Influence of intrinsic and extrinsic religiosity on youth cannabis use: A structural equation modelling analysis on national survey on drug use and health (NSDUH) 2015-2019.

Religiosity may reduce the risk of substance use in adults and young people. However, religiosity is a complex construct, variously defined and assessed. We explored the role of different religious components: intrinsic (subjective), extrinsic-personal (service attendance) and extrinsic-social (church-based social activities) in deterring cannabis use among adolescents. Combining several years (2015-2019) of NSDUH data on 68,263 adolescents between 12 and 17 years, a structural equation modelling (SEM) approach was used to evaluate pathways from intrinsic and extrinsic components of religiosity to cannabis use. We analyzed the role of several covariates, including comorbid depression and secular volunteering activities. About 15% of participants said they had used cannabis at some level in the previous year. Some degree of intrinsic and of extrinsic-personal religiosity was reported by 66% and 25% of the sample. 57% were committed to at least one faith-based activity, while 74% reported participation in non-faith-based community activities. The SEM regression model -controlling for putative confounders- showed that both intrinsic and extrinsic-personal religious components reduced the likelihood of cannabis use (Cannabis use coeff.: -0.065, p = 0.001; coeff.: -0.176, p < 0.001, respectively). However, the extrinsic-social component had no effect on refraining from cannabis use, despite involvement in non-faith based volunteering activities was protectively associated. Support for secular volunteering programs may be a cost-effective mechanism for reducing cannabis use. Moreover, whilst promoting religiosity is beyond the scope of any preventive programs, religious practices should be considered relevant protective factors, deserving consideration and support in terms of public health.

Sexual abuse and psychotic phenomena: a directed acyclic graph analysis of affective symptoms using English national psychiatric survey data.

BACKGROUND: Sexual abuse and bullying are associated with poor mental health in adulthood. We previously established a clear relationship between bullying and symptoms of psychosis. Similarly, we would expect sexual abuse to be linked to the emergence of psychotic symptoms, through effects on negative affect. METHOD: We analysed English data from the Adult Psychiatric Morbidity Surveys, carried out in 2007 (N = 5954) and 2014 (N = 5946), based on representative national samples living in private households. We used probabilistic graphical models represented by directed acyclic graphs (DAGs). We obtained measures of persecutory ideation and auditory hallucinosis from the Psychosis Screening Questionnaire, and identified affective symptoms using the Clinical Interview Schedule. We included cannabis consumption and sex as they may determine the relationship between symptoms. We constrained incoming edges to sexual abuse and bullying to respect temporality. RESULTS: In the DAG analyses, contrary to our expectations, paranoia appeared early in the cascade of relationships, close to the abuse variables, and generally lying upstream of affective symptoms. Paranoia was consistently directly antecedent to hallucinations, but also indirectly so, via non-psychotic symptoms. Hallucinosis was also the endpoint of pathways involving non-psychotic symptoms. CONCLUSIONS: Via worry, sexual abuse and bullying appear to drive a range of affective symptoms, and in some people, these may encourage the emergence of hallucinations. The link between adverse experiences and paranoia is much more direct. These findings have implications for managing distressing outcomes. In particular, worry may be a salient target for intervention in psychosis.

Receiving threatening or obscene messages from a partner and mental health, self-harm and suicidality: results from the Adult Psychiatric Morbidity Survey.

PURPOSE: Threatening or obscene messaging is repeated, unwanted texts, emails, letters or cards experienced by the recipient as threatening or obscene, and causing fear, alarm or distress. It is rarely examined as an aspect of intimate partner violence. We describe the prevalence of exposure to threatening/obscene messaging from a current or ex-partner; characteristics of victims; and associations with other forms of violence and abuse, mental disorder, self-harm, and suicidality. METHODS: Cross-sectional probability-sample survey of the general population in England aged 16 + . Multivariable regression modelling tested associations between receipt of threatening/obscene messaging and current common mental disorder, past-year self-harm and suicidality. RESULTS: Threatening/obscene messages were received from a current/ex-partner by 6.6% (95%CI: 5.9-7.3) of adults who had been in a relationship; 1.7% received these in the past year. Victims were more likely to be female, under 35, single or divorced, socioeconomically disadvantaged, and to have experienced other forms of sexual and partner violence and abuse. Those who received threatening/obscene messages in the past year were more likely to experience common mental disorder (adjusted odds ratio 1.89; 1.01-3.55), self-harm (2.31; 1.00-5.33), and suicidal thoughts (2.00; 1.06-3.78). CONCLUSION: Threatening/obscene messaging commonly occurs in the context of intimate partner violence. While often occurring alongside sexual and physical violence, messaging has an additional association with mental disorder and suicidality. Routine enquiry in service settings concerning safety, including those working with people who have escaped domestic violence, should ask about ongoing contact from previous as well as current partners. This should include asking about messaging, as well as other forms of potentially technology-enabled abuse which may become increasingly common.

