Social recovery therapy in improving activity and social outcomes in early psychosis: current evidence and longer term outcomes

Background: Social Recovery Therapy (SRT) is a cognitive behavioural therapy which targets young people with early psychosis who have complex problems associated with severe social disability. This paper provides a nar-rative overview of current evidence for SRT and reports new data on a 2 year follow-up of participants recruited into the Improving Social Recovery in Early Psychosis (ISREP) trial. Method: In the ISREP study 50 participants (86%) were followed up at 2 years, 15 months post treatment. The pri-mary outcome was engagement in paid work, assessed using the Time Use Survey. Engagement in education and voluntary work were also assessed. In addition, the Positive and Negative Syndrome Scales (PANSS) and the Beck Hopelessness Scale (BHS) were administered. Results: 25% of individuals with non-affective psychosis in the treatment group had engaged in paid work at some point in the year following the end of therapy, compared with none of the control group. Data from the PANSS and BHS suggested no worsening of symptoms and an indication that gains in hope were maintained over the 15 month period following the end of therapy. Conclusion: Social Recovery Therapy is a promising psychological intervention which may improve social recov-ery in individuals with early psychosis. The new data reported in this paper shows evidence of gains in engage-ment in paid employment outcomes that persisted 15 months beyond the period of active intervention

Pathways to care in at-risk mental states: a systematic review

Aim: Pathways to care are well studied in the First Episode Psychosis field, but less attention has been given to At‐Risk Mental States or prodromal psychosis. This is important because accessing appropriate help at the earliest opportunity is likely to improve outcomes, particularly for those who make transition to psychosis. The present systematic review aimed to synthesize the available literature on pathways to care in ARMS or prodromal psychosis, and investigate the barriers and facilitators to receiving care for ARMS. Methods: The CINAHL Complete, EMBASE, Medline Complete, PsycINFO and PubMED databases were searched. Studies were included if they were published in English between 1985 and 2019, where reported data came exclusively from an At‐Risk Mental State population, and the study described or related to pathways to care. Results: Ten studies met the inclusion criteria, of which 8 were quantitative. Screening tools and pathways to care instruments varied. Mental health professionals, and general practitioners played a key role in help seeking. Family involvement was also found to be an important factor. Conclusions: Pathways to care research in At‐Risk Mental States are more scarce than in the field of First Episode Psychosis. More research is warranted, especially concerning the role of patient‐level characteristics on pathways to care. A validated measure of pathways to care may also be of benefit

The effectiveness of public health interventions, initiatives, and campaigns designed to improve pathways to care for individuals with psychotic disorders: A systematic review

Purpose: Lengthy duration of untreated psychosis (DUP) and duration of untreated illness (DUI) in people at clinical high-risk for psychosis (CHR-P) and first episode psychosis (FEP) is associated with poorer outcomes. However, individuals with FEP often experience negative pathways to care involving contacts with police, crisis services and requiring compulsory admissions, and evidence suggests individuals with both FEP and CHR-P often experience lengthy delays to treatment. Early detection interventions, such as public health interventions, may be one way to reduce delays. This systematic review aimed to synthesise the available evidence on such interventions. Methods: The EMBASE, PsychINFO, CINAHL, and MEDLINE databases were searched. Studies were included if they compared an intervention designed to improve timely access to treatment for individuals with FEP or CHR-P to standard treatment provision. Interventions may be targeted at potential patients, their families, the general public, or non-healthcare professionals. Outcomes of interest were DUP or DUI, and/or characteristics of pathways to care. Results: Nineteen studies met the inclusion criteria. All consisted of FEP populations, none of CHR-P populations. Employing narrative synthesis, we found mixed results about the effectiveness of interventions at reducing DUP and interventions appeared to differentially impact groups. Pathways to care information was limited and mixed. Conclusion: Findings on the effectiveness of interventions designed to improve timely access to treatment were inconclusive. More research is warranted to better understand where delays occur and factors which may influence this for both FEP and CHR-P populations which may help to develop targeted interventions to address delays

