Exploring Data Collection Priorities of Community Partners in Early Psychosis Care.

OBJECTIVE: Learning health care networks can significantly improve the effectiveness, consistency, and cost-effectiveness of care delivery. As part of a data harmonization process, incorporation of the perspectives of community partners to maximize the relevance and utility of the data is critical. METHODS: A mixed-methods focus group study was conducted with early psychosis program providers, leadership, service users, and family members to explore their priorities regarding data collection in early psychosis care. Focus group transcripts were analyzed through thematic analysis. RESULTS: Twenty-two focus groups comprising 178 participants were conducted across 10 early psychosis programs. Participants considered functioning, quality of life, recovery, and symptoms of psychosis as key outcomes to assess, although variation by participants' roles was also evident. Participants emphasized the clinical utility of assessing a broad range of predictors of care outcomes, favored a broad conceptualization of the constructs assessed, and indicated a preference for client-reported measures. Participants also emphasized the importance of surveys adopting a recovery-oriented, strengths-based approach. CONCLUSIONS: Large-scale aggregation of health care data collected as part of routine care offers opportunities for research and may have a positive impact on care delivery and quality improvement activities. However, these benefits are contingent on the data being both relevant and accessible to those who deliver and receive such care. This study highlights an approach that may inform the development of core assessment batteries used, optimizing the utility of such data for all community partners.

The diagnostic accuracy of screening for psychosis spectrum disorders in behavioral health clinics integrated into primary care.

Screening for psychosis spectrum disorders in primary care could improve early identification and reduce the duration of untreated psychosis. However, the accuracy of psychosis screening in this setting is unknown. To address this, we conducted a diagnostic accuracy study of screening for psychosis spectrum disorders in eight behavioral health services integrated into primary care clinics. Patients attending an integrated behavioral health appointment at their primary care clinic completed the Prodromal Questionnaire - Brief (PQ-B) immediately prior to their intake assessment. This was compared to a diagnostic phone interview based on the Structured Interview for Psychosis Risk Syndromes (SIPS). In total, 145 participants completed all study procedures, of which 100 screened positive and 45 negative at a provisional PQ-B threshold of ≥20. The PQ-B was moderately accurate at differentiating psychosis spectrum from no psychosis spectrum disorders; a PQ-B distress score of ≥27 had a sensitivity and specificity of 71.2 % and 57.0 % respectively. In total, 66 individuals (45.5 %) met criteria for a psychosis spectrum disorder and 24 (16.7 %) were diagnosed with full psychosis, indicating a high prevalence of psychosis in the sample. Overall, screening for psychosis spectrum disorders in an IBH primary care setting identified a relatively high number of individuals and may identify people that would otherwise be missed. The PQ-B performed slightly less well than in population-based screening in community mental health settings. However, the findings suggest this may represent an effective way to streamline the pathway between specialty early psychosis programs and primary care clinics for those in need.

Incorporating Community Partner Perspectives on eHealth Technology Data Sharing Practices for the California Early Psychosis Intervention Network: Qualitative Focus Group Study With a User-Centered Design Approach.

BACKGROUND: Increased use of eHealth technology and user data to drive early identification and intervention algorithms in early psychosis (EP) necessitates the implementation of ethical data use practices to increase user acceptability and trust. OBJECTIVE: First, the study explored EP community partner perspectives on data sharing best practices, including beliefs, attitudes, and preferences for ethical data sharing and how best to present end-user license agreements (EULAs). Second, we present a test case of adopting a user-centered design approach to develop a EULA protocol consistent with community partner perspectives and priorities. METHODS: We conducted an exploratory, qualitative, and focus group-based study exploring mental health data sharing and privacy preferences among individuals involved in delivering or receiving EP care within the California Early Psychosis Intervention Network. Key themes were identified through a content analysis of focus group transcripts. Additionally, we conducted workshops using a user-centered design approach to develop a EULA that addresses participant priorities. RESULTS: In total, 24 participants took part in the study (14 EP providers, 6 clients, and 4 family members). Participants reported being receptive to data sharing despite being acutely aware of widespread third-party sharing across digital domains, the risk of breaches, and motives hidden in the legal language of EULAs. Consequently, they reported feeling a loss of control and a lack of protection over their data. Participants indicated these concerns could be mitigated through user-level control for data sharing with third parties and an understandable, transparent EULA, including multiple presentation modalities, text at no more than an eighth-grade reading level, and a clear definition of key terms. These findings were successfully integrated into the development of a EULA and data opt-in process that resulted in 88.1% (421/478) of clients who reviewed the video agreeing to share data. CONCLUSIONS: Many of the factors considered pertinent to informing data sharing practices in a mental health setting are consistent among clients, family members, and providers delivering or receiving EP care. These community partners' priorities can be successfully incorporated into developing EULA practices that can lead to high voluntary data sharing rates.

