Substance use and self-poisoning in schizophrenia: 11-year findings from a national clinical survey of suicide in mental health patients in England.

Suicide is the leading cause of unnatural death among people with schizophrenia. Substance use is a highly prevalent comorbid feature of schizophrenia and a modifiable risk factor for suicide. However, no studies have examined changes in the frequency of substance use or self-poisoning in those who died by suicide over time. Knowing this could support more tailored approaches to reducing specific risk factors and access to means in those with schizophrenia who are at risk of suicide. We conducted an 11-year observational study on a clinical survey of people with schizophrenia in England who died by suicide within 12 months of contact with mental health services between 2010 and 2020 (n = 2718). Overall, alcohol, cannabis and stimulants were the most frequently reported substances. The odds of lifetime use significantly increased over time for cannabis, stimulants, heroin, and benzodiazepines. There were differences in socio-demographic, behavioural and clinical factors between those with recent and historical alcohol and drug use before death. Deaths by hanging, jumping and self-poisoning were the most common suicide methods. Though deaths by hanging significantly increased over time, deaths by self-poisoning significantly decreased, especially by means of psychotropic medication and opioids. To improve risk management, clinical efforts should focus on identifying and treating people with schizophrenia using specific substances. Nationwide initiatives for improving safety in prescribing could be contributing to reduced risks of suicide via self-poisoning in this group.

Alcohol use and suicide-related outcomes in people with a diagnosis of schizophrenia: a comprehensive systematic review and meta-analysis.

Suicide is the leading cause of unnatural death among people with a diagnosis of schizophrenia. Alcohol use is a prevalent comorbid feature of schizophrenia and a modifiable risk factor for suicide. We conducted a prospectively registered (PROSPERO, CRD42022358214) systematic review and meta-analysis to quantify the relationship between alcohol use and suicide-related outcomes in schizophrenia.We searched Medline, Embase, and PsycINFO for cross-sectional, case-control and longitudinal studies using exhaustive terms from database inception to December 2022 inclusive. Computation of odds ratios (ORs) and hazard ratios (HRs) were performed using a random-effects model with DerSimonian-Laird estimation. We also evaluated publication bias, study quality, and performed subgroup analysis and meta-regression. Fifty studies, comprising 65 samples, met eligibility criteria. Overall, alcohol use was associated with suicide (OR 1.38, 95% CI 1.21-1.58; HR = 1.32, 95% CI 1.00-1.74), attempted suicide (OR 1.69, 95% CI 1.45-1.98), and suicidal ideation (OR 1.69, 95% CI 1.22-2.34). While there was no evidence of publication bias, between-sample heterogeneity was moderate in analyses of attempted suicide (I2 = 39.6%, p = 0.01) and suicidal ideation (I2 = 56.0%, p = 0.01). Summary effects were significant in all subgroups except for longitudinal studies of attempted suicide (OR 1.60, 95% CI 0.86-3.00) and studies of suicidal ideation using gender combined samples (OR 1.63, 95% CI 0.99-2.67). Alcohol use is significantly associated with suicide-related outcomes in schizophrenia. Clinicians should routinely inquire about alcohol use in mental health services to focus preventative treatment efforts.

Clinical Effects of the 'Crisis Toolbox' (CTB): A Brief, Skills Based, Intervention Delivered in a Crisis Resolution and Home Treatment Team.

Access to psychological interventions for people under Crisis Resolution and Home Treatment Teams (CRHTTs) is limited. The Crisis Toolbox (CTB) is a skills-based intervention designed to increase access using flexible methods of delivery. This study aimed to evaluate the clinical effects of the CTB. A retrospective service evaluation of 399 participants who accessed the CTB between November 2020 and February 2021 was employed. Sessional measures comprising the Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Scale (GAD-7) were recorded across three time points. Overall, there were significantly decreasing trends in PHQ-9 (ß = - 1.6, p < 0.001) and GAD-7 scores (ß = - 1.5, p < 0.001) in participants who accessed the CTB. The magnitude and direction of specific trends differed according to age, diagnosis, and neurodiversity. The CTB could help reduce depression and anxiety in people experiencing crisis. Randomised controlled trials are now required to test its acceptability, feasibility, and effectiveness.

