Developing psychological treatments for psychosis.

Evidence shows that talking with patients about psychotic experiences can be beneficial. The key question is therefore: which psychological methods can help patients most? This editorial presents ten principles for the design and development of effective psychological treatments. These principles are perceptible characteristics of successful interventions.

Psychological framework to understand interpersonal violence by forensic patients with psychosis.

BACKGROUND: Forensic patients with psychosis often engage in violent behaviour. There has been significant progress in understanding risk factors for violence, but identification of causal mechanisms of violence is limited. AIMS: To develop a testable psychological framework explaining violence in psychosis - grounded in patient experience - to guide targeted treatment development. METHOD: We conducted in-depth interviews with 20 patients with psychosis using forensic psychiatric services across three regions in England. Interviews were analysed using reflexive thematic analysis. People with lived experience contributed to the analysis. RESULTS: Analysis of interviews identified several psychological processes involved in the occurrence of violence. Violence was the dominant response mode to difficulties that was both habitual and underpinned by rules that engaged and justified an attack. Violence was triggered by a trio of sensitivities to other people: sensitivity to physical threat, from which violence protected; sensitivity to social disrespect, by which violence increased status; and sensitivity to unfairness, by which violence delivered revenge. Violence was an attempt to regulate difficult internal states: intense emotions were released through aggression and violence was an attempt to escape being overwhelmed by voices, visions or paranoia. There were different patterns of emphasis across these processes when explaining an individual participant's offending behaviour. CONCLUSIONS: The seven-factor model of violence derived from our analysis of patient accounts highlights multiple modifiable psychological processes that can plausibly lead to violence. The model can guide the research and development of targeted treatments to reduce violence by individuals with psychosis.

Daydreaming and grandiose delusions: development of the Qualities of Daydreaming Scale.

BACKGROUND: Daydreaming may contribute to the maintenance of grandiose delusions. Repeated, pleasant and vivid daydreams about the content of grandiose delusions may keep the ideas in mind, elaborate the details, and increase the degree of conviction in the delusion. Pleasant daydreams more generally could contribute to elevated mood, which may influence the delusion content. AIMS: We sought to develop a brief questionnaire, suitable for research and clinical practice, to assess daydreaming and test potential associations with grandiosity. METHOD: 798 patients with psychosis (375 with grandiose delusions) and 4518 non-clinical adults (1788 with high grandiosity) were recruited. Participants completed a daydreaming item pool and measures of grandiosity, time spent thinking about the grandiose belief, and grandiose belief conviction. Factor analysis was used to derive the Qualities of Daydreaming Scale (QuOD) and associations were tested using pairwise correlations and structural equation modelling. RESULTS: The questionnaire had three factors: realism, pleasantness, and frequency of daydreams. The measure was invariant across clinical and non-clinical groups. Internal consistency was good (alpha-ordinals: realism=0.86, pleasantness=0.93, frequency=0.82) as was test-retest reliability (intra-class coefficient=0.75). Daydreaming scores were higher in patients with grandiose delusions than in patients without grandiose delusions or in the non-clinical group. Daydreaming was significantly associated with grandiosity, time spent thinking about the grandiose delusion, and grandiose delusion conviction, explaining 19.1, 7.7 and 5.2% of the variance in the clinical group data, respectively. Similar associations were found in the non-clinical group. CONCLUSIONS: The process of daydreaming may be one target in psychological interventions for grandiose delusions.

Measuring dissociation across adolescence and adulthood: developing the short-form Cernis Felt Sense of Anomaly scale (CEFSA-14).

