Ethnic differences in receipt of psychological interventions in Early Intervention in Psychosis services in England - a cross-sectional study.

There is some evidence of differences in psychosis care provision by ethnicity. We investigated variations in the receipt of Cognitive Behavioural Therapy for psychosis (CBTp) and family intervention across ethnic groups in Early Intervention in Psychosis (EIP) teams throughout England, where national policy mandates offering these interventions to all. We included data on 29,610 service users from the National Clinical Audit of Psychosis (NCAP), collected between 2018 and 2021. We conducted mixed effects logistic regression analyses to examine odds ratios of receiving an intervention (CBTp, family intervention, either intervention) across 17 ethnic groups while accounting for the effect of years and variance between teams and adjusting for individual- (age, gender, occupational status) and team-level covariates (care-coordinator caseload, inequalities strategies). Compared with White British people, every minoritized ethnic group, except those of mixed Asian-White and mixed Black African-White ethnicities, had significantly lower adjusted odds of receiving CBTp. People of Black African, Black Caribbean, non-African/Caribbean Black, non-British/Irish White, and of "any other" ethnicity also experienced significantly lower adjusted odds of receiving family intervention. Pervasive inequalities in receiving CBTp for first episode psychosis exist for almost all minoritized ethnic groups, and family intervention for many groups. Investigating how these inequalities arise should be a research priority.

Effectiveness of outpatient and community treatments for people with a diagnosis of 'personality disorder': systematic review and meta-analysis.

BACKGROUND: Quality of care and access to effective interventions have been widely criticised as limited for people diagnosed with 'personality disorder' or who have comparable needs (described in some recent papers as "Complex Emotional Needs" (CEN). It is important to identify effective interventions and the optimal context and mode of delivery for people with CEN. We aimed to investigate the effectiveness of psychosocial interventions delivered in community and outpatient settings in treating symptoms associated with 'personality disorder', and the moderating effects of treatment-related variables. METHODS: We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC, ASSIA for articles published in English, from inception to November 23, 2020. We included randomized controlled trials examining interventions provided in community or outpatient settings for CEN. The primary outcome was 'personality disorder' symptoms, while secondary outcomes included anxiety symptoms, depressive symptoms, and global psychiatric symptoms. Random-effects meta-analysis was conducted for each outcome, and meta-regression analysis was performed to assess the moderating effects of treatment characteristics. The quality of the studies and the degree of publication bias was assessed. RESULTS: We included 54 trials (n = 3716 participants) in the meta-analysis. We found a large effect size (g = 0.78, 95% CI: 0.56 to 1.01, p < 0.0001) favoring interventions for 'borderline personality disorder' (BPD) symptoms over Treatment as Usual or Waitlist (TAU/WL), and the efficacy was maintained at follow-up (g = 1.01, 95% CI: 0.37 to 1.65, p = 0.002). Interventions effectively reduced anxiety symptoms (g = 0.58, 95% CI: 0.21 to 0.95, p = 0.002), depressive symptoms (g = 0.57, 95% CI: 0.32 to 0.83, p < 0.0001), and global psychiatric symptoms (g = 0.50, 95% CI: 0.35 to 0.66, p < 0.0001) compared to TAU/WL. The intervention types were equally effective in treating all symptom categories assessed. Treatment duration and treatment intensity did not moderate the effectiveness of the interventions for any outcome. CONCLUSIONS: People with a 'personality disorder' diagnosis benefited from psychological and psychosocial interventions delivered in community or outpatient settings, with all therapeutic approaches showing similar effectiveness. Mental health services should provide people with CEN with specialised treatments in accordance with the availability and the patients' preferences.

Variations in the uptake of telemental health technologies in community and crisis mental health services during the early pandemic: a survey of mental health professionals in the UK.