Acceptability of the 'Crisis Toolbox': a skills-based intervention delivered in a Crisis Resolution and Home Treatment Team during COVID-19.

Crisis Resolution and Home Treatment Teams (CRHTTs) provide 24-hour, seven day per week support for people in crisis. The COVID-19 pandemic has placed significant demand on urgent care and increased the need for brief interventions in CRHTT settings with flexible methods of delivery. This evaluation aimed to examine client satisfaction with the 'Crisis Toolbox' (CTB), a brief, skills-based intervention delivered in one CRHTT during COVID-19. All participants who received the CTB completed a satisfaction questionnaire. Descriptive statistics were calculated to quantify acceptability and qualitative themes were generated using thematic analysis. Fifty-eight people participated, all of whom reported high levels of satisfaction with the CTB. Four qualitative themes also emerged relating to 'Active ingredients of the CTB', 'The therapeutic relationship', 'Service-user preferences' and 'Expectations and continuity of care'. The CTB appears to be a valued intervention. Further research is now needed to assess its clinical impact and effect on operational indicators.

Does exercise improve sleep for adults with insomnia? A systematic review with quality appraisal.

Insomnia is recognised as the most prevalent sleep disorder. Untreated insomnia carries a heavy burden for patients and society. Exercise is proposed as a safe, inexpensive, and accessible non-pharmacological treatment. To the author's knowledge this is the first systematic review to investigate the sleep-enhancing effects of exercise by focusing exclusively on controlled trials comprising poor sleepers only and examining interventions consistent with national guidelines. Using a narrative synthesis, this review aimed to identify whether exercise improves objective and subjective sleep outcomes for people with insomnia. Five papers including participants with insomnia disorder, and six papers including participants with insomnia symptoms were identified through electronic database searches (CINAHL plus, PsycINFO, EMBASE, MEDLINE, SPORTDiscus, CENTRAL) and quality assessed using the Clinical Trial Assessment Measure. We found that exercise interventions led to improvements in subjective sleep quality for people with insomnia disorder and insomnia symptoms. However, exercise only improved objective and subjective measures of sleep continuity (sleep onset latency and sleep efficiency) for people presenting with insomnia symptoms, with a reduction in sleep onset latency being the most consistently observed effect across studies. The reliability of significant findings is reduced by methodological limitations. Recommendations are made to improve the quality of future research.

Metacognitive Therapy for Individuals at High Risk of Developing Psychosis: A Pilot Study.

Developing effective interventions for preventing first episode psychosis have been an important research focus in the last decade. Cognitive behavioral therapy is a currently indicated treatment for people at ultra-high risk of psychosis, however, access and resource issues limit its delivery within the NHS. Treatments which partial out potential active ingredients and are aimed at a range of psychological difficulties seen within this population have the potential to be more efficacious and efficient. We conducted a single-arm exploratory pilot trial, designed to investigate the feasibility and acceptability of Metacognitive therapy for individuals at ultra-high risk (UHR) of developing psychosis. Trial uptake was good, with 11 out of 12 referred individuals meeting for an eligibility assessment (one individual was excluded prior to the assessment). Of these, 10 individuals were eligible and included in the trial. Retention to treatment was high with 80% treatment adherence gained and an overall average of 8 sessions completed. All participants were offered follow-up assessments immediately post-treatment and at 6 months, which comprised measures of psychotic like experiences, anxiety and depression, and metacognitive processes implicated in the model. Retention to the post-treatment (12-week) follow-up was good, with 80% completion; however retention to the 6-month follow-up was lower at 60%. Clinically significant results were observed in psychotic like experiences, anxiety, depression and functioning with medium to large effect sizes. Measures related to beliefs and processes targeted within MCT showed clinically significant change with medium to large effect sizes. Our results suggest that MCT based upon a specific metacognitive model for individuals meeting ARMS criteria may be an important treatment target and warrants further attention. Limitations and possible focuses for future research are discussed. Registration: ISRCTN53190465 http://www.isrctn.com/ISRCTN53190465.

