Consultations With Muslims From Minoritised Ethnic Communities Living in Deprived Areas: Identifying Inequities in Mental Health Care and Support.

BACKGROUND: Limited research concerning existing inequities in mental health care and support services in the United Kingdom captures perceptions and lived experiences of the significantly underrepresented Muslim population. METHODS: Underpinned by social constructivist theory, we used consultation to facilitate public and patient involvement and engagement (PPIE) to identify inequities in mental health care and support experienced by Muslims from minoritised ethnic communities living in deprived areas in Liverpool, UK. The rationale was to (a) better inform standards and policies in healthcare and (b) provide a psychologically safe space to members of the Muslim community to share perceptions and experiences of mental health care and support services. To ensure trustworthiness of the data, member checking was adopted. This paper describes the procedure to achieving this consultation, including our recruitment strategy, data collection and analysis as well as key findings. FINDINGS: Twenty-seven consultees attended the women's consultation and eight consultees attended the men's consultation. Consultees were from Yemeni, Somali, Sudanese, Egyptian, Algerian, Pakistani and Moroccan communities and share the Islamic faith. Four key interlinked themes were identified from consultees' narratives: (1) broken cycle of trust; (2) an overmedicalised model of care; (3) community mental health prevention initiatives; and (4) culturally conscious training and education. CONCLUSIONS: The Muslim population has identified numerous barriers to accessing mental health support and there is a need to resource activities that would aid deeper understanding of mental health support needs through continuous and meaningful community initiatives. This would afford mental health practitioners and organisations opportunities for developing realistic anti-racism strategies, effectively adopting social prescription, strengthening partnerships and collaborations aimed at supporting delivery of evidence-based mental health care provisions to tackle mental health inequities. PATIENT AND PUBLIC INVOLVEMENT: This paper reports on the involvement and engagement of Muslims from minoritised ethnic communities living in the Liverpool city region.

Mindfulness of voices, self-compassion, and secure attachment in relation to the experience of hearing voices.

OBJECTIVES: Developing compassion towards oneself has been linked to improvement in many areas of psychological well-being, including psychosis. Furthermore, developing a non-judgemental, accepting way of relating to voices is associated with lower levels of distress for people who hear voices. These factors have also been associated with secure attachment. This study explores associations between the constructs of mindfulness of voices, self-compassion, and distress from hearing voices and how secure attachment style related to each of these variables. DESIGN: Cross-sectional online. METHOD: One hundred and twenty-eight people (73% female; Mage  = 37.5; 87.5% Caucasian) who currently hear voices completed the Self-Compassion Scale, Southampton Mindfulness of Voices Questionnaire, Relationships Questionnaire, and Hamilton Programme for Schizophrenia Voices Questionnaire. RESULTS: Results showed that mindfulness of voices mediated the relationship between self-compassion and severity of voices, and self-compassion mediated the relationship between mindfulness of voices and severity of voices. Self-compassion and mindfulness of voices were significantly positively correlated with each other and negatively correlated with distress and severity of voices. CONCLUSION: Mindful relation to voices and self-compassion are associated with reduced distress and severity of voices, which supports the proposed potential benefits of mindful relating to voices and self-compassion as therapeutic skills for people experiencing distress by voice hearing. PRACTITIONER POINTS: Greater self-compassion and mindfulness of voices were significantly associated with less distress from voices. These findings support theory underlining compassionate mind training. Mindfulness of voices mediated the relationship between self-compassion and distress from voices, indicating a synergistic relationship between the constructs. Although the current findings do not give a direction of causation, consideration is given to the potential impact of mindful and compassionate approaches to voices.

Identifying the priorities for supervision by lived experience researchers: a Q sort study.