Longitudinal symptomatic interactions in long-standing schizophrenia: a novel five-point analysis based on directed acyclic graphs.

BACKGROUND: Recent network models propose that mutual interaction between symptoms has an important bearing on the onset of schizophrenic disorder. In particular, cross-sectional studies suggest that affective symptoms may influence the emergence of psychotic symptoms. However, longitudinal analysis offers a more compelling test for causation: the European Schizophrenia Cohort (EuroSC) provides data suitable for this purpose. We predicted that the persistence of psychotic symptoms would be driven by the continuing presence of affective disturbance. METHODS: EuroSC included 1208 patients randomly sampled from outpatient services in France, Germany and the UK. Initial measures of psychotic and affective symptoms were repeated four times at 6-month intervals, thereby furnishing five time-points. To examine interactions between symptoms both within and between time-slices, we adopted a novel technique for modelling longitudinal data in psychiatry. This was a form of Bayesian network analysis that involved learning dynamic directed acyclic graphs (DAGs). RESULTS: Our DAG analysis suggests that the main drivers of symptoms in this long-term sample were delusions and paranoid thinking. These led to affective disturbance, not vice versa as we initially predicted. The enduring relationship between symptoms was unaffected by whether patients were receiving first- or second-generation antipsychotic medication. CONCLUSIONS: In this cohort of people with chronic schizophrenia treated with medication, symptoms were essentially stable over long periods. However, affective symptoms appeared driven by the persistence of delusions and persecutory thinking, a finding not previously reported. Although our findings as ever remain hostage to unmeasured confounders, these enduring psychotic symptoms might nevertheless be appropriate candidates for directly targeted psychological interventions.

Losing the thread: experiences of cognitive decline in Alzheimer's disease.

In an initiative to reduce stigma, an academic psychiatrist comes out of the dementia closet: describing his own experience of developing Alzheimer's disease, the accompanying memory problems, the restriction of some of his activities, emotional lability and his increasing reliance on others.

Bridging the Digital Divide in Psychological Therapies: Observational Study of Engagement With the SlowMo Mobile App for Paranoia in Psychosis.

BACKGROUND: Marginalized groups are more likely to experience problems with technology-related access, motivation, and skills. This is known as the "digital divide." Technology-related exclusion is a potential barrier to the equitable implementation of digital health. SlowMo therapy was developed with an inclusive, human-centered design to optimize accessibility and bridge the "digital divide." SlowMo is an effective, blended digital psychological therapy for paranoia in psychosis. OBJECTIVE: This study explores the "digital divide" and mobile app engagement in the SlowMo randomized controlled trial. METHODS: Digital literacy was assessed at baseline, and a multidimensional assessment of engagement (ie, adherence [via system analytics and self-report] and self-reported user experience) was conducted at 12 weeks after therapy. Engagement was investigated in relation to demographics (ie, gender, age, ethnicity, and paranoia severity). RESULTS: Digital literacy data demonstrated that technology use and confidence were lower in Black people and older people (n=168). The engagement findings indicated that 80.7% (96/119) of therapy completers met the a priori analytics adherence criteria. However, analytics adherence did not differ by demographics. High rates of user experience were reported overall (overall score: mean 75%, SD 17.1%; n=82). No differences in user experience were found for ethnicity, age, or paranoia severity, although self-reported app use, enjoyment, and usefulness were higher in women than in men. CONCLUSIONS: This study identified technology-related inequalities related to age and ethnicity, which did not influence engagement with SlowMo, suggesting that the therapy design bridged the "digital divide." Intervention design may moderate the influence of individual differences on engagement. We recommend the adoption of inclusive, human-centered design to reduce the impact of the "digital divide" on therapy outcomes. TRIAL REGISTRATION: ISRCTN Registry ISRCTN32448671; https://www.isrctn.com/ISRCTN32448671.

