Negative symptoms in first-episode psychosis: a mixed methods investigation

Negative symptoms – reductions in expression, motivation, pleasure and sociability – are observed across the spectrum of functional psychoses. They have been identified as a significant predictor of poor outcomes following first-episode psychosis and are a treatment priority for individuals with lived-experience of psychosis. However, the mechanisms underlying negative symptoms remain poorly understood. This thesis aims to contribute to our understanding of negative symptoms in the early phase of psychosis using a mixed methods approach. Participants in the EDEN study (n = 1006) were followed up for 12 months following acceptance into UK Early Intervention in Psychosis services. Negative symptom severity data were modelled using latent class growth analysis, allowing latent classes comprising individuals with similar patterns of change in negative symptoms severity over time to be identified. Predictors of latent class membership were ascertained and the relationship between negative symptom trajectories and concurrent social recovery explored. Subsequently, transcripts of qualitative interviews conducted with a subsample (n = 24) of the cohort were analysed thematically. Comparisons were made between the accounts of members of the identified latent classes. Experiences and personal understandings of negative symptoms, psychosis, treatment and recovery were explored, providing insights into potential mechanisms underlying negative symptoms and their relationship with social recovery. The quantitative and qualitative findings were integrated and interpreted in relation to existing research and theory. Together they informed the development of a conceptual model of negative symptoms and their relationship with poor social recovery following first-episode psychosis. The model suggests that active psychological processes may be important to negative symptoms and their contribution to poor social recovery. It is proposed that offering tailored psychosocial interventions at the earliest stage of disorder – after the onset of nonspecific negative symptoms but before the emergence of attenuated positive symptoms – may be warranted to improve outcomes following psychosis onset

Service user experience of the Norfolk youth service

Purpose: There is an international drive to improve mental health services for young people. This study aims to investigate service user experience of a youth mental health service in Norfolk, UK. In addition to suggesting improvements to this service, recommendations are made for the development of youth mental health services in general. Design/methodology/approach: A mixed-methods approach was used. Quantitative data from satisfaction questionnaires were analysed using descriptive statistics and compared between two time points. A semi-structured interview was used to generate qualitative data. Thematic analysis was used to identify themes in the interview transcripts and triangulation was used to synthesise quantitative and qualitative data. Findings: Service users appeared satisfied with the service. Significant improvements in satisfaction were found between two time points. Qualitative analysis identified three main themes that were important to service users, including support, information and personhood. Practical implications: Recommendations for the development of youth mental health services are provided. Although these are based on findings from the Norfolk youth service, they are likely to apply to other mental health services for young people. Originality/value: Mental health care for young people requires significant improvement. The Norfolk youth service is one of the first services of its kind in the UK. The findings from this study might be helpful to consider in the development of youth mental health services across the world

Educational and psychosocial interventions to prevent uptake of smoking by young people