BACKGROUND: Lived experience researchers draw on their lived and living experiences to either lead on or inform research. Their personal experiences are relevant to the research topic and so they must manage the interplay of their health and healthcare experiences with the research, population, and data they work with, as well as the more general challenges of being a researcher. Lived experience researchers must navigate these dilemmas in addition to queries over their competency, due to issues relating to intersectionality and epistemic injustice. This justifies a motivation to better understand the experiences of lived experience researchers and develop appropriate and personalised supervision based on their preferences and needs. METHODS: Q methodology was used to identify a collection of identity-related issues that impact lived experience researchers during PhD research in the context of the UK. These issues were presented in the form of 54 statements to 18 lived experience researchers to prioritise as topics to explore in supervision. RESULT: It was found that lived experiences researchers could be grouped into three distinct factors following an inverted factor analysis: Factor 1: Strengthening my identity, skills, growth, and empowerment; Factor 2: Exploring the emotional and relational link I have with the research and Factor 3: Navigating my lived and professional experiences practically and emotionally. The findings suggest that there may be three types of lived experience researchers, each with different needs from supervision, suggesting the population is heterogeneous. CONCLUSION: The research identified a deeper understanding of the needs of lived experience researchers and highlights the importance of personalised supervision according to the individual needs of the researcher and their preferences for supervision. The findings reinforce the importance of integrating a clinical dimension into supervision to support the needs of all lived experience researchers.

Understanding the identity of lived experience researchers and providers: a conceptual framework and systematic narrative review.

BACKGROUND: Identity is how we understand ourselves and others through the roles or social groups we occupy. This review focuses on lived experience researchers and providers and the impact of these roles on identity. Lived experience researchers and providers use their lived experience of mental or physical disability either as experts by experience, researchers, peer workers, or mental health professionals with lived experience. They must navigate both professional and personal aspects to their roles which can be complex. Performing roles simultaneously embodying professional and lived experiences contribute towards a lack of clarity to identity. This is not adequately explained by the theoretical evidence base for identity. MAIN BODY: This systematic review and narrative synthesis aimed to provide a conceptual framework to understand how identity of lived experience researchers and providers is conceptualised. A search strategy was entered into EBSCO to access Academic search complete, CINAHL, MEDLINE, PsycINFO, Psych Articles, and Connected papers. Out of the 2049 yielded papers, thirteen qualitative papers were eligible and synthesised, resulting in a conceptual framework. Five themes explained identity positions: Professional, Service user, Integrated, Unintegrated and Liminal. The EMERGES framework, an original conception of this review, found themes of: Enablers and Empowerment, Motivation, Empathy of the self and others, Recovery model and medical model, Growth and transformation, Exclusion and Survivor roots contributed to lived experience researcher and provider identities. CONCLUSIONS: The EMERGES framework offers a novel way to understand the identities of lived experience researchers and providers, helping support effective team working in mental health, education, and research settings.

Patients now commonly help to teach healthcare professionals from their own perspective of what it is like to experience health difficulties and healthcare services. Consequently, the needs of patients are being better recognised by healthcare providers. Patients are also involved in research. These types of patient involvement lead to improved research and care. Patients included in this type of work are frequently referred to as patient providers, service user researchers, peer workers, experts by experience or lived experience researchers and providers. This might mean they are no longer viewed as people who use services but as people who provide a service. This review helps us understand how those in these roles are affected and how they understand themselves. We found they were sometimes described as either patients or professionals. Sometimes they were described as both patient and professional at the same time. Other times they were described as somewhere between a patient or professional. There were other important ideas that affected how they viewed themselves because of these experiences. These included feelings of empowerment and motivation from doing this important teaching and clinical work. The roles gave them a better understanding of their own experiences. These roles led to a personal growth and sense of achievement. The experiences of exclusion, and of being a patient affected how patient providers think of themselves. This understanding can lead to patient providers being better understood and leads to better teaching and training of healthcare professionals.

The role of repetitive thinking and spirituality in the development of posttraumatic growth and symptoms of posttraumatic stress disorder.