Effect of Technology-Enhanced Screening in Addition to Standard Targeted Clinician Education on the Duration of Untreated Psychosis: A Cluster Randomized Clinical Trial.

Importance: Reducing the duration of untreated psychosis (DUP) is essential to improving outcomes for people with first-episode psychosis (FEP). Current US approaches are insufficient to reduce DUP to international standards of less than 90 days. Objective: To determine whether population-based electronic screening in addition to standard targeted clinician education increases early detection of psychosis and decreases DUP, compared with clinician education alone. Design, Setting, and Participants: This cluster randomized clinical trial included individuals aged 12 to 30 years presenting for services between March 2015 and September 2017 at participating sites that included community mental health clinics and school support and special education services. Eligible participants were referred to the Early Diagnosis and Preventative Treatment (EDAPT) Clinic. Data analyses were performed in September and October 2019 for the primary and secondary analyses, with the exploratory subgroup analyses completed in May 2021. Interventions: All sites in both groups received targeted education about early psychosis for health care professionals. In the active screening group, clients also completed the Prodromal Questionnaire-Brief using tablets at intake; referrals were based on those scores and clinical judgment. In the group receiving treatment as usual (TAU), referrals were based on clinical judgment alone. Main Outcomes and Measures: Primary outcomes included DUP, defined as the period from full psychosis onset to the date of the EDAPT diagnostic telephone interview, and the number of individuals identified with FEP or a psychosis spectrum disorder. Exploratory analyses examined differences by site type, completion rates between conditions, and days from service entry to telephone interview. Results: Twenty-four sites agreed to participate, and 12 sites were randomized to either the active screening or TAU group. However, only 10 community clinics and 4 school sites were able to fully implement population screening and were included in the final analysis. The total potentially eligible population size within each study group was similar, with 2432 individuals entering at active screening group sites and 2455 at TAU group sites. A total of 303 diagnostic telephone interviews were completed (178 [58.7%] female individuals; mean [SD] age, 17.09 years [4.57]). Active screening sites reported a significantly higher detection rate of psychosis spectrum disorders (136 cases [5.6%], relative to 65 [2.6%]; P < .001) and referred a higher proportion of individuals with FEP and DUP less than 90 days (13 cases, relative to 4; odds ratio, 0.30; 95% CI, 0.10-0.93; P = .03). There was no difference in mean (SD) DUP between groups (active screening group, 239.0 days [207.4]; TAU group 262.3 days [170.2]). Conclusions and Relevance: In this cluster trial, population-based technology-enhanced screening across community settings detected more than twice as many individuals with psychosis spectrum disorders compared with clinical judgment alone but did not reduce DUP. Screening could identify people undetected in US mental health services. Significant DUP reduction may require interventions to reduce time to the first mental health contact. Trial Registration: ClinicalTrials.gov Identifier: NCT02841956.

Online Psychosis Screening: Characterizing an Underexamined Population to Improve Access and Equity.

