with intensive psychiatric care, even in a population where the minority use these services. Investment in therapy may lead to both clinical and financial benefits.

Night shift work and risk of breast cancer in women: the Generations Study cohort.

BACKGROUND: It is plausible that night shift work could affect breast cancer risk, possibly by melatonin suppression or circadian clock disruption, but epidemiological evidence is inconclusive. METHODS: Using serial questionnaires from the Generations Study cohort, we estimated hazard ratios (HR) and 95% confidence intervals (95%CI) for breast cancer in relation to being a night shift worker within the last 10 years, adjusted for potential confounders. RESULTS: Among 102,869 women recruited in 2003-2014, median follow-up 9.5 years, 2059 developed invasive breast cancer. The HR in relation to night shift work was 1.00 (95%CI: 0.86-1.15). There was a significant trend with average hours of night work per week (P = 0.035), but no significantly raised risks for hours worked per night, nights worked per week, average hours worked per week, cumulative years of employment, cumulative hours, time since cessation, type of occupation, age starting night shift work, or age starting in relation to first pregnancy. CONCLUSIONS: The lack of overall association, and no association with all but one measure of dose, duration, and intensity in our data, does not support an increased risk of breast cancer from night shift work in women.

Domestic light at night and breast cancer risk: a prospective analysis of 105 000 UK women in the Generations Study.

BACKGROUND: Circadian disruption caused by exposure to light at night (LAN) has been proposed as a risk factor for breast cancer and a reason for secular increases in incidence. Studies to date have largely been ecological or case-control in design and findings have been mixed. METHODS: We investigated the relationship between LAN and breast cancer risk in the UK Generations Study. Bedroom light levels and sleeping patterns at age 20 and at study recruitment were obtained by questionnaire. Analyses were conducted on 105 866 participants with no prior history of breast cancer. During an average of 6.1 years of follow-up, 1775 cases of breast cancer were diagnosed. Cox proportional hazard models were used to calculate hazard ratios (HRs), adjusting for potential confounding factors. RESULTS: There was no association between LAN level and breast cancer risk overall (highest compared with lowest LAN level at recruitment: HR=1.01, 95% confidence interval (CI): 0.88-1.15), or for invasive (HR=0.98, 95% CI: 0.85-1.13) or in situ (HR=0.96, 95% CI: 0.83-1.11) breast cancer, or oestrogen-receptor (ER) positive (HR=0.98, 95% CI: 0.84-1.14); or negative (HR=1.16, 95% CI: 0.82-1.65) tumours separately. The findings did not differ by menopausal status. Adjusting for sleep duration, sleeping at unusual times (non-peak sleep) and history of night work did not affect the results. Night waking with exposure to light, occurring around age 20, was associated with a reduced risk of premenopausal breast cancer (HR for breast cancer overall=0.74, 95% CI: 0.55-0.99; HR for ER-positive breast cancer=0.69, 95% CI: 0.49-0.97). CONCLUSIONS: In this prospective cohort analysis of LAN, there was no evidence that LAN exposure increased the risk of subsequent breast cancer, although the suggestion of a lower breast cancer risk in pre-menopausal women with a history of night waking in their twenties may warrant further investigation.

Treating Sleep Problems in Young People at Ultra-High Risk of Psychosis: A Feasibility Case Series.