Both post-traumatic growth (PTG) and post-traumatic stress disorder (PTSD) are associated with spirituality and different kinds of repetitive thinking, such as deliberate rumination (DR) and intrusive rumination (IR), respectively. This study aimed to examine if spirituality modifies the relationship between types of rumination and trauma outcomes. Ninety-six students completed an online survey of four questionnaires in a cross-sectional online survey: The Posttraumatic Stress Diagnostic Scale, the Event Related Rumination Inventory, the Posttraumatic Growth Inventory-Short form and the Expressions of Spirituality Inventory- Revised. Findings revealed that spirituality was related to DR and PTG, but not to IR or PTSD symptoms. Moderation analysis showed that spirituality significantly moderated the relationship between PTG and DR, but not the relationship between PTSD and IR. These findings indicate that while spirituality has no relationship with negative outcomes of trauma, it may help individuals to ruminate in a constructive manner in order to develop positive outcomes.

An exploration of the relationship between adverse events on the farm and suicidal ideation in farmers.

BACKGROUND: The risk of suicide for agricultural workers in parts of the United Kingdom (UK) is almost twice the national average. Existing literature has suggested that adverse farming events, where failure is determined by uncontrollable and unpredictable forces, may be to blame. Yet, the impact of such events on farmer suicidality has not been explicitly explored. AIMS: The present paper therefore aimed to investigate the relationship between adverse farming events and suicidal ideation in farmers. METHODS: A cross-sectional questionnaire battery was disseminated between July 2018 and February 2019, and completed by 170 adult farmers. RESULTS: Over a 12-month period, 88.8% reported that they had experienced an adverse farming event and 32.9% said that they had experienced suicidal thoughts. Correlational analysis revealed a relationship between these variables. CONCLUSIONS: The high prevalence of suicidal ideation within farmers demonstrates a critical need for intervention. Likewise, the prevalence of adverse farming events suggests that interventions need to be appropriately tailored, with greater understanding about the impact of such events on the mental wellbeing of farmers.

Ordinary Magic in Extraordinary Circumstances: Factors Associated with Positive Mental Health Outcomes for Early Adolescents During the COVID-19 Pandemic.

The COVID-19 pandemic and associated restrictions have had a negative impact on the mental health and wellbeing of many people worldwide, but this may have been particularly challenging for adolescents. However, there is a paucity of research examining the factors associated with good mental health during this time. The aim of the current study was to identify the protective factors amongst early adolescents in the UK that were associated with better mental health outcomes (internalising and externalising difficulties, and wellbeing) during the first national COVID-19 lockdown. Between September and December 2020, 290 11-14 year olds across North West England completed an online survey consisting of several measures pertaining to experiences of lockdown, and mental health and wellbeing. Hierarchical multiple regression was used to analyse the data. Results indicated that higher participant-rated lockdown experience (the extent to which it was fun, easy, and good) and higher levels of optimism were protective factors for all three outcomes of interest. Greater adherence to government guidance was a protective factor for internalising difficulties and wellbeing only, while family keyworker status was protective for externalising difficulties and wellbeing only. Community and school connection were protective factors for internalising difficulties; family connection and number of parents at home were protective factors for externalising difficulties; and peer support and family knowledge of COVID-19 were protective factors for wellbeing. In summary, the 'ordinary magic' of supportive relationships and positive experiences appear to be some of the key factors needed to maintain adolescents' mental health and wellbeing, and to help them overcome difficulties posed by the COVID-19 pandemic.

Long-term effectiveness of a parenting intervention for children at risk of developing conduct disorder.

