Development of the Prevention of Suicide Behaviour in Prisons: Enhancing Access to Therapy (PROSPECT) logic model and implementation strategies.

AIMS AND METHOD: This study aimed to develop and articulate a logic model and programme theories for implementing a new cognitive-behavioural suicide prevention intervention for men in prison who are perceived to be at risk of death by suicide. Semi-structured one-to-one interviews with key stakeholders and a combination of qualitative analysis techniques were used to develop programme theories. RESULTS: Interviews with 28 stakeholders resulted in five programme theories, focusing on: trust, willingness and engagement; readiness and ability; assessment and formulation; practitioner delivering the 'change work' stage of the intervention face-to-face in a prison environment; and practitioner training, integrating the intervention and onward care. Each theory provides details of what contextual factors need to be considered at each stage, and what activities can facilitate achieving the intended outcomes of the intervention, both intermediate and long term. CLINICAL IMPLICATIONS: The PROSPECT implementation strategy developed from the five theories can be adapted to different situations and environments.

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

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

The interplay between suicidal experiences, psychotic experiences and interpersonal relationships: a qualitative study.

BACKGROUND: Suicidal thoughts, acts, plans and deaths are considerably more prevalent in people with non-affective psychosis, including schizophrenia, compared to the general population. Social isolation and interpersonal difficulties have been implicated in pathways which underpin suicidal experiences in people with severe mental health problems. However, the interactions between psychotic experiences, such as hallucinations and paranoia, suicidal experiences, and the presence, and indeed, absence of interpersonal relationships is poorly understood and insufficiently explored. The current study sought to contribute to this understanding. METHODS: An inductive thematic analysis was conducted on transcripts of 22, individual, semi-structured interviews with adult participants who had both non-affective psychosis and recent suicidal experiences. A purposive sampling strategy was used. Trustworthiness of the analysis was assured with researcher triangulation. RESULTS: Participants relayed both positive and negative experiences of interpersonal relationships. A novel conceptual model is presented reflecting a highly complex interplay between a range of different suicidal experiences, psychosis, and aspects of interpersonal relationships. Three themes fed into this interplay, depicting dynamics between perceptions of i. not mattering and mattering, ii. becoming disconnected from other people, and iii. constraints versus freedom associated with sharing suicidal and psychotic experiences with others. CONCLUSION: This study revealed a detailed insight into ways in which interpersonal relationships are perceived to interact with psychotic and suicidal experiences in ways that can be both beneficial and challenging. This is important from scientific and clinical perspectives for understanding the complex pathways involved in suicidal experiences. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03114917), 14th April 2017. ISRCTN (reference ISRCTN17776666 .); 5th June 2017). Registration was recorded prior to participant recruitment commencing.

What is important to service users and staff when implementing suicide-focused psychological therapies for people with psychosis into mental health services?

Introduction: Suicide is a leading cause of death globally. People with psychosis are at increased risk of suicide death and up to half experience suicidal thoughts and/or engage in suicidal behaviors in their lifetime. Talking therapies can be effective in alleviating suicidal experiences. However, research is yet to be translated into practice, demonstrating a gap in service provision. The barriers and facilitators in therapy implementation require a thorough investigation including the perspectives of different stakeholders such as service users and mental health professionals. This study aimed to investigate stakeholders' (health professionals and service users) perspectives of implementing a suicide-focused psychological therapy for people experiencing psychosis in mental health services. Methods: Face-to-face, semi-structured interviews with 20 healthcare professionals and 18 service users were conducted. Interviews were audio recorded and transcribed verbatim. Data were analyzed and managed using reflexive thematic analysis and NVivo software. Results: For suicide-focused therapy to be successfully implemented in services for people with psychosis, there are four key aspects that need to be considered: (i) Creating safe spaces to be understood; (ii) Gaining a voice; (iii) Accessing therapy at the right time; and (iv) Ensuring a straightforward pathway to accessing therapy. Discussion: Whilst all stakeholders viewed a suicide-focused therapy as valuable for people experiencing psychosis, they also recognize that enabling successful implementation of such interventions will require additional training, flexibility, and resources to existing services.

Acceptability of a novel suicide prevention psychological therapy for people who experience non-affective psychosis.

