Positive risk management: Staff perspectives in acute mental health inpatient settings.

AIMS: To explore inpatient staff's understanding and implementation of positive risk management. BACKGROUND: Risk management is an essential skill for staff working in acute mental health inpatient settings. National policies advocate the use of positive risk management as a form of collaborative, recovery-focused risk management. However, little is known about how staff understand, operationalize, and use positive risk management in practice. DESIGN: Qualitative reflexive thematic analysis study. METHODS: The authors recruited a purposive sample of healthcare professionals working in acute inpatient settings (N = 16) in 2019 across three National Health Service Trusts in the North-West of England. Participants completed semi-structured interviews which were analysed using reflexive thematic analysis. RESULTS: The analysis generated three themes: (a) within staff barriers; (b) within service user barriers; and (c) delivery in practice. CONCLUSION: Understanding and implementation of positive risk management was dependant on multiple factors, including staffs' beliefs about mental health, levels of worry and anxiety, and amount of experience and seniority. Staff were more likely to use positive risk management with service users that they perceived as being trustworthy and less risky. Use of positive risk management was reliant on the support practitioners received, how able they were to view situations from multiple perspectives, and the degree to which they felt able to prioritize positive risk management. IMPACT: Although staff expressed the desire and intention to practice positive risk management, the current study highlights challenges around operationalization and implementation. The authors discuss the clinical implications of the findings.

Appraisals to affect: Testing the integrative cognitive model of bipolar disorder.

OBJECTIVE: Cognitive models have suggested that extreme appraisals of affective states and maladaptive affect regulation strategies are important in the development of bipolar symptomatology. Little is known about the pathway by which these appraisals and behaviours interact in the formation of activated and depressed affective states. This study tested the predictions that (1) ascent behaviours mediate the relationship between positive appraisals of activated mood and activation; and (2) descent behaviours mediate the relationship between negative appraisals of activated mood and depression. METHOD: A total of 52 individuals with a DSM-IV diagnosis of bipolar I or II disorder (confirmed by structured interview) completed biweekly assessments of affect regulation behaviours and mood for 4 weeks. Positive and negative appraisals of affective states were assessed at baseline through the Hypomanic Attitudes and Positive Prediction Inventory. Multilevel mediation analysis was used to explore the data. RESULTS: Ascent behaviours partially mediated the relationship between positive appraisals of activated mood and activation. Descent behaviours, but not negative appraisals of activated mood, predicted levels of depression indicating the absence of a mediation effect. CONCLUSION: The results suggest that positive appraisals of activated mood can escalate activation in individuals with bipolar disorder. Such appraisals may be inherently rewarding and reinforcing directly elevating levels of activation, whilst increasing individuals' use of ascent behaviours. The results are consistent with the view that appraisals and behaviours should be targeted during cognitive behavioural therapy for bipolar disorder. PRACTITIONER POINTS: It may be beneficial to target positive appraisals of activated mood in cognitive behavioural therapy for mania. Cognitive behavioural therapists may also wish to focus on identifying and targeting individuals' use of ascent behaviours to reduce highly activated states.

Integrating mobile-phone based assessment for psychosis into people's everyday lives and clinical care: a qualitative study.

BACKGROUND: Over the past decade policy makers have emphasised the importance of healthcare technology in the management of long-term conditions. Mobile-phone based assessment may be one method of facilitating clinically- and cost-effective intervention, and increasing the autonomy and independence of service users. Recently, text-message and smartphone interfaces have been developed for the real-time assessment of symptoms in individuals with schizophrenia. Little is currently understood about patients' perceptions of these systems, and how they might be implemented into their everyday routine and clinical care. METHOD: 24 community based individuals with non-affective psychosis completed a randomised repeated-measure cross-over design study, where they filled in self-report questions about their symptoms via text-messages on their own phone, or via a purpose designed software application for Android smartphones, for six days. Qualitative interviews were conducted in order to explore participants' perceptions and experiences of the devices, and thematic analysis was used to analyse the data. RESULTS: Three themes emerged from the data: i) the appeal of usability and familiarity, ii) acceptability, validity and integration into domestic routines, and iii) perceived impact on clinical care. Although participants generally found the technology non-stigmatising and well integrated into their everyday activities, the repetitiveness of the questions was identified as a likely barrier to long-term adoption. Potential benefits to the quality of care received were seen in terms of assisting clinicians, faster and more efficient data exchange, and aiding patient-clinician communication. However, patients often failed to see the relevance of the systems to their personal situations, and emphasised the threat to the person centred element of their care. CONCLUSIONS: The feedback presented in this paper suggests that patients are conscious of the benefits that mobile-phone based assessment could bring to clinical care, and that the technology can be successfully integrated into everyday routine. However, it also suggests that it is important to demonstrate to patients the personal, as well as theoretical, benefits of the technology. In the future it will be important to establish whether clinical practitioners are able to use this technology as part of a personalised mental health regime.

A comparison of two delivery modalities of a mobile phone-based assessment for serious mental illness: native smartphone application vs text-messaging only implementations.