BACKGROUND: Our view is that sleep disturbance may be a contributory causal factor in the development and maintenance of psychotic experiences. A recent series of randomized controlled intervention studies has shown that cognitive-behavioural approaches can improve sleep in people with psychotic experiences. However, the effects of psychological intervention for improving sleep have not been evaluated in young people at ultra-high risk of psychosis. Improving sleep might prevent later transition to a mental health disorder. AIMS: To assess the feasibility and acceptability of an intervention targeting sleep disturbance in young people at ultra-high risk of psychosis. METHOD: Patients were sought from NHS mental health services. Twelve young people at ultra-high risk of psychosis with sleep problems were offered an eight-session adapted CBT intervention for sleep problems. The core treatment techniques were stimulus control, circadian realignment, and regulating day-time activity. Participants were assessed before and after treatment and at a one month follow-up. RESULTS: All eligible patients referred to the study agreed to take part. Eleven patients completed the intervention, and one patient withdrew after two sessions. Of those who completed treatment, the attendance rate was 89% and an average of 7.6 sessions (SD = 0.5) were attended. There were large effect size improvements in sleep. Post-treatment, six patients fell below the recommended cut-off for clinical insomnia. There were also improvements in negative affect and psychotic experiences. CONCLUSION: This uncontrolled feasibility study indicates that treating sleep problems in young people at ultra-high of psychosis is feasible, acceptable, and may be associated with clinical benefits.

Effect of population breast screening on breast cancer mortality up to 2005 in England and Wales: an individual-level cohort study.

BACKGROUND: Population breast screening has been implemented in the UK for over 25 years, but the size of benefit attributable to such programmes remains controversial. We have conducted the first individual-based cohort evaluation of population breast screening in the UK, to estimate the impact of the NHS breast screening programme (NHSBSP) on breast cancer mortality. METHODS: We followed 988 090 women aged 49-64 years in 1991 resident in England and Wales, who because of the staggered implementation of the NHSBSP, included both invited subjects and an uninvited control group. Individual-level breast screening histories were linked to individual-level mortality and breast cancer incidence data from national registers. Risk of death from breast cancer was investigated by incidence-based mortality analyses in relation to intention to screen and first round attendance. Overdiagnosis of breast cancer following a single screening round was also investigated. RESULTS: Invitation to NHSBSP screening was associated with a reduction in breast cancer mortality in 1991-2005 of 21% (RR=0.79, 95% CI: 0.73-0.84, P<0·001) after adjustment for age, socioeconomic status and lead-time. Breast cancer deaths among first invitation attenders were 46% lower than among non-attenders (RR=0.54, 95% CI: 0.51-0·57, P<0.001) and 32% lower following adjustment for age, socioeconomic status and self-selection bias (RR=0.68, 95% CI: 0.63-0·73, P<0.001). There was little evidence of overdiagnosis associated with invitation to first screen. CONCLUSIONS: The results indicate a substantial, statistically significant reduction in breast cancer mortality between 1991 and 2005 associated with NHSBSP activity. This is important in public health terms.

Are We Speaking the Same Language? Finding Theoretical Coherence and Precision in "Mindfulness-Based Mechanisms" in Chronic Pain.

OBJECTIVE: Over the past 50 years, the field of chronic pain has witnessed an evolution of psychological approaches with some notable success. Some of this evolution has included "mindfulness-based interventions" (MBIs), now regarded as having encouraging partial support for their effectiveness. However, several theoretical challenges remain that may inhibit the progress of MBIs. These challenges include a lack of clarity surrounding the mindfulness construct itself, the proliferation of purported underlying mechanisms arising from different theories, and limited evidence for the mechanisms through which MBIs work. The current conceptual review provides a critique of existing theoretical models of mindfulness that have been applied to understanding and treating chronic pain. DESIGN: A conceptual narrative review was conducted. SETTING: Treatment programs for people with chronic pain. PATIENTS: Individuals with any type of chronic pain. INTERVENTIONS: MBIs for chronic pain. OUTCOME MEASURES: Mindfulness-based mechanisms explored in relation to several domains of functioning. RESULTS AND CONCLUSIONS: Based on this assessment, a summary of available evidence for a particular contextual behavioral theory of "mindfulness"-psychological flexibility-is outlined. Findings show the need for further integration of existing mindfulness constructs to better guide development and evaluation of mindfulness-based treatment methods in the future.

Service user satisfaction with cognitive behavioural therapy for psychosis: Associations with therapy outcomes and perceptions of the therapist.