OBJECTIVES: Suicide is a leading cause of death worldwide. People experiencing psychosis are at increased risk of death by suicide. Talking therapies can alleviate suicidal thoughts, plans, and attempts. Therapies need to also be acceptable to recipients. The aim of this study was to investigate the views on psychological therapy for people experiencing psychosis and suicidality using the Theoretical Framework of Acceptability. DESIGN: Qualitative interview study. METHODS: Participants were recruited from a randomised controlled trial comparing suicide prevention psychological therapy with treatment as usual. Individuals had a diagnosis of non-affective psychosis and experience of suicidal thoughts, plans and/or attempts. To assess the acceptability of the therapy, semi-structured interviews were conducted with 20 participants randomised to receive therapy. Data were deductively analysed using an adaptation of the Theoretical Framework of Acceptability. RESULTS: Interviews (Mean = 45 min) were conducted and audio recorded with 21 participants. Data were organised into six themes: 1. Affective attitude, 2. Burden, 3. Alliance, 4. Intervention coherence, 5. Perceived effectiveness, and 6. Self-efficacy. There was no evidence of issues relating to domains of ethicality and opportunity costs associated with receiving therapy. CONCLUSIONS: Talking about suicide was difficult and, at times, distressing, but it was perceived to be useful for understanding experiences. To be acceptable, it is important for therapists to ensure that clients' understanding of therapy aligns with expectations of effectiveness and to invest in building strong therapeutic alliances. Future research will benefit from examining therapists' experiences of delivering therapy through different modes (e.g. online, telephone).

Eye movement desensitization and reprocessing therapy for psychosis (EMDRp): Protocol of a feasibility randomized controlled trial with early intervention service users.

AIM: Traumatic events are involved in the development and maintenance of psychotic symptoms. There are few trials exploring trauma-focused treatments as interventions for psychotic symptoms, especially in individuals with early psychosis. This trial will evaluate the feasibility and acceptability of conducting a definitive trial of Eye Movement Desensitization and Reprocessing for psychosis (EMDRp) in people with early psychosis. METHODS: Sixty participants with first episode psychosis and a history of a traumatic/adverse life event(s)will be recruited from early intervention services in the North West of England and randomized to receive16 sessions of EMDRp + Treatment as Usual (TAU) or TAU alone. Participants will be assessed at baseline, 6 and 12 months post-randomization using several measures of psychotic symptoms, trauma symptoms, anxiety, depression, functioning, service-user defined recovery, health economics indicators and quality of life. Two nested qualitative studies to assess participant feedback of therapy and views of professional stakeholders on the implementation of EMDRp into services will also be conducted. The feasibility of a future definitive efficacy and cost-effectiveness evaluation of EMDRp will be tested against several outcomes, including ability to recruit and randomize participants, trial retention at 6- and 12-month follow-up assessments, treatment engagement and treatment fidelity. CONCLUSIONS: If it is feasible to deliver a multi-site trial of this intervention, it will be possible to evaluate whether EMDRp represents a beneficial treatment to augment existing evidence-based care of individuals with early psychosis supported by early intervention services.

A psychological intervention for suicide applied to non-affective psychosis: the CARMS (Cognitive AppRoaches to coMbatting Suicidality) randomised controlled trial protocol.

