Effects on voice hearing distress and social functioning of unguided application of a smartphone app - A randomized controlled trial.

Background: Temstem is a smartphone app developed with and for clinical voice hearing individuals with the aim to reduce their voice hearing distress and improve social functioning. Methods: A randomized controlled trial with adult outpatients suffering from distressing and frequent auditory verbal hallucinations (AVH) was conducted. Participants were randomized to unguided 'Temstem+AVH monitoring' or unguided 'AVH monitoring only' (control condition). Assessments were performed at baseline, post-intervention (week 5-6), and follow-up (week 9-10). Primary outcomes were voice hearing distress and social functioning, as measured with Experience Sampling Method (ESM), consisting of multiple daily questionnaires during six days. In addition, voices and mood were self-monitored with help of a daily reflective questionnaire. Analyses were linear regression models (intention-to-treat). Results: 44 Participants were allocated to Temstem and 45 to the control condition. No significant differences between the groups were found on both primary outcomes. Conclusion: Our results do not support the effectiveness of stand-alone use of Temstem versus symptom monitoring on voice hearing distress or social functioning in voice hearing individuals. In order to potentially improve effectiveness of an mHealth tool in a population of people with frequent and distressing voices, we recommend to involve persons with lived experience in all stages of development and research; to thoroughly test the (technological) usability before performing an RCT; to test whether guidance of a therapist is needed to optimize effectiveness; and to provide prompts to remind the user to actually use the tool.

Testing the combination of Feeling Safe and peer counselling against formulation-based cognitive behaviour therapy to promote psychological wellbeing in people with persecutory delusions: study protocol for a randomized controlled trial (the Feeling Safe-NL Trial).

BACKGROUND: Persecutory delusions are strong threat beliefs about others' negative intentions. They can have a major impact on patients' day-to-day life. The Feeling Safe Programme is a new translational cognitive-behaviour therapy that helps patients modify threat beliefs and relearn safety by targeting key psychological causal factors. A different intervention approach, with growing international interest, is peer counselling to facilitate personal recovery. Combining these two approaches is a potential avenue to maximize patient outcomes. This combination of two different treatments will be tested as the Feeling Safe-NL Programme, which aims to promote psychological wellbeing. We will test whether Feeling Safe-NL is more effective and more cost-effective in improving mental wellbeing and reducing persecutory delusions than the current guideline intervention of formulation-based CBT for psychosis (CBTp). METHODS: A single-blind parallel-group randomized controlled trial for 190 out-patients who experience persecutory delusions and low mental wellbeing. Patients will be randomized (1:1) to Feeling Safe-NL (Feeling Safe and peer counselling) or to formulation-based CBTp, both provided over a period of 6 months. Participants in both conditions are offered the possibility to self-monitor their recovery process. Blinded assessments will be conducted at 0, 6 (post-treatment), 12, and 18 months. The primary outcome is mental wellbeing. The overall effect over time (baseline to 18-month follow-up) and the effects at each timepoint will be determined. Secondary outcomes include the severity of the persecutory delusion, general paranoid ideation, patient-chosen therapy outcomes, and activity. Service use data and quality of life data will be collected for the health-economic evaluation. DISCUSSION: The Feeling Safe-NL Trial is the first to evaluate a treatment for people with persecutory delusions, while using mental wellbeing as the primary outcome. It will also provide the first evaluation of the combination of a peer counselling intervention and a CBT-based program for recovery from persecutory delusions. TRIAL REGISTRATION: Current Controlled Trials ISRCTN25766661 (retrospectively registered 7 July 2022).

The bumpy road of trauma-focused treatment: Posttraumatic stress disorder symptom exacerbation in people with psychosis.