Diagnosis and dilemma: Clinician experiences of the use of ‘borderline personality disorder’ diagnosis in children and adolescents

Borderline personality disorder (BPD) diagnosis in adolescents is a relatively recent concept and a fast-emerging research area. Regarded by some as controversial, it is important for research to provide greater understanding of differing perspectives and their impact on the use of this diagnosis. Perspectives of 13 clinicians (therapists, psychiatrists and mental health nurses) were explored, to provide a contemporary understanding of perceptions and use of BPD diagnosis within child and adolescent mental health services in England. A particular focus was to explore dilemmas faced by clinicians and how these dilemmas were negotiated. This research took a qualitative, social constructionist approach to explore the in-depth views and experiences of each participant. Interviews were analysed using thematic analysis, to seek out patterns and commonalities across these clinical perspectives. Three overarching themes were generated: ‘Who holds the power?’, ‘Dilemmas within the multidisciplinary team (MDT)’ and ‘The weightiness of making this decision’. Professional opinions of an adolescent BPD diagnosis are influenced by dominant and less dominant mental health discourses, including the impact of power, and availability of resources within the service context. The role of meaningful collaboration with young people, clinical implications and directions for future research are discussed

Cognitive bias modification for social anxiety in adults who stutter: a feasibility study of a randomised controlled trial

Objective: To determine the feasibility and acceptability of a computerised treatment for social anxiety disorder for adults who stutter including identification of recruitment, retention and completion rates, large cost drivers and selection of most appropriate outcome measure(s) to inform the design of a future definitive trial. Design: Two-group parallel design (treatment vs placebo), double-blinded feasibility study. Participants: 31 adults who stutter. Intervention: Attention training via an online probe detection task in which the stimuli were images of faces displaying neutral and disgusted expressions. Main outcome measures Psychological measures: Structured Clinical Interview Global Assessment of Functioning score; Liebowitz Social Anxiety Scale; Social Phobia and Anxiety Inventory; State-Trait Anxiety Inventory; Unhelpful Thoughts and Beliefs about Stuttering. Speech fluency: percent syllables stuttered. Economic evaluation: resource use questionnaire; EuroQol three-dimension questionnaire. Acceptability: Likert Scale questionnaire of experience of trial, acceptability of the intervention and randomisation procedure. Results: Feasibility of recruitment strategy was demonstrated. Participant feedback indicated that the intervention and definitive trial, including randomisation, would be acceptable to adults who stutter. Of the 31 participants who were randomised, 25 provided data at all three data collection points. Conclusions: The feasibility study informed components of the intervention. Modifications to the design are needed before a definitive trial can be undertaken. Trial registration number I SRCTN55065978

The course of negative symptom in first episode psychosis and the relationship with social recovery.

AIMS: To investigate trajectories of negative symptoms during the first 12months of treatment for first episode psychosis (FEP), their predictors and relationship to social recovery. METHOD: 1006 participants were followed up for 12months following acceptance into Early Intervention in Psychosis services. Negative symptom trajectories were modelled using latent class growth analysis (LCGA) and predictors of trajectories examined using multinomial regression. Social recovery trajectories - also modelled using LCGA - of members of each negative symptom trajectory were ascertained and the relationship between negative symptom and social recovery trajectories examined. RESULTS: Four negative symptom trajectories were identified: Minimal Decreasing (63.9%), Mild Stable (13.5%), High Decreasing (17.1%) and High Stable (5.4%). Male gender and family history of non-affective psychosis predicted stably high negative symptoms. Poor premorbid adolescent adjustment, family history of non-affective psychosis and baseline depression predicted initially high but decreasing negative symptoms. Members of the Mild Stable, High Stable and High Decreasing classes were more likely to experience stably low functioning than the Minimal Decreasing class. CONCLUSIONS: Distinct negative symptom trajectories are evident in FEP. Only a small subgroup present with persistently high levels of negative symptoms. A substantial proportion of FEP patients with elevated negative symptoms at baseline will achieve remission of these symptoms within 12months. However, elevated negative symptoms at baseline, whether or not they remit, are associated with poor social recovery, suggesting targeted interventions for service users with elevated baseline negative symptoms may help improve functional outcomes.This is the author accepted manuscript. The final version is available from Elsevier via http://dx.doi.org/10.1016/j.schres.2016.04.01