OBJECTIVE: Online resources represent an important avenue to identify and support individuals who may be experiencing symptoms of psychosis but have yet to engage in care. Understanding the experiences and needs of this group is critical to inform outreach for early psychosis and improve outcomes by addressing barriers to early treatment. METHODS: The authors conducted a retrospective, explorative, cross-sectional analysis by using data collected by Mental Health America as part of their online psychosis screening and support program. Data included scores from the Prodromal Questionnaire-Brief, basic demographic information, and respondents' plans for next steps. RESULTS: Of 120,937 respondents, most (82.1%) reported distressing psychosis-like experiences at levels sufficient to merit a referral to specialty care for additional evaluation. However, only 17.1% planned to seek treatment as a next step, with most (53.6%) wanting instead more information. Higher distress was only weakly associated with the plan to seek treatment. In the multivariable analysis, respondents who were younger; lesbian, gay, bisexual, transgender, or queer; or Native American or who had lower income reported the greatest symptom-related distress. Younger and higher-income respondents were less likely to plan to seek treatment next. Across race-ethnicity, African Americans were most likely to plan to seek treatment. CONCLUSIONS: Most respondents reported that psychosis-like experiences caused significant distress, but they did not plan to seek treatment next. Addressing this treatment gap requires careful consideration regarding what services individuals want, how services should be presented, and what barriers may limit help seeking. These steps are critical to improve access to early intervention for individuals with psychosis spectrum disorders.

Persistent and distressing psychotic-like experiences using adolescent brain cognitive development℠study data.

Childhood psychotic-like experiences (PLEs) are associated with a range of impairments; a subset of children experiencing PLEs will develop psychiatric disorders, including psychotic disorders. A potential distinguishing factor between benign PLEs versus PLEs that are clinically relevant is whether PLEs are distressing and/or persistent. The current study used three waves of Adolescent Brain Cognitive Development℠ (ABCD) study PLEs assessments to examine the extent to which persistent and/or distressing PLEs were associated with relevant baseline risk factors (e.g., cognition) and functioning/mental health service utilization domains. Four groups varying in PLE persistence and distress endorsement were created based on all available data in ABCD Release 3.0, with group membership not contingent on complete data: persistent distressing PLEs (n = 272), transient distressing PLEs (n = 298), persistent non-distressing PLEs (n = 221), and transient non-distressing PLEs (n = 536) groups. Using hierarchical linear models, results indicated youth with distressing PLEs, whether transient or persistent, showed delayed developmental milestones (ß = 0.074, 95%CI:0.013,0.134) and altered structural MRI metrics (ß = -0.0525, 95%CI:-0.100,-0.005). Importantly, distress interacted with PLEs persistence for the domains of functioning/mental health service utilization (ß = 0.079, 95%CI:0.016,0.141), other reported psychopathology (ß = 0.101, 95%CI:0.030,0.170), cognition (ß = -0.052, 95%CI:0.-0.099,-0.002), and environmental adversity (ß = 0.045, 95%CI:0.003,0.0.86; although no family history effects), with the interaction characterized by greatest impairment in the persistent distressing PLEs group. These results have implications for disentangling the importance of distress and persistence for PLEs with regards to impairments, including functional, pathophysiological, and environmental outcomes. These novel longitudinal data underscore that it is often only in the context of distress that persistent PLEs were related to impairments.

Replication of Associations With Psychotic-Like Experiences in Middle Childhood From the Adolescent Brain Cognitive Development (ABCD) Study.

The fields of psychology and psychiatry are increasingly recognizing the importance of replication efforts. The current study aimed to replicate previous findings examining the construct validity and psychometric properties of a psychotic-like experiences (PLEs) measure in middle childhood using an independent subset of the baseline Adolescent Brain Cognitive Development (ABCD) sample. Using a remainder baseline sample of 7013 nine- to eleven-year-old children with complete data, we examined measurement invariance across race/ethnicity and sex, and examined the associations between the Prodromal Questionnaire Brief-Child Version (PQ-BC) and other measures of PLEs, internalizing symptoms, neuropsychological test performance, and developmental milestones, to determine whether previously obtained results replicated in this nonoverlapping baseline sample subset. The results replicated measurement invariance across ethnicity and sex, and analyses again found higher PQ-BC scores for African American (ß = .364, 95% CI = 0.292, 0.435) and Hispanic (ß = .255, 95% CI = 0.185, 0.324) groups. We also replicated that higher PQ-BC scores were associated with psychosis risk measures, higher rates of child-reported internalizing symptoms (Distress: ß = .378, 95% CI = 0.357,0.398), neuropsychological test performance deficits (eg, working memory; Distress: ß = -.069, 95% CI = -0.096, -0.042), and motor (Distress: ß = .026, 95% CI = 0.003, 0.049) and speech (Distress: ß = .042, 95% CI = 0.018, 0.065) developmental milestone delays. The current results replicated many findings from the original study examining the PQ-BC. We replicated evidence for mean differences in race/ethnicity, and associations with other PLE measures, greater internalizing symptoms, cognitive impairments, and developmental milestone delays. These findings indicate robust and reliable associations between PLEs and hypothesized correlates can be found in middle childhood nonclinical samples.

