Is doing a PhD bad for your mental health?

Poor mental health amongst PhD researchers is increasingly being recognised as an issue within higher education institutions. However, there continues to be unanswered questions relating to the propensity and causality of poor mental health amongst PhD researchers. Reporting on a new comparative survey of PhD researchers and their peers from different professions, Dr Cassie M Hazell and Dr Clio Berry find that PhD researchers are particularly vulnerable to poor mental health compared to their peers. Arguing against an inherent and individualised link between PhD research and mental health, they suggest institutions have a significant role to play in reviewing cultures and working environments that contribute to the risk of poor mental health

Is 16 the magic number? Guided self-help CBT intervention for Voices Evaluated (GiVE).

Hearing distressing voices (also known as auditory verbal hallucinations) is a common symptom associated with a number of mental health problems. Psychological therapies, specifically cognitive behaviour therapy (CBT) can be an effective intervention for this patient group. The aim of CBT for voices (CBTv) is to reduce the distress associated with the experience, by encouraging the patient to re-evaluate their beliefs about the voice’s omnipotence, omniscience, and malevolence. Despite the evidence for CBTv, very few patients are offered this therapy; largely due to a lack of resources. The aim of this thesis was to develop and begin to evaluate a CBT-based intervention for voices that was resource-light; in the hope that it could be more easily be implemented into clinical services, and therefore increase access. This thesis begins with an introduction to the research area, and is followed by a review and evaluation of the methods used in this thesis. Chapter 6 is a systematic review and meta-analysis of the current literature on brief (<16 NICE recommended sessions) CBT for psychosis (CBTp). Chapters 7 and 8 describe the process of developing a brief CBT intervention for voices, based on the CBT self-help book ‘Overcoming Distressing Voices’. Both people who hear voices, and mental health clinicians were consulted on the intervention concept and design. The outcome of these studies was guided self-help CBTv, and an accompanying therapy workbook to guide the intervention. Chapters 9 and 10 detail the design and findings of a randomised controlled trial of guided self-help CBTv delivered by Clinical Psychologists, versus a wait-list control group. Data was collected at baseline (pre-randomisation) and 12 weeks post-randomisation. The primary outcome was voice-related distress. The findings across all of the studies are then summarised and reflected upon within the Discussion chapter – including consideration of the extent to which the overall aim of this thesis (increasing access) has been achieved

Measurement practices in hallucinations research

In several sub-fields of psychology, there has been a renewed focus on measurement practices. As far as we are aware, this has been absent in hallucinations research. Thus, we investigated (a) cross-study variation in how hallucinatory experiences are measured and (b) the reliability of measurements obtained using two tasks that are widely employed in hallucinations research

Creating a hierarchy of mental health stigma: testing the effect of psychiatric diagnosis on stigma

Levels of mental health stigma experienced can vary as a function of the presenting mental health problem (e.g. diagnosis and symptoms). However, these studies are limited because they exclusively use pairwise comparisons. A more comprehensive examination of diagnosis-specific stigma is needed. The aim of our study was to determine how levels of mental health stigma vary in relation to a number of psychiatric diagnoses, and identify what attributions predict levels of diagnosis-specific stigma. We conducted an online survey with members of the public. Participants were assessed in terms of how much stigma they had, and their attributions toward, nine different case vignettes, each describing a different mental health diagnosis. We recruited 665 participants. After controlling for social desirability bias and key demographic variables, we found that mental health stigma varied in relation to psychiatric diagnosis. Schizophrenia and antisocial personality disorder were the most stigmatised diagnoses, and depression, generalised anxiety disorder and obsessive-compulsive disorder were the least stigmatised diagnoses. No single attribution predicted stigma across diagnoses, but fear was the most consistent predictor. Assessing mental health stigma as a single concept masks significant between-diagnosis variability. Anti-stigma campaigns are likely to be most successful if they target fearful attributions

Pilot evaluation of a brief training video aimed at reducing mental health stigma amongst emergency first responders (the ENHANcE II study)

