‘Like I said about culture. You don't talk about mental health’: An interpretative phenomenological analysis of the experience of first-episode psychosis in South Asian individuals

Background There is strong evidence of inequalities in mental healthcare access, experiences and outcomes for service users belonging to Black and Asian Minority Ethnic groups experiencing psychosis. Clinicians and academics have speculated that cultural variation in conceptualisations of psychosis, alongside inequitable service provision may explain disparities. There is, however, a dearth of literature exploring this in a South Asian population, despite this ethnic group being the second largest in the United Kingdom. The present study aimed to explore how people from this minority group have experienced and made sense of first-episode psychosis (FEP). Methods A qualitative approach was used to explore the lived experience and sense-making of South Asian individuals experiencing FEP and accessing early intervention services. Eight people were interviewed using a semi-structured format. The data were analysed using Interpretative Phenomenological Analysis. Results Three superordinate themes were identified in the group analysis: (1) Disconnection from self and others (2) Doubt and dispute (3) Power and shame. Conclusions Distinctive ethnic, cultural and systemic influences were strongly evident in how people conceptualized their experiences, how they managed their sense-making and where they sought support. Experiences were discussed in the context of power and shame, and this research proposes that socio-cultural context and racialised discourses have an impact on self-concept, the experiences of help-seeking (formal and informal), and fundamentally how services help individuals from marginalized communities

Art therapy for people with dementia

Background: Art therapy is defined by the British Association of Art Therapists as: “a form of psychotherapy that uses art media as its primary mode of communication. Clients who are referred to an art therapist need not have experience or skill in art. The art therapist is not primarily concerned with making an aesthetic or diagnostic assessment of the client’s image. The overall aim of its practitioners is to enable a client to change and grow on a personal level through the use of art materials in a safe and facilitating environment”. Historically, drawings and paintings have been recognised as a useful part of therapeutic processes within psychiatric and psychological specialties, and this has been acknowledged within medical and neurology‐based disciplines. Arts‐based therapies are generally considered as interventions managing manifestations of dementia, as they may help to slow cognitive deterioration, address symptoms related to psychosocially challenging behaviours and improve quality of life. Objectives: To review the effects of art therapy as an adjunctive treatment for dementia compared with standard care and other non‐pharmacological interventions. Search methods: We identified trials from ALOIS ‐ the Cochrane Dementia and Cognitive Improvement Group’s Specialised Register ‐ on 12 May 2014, 20 March 2015, 15 January 2016, 4 November 2016, and 4 October 2017. We also handsearched the grey literature and contacted specialists in the field and authors of relevant reviews or studies to enquire about other sources of relevant information. Selection criteria: All randomised controlled trials examining art therapy as an intervention for dementia. Data collection and analysis: Two review authors independently extracted data. We examined scales measuring cognition, affect and emotional well‐being, social functioning, behaviour and quality of life. Main results: We found two studies that met the inclusion criteria, incorporating data on a total of 60 participants (from 88 randomised), in experimental groups (n = 29) and active control groups (n = 31). One study compared group art therapy with simple calculation activities over 12 weeks. The other study compared group art therapy with recreational activities over 40 weeks. It was not possible to pool the data for analysis from the included studies, due to heterogeneity in terms of differences in the interventions, control treatments and choice of outcome measures. In both studies there were no clear changes reported between the intervention group and the control group in the important outcome measures. According to GRADE ratings, we judged the quality of evidence for these outcome measures to be 'very low'. Authors' conclusions: There is insufficient evidence about the efficacy of art therapy for people with dementia. More adequately‐powered and high‐quality studies using relevant outcome measures are needed

Heritability of Individual Psychotic Experiences Captured by Common Genetic Variants in a Community Sample of Adolescents.

