Trauma-focused therapy in early psychosis: results of a feasibility randomized controlled trial of EMDR for psychosis (EMDRp) in early intervention settings.

BACKGROUND: Trauma is prevalent amongst early psychosis patients and associated with adverse outcomes. Past trials of trauma-focused therapy have focused on chronic patients with psychosis/schizophrenia and comorbid Post-Traumatic Stress Disorder (PTSD). We aimed to determine the feasibility of a large-scale randomized controlled trial (RCT) of an Eye Movement Desensitization and Reprocessing for psychosis (EMDRp) intervention for early psychosis service users. METHODS: A single-blind RCT comparing 16 sessions of EMDRp + TAU v. TAU only was conducted. Participants completed baseline, 6-month and 12-month post-randomization assessments. EMDRp and trial assessments were delivered both in-person and remotely due to COVID-19 restrictions. Feasibility outcomes were recruitment and retention, therapy attendance/engagement, adherence to EMDRp treatment protocol, and the 'promise of efficacy' of EMDRp on relevant clinical outcomes. RESULTS: Sixty participants (100% of the recruitment target) received TAU or EMDR + TAU. 83% completed at least one follow-up assessment, with 74% at 6-month and 70% at 12-month. 74% of EMDRp + TAU participants received at least eight therapy sessions and 97% rated therapy sessions demonstrated good treatment fidelity. At 6-month, there were signals of promise of efficacy of EMDRp + TAU v. TAU for total psychotic symptoms (PANSS), subjective recovery from psychosis, PTSD symptoms, depression, anxiety, and general health status. Signals of efficacy at 12-month were less pronounced but remained robust for PTSD symptoms and general health status. CONCLUSIONS: The trial feasibility criteria were fully met, and EMDRp was associated with promising signals of efficacy on a range of valuable clinical outcomes. A larger-scale, multi-center trial of EMDRp is feasible and warranted.

A two-arm, randomised feasibility trial using link workers to improve dental visiting in people with severe mental illness: a protocol paper.

BACKGROUND: People with severe mental illness (e.g. psychosis, bipolar disorder) experience poor oral health compared to the general population as shown by more decayed, missing and filled teeth and a higher prevalence of periodontal disease. Attending dental services allows treatment of oral health problems and support for prevention. However, people with severe mental illness face multiple barriers to attending routine dental appointments and often struggle to access care. Link work interventions use non-clinical support staff to afford vulnerable populations the capacity, opportunity, and motivation to navigate use of services. The authors have co-developed with service users a link work intervention for supporting people with severe mental illness to access routine dental appointments. The Mouth Matters in Mental Health Study aims to explore the feasibility and acceptability of this intervention within the context of a feasibility randomised controlled trial (RCT) measuring outcomes related to the recruitment of participants, completion of assessments, and adherence to the intervention. The trial will closely monitor the safety of the intervention and trial procedures. METHODS: A feasibility RCT with 1:1 allocation to two arms: treatment as usual (control) or treatment as usual plus a link work intervention (treatment). The intervention consists of six sessions with a link worker over 9 months. Participants will be adults with severe mental illness receiving clinical input from secondary care mental health service and who have not attended a planned dental appointment in the past 3 years. Assessments will take place at baseline and after 9 months. The target recruitment total is 84 participants from across three NHS Trusts. A subset of participants and key stakeholders will complete qualitative interviews to explore the acceptability of the intervention and trial procedures. DISCUSSION: The link work intervention aims to improve dental access and reduce oral health inequalities in people with severe mental illness. There is a dearth of research relating to interventions that attempt to improve oral health outcomes in people with mental illness and the collected feasibility data will offer insights into this important area. TRIAL REGISTRATION: The trial was preregistered on ISRCTN (ISRCTN13650779) and ClinicalTrials.gov (NCT05545228).

Sailing between Scylla and Charybdis: invited response to 'Blame or discovery?'

This brief commentary reflects on navigating two dangers of historical research into psychiatry: hagiographic representations of psychiatrists; and accusations of their self-interest and oppression of vulnerable people.

Our values and our historical understanding of psychiatrists.

Many people like to perceive themselves as better than previous generations: more knowledgeable, moral, tolerant and humane. Values associated with these aspects of ourselves may affect how we understand our professional forebears. In the early 20th century, some psychiatrists adopted new biomedical theories, including focal sepsis and eugenics, which resulted in inestimable harm. Detrimental clinical practices arose and were perpetuated in the context of societal values, medical ethics and other forces within and outside the medical profession. Historical understanding of the processes by which these things took place may help inform debate concerning current and future challenges of providing psychiatric care. The methods by which psychiatrists consider their predecessors may also have a bearing on how psychiatrists of the future will perceive us, the psychiatrists of the 2020s.