BACKGROUND: Dissociation may be important across many mental health disorders, but has been variously conceptualised and measured. We introduced a conceptualisation of a common type of dissociative experience, 'felt sense of anomaly' (FSA), and developed a corresponding measure, the Cernis Felt Sense of Anomaly (CEFSA) scale. AIMS: We aimed to develop a short-form version of the CEFSA that is valid for adolescent and adult respondents. METHOD: Data were collected from 1031 adult NHS patients with psychosis and 932 adult and 1233 adolescent non-clinical online survey respondents. Local structural equation modelling (LSEM) was used to establish measurement invariance of items across the age range. Ant colony optimisation (ACO) was used to produce a 14-item short-form measure. Finally, the expected test score function derived from item response theory modelling guided the establishment of interpretive scoring ranges. RESULTS: LSEM indicated 25 items of the original 35-item CEFSA were age invariant. They were also invariant across gender and clinical status. ACO of these items produced a 14-item short-form (CEFSA-14) with excellent psychometric properties (CFI=0.992; TLI=0.987; RMSEA=0.034; SRMR=0.017; Cronbach's alpha=0.92). Score ranges were established based on the expected test scores at approximately 0.7, 1.25 and 2.0 theta (equivalent to standard deviations above the mean). Scores of 29 and above may indicate elevated levels of FSA-dissociation. CONCLUSIONS: The CEFSA-14 is a psychometrically valid measure of FSA-dissociation for adolescents and adults. It can be used with clinical and non-clinical respondents. It could be used by clinicians as an initial tool to explore dissociation with their clients.

Automated VR therapy for improving positive self-beliefs and psychological well-being in young patients with psychosis: a proof of concept evaluation of Phoenix VR self-confidence therapy.

BACKGROUND: Low self-confidence in patients with psychosis is common. This can lead to higher symptom severity, withdrawal from activities, and low psychological well-being. There are effective psychological techniques to improve positive self-beliefs but these are seldom provided in psychosis services. With young people with lived experience of psychosis we developed a scalable automated VR therapy to enhance positive-self beliefs. AIMS: The aim was to conduct a proof of concept clinical test of whether the new VR self-confidence therapy (Phoenix) may increase positive self-beliefs and psychological well-being. METHOD: Twelve young patients with non-affective psychosis and with low levels of positive self-beliefs participated. Over 6 weeks, patients were provided with a stand-alone VR headset so that they could use Phoenix at home and were offered weekly psychologist meetings. The outcome measures were the Oxford Positive Self Scale (OxPos), Brief Core Schema Scale, and Warwick-Edinburgh Well-being Scale (WEMWBS). Satisfaction, adverse events and side-effects were assessed. RESULTS: Eleven patients provided outcome data. There were very large end-of-treatment improvements in positive self-beliefs (OxPos mean difference = 32.3; 95% CI: 17.3, 47.3; Cohen's d=3.0) and psychological well-being (WEMWBS mean difference = 11.2; 95% CI: 8.0, 14.3; Cohen's d=1.5). Patients rated the quality of the VR therapy as: excellent (n=9), good (n=2), fair (n=0), poor (n=0). An average of 5.3 (SD=1.4) appointments were attended. CONCLUSIONS: Uptake of the VR intervention was high, satisfaction was high, and side-effects extremely few. There were promising indications of large improvements in positive self-beliefs and psychological well-being. A randomized controlled clinical evaluation is warranted.

[Recent developments in the modeling and psychological management of persecutory ideation]. / Actualités récentes dans la modélisation et la prise en charge psychologique des idées de persécution.

Persecutory ideas are a major clinical problem and are associated with impaired functioning, reduced compliance with medication and increased risk of hospitalization. Persecutory ideation is defined as the false conviction that others are threatening or conspiring against one. Although persecutory delusions are mainly described and experienced in schizophrenia spectrum disorders, they also occur in other neurological and psychiatric diagnoses including Alzheimer disease, epilepsy, depression, mania, dementia and post-traumatic stress disorder. Moreover, epidemiological data from general and clinical populations indicated that paranoid beliefs occur on a hierarchy of severity and are present to a lesser degree in the general population, with paranoid delusions representing the severe end of a continuum. In this review we focus on the important advances following a decade of research from psychological sciences, and more particularly the work of Daniel Freeman and Philippa Garety in England. Their work has demonstrated that a range of causal factors are involved in the development and maintenance of delusions beyond the traditional cognitive and behavioural models. Indeed, there is now well-validated evidence that sleep disturbances, worry proneness, reasoning biases, such as failure to consider alternative explanations or belief confirmation bias, abnormal experiences such as hallucinations, negative self-beliefs, and safety behaviours, are central factors that contribute to the paranoid phenomenon. In this review, we describe each of these causal factors in detail as well as the clinical interventions developed by Freeman and his collaborators, including the integrative and modular "Feeling Safe" intervention. Broadly speaking, the aim of this psychological intervention is for patients to relearn safety by exposing them to situations they consider as potentially dangerous after reduction of the influence of the maintenance factors described above. A recent publication showed that the Feeling Safe program led to recovery in persecutory delusions for 50% of patients having poor response to antipsychotic medication, making the intervention as the most effective psychological treatment for persecutory delusions. Finally, we will critically discuss the efficacy data from the numerous clinical studies validating its effectiveness. Prospects for the implementation of the Feeling Safe program in France also is discussed.