BACKGROUND: Mobile phone-based assessment may represent a cost-effective and clinically effective method of monitoring psychotic symptoms in real-time. There are several software options, including the use of native smartphone applications and text messages (short message service, SMS). Little is known about the strengths and limitations of these two approaches in monitoring symptoms in individuals with serious mental illness. OBJECTIVE: The objective of this study was to compare two different delivery modalities of the same diagnostic assessment for individuals with non-affective psychosis-a native smartphone application employing a graphical, touch user interface against an SMS text-only implementation. The overall hypothesis of the study was that patient participants with sewrious mental illness would find both delivery modalities feasible and acceptable to use, measured by the quantitative post-assessment feedback questionnaire scores, the number of data points completed, and the time taken to complete the assessment. It was also predicted that a native smartphone application would (1) yield a greater number of data points, (2) take less time, and (3) be more positively appraised by patient participant users than the text-based system. METHODS: A randomized repeated measures crossover design was employed. Participants with currently treated Diagnostic and Statistical Manual (Fourth Edition) schizophrenia or related disorders (n=24) were randomly allocated to completing 6 days of assessment (four sets of questions per day) with a native smartphone application or the SMS text-only implementation. There was then a 1-week break before completing a further 6 days with the alternative delivery modality. Quantitative feedback questionnaires were administered at the end of each period of sampling. RESULTS: A greater proportion of data points were completed with the native smartphone application in comparison to the SMS text-only implementation (ß = -.25, SE=.11, P=.02), which also took significantly less time to complete (ß =.78, SE= .09, P<.001). Although there were no significant differences in participants' quantitative feedback for the two delivery modalities, most participants reported preferring the native smartphone application (67%; n=16) and found it easier to use (71%; n=16). 33% of participants reported that they would be willing to complete mobile phone assessment for 5 weeks or longer. CONCLUSIONS: Native smartphone applications and SMS text are both valuable methods of delivering real-time assessment in individuals with schizophrenia. However, a more streamlined graphical user interface may lead to better compliance and shorter entry times. Further research is needed to test the efficacy of this technology within clinical services, to assess validity over longer periods of time and when delivered on patients' own phones.

The feasibility and validity of ambulatory self-report of psychotic symptoms using a smartphone software application.

BACKGROUND: Semi-structured interview scales for psychosis are the gold standard approach to assessing psychotic and other symptoms. However, such assessments have limitations such as recall bias, averaging, insensitivity to change and variable interrater reliability. Ambulant, real-time self-report assessment devices may hold advantages over interview measures, but it needs to be shown that the data thus collected are valid, and the collection method is acceptable, feasible and safe. We report on a monitoring system for the assessment of psychosis using smartphone technology. The primary aims were to: i) assess validity through correlations of item responses with those on widely accepted interview assessments of psychosis, and ii) examine compliance to the procedure in individuals with psychosis of varying severity. METHODS: A total of 44 participants (acute or remitted DSM-4 schizophrenia and related disorders, and prodromal) completed 14 branching self-report items concerning key psychotic symptoms on a touch-screen mobile phone when prompted by an alarm at six pseudo-random times, each day, for one week. Face to face PANSS and CDS interviews were conducted before and after the assessment period blind to the ambulant data. RESULTS: Compliance as defined by completion of at least 33% of all possible data-points over seven days was 82%. In the 36 compliant participants, 5 items (delusions, hallucinations, suspiciousness, anxiety, hopelessness) showed moderate to strong (rho 0.6-0.8) associations with corresponding items from interview rating scales. Four items showed no significant correlation with rating scales: each was an item based on observable behaviour. Ambulant ratings showed excellent test-retest reliability and sensitivity to change. CONCLUSIONS: Ambulatory monitoring of symptoms several times daily using smartphone software applications represents a feasible and valid way of assessing psychotic phenomena for research and clinical management purposes. Further evaluation required over longer assessment periods, in clinical trials and service settings.

Metacognitive Therapy for Individuals at High Risk of Developing Psychosis: A Pilot Study.

Developing effective interventions for preventing first episode psychosis have been an important research focus in the last decade. Cognitive behavioral therapy is a currently indicated treatment for people at ultra-high risk of psychosis, however, access and resource issues limit its delivery within the NHS. Treatments which partial out potential active ingredients and are aimed at a range of psychological difficulties seen within this population have the potential to be more efficacious and efficient. We conducted a single-arm exploratory pilot trial, designed to investigate the feasibility and acceptability of Metacognitive therapy for individuals at ultra-high risk (UHR) of developing psychosis. Trial uptake was good, with 11 out of 12 referred individuals meeting for an eligibility assessment (one individual was excluded prior to the assessment). Of these, 10 individuals were eligible and included in the trial. Retention to treatment was high with 80% treatment adherence gained and an overall average of 8 sessions completed. All participants were offered follow-up assessments immediately post-treatment and at 6 months, which comprised measures of psychotic like experiences, anxiety and depression, and metacognitive processes implicated in the model. Retention to the post-treatment (12-week) follow-up was good, with 80% completion; however retention to the 6-month follow-up was lower at 60%. Clinically significant results were observed in psychotic like experiences, anxiety, depression and functioning with medium to large effect sizes. Measures related to beliefs and processes targeted within MCT showed clinically significant change with medium to large effect sizes. Our results suggest that MCT based upon a specific metacognitive model for individuals meeting ARMS criteria may be an important treatment target and warrants further attention. Limitations and possible focuses for future research are discussed. Registration: ISRCTN53190465 http://www.isrctn.com/ISRCTN53190465.

The temporal association between self-injurious thoughts and psychotic symptoms: a mobile phone assessment study.

The relationship between psychotic symptoms and self-injurious thoughts (SITs) remains unclear. The short-term temporal associations between psychotic symptoms and SITs were explored. A sample of 36 people with a diagnosis of a psychotic disorder or at-risk mental state completed mobile phone-based measures at multiple times each day for 1 week. Clustered regression with time-lagged variables supported a relationship between paranoia and subsequent SITs. Hallucinations did not predict these thoughts when controlling for paranoia. The role of specific psychotic symptoms in triggering SITs is highlighted and the importance of considering these factors in risk management is discussed.