Psychosis screening in schools: Considerations and implementation strategies.

AIM: Duration of untreated psychosis, or the time between onset of psychosis symptoms and accurate diagnosis and treatment, is a significant predictor of both initial treatment response and long-term outcomes. As such, efforts to improve rapid identification are key. Because early signs of psychosis commonly emerge in adolescence, schools have the potential to play an important role in the identification of psychosis-spectrum disorders. METHODS: To illustrate the potential role of schools in this effort, the current paper describes implementation of a psychosis screening tool as part of a larger study focused on reducing the duration of untreated psychosis in Sacramento, CA. RESULTS: Clinical considerations related to screening for psychosis in schools, including ethical concerns, logistics, screening population and stigma are addressed. Implementation strategies to address these concerns are suggested. CONCLUSIONS: Early psychosis screening in the school system could improve early identification, reduce stigma and may represent an important further step towards an integrative system of mental health.

The Rise of Early Psychosis Care in California: An Overview of Community and University-Based Services.

OBJECTIVE: California's Mental Health Services Act Prevention and Early Intervention funds provide a unique opportunity for counties to initiate programs focused on early intervention in mental health, including early psychosis. To explain the configuration of early psychosis programs and plan for a statewide evaluation, this report provides an overview of California's early psychosis programming, including service composition, funding sources, inclusion criteria, and data collection practices. METHODS: Following a comprehensive identification process, early psychosis program representatives were contacted to complete the California Early Psychosis Assessment Survey (CEPAS). RESULTS: The response rate to the CEPAS was excellent (97%, 29 of 30 active programs across 24 of 58 counties). Most programs (N=27, 93%) serve individuals with first-episode psychosis between the ages of 12 and 25. Twenty-two programs (79%) provide more than half of the standard components of early psychosis care outlined in the First-Episode Psychosis Service Fidelity Scale. Sixty-four percent of programs collect client-level data at intake and follow up on five or more relevant outcome domains; however, these varied significantly across sites. CONCLUSIONS: Substantial variability in services, inclusion criteria, and data recorded was evident across programs. Prior to conducting any large-scale evaluation, these findings highlight the significant challenges in retrospectively evaluating program effectiveness, need to harmonize program data collection methods, and importance of assessing the impact of program variability on outcomes.

Which components of specialized early intervention for psychosis do senior providers see as most important?

AIM: Specialized early interventions improve outcomes in early psychosis (EP). Experts have proposed a number of essential treatment components. However, it is unclear whether these reflect the views of senior clinic staff charged with implementing this model in practice. METHOD: Twenty-Five senior EP clinic staff across California completed a survey indicating which features of EP treatment they considered most important. RESULTS: Components related to the service structure and the need for a prompt, comprehensive assessment and care planning were considered most important, despite the limited evidence base evaluating these aspects of care. Administration of clozapine to treatment-refractory patients and weight gain interventions were considered the least important, despite the relatively strong evidence base supporting these treatment components. CONCLUSION: The findings suggest a bi-directional dissemination gap, where components considered most important by senior providers receive limited research attention, while some areas with supporting evidence may be underappreciated in clinical practice.

How Do Early Psychosis Services Define and Operationalize the Duration of Untreated Psychosis?