Intimate partner violence, suicidality, and self-harm: a probability sample survey of the general population in England.

BACKGROUND: Intimate partner violence (IPV) is a recognised risk factor for psychiatric disorders. There is little current evidence on IPV and self-harm and suicidality, and we therefore aimed to investigate the associations between experience of lifetime and past-year IPV with suicidal thoughts, suicide attempt, and self-harm in the past year. METHODS: We analysed the 2014 Adult Psychiatric Morbidity Survey, a cross-sectional survey of 7058 adults (aged ≥16 years) in England, which used a multistage random probability sampling design and involved face-to-face interviews. Participants were asked about experience of physical violence and sexual, economic, and emotional abuse from a current or former partner, and about suicidal thoughts, suicide attempts, and self-harm. Other adversities were recorded through an adapted version of the List of Threatening Experiences. Multivariable logistic regression models quantified associations between different indicators of lifetime and past-year IPV, with past-year non-suicidal self-harm, suicidal thoughts, and suicide attempts. All analyses were weighted. FINDINGS: Using weighted percentages, we found that a fifth (21·4%) of 7058 adults reported lifetime experience of IPV, and that 27·2% of women and 15·3% of men had experienced IPV. Among women, 19·6% had ever experienced emotional IPV, 18·7% physical IPV, 8·5% economic IPV, and 3·7% sexual IPV, which was higher than in men (8·6%, 9·3%, 3·6%, and 0·3%, respectively). Findings for ethnicity were unclear. Lifetime prevalence of IPV was higher in those living in rented accommodation or deprived neighbourhoods. Among people who had attempted suicide in the past year, 49·7% had ever experienced IPV and 23·1% had experienced IPV in the past year (including 34·8% of women and 9·4% of men). After adjusting for demographics, socioeconomics, and lifetime experience of adversities, the odds ratio of a past-year suicide attempt were 2·82 (95% CI 1·54-5·17) times higher in those who have ever experienced IPV, compared with those who had not. Fully adjusted odds ratios for past-year self-harm (2·20, 95% CI 1·37-3·53) and suicidal thoughts (1·85, 1·39-2·46) were also raised in those who had ever experienced IPV. INTERPRETATION: IPV is common in England, especially among women, and is strongly associated with self-harm and suicidality. People presenting to services in suicidal distress or after self-harm should be asked about IPV. Interventions designed to reduce the prevalence and duration of IPV might protect and improve the lives of people at risk of self-harm and suicide. FUNDING: UK Prevention Research Partnership.

Influence of positive and negative symptoms on hedonic and eudaemonic well-being in people with schizophrenia: A longitudinal analysis from the EuroSc study.

BACKGROUND: Subjective well-being in people with schizophrenia is likely to be impaired by positive and negative psychotic symptoms. However, these may impact differentially on hedonic (satisfaction and interest in life) and eudaemonic (optimal psychological and social functioning) components. AIMS: We hypothesized that positive symptoms would influence the hedonic component, while negative symptoms would be linked to eudaemonic well-being. METHODS: We tested this using longitudinal data (N = 1208) from the EUROSC study. Measures were repeated after 6, 12, 18 and 24 months. Hedonic and eudaemonic features were identified using the Quality of Life Interview. Positive and negative symptoms were assessed with the Positive and Negative Syndrome Scale. We used latent variable structural equation modelling to investigate the impact of positive and negative symptoms at each of the four data points on well-being components 6 months later, controlling for depressed mood. RESULTS: The measurement model yielded acceptable fit. People with higher scores on positive symptoms at a given time-point were more likely to report lower scores for hedonic components six months later (6-, 12-, and 24-month), whereas we found no significant paths from negative symptoms to hedonic or eudaemonic features. CONCLUSIONS: Although we found a longitudinal influence of positive symptoms on hedonic well-being, negative symptoms had no effect on either hedonic or eudaemonic components. While symptom reduction strategies may be helpful for hedonic well-being, the amelioration of eudaemonic features may require targeted psychosocial programmes to help individuals attain more rewarding lives.