BACKGROUND: Suicide is a leading cause of death globally. Suicide deaths are elevated in those experiencing severe mental health problems, including schizophrenia. Psychological talking therapies are a potentially effective means of alleviating suicidal thoughts, plans, and attempts. However, talking therapies need to i) focus on suicidal experiences directly and explicitly, and ii) be based on testable psychological mechanisms. The Cognitive AppRoaches to coMbatting Suicidality (CARMS) project is a Randomised Controlled Trial (RCT) which aims to investigate both the efficacy and the underlying mechanisms of a psychological talking therapy for people who have been recently suicidal and have non-affective psychosis. METHODS: The CARMS trial is a two-armed single-blind RCT comparing a psychological talking therapy (Cognitive Behavioural Suicide Prevention for psychosis [CBSPp]) plus Treatment As Usual (TAU) with TAU alone. There are primary and secondary suicidality outcome variables, plus mechanistic, clinical, and health economic outcomes measured over time. The primary outcome is a measure of suicidal ideation at 6 months after baseline. The target sample size is 250, with approximately 125 randomised to each arm of the trial, and an assumption of up to 25% attrition. Hence, the overall recruitment target is up to 333. An intention to treat analysis will be used with primary stratification based on National Health Service (NHS) recruitment site and antidepressant prescription medication. Recruitment will be from NHS mental health services in the North West of England, UK. Participants must be 18 or over; be under the care of mental health services; have mental health problems which meet ICD-10 non-affective psychosis criteria; and have experienced self-reported suicidal thoughts, plans, and/or attempts in the 3 months prior to recruitment. Nested qualitative work will investigate the pathways to suicidality, experiences of the therapy, and identify potential implementation challenges beyond a trial setting as perceived by numerous stake-holders. DISCUSSION: This trial has important implications for countering suicidal experiences for people with psychosis. It will provide definitive evidence about the efficacy of the CBSPp therapy; the psychological mechanisms which lead to suicidal experiences; and provide an understanding of what is required to implement the intervention into services should it be efficacious. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03114917), 14th April 2017. ISRCTN (reference ISRCTN17776666 https://doi.org/10.1186/ISRCTN17776666); 5th June 2017). Registration was recorded prior to participant recruitment commencing.

Qualitative analysis of ward staff experiences during research of a novel suicide-prevention psychological therapy for psychiatric inpatients: Understanding the barriers and facilitators.

BACKGROUND: Suicide prevention is a global priority. Psychiatric hospitalization presents an opportunity to intervene positively with, for example, psychological therapies. However, evidenced-based suicide-prevention psychological treatments are rarely available on in-patient wards. Understanding staff engagement with research investigating suicide-prevention psychological treatments is crucial for their effective, efficacious, and pragmatic implementation. A pilot randomised control trial and feasibility study of Cognitive Behavioural Suicide Prevention therapy provided the opportunity for a qualitative investigation of staff experiences and views of a psychological intervention for people with suicidal experiences on psychiatric in-patient wards. AIMS: To investigate staff acceptability of Cognitive Behavioural Suicide Prevention therapy for psychiatric inpatients based on their perceptions of their experiences during the conduct of a clinical trial. METHOD: Transcribed audio-recordings of qualitative interviews and a focus group (n = 19) of purposively sampled staff from eight psychiatric wards were analysed using inductive Thematic Analysis. RESULTS: Facilitators and barriers were identified for: i) the conduct of the research, and, ii) the suicide-prevention intervention (Cognitive Behavioural Suicide Prevention therapy). Research-related barriers comprised communication difficulties between staff and researchers, and increased staff workload. Research-related facilitators included effective staff/researcher relationships, and alignment of the intervention with organisational goals. Suicide-prevention intervention-related barriers comprised staffs' negative beliefs about suicide which impacted on their referral of inpatients to the clinical trial, and staff perceptions of insufficient information and unfulfilled expectations for involvement in the therapy. Facilitators included staff beliefs that the therapy was beneficial for inpatients, the service and their own clinical practice. CONCLUSIONS: Staff beliefs that 'suicide-talk' could precipitate suicidal behaviour resulted in covert gatekeeping and restricted referral of only inpatients judged as stable or likely to engage in therapy, which may not be those who could most benefit. Such threats to sample representativeness have implications for future therapy research design. The findings provide novel information for researchers and practitioners regarding the conduct of psychological treatment and research in psychiatric units.

Feasibility and acceptability of suicide prevention therapy on acute psychiatric wards: randomised controlled trial.