George Stephen Penny (1885-1964): his life and medical encounters before, during and after admission to Broadmoor Criminal Lunatic Asylum.

Amid extensive press coverage, George Stephen Penny (1885-1964) was tried for murder in 1923. He was found 'guilty but insane' due to 'confusional insanity' associated with malaria which he suffered during World War I. Penny was admitted to Broadmoor Criminal Lunatic Asylum at a time of great public concern about inadequate and cruel care in mental institutions, but he was treated with humanity and respect. Penny's story also reveals much about challenges of psychiatric diagnosis and the relationships between crime, insanity, the public, lawyers and the medical profession. Following discharge from Broadmoor, Penny built himself a life in the community. His pseudonymous memoir, with masterly concealment of his identity and crime, tells his story up to 1925.

Montagu Lomax: The background and motivation of a 'remarkable man' who spearheaded lunacy reform.

Doctor Montagu Lomax was a retired General Practioner, whose service in English lunatic asylums during the First World War inspired him to write The experiences of an asylum doctor: with suggestions for asylum and lunacy law reform. Published in 1921, the book acted as a catalyst for lunacy reform and stimulated improvements in the mental health services in the United Kingdom. Lomax spent the remainder of his retirement campaigning for lunacy reform. He suffered financial and personal hardship following the publication of the book and was castigated by his own profession. On the centenary of the publication of Experiences, this article explores the background and motivation of a remarkable man.

'I have to-day seen all the 671 patients in residence in this institution': not listening to patients in the long 1920s.

In the 1920s, patients and former patients produced oral and written accounts of their mental hospital experiences. Many aimed to inform the public about the institutions and to improve standards of care, but their views were usually ignored. The assumption that mental disorders affected all aspects of a person's judgement, plus defensive and disparaging attitudes of hospital authorities and formal committees of inquiry, contributed to this. Various other public agendas, financial crises and rising unemployment detracted from the needs of mentally unwell people. Small improvements in care materialized, but lay, professional and institutional cultures generally preserved the status quo. Regarding learning from patients' feedback, some hurdles encountered in the 1920s resonate with challenges in today's National Health Service.

Self-Report Measures Assessing Aspects of Personal Recovery in Relatives and Other Informal Carers of Those With Psychosis: A Systematic Review.

Background: Providing long-term care for a family member with psychosis can cause significant distress for informal carers due to the trauma of seeing their loved one in crisis, dealing with the difficult symptoms of psychosis and the burden of providing care. An important aspect of carers' adjustment can be construed as their personal recovery in relation to having a relative affected by psychosis. Self-report measures are increasingly used to assess personal recovery in service users, but less is known about the utility of such tools for carers. Aims: This review aimed to identify all self-report measures assessing aspects of carers' personal recovery, and to quality appraise them. Methods: Academic Search Ultimate, CINAHL, MEDLINE, PsychINFO and PubMed were searched for articles that reported the development of self-report measures created for carers of those with psychosis. Studies were appraised using the Consensus-based Standards for the Selection of health status Measurement INstruments (COSMIN) checklist. A Levels of Evidence synthesis provided overall quality scores for each measure. Results: The search identified 3,154 articles for initial screening. From a total of 322 full text articles, 95 self-report measures were identified with a final 10 measures included for the quality assessment showing varying levels of psychometric rigor. Conclusions: The results show that no single self-report measure is currently available for use to comprehensively assess personal recovery for carers, highlighting the need for further research in this area and the development of a new measure.

Learning from the past: inequalities and discrimination in psychiatry's chequered history.

The Royal College of Psychiatrists' antiquarian book collection originated from the library of psychiatrist Daniel Hack Tuke (1827-1895). A proposal to name the collection after him led us to investigate aspects of his life and work, particularly related to his attitudes concerning race, gender and homosexuality. We juxtaposed his ideas with those of some of his contemporaries. We cannot separate psychiatrists, past or present, from the societal and scientific context that shapes their professional understanding and standards. However, changes in language, knowledge, values and other sociocultural factors over time can affect how we perceive our forebears and how future generations of psychiatrists may perceive us.

Overcoming challenges in delivering integrated motivational interviewing and cognitive behavioural therapy for bipolar disorder with co-morbid alcohol use: therapist perspectives.