A systematic review of the nature and correlates of sleep disturbance in early psychosis.

Sleep disturbances are common in people with a diagnosis of schizophrenia and have been associated with increased symptom severity, neurocognitive deficits and reduced quality of life. Despite a significant body of literature in this field, there has been limited investigation of sleep disturbance in the early course of the illness. This systematic review aims to synthesise and evaluate the available data exploring sleep in early psychosis, with two key research questions: 1) What is the nature of sleep disturbance in early psychosis? and 2) What are the correlates of sleep disturbance in early psychosis? From an initial search, 16,675 papers were identified, of which 21 met inclusion/exclusion criteria. The preliminary evidence suggests that self-reported sleep disturbances are prevalent in early psychosis and may be associated with symptom severity, as well as elevated rates of both help-seeking and suicidality. Abnormalities in sleep architecture and sleep spindles are also commonly observed and may correlate with symptom severity and neurocognitive deficits. However, due to significant methodological limitations and considerable heterogeneity across studies, evidence to support the reliability of these associations is limited. We outline a research agenda, emphasising the prospective use of gold-standard sleep measurement to investigate the prevalence and nature of sleep disturbances in early psychosis, as well as how these may be related to the onset and persistence of psychotic symptoms.

High resolution examination of the role of sleep disturbance in predicting functioning and psychotic symptoms in schizophrenia: A novel experience sampling study.

Sleep disturbance is common in schizophrenia, but its role in predicting functioning and psychotic symptoms has yet to be rigorously examined. The purpose of this study was to conduct a prospective, high-resolution examination of the relationship between nightly sleep and next-day functioning and psychotic symptoms in people with a diagnosis of schizophrenia. Experience sampling methodology was integrated with actigraphy and sleep diaries across 7 days in 22 patients with a diagnosis of schizophrenia. Momentary assessments of mood, psychotic symptoms, and functioning were gathered at 5 points each day following pseudorandom schedules. Multilevel modeling was performed to evaluate the links between variables. Objective and subjective sleep disturbance predicted reduced next-day functioning, which remained significant after controlling for psychotic symptom severity. Increased sleep fragmentation and reduced subjective and objective sleep efficiency predicted greater next-day auditory hallucinations, whereas increased objective sleep fragmentation and reduced subjective sleep quality predicted greater paranoia and delusions of control. Negative affect on awakening mediated a proportion of these relationships (range: 17.9-57.3%). For the first time, we show that sleep disturbance is a predictor of next-day impaired functioning and psychotic symptom severity in people with a diagnosis of schizophrenia. Therefore, interventions targeting sleep may have the potential to directly and indirectly enhance functional and symptomatic recovery in those experiencing psychosis. (PsycINFO Database Record

Recovery-focused cognitive-behavioural therapy for recent-onset bipolar disorder: randomised controlled pilot trial.

BACKGROUND: Despite evidence for the effectiveness of structured psychological therapies for bipolar disorder no psychological interventions have been specifically designed to enhance personal recovery for individuals with recent-onset bipolar disorder. AIMS: A pilot study to assess the feasibility and effectiveness of a new intervention, recovery-focused cognitive-behavioural therapy (CBT), designed in collaboration with individuals with recent-onset bipolar disorder intended to improve clinical and personal recovery outcomes. METHOD: A single, blind randomised controlled trial compared treatment as usual (TAU) with recovery-focused CBT plus TAU (n = 67). RESULTS: Recruitment and follow-up rates within 10% of pre-planned targets to 12-month follow-up were achieved. An average of 14.15 h (s.d. = 4.21) of recovery-focused CBT were attended out of a potential maximum of 18 h. Compared with TAU, recovery-focused CBT significantly improved personal recovery up to 12-month follow-up (Bipolar Recovery Questionnaire mean score 310.87, 95% CI 75.00-546.74 (s.e. = 120.34), P = 0.010, d = 0.62) and increased time to any mood relapse during up to 15 months follow-up (χ2 = 7.64, P<0.006, estimated hazard ratio (HR) = 0.38, 95% CI 0.18-0.78). Groups did not differ with respect to medication adherence. CONCLUSIONS: Recovery-focused CBT seems promising with respect to feasibility and potential clinical effectiveness. Clinical- and cost-effectiveness now need to be reliably estimated in a definitive trial.