BACKGROUND: Suicidal behaviour is common in acute psychiatric wards resulting in distress, and burden for patients, carers and society. Although psychological therapies for suicidal behaviour are effective in out-patient settings, there is little research on their effectiveness for in-patients who are suicidal.AimsOur primary objective was to determine whether cognitive-behavioural suicide prevention therapy (CBSP) was feasible and acceptable, compared with treatment as usual (TAU) for in-patients who are suicidal. Secondary aims were to assess the impact of CBSP on suicidal thinking, behaviours, functioning, quality of life, service use, cost-effectiveness and psychological factors associated with suicide. METHOD: A single-blind pilot randomised controlled trial comparing TAU to TAU plus CBSP in in-patients in acute psychiatric wards who are suicidal (the Inpatient Suicide Intervention and Therapy Evaluation (INSITE) trial, trial registration: ISRCTN17890126). The intervention consisted of TAU plus up to 20 CBSP sessions, over 6 months continuing in the community following discharge. Participants were assessed at baseline and at 6 weeks and 6 months post-baseline. RESULTS: A total of 51 individuals were randomised (27 to TAU, 24 to TAU plus CBSP) of whom 37 were followed up at 6 months (19 in TAU, 18 in TAU plus CBSP). Engagement, attendance, safety and user feedback indicated that the addition of CBSP to TAU for in-patients who are acutely suicidal was feasible and acceptable while on in-patient wards and following discharge. Economic analysis suggests the intervention could be cost-effective.DiscussionPsychological therapy can be delivered safely to patients who are suicidal although modifications are required for this setting. Findings indicate a larger, definitive trial should be conducted.Declaration of interestThe trial was hosted by Greater Manchester Mental health NHS Trust (formerly, Manchester Mental Health and Social Care NHS Trust). The authors are affiliated to the University of Manchester, Greater Manchester Mental Health Foundation Trust, Lancashire Care NHS Foundation trust and the Manchester Academic Health Sciences Centre. Y.A. is a trustee for a North-West England branch of the charity Mind.

A qualitative analysis of suicidal psychiatric inpatients views and expectations of psychological therapy to counter suicidal thoughts, acts and deaths.

BACKGROUND: Suicide is a global problem and suicidal behavior is common in acute psychiatric wards. Inpatient suicides regularly occur with 10.4/100,000 such deaths recorded in the UK in 2016. Inpatient suicides are potentially the most avoidable of all suicides as inpatients have 24-h staff contact. Current inpatient treatment prioritizes maintenance of physical safety by observation, medication and general supportive measures, however efficacious and effective specific treatments are lacking. Psychological treatments have a growing evidence base for suicide prevention yet provision of inpatient therapy is uncommon. The present qualitative study aimed to understand the patient acceptability issues by investigating suicidal inpatients views and expectations of a novel suicide-focussed cognitive behavioural psychological therapy which was nested alongside a pilot clinical trial of the intervention. METHODS: Thematic analysis of semi-structured individual qualitative interviews with twenty suicidal psychiatric inpatients to investigate their views and expectations about ward-based suicide-focused psychological treatment. RESULTS: Two main themes were identified. The first, 'A therapy that works', revealed inpatients' views of the necessary components for effective ward-based suicide-focused psychological therapy. The second, 'Concerns about in-patient suicide-focused therapy', depicted their fears about engaging in this treatment. Results suggested that suicide-focused psychological therapy was cautiously welcomed by inpatients' whose narratives expressed their needs, priorities and concerns. Further data analysis enabled formation of a user-informed model of suicide-focussed psychological therapy which offers guidance for researchers and clinicians. CONCLUSIONS: We conclude that hospitalization of suicidal individuals offers a critical opportunity to intervene with effective treatment to preserve life and that suicide-focussed psychological therapy is likely to be well received by suicidal inpatients warranting further testing with a sufficiently powered definitive trial. It is important that provision of ward-based psychological therapy for suicidal inpatients addresses the considerable context-specific challenges inherent in this setting. TRIAL REGISTRATION NUMBER: ISRCTN 17890126 , Registry: UK Clinical Trials Gateway, Date of registration: 22/04/15, Date of enrolment of first participant to the trial: 20/05/14 (retrospectively registered).

A qualitative study: experiences of stigma by people with mental health problems.

