Jerica Radez - Thesis submitted in partial fulfilment of the degree of Doctor of Clinical Psychology (DClinPsych)

Identifying individuals at risk of developing psychosis: A systematic review of the literature in primary care services. Aim: Psychosis and related disorders are a major public health issue. Early identification and prevention for those at high risk (at-risk-mental-state, ARMS) is important. General practitioners (GPs) are often the first point of contact for health services. In this review we aim to identify 1) the most common methods for identifying individuals with an ARMS in primary care, 2) the methods for improving identification of individuals with an ARMS in primary care, and 3) the most common barriers that prevent GPs from screening for individuals with an ARMS. Methods: We conducted a systematic review (PROSPERO CRD42021245095) of quantitative and qualitative studies with no date restriction. Searches were performed in September 2021. Studies’ quality was appraised using Mixed Methods Appraisal tool (MMAT). Results: We identified 16 eligible studies, and all but one provided quantitative data. Nearly two-thirds of studies were classified as ‘medium’ quality. Employing narrative synthesis, we identified three themes relating to 1) improving GP knowledge and confidence in identifying individuals with an ARMS, 2) balancing the over- and under-identification of individuals with an ARMS in primary care, and 3) supporting GPs as significant stakeholders in early diagnosis and treatment of individuals with an ARMS. Conclusions: Improved identification of individuals with an ARMS is needed. We identified various strategies, including development and implementation of identification methods (e.g., screening measures), educational interventions for GPs (e.g., workshops), and systemic interventions (e.g., simplifying referrals to secondary care, developing integrated services). When implemented successfully, these interventions may help facilitate the access to appropriate care for individuals with an ARMS

Improving access to treatment for anxiety and depressive disorders in adolescents by understanding barriers to seeking help and developing a short screening questionnaire

Anxiety and depressive disorders are the most common mental health disorders in adolescents. However, only a minority of those affected access evidence-based professional help. Understanding the reasons for not seeking or accessing professional help from the perspectives of young people is crucial to address this treatment gap. The aims of this thesis were to 1) identify the most common reasons that stop young people from seeking and accessing help (Paper 1), 2) explore barriers and facilitators to helpseeking/accessing among adolescents who met diagnostic criteria for anxiety and/or depressive disorders and were identified in a community (Paper 2), and 3) identify ways to reduce barriers to seeking/accessing treatment for anxiety and depressive disorders in adolescents (Papers 2 and 3). A multiple methods approach was chosen to fully address the complexity of the thesis aims. Findings identified a large number of barriers and facilitators that influence adolescents’ help-seeking behaviour. Notably, barriers and facilitators were identified at the level of adolescents, their support network, professional services and the broader context. The findings have clear implications for reducing barriers to adolescent mental health treatment. Firstly, mental health knowledge among young people and surrounding adults (parents and professionals) needs to improve. Brief and accurate identification tools, such as a set of 11 RCADS items developed in this thesis, have the potential to help various stakeholders identify adolescents with anxiety and/or depressive disorders in community settings. Secondly, adolescents’, parents’ and broader societal negative attitudes and views towards mental health and help-seeking need to be reduced. Finally, efforts need to be made to enable adolescents and their families to access evidence-based support. Future research should focus on developing developmentally appropriate interventions to improve treatment rates for anxiety and depressive disorders in adolescents. Including young people in each step of the research will be essential

Cognitive behavioural therapy for psychogenic nonepileptic seizures (PNES) in an adult with a learning disability: a case study

Background Psychogenic nonepileptic seizures (PNES) are attacks that often look like epileptic seizures (ES). Unlike ES, PNES are not triggered by underlying neurological factors. PNES are relatively rare in the general population; however, their prevalence in people with learning disabilities is much higher—up to 10%. Individuals with PNES and learning disabilities often have psychiatric comorbidities, such as anxiety disorders, depression and posttraumatic stress disorder. There are currently no treatment guidelines for PNES in people with or without learning disabilities. However, talking therapies, such as cognitive-behavioural therapy (CBT), are recommended. This study explores the effectiveness of CBT for the treatment of PNES in a woman (Susan) with PNES and learning disabilities. Methods We used a single-case experimental design (SCED) to investigate the effectiveness of CBT intervention. Specifically, the withdrawal (also known as ABA) design was applied. The patient's average PNES frequency, as well as idiosyncratic mood measure and standardised outcome measures for people with learning disabilities (Glasgow Anxiety Scale for People with an Intellectual Disability and Mini-Maslow Assessment of Needs Scale-Learning Disabilities), were used to assess the effectiveness of treatment. Findings Results show that Susan's monthly PNES frequency reduced from phase A1 (assessment phase) to phase B (treatment phase), and this persisted to the follow-up phase (phase A2). However, the reduction was not statistically significant. The intervention was associated with improvements in Susan's mood, anxiety and quality of life. Reduction of Susan's anxiety was clinically significant. Conclusions This SCED study demonstrates that CBT might be associated with reduction of PNES frequency and improvements in general functioning in people with PNES and learning disabilities; however, further research, especially around confounding variables is needed