BACKGROUND: Alcohol misuse is common in bipolar disorder and is associated with worse outcomes. A recent study evaluated integrated motivational interviewing and cognitive behavioural therapy for bipolar disorder and alcohol misuse with promising results in terms of the feasibility of delivering the therapy and the acceptability to participants. AIMS: Here we present the experiences of the therapists and supervisors from the trial to identify the key challenges in working with this client group and how these might be overcome. METHOD: Four therapists and two supervisors participated in a focus group. Topic guides for the group were informed by a summary of challenges and obstacles that each therapist had completed at the end of therapy for each individual client. The audio recording of the focus group was transcribed and data were analysed using thematic analysis. RESULTS: We identified five themes: addressing alcohol use versus other problems; impact of bipolar disorder on therapy; importance of avoidance and overcoming it; fine balance in relation to shame and normalising use; and 'talking the talk' versus 'walking the walk'. CONCLUSIONS: Findings suggest that clients may be willing to explore motivations for using alcohol even if they are not ready to change their drinking, and they may want help with a range of mental health problems. Emotional and behavioural avoidance may be a key factor in maintaining alcohol use in this client group and therapists should be aware of a possible discrepancy between clients' intentions to reduce misuse and their actual behaviour.

History of psychiatry in the curriculum? History is part of life and life is part of history: why psychiatrists need to understand it better.

The General Medical Council has introduced a generic professional capabilities framework. It includes the need to develop the professional values, actions and aspirations fundamental to becoming a 'dedicated doctor'. The history of psychiatry has potential to facilitate this learning, both by an understanding of content and the ability to think historically.

Measuring social and occupational functioning of people with bipolar disorder: A systematic review.

Previous literature has focused on impaired social and occupational functioning in Bipolar Disorder (BD), however this ignores people who may be functioning well or even exceptionally. This paper presents the first systematic review of how functioning is measured and the range of functioning observed in BD to aid applied research and practice in this area. Identified measures from studies reporting use of a social and/or occupational functioning measure in BD were organised according to frequency of use over the last 10 years, resulting in six measures (Global Assessment of Functioning (GAF), Functioning Assessment Short Test (FAST), Social and Occupational Functioning Scale (SOFAS), Social Adjustment Scale (SAS)), Social Functioning Scale (SFS) and LIFE-Range of Impaired Functioning (LIFE-RIFT). Descriptive statistics of sample scores were extracted and pooled to provide cross-study values for each measure. Around 16% of individuals with BD can be estimated to function at a high level, defined as those falling within two standard deviations of the mean score on each measure. Evidence of a ceiling effect for some measures suggests that BD functioning may have been underestimated during measure development. Future research is needed to further understand higher functioning in people with BD, and factors which may support this.

Feasibility and acceptability of integrated psychological therapy versus treatment as usual for people with bipolar disorder and co-morbid alcohol use: A single blind randomised controlled trial.

BACKGROUND: Alcohol use is a common problem in bipolar disorder (BD) and evidence indicates more promising outcomes for alcohol use than other substances. No trials have evaluated individual integrated motivational interviewing and cognitive behaviour therapy (MI-CBT) for problematic alcohol use in BD. We therefore assessed the feasibility and acceptability of a novel MI-CBT intervention for alcohol use in BD. METHODS: A single blind RCT was conducted to compare MI-CBT plus treatment as usual (TAU) with TAU only. MI-CBT was delivered over 20 sessions with participants followed up at 3, 6, 9 and 12 months post-randomisation. Primary outcomes were the feasibility and acceptability of MI-CBT (recruitment to target, retention to follow-up and therapy, acceptability of therapy and absence of adverse events). We also conducted preliminary analyses of alcohol and mood outcomes (frequency and severity of alcohol use and time to mood relapse). RESULTS: 44 participants were recruited with 75% retention to 6 and 12 months follow-up. Therapy participants attended a mean of 17.6 (SD 4.5) sessions. Therapy alliance and treatment fidelity were acceptable. Qualitative interviews indicated the intervention was experienced as collaborative, and helpful, in addressing mood and alcohol issues, although risk of overconfidence following therapy was also identified. Clinical outcomes did not differ between arms at 12 months follow-up. LIMITATIONS: As a feasibility and acceptability trial any secondary results should be treated with caution. CONCLUSIONS: Integrated MI-CBT is feasible and acceptable, but lack of clinical impact, albeit in a feasibility study, suggests need for further development. Potential adaptations are discussed.

Psychiatry past and present: do we need history?

Historical evidence can be useful to inform debate about current dilemmas in health service policy. However, concepts of historical analysis may be problematic for doctors, for whom a model of 'history' is often based on clinical history-taking: a clinical history aims to explain the present, whereas a historical analysis aims to elucidate the past. This article discusses and illustrates these concepts, and highlights potential pitfalls of poor historical methodology. It also provides pointers about researching the history of psychiatry in the UK and how to contribute historical evidence to health service policy debates today.Declaration of interestNone.