Concern for symptom exacerbation and treatment drop-out is an important barrier to the implementation of trauma-focused therapy (TFT), especially in people with a psychotic disorder. This study, which was part of a multicenter randomized controlled trial, investigated posttraumatic stress disorder (PTSD) symptom exacerbation during eye movement desensitization reprocessing (EMDR) therapy and prolonged exposure (PE) in a sample of 99 participants with PTSD and psychosis. Symptom exacerbations during the first four sessions (early exacerbation) and between-session exacerbations over the course of therapy were monitored using the PTSD Symptom Scale-Self Report. Analyses of covariance and chi-square tests were conducted to investigate exacerbation rates and their associations with treatment response and drop-out. Both early exacerbation and between-session exacerbation were relatively common (32.3% and 46.5%, respectively) but were unrelated to poor treatment response or an increased likelihood of treatment drop-out. Both clinicians and patients need to be aware that symptom exacerbation during TFT is common and not related to poor outcomes. Symptom exacerbation can be part of the therapeutic process, should be acknowledged and guided, and should not be a barrier to the implementation of TFT in people with psychosis.

Voice phenomenology as a mirror of the past.

BACKGROUND: Post-traumatic mechanisms are theorised to contribute to voice-hearing in people with psychosis and a history of trauma. Phenomenological links between trauma and voices support this hypothesis, as they suggest post-traumatic processes contribute to the content of, and relationships with, voices. However, research has included small samples and lacked theory-based comprehensive assessments. METHOD: In people with distressing voices (n = 73) who experienced trauma prior to voice-hearing, trauma-voice links were assessed both independently and dependently (descriptions were presented and rated separately and together, respectively) by both participants and researchers. A structured coding frame assessed four types of independent links (i.e. victimisation type, physiological-behavioural, emotional, and cognitive response themes including negative self-beliefs) and three types of dependent links: relational (similar interaction with/response to, voice and trauma); content (voice and trauma content are exactly the same); and identity (voice identity is the same as perpetrator). RESULTS: Independent links were prevalent in participants (51-58%) and low to moderately present in researcher ratings (8-41%) for significant themes. Identification of negative self-beliefs in trauma was associated with a significantly higher likelihood of negative self-beliefs in voices [participants odds ratio (OR) 9.8; researchers OR 4.9]. Participants and researchers also reported many dependent links (80%, 66%, respectively), most frequently relational links (75%, 64%), followed by content (60%, 25%) and identity links (51%, 22%). CONCLUSION: Trauma appears to be a strong shaping force for voice content and its psychological impact. The most common trauma-voice links involved the experience of cognitive-affective psychological threat, embodied in relational experiences. Trauma-induced mechanisms may be important intervention targets.

Trauma-focused therapies for post-traumatic stress in psychosis: study protocol for the RE.PROCESS randomized controlled trial.

INTRODUCTION: Many people with psychotic disorders experience symptoms of post-traumatic stress disorder (PTSD). In recent years, several trauma-focused therapies (TFTs), including cognitive restructuring (CR), prolonged exposure (PE), and eye movement desensitization and reprocessing (EMDR) have been studied and found to be safe and effective in reducing PTSD symptoms in individuals with psychosis. However, studies were conducted in different countries, with varying inclusion criteria, therapy duration, control groups, and trial outcomes. RE.PROCESS will be the first study to compare the impact of CR, PE, and EMDR with a waiting list control condition within the same context. METHODS AND ANALYSIS: This is the protocol of a pragmatic, single-blind, multicentre, superiority randomized controlled trial, in which CR, PE, and EMDR are compared to a waiting list control condition for TFT (WL) in a naturalistic treatment setting. Inclusion criteria are as follows: age ≥ 16 years; meeting full DSM-5 diagnostic criteria for PTSD on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), with a total CAPS score ≥ 23; and a psychotic disorder in the schizophrenia spectrum confirmed by the Structured Clinical Interview for DSM-5 (SCID-5). Participants (N=200) will be randomly allocated to 16 sessions of one of the TFTs or WL, in addition to receiving treatment as usual (TAU) for psychosis. The primary objective is to compare the effects of CR, PE, and EMDR to WL on researcher-rated severity of PTSD symptoms over time from baseline to 6-month follow-up. Secondary objectives are to examine these effects at the separate time-points (i.e., mid-treatment, post-treatment, and at 6-month follow-up) and to test the effects for clinician-rated presence of PTSD diagnosis, and self-rated severity of (complex) PTSD symptoms. DISCUSSION: This is the first RCT to directly compare the effects of CR, PE, and EMDR within the same context to TAU on PTSD symptoms in individuals with psychosis and PTSD. Secondary effects on clinical and functional outcomes will be investigated both directly after therapy and long term. TRIAL REGISTRATION: ISRCTN ISRCTN56150327 . Registered 18 June 2019.