Reducing the duration of untreated psychosis (DUP) is a key aim of early psychosis (EP) care. However, substantial variability in how the start and end points of DUP are defined impact its utility in clinical decision-making, and as an outcome measure. In this study, qualitative interviews were conducted with providers to assess how EP services and providers define, operationalize, and measure DUP. Twenty-five providers across 14 clinics were interviewed. Participants emphasized symptom frequency, conviction, distress caused, and impact when determining psychosis onset. DUP endpoint was typically identified as the first assessment in an episode of care that included an accurate diagnosis, leading to specialty EP treatment. Participants proposed a more structured operationalization of DUP, relative to those historically adopted in the literature. Integrating front-line provider perspectives could improve the accuracy of DUP measurement and address the heterogeneity in how the construct is operationalized across research and practice.

Assessment of the Prodromal Questionnaire-Brief Child Version for Measurement of Self-reported Psychoticlike Experiences in Childhood.

Importance: Childhood psychoticlike experiences (PLEs) are associated with greater odds of a diagnosis of a psychotic disorder during adulthood. However, no known, well-validated self-report tools have been designed to measure childhood PLEs. Objective: To examine the construct validity and psychometric properties of a measure of PLEs, the Prodromal Questionnaire-Brief Child Version (PQ-BC). Design, Setting, and Participants: This validation study used data from the first wave of the Adolescent Brain and Cognitive Development (ABCD) Study, a prospective longitudinal study aimed at assessing risk factors associated with adverse physical and mental health outcomes from ages 9 to 10 years into late adolescence and early adulthood. The population-based sample of 3984 children within the ABCD data set was recruited from 20 research sites across the United States. Data for this study were collected from June 1, 2016, through August 31, 2017. Main Outcomes and Measures: The PQ-BC Total and Distress scores were analyzed for measurement invariance across race/ethnicity and sex, their associations with measures of PLEs, and their associations with known correlates of PLEs, including internalizing and externalizing symptoms, neuropsychological test performance, and developmental milestones. Results: The study analyses included 3984 participants (1885 girls [47.3%] and 2099 boys [52.7%]; mean [SE] age, 10.0 [0.01] years). The results demonstrated measurement invariance across race/ethnicity and sex. A family history of psychotic disorder was associated with higher mean (SE) PQ-BC Total (3.883 [0.352]; ß = 0.061; 95% CI, 0.027-0.094) and Distress (10.210 [1.043]; ß = 0.051; 95% CI, 0.018-0.084) scores, whereas a family history of depression or mania was not. Higher PQ-BC scores were associated with higher rates of child-rated internalizing symptoms (Total score: ß range, 0.218 [95% CI, 0.189-0.246] to 0.273 [95% CI, 0.245-0.301]; Distress score: ß range, 0.248 [95% CI, 0.220-0.277] to 0.310 [95% CI, 0.281-0.338]), neuropsychological test performance deficits such as working memory (Total score: ß = -0.042 [95% CI, -0.077 to -0.008]; Distress score: ß = -0.051 [95% CI, -0.086 to -0.017]), and motor and speech developmental milestone delays (Total score: ß = 0.057 [95% CI, 0.026-0.086] for motor; ß = 0.042 [95% CI, 0.010-0.073] for speech; Distress score: ß = 0.048 [95% CI, 0.017-0.079] for motor; ß = 0.049 [95% CI, 0.018-0.081] for speech). Conclusions and Relevance: These results provide support for the construct validity and demonstrate adequate psychometric properties of a self-report instrument designed to measure childhood PLEs, providing evidence that the PQ-BC may be a useful measure of early risk for psychotic disorders. Furthermore, these data suggest that PLEs at school age are associated with many of the same familial, cognitive, and emotional factors associated with psychotic symptoms in older populations, consistent with the dimensionality of psychosis across the lifespan.

Acceptability of Psychosis Screening and Factors Affecting Its Implementation: Interviews With Community Health Care Providers.