OBJECTIVES: Prior research has examined various components involved in the impact of public and internalized stigma on people with mental health problems. However, studies have not previously investigated the subjective experiences of mental health stigma by those affected in a non-statutory treatment-seeking population. DESIGN: An in-depth qualitative study was conducted using thematic analysis to investigate the experiences of stigma in people with mental health problems. METHODS: Eligible participants were recruited through a local mental health charity in the North West of England. The topic of stigma was examined using two focus groups of thirteen people with experience of mental health problems and stigma. RESULTS: Two main themes and five subthemes were identified. Participants believed that (1) the 'hierarchy of labels' has a profound cyclical impact on several levels of society: people who experience mental health problems, their friends and family, and institutional stigma. Furthermore, participants suggested (2) ways in which they have developed psychological resilience towards mental health stigma. CONCLUSIONS: It is essential to utilize the views and experiences gained in this study to aid understanding and, therefore, develop ways to reduce the negative impact of public and internal stigma. PRACTITIONER POINTS: People referred to their mental health diagnosis as a label and associated that label with stigmatizing views. Promote awareness and develop improved strategies (e.g., training) to tackle the cyclical impact of the 'hierarchy of labels' on people with mental health problems, their friends and family, and institutional stigma. Ensure the implementation of clinical guidelines in providing peer support to help people to combat feeling stigmatized. Talking about mental health in psychological therapy or health care professional training helped people to take control and develop psychological resilience.

Improving the quality of prison research: A qualitative study of ex-offender service user involvement in prison suicide prevention research.

BACKGROUND: Suicide is the leading cause of avoidable death in prisons worldwide and suicide prevention is an international priority. Consequently, there is an urgent need to develop evidence-based treatments. We conducted a randomized controlled trial of a novel suicide prevention psychological therapy for male prisoners. To promote ecological validity by addressing the "real-world" situation of suicidal prisoners, we involved a consultant group of ex-offenders with past experience of being suicidal during imprisonment. Service user involvement in prison research is challenging and underdeveloped. OBJECTIVE: We aimed to investigate the ex-offender service user consultants' experiences of being involved in the research. DESIGN: Individual qualitative interviews were conducted and analysed using an Interpretative Phenomenology Analysis (IPA) framework. SETTING/PARTICIPANTS: The study was conducted at a university in North England, UK, comprising four ex-offenders with experience of being suicidal during past imprisonments. RESULTS: Two superordinate themes were identified: "Working Together" depicted participants' perceptions of the pivotal role of good relationships with researchers, and "Journey of Change" outlined how participants' involvement in the research impacted on their personal lives. DISCUSSION: Little is known about how to successfully involve ex-offender service users in research. Our results indicate the conditions necessary for successfully engaging ex-offender service users in research and have important implications for improving the quality of prison research. CONCLUSIONS: Involving forensic service users in research is feasible and should be encouraged, as despite certain challenges, it is highly rewarding both for the research and the ex-offender service users.

Staff experiences and perceptions of working with in-patients who are suicidal: qualitative analysis.

BackgroundSuicidal behaviour is frequent in psychiatric in-patients and much staff time and resources are devoted to assessing and managing suicide risk. However, little is known about staff experiences of working with in-patients who are suicidal.AimsTo investigate staff experiences of working with in-patients who are suicidal.MethodQualitative study guided by thematic analysis of semi-structured interviews with mental health staff with experience of psychiatric in-patient care.ResultsTwenty staff participated. All had encountered in-patient suicide deaths or attempts. Three key themes were identified: (a) experiences of suicidality, (b) conceptualising suicidality and (c) talking about suicide.ConclusionsSuicidal behaviour in psychiatric wards has a large impact on staff feelings, practice and behaviour. Staff felt inadequately equipped to deal with such behaviours, with detrimental consequences for patients and themselves. Organisational support is lacking. Training and support should extend beyond risk assessment to improving staff skills in developing therapeutic interactions with in-patients who are suicidal.

Premature Death Among Primary Care Patients With a History of Self-Harm.