BACKGROUND: The typical pattern for intervention outcome studies for conduct problems has been for effect sizes to dissipate over time with decreasing effects across subsequent follow-ups. AIMS: To establish whether the short-term positive effects of a parenting programme are sustained longer term. To observe trends, and costs, in health and social service use after intervention. METHOD: Parents with children aged 36-59 months at risk of developing conduct disorder (n = 104) received intervention between baseline and first follow-up (6 months after baseline n = 86) in 11 Sure Start areas in North Wales. Follow-ups two (n = 82) and three (n = 79) occurred 12 and 18 months after baseline. Child problem behaviour and parenting skills were assessed via parent self-report and direct observation in the home. RESULTS: The significant parent-reported improvements in primary measures of child behaviour, parent behaviour, parental stress and depression gained at follow-up one were maintained to follow-up three, as were improved observed child and parent behaviours. Overall, 63% of children made a minimum significant change (0.3 standard deviations) on the Eyberg Child Behavior Inventory problem scale between baseline and follow-up (using intention-to-treat data), 54% made a large change (0.8 standard deviations) and 39% made a very large change (1.5 standard deviations). Child contact with health and social services had reduced at follow-up three. CONCLUSIONS: Early parent-based intervention reduced child antisocial behaviour and benefits were maintained, with reduced reliance on health and social service provision, over time.

The Utility of Home-Practice in Mindfulness-Based Group Interventions: A Systematic Review.

A growing body of research supports the efficacy of mindfulness-based interventions (MBIs). MBIs consider home-practice as essential to increasing the therapeutic effects of the treatment. To date however, the synthesis of the research conducted on the role of home-practice in controlled MBI studies has been a neglected area. This review aimed to conduct a narrative synthesis of published controlled studies, evaluating mindfulness-based group interventions, which have specifically measured home-practice. Empirical research literature published until June 2016 was searched using five databases. The search strategy focused on mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and home-practice. Included studies met the following criteria: controlled trials, participants 18 years and above, evaluations of MBSR or MBCT, utilised standardised quantitative outcome measures and monitored home-practice using a self-reported measure. Fourteen studies met the criteria and were included in the review. Across all studies, there was heterogeneity in the guidance and resources provided to participants and the approaches used for monitoring home-practice. In addition, the guidance on the length of home-practice was variable across studies, which indicates that research studies and teachers are not adhering to the published protocols. Finally, only seven studies examined the relationship between home-practice and clinical outcomes, of which four found that home-practice predicted improvements on clinical outcome measures. Future research should adopt a standardised approach for monitoring home-practice across MBIs. Additionally, studies should assess whether the amount of home-practice recommended to participants is in line with MBSR/MBCT manualised protocols. Finally, research should utilise experimental methodologies to explicitly explore the relationship between home-practice and clinical outcomes.

Examining the relationship between burnout and empathy in healthcare professionals: A systematic review.

OBJECTIVE: Empathy and burnout are two related yet distinct constructs that are relevant to clinical healthcare staff. The nature of their relationship is uncertain and this review aimed to complete a rigorous, systematic exploration of the literature investigating the relationship between burnout and empathy in healthcare staff. DESIGN: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. DATA SOURCES: Search terms (Burnout OR Burn-out OR "Burn out") AND (Empathy OR Empath*) enabled identification of studies investigating burnout and empathy in healthcare staff, using five electronic data bases (MEDLINE, PsycINFO, CINAHL Plus, PubMed, and SCOPUS). Manual searching amongst reference lists of eligible articles was also completed. REVIEW METHODS: Databases were searched for studies published in the English language, from inception to February 2017. Key inclusion criteria were: 1) participants who were nurses or medical professionals, 2) full written manuscript in English, 3) use of the Maslach Burnout Inventory to assess burnout and a standardized outcome measure for empathy, 4) quantitative methodology exclusively. RESULTS: Ten eligible studies were reviewed. Of those, seven were conducted in countries where English was not the first language. Eight of the studies provided empirical support for a negative relationship between empathy and burnout. One study provided support for a positive relationship between burnout and empathy. One study reported contradictory evidence with positive and negative correlations between different subscales of the empathy and burnout measures. In general, the quality of the studies was assessed to be good. However, some of the studies failed to provide information pertaining to sample size, with the reporting of data less than adequate from one study. CONCLUSIONS: There was consistent evidence for a negative association between burnout and empathy. This review avoided a common English-speaking country bias of some areas of the literature. Given that all of the studies reviewed were cross sectional, further research is necessary to establish causality.