BACKGROUND: One of the many challenges faced by mental health services during the COVID-19 pandemic was how to deliver care during lockdown. In community and crisis services, this often meant rapidly adopting or expanding the use of telemental health technologies, including phone and video calls. The aim of this study is to explore variations in use and report staff views of such technologies during the early stages of the pandemic. The primary analysis compared rates of use between professions, demographic groups, genders, regions, and crisis and community services. METHODS: We used data from an online survey conducted by the Mental Health Policy Research Unit in Spring 2020 regarding the impact of the pandemic on mental healthcare in the United Kingdom. We included quantitative data from all professional groups working in community or crisis services providing care to working age adults, including general and specialist services. Our outcome of interest was the percentage of clients whom clinicians primarily interacted with via videocall. We also collected demographics and professional characteristics such as the type of mental health service respondents worked in. In addition, we explored respondents' views and experiences of telemental health as a medium for providing care. RESULTS: 978 participants were included in the primary analysis (834 provided outcome data for community services, 193 for crisis services). In community services, virtually all staff reported stopping some or all face-to-face appointments following the onset of the pandemic, with a large majority using video or phone call appointments where possible instead. Telemental health use was higher in community than in crisis services, and amongst professionals who mainly provided psychotherapy or peer support than in other groups. There was also evidence of use being lower in regions in Northern England, Scotland, and Wales than elsewhere. There was no evidence of an association with staff gender, age, or ethnicity. Staff were generally positive about telemental health and intended to make more use of technologies following the pandemic. However, significant barriers to its use were also reported, often involving skills and available infrastructure. CONCLUSIONS: Despite its rapid implementation, telemental health was viewed positively by clinicians who saw it as an effective alternative to face-to-face appointments in some contexts, including during the pandemic. However, adoption of the technology also has the potential to exacerbate existing or create new inequalities without effective management of training and infrastructure needs.

Current state of the evidence on community treatments for people with complex emotional needs: a scoping review.

BACKGROUND: Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN. METHODS: We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020. RESULTS: We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services. CONCLUSIONS: Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.

Peer support in early intervention in psychosis: a qualitative research study.

BACKGROUND: There is evidence that peer support can be helpful for people suffering from psychosis, but there is a lack of research describing peer support in the context of Early Intervention in Psychosis (EIP). AIMS: We aim to investigate the key elements of peer support in EIP and how peer support workers might best be recruited and supported in their work. METHOD: We used purposive sampling to recruit seven participants for semi-structured interviews. Thematic analysis was used to analyse the data. RESULTS: Destigmatisation of psychotic experiences is a central concept that runs through all themes. Participants perceived peer support as a meaningful source of support that could provide benefits to peers (service users) and peer support workers. Themes included a "symbol of hope," "practical support," "mutuality and reciprocity," "bridge between service and peers," "ideal requirements of peer support workers," "delivering peer support," and "team-working and role clarification." CONCLUSIONS: Peer support makes a strong contribution to destigmatising psychosis. Findings potentially contribute to developing peer support workers' roles in EIP. Future research is recommended to investigate the perspectives of ethnic minorities on this topic and practical applications of these findings.

Service user experiences and views regarding telemental health during the COVID-19 pandemic: A co-produced framework analysis.

BACKGROUND: The prominence of telemental health, including providing care by video call and telephone, has greatly increased during the COVID-19 pandemic. However, there are clear variations in uptake and acceptability, and concerns that digital exclusion may exacerbate previous inequalities in access to good quality care. Greater understanding is needed of how service users experience telemental health, and what determines whether they engage and find it acceptable. METHODS: We conducted a collaborative framework analysis of data from semi-structured interviews with a sample of people already experiencing mental health problems prior to the pandemic. Data relevant to participants' experiences and views regarding telemental health during the pandemic were identified and extracted. Data collection and analysis used a participatory, coproduction approach where researchers with relevant lived experience, contributed to all stages of data collection, analysis and interpretation of findings alongside clinical and academic researchers. FINDINGS: The experiences and preferences regarding telemental health care of the forty-four participants were dynamic and varied across time and settings, as well as between individuals. Participants' preferences were shaped by reasons for contacting services, their relationship with care providers, and both parties' access to technology and their individual preferences. While face-to-face care tended to be the preferred option, participants identified benefits of remote care including making care more accessible for some populations and improved efficiency for functional appointments such as prescription reviews. Participants highlighted important challenges related to safety and privacy in online settings, and gave examples of good remote care strategies they had experienced, including services scheduling regular phone calls and developing guidelines about how to access remote care tools. DISCUSSION: Participants in our study have highlighted advantages of telemental health care, as well as significant limitations that risk hindering mental health support and exacerbate inequalities in access to services. Some of these limitations are seen as potentially removable, for example through staff training or better digital access for staff or service users. Others indicate a need to maintain traditional face-to-face contact at least for some appointments. There is a clear need for care to be flexible and individualised to service user circumstances and preferences. Further research is needed on ways of minimising digital exclusion and of supporting staff in making effective and collaborative use of relevant technologies.