The service user experience of SlowMo therapy: A co-produced thematic analysis of service users' subjective experience.

OBJECTIVES: SlowMo is the first blended digital therapy for paranoia, showing significant small-moderate reductions in paranoia in a recent large-scale randomized controlled trial (RCT). This study explored the subjective service-user experience of the SlowMo therapy content and design; the experience of the blended therapy approach, including the triangle of the therapeutic alliance; and the experience of the digital aspects of the intervention. DESIGN: Qualitative co-produced sub-study of an RCT. METHODS: Participants were 22 adult service users with schizophrenia-spectrum psychosis and persistent distressing paranoia, who completed at least one SlowMo therapy session and a 24-week follow-up, at one of 3 sites in Oxford, London, and Sussex, UK. They were interviewed by peer researchers, using a topic guide co-produced by the Patient and Public Involvement (PPI) team. The transcribed data were analysed thematically. Multiple coding and triangulation, and lay peer researcher validation were used to reach a consensus on the final theme structure. RESULTS: Six core themes were identified: (i) starting the SlowMo journey; (ii) the central role of the supportive therapist; (iii) slowing things down; (iv) value and learning from social connections; (v) approaches and challenges of technology; and (vi) improvements in paranoia and well-being. CONCLUSIONS: For these service users, slowing down for a moment was helpful, and integrated into thinking over time. Learning from social connections reflected reduced isolation, and enhanced learning through videos, vignettes, and peers. The central role of the supportive therapist and the triangle of alliance between service user, therapist, and digital platform were effective in promoting positive therapeutic outcomes.

SlowMo therapy, a new digital blended therapy for fear of harm from others: An account of therapy personalisation within a targeted intervention.

OBJECTIVES: SlowMo therapy is a pioneering blended digital therapy for paranoia, augmenting face-to-face therapy with an interactive 'webapp' and a mobile app. A recent large-scale trial demonstrated small-moderate effects on paranoia alongside improvements in self-esteem, worry, well-being and quality of life. This paper provides a comprehensive account of therapy personalisation within this targeted approach. DESIGN: Case examples illustrate therapy delivery and descriptive data are presented on personalised thought content. METHOD: Thought content was extracted from the webapp (n = 140 participants) and coded using newly devised categories: Worries: (1) Persecutory, (2) Negative social evaluation, (3) Negative self-concept, (4) Loss/life stresses, (5) Sensory-perceptual experiences and (6) Health anxieties. Safer thoughts: (1) Safer alternative (specific alternatives to worries), (2) Second-wave (generalised) coping, (3) Positive self-concept, (4) Positive activities and (5) Third-wave (mindfulness-based) coping. Data on therapy fidelity are also presented. RESULTS: Worries: 'Persecutory' (92.9% of people) and 'Negative social evaluation' (74.3%) were most common. 'General worries/ life stresses' (31.4%) and 'Negative self-concept' (22.1%) were present in a significant minority; 'Health anxieties' (10%) and 'Sensory-perceptual' (10%) were less common. Safer thoughts: 'Second-wave (general) coping' (85%), 'Safer alternatives' (76.4%), 'Positive self-concept' (65.7%) and 'Positive activities' (64.3%) were common with 'Third-wave' (mindfulness) coping observed for 30%. Fidelity: Only three therapy withdrawals were therapy related. Session adherence was excellent (mean = 15.2/16; SD = 0.9). Behavioural work was conducted with 71% of people (119/168). CONCLUSION: SlowMo therapy delivers a targeted yet personalised approach. Potential mechanisms of action extend beyond reasoning. Implications for cognitive models of paranoia and causal interventionist approaches are discussed.

Innovations in community-based mental health care: an overview of meta-analyses.

In the last four decades, mental health services for people with Severe Mental Illness (SMI) have seen asylums replaced by a balanced model of Community Mental Healthcare (CMH). Innovative approaches and strategies in the field of CMH have been extensively researched. However, this research has been hampered by issues limiting their capacity to inform clinicians and policymakers. We conducted an overview of meta-analyses of the effectiveness of innovative CMH models focussing on clinical and psychosocial outcomes in comparisons with standard care in adults with SMI. Based on the 12 eligible studies, we appraised, synthesised and graded the resulting evidence. There was moderate quality evidence that case management, Early Intervention Services (EIS) and caregiver-directed interventions were superior to standard care in reducing hospital admission. In relation to psychosocial outcomes, EIS showed high quality evidence of a small effect on global functioning. There was moderate quality evidence for a similar effect of Intensive Case Management, and for a large effect of family intervention. For quality of life, both EIS and self-management education had a small effect, with moderate quality. The level of research about effective CMH models is therefore substantial. However, several gaps related to innovative CMH not yet covered in meta-analytic synthesis, need to be filled.