Voice-hearers' beliefs about the causes of their voices.

Despite empirical evidence for multifactorial causes of voice-hearing, people's own beliefs about what caused their voices are understudied. People with distressing voices (n=125) completed measures of trauma, post-traumatic stress disorder (PTSD) symptoms, and beliefs about causality. Most participants reported trauma in the past (97%) and PTSD symptoms were prevalent. Traumatic experiences were the most commonly endorsed causal factor of voice-hearing (64%), followed by distress (62%). Beliefs about biological causes, including drug use (22%), were least endorsed. Those who experienced more traumatic events and more PTSD symptoms were more likely to endorse trauma as a causal factor of voice-hearing (R2=0.38).

To continue or not to continue? Antipsychotic medication maintenance versus dose-reduction/discontinuation in first episode psychosis: HAMLETT, a pragmatic multicenter single-blind randomized controlled trial.

BACKGROUND: Antipsychotic medication is effective for symptomatic treatment in schizophrenia-spectrum disorders. After symptom remission, continuation of antipsychotic treatment is associated with lower relapse rates and lower symptom severity compared to dose reduction/discontinuation. Therefore, most guidelines recommend continuation of treatment with antipsychotic medication for at least 1 year. Recently, however, these guidelines have been questioned as one study has shown that more patients achieved long-term functional remission in an early discontinuation condition-a finding that was not replicated in another recently published long-term study. METHODS/DESIGN: The HAMLETT (Handling Antipsychotic Medication Long-term Evaluation of Targeted Treatment) study is a multicenter pragmatic single-blind randomized controlled trial in two parallel conditions (1:1) investigating the effects of continuation versus dose-reduction/discontinuation of antipsychotic medication after remission of a first episode of psychosis (FEP) on personal and social functioning, psychotic symptom severity, and health-related quality of life. In total 512 participants will be included, aged between 16 and 60 years, in symptomatic remission from a FEP for 3-6 months, and for whom psychosis was not associated with severe or life-threatening self-harm or violence. Recruitment will take place at 24 Dutch sites. Patients are randomized (1:1) to: continuation of antipsychotic medication until at least 1 year after remission (original dose allowing a maximum reduction of 25%, or another antipsychotic drug in similar dose range); or gradual dose reduction till eventual discontinuation of antipsychotics according to a tapering schedule. If signs of relapse occur in this arm, medication dose can be increased again. Measurements are conducted at baseline, at 3, and 6 months post-baseline, and yearly during a follow-up period of 4 years. DISCUSSION: The HAMLETT study will offer evidence to guide patients and clinicians regarding questions concerning optimal treatment duration and when to taper off medication after remission of a FEP. Moreover, it may provide patient characteristics associated with safe dose reduction with a minimal risk of relapse. TRIAL STATUS: Protocol version 1.3, October 2018. The study is active and currently recruiting patients (since September 2017), with the first 200 participants by the end of 2019. We anticipate completing recruitment in 2022 and final assessments (including follow-up 3.5 years after phase one) in 2026. TRIAL REGISTRATION: European Clinical Trials Database, EudraCT number 2017-002406-12. Registered 7 June 2017.

Virtual reality-based cognitive behavioural therapy for patients with generalized social anxiety disorder: a pilot study.

BACKGROUND: Patients with generalized social anxiety disorder (SAD) avoid various social situations and can be reluctant to engage in in vivo exposure therapy. Highly personalized practising can be required before patients are ready to perform in vivo exposure. Virtual reality-based therapy could be beneficial for this group. AIMS: To assess the feasibility and potential effect of virtual reality-based cognitive behavioural therapy (VR-CBT) for patients with severe generalized SAD. METHODS: Fifteen patients with generalized SAD attended up to 16 VR-CBT sessions. Questionnaires on clinical and functional outcomes, and diary assessments on social activity, social anxiety and paranoia were completed at baseline, post-treatment and at 6-months follow-up. RESULTS: Two patients dropped out of treatment. Improvements in social anxiety and quality of life were found at post-treatment. At follow-up, depressive symptoms had decreased, and the effect on social anxiety was maintained. With respect to diary assessments, social anxiety in company and paranoia were significantly reduced by post-treatment. These improvements were maintained at follow-up. No increase was observed in social activity. CONCLUSIONS: This uncontrolled pilot study demonstrates the feasibility and treatment potential of VR-CBT in a difficult-to-treat group of patients with generalized SAD. Results suggest that VR-CBT may be effective in reducing anxiety as well as depression, and can increase quality of life.