Introduction: More than 200,000 UK children aged 11–15 years start smoking each year and up to 50% of children who try smoking will become regular smokers within 2–3 years. Given the high personal, social and economic cost of smoking, intervening to prevent children and young people from beginning to smoke is an important public health goal. Whilst rates of smoking uptake have decreased significantly in recent years, the social gradient in young people taking up smoking remains marked, contributing to health inequalities. Methods: Using National Institute for Health Research (NIHR) Research Capability Funding (RCF) from a pooled fund contributed to by the Norfolk and Waveney Clinical Commissioning Groups, a team at the University of East Anglia undertook a comprehensive literature review and programme of public and patient involvement (PPI) in order to gather current evidence about the educational and psychosocial interventions that are effective in preventing smoking uptake, and improve understanding of current smoking prevention practice. The aim was both to provide evidence to inform commissioning decisions and to facilitate the development of an application for research funding for a trial of an intervention to support young people to choose not to start smoking. Results of review: The literature review identified a large number of educational and psychosocial interventions that have been found to be effective in reducing smoking uptake. Most of the identified interventions are universal, classroom-based interventions, designed to be delivered in mainstream schools. There is evidence that approaches to smoking prevention that combine elements designed to help young people refuse offers to smoke by improving general social competence, with elements aimed at increasing awareness of the social influences that promote smoking, may be most effective. However, it is important that smoking prevention interventions are tailored to the developmental stage of the age group targeted: interventions effective in one group may be ineffective, or even detrimental, in other populations. The ASSIST approach, involving training influential children to encourage their peers not to smoke, was the only approach identified with recent, UK evidence of both effectiveness and cost-effectiveness. Despite a clear rationale for targeting smoking prevention at high-risk groups, few interventions specifically targeting such groups have been trialled to-date. Results of PPI work: The PPI work carried out suggests that teaching in science lessons and/or Personal Social and Health education are the most common approaches to smoking prevention in Norfolk secondary schools. Providing information about the health threats of smoking was perceived by both teachers and pupils to be the most effective means of preventing smoking uptake. Given that research findings suggest that simply providing information about smoking is not the most effective means of preventing young people from taking up smoking, this may point to the need to provide schools with evidence-based information about optimum smoking prevention strategies. The use of peers to discourage smoking initiation was rarely reported as a currently used strategy in Norfolk, but most teachers and pupils responded that they believed this to be a good idea when specifically asked about this approach. Whilst all teachers and majority of pupils reported that their school had a policy in place in the event that pupils are found to be/suspected of smoking, fewer had a similar policy for pupils found to be/suspected of vaping (using e-cigarettes). Teachers reported awareness of school policies to also support smoking cessation where applicable (e.g. referral to specialist services), but pupils were generally unaware of such policies. Conclusions/recommendations: A range of evidence-based educational/psychosocial interventions for preventing uptake of smoking by young people are available, most of which are designed to be delivered within the school environment. The implementation of these interventions within schools has the potential to significantly reduce smoking prevalence, contributing to improvements in public health. However, it appears that many Norfolk schools may not be implementing these evidence-based interventions at present. Schools should be provided with information about the most effective strategies for preventing uptake of smoking by children and young people and encouraged to implement evidence-based smoking prevention initiatives. Equally, further research is needed to identify interventions that are effective in targeting groups of young people at high-risk of smoking uptake

The effect of non-pharmacological sleep interventions on depression symptoms: a meta-analysis of randomised controlled trials

Poor sleep is a significant risk factor for depression across the lifespan and sleep problems have been hypothesised to contribute to the onset and maintenance of depression symptoms. However, sleep problems are usually not a direct target of interventions for depression. A range of non-pharmacological treatments can reduce sleep problems but it is unclear whether these interventions also reduce other depression symptoms. The aim of this review was to examine whether non-pharmacological interventions for sleep problems are effective in reducing symptoms of depression. We carried out a systematic search for randomised controlled trials of non-pharmacological sleep interventions that measured depression symptoms as an outcome. Forty-nine trials (n=5908) were included in a random effects meta-analysis. The pooled standardised mean difference for depression symptoms after treatment for sleep problems was -0.45 (95% CI: -0.55,-0.36). The size of the effect on depression symptoms was moderated by the size of the effect on subjective sleep quality. In studies of participants with mental health problems, sleep interventions had a large effect on depression symptoms (d=-0.81, 95% CI: -1.13,-0.49). The findings indicate that non-pharmacological sleep interventions are effective in reducing the severity of depression, particularly in clinical populations. This suggests that non-pharmacological sleep interventions could be offered as a treatment for depression, potentially improving access to treatment

The effect of non-pharmacological sleep interventions on depression symptoms: a meta-analysis of randomised controlled trials

Poor sleep is a significant risk factor for depression across the lifespan and sleep problems have been hypothesised to contribute to the onset and maintenance of depression symptoms. However, sleep problems are usually not a direct target of interventions for depression. A range of non-pharmacological treatments can reduce sleep problems but it is unclear whether these interventions also reduce other depression symptoms. The aim of this review was to examine whether non-pharmacological interventions for sleep problems are effective in reducing symptoms of depression. We carried out a systematic search for randomised controlled trials of non-pharmacological sleep interventions that measured depression symptoms as an outcome. Forty-nine trials (n=5908) were included in a random effects meta-analysis. The pooled standardised mean difference for depression symptoms after treatment for sleep problems was -0.45 (95% CI: -0.55,-0.36). The size of the effect on depression symptoms was moderated by the size of the effect on subjective sleep quality. In studies of participants with mental health problems, sleep interventions had a large effect on depression symptoms (d=-0.81, 95% CI: -1.13,-0.49). The findings indicate that non-pharmacological sleep interventions are effective in reducing the severity of depression, particularly in clinical populations. This suggests that non-pharmacological sleep interventions could be offered as a treatment for depression, potentially improving access to treatment