OBJECTIVES: Few studies have investigated service user satisfaction with cognitive behavioural therapy for psychosis (CBTp). This study explored its associations with clinical presentation and outcomes, retrospective expectations of progress, perceptions of the therapist, and demographic variables. DESIGN AND METHODS: One hundred and sixty-five service users completed self-report questionnaires pre- and post-CBTp in relation to the constructs of interest. Regression analyses explored associations with (1) overall satisfaction with therapy and (2) perceived progress, skills, and knowledge gained. RESULTS: Ninety-six per cent of service users reported satisfaction with therapy. Higher levels of overall satisfaction with, and perceived benefit from, therapy were associated with positive therapy expectations, positive ratings of therapist's personal qualities, competence and trustworthiness, lower pre-therapy depression, and improvements in quality of life. Symptom improvements were not related to overall satisfaction with therapy; however, with the exception of voices, better clinical outcomes were associated with subjective ratings of having made more progress and gained more CBT skills and knowledge. Demographic factors were not associated with satisfaction or perceived progress. In multiple regression analyses, expectations of progress showed the strongest associations with both satisfaction and perceived benefits. Other remaining significant associations consisted of perceptions of the therapist for satisfaction, and both pre-therapy levels of, and changes in, depression for perceived benefits. Qualitative feedback emphasized the importance of the therapeutic relationship and developing new coping strategies. CONCLUSIONS: The findings provide preliminary evidence that high levels of satisfaction with therapy are not contingent on good clinical outcomes and are instead associated with positive therapy expectations and perceptions of the therapist. PRACTITIONER POINTS: Therapy expectations represent a neglected area of research and may have implications for levels of satisfaction with therapy and perceived benefit. The findings reinforce the importance of cognitive behavioural therapy for psychosis (CBTp) therapists demonstrating that they are supportive, competent, and trustworthy. The findings suggest that positive experiences of therapy do not require changes in psychosis symptoms and are instead related to changes in quality of life. Depressive symptoms at the start of therapy may adversely influence the extent to which CBT skills and knowledge are gained and levels of perceived progress at the end of therapy. The present sample was restricted to service users who completed therapy. Satisfaction levels were high. Further research is needed to explore factors associated with dissatisfaction with therapy.

Experiences of outcome monitoring in service users with psychosis: Findings from an Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI) demonstration site.

OBJECTIVES: Psychological therapy services are increasingly required to instate routine outcome monitoring (ROM), to demonstrate the clinical and economic impact of interventions. Professionals' views of ROM are an acknowledged barrier to implementation. Service user perspectives have rarely been examined, but acceptability and perceptions of ROM are critical to successful implementation. We investigated service users' experiences of ROM in an Improving Access to Psychological Therapies for people with Severe Mental Illness psychosis demonstration site. DESIGN: ROM comprised a periodic assessment battery completed at baseline, mid-therapy, and end-of-therapy and a single measure completed session-by-session. Qualitative and quantitative feedback were sought at each periodic ROM administration, and, for sessional ROM, at mid-therapy and end-of-therapy. Demographic and clinical correlates of satisfaction were examined cross-sectionally at baseline. Consistency of satisfaction over time and associations of satisfaction with engagement were examined longitudinally. METHODS: Service users rated baseline (n = 281/289), mid-therapy (n = 114/121), end-of-therapy (n = 124/154), and session-by-session (mid-therapy n = 63/87 and end-of-therapy n = 90/123) ROM from 0 ('extremely unhelpful') to 10 ('extremely helpful') and gave qualitative feedback. RESULTS: Service users predominantly found ROM helpful (score 6-10; 64-72%) or neutral (score 5; 19-29%). Finding ROM less helpful was associated with younger age and poorer general outcomes, but not with psychotic symptoms or therapy dropout. Emerging qualitative themes included feeling understood, valuing opportunities to reflect, expressing feelings, and tracking progress towards goals. Shorter batteries would be preferable, particularly for younger respondents, and those with poorer outcomes. CONCLUSIONS: ROM is acceptable for people with psychosis. Tailoring assessments to specific subgroups should be considered. PRACTITIONER POINTS: Routine outcome monitoring for psychological therapy is acceptable to people with psychosis. Most respondents experienced outcome monitoring as an opportunity to feel understood. Younger people and those with poorer functioning and well-being might be at higher risk of dissatisfaction. Short assessment batteries and less frequent outcome monitoring might be preferable for some service users. Limitations of the study Feedback about session-by-session outcome monitoring was not contemporaneous with completion and may be subject to memory or other biases. Only two-thirds of service users provided feedback about session-by-session ROM (compared to >94% for periodic ROM) so findings may not be fully representative. Feedback about measures was not provided anonymously, and it is possible that service users were reluctant to express criticism about ROM to the assessor.