OBJECTIVE: Although screening for psychosis may reduce the duration of untreated psychosis, the barriers and facilitators associated with implementing such a procedure in various care settings have not been explored. METHODS: Investigators conducted in-depth, semistructured interviews with 17 members of school counseling services or community mental health staff at sites that administer a psychosis screening tool. Using an inductive approach to thematic analysis, they evaluated the acceptability of psychosis screening and barriers to and facilitators of implementation. RESULTS: Participants reported few barriers to implementation. However, several service-, client-, and program-level factors were considered to significantly affect the implementation of screening. Most participants found that using the screening tool did not significantly affect their overall workload. Facilitators included leadership support, the novelty of using a technology-based screener, regular staff training, and the importance of establishing an effective link between community services and specialty care, with these factors important at different stages of the process. Screening for psychosis was associated with significant advantages over referrals based on clinical judgment alone, including increased speed and accuracy of identification, increased confidence in diagnosis, and the provision of a clear pathway to specialty treatment. CONCLUSIONS: The experiences of school counseling and community mental health teams suggest that incorporating a technology-based screening procedure for early psychosis is feasible. Identifying barriers and facilitators at various stages of the screening procedure may reduce the dropout of clients potentially eligible for early psychosis care.

Psychosis risk screening in different populations using the Prodromal Questionnaire: A systematic review.

AIM: Diagnosing individuals at ultra high risk (UHR) for psychosis can improve early access to treatment, and a two-stage model utilizing self-report screening followed by a clinical interview can be accurate and efficient. However, it is currently unclear which screening cut-offs to adopt with different populations. METHODS: A systematic review of diagnostic accuracy studies evaluating the Prodromal Questionnaire (PQ) as a preliminary screener for UHR and psychosis was conducted to examine screening effectiveness in different contexts. MedLine, PsycInfo, SCOPUS and ProQuest Dissertations and Abstracts databases were electronically searched, along with a review screen and citation search of key papers. Findings were summarized in a narrative synthesis. RESULTS: In total, 14 diagnostic accuracy studies and 45 studies using the PQ as a screening tool for UHR and psychosis were included. In all settings, the 3 different versions of the PQ were all found to accurately identify UHR and full psychosis. Higher cut-off points were required in non-help-seeking samples, relative to general help-seeking populations, which in turn were higher than those needed in samples highly enriched with UHR participants. CONCLUSION: The findings support the use of the PQ as a preliminary screening tool for UHR in different settings; however, higher thresholds in lower UHR-prevalence populations are necessary to minimize false positives. Including the distress criteria, rather than just number of symptoms, may improve screening effectiveness. Different thresholds may be appropriate in different contexts depending on the importance of sensitivity vs specificity. Protocol registration: CRD42016033004.

Correspondence between negative symptoms and potential sources of secondary negative symptoms over time.

There has been a debate in the literature about the distinction between primary and secondary negative symptoms of schizophrenia. Our aim was to study the associations between negative symptoms and potential sources of secondary negative symptoms over time. A sample of 275 participants with at least mid-moderate negative symptoms was randomized into body psychotherapy or Pilates class in a previous study. No significant differences were found between groups over time and changes in the symptom domains were modest. The present investigation considers the longitudinal correlation between variables of interest at baseline, 3 and 9 months follow-up. Measures were the Clinical Assessment Interview for Negative Symptoms (CAINS), the Positive and Negative Symptom Scale (PANSS), the Calgary Depression Scale (CDSS) and the Simpson-Angus Extrapyramidal side-effects Scale (SAS). Mixed models were computed to test the longitudinal association between these variables. In a sensitivity analysis, the dosages of antipsychotic, illness duration and allocated intervention were taken into account. Overall, the course of extrapyramidal side-effects, depressive and positive symptoms was significantly related to the course of negative symptoms. Only extrapyramidal effects were longitudinally correlated to expressive negative symptoms. The sensitivity analyses showed unaltered results for positive symptoms and depression but a lack of association between extrapyramidal effects and the CAINS outcomes. In conclusion, the unambiguous interpretation between primary and secondary negative symptoms may lead to refined treatment approaches for schizophrenia and to increased effects of the interventions.

The impact of gender on treatment effectiveness of body psychotherapy for negative symptoms of schizophrenia: A secondary analysis of the NESS trial data.