Social recovery therapy in combination with early intervention services for enhancement of social recovery in patients with first-episode psychosis (SUPEREDEN3): a single-blind, randomised controlled trial

SUMMARY Background: We conducted a randomised controlled trial to evaluate the efficacy of enhancing social recovery from First Episode Psychosis (FEP) by augmenting Early Intervention Service (EIS) provision with Social Recovery Therapy (SRT). The primary hypothesis was that SRT plus EIS would lead to improvements in social recovery. Methods: SUPEREDEN3 was an assessor blind randomised controlled trial. It was conducted at 4 specialist Early Intervention Services across the UK. Participants had (a) been clients of Early Intervention Services for 12-30 months; and (b) showed persistent and severe social disability defined as engaged in less than 30 hours per week of structured activity. Participants were randomised 1:1. Assessment of outcomes was conducted at baseline, 9 months (post intervention) and 15 month follow up. The primary outcome was time spent in structured activity at 9 months. The trial is registered (ISRCTN61621571). Findings: 75 (49%) of 154 participants were assigned to SRT plus EIS and 79 (51%) were assigned to EIS alone. At 9 months 143 participants (93%) provided data on the primary outcome. Randomisation to SRT plus EIS was associated with an increase in structured activity of 8.1 hours greater than EIS alone (95% CI 2.5 to 13.6; p = 0.0050). Jointly modelling loss to follow up and secondary outcomes provided supportive evidence of continued effects of SRT plus EIS. Interpretation: The findings show a clinically important benefit of enhanced social recovery for the SRT plus EIS group on the primary outcome of structured activity. Funding: National Institute for Health Research (NIHR)

Persecutory delusions: Effects of cognitive bias modification for interpretation and the Maudsley Review Training Programme on social anxiety, jumping to conclusions, belief inflexibility and paranoia

Background and objectives: The Threat Anticipation Model (Freeman, 2007) implicates social anxiety, jumping to conclusions (JTC) and belief inflexibility in persecutory delusions. We investigated whether Cognitive Bias Modification for Interpretation (CBM-I; Turner et al., 2011) improves social anxiety by targeting negative interpretation bias of ambiguous social information. We determined whether the Maudsley Review Training Programme (MRTP; Waller et al., 2011) improves JTC, belief inflexibility and paranoia. We also explored effects of CBM-I on JTC/belief inflexibility and paranoia, as well as the MRTP on social anxiety. Methods: Twelve participants from Early Intervention and Recovery Services in East Anglia completed measures of social anxiety, paranoia, JTC and belief inflexibility. A concurrent multiple baseline case series design was used. Results: Three of twelve participants improved in social anxiety following CBM-I, paranoia improved in 6/12 cases. CBM-I had no effect on JTC/belief inflexibility. The MRTP improved JTC and/or belief inflexibility in 9/12 cases, while improving paranoia for 6/12 individuals. The MRTP improved social anxiety in one case. Limitations: The small sample size and large effects necessary for single case series designs limit the generality of findings. These are discussed in more detail. Conclusions: This study suggests that whilst both CBM-I and the MRTP may have a positive impact on paranoia and social anxiety, the effects on JTC/belief inflexibility are largely specific to the MRTP. Relationships between social anxiety, JTC, belief inflexibility and paranoia existed in 10/12 individuals, supporting the Threat Anticipation Model