Cognitive behavioral therapy for social activation in recent-onset psychosis: Randomized controlled trial.

OBJECTIVE: Negative symptoms largely account for poor outcome in psychotic disorders but remain difficult to treat. A cognitive-behavioral approach to these symptoms showed promise in chronic schizophrenia patients. We explored whether a combination of group and individual treatment focused on social activation (CBTsa) could benefit patients recently diagnosed with a psychotic disorder. METHOD: A single-blind randomized controlled trial enrolled 99 participants recently diagnosed with schizophrenia or a related disorder that received treatment as usual (TAU; n = 50), or TAU plus CBTsa (n = 49). Negative symptoms (Brief Negative Symptom Scale) and social withdrawal (Positive and Negative Syndrome Scale) were primary outcomes. Secondary outcome measures included dysfunctional beliefs (Dysfunctional Attitudes Scale-Defeatist Performance Attitude), stigma Internalized Stigma of Mental Illness Scale (ISMIS), and symptom severity and functioning as measured with the Global Assessment of Functioning (GAF). Outcomes were compared directly posttreatment and at follow-up (6 months posttreatment). RESULTS: Intention-to-treat analyses showed significant improvement in GAF symptoms (p = .02, d = 0.36) and a decrease in negative symptoms on trend level (p = .08, d = -0.29) in CBTsa compared to TAU at posttreatment. These group differences were no longer apparent at 6 months follow-up. Social withdrawal and negative symptoms improved over time in both conditions. CONCLUSIONS: The current trial showed small positive effects on symptom severity posttreatment but did not demonstrate maintenance of longer-term effects in favor of the CBTsa group. Findings suggest that the treatment duration may have been too short to change dysfunctional beliefs, a potentially important maintaining factor of negative symptom severity. Longer intervention periods in later, more stable stages of the illness when intensive standard treatment has tapered off may yield more beneficial effects. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Virtual-reality-based cognitive behavioural therapy versus waiting list control for paranoid ideation and social avoidance in patients with psychotic disorders: a single-blind randomised controlled trial.

BACKGROUND: Many patients with psychotic disorders have persistent paranoid ideation and avoid social situations because of suspiciousness and anxiety. We investigated the effects of virtual-reality-based cognitive behavioural therapy (VR-CBT) on paranoid thoughts and social participation. METHODS: In this randomised controlled trial at seven Dutch mental health centres, outpatients aged 18-65 years with a DSM-IV-diagnosed psychotic disorder and paranoid ideation in the past month were randomly assigned (1:1) via block randomisation to VR-CBT (in addition to treatment as usual) or the waiting list control group (treatment as usual). VR-CBT consisted of 16 individual therapy sessions (each 1 h long). Assessments were done at baseline, after treatment (ie, 3 months from baseline), and at a 6 month follow-up visit. The primary outcome was social participation, which we operationalised as the amount of time spent with other people, momentary paranoia, perceived social threat, and momentary anxiety. Analysis was by intention to treat. This trial was retrospectively registered with ISRCTN, number 12929657. FINDINGS: Between April 1, 2014, and Dec 31, 2015, 116 patients with a psychotic disorder were randomly assigned, 58 to the VR-CBT group and 58 to the waiting list control group. Compared with the control, VR-CBT did not significantly increase the amount of time spent with other people at the post-treatment assessment. Momentary paranoid ideation (b=-0·331 [95% CI -0·432 to -0·230], p<0·0001; effect size -1·49) and momentary anxiety (-0·288 [-0·438 to -0·1394]; p=0·0002; -0·75) were significantly reduced in the VR-CBT group compared with the control group at the post-treatment assessment, and these improvements were maintained at the follow-up assessment. Safety behaviour and social cognition problems were mediators of change in paranoid ideation. No adverse events were reported relating to the therapy or assessments. INTERPRETATION: Our results suggest that the addition of VR-CBT to standard treatment can reduce paranoid ideation and momentary anxiety in patients with a psychotic disorder. FUNDING: Fonds NutsOhra, Stichting tot Steun VCVGZ.