The impact of Patient and Public Involvement in the SlowMo study: Reflections on peer innovation.

BACKGROUND: The SlowMo study demonstrated the effects of SlowMo, an eight-session digitally supported reasoning intervention, on paranoia in a large-scale randomized-controlled trial with 362 participants with schizophrenia-spectrum psychosis. AIM: The current evaluation aimed to investigate the impact of Patient and Public Involvement (PPI) in the SlowMo study. METHOD: PPI members were six women and three men from Sussex, Oxford and London with experience of using mental health services for psychosis. They received training and met at least 3-monthly throughout the project. The impact of PPI was captured quantitatively and qualitatively through (i) a PPI log of recommendations and implementation; (ii) written subjective experiences of PPI members; (iii) meeting minutes; and (iv) outputs produced. RESULTS: The PPI log revealed 107 recommendations arising from PPI meetings, of which 87 (81%) were implemented. Implementation was greater for recruitment-, data collection- and organization-related actions than for dissemination and emergent innovations. Qualitative feedback revealed impacts on study recruitment, data collection, PPI participants' confidence, knowledge, career aspirations and society more widely. Outputs produced included a film about psychosis that aired on BBC primetime television, novel webpages and journal articles. Barriers to PPI impact included geography, travel, funding, co-ordination and well-being. DISCUSSION: A future challenge for PPI impact will be the extent to which peer innovation (innovative PPI-led ideas) can be supported within research study delivery. PATIENT AND PUBLIC CONTRIBUTION: Planned Patient and Public Contribution in SlowMo comprised consultation and collaboration in (i) design, (ii) recruitment, (iii) qualitative interviews and analysis of service users' experiences of SlowMo therapy and (iv) dissemination.

A syndemic of psychiatric morbidity, substance misuse, violence, and poor physical health among young Scottish men with reduced life expectancy.

BACKGROUND: Scotland has the shortest life expectancy in Western Europe, driven by high rates of cancer, suicides, alcohol-related causes and drug-related poisonings. These disparities cannot be explained solely by socioeconomic deprivation. Our aim was to investigate whether a syndemic in a socioeconomically deprived area of Glasgow might account for premature mortality among men. METHODS: We analysed data from two cross-sectional population surveys: a national sample of 1916 British men and another of 765 men in Glasgow East. The survey included men aged 18-34, and was undertaken in 2011 to study correlates of violence. Questionnaires covered current physical health, psychiatric symptoms, substance misuse, and crime and violence. Syndemic components were identified using confirmatory factor analysis. Associations and synergistic interactions between these variables and health status were estimated using logistic regression. RESULTS: An aggregation of multiple health conditions and health-related behaviours was found in Glasgow East. A syndemic model of joint effects, adducing a four-component latent variable (violence, substance dependence, psychiatric morbidity and a diathesis of biological/behavioural risk) showed synergy between components and explained persistent disparities in poor physical health/chronic health conditions. Effect modification was found between the general syndemic factor and contextual variables at individual and social environmental level according to location. CONCLUSIONS: Syndemic effects from synergistic interactions were confirmed between psychiatric morbidity, substance misuse, violence, and biological/behavioural risk for physical health. A hypothetical model was developed to explain how the syndemic leads to potentially life-threatening risks to young men, both currently and as precursors of physical health conditions which may shorten their lives in the future.

Self-harm, suicidal ideation, and the positive symptoms of psychosis: Cross-sectional and prospective data from a national household survey.