Negative affect is associated with reporting of both own and others' symptoms.

Negative affectivity (NA) has been defined as the disposition to experience and communicate negative emotional states. NA has been shown to correlate with self-reports of physical symptoms. This study examined whether NA is also correlated with the informant-reporting of another person's symptoms. In two separate studies (N = 200, N = 159), students completed questionnaire measures of their own NA and of affect and symptoms in a significant other. In the second study, participants additionally reported on their own symptoms. In study one, participants' NA was correlated with their reports of a significant others' symptoms (r = .315, p = .000), which remained significant after controlling for the effect of gender (r = .227, p = .004). In study two, participants' NA was correlated with reports of their own (r = .338, p = .000) and others' (r = .216, p = .006) symptoms, particularly when symptoms were non-specific in nature (r = .221, p = .001). The correlation between informant-reports of others' affect and others' symptoms (r = .312, p = .000) remained significant (r = .256, p = .001) when self-reported NA was partialled out. When obtaining informant-reports on others' health it may be important to measure the informant's affective state, particularly when the information being sought is non-specific in nature. Limitations of the study, implications of its findings and possibilities for further research involving dyads each reporting on themselves and each other are discussed.

The bipolar recovery questionnaire: psychometric properties of a quantitative measure of recovery experiences in bipolar disorder.

BACKGROUND: The importance of personal recovery in mental health is increasing widely recognised. However, there is no measure available to assess recovery experiences in individuals with a diagnosis of bipolar disorder. This paper reports on the development of the Bipolar Recovery Questionnaire (BRQ) to aid recovery informed developments in research and clinical practice. METHODS: A draft 45 item BRQ was developed based on prior literature review and qualitative research. In the current study a panel of clinicians, academics and consumers rated draft items on recovery relevance and comprehensibility leading to the 36 item questionnaire subjected to psychometric evaluation. 60 participants with bipolar disorder completed BRQ along with measures of mood, quality of life, functioning and personal growth. RESULTS: BRQ was internally consistent and reliable over a month long test-retest period. BRQ scores were significantly associated with lower depression and mania scores and with higher wellbeing. BRQ was also significantly associated with better functioning, better mental health quality of life and personal growth. Regression analysis indicated that depression, wellbeing and personal growth were all uniquely associated with BRQ. LIMITATIONS: Sample size did not permit exploration of the factor structure of BRQ. The sample is drawn from the North West of England thus it is not clear how these findings might generalise beyond this group. CONCLUSIONS: BRQ is designed to assess personal experiences of recovery in bipolar disorder. The present study indicates that it is reliable and valid, being associated with both symptomatic and functional outcomes consistent with established definitions of recovery.

A randomised controlled trial of recovery focused CBT for individuals with early bipolar disorder.

BACKGROUND: There is increasing evidence for the effectiveness of structured psychological therapies for bipolar disorder. To date however there have been no psychological interventions specifically designed for individuals with early bipolar disorder. The primary objective of this trial is to establish the acceptability and feasibility of a new CBT based intervention (Recovery focused CBT; RfCBT) designed in collaboration with individuals with early bipolar disorder intended to improve clinical and personal recovery outcomes. METHODS AND DESIGN: This article describes a single blind randomised controlled trial to assess the feasibility and acceptability of RfCBT compared with treatment as usual. Participants will be recruited from across the North West of England from specialist mental health services and through primary care and self referral. The primary outcome of the study is the feasibility and acceptability of RfCBT as indicated by recruitment to target and retention to follow-up as well as absence of untoward incidents associated with RfCBT. We also intend to estimate the effect size of the impact of the intervention on recovery and mood outcomes and explore potential process measures (self appraisal, stigma, hope and self esteem). DISCUSSION: This is the first trial of recovery informed CBT for early bipolar disorder and will therefore be of interest to researchers in this area as well as indicating the wider potential for evaluating approaches to the recovery informed treatment of recent onset severe mental illness in general. TRIAL REGISTRATION NUMBER: ISRCTN43062149.