Financial incentives for improving adherence to maintenance treatment in patients with psychotic disorders (Money for Medication): a multicentre, open-label, randomised controlled trial.

BACKGROUND: Provision of financial incentives is a promising intervention for improving adherence in patients taking antipsychotic medication. We aimed to assess the effectiveness of this intervention for improving adherence to antipsychotic depot medication in patients with psychotic disorders, irrespective of their previous compliance. METHODS: We did this multicentre, open-label, randomised controlled trial at three mental health-care institutions in secondary psychiatric care services in the Netherlands. Eligible patients were aged 18-65 years, had been diagnosed with schizophrenia or another psychotic disorder, had been prescribed antipsychotic depot medication or had an indication to start using depot medication, and were participating in outpatient treatment. Patients were randomly assigned (1:1), via computer-generated randomisation with a block size of four, to receive 12 months of either treatment as usual plus a financial reward for each depot of medication received (€30 per month if fully compliant; intervention group) or treatment as usual alone (control group). Randomisation was stratified by treatment site and suspected prognostic factors: sex, comorbid substance-use disorder (absent vs present), and compliance with antipsychotic medication in the 4 months before baseline (<50% vs ≥50%). Patients, clinicians, interviewers, and research assistants were masked to group allocation before, but not after, group assignment. The primary outcome was the Medication Possession Ratio (MPR), defined as the number of depots of antipsychotic medication received divided by the total number of depots of antipsychotic medication prescribed during the 12 month intervention period. Patients were followed up for 6 months, during which time no monetary rewards were offered for taking antipsychotic medication. We did analysis by intention to treat. This trial is registered with the Nederlands Trial Register, number NTR2350. FINDINGS: Between May 21, 2010, and Oct 15, 2014, we randomly assigned 169 patients to the intervention group (n=84) or the control group (n=85). Primary outcome data were available for 155 (92%) patients. At baseline, the mean MPR was 76·0% (SD 28·2%) in the intervention group versus 77·9% (28·5%) in the control group. At 12 months, the mean MPR was higher in the intervention group (94·3% [SD 11·3%]) than in the control group (80·3% [19·1%]), with an adjusted difference of 14·9% (95% CI 8·9-20·9%; p<0·0001). This difference was maintained throughout the 6 month follow-up period: mean MPR of 86·6% (SD 22·2%) in the intervention group versus 76·0% (22·7%) in the control group (adjusted difference 6·5%, 95% CI 2·0-10·9; p=0·047). INTERPRETATION: Financial incentives are an effective way of improving adherence to antipsychotic depot medication among patients with psychotic disorders. Further research is needed to study the long-term effects of this intervention. FUNDING: Dual Diagnosis Center.

Predicting trauma-focused treatment outcome in psychosis.

OBJECTIVE: Although TF treatments are effective in patients with psychosis, it is unknown whether specific psychosis-related obstacles limit the effects, and what determines good outcome. METHODS: Baseline posttraumatic stress disorder (PTSD) symptom severity and seven psychosis-specific variables were tested as predictors in patients with a psychotic disorder and PTSD (n=108), who received eight sessions of TF treatment (Prolonged Exposure, or Eye Movement Desensitization and Reprocessing therapy) in a single-blind randomized controlled trial. Multiple regression analyses were performed. RESULTS: Baseline PTSD symptom severity was significantly associated with posttreatment PTSD symptom severity, explaining 11.4% of the variance. Additionally, more severe PTSD at baseline was also significantly associated with greater PTSD symptom improvement during treatment. After correction for baseline PTSD symptom severity, the model with the seven baseline variables did not significantly explain the variance in posttreatment PTSD outcome. Within this non-significant model, the presence of auditory verbal hallucinations contributed uniquely to posttreatment outcome but explained little variance (5.4%). Treatment completers and dropouts showed no significant difference on any of the psychosis-related variables. CONCLUSIONS: Given the low predictive utility of baseline psychosis-related factors, we conclude that there is no evidence-based reason to exclude patients with psychotic disorders from TF treatments. Also, we speculate that patients with psychosis and severe baseline PTSD might derive more benefit if given more than eight sessions. Trial registration current controlled-trials.com | Identifier: ISRCTN79584912 | http://www.isrctn.com/ISRCTN79584912.