BACKGROUND: Schizophrenia is associated with premature mortality, partly through increased suicide rates. AIMS: To examine (1) if persecutory ideas, auditory hallucinations, and probable cases of psychosis are associated with suicidal thoughts or attempts cross-sectionally and prospectively, and (2) if such links are mediated by specific affective factors (depression, impulsivity, mood instability). METHOD: We analysed the 2000, 2007, and 2014 British Adult Psychiatric Morbidity Surveys (APMS) separately. Measures of psychosis provided independent variables for multi-stage logistic regressions, with suicidal thoughts and attempts as dependent variables. We also conducted analyses to assess mediation by affective variables, and longitudinal analyses on a subset of the 2000 dataset. RESULTS: In every dataset, persecutory ideas, auditory hallucinations and probable psychosis were associated cross-sectionally with lifetime suicidal attempts and thoughts, even after controlling for confounders, with a single exception (persecutory ideation and suicide attempts were unconnected in APMS 2014). Cross-sectional associations between auditory hallucinations and suicidal phenomena were moderated by persecutory ideation. In the 2000 follow-up, initial persecutory ideas were associated with later suicidal thoughts (O.R. 1.77, p < 0.05); there were no other longitudinal associations. In the 2007 and 2014 datasets, mood instability mediated the effects of psychotic phenomena on suicidality more strongly than impulsivity; depression was also an important mediator. There were appreciable direct effects of positive symptoms on suicidal thoughts and behaviour. CONCLUSIONS: Improving psychotic symptoms and ameliorating co-morbid distress may in itself be effective in reducing suicidal risk in schizophrenia. Given their potential mediating role, mood instability and depression may also be targets for intervention.

Interpersonal violence in a deprived Scottish urban area with aggregations of physical health risks and psychiatric morbidity: an ecological study.

BACKGROUND: Glasgow, Scotland, has previously shown exceptional levels of violence among young men, shows aggregations of health conditions, with shortened life expectancy. Health conditions can be both causes and consequences of violence, of shared community-level socio-economic risk factors, and can result from large-scale social forces beyond the control of populations with high levels of violence. The aim of the study was to provide an in depth understanding of the Public Health problem of violence among young adult men in Glasgow East. METHOD: Ecological investigation of violence and its associations with health conditions in areas of contrasting socioeconomic deprivation. National survey of 1916 British men aged 18-34 years, augmented by a sub-sample of 765 men in Glasgow East (GE). Participants completed questionnaires covering current physical and sexual health, psychiatric symptoms, substance misuse, lifestyle, and crime and violence. RESULTS: The 5-year prevalence of violence was similar in both surveys but fights involving weapons (AOR 3.32, 95% CI 2.29-4.79), gang fights (AOR 2.30, 95% CI 1.77-2.98), and instrumental violence supporting criminal lifestyles were more common in GE, where 1 in 9 men had been in prison. Violent men in both samples reported poorer physical and sexual health and all types of psychiatric morbidity except depression, with multiple high-risk behaviours for both future poor health and violence. Associations between drug and alcohol dependence and violence in GE could not be entirely explained by deprivation. CONCLUSION: Violence in deprived urban areas is one among many high-risk behaviours and lifestyle factors leading to, as well as resulting from, aggregations of both psychiatric and physical health conditions. Poverty partly explained raised levels of violence in GE. Other factors such as drug and alcohol misuse and macho attitudes to violence, highly prevalent among men in this socially excluded community, also contributed. Multi-component preventive interventions may be needed in deprived areas and require future investigations into how multiple co-existing risk factors produce multimorbidity, including psychiatric disorders, substance misuse, poor physical health and violence.

Effects of SlowMo, a Blended Digital Therapy Targeting Reasoning, on Paranoia Among People With Psychosis: A Randomized Clinical Trial.