Background First responders (i.e. police and ambulance staff) have increasingly become part of the mental health care system, often being the first port of call for those experiencing a crisis. Despite their frequent involvement in supporting those with mental health problems, there is evidence that mental health stigma is high amongst first responders. Aims The aim of the present study was to evaluate a brief training video aimed at reducing mental health stigma amongst first responders. Methods First responders watched a training video based on the cognitive behavioural model of mental health stigma, and involved contributions from people with lived experience, and first responders. Measures of mental health stigma were collected before and after viewing the training. Results The training video produced small but significant improvements in mental health stigma, and these effects did not differ between police and ambulance staff. We were unable to determine what psychological constructs mediated this change in stigma. The feedback on the training video was generally positive, but also indicated some key areas for future development. Conclusions The present study provides encouraging evidence that levels of mental health stigma can be improved using a resource-light training intervention

Increasing access to CBT for psychosis patients: a feasibility, randomised controlled trial evaluating brief, targeted CBT for distressing voices delivered by assistant psychologists (GiVE2)

Background: The National Institute for Health and Care Excellence (NICE) recommends that Cognitive Behaviour Therapy for psychosis (CBTp) is offered to all patients with a psychosis diagnosis. However, only a minority of psychosis patients in England and Wales are offered CBTp. This is attributable, in part, to the resource-intensive nature of CBTp. One response to this problem has been the development of CBTp in brief formats that are targeted at a single symptom and the mechanisms that maintain distress. We have developed a brief form of CBTp for distressing voices and reported preliminary evidence for its effectiveness when delivered by highly trained therapists (clinical psychologists). This study will investigate the delivery of this intervention by a cost-effective workforce of assistant psychologists following a brief training and evaluate the acceptability and feasibility of conducting a future, definitive, randomised controlled trial (RCT). Methods: This is a feasibility study for a pragmatic, three-arm, parallel-group, superiority 1:1:1 RCT comparing a Guided self-help CBT intervention for voices and treatment as usual (GiVE) to Supportive Counselling and treatment as usual (SC) to treatment as usual alone (TAU), recruiting across two sites, with blinded post-treatment and follow-up assessments. A process evaluation will quantitatively and qualitatively explore stakeholder experience. Discussion: Expected outcomes will include an assessment of the feasibility of conducting a definitive RCT, and data to inform the calculation of its sample size. If evidence from a subsequent, fully powered RCT suggests that GiVE is clinically and cost-effective when delivered by briefly trained assistant psychologists, CBTp offered in these less resource-intensive forms has the potential to generate benefits for individual patients (reduced distress, enhanced recovery and enhanced quality of life), service-level patient benefit (increased access to evidence-based psychological therapies) and economic benefits to the NHS (in terms of the reduced use of mental health inpatient services). Trial registration: Current Controlled Trials, ISRCTN registration number: 16166070. Registered on 5 February 2019

Understanding clinician attitudes towards implementation of guided self-help cognitive behaviour therapy for those who hear distressing voices: using factor analysis to test normalisation process theory

Background The Normalisation Process Theory (NPT) has been used to understand the implementation of physical health care interventions. The current study aims to apply the NPT model to a secondary mental health context, and test the model using exploratory factor analysis. This study will consider the implementation of a brief cognitive behaviour therapy for psychosis (CBTp) intervention. Methods Mental health clinicians were asked to complete a NPT-based questionnaire on the implementation of a brief CBTp intervention. All clinicians had experience of either working with the target client group or were able to deliver psychological therapies. In total, 201 clinicians completed the questionnaire. Results The results of the exploratory factor analysis found partial support for the NPT model, as three of the NPT factors were extracted: (1) coherence, (2) cognitive participation, and (3) reflexive monitoring. We did not find support for the fourth NPT factor (collective action). All scales showed strong internal consistency. Secondary analysis of these factors showed clinicians to generally support the implementation of the brief CBTp intervention. Conclusions This study provides strong evidence for the validity of the three NPT factors extracted. Further research is needed to determine whether participants’ level of seniority moderates factor extraction, whether this factor structure can be generalised to other healthcare settings, and whether pre-implementation attitudes predict actual implementation outcomes