Money for medication: a randomized controlled study on the effectiveness of financial incentives to improve medication adherence in patients with psychotic disorders.

BACKGROUND: Non-adherence with antipsychotic medication is a frequently occurring problem, particularly among patients with psychotic disorders. Prior research has generally shown encouraging results for interventions based on 'Contingency Management' (CM), in which desirable behaviour is encouraged by providing rewards contingent upon the behaviour. However, little is known about the application of CM on medication adherence in patients with psychotic disorders. An earlier pilot-study by our study group showed promising results in reducing admission days and increasing adherence. The current study is a randomized controlled trial concerning the effectiveness of a CM procedure called 'Money for Medication' (M4M), aimed at improving adherence with antipsychotic depot medication in psychotic disorder patients. METHODS/DESIGN: Outpatients (n =168) with a psychotic disorder will be randomly assigned to either the experimental group (n =84), receiving a financial reward for each accepted antipsychotic medication depot, or the control group (n =84), receiving treatment as usual without financial rewards. Patients are included regardless of their previous adherence. The intervention has a duration of twelve months. During the subsequent six months follow-up, the effects of discontinuing the intervention on depot acceptance will be assessed. The primary goal of this study is to assess the effectiveness of providing financial incentives for improving adherence with antipsychotic depot medication (during and after the intervention). The primary outcome measure is the percentage of accepted depots in comparison to prescription. Secondary, we will consider alternative measures of medication acceptance, i.e. the longest period of uninterrupted depot acceptance and the time expired before depot is taken. Additionally, the effectiveness of the experimental intervention will be assessed in terms of psychosocial functioning, substance use, medication side-effects, quality of life, motivation, cost-utility and patients' and clinicians' attitudes towards M4M. DISCUSSION: This RCT assesses the effectiveness and side-effects of financial incentives in improving adherence with antipsychotic depot medication in patients with psychotic disorders. This study is designed to assess whether M4M is an effective intervention to improve patients' acceptance of their antipsychotic depot medication and to examine how this intervention contributes to patients' functioning and wellbeing. TRIAL REGISTRATION: NTR2350 .

[Payment for accepting depot medication]. / Betalen voor het accepteren van depotmedicatie: meer depots maar geen klinisch effect.

Non-compliance with medication constitutes a large problem in medicine. Recently the results of a cluster randomised controlled trial were published in which financial incentives were offered to patients with psychotic disorders. The objective of this study was to test if financial incentives effectively improved adherence to maintenance treatment with depot antipsychotics. The financial incentives increased acceptance of depot medication but did not lead to any clinical benefits. Therefore, the implementation of contingency management using financial incentives is not yet desirable.

Cognitive Behavioral Therapy for negative symptoms (CBT-n) in psychotic disorders: a pilot study.

BACKGROUND AND OBJECTIVES: The treatment of negative symptoms in schizophrenia is a major challenge for mental health care. One randomized controlled trial found that cognitive therapy for low-functioning patients reduced avolition and improved functioning, using an average of 50.5 treatment sessions over the course of 18 months. The aim of our current pilot study was to evaluate whether 20 sessions of Cognitive Behavioral Therapy for negative symptoms (CBT-n) would reduce negative symptoms within 6 months. Also, we wanted to test the cognitive model of negative symptoms by analyzing whether a reduction in dysfunctional beliefs mediated the effects on negative symptoms. METHOD: In an open trial 21 adult outpatients with a schizophrenia spectrum disorder with negative symptoms received an average of 17.5 sessions of CBT-n. At baseline and end-of-treatment, we assessed negative symptoms (PANSS) and dysfunctional beliefs about cognitive abilities, performance, emotional experience, and social exclusion. Bootstrap analysis tested mediation. RESULTS: The dropout rate was 14% (three participants). Intention-to-treat analyses showed a within group effect size of 1.26 on negative symptoms (t = 6.16, | Sig = 0.000). Bootstrap analysis showed that dysfunctional beliefs partially mediated the change. LIMITATIONS: The uncontrolled design induced efficacy biases. Also, the sample was relatively small, and there were no follow-up assessments. CONCLUSIONS: CBT-n may be effective in reducing negative symptoms. Also, patients reported fewer dysfunctional beliefs about their cognitive abilities, performance, emotional experience, and social exclusion, and this reduction partially mediated the change in negative symptoms. The reductions were clinically important. However, larger and controlled trials are needed.