Mindfulness-based cognitive therapy (MBCT) reduces the association between depressive symptoms and suicidal cognitions in patients with a history of suicidal depression.

OBJECTIVE: In patients with a history of suicidal depression, recurrence of depressive symptoms can easily reactivate suicidal thinking. In this study, we investigated whether training in mindfulness, which is aimed at helping patients "decenter" from negative thinking, could help weaken the link between depressive symptoms and suicidal cognitions. METHOD: Analyses were based on data from a recent randomized controlled trial, in which previously suicidal patients were allocated to mindfulness-based cognitive therapy (MBCT), an active control treatment, cognitive psychoeducation (CPE), which did not include any meditation practice, or treatment as usual (TAU). After the end of the treatment phase, we compared the associations between depressive symptoms, as assessed through self-reports on the Beck Depression Inventory-II (Beck, Steer, & Brown, 1996), and suicidal thinking, as assessed through the Suicidal Cognitions Scale (Rudd et al., 2001). RESULTS: In patients with minimal to moderate symptoms at the time of assessment, comparisons of the correlations between depressive symptoms and suicidal cognitions showed significant differences between the groups. Although suicidal cognitions were significantly related to levels of symptoms in the 2 control groups, there was no such relation in the MBCT group. CONCLUSION: The findings suggest that, in patients with a history of suicidal depression, training in mindfulness can help to weaken the association between depressive symptoms and suicidal thinking, and thus reduce an important vulnerability for relapse to suicidal depression.

The effects of amount of home meditation practice in Mindfulness Based Cognitive Therapy on hazard of relapse to depression in the Staying Well after Depression Trial.

Few empirical studies have explored the associations between formal and informal mindfulness home practice and outcome in Mindfulness-based Cognitive Therapy (MBCT). In this study ninety-nine participants randomised to MBCT in a multi-centre randomised controlled trial completed self-reported ratings of home practice over 7 treatment weeks. Recurrence of Major Depression was assessed immediately after treatment, and at 3, 6, 9, and 12-months post-treatment. Results identified a significant association between mean daily duration of formal home practice and outcome and additionally indicated that participants who reported that they engaged in formal home practice on at least 3 days a week during the treatment phase were almost half as likely to relapse as those who reported fewer days of formal practice. These associations were independent of the potentially confounding variable of participant-rated treatment plausibility. The current study identified no significant association between informal home practice and outcome, although this may relate to the inherent difficulties in quantifying informal home mindfulness practice. These findings have important implications for clinicians discussing mindfulness-based interventions with their participants, in particular in relation to MBCT, where the amount of participant engagement in home practice appears to have a significant positive impact on outcome.

Trait mindfulness as a limiting factor for residual depressive symptoms: an explorative study using quantile regression.

Mindfulness has been suggested to be an important protective factor for emotional health. However, this effect might vary with regard to context. This study applied a novel statistical approach, quantile regression, in order to investigate the relation between trait mindfulness and residual depressive symptoms in individuals with a history of recurrent depression, while taking into account symptom severity and number of episodes as contextual factors. Rather than fitting to a single indicator of central tendency, quantile regression allows exploration of relations across the entire range of the response variable. Analysis of self-report data from 274 participants with a history of three or more previous episodes of depression showed that relatively higher levels of mindfulness were associated with relatively lower levels of residual depressive symptoms. This relationship was most pronounced near the upper end of the response distribution and moderated by the number of previous episodes of depression at the higher quantiles. The findings suggest that with lower levels of mindfulness, residual symptoms are less constrained and more likely to be influenced by other factors. Further, the limiting effect of mindfulness on residual symptoms is most salient in those with higher numbers of episodes.

Comfort from suicidal cognition in recurrently depressed patients.

