A psychological intervention for suicide applied to non-affective psychosis: the CARMS (Cognitive AppRoaches to coMbatting Suicidality) randomised controlled trial protocol

From Springer Nature via Jisc Publications RouterHistory: received 2020-04-21, accepted 2020-05-27, registration 2020-05-28, pub-electronic 2020-06-16, online 2020-06-16, collection 2020-12Publication status: PublishedFunder: Efficacy and Mechanism Evaluation Programme; doi: http://dx.doi.org/10.13039/501100001922; Grant(s): 13/161/25Abstract: Background: Suicide is a leading cause of death globally. Suicide deaths are elevated in those experiencing severe mental health problems, including schizophrenia. Psychological talking therapies are a potentially effective means of alleviating suicidal thoughts, plans, and attempts. However, talking therapies need to i) focus on suicidal experiences directly and explicitly, and ii) be based on testable psychological mechanisms. The Cognitive AppRoaches to coMbatting Suicidality (CARMS) project is a Randomised Controlled Trial (RCT) which aims to investigate both the efficacy and the underlying mechanisms of a psychological talking therapy for people who have been recently suicidal and have non-affective psychosis. Methods: The CARMS trial is a two-armed single-blind RCT comparing a psychological talking therapy (Cognitive Behavioural Suicide Prevention for psychosis [CBSPp]) plus Treatment As Usual (TAU) with TAU alone. There are primary and secondary suicidality outcome variables, plus mechanistic, clinical, and health economic outcomes measured over time. The primary outcome is a measure of suicidal ideation at 6 months after baseline. The target sample size is 250, with approximately 125 randomised to each arm of the trial, and an assumption of up to 25% attrition. Hence, the overall recruitment target is up to 333. An intention to treat analysis will be used with primary stratification based on National Health Service (NHS) recruitment site and antidepressant prescription medication. Recruitment will be from NHS mental health services in the North West of England, UK. Participants must be 18 or over; be under the care of mental health services; have mental health problems which meet ICD-10 non-affective psychosis criteria; and have experienced self-reported suicidal thoughts, plans, and/or attempts in the 3 months prior to recruitment. Nested qualitative work will investigate the pathways to suicidality, experiences of the therapy, and identify potential implementation challenges beyond a trial setting as perceived by numerous stake-holders. Discussion: This trial has important implications for countering suicidal experiences for people with psychosis. It will provide definitive evidence about the efficacy of the CBSPp therapy; the psychological mechanisms which lead to suicidal experiences; and provide an understanding of what is required to implement the intervention into services should it be efficacious. Trial registration: ClinicalTrials.gov (NCT03114917), 14th April 2017. ISRCTN (reference ISRCTN17776666 https://doi.org/10.1186/ISRCTN17776666); 5th June 2017). Registration was recorded prior to participant recruitment commencing

Clinician perspectives on supporting adults with psychosis who wish to discontinue neuroleptic medication:qualitative analysis

Purpose: Research consistently demonstrates that service-users perceive limited choice in whether neuroleptic medication should be dis- continued. Clinicians identify barriers to making shared decisions around medication; however, little is known about how clinical decisions are made regarding whether to support service-users in discontinuing neuroleptic medication. This study examined clinicians’ perspectives on supporting adults who wish to discontinue neuroleptic medication. Materials and Methods: Grounded theory was used to investigate the views and perspectives of clinicians by individual in-depth interviews. Results and Conclusions: A theoretical model (Figure 1) was developed depicting a complex process of decision-making for clinicians working with service-users wishing to discontinue neuroleptics. Decision-making was influenced by clinicians’ personal and professional experiences, and underpinned by their assessment of risk factors and anticipated prognoses for service- users wishing to discontinue neuroleptics. This determined whether clinicians adopted a collaborative or coercive communication style with service-users. Decisions to support discontinuation elicited a range of anxieties in clinicians, leading to actions focused on harm reduction. Decisions about neuroleptic discontinuation are subjective and dependent on clinicians’ previous experiences and judgements regarding potential risk factors. The development of national guidelines, training, resources and support services are required for clinicians to be able to effectively support service-users to discontinue neuroleptic medication.</p

Personal Accounts of Discontinuing Neuroleptic Medication for Psychosis

We conducted this study to explore personal accounts of making choices about taking medication prescribed for the treatment of psychosis (neuroleptics). There are costs and benefits associated with continuing and discontinuing neuroleptics. Service users frequently discontinue neuroleptics; therefore, we specifically considered these decisions. We used a grounded theory approach to analyze transcripts from interviews with 12 participants. We present a preliminary grounded theory of the processes involved in making choices about neuroleptic medication. We identified three tasks as important in mediating participants’ choices: (a) forming a personal theory of the need for, and acceptability of taking, neuroleptic medication; (b) negotiating the challenges of forming alliances with others; and (c) weaving a safety net to safeguard well-being. Progress in the tasks reflected a developmental trajectory of becoming an expert over time and was influenced by systemic factors. Our findings highlight the importance of developing resources for staff to facilitate service user choice. </jats:p