Importance: Persistent paranoia is common among patients with psychosis. Cognitive-behavioral therapy for psychosis can be effective. However, challenges in engagement and effectiveness remain. Objective: To investigate the effects on paranoia and mechanisms of action of SlowMo, a digitally supported reasoning intervention, plus usual care compared with usual care only. Design, Setting, and Participants: This parallel-arm, assessor-blinded, randomized clinical trial recruited participants at UK community health services from May 1, 2017, to May 14, 2019. Eligible participants consisted of a referral sample with schizophrenia-spectrum psychosis and distressing, persistent (≥3 months) paranoia. Interventions: Individuals were randomized 1:1 to SlowMo, consisting of 8 digitally supported face-to-face sessions and a mobile app, plus usual care (n = 181) and usual care only (n = 181). Main Outcomes and Measures: The primary outcome was paranoia, measured by the Green et al Paranoid Thoughts Scale (GPTS) total score at 24 weeks. Secondary outcomes included GPTS total score at 12 weeks and GPTS Part A (reference) and Part B (persecutory) scores, the Psychotic Symptom Rating Scales (PSYRATS Delusion subscale), reasoning (belief flexibility, possibility of being mistaken [Maudsley Assessment of Delusions, rated 0%-100%]), and jumping to conclusions (Beads Task). Results: A total of 361 participants were included in intention-to-treat analysis, of whom 252 (69.8%) were male and 249 (69.0%) were White; the mean (SD) age was 42.6 (11.6) years. At 24 weeks, 332 participants (92.0%) provided primary outcome data. Of 181 participants in the SlowMo group, 145 (80.1%) completed therapy. SlowMo plus usual care was not associated with greater reductions than usual care in GPTS total score at 24 weeks (Cohen d, 0.20; 95% CI, -0.02 to 0.40; P = .06). There were significant effects on secondary paranoia outcomes at 12 weeks, including GPTS total score (Cohen d, 0.30; 95% CI, 0.09-0.51; P = .005), Part A score (Cohen d, 0.22; 95% CI, 0.06-0.39; P = .009), and Part B score (Cohen d, 0.32; 95% CI, 0.08-0.56; P = .009), and at 24 weeks, including Part B score (Cohen d, 0.25; 95% CI, 0.01-0.49; P = .04) but not Part A score (Cohen d, 0.12; 95% CI, -0.05 to 0.28; P = .18). Improvements were observed in an observer-rated measure of persecutory delusions (PSYRATS delusion) at 12 weeks (Cohen d, 0.47; 95% CI, 0.17-0.78; P = .002) and 24 weeks (Cohen d, 0.50; 95% CI, 0.20-0.80; P = .001) and belief flexibility at 12 weeks (Cohen d, 0.29; 95% CI, 0.09-0.49; P = .004) and 24 weeks (Cohen d, 0.28; 95% CI, 0.08-0.49; P = .005). There were no significant effects on jumping to conclusions. Improved belief flexibility and worry mediated paranoia change (range mediated, 36%-56%). Conclusions and Relevance: SlowMo did not demonstrate significant improvements in the primary measure of paranoia at 24 weeks; however, a beneficial effect of SlowMo on paranoia was indicated by the results on the primary measure at an earlier point and on observer-rated paranoia and self-reported persecution at 12 and 24 weeks. Further work to optimize SlowMo's effects is warranted. Trial Registration: isrctn.org Identifier: ISRCTN 32448671.

The mental health of ex-prisoners: analysis of the 2014 English National Survey of Psychiatric Morbidity.

PURPOSE: Prisoners experience extremely high rates of psychiatric disturbance. However, ex-prisoners have never previously been identified in representative population surveys to establish how far this excess persists after release. Our purpose was to provide the first community-based estimate of ex-prisoners' mental health in England using the data from the 2014 Adult Psychiatric Morbidity Survey (APMS). METHODS: APMS 2014 provides cross-sectional data from a random sample (N = 7546) of England's household population aged 16 or above. Standardised instruments categorised psychiatric disorders and social circumstances. Participants who had been in prison were compared with the rest of the sample. RESULTS: One participant in seventy had been in prison (1.4%; 95% CI 1.1-1.7; n = 103). Ex-prisoners suffered an excess of current psychiatric problems, including common mental disorders (CMDs), psychosis, post-traumatic disorder, substance dependence, and suicide attempts. They were more likely to screen positive for attention-deficit/hyperactivity disorder and autistic traits, to have low verbal IQ, and to lack qualifications. They disclosed higher rates of childhood adversity, including physical and sexual abuse and local authority care. The odds (1.88; 95% CI 1.02-3.47) of CMDs were nearly doubled in ex-prisoners, even after adjusting for trauma and current socioeconomic adversity. CONCLUSIONS: Prison experience is a marker of enduring psychiatric vulnerability, identifying an important target population for intervention and support. Moreover, the psychiatric attributes of ex-prisoners provide the context for recidivism. Without effective liaison between the criminal justice system and mental health services, the vulnerability of ex-prisoners to relapse and to reoffending will continue, with consequent personal and societal costs.