Despite promising findings from small-scale studies suggesting that body psychotherapy may be an effective treatment for negative symptoms, these results were not replicated in a recent multisite trial. In this trial a far smaller proportion of women were recruited relative to earlier studies, which may be an issue given the gender mix of the sample evaluated has been found to affect trial outcomes in schizophrenia. Using data from our multisite trial, the interaction between gender and treatment allocation as a predictor of outcomes was examined in 275 participants (72 women and 203 men) randomised to either a body psychotherapy or Pilates group. Negative symptoms were found to significantly reduce in women randomised to the body psychotherapy condition in comparison to Pilates, while no such effect was detected in men. Consistent with the smaller trials, this improvement was found to relate predominantly to expressive deficits. These findings suggest that body psychotherapy may be an effective treatment for negative symptoms in women. These findings emphasise the importance of sample characteristics in determining trial outcome in psychological treatment studies.

Clinical effectiveness and cost-effectiveness of body psychotherapy in the treatment of negative symptoms of schizophrenia: a multicentre randomised controlled trial.

BACKGROUND: The negative symptoms of schizophrenia significantly impact on quality of life and social functioning, and current treatment options are limited. In this study the clinical effectiveness and cost-effectiveness of group body psychotherapy as a treatment for negative symptoms were compared with an active control. DESIGN: A parallel-arm, multisite randomised controlled trial. Randomisation was conducted independently of the research team, using a 1 : 1 computer-generated sequence. Assessors and statisticians were blinded to treatment allocation. Analysis was conducted following the intention-to-treat principle. In the cost-effectiveness analysis, a health and social care perspective was adopted. ELIGIBILITY CRITERIA: age 18-65 years; diagnosis of schizophrenia with symptoms present at > 6 months; score of ≥ 18 on Positive and Negative Syndrome Scale (PANSS) negative symptoms subscale; no change in medication type in past 6 weeks; willingness to participate; ability to give informed consent; and community outpatient. EXCLUSION CRITERIA: inability to participate in the groups and insufficient command of English. SETTINGS: Participants were recruited from NHS mental health community services in five different Trusts. All groups took place in local community spaces. INTERVENTIONS: Control intervention: a 10-week, 90-minute, 20-session group beginners' Pilates class, run by a qualified Pilates instructor. Treatment intervention: a 10-week, 90-minute, 20-session manualised group body psychotherapy group, run by a qualified dance movement psychotherapist. OUTCOMES: The primary outcome was the PANSS negative symptoms subscale score at end of treatment. Secondary outcomes included measures of psychopathology, functional, social, service use and treatment satisfaction outcomes, both at treatment end and at 6-month follow-up. RESULTS: A total of 275 participants were randomised (140 body psychotherapy group, 135 Pilates group). At the end of treatment, 264 participants were assessed (137 body psychotherapy group, 127 Pilates group). The adjusted difference in means of the PANSS negative subscale at the end of treatment was 0.03 [95% confidence interval (CI) -1.11 to 1.17], showing no advantage of the intervention. In the secondary outcomes, the mean difference in the Clinical Assessment Interview for negative symptoms expression subscale at the end of treatment was 0.62 (95% CI -1.23 to 0.00), and in extrapyramidal movement disorder symptoms -0.65 (95% CI -1.13 to -0.16) at the end of treatment and -0.58 (95% CI -1.07 to -0.09) at 6 months' follow-up, showing a small significant advantage of body psychotherapy. No serious adverse events related to the interventions were reported. The total costs of the intervention were comparable with the control, with no clear evidence of cost-effectiveness for either condition. LIMITATIONS: Owing to the absence of a treatment-as-usual arm, it is difficult to determine whether or not both arms are an improvement over routine care. CONCLUSIONS: In comparison with an active control, group body psychotherapy does not have a clinically relevant beneficial effect in the treatment of patients with negative symptoms of schizophrenia. These findings conflict with the review that led to the current National Institute for Health and Care Excellence guidelines suggesting that arts therapies may be an effective treatment for negative symptoms. FUTURE WORK: Determining whether or not this lack of effectiveness extends to all types of art therapies would be informative. TRIAL REGISTRATION: Current Controlled Trials ISRCTN842165587. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 11. See the NIHR Journals Library website for further project information.

Effectiveness and cost-effectiveness of body psychotherapy in the treatment of negative symptoms of schizophrenia--a multi-centre randomised controlled trial.