Body image concerns in patients with persecutory delusions.

BACKGROUND: Persecutory fears build on feelings of vulnerability that arise from negative views of the self. Body image concerns have the potential to be a powerful driver of feelings of vulnerability. Body image concerns are likely raised in patients with psychosis given the frequent weight gain. We examined for the first-time body esteem - the self-evaluation of appearance - in relation to symptom and psychological correlates in patients with current persecutory delusions. METHODS: One-hundred and fifteen patients with persecutory delusions in the context of non-affective psychosis completed assessments of body image, self-esteem, body mass index (BMI), psychiatric symptoms and well-being. Body esteem was also assessed in 200 individuals from the general population. RESULTS: Levels of body esteem were much lower in patients with psychosis than non-clinical controls (d = 1.2, p < 0.001). In patients, body esteem was lower in women than men, and in the overweight or obese BMI categories than the normal weight range. Body image concerns were associated with higher levels of depression (r = -0.55, p < 0.001), negative self-beliefs (r = -0.52, p < 0.001), paranoia (r = -0.25, p = 0.006) and hallucinations (r = -0.21, p = 0.025). Body image concerns were associated with lower levels of psychological wellbeing (r = 0.41, p < 0.001), positive self-beliefs (r = 0.40, p < 0.001), quality of life (r = 0.23, p = 0.015) and overall health (r = 0.31, p = 0.001). CONCLUSIONS: Patients with current persecutory delusions have low body esteem. Body image concerns are associated with poorer physical and mental health, including more severe psychotic experiences. Improving body image for patients with psychosis is a plausible target of intervention, with the potential to result in a wide range of benefits.

Psychotic experiences and negative symptoms from adolescence to emerging adulthood: developmental trajectories and associations with polygenic scores and childhood characteristics.

BACKGROUND: Psychotic experiences and negative symptoms (PENS) are common in non-clinical populations. PENS are associated with adverse outcomes, particularly when they persist. Little is known about the trajectories of PENS dimensions in young people, nor about the precursory factors associated with these trajectories. METHODS: We conducted growth mixture modelling of paranoia, hallucinations, and negative symptoms across ages 16, 17, and 22 in a community sample (N = 12 049-12 652). We then described the emergent trajectory classes through their associations with genome-wide polygenic scores (GPS) for psychiatric and educational phenotypes, and earlier childhood characteristics. RESULTS: Three trajectory classes emerged for paranoia, two for hallucinations, and two for negative symptoms. Across PENS, GPS for clinical help-seeking, major depressive disorder, and attention deficit hyperactivity disorder were associated with increased odds of being in the most elevated trajectory class (OR 1.07-1.23). Lower education GPS was associated with the most elevated trajectory class for hallucinations and negative symptoms (OR 0.77-0.91). Conversely for paranoia, higher education GPS was associated with the most elevated trajectory class (OR 1.25). Trajectory class associations were not significant for schizophrenia, obsessive-compulsive disorder, bipolar disorder, or anorexia GPS. Emotional/behaviour problems and life events in childhood were associated with increased odds of being in the most elevated trajectory class across PENS. CONCLUSIONS: Our results suggest latent heterogeneity in the development of paranoia, hallucinations, and negative symptoms in young people that is associated with specific polygenic scores and childhood characteristics.