Understanding unusual sensory experiences: a randomised experimental study of a school-based intervention for adolescents

Background: One in ten young people experience unusual sensory experiences (USE), such as hallucinations. From a cognitive perspective, the appraisal of USE determines the impact of these experiences. Negative appraisal, as well as other psychological processes (e.g. thinking flexibility, maladaptive schemas, anxiety/depression), is associated with more distress. Our aim was to (a) develop a universal single-session school-based intervention on USE for adolescents and (b) evaluate the effect of the intervention on appraisals of and help seeking intentions for USE. Methods: A randomised controlled experimental design with a one-month follow-up was used to test the effectiveness of the intervention in one school. Students (n = 223) aged 12–13 were randomised by class to a single-session intervention on USE or a control intervention (generic mental wellbeing). Participants completed measures of appraisals of and help-seeking intentions for USE at pre- and postintervention and at one-month follow-up. They also completed measures of schemas, thinking flexibility and anxiety/depression at preintervention. Results: Overall, 190 adolescents completed the main outcome measures at all three points. The intervention on USE led to a significant (p < .05) increase of positive appraisals of USE compared with the control, with effects sustained at one-month follow-up. The intervention on USE did not lead to significantly greater help-seeking intentions for USE (p = .26). Adolescents' schemas were associated with appraisals and slow thinking and anxiety/depressive symptoms with help-seeking behaviour for USE. Conclusions: A single-session universal school-based intervention shows promise by improving appraisals of USE. Further research is required across different school populations

The experience of seeking and accessing help from mental health services among young people of Eastern European backgrounds: A qualitative interview study

Objectives: Most lifetime mental health problems (MHP) start before the age of 25. Yet young people—particularly those of minority backgrounds—often do not seek or access professional help. In the UK, young people of Eastern European (EE) backgrounds represent a large minority group; however, little is known about their experiences of MHP and help‐seeking. In this study, we aim to understand the help‐seeking process from the perspectives of EE young people. Design: We used a qualitative study design with semi‐structured individual interviews. The results were analysed using reflexive thematic analysis. Method: Twelve young people (18–25 years) of EE backgrounds, living in Oxfordshire, UK, took part. All participants had experienced a severe MHP and were identified in the community. Results: EE young people's experiences of MHP and help‐seeking were driven by a sense of being caught between different cultures and simultaneously needing to navigate the potentially contrasting expectations of both cultures. This process was reinforced or tempered by the perceived continuing influence of young people's families, that is, families with more open views about MHP made it easier for young people to navigate through the process of help‐seeking. Young people's internalised cultural and familial beliefs about MHP affected their decision‐making when experiencing difficulties, their levels of trust in services, and perceived sense of resourcefulness and ability to cope. Conclusions: Recognising and responding to the cultural tension that young people of EE backgrounds may experience can help us to develop more accessible and inclusive mental health services

Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies

Mental health disorders in children and adolescents are highly prevalent yet undertreated. A detailed understanding of the reasons for not seeking or accessing help as perceived by young people is crucial to address this gap. We conducted a systematic review (PROSPERO 42018088591) of quantitative and qualitative studies reporting barriers and facilitators to children and adolescents seeking and accessing professional help for mental health problems. We identified 53 eligible studies; 22 provided quantitative data, 30 provided qualitative data, and one provided both. Four main barrier/facilitator themes were identified. Almost all studies (96%) reported barriers related to young people’s individual factors, such as limited mental health knowledge and broader perceptions of help-seeking. The second most commonly (92%) reported theme related to social factors, for example, perceived social stigma and embarrassment. The third theme captured young people’s perceptions of the therapeutic relationship with professionals (68%) including perceived confidentiality and the ability to trust an unknown person. The fourth theme related to systemic and structural barriers and facilitators (58%), such as financial costs associated with mental health services, logistical barriers, and the availability of professional help. The findings highlight the complex array of internal and external factors that determine whether young people seek and access help for mental health difficulties. In addition to making effective support more available, targeted evidence-based interventions are required to reduce perceived public stigma and improve young people’s knowledge of mental health problems and available support, including what to expect from professionals and services

Adolescents’ perceived barriers and facilitators to seeking and accessing professional help for anxiety and depressive disorders: a qualitative interview study