PURPOSE: Self-harm is a public health problem that requires a better understanding of mortality risk. We undertook a study to examine premature mortality in a nationally representative cohort of primary care patients who had harmed themselves. METHODS: During 2001-2013, a total of 385 general practices in England contributed data to the Clinical Practice Research Datalink with linkage to Office for National Statistics mortality records. We identified 30,017 persons aged 15 to 64 years with a recorded episode of self-harm. We estimated the relative risks of all-cause and cause-specific natural and unnatural mortality using a comparison cohort of 600,258 individuals matched on age, sex, and general practice. RESULTS: We found an elevated risk of dying prematurely from any cause among the self-harm cohort, especially in the first year of follow-up (adjusted hazard ratio for that year, 3.6; 95% CI, 3.1-4.2). In particular, suicide risk was especially high during the first year (adjusted hazard ratio, 54.4; 95% CI, 34.3-86.3); although it declined sharply, it remained much higher than that in the comparison cohort. Large elevations of risk throughout the follow-up period were also observed for accidental, alcohol-related, and drug poisoning deaths. At 10 years of follow-up, cumulative incidence values were 6.5% (95% CI, 6.0%-7.1%) for all-cause mortality and 1.3% (95% CI, 1.2%-1.5%) for suicide. CONCLUSIONS: Primary care patients who have harmed themselves are at greatly increased risk of dying prematurely by natural and unnatural causes, and especially within a year of a first episode. These individuals visit clinicians at a relatively high frequency, which presents a clear opportunity for preventive action. Primary care patients with myriad comorbidities, including self-harming behavior, mental disorder, addictions, and physical illnesses, will require concerted, multipronged, multidisciplinary collaborative care approaches.

Personal Accounts of Discontinuing Neuroleptic Medication for Psychosis.

We conducted this study to explore personal accounts of making choices about taking medication prescribed for the treatment of psychosis (neuroleptics). There are costs and benefits associated with continuing and discontinuing neuroleptics. Service users frequently discontinue neuroleptics; therefore, we specifically considered these decisions. We used a grounded theory approach to analyze transcripts from interviews with 12 participants. We present a preliminary grounded theory of the processes involved in making choices about neuroleptic medication. We identified three tasks as important in mediating participants' choices: (a) forming a personal theory of the need for, and acceptability of taking, neuroleptic medication; (b) negotiating the challenges of forming alliances with others; and (c) weaving a safety net to safeguard well-being. Progress in the tasks reflected a developmental trajectory of becoming an expert over time and was influenced by systemic factors. Our findings highlight the importance of developing resources for staff to facilitate service user choice.

Understanding Outcomes in a Randomized Controlled Trial of a Ward-based Intervention on Psychiatric Inpatient Wards: A Qualitative Analysis of Staff and Patient Experiences.

OBJECTIVE: Team formulation is advocated to improve quality of care in mental health care and evidence from a recent U.K.-based trial supports its use in inpatient settings. This study aimed to identify the effects of formulation on practice from the perspectives of staff and patient participating in the trial, including barriers and enhancers to implementing the intervention. METHOD: We carried out semistructured interviews with 57 staff and 20 patients. Data were analyzed using thematic analysis. RESULTS: Main outcomes were: improved staff understanding of patients, better team collaboration and increased staff awareness of their own feelings. Key contextual factors were as follows: overcoming both staff and patient anxiety, unwelcome expert versus collaborative stance, competing demands, and management support. CONCLUSION: Team formulation should be implemented to improve quality of care in inpatient settings and larger definitive trials should be carried out to assess the effect of this intervention on patient outcomes.

A systematic review of service-user reasons for adherence and nonadherence to neuroleptic medication in psychosis.

People diagnosed with psychosis, such as those with schizophrenia-related disorders, are routinely prescribed neuroleptic medication as a primary treatment. Despite reported benefits of neuroleptic treatment for symptom remission and relapse prevention, discontinuation rates are high. Research examining factors associated with neuroleptic non-adherence report inconsistent findings. Reasons for adherence to neuroleptic medication are under-researched. The current review aimed to synthesise evidence exploring service-user self-reported reasons for adherence and non-adherence to neuroleptic medication. A systematic literature search of databases and reference list searching identified 21 studies investigating service-user accounts of reasons for adherence and/or non-adherence to neuroleptic medication. Qualitative, quantitative and mixed-method studies were included in the review. Several themes of reasons were identified. Reasons for both adherence and non-adherence were largely similar; medication efficacy, compatibility with personal medication or religious beliefs, side-effects and the influence of relationships with other people. Experiences of stigma and economic difficulties were generally identified as reasons for non-adherence only while experiences of fear and coercion were identified as reasons for adherence only. The review identified crucial factors which may aid service providers in bettering treatment for people with psychosis and will provide evidence which could contribute to future prescribing guidelines.

Cognitive Behavioural Suicide Prevention for Male Prisoners: Case examples.