Determinants of subjective well-being in people with psychosis referred for psychological therapy in South London.

OBJECTIVES: Improving subjective well-being (SWB) for people with mental health problems is a United Kingdom national health priority and is increasingly important in justifying funding of mental health services. Aside from the economic advantages, maximizing SWB confers obvious individual and clinical benefits for people with severe mental illness, such as psychosis. Gaining a better understanding of well-being and its determinants will enable current evidence-based interventions to be targeted and refined appropriately. This study therefore sought to identify the cross-sectional correlates of SWB in an Improving Access to Psychological Therapies for people with Severe Mental Illness psychosis demonstration site, to inform a future longitudinal investigation. METHODS: Participants with a psychosis or bipolar spectrum diagnosis referred to the demonstration site (n = 410) rated SWB as part of their initial assessment before starting psychological therapy. Potential influencing factors including age, gender, ethnicity, employment status, illness duration, perceived social support, perceived coping, and psychotic symptoms (voices and beliefs) were also assessed. RESULTS: Regression analyses showed that unemployment (ß = -.16, p < .001), lack of social support (ß = -.20, p < .001), distressing beliefs (ß = -.12, p = .004), and poorer coping (ß = -.43, p < .001) were associated with reduced SWB, together accounting for 43% of the variance in well-being, F(5, 392) = 58.42, p < .001; mean SWB = 39.09, SD = 11.61. CONCLUSIONS: This study provides preliminary insights into the determinants of SWB in a large sample of people with psychosis. Improving employability, social interactions, coping strategies, and psychotic symptoms may improve SWB. Further longitudinal investigation will determine the potential value of preferentially targeting these areas in therapy to meet national requirements to prioritize well-being outcomes. PRACTITIONER POINTS: Average well-being in people with psychosis was lower than SWB previously reported for the general population. Unemployment, lack of social support, poorer coping, and distressing beliefs were all associated with lower levels of well-being in people with psychosis. Psychological interventions targeting the positive symptoms of psychosis may impact on well-being. Greater focus on promoting social contact and inclusion and facilitating a return to employment may further improve well-being outcomes following psychological intervention. The cross-sectional design of the study does not allow for firm conclusions about the causal relationship between well-being and associated factors in psychosis. The study was carried out within a particular service context, and the findings need replicating before they can be considered to be generalizable outside this setting.

Duration of untreated psychosis and need for admission in patients who engage with mental health services in the prodromal phase.

BACKGROUND: It is unknown whether prodromal services improve outcomes in those who go on to develop psychosis, and whether these patients are demographically different from the overall first-episode population. AIMS: To compare sociodemographic features, duration of untreated psychosis, hospital admission and frequency of compulsory treatment in the first year after the onset of psychosis in patients who present to prodromal services with patients who did not present to services until the first episode of psychosis. METHOD: We compared two groups of patients with first-episode psychosis: one who made transition after presenting in the prodromal phase and the other who had presented with a first episode. RESULTS: The patients who had presented before the first episode were more likely to be employed and less likely to belong to an ethnic minority group. They had a shorter duration of untreated psychosis, and were less likely to have been admitted to hospital and to have required compulsory treatment. CONCLUSIONS: Patients who develop psychosis after being engaged in the prodromal phase have a better short-term clinical outcome than patients who do not present until the first episode. Patients who present during first episodes may be more likely to have sociodemographic features associated with relatively poor outcomes.