BACKGROUND: Negative symptoms of schizophrenia are frequently associated with poor long term outcomes. Established interventions have little, if any, positive effects on negative symptoms. Arts Therapies such as Body Psychotherapy (BPT) have been suggested to reduce negative symptoms, but the existing evidence is limited. In a small exploratory trial a manualised form of group BPT led to significantly lower negative symptom levels both at the end of treatment and at 4 months follow-up as compared to supportive counseling. We designed a large multi-site trial to assess the effectiveness of a manualised BPT intervention in reducing negative symptoms, compared to an active control. METHODS/DESIGN: In a randomised controlled trial, 256 schizophrenic outpatients with negative symptoms will be randomly allocated either to BPT or Pilates groups. In both conditions, patients will be offered two 90 minutes sessions per week in groups of about 8 patients over a period of 10 weeks. Outcomes are assessed at the end of treatment and at six months follow-up. The primary outcome is severity of negative symptoms, as measured by the Positive and Negative Symptom Scale (PANSS), whilst a range of secondary outcome measures include general psychopathology, social contacts, and quality of life. We will also assess the cost-effectiveness of the intervention. DISCUSSION: The study aims to evaluate the effectiveness of a promising form of group therapy which may help alleviate negative symptoms that are associated with unfavourable long-term outcomes and have so far been difficult to treat. If the trial is successful, it will add a new and effective option in the treatment of negative symptoms. Group BPT is manualised, might be attractive to many patients because of its unusual approach, and could potentially be rolled out to services at relatively little additional cost. TRIAL REGISTRATION: Current Controlled Trials ISRCTN84216587.

Factors predicting the outcome of psychotherapy for borderline personality disorder: a systematic review.

BACKGROUND: There is substantial variation between individuals with borderline personality disorder (BPD) in the degree of benefit gained from psychotherapy. Information on factors predicting the outcome of therapy for this group could facilitate identification of those at risk for poor outcome, and could enable helpful therapy processes to be identified. METHOD: A systematic search of PsycInfo, EMBASE, CINHAL and Medline identified research on factors predicting symptom change during therapy for patients with a BPD diagnosis. Non-English language papers and dissertations were included. RESULTS: Two consistent positive predictors of symptom change were identified: pre-treatment symptom severity and patient-rated therapeutic alliance. Contrary to theories predicting increasing immutability with age, there was no evidence that age predicted poorer outcome. CONCLUSION: More severely ill patients may have greater potential to achieve change during therapy, and should remain a focus for psychotherapy services. The therapeutic alliance is an important common factor predicting outcome in patients with BPD, even in highly disorder-specific treatments. Outcomes may be improved by further clinical and research focus on forming strong therapeutic alliances. The advancement of the field requires identification and testing of new predictors of outcome, especially those related to specific theories of therapeutic change in BPD.

Recovery in Borderline Personality Disorder (BPD): a qualitative study of service users' perspectives.

BACKGROUND: Symptom improvement in Borderline Personality Disorder (BPD) is more common than previously hypothesised. However, it remains unclear whether it reflects service users' personal goals of recovery. The present study aimed to explore what service users with BPD view as recovery. METHODS: 48 service users were recruited from secondary mental health services and their views on their personal goals and the meaning of recovery were explored in in-depth semi-structured interviews. The study drew on grounded theory and thematic analysis. RESULTS: Service users believed that recovery involved developing self-acceptance and self-confidence, gaining control over emotions, improving relationships, employment, and making progress in symptoms like suicidality and self-harming. They felt that psychotherapies for BPD often had an extreme focus on specific areas, like self-harming or relationships, and that some of their goals were neglected. Although full recovery was seen as a distant goal, interviewees felt that they could learn how to deal with their problems in more effective ways and make meaningful progress in their lives. CONCLUSIONS: Specialist therapies for BPD explicitly address some of the recovery goals that are important to service users, whereas other goals are only indirectly or poorly addressed. Professionals might need to work with service users towards devising comprehensive individualised case formulations, including all treatment targets that are important to service users, their priorities, and long-term plans on how their targets might be met and which services might be involved.