The Oxford Positive Self Scale: psychometric development of an assessment of cognitions associated with psychological well-being.

BACKGROUND: Developing, elaborating, and consolidating positive views of the self is a plausible route to increased psychological well-being. We set out to provide an assessment of positive self-beliefs that could be used in research and clinical practice. METHODS: A non-probability online survey was conducted with 2500 UK adults, quota sampled to match the population for age, gender, ethnicity, income, and region. Exploratory factor analysis of a 94-item pool - generated with guidance from people with lived experience of mental health difficulties - was conducted to develop the Oxford Positive Self Scale (OxPos). The item pool was further reduced using regularised structural equation modelling (SEM) before confirmatory factor analysis. Optimal cut-off scores were developed using receiver operating characteristic curves. Additional validations were carried out with two further general population cohorts (n = 1399; n = 1693). RESULTS: A 24-item scale was developed with an excellent model fit [robust χ2 = 995.676; df = 246; CFI = 0.956; TLI = 0.951; RMSEA = 0.049 (0.047, 0.052); SRMR = 0.031]. The scale comprises four factors: mastery; strength; enjoyment; and character. SEM indicated that the scale explains 68.6% of variance in psychological well-being. The OxPos score was negatively correlated with depression (r = -0.49), anxious avoidance (r = -0.34), paranoia (r = -0.23), hallucinations (r = -0.20), and negative self-beliefs (r = -0.50), and positively correlated with psychological well-being (r = 0.79), self-esteem (r = 0.67), and positive social comparison (r = 0.72). Internal reliability and test-retest reliability were excellent. Cut-offs by age and gender were generated. A short-form was developed, explaining 96% of the full-scale variance. CONCLUSIONS: The new open access scale provides a psychometrically robust assessment of positive cognitions that are strongly connected to psychological well-being.

Injection fears and COVID-19 vaccine hesitancy.

BACKGROUND: When vaccination depends on injection, it is plausible that the blood-injection-injury cluster of fears may contribute to hesitancy. Our primary aim was to estimate in the UK adult population the proportion of COVID-19 vaccine hesitancy explained by blood-injection-injury fears. METHODS: In total, 15 014 UK adults, quota sampled to match the population for age, gender, ethnicity, income and region, took part (19 January-5 February 2021) in a non-probability online survey. The Oxford COVID-19 Vaccine Hesitancy Scale assessed intent to be vaccinated. Two scales (Specific Phobia Scale-blood-injection-injury phobia and Medical Fear Survey-injections and blood subscale) assessed blood-injection-injury fears. Four items from these scales were used to create a factor score specifically for injection fears. RESULTS: In total, 3927 (26.2%) screened positive for blood-injection-injury phobia. Individuals screening positive (22.0%) were more likely to report COVID-19 vaccine hesitancy compared to individuals screening negative (11.5%), odds ratio = 2.18, 95% confidence interval (CI) 1.97-2.40, p < 0.001. The population attributable fraction (PAF) indicated that if blood-injection-injury phobia were absent then this may prevent 11.5% of all instances of vaccine hesitancy, AF = 0.11; 95% CI 0.09-0.14, p < 0.001. COVID-19 vaccine hesitancy was associated with higher scores on the Specific Phobia Scale, r = 0.22, p < 0.001, Medical Fear Survey, r = 0.23, p = <0.001 and injection fears, r = 0.25, p < 0.001. Injection fears were higher in youth and in Black and Asian ethnic groups, and explained a small degree of why vaccine hesitancy is higher in these groups. CONCLUSIONS: Across the adult population, blood-injection-injury fears may explain approximately 10% of cases of COVID-19 vaccine hesitancy. Addressing such fears will likely improve the effectiveness of vaccination programmes.

Virtual reality (VR) therapy for patients with psychosis: satisfaction and side effects.