BACKGROUND: Previous research has suggested that some individuals may obtain comfort from their suicidal cognitions. METHOD: This study explored clinical variables associated with comfort from suicidal cognition using a newly developed 5 item measure in 217 patients with a history of recurrent depression and suicidality, of whom 98 were followed up to at least one relapse to depression and reported data on suicidal ideation during the follow-up phase. RESULTS: Results indicated that a minority of patients, around 15%, reported experiencing comfort from suicidal cognitions and that comfort was associated with several markers of a more severe clinical profile including both worst ever prior suicidal ideation and worst suicidal ideation over a 12 month follow-up period. LIMITATIONS: Few patients self-harmed during the follow-up period preventing an examination of associations between comfort and repetition of self-harm. CONCLUSIONS: These results, although preliminary, suggest that future theoretical and clinical research would benefit from further consideration of the concept of comfort from suicidal thinking.

Mindfulness-based cognitive therapy for preventing relapse in recurrent depression: a randomized dismantling trial.

OBJECTIVE: We compared mindfulness-based cognitive therapy (MBCT) with both cognitive psychological education (CPE) and treatment as usual (TAU) in preventing relapse to major depressive disorder (MDD) in people currently in remission following at least 3 previous episodes. METHOD: A randomized controlled trial in which 274 participants were allocated in the ratio 2:2:1 to MBCT plus TAU, CPE plus TAU, and TAU alone, and data were analyzed for the 255 (93%; MBCT = 99, CPE = 103, TAU = 53) retained to follow-up. MBCT was delivered in accordance with its published manual, modified to address suicidal cognitions; CPE was modeled on MBCT, but without training in meditation. Both treatments were delivered through 8 weekly classes. RESULTS: Allocated treatment had no significant effect on risk of relapse to MDD over 12 months follow-up, hazard ratio for MBCT vs. CPE = 0.88, 95% CI [0.58, 1.35]; for MBCT vs. TAU = 0.69, 95% CI [0.42, 1.12]. However, severity of childhood trauma affected relapse, hazard ratio for increase of 1 standard deviation = 1.26 (95% CI [1.05, 1.50]), and significantly interacted with allocated treatment. Among participants above median severity, the hazard ratio was 0.61, 95% CI [0.34, 1.09], for MBCT vs. CPE, and 0.43, 95% CI [0.22, 0.87], for MBCT vs. TAU. For those below median severity, there were no such differences between treatment groups. CONCLUSION: MBCT provided significant protection against relapse for participants with increased vulnerability due to history of childhood trauma, but showed no significant advantage in comparison to an active control treatment and usual care over the whole group of patients with recurrent depression.

Development and validation of the mindfulness-based interventions - teaching assessment criteria (MBI:TAC).

BACKGROUND: The assessment of intervention integrity is essential in psychotherapeutic intervention outcome research and psychotherapist training. There has been little attention given to it in mindfulness-based interventions research, training programs, and practice. AIMS: To address this, the Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC) was developed. This article describes the MBI:TAC and its development and presents initial data on reliability and validity. METHOD: Sixteen assessors from three centers evaluated teaching integrity of 43 teachers using the MBI:TAC. RESULTS: Internal consistency (α = .94) and interrater reliability (overall intraclass correlation coefficient = .81; range = .60-.81) were high. Face and content validity were established through the MBI:TAC development process. Data on construct validity were acceptable. CONCLUSIONS: Initial data indicate that the MBI:TAC is a reliable and valid tool. It can be used in Mindfulness-Based Stress Reduction/Mindfulness-Based Cognitive Therapy outcome evaluation research, training and pragmatic practice settings, and in research to assess the impact of teaching integrity on participant outcome.

The feasibility and effectiveness of mindfulness-based cognitive therapy for mixed diagnosis patients in primary care: a pilot study.