Guided self-help cognitive-behaviour Intervention for VoicEs (GiVE): results from a pilot randomised controlled trial in a transdiagnostic sample

Background: Few patients have access to cognitive behaviour therapy for psychosis (CBTp) even though at least 16 sessions of CBTp is recommended in treatment guidelines. Briefer CBTp could improve access as the same number of therapists could see more patients. In addition, focusing on single psychotic symptoms, such as auditory hallucinations (‘voices’), rather than on psychosis more broadly, may yield greater benefits. Method: This pilot RCT recruited 28 participants (with a range of diagnoses) from NHS mental health services who were distressed by hearing voices. The study compared an 8-session guided self-help CBT intervention for distressing voiceswith a wait-list control. Data were collected at baseline and at 12 weekswith post-therapy assessments conducted blind to allocation. Voice-impact was the pre-determined primary outcome. Secondary outcomes were depression, anxiety, wellbeing and recovery. Mechanism measures were self-esteem, beliefs about self, beliefs about voices and voice-relating. Results: Recruitment and retention was feasible with low study (3.6%) and therapy (14.3%) dropout. There were large, statistically significant between-group effects on the primary outcome of voice-impact (d=1.78; 95% CIs: 0.86–2.70), which exceeded the minimum clinically important difference. Large, statistically significant effects were found on a number of secondary and mechanism measures. Conclusions: Large effects on the pre-determined primary outcome of voice-impact are encouraging, and criteria for progressing to a definitive trial are met. Significant between-group effects on measures of self-esteem, negative beliefs about self and beliefs about voiceomnipotence are consistentwith these beingmechanisms of change and this requires testing in a future trial

Barriers to disseminating brief CBT for voices from a lived experience and clinician perspective

Access to psychological therapies continues to be poor for people experiencing psychosis. To address this problem, researchers are developing brief interventions that address the specific symptoms associated with psychosis, i.e., hearing voices. As part of the development work for a brief Cognitive Behaviour Therapy (CBT) intervention for voices we collected qualitative data from people who hear voices (study 1) and clinicians (study 2) on the potential barriers and facilitators to implementation and engagement. Thematic analysis of the responses from both groups revealed a number of anticipated barriers to implementation and engagement. Both groups believed the presenting problem (voices and psychosis symptoms) may impede engagement. Furthermore clinicians identified a lack of resources to be a barrier to implementation. The only facilitator to engagement was reported by people who hear voices who believed a compassionate, experienced and trustworthy therapist would promote engagement. The results are discussed in relation to how these barriers could be addressed in the context of a brief intervention using CBT techniques

A systematic review and meta-analysis of low intensity CBT for psychosis

Sixteen sessions of individual cognitive behavior therapy for people with psychosis (CBTp) is recommended. However, access to CBTp is poor, so the potential of low intensity CBTp (fewer than 16 sessions of face-to-face contact) is being explored. A systematic review and meta-analysis was conducted of 10 controlled trials evaluating low intensity CBTp. Significant between-group effects were found on the primary outcome, symptoms of psychosis, at post-intervention (d = − 0.46, 95% CI: − 0.06, − 0.86) and follow-up (d = − 0.40, 95% CI: − 0.06, − 0.74). Study quality did not moderate post-intervention psychosis outcomes, nor did contact time/number of sessions or therapy format (individual versus group). Between-group effects on secondary outcomes (depression, anxiety and functioning) were not significant at post-intervention, but became significant at follow-up for depression and functioning outcomes (but not for anxiety). Overall, findings suggest that low intensity CBTp shows promise with effect sizes comparable to those found in meta-analyses of CBTp more broadly. We suggest that low intensity CBTp could help widen access. Future research is called for to identify mechanisms of change and to ascertain moderators of outcome so that low intensity CBTp targets key mechanisms (so that scarce therapy time is used effectively) and so that interventions offered are matched to patient need