BACKGROUND: Automated virtual reality therapies are being developed to increase access to psychological interventions. We assessed the experience with one such therapy of patients diagnosed with psychosis, including satisfaction, side effects, and positive experiences of access to the technology. We tested whether side effects affected therapy. METHODS: In a clinical trial 122 patients diagnosed with psychosis completed baseline measures of psychiatric symptoms, received gameChange VR therapy, and then completed a satisfaction questionnaire, the Oxford-VR Side Effects Checklist, and outcome measures. RESULTS: 79 (65.8%) patients were very satisfied with VR therapy, 37 (30.8%) were mostly satisfied, 3 (2.5%) were indifferent/mildly dissatisfied, and 1 (0.8%) person was quite dissatisfied. The most common side effects were: difficulties concentrating because of thinking about what might be happening in the room (n = 17, 14.2%); lasting headache (n = 10, 8.3%); and the headset causing feelings of panic (n = 9, 7.4%). Side effects formed three factors: difficulties concentrating when wearing a headset, feelings of panic using VR, and worries following VR. The occurrence of side effects was not associated with number of VR sessions, therapy outcomes, or psychiatric symptoms. Difficulties concentrating in VR were associated with slightly lower satisfaction. VR therapy provision and engagement made patients feel: proud (n = 99, 81.8%); valued (n = 97, 80.2%); and optimistic (n = 96, 79.3%). CONCLUSIONS: Patients with psychosis were generally very positive towards the VR therapy, valued having the opportunity to try the technology, and experienced few adverse effects. Side effects did not significantly impact VR therapy. Patient experience of VR is likely to facilitate widespread adoption.

The Oxford Agoraphobic Avoidance Scale.

BACKGROUND: Agoraphobic avoidance of everyday situations is a common feature in many mental health disorders. Avoidance can be due to a variety of fears, including concerns about negative social evaluation, panicking, and harm from others. The result is inactivity and isolation. Behavioural avoidance tasks (BATs) provide an objective assessment of avoidance and in situ anxiety but are challenging to administer and lack standardisation. Our aim was to draw on the principles of BATs to develop a self-report measure of agoraphobia symptoms. METHOD: The scale was developed with 194 patients with agoraphobia in the context of psychosis, 427 individuals in the general population with high levels of agoraphobia, and 1094 individuals with low levels of agoraphobia. Factor analysis, item response theory, and receiver operating characteristic analyses were used. Validity was assessed against a BAT, actigraphy data, and an existing agoraphobia measure. Test-retest reliability was assessed with 264 participants. RESULTS: An eight-item questionnaire with avoidance and distress response scales was developed. The avoidance and distress scales each had an excellent model fit and reliably assessed agoraphobic symptoms across the severity spectrum. All items were highly discriminative (avoidance: a = 1.24-5.43; distress: a = 1.60-5.48), indicating that small increases in agoraphobic symptoms led to a high probability of item endorsement. The scale demonstrated good internal reliability, test-retest reliability, and validity. CONCLUSIONS: The Oxford Agoraphobic Avoidance Scale has excellent psychometric properties. Clinical cut-offs and score ranges are provided. This precise assessment tool may help focus attention on the clinically important problem of agoraphobic avoidance.

The Disease Influenced Vaccine Acceptance Scale-Six (DIVAS-6): Validation of a Measure to Assess Disease-Related COVID-19 Vaccine Attitudes and Concerns.