Background Mindfulness-based cognitive therapy (MBCT) is an intervention developed for the prevention of recurrent depression which is now being applied to widening numbers of clinical populations. Despite evidence for its effectiveness in preventing relapse in depression, less is known about its efficacy within routine clinical practice for groups of patients with more varied mental health problems, despite this being a potentially promising context for its application. Aims This pilot study aimed to investigate whether MBCT would be feasible and effective when delivered in a primary care context for patients who are vulnerable to recurrent depression and anxiety. Results Attrition from the programme was low and both attendance and engagement with home practices (during and after the intervention) were comparable with or higher than those observed in the existing literature. Improvements in self-reported depression, anxiety, rumination, self-compassion and well-being were evident over the 8-week programme and at 6-month post intervention follow-up. Conclusions Despite limitations in terms of sample size and the absence of a control group, the results demonstrate that the promising research results of MBCT for depression are transferable from a research to a practice setting, and demonstrate that it may be an effective and feasible intervention when delivered in a primary care setting for a range of mental health problems.

Pre-adult onset and patterns of suicidality in patients with a history of recurrent depression.

BACKGROUND: This report assesses the association between age of onset of major depression and later suicidality in a sample of 276 recurrently depressed patients recruited for the Oxford/Bangor Staying Well after Depression (SWAD) Trial, and interviewed when in remission. METHODS: The study enrolled adult patients with a history of at least three episodes of non-psychotic major depressive disorder from primary care and psychiatric care practices and through community advertisements. At study entry, all participants estimated the age of their first onset of a major depressive episode and completed both self-report and interview-based assessments of past and current suicidal ideation and behavior. Participants were divided into pre-adult and adult onset groups using a cut-off age of 18. RESULTS: Forty-eight percent of the sample reported a pre-adult age of onset. Pre-adult age of onset was significantly associated with suicidality, both from self-report and from interviewer assessment even when adjusting for differences in age, gender, employment status, length of the disorder and early adversity. LIMITATIONS: Relevant variables were all assessed through retrospective reports. CONCLUSIONS: Pre-adult age of onset is closely associated with risk for and severity of later suicidality, replicating, in a sample of patients assessed when in remission, findings from studies that assessed patients when currently depressed. The association of pre-adult age of onset with suicidality is not due to differences in sociodemographic variables, length of the disorder and early adversity.

Parenting intervention in Sure Start services for children at risk of developing conduct disorder: pragmatic randomised controlled trial.

OBJECTIVE: To evaluate the effectiveness of a parenting programme as a preventive intervention with parents of preschool children considered to be at risk of developing conduct disorder. DESIGN: Pragmatic randomised controlled trial using a block design with allocation by area. SETTING: Eleven Sure Start areas in north and mid-Wales. PARTICIPANTS: 153 parents from socially disadvantaged areas, with children aged 36-59 months at risk of conduct disorder defined by scoring over the clinical cut off on the Eyberg child behaviour inventory. Participants were randomised on a 2:1 basis, 104 to intervention and 49 to remaining on the wait listing (control). Twenty (13%) were lost to follow-up six months later, 18 from the intervention group. INTERVENTION: The Webster-Stratton Incredible Years basic parenting programme, a 12 week group based intervention. MAIN OUTCOME MEASURES: Problem behaviour in children and parenting skills assessed by self reports from parents and by direct observation in the home. Parents' self reported parenting competence, stress, and depression. Standardised and well validated instruments were used throughout. RESULTS: At follow-up, most of the measures of parenting and problem behaviour in children showed significant improvement in the intervention group. The intention to treat analysis for the primary outcome measure, the Eyberg child behaviour inventory, showed a mean difference between groups of 4.4 points (95% confidence interval 2.0 to 6.9, P<0.001) on the problem scale with an effect size of 0.63, and a mean difference of 25.1 (14.9 to 35.2, P<0.001) on the intensity scale with an effect size of 0.89. CONCLUSION: This community based study showed the effectiveness of an evidence based parenting intervention delivered with fidelity by regular Sure Start staff. It has influenced policy within Wales and provides lessons for England where, to date, Sure Start programmes have not been effective. TRIAL REGISTRATION: ISRCTN46984318.