IMPlementation of An online Relatives' Toolkit for psychosis or bipolar (IMPART study): iterative multiple case study to identify key factors impacting on staff uptake and use.

BACKGROUND: Despite the potential of digital health interventions to improve the delivery of psychoeducation to people with mental health problems and their relatives, and substantial investment in their development, there is little evidence of successful implementation into clinical practice. We report the first implementation study of a digital health intervention: Relatives Education And Coping Toolkit (REACT), into routine mental healthcare. Our main aim was to identify critical factors affecting staff uptake and use of this online self-management tool for relatives of people with psychosis or bipolar. METHODS: A mixed-methods, theory-driven (Normalisation Process Theory), iterative multiple case study approach using qualitative analysis of interviews with staff and quantitative reporting of uptake. Carer researchers were part of the research team. RESULTS: In all, 281 staff and 159 relatives from Early Intervention teams across six catchment areas (cases) in England registered on REACT; 129 staff took part in qualitative interviews. Staff were positive about REACT helping services improve support and meet clinical targets. Implementation was hindered by: high staff caseloads and difficulties prioritising carers; perception of REACT implementation as research; technical difficulties using REACT; poor interoperability with trust computer systems and care pathways; lack of access to mobile technology and training; restricted forum populations; staff fears of risk, online trolling, and replacement by technology; and uncertainty around REACT's long-term availability. CONCLUSIONS: Digital health interventions, such as REACT, should be iteratively developed, evaluated, adapted and implemented, in partnership with the services they aim to support, and as part of a long term national strategy to co-develop integrated technology-enabled mental healthcare. Implementation strategies must instil a sense of ownership for staff and ensure they have adequate IT training, appropriate governance protocols for online working, and adequate mobile technologies. Wider contextual factors including adequate funding for mental health services and prioritisation of carer support, also need to be addressed for successful implementation of carer focussed digital interventions. TRIAL REGISTRATION: Study registration: ISCTRN 16267685.

A randomized controlled trial of cognitive-behavior therapy for persistent symptoms in schizophrenia: a five-year follow-up.

Meta-analyses of randomized controlled trials support the efficacy of cognitive behavioral therapy (CBT) in the treatment of symptoms of schizophrenia refractory to antipsychotic medication. This article addresses the issue of medium term durability. A five-year follow-up was undertaken of a sample of 90 subjects who participated in a randomized controlled trial of CBT and befriending (BF). Patients received routine care throughout the trial and the follow-up period. Intention to treat multivariate analysis was performed by an independent statistician following multiple imputation of missing data. Fifty-nine out of ninety patients were followed up at 5 years (CBT=31, BF=28). In comparison to BF and usual treatment, CBT showed evidence of a significantly greater and more durable effect on overall symptom severity (NNT=10.36, CI -10.21, 10.51) and level of negative symptoms (NNT=5.22, CI -5.06 -5.37). No difference was found between CBT and BF on either overall symptoms of schizophrenia or depression. The initial cost of an adjunctive course of CBT for individuals with medication refractory schizophrenia may be justified in light of symptomatic benefits that persist over the medium term.

Cognitive-behavioural therapy in first-episode and early schizophrenia. 18-month follow-up of a randomised controlled trial.

BACKGROUND: The initial phase of a trial of cognitive-behavioural therapy (CBT) for acutely ill patients with schizophrenia of recent onset showed that it speeded recovery. AIMS: To test the hypothesis that CBT in addition to treatment as usual (TAU) during the first or second acute episode of schizophrenia will confer clinical benefit over a follow-up period. METHOD: This was an 18-month follow-up of a multicentre prospective trial of CBT or supportive counselling administered as an adjunct to TAU, compared with TAU alone, for patients hospitalised for an acute episode of schizophrenia of recent onset. Primary outcomes were total and positive symptom scales, time to relapse and re-hospitalisation. RESULTS: There were significant advantages for CBT and supportive counselling over TAU alone on symptom measures at 18 months but no group difference was seen for relapse or re-hospitalisation. There was a significant centre-treatment interaction, reflecting centre differences in the effect of introducing either treatment, but not in the comparison of CBT and supportive counselling. Medication dosage and compliance did not explain group differences. CONCLUSIONS: Adjunctive psychological treatments can have a beneficial long-term effect on symptom reduction.

Domestic violence and anger: what can primary care nurses do?

Patients with anger problems can cause difficulties for themselves, their families and society. Though psychological treatments are available, they are not always accessible. In order to help the victims of domestic violence, we focus here on working with perpetrators of violence. This article offers some statistics about the extent of the problem. It discusses difficulties in motivating patients for therapy and describes the cognitive model of anger. A number of intervention strategies based on this model are then discussed. The purpose is to assist clinicians with less experience of this patient group to help their patients minimize the frequency and severity of the anger incidents. Pointers for good practice are outlined.

Religious delusions in patients admitted to hospital with schizophrenia.

BACKGROUND: Religious delusions are clinically important because they may be associated with selfharm and poorer outcomes from treatment. They have not been extensively researched. This study sought to investigate the prevalence of religious delusions in a sample of patients admitted to hospital with schizophrenia, to describe these delusions and to compare the characteristics of the patients with religious delusions with schizophrenia patients with all other types of delusion. METHOD: A cross-sectional investigation was carried out. The prevalence of religious delusions was assessed and comparisons were made between religiously deluded patients and a control group on demographic, symptom, functioning and religious variables. One hundred and ninety-three subjects were examined of whom 24% had religious delusions. RESULTS: Patients with religious delusions had higher symptom scores (as measured by the PANSS), they were functioning less well (as measured by the GAF) and they were prescribed more medication than those patients with schizophrenia who had other types of delusion. CONCLUSION: It is concluded that religious delusions are commonly found in schizophrenia and that by comparison with other patients who have schizophrenia, those patients with religious delusions appear to be more severely ill. This warrants further investigation.