Patients with underlying comorbidities are particularly vulnerable to poor outcomes from SARS-CoV-2 infection. Despite the context-specific nature of vaccine hesitancy, there are currently no scales that incorporate disease or treatment-related hesitancy factors. We developed a six-item scale assessing disease-related COVID-19 vaccine attitudes and concerns (The Disease Influenced COVID-19 Vaccine Acceptance Scale-Six: DIVAS-6). A survey incorporating the DIVAS-6 was completed by 4683 participants with severe and/or chronic illness (3560 cancer; 842 diabetes; 281 multiple sclerosis (MS)). The survey included the Oxford COVID-19 Vaccine Hesitancy Scale, the Oxford COVID-19 Vaccine Confidence and Complacency Scale, demographic, disease-related, and vaccination status questions. The six items loaded onto two factors (disease complacency and vaccine vulnerability) using exploratory factor analysis and exploratory structural equation modeling. The two factors were internally consistent. Measurement invariance analysis showed the two factors displayed psychometric equivalence across the patient groups. Each factor significantly correlated with the two Oxford COVID-19 Vaccine scales, showing convergent validity. The summary score showed acceptable ability to discriminate vaccination status across diseases, with the total sample providing good-to-excellent discriminative ability. The DIVAS-6 has two factors measuring COVID-19 vaccine attitudes and concerns relating to potential complications of SARS-CoV-2 infection due to underlying disease (disease complacency) and vaccine-related impact on disease progression and treatment (vaccine vulnerability). This is the first validated scale to measure disease-related COVID-19 vaccine concerns and has been validated in people with cancer, diabetes, and MS. It is quick to administer and should assist with guiding information delivery about COVID-19 vaccination in medically vulnerable populations.

Arts for Whose Sake? Arts Course-taking and Math Achievement in US High Schools.

Math achievement in U.S. high schools is a consistent predictor of educational attainment. While emphasis on raising math achievement continues, school-level interventions often come at the expense of other subjects. Arts courses are particularly at risk of being cut, especially in schools serving lower socioeconomic status youth. Evidence suggests, however, that arts coursework is beneficial to many educational outcomes. We use data on 20,590 adolescents from the High School Longitudinal Study of 2009 to answer two research questions: (1) Does student accumulation of fine arts courses across different topic areas relate positively to math test scores in high school? (2) Does school SES differentiate this potential association? Results indicate that youth attending higher-SES schools take more art courses and taking music courses is related to higher math test scores. However, this benefit only seems to only apply to more socially advantaged student bodies. Results reveal a site of additional educational advantage for already privileged youth.

Developing a virtual reality environment for educational and therapeutic application to investigate psychological reactivity to bullying.

Understanding how bullying victimisation influences cognitive and emotional processes may help to direct early intervention to prevent the development of psychopathology. In a convenience sample of 67 female adolescents, we assessed the potential of a newly developed classroom-set bullying experience in virtual reality (VR) to evoke psychological reactions. Two VR experiences were co-developed with young people, one neutral and one hostile (bullying). Participants were matched and assigned to a condition based on measures of anxiety, depression, paranoia, and previous bullying, before experiencing either the neutral or hostile scenario. Before and after the VR session, participants completed measures of negative affect and levels of distress. All participants remained immersed for the whole duration, which supports the acceptability of using these VR experiences with more vulnerable participants. Those experiencing the hostile version reported greater negative affect post-immersion compared to those experiencing the neutral version (p = .018; d = 0.61). Although non-significant, a similar outcome was found regarding distress (p = .071; d = 0.37). Whilst we did not find a significant relationship between pre-existing internalisation on negative affect and distress, our sample was limited by containing adolescents with relatively low levels of previous bullying experience. Yet we still found evidence that the VR scenario evoked bullying-related psychological reactions. Further testing with a more representative groups of adolescents, especially those with more experience of bullying, would be advised. The VR scenario could potentially be used in educational and therapeutic settings to enhance empathy towards victimised children or enhance resilience following victimisation.

Coronavirus conspiracy beliefs, mistrust, and compliance with government guidelines in England.