Trauma, psychosis, post-traumatic stress disorder and the application of EMDR.

In this article we describe three interactions between trauma, post-traumatic stress disorder (PTSD) and psychosis: 1. many patients with psychotic disorders suffered from traumatic life experiences that play an important role in the onset and content of their psychosis; 2. the experience of psychosis as well as its psychiatric treatment may result in post-traumatic stress symptoms; 3. if psychosis and PTSD occur simultaneously, there is a substantial risk for reciprocal negative reinforcement of both symptom groups as well as for potentially on going traumatization. Although these interactions are highly relevant from a clinical perspective, they usually remain unattended in routine care. The three interactions will be illustrated by a case history as well as an impression of the psychological treatment including EMDR. We recommend to pay attention to traumatization and comorbid PTSD in routine care for people with psychosis, as well as to offer them treatment.

Why do patients with schizophrenia who have poor insight still take antipsychotics? Memory deficits as moderators between adherence belief and behavior.

While lack of insight is often predictive of antipsychotic nonadherence, some inconsistency in the literature remains unexplained. Verbal memory deficits may moderate the association between insight and adherence. Based on cross-sectional data, outpatients treated with antipsychotics for a psychotic disorder were divided into those with good (n=53) and poor (n=59) memory. Poor insight predicted nonadherence only among the subgroup with relatively good memory (r=0.43; P<0.01), but had no effect in the subgroup with worse memory (r=0.08; ns). Structural equation modelling revealed significant moderation (χ=4.72; df=1; P<0.05), which means that a significantly better model fit was found by allowing the analysis to differentiate between the two memory groups. Thus, poor insight was only associated with poor medication adherence among patients with relatively good memory. We speculate that memory deficits commonly associated with schizophrenia may partly explain why poor insight does not always lead to poor medication adherence.

Recovery style predicts remission at one-year follow-up in outpatients with schizophrenia spectrum disorders.

Although people with schizophrenia use various coping strategies, it is largely unknown how their coping style contributes to remission of the illness. The concept of recovery style-either by sealing over or integrating-reflects an important distinction. We wanted to examine whether recovery style predicts remission at a 1-year follow-up. We examined the recovery style, insight, therapeutic alliance, and symptoms in 103 patients with psychotic disorders. To assess the remission status, the symptoms were measured at 6 and 12 months. Logistic regression analyses were used. Results showed that scoring an extra category toward integration (six categories exist) increased the odds of remission 1.84-fold (95% confidence interval, 1.11 to 3.03). Insight and therapeutic alliance were not predictive. Although remission was also predicted by positive symptom levels at baseline, this did not influence the effect of recovery style. In conclusion, independently of symptom levels, insight, or therapeutic alliance, an integrating recovery style increases the odds of remission at a 1-year follow-up.

Financial incentives to improve adherence to medication in five patients with schizophrenia in the Netherlands.

OBJECTIVE: Non-adherence to antipsychotic medication is common and increases the risk of psychotic relapse. A promising intervention may be a strategy wherein financial incentives are offered. METHODS: In a pilot study in The Netherlands, five patients with schizophrenia were offered financial incentives for a duration of one year to improve adherence to medication. Adherence and hospital days were measured. RESULTS: The percentage of accepted depot injections increased from an average of 44% in the previous year to 100% in the year when financial incentives were offered. While patients had been hospitalised for an average of 100.2 days in the previous year, only one was re-admitted for 17 days during the year of the intervention. CONCLUSIONS: The differences in adherence before and after the intervention were large and of clinical significance. However, randomised controlled trials are required to provide conclusive evidence on the effectiveness of offering financial incentives and potential consequences.