Correction to: The accuracy and accessibility of cited evidence: a study examining mental health policy documents.

In the original publication of the article there was an error in the results section of the abstract. The first sentence should have read.

The accuracy and accessibility of cited evidence: a study examining mental health policy documents.

PURPOSE: Evidence-based policy making is increasingly being advocated by governments and scholars. To show that policies are informed by evidence, policy-related documents that cite external sources should ideally provide direct access to, and accurately represent, the referenced source and the evidence it provides. Our aim was to find a way to systematically assess the prevalence of referencing accuracy and accessibility issues in referenced statements selected from a sample of mental health-related policy documents. METHOD: 236 referenced statements were selected from 10 mental health-related policy documents published between 2013 and 2018. Policy documents were chosen as the focus of this investigation because of their relative accessibility and impact on clinical practice. Statements were rated against their referenced sources in terms of the (i) content accuracy in relation to the information provided by the referenced source and (ii) degree of accessibility of the source and the required evidence from the references provided. RESULTS: Of the 236 statements, 141 (59.7%) accurately represented the referenced source, 45 (19.1%) contained major errors and 50 (21.2%) contained minor errors in accuracy. For accessibility, 126 (53.4%) directly referenced primary sources of evidence that supported the claims made, 36 (15.3%) contained indirect references, 18 (7.6%) provided 'dead-end' references, and 11 (4.7%) references were completely inaccessible. CONCLUSIONS: With only slightly over half of all statements assessed providing fully accessible references and accurately representing the referenced source, these components of referencing quality deserve further attention if evidence-informed policy goals are to be achieved. The rating framework used in the current study proved to be a simple and straightforward method to assess these components and can provide a baseline against which interventions can be designed to improve referencing quality.

A contingency management intervention to reduce cannabis use and time to relapse in early psychosis: the CIRCLE RCT.

BACKGROUND: Cannabis is the most prevalent illicit substance among people with psychosis, and its use is associated with poorer clinical and social outcomes. However, so far, there has been limited evidence that any treatment is effective for reducing use. Contingency management (CM) is an incentive-based intervention for substance misuse that has a substantial evidence base across a range of substances and cohorts. However, to date there have been no randomised controlled trials (RCTs) of CM as a treatment for cannabis use specifically in psychosis. OBJECTIVE: To conduct a RCT investigating the clinical effectiveness and cost-effectiveness of CM in reducing cannabis use among Early Intervention in Psychosis (EIP) service users. DESIGN: The CIRCLE (Contingency Intervention for Reduction of Cannabis in Early Psychosis) trial was a rater-blinded, multicentre RCT with two arms. Participants were randomised 1 : 1 to either an CM arm, in which participants received CM for cannabis use alongside an optimised treatment-as-usual programme including structured psychoeducation, or a control arm in which participants received the treatment as usual only. SETTING: EIP services across the Midlands and the south-east of England. PARTICIPANTS: The main eligibility criteria were EIP service users with a history of psychosis, aged 18-36 years, and having used cannabis at least once per week during 12 of the previous 24 weeks. INTERVENTION: The CM intervention offered financial incentives (i.e. shopping vouchers) for cannabis abstinence over 12 once-weekly sessions, confirmed using urinalysis. The maximum value in vouchers that participants could receive was £240. MAIN OUTCOME MEASURES: The main outcome was time to relapse, operationalised as admission to an acute mental health service or hospital. The primary outcome was assessed at 18 months post inclusion using electronic patient records. Secondary outcomes assessed the clinical effectiveness and cost-effectiveness of the intervention, for which data were collected at 3 and 18 months. RESULTS: A total of 278 participants were randomised to the CM arm and 273 were randomised to the control arm. In total, 530 (96%) participants were followed up for the primary outcome. There was no significant difference in time to admission between trial arms by 18 months following consent (hazard ratio 1.03, 95% confidence interval 0.76 to 1.40). There were no statistically significant differences in most secondary outcomes, including cannabis use, at either follow-up assessment. There were 58 serious adverse events, comprising 52 inpatient episodes, five deaths and one arrest. LIMITATIONS: Participant retention was low at 18 months, limiting the assessment of secondary outcomes. A different CM intervention design or reward level may have been effective. CONCLUSIONS: The CM intervention did not appear to be effective in reducing cannabis use and acute relapse among people with early psychosis and problematic cannabis use. FUTURE WORK: Cannabis use is still a significant clinical concern in this population. A pressing need remains to identify suitable treatments. A wider perspective on the social circumstances of young people with psychosis may be needed for a successful intervention to be found. TRIAL REGISTRATION: Current Controlled Trials ISRCTN33576045. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 45. See the NIHR Journals Library website for further project information.