Suicide is a serious public health problem but a problem that is preventable. This complex and challenging problem is particularly prevalent amongst prisoners; associated with a five-fold increase in risk compared to the general community. Being in prison can lead people to experience fear, distrust, lack of control, isolation, and shame, which is often experienced as overwhelming and intolerable with some choosing suicide as a way to escape. Few effective psychological interventions exist to prevent suicide although cognitive behaviour therapies appear to offer some promise. Offering cognitive behaviour suicide prevention (CBSP) therapy to high risk prisoners may help to reduce the likelihood of preventable self-inflicted deaths. In this paper we present three cases drawn from a randomised controlled trial designed to investigate the feasibility of CBSP for male prisoners. Implications of the current findings for future research and clinical practice are considered.

The epidemiology of self-harm in a UK-wide primary care patient cohort, 2001-2013.

BACKGROUND: Most of the research conducted on people who harm themselves has been undertaken in secondary healthcare settings. Little is known about the frequency of self-harm in primary care patient populations. This is the first study to describe the epidemiology of self-harm presentations to primary care using broadly representative national data from across the United Kingdom (UK). METHODS: Using the Clinical Practice Research Datalink (CPRD), we calculated directly standardised rates of incidence and annual presentation during 2001-2013. Rates were compared by gender and age and across the nations of the UK, and also by degree of socioeconomic deprivation measured ecologically at general practice level. RESULTS: We found significantly elevated rates in females vs. males for incidence (rate ratio - RR, 1.45, 95 % confidence interval - CI, 1.42-1.47) and for annual presentation (RR 1.56, CI 1.54-1.58). An increasing trend over time in incidence was apparent for males (P < 0.001) but not females (P = 0.08), and both genders exhibited rising temporal trends in presentation rates (P < 0.001). We observed a decreasing gradient of risk with increasing age and markedly elevated risk for females in the youngest age group (aged 15-24 years vs. all other females: RR 3.75, CI 3.67-3.83). Increasing presentation rates over time were observed for males across all age bands (P < 0.001). We found higher rates when comparing Northern Ireland, Scotland, and Wales with England, and increasing rates of presentation over time for all four nations. We also observed higher rates with increasing levels of deprivation - most vs. least deprived male patients: RR 2.17, CI 2.10-2.25. CONCLUSIONS: Incorporating data from primary care yields a more comprehensive quantification of the health burden of self-harm. These novel findings may be useful in informing public health programmes and the targeting of high-risk groups toward the ultimate goal of lowering risk of self-harm repetition and premature death in this population.

Clinical management following self-harm in a UK-wide primary care cohort.

BACKGROUND: Little is known about the clinical management of patients in primary care following self-harm. METHODS: A descriptive cohort study using data from 684 UK general practices that contributed to the Clinical Practice Research Datalink (CPRD) during 2001-2013. We identified 49,970 patients with a self-harm episode, 41,500 of whom had one complete year of follow-up. RESULTS: Among those with complete follow-up, 26,065 (62.8%, 62.3-63.3) were prescribed psychotropic medication and 6318 (15.2%, 14.9-15.6) were referred to mental health services; 4105 (9.9%, CI 9.6-10.2) were medicated without an antecedent psychiatric diagnosis or referral, and 4,506 (10.9%, CI 10.6-11.2) had a diagnosis but were not subsequently medicated or referred. Patients registered at practices in the most deprived localities were 27.1% (CI 21.5-32.2) less likely to be referred than those in the least deprived. Despite a specifically flagged NICE 'Do not do' recommendation in 2011 against prescribing tricyclic antidepressants following self-harm because of their potentially lethal toxicity in overdose, 8.8% (CI 7.8-9.8) of individuals were issued a prescription in the subsequent year. The percentage prescribed Citalopram, an SSRI antidepressant with higher toxicity in overdose, fell sharply during 2012/2013 in the aftermath of a Medicines and Healthcare products Regulatory Agency (MHRA) safety alert issued in 2011. CONCLUSIONS: A relatively small percentage of these vulnerable patients are referred to mental health services, and reduced likelihood of referral in more deprived localities reflects a marked health inequality. National clinical guidelines have not yet been effective in reducing rates of tricyclic antidepressant prescribing for this high-risk group.