Review: Delivering mental health support within schools and colleges – a thematic synthesis of barriers and facilitators to implementation of indicated psychological interventions for adolescents

Background: Increasing the role of schools and colleges in the provision of mental health services for young people has the potential to improve early intervention and access to treatment. We aimed to understand what factors influence the successful implementation of indicated psychological interventions within schools and colleges to help guide increased provision of mental health support within education settings. Methods: Systematic search for studies that have reported barriers or facilitators to the implementation of indicated interventions for adolescent emotional disorders delivered within schools and further education/sixth form colleges (CRD42018102830). Databases searched were EMBASE, MEDLINE, PsycINFO, CINAHL, British Nursing Index, ASSIA, ERIC and British Education Index. A thematic synthesis of factors reported to impact implementation was conducted. Results: Two thousand five hundred and sixty-nine records and 177 full texts were screened. Fifty studies were identified for inclusion, all of which were of school-based interventions. Eleven analytic themes were developed encompassing intervention characteristics, organisational capacity, training and technical assistance, provider characteristics and community-level factors. Findings indicate the need to select appropriate interventions, consider logistical challenges of the school context and provide training and supervision to enable staff to deliver interventions with fidelity. However, structural and environmental support is required for these facilitators to have the greatest impact on successful implementation. Conclusions: Implementing indicated school-based mental health interventions is challenging. Those involved in planning school-based mental health initiatives must be alert to the impact of factors on multiple interacting levels. There is a lack of research on implementing mental health support within further education and sixth form colleges

Foregrounding the perspectives of mental health service users during the COVID-19 pandemic

This viewpoint highlights the critical importance of the perspectives of mental health service-users during the COVID-19 pandemic. This viewpoint is based on a review of recent research and literature and draws on consultations with experts by experience, including the lead author. We argue that expertise-by-experience is critical to policy, service development and research; but there is a risk it will be neglected at a time of rapid and reactive clinical development. Understanding and responding to the nuances of individual need can only be achieved through coproducing service strategy design, delivery and research with mental health service users. The consultation outlined in this viewpoint gives some indication of the type of valuable insights that can be gained through seeking and listening to the perspectives of experts by experience. Our discussions revealed that experience of managing severe and complex mental health conditions can actually be advantageous when facing a crisis such as COVID-19

Risk factors for depression in trauma-exposed children and adolescents: a systematic review and meta-analysis

Background: While Post Traumatic Stress Disorder (PTSD) has been the most frequently studied sequela in the aftermath of trauma, post-traumatic depression is at least as prevalent, if not more so. The impacts of depression are wide-ranging, deleterious and potentially long-term. Understanding the risk factors for post-traumatic depression in children and adolescents is therefore critical. The present systematic review and meta-analysis considered this question. Method: Three databases (Medline, PsycINFO, and Published International Literature on Traumatic Stress [PILOTS]) were searched for pertinent studies. Results: Fifty-seven studies (N = 45,981) allowed for the derivation of pooled effect sizes for 12 risk factors, contributing 145 effect sizes. All effect sizes were statistically significant. Negligible to small effect sizes were largely found for pre-trauma variables (age [r=0.09], gender [r=0.16], low family income [r=0.16] and prior trauma exposure [r=0.16) and trauma-related risk factors (trauma severity [r=0.20], peri‑traumatic distress [r=0.24] and direct exposure [r=0.07]). Small to large effect sizes were found for post-trauma variables (comorbid PTSD symptoms [r=0.58], avoidant coping [r=0.26], low social support [r=0.29] and maternal depression [r=0.20]) and bereavement (r=0.29). Limitations: Risk factor effect size estimates were characterised by significant heterogeneity, and several effect sizes were based on only a few studies (e.g. income, maternal depression). Conclusions: These findings suggest that the post-traumatic responses and environments of children and adolescents may be prominent risk factors for the emergence or maintenance of post-traumatic depression in children and adolescents. This highlights potential targets for assessment and monitoring those most at risk and may also inform treatment