A large proportion of people with psychosis use cannabis, despite the negative impact that it has on their recovery. So far, a clearly effective way of helping young people in the early stages of psychosis to cut down their cannabis use has not been found. The CIRCLE trial investigated if an approach known as contingency management (CM) would be beneficial for this group. This approach involves offering voucher rewards for not using cannabis. It has been effective in addressing drug use problems in general, but there is not much evidence about its effects on cannabis use in those with psychosis. A total of 551 service users with psychosis who used cannabis agreed to enter the trial. Half of the sample group was chosen by a chance method to receive CM. The other half formed a comparison group. The CM group received shopping vouchers if urine samples showed that they had not used cannabis for the previous week, measured over 12 weekly sessions. Participants could obtain £240-worth of vouchers if they did not use cannabis during the treatment period. The participants in both groups were also offered a six-session psychoeducation programme about the pros and cons of cannabis use and ways to reduce use of it. The main comparison in the trial was the average length of time in each group before a relapse of psychosis occurred, which was recorded for each participant over 18 months after they joined the trial. The results found no difference between the two trial groups in this measure. Furthermore, there were no differences found between the groups in terms of the levels of cannabis use, clinical symptoms, or engagement with work or education. However, a cost-effectiveness analysis found an 85% chance of CM being more effective than the treatment-as-usual psychoeducation package, which appears to be because of the lower use of inpatient services by those receiving CM. However, it is difficult to understand why this was, because there was no drop in cannabis use. The results suggest that CM is unlikely to be clinically effective and that alternative treatments are still needed.

Exploring psychotic symptoms: a comparison of motor related neuronal activation during and after acute psychosis.

BACKGROUND: Delusions and hallucinations are classic positive symptoms of schizophrenia. A contemporary cognitive theory called the 'forward output model' suggests that the misattribution of self-generated actions may underlie some of these types of symptoms, such as delusions of control - the experience of self-generated action being controlled by an external agency. In order to examine the validity of this suggestion, we performed a longitudinal functional magnetic resonance imaging (fMRI) study examining neuronal activation associated with motor movement during acute psychosis. METHODS: We studied brain activation using fMRI during a motor task in 11 patients with schizophrenia and 9 healthy controls. The patient group was tested at two time points separated by 6-8 weeks. RESULTS: At initial testing, the patient group had a mean Positive and Negative Syndrome Scale score of 56.3, and showed significantly increased activation within the left inferior parietal lobe (IPL) compared to controls. Patients reported significantly decreased positive symptoms at 6-8 week followup and IPL activation had returned to normal. Our results demonstrate that first-rank positive symptoms are associated with hyperactivation in the secondary somatosensory cortex (IPL). CONCLUSIONS: These findings lend further credence to the theory that a dysfunction in the sensory feedback system located in the IPL, and which is thought to underlie our sense of agency, may contribute to the aetiology of delusions of control.

Can "pure" implicit memory be isolated? A test of a single-system model of recognition and repetition priming.

Implicit memory is widely regarded as an unconscious form of memory. However, evidence for what is arguably a defining characteristic of implicit memory-that its contents are not accessible to awareness-has remained elusive. Such a finding of "pure" implicit memory would constitute evidence against a single-system model of recognition and priming that predicts that priming will not occur in the (true) absence of recognition. In three experiments, using a rapid serial visual presentation procedure at encoding, we tested this prediction by attempting to replicate some previous studies that claimed to obtain pure implicit memory. We found no evidence of priming in the absence of recognition; instead, priming and recognition were associated across experiments: when priming was absent, recognition was also absent (Experiments 1 and 2), and when priming was reliably greater than chance, recognition was similarly greater than chance (Experiment 3). The results are consistent with the prediction of a single-system model, which was fit to the data from all the experiments. The results are also consistent with the notion that the memory driving priming is accessible to awareness.