BACKGROUND: An invisible threat has visibly altered the world. Governments and key institutions have had to implement decisive responses to the danger posed by the coronavirus pandemic. Imposed change will increase the likelihood that alternative explanations take hold. In a proportion of the general population there may be strong scepticism, fear of being misled, and false conspiracy theories. Our objectives were to estimate the prevalence of conspiracy thinking about the pandemic and test associations with reduced adherence to government guidelines. METHODS: A non-probability online survey with 2501 adults in England, quota sampled to match the population for age, gender, income, and region. RESULTS: Approximately 50% of this population showed little evidence of conspiracy thinking, 25% showed a degree of endorsement, 15% showed a consistent pattern of endorsement, and 10% had very high levels of endorsement. Higher levels of coronavirus conspiracy thinking were associated with less adherence to all government guidelines and less willingness to take diagnostic or antibody tests or to be vaccinated. Such ideas were also associated with paranoia, general vaccination conspiracy beliefs, climate change conspiracy belief, a conspiracy mentality, and distrust in institutions and professions. Holding coronavirus conspiracy beliefs was also associated with being more likely to share opinions. CONCLUSIONS: In England there is appreciable endorsement of conspiracy beliefs about coronavirus. Such ideas do not appear confined to the fringes. The conspiracy beliefs connect to other forms of mistrust and are associated with less compliance with government guidelines and greater unwillingness to take up future tests and treatment.

COVID-19 vaccine hesitancy in the UK: the Oxford coronavirus explanations, attitudes, and narratives survey (Oceans) II.

BACKGROUND: Our aim was to estimate provisional willingness to receive a coronavirus 2019 (COVID-19) vaccine, identify predictive socio-demographic factors, and, principally, determine potential causes in order to guide information provision. METHODS: A non-probability online survey was conducted (24th September-17th October 2020) with 5,114 UK adults, quota sampled to match the population for age, gender, ethnicity, income, and region. The Oxford COVID-19 vaccine hesitancy scale assessed intent to take an approved vaccine. Structural equation modelling estimated explanatory factor relationships. RESULTS: 71.7% (n=3,667) were willing to be vaccinated, 16.6% (n=849) were very unsure, and 11.7% (n=598) were strongly hesitant. An excellent model fit (RMSEA=0.05/CFI=0.97/TLI=0.97), explaining 86% of variance in hesitancy, was provided by beliefs about the collective importance, efficacy, side-effects, and speed of development of a COVID-19 vaccine. A second model, with reasonable fit (RMSEA=0.03/CFI=0.93/TLI=0.92), explaining 32% of variance, highlighted two higher-order explanatory factors: 'excessive mistrust' (r=0.51), including conspiracy beliefs, negative views of doctors, and need for chaos, and 'positive healthcare experiences' (r=-0.48), including supportive doctor interactions and good NHS care. Hesitancy was associated with younger age, female gender, lower income, and ethnicity, but socio-demographic information explained little variance (9.8%). Hesitancy was associated with lower adherence to social distancing guidelines. CONCLUSIONS: COVID-19 vaccine hesitancy is relatively evenly spread across the population. Willingness to take a vaccine is closely bound to recognition of the collective importance. Vaccine public information that highlights prosocial benefits may be especially effective. Factors such as conspiracy beliefs that foster mistrust and erode social cohesion will lower vaccine up-take.

Differential psychological response to the COVID-19 pandemic in psychiatric inpatients compared to a non-clinical population from Germany.

The COVID-19 pandemic is an inherently stressful situation, which may lead to adverse psychosocial outcomes in various populations. Yet, individuals may not be affected equally by stressors posed by the pandemic and those with pre-existing mental disorders could be particularly vulnerable. To test this hypothesis, we assessed the psychological response to the pandemic in a case-control design. We used an age-, sex- and employment status-matched case-control sample (n = 216) of psychiatric inpatients, recruited from the LMU Psychiatry Biobank Munich study and non-clinical individuals from the general population. Participants completed validated self-report measures on stress, anxiety, depression, paranoia, rumination, loneliness, well-being, resilience, and a newly developed index of stressors associated with the COVID-19 pandemic. Multiple linear regression analyses were conducted to assess the effects of group, COVID-19-specific stressors, and their interaction on the different psychosocial outcomes. While psychiatric inpatients reported larger mental health difficulties overall, the impact of COVID-19-specific stressors was lower in patients and not associated with worse psychological functioning compared to non-clinical individuals. In contrast, depressive symptoms, rumination, loneliness, and well-being were more strongly associated with COVID-19-specific stressors in non-clinical individuals and similar to the severity of inpatients for those who experienced the greatest COVID-19-specific stressor impact Contrary to expectations, the psychological response to the pandemic may not be worse in psychiatric inpatients compared to non-clinical individuals. Yet, individuals from the general population, who were hit hardest by the pandemic, should be monitored and may be in need of mental health prevention and treatment efforts.