The effect of a youth mental health service model on access to secondary mental healthcare for young people aged 14–25 years

Aims and method: The Norfolk Youth Service was created in 2012 in response to calls to redesign mental health services to better meet the needs of young people. The new service model transcends traditional boundaries by creating a single, ‘youth friendly’ service for young people aged 14–25 years. The aim of this study was to investigate the effect of the transition to this new model on patterns of referral, acceptance and service use. We analysed routinely collected data on young people aged 14–25 years referred for secondary mental healthcare in Norfolk before and after implementation of the youth mental health service. The number of referrals, their age and gender, proportion of referrals accepted and average number of service contacts per referral by age pre- and post-implementation were compared. Results: Referrals increased by 68% following implementation of the new service model, but the proportion of referrals accepted fell by 27 percentage points. Before implementation of the youth service, there was a clear discrepancy between the peak age of referral and the age of those seen by services. Following implementation, service contacts were more equitable across ages, with no marked discontinuity at age 18 years. Clinical implications: Our findings suggest that the transformation of services may have succeeded in reducing the ‘cliff edge’ in access to mental health services at the transition to adulthood. However, the sharp rise in referrals and reduction in the proportion of referrals accepted highlights the importance of considering possible unintended consequences of new service models. Declaration of interests: None

Brief education supported psychological treatment for adolescent borderline personality disorder: the BEST feasibility RCT

Background: Borderline personality disorder is a severe mental health condition characterised by a pattern of emotional instability, interpersonal dysfunction, disturbed self-image and impulsive behaviour, including self-harm. Symptoms of borderline personality disorder typically emerge during adolescence. Although there is compelling evidence in support of early intervention for borderline personality disorder, current evidence-based interventions are resource intensive, with the result that few young people access timely treatment. Therefore, there is an urgent need for accessible interventions to facilitate early intervention for adolescents with borderline personality disorder symptoms. Objectives: The first objective was to adapt a brief psychological treatment for adolescent borderline personality disorder that had previously been delivered within secondary mental health services for co-delivery within schools and colleges. The second objective was to assess the feasibility of evaluating the clinical effectiveness and cost-effectiveness of this intervention in a future randomised controlled trial. Design: We first conducted a rapid evidence synthesis of barriers to and facilitators of the implementation of indicated mental health interventions for adolescents within educational settings and piloted the prototype intervention with three schools/colleges. Based on the findings of the evidence synthesis and pilot, we refined the intervention and study procedures in preparation for a feasibility randomised controlled trial. The feasibility randomised controlled trial involved 12 schools and colleges, whose pastoral staff members received training to deliver the intervention alongside a mental health practitioner. Participants were randomised in a 1 : 1 ratio to receive either the BEST (Brief Education Supported Treatment) intervention plus treatment as usual or treatment as usual alone. Participants were assessed pre randomisation (baseline) and at 12 and 24 weeks post randomisation. Mixed-methods process data were collected to understand how the intervention was implemented, to assess acceptability and to monitor contamination of the control arm. Participants: Young people eligible to participate were aged 13–18 years, reported symptoms of borderline personality disorder above an established threshold and had a history of repeated self-harm. Results: The intervention was refined based on findings of the rapid evidence synthesis, which included 50 studies, feedback from staff participants in the pilot and analysis of session recordings. In the feasibility randomised controlled trial, we randomised 32 participants prior to the premature closure of recruitment. The rate of recruitment was slower than anticipated but would probably have narrowly surpassed our progression criterion over the full recruitment window. Participant retention was high (89.5% at 12 weeks and 73.7% at 24 weeks) and the performance of the proposed outcome measures was satisfactory. We did not find any evidence that participants allocated to the treatment-as-usual arm received the BEST intervention or its components. Fidelity of intervention delivery was high (93.5% of recordings rated as adherent) and the intervention was viewed as offering benefits for individual participants, practitioners involved in co-delivery and the wider school/college. Limitations: The feasibility randomised controlled trial was disrupted by the closure of schools and colleges in response to the COVID-19 pandemic. This reduced the window for participant recruitment and limited the data that could be collected. Conclusions: The refined BEST intervention was able to be delivered successfully within schools and colleges and was found to be acceptable to staff and young people. The findings provide support for continuing this programme of research and would inform the design of a future trial