Anxiety and depressive disorders are the most common mental health disorders in adolescents, yet only a minority of young people with these disorders access professional help. This study aims to address this treatment gap by improving our understanding of barriers and facilitators to seeking/accessing professional help as perceived by adolescents with anxiety/depressive disorders identified in the community. Twenty-two adolescents, aged 11–17 years, who met diagnostic criteria for a current anxiety and/or depressive disorder were identified through school-based screening. In-depth qualitative interviews were conducted one-to-one with each adolescent and adolescents’ parents were interviewed separately for the purpose of data triangulation. Data were analysed using reflexive thematic analysis. We identified four themes capturing adolescent perceived barriers and facilitators to seeking/accessing professional help for anxiety and depressive disorders: (1) making sense of difficulties, (2) problem disclosure, (3) ambivalence to seeking help, and (4) the instrumental role of others. Barriers/facilitators identified within each theme reflect important developmental characteristics of adolescence, such as a growing need for autonomy and concerns around negative social evaluation. At the same time, the results highlight adolescents’ dependency on other people, mainly their parents and school staff, when it comes to successfully accessing professional help for their mental health difficulties. This study identifies a number of barriers/facilitators that influence help-seeking behaviour of adolescents with anxiety and/or depressive disorders. These factors need to be addressed when targeting treatment utilisation rates in this particular group of young people

Using the 11-item version of the RCADS to identify anxiety and depressive disorders in adolescents

The purpose of this study was to identify items from the Revised Children’s Anxiety and Depression Scale – RCADS-C/P that provided a brief, reliable and valid screen for anxiety and/or depressive disorders in adolescents. In addition, we examined whether adding items assessing suicidal ideation (Moods and Feelings Questionnaire – MFQ- C/P) and symptom impact and duration (items adapted from the Strengths and Difficulties Questionnaire – SDQ) improved the identification of adolescents with anxiety and/or depressive disorders. We compared two samples of adolescents and their parents – a community sample, recruited through secondary schools in England (n = 214) and a clinic-referred sample, who met diagnostic criteria for anxiety and/or depressive disorder and were recruited through a university-based research clinic (n = 246). Participants completed the RCADS-C/P with additional symptom impact and duration items, and the MFQ-C/P. Using ROC curve analyses, we identified a set of 11 RCADS-C/P items (6 addressing anxiety and 5 depression symptoms) for adolescent- and parent-report. This set of 11 symptom items achieved sensitivity/specificity values > .75, which were comparable to corresponding values for the RCADS-47-C/P. Combining adolescent and parent-report improved the identification of anxiety/depression in adolescents compared to using adolescent-report alone. Finally, adding two symptom impact items further improved the sensitivity/specificity of the 11 symptom items, whereas adding suicidal ideation items did not. The 11 RCADS items accurately discriminated between the community and clinic-referred sample with anxiety and/or depressive disorders and have the potential to quickly and accurately identify adolescents with these disorders in community settings

Understanding unusual sensory experiences: a randomised experimental study of a school-based intervention for adolescents

A pilot study with adolescents, aged 12-1

Identifying individuals at risk of developing psychosis: A systematic review of the literature in primary care services

Aim Psychosis and related disorders are a major public health issue. Early identification and prevention for those at high risk (at-risk-mental-state, ARMS) is important. General practitioners (GPs) are often the first point of contact for health services. In this review we aim to identify (1) the most common methods for identifying individuals with an ARMS in primary care, (2) the methods for improving identification of individuals with an ARMS in primary care, and (3) the most common barriers that prevent GPs from screening for individuals with an ARMS. Methods We conducted a systematic review (PROSPERO 42021245095) of quantitative and qualitative studies with no date restriction. Searches were performed in September 2021. Studies' quality was appraised using Mixed Methods Appraisal tool (MMAT). Results We identified 16 eligible studies, and all but one provided quantitative data. Nearly two-thirds of studies were classified as ‘medium’ quality. Employing narrative synthesis, we identified three themes relating to (1) improving GP knowledge and confidence in identifying individuals with an ARMS, (2) balancing the over- and under-identification of individuals with an ARMS in primary care, and (3) supporting GPs as significant stakeholders in early diagnosis and treatment of individuals with an ARMS. Conclusions Improved identification of individuals with an ARMS is needed. We identified various strategies, including development and implementation of identification methods (e.g., screening measures), educational interventions for GPs (e.g., workshops), and systemic interventions (e.g., simplifying referrals to secondary care, developing integrated services). When implemented successfully, these interventions may help facilitate the access to appropriate care for individuals with an ARMS