The impact of Patient and Public Involvement in the SlowMo study: Reflections on peer innovation.

BACKGROUND: The SlowMo study demonstrated the effects of SlowMo, an eight-session digitally supported reasoning intervention, on paranoia in a large-scale randomized-controlled trial with 362 participants with schizophrenia-spectrum psychosis. AIM: The current evaluation aimed to investigate the impact of Patient and Public Involvement (PPI) in the SlowMo study. METHOD: PPI members were six women and three men from Sussex, Oxford and London with experience of using mental health services for psychosis. They received training and met at least 3-monthly throughout the project. The impact of PPI was captured quantitatively and qualitatively through (i) a PPI log of recommendations and implementation; (ii) written subjective experiences of PPI members; (iii) meeting minutes; and (iv) outputs produced. RESULTS: The PPI log revealed 107 recommendations arising from PPI meetings, of which 87 (81%) were implemented. Implementation was greater for recruitment-, data collection- and organization-related actions than for dissemination and emergent innovations. Qualitative feedback revealed impacts on study recruitment, data collection, PPI participants' confidence, knowledge, career aspirations and society more widely. Outputs produced included a film about psychosis that aired on BBC primetime television, novel webpages and journal articles. Barriers to PPI impact included geography, travel, funding, co-ordination and well-being. DISCUSSION: A future challenge for PPI impact will be the extent to which peer innovation (innovative PPI-led ideas) can be supported within research study delivery. PATIENT AND PUBLIC CONTRIBUTION: Planned Patient and Public Contribution in SlowMo comprised consultation and collaboration in (i) design, (ii) recruitment, (iii) qualitative interviews and analysis of service users' experiences of SlowMo therapy and (iv) dissemination.

Estimating the Economic Value of Automated Virtual Reality Cognitive Therapy for Treating Agoraphobic Avoidance in Patients With Psychosis: Findings From the gameChange Randomized Controlled Clinical Trial.

BACKGROUND: An automated virtual reality cognitive therapy (gameChange) has demonstrated its effectiveness to treat agoraphobia in patients with psychosis, especially for high or severe anxious avoidance. Its economic value to the health care system is not yet established. OBJECTIVE: In this study, we aimed to estimate the potential economic value of gameChange for the UK National Health Service (NHS) and establish the maximum cost-effective price per patient. METHODS: Using data from a randomized controlled trial with 346 patients with psychosis (ISRCTN17308399), we estimated differences in health-related quality of life, health and social care costs, and wider societal costs for patients receiving virtual reality therapy in addition to treatment as usual compared with treatment as usual alone. The maximum cost-effective prices of gameChange were calculated based on UK cost-effectiveness thresholds. The sensitivity of the results to analytical assumptions was tested. RESULTS: Patients allocated to gameChange reported higher quality-adjusted life years (0.008 QALYs, 95% CI -0.010 to 0.026) and lower NHS and social care costs (-£105, 95% CI -£1135 to £924) compared with treatment as usual (£1=US $1.28); however, these differences were not statistically significant. gameChange was estimated to be worth up to £341 per patient from an NHS and social care (NHS and personal social services) perspective or £1967 per patient from a wider societal perspective. In patients with high or severe anxious avoidance, maximum cost-effective prices rose to £877 and £3073 per patient from an NHS and personal social services perspective and societal perspective, respectively. CONCLUSIONS: gameChange is a promising, cost-effective intervention for the UK NHS and is particularly valuable for patients with high or severe anxious avoidance. This presents an opportunity to expand cost-effective psychological treatment coverage for a population with significant health needs. TRIAL REGISTRATION: ISRCTN Registry ISRCTN17308399; https://www.isrctn.com/ISRCTN17308399. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2019-031606.