Occurrence of psychotic experiences is common amongst adolescents in the general population. Twin studies suggest that a third to a half of variance in adolescent psychotic experiences is explained by genetic influences. Here we test the extent to which common genetic variants account for some of the twin-based heritability. Psychotic experiences were assessed with the Specific Psychotic Experiences Questionnaire in a community sample of 2152 16-year-olds. Self-reported measures of Paranoia, Hallucinations, Cognitive Disorganization, Grandiosity, Anhedonia, and Parent-rated Negative Symptoms were obtained. Estimates of SNP heritability were derived and compared to the twin heritability estimates from the same sample. Three approaches to genome-wide restricted maximum likelihood (GREML) analyses were compared: (1) standard GREML performed on full genome-wide data; (2) GREML stratified by minor allele frequency (MAF); and (3) GREML performed on pruned data. The standard GREML revealed a significant SNP heritability of 20 % for Anhedonia (SE = 0.12; p < 0.046) and an estimate of 19 % for Cognitive Disorganization, which was close to significant (SE = 0.13; p < 0.059). Grandiosity and Paranoia showed modest SNP heritability estimates (17 %; SE = 0.13 and 14 %; SE = 0.13, respectively, both n.s.), and zero estimates were found for Hallucinations and Negative Symptoms. The estimates for Anhedonia, Cognitive Disorganization and Grandiosity accounted for approximately half the previously reported twin heritability. SNP heritability estimates from the MAF-stratified approach were mostly consistent with the standard estimates and offered additional information about the distribution of heritability across the MAF range of the SNPs. In contrast, the estimates derived from the pruned data were for the most part not consistent with the other two approaches. It is likely that the difference seen in the pruned estimates was driven by the loss of tagged causal variants, an issue fundamental to this approach. The current results suggest that common genetic variants play a role in the etiology of some adolescent psychotic experiences, however further research on larger samples is desired and the use of MAF-stratified approach recommended

Migration and Psychosis: Evidence from South Asian Communities in Bradford

Objective: To study the risk of psychosis in south Asian communities in Bradford and investigate the role of cannabis as a contributory factor. Study Design: Naturalistic studies based on electronic summary records. Place and Duration of Study: The studies were conducted at the Becklin Centre, St James's University Hospital, Leeds and the University of Leeds, School of Medicine from 2018 to 2020. Material and Method: A service evaluation and research project looking into the role of cannabis included 194 patients admitted to acute psychiatry wards at the Becklin Centre between 1st January 2016 and 30th November 2018. Epidemiological study used electronic summary records provided by the Bradford Early Intervention for Psychosis Service of 15-35-year old newly diagnosed cases with first episode psychosis in 2013-15 and local census data to calculate the risks ratios. Results: Compared with indigenous white population, Pakistanis in Bradford had significantly higher risk of psychosis (RR: 1.41, 95% CI 1.07, 1.85*). This trend was also seen in Bangladeshi community (RR 1.72, 95% CI 0.91, 3.28*). Indian community, on the other hand, experienced lower risk (RR 0.54, 95% CI 0.20, 1.27). Conclusion: We found increased risk of psychosis in Pakistani and Bangladeshi communities but not in Indian community

Are genetic risk factors for psychosis also associated with dimension-specific psychotic experiences in adolescence?

Psychosis has been hypothesised to be a continuously distributed quantitative phenotype and disorders such as schizophrenia and bipolar disorder represent its extreme manifestations. Evidence suggests that common genetic variants play an important role in liability to both schizophrenia and bipolar disorder. Here we tested the hypothesis that these common variants would also influence psychotic experiences measured dimensionally in adolescents in the general population. Our aim was to test whether schizophrenia and bipolar disorder polygenic risk scores (PRS), as well as specific single nucleotide polymorphisms (SNPs) previously identified as risk variants for schizophrenia, were associated with adolescent dimension-specific psychotic experiences. Self-reported Paranoia, Hallucinations, Cognitive Disorganisation, Grandiosity, Anhedonia, and Parent-rated Negative Symptoms, as measured by the Specific Psychotic Experiences Questionnaire (SPEQ), were assessed in a community sample of 2,152 16-year-olds. Polygenic risk scores were calculated using estimates of the log of odds ratios from the Psychiatric Genomics Consortium GWAS stage-1 mega-analysis of schizophrenia and bipolar disorder. The polygenic risk analyses yielded no significant associations between schizophrenia and bipolar disorder PRS and the SPEQ measures. The analyses on the 28 individual SNPs previously associated with schizophrenia found that two SNPs in TCF4 returned a significant association with the SPEQ Paranoia dimension, rs17512836 (p-value=2.57x10-4) and rs9960767 (p-value=6.23x10-4). Replication in an independent sample of 16-year-olds (N=3,427) assessed using the Psychotic-Like Symptoms Questionnaire (PLIKS-Q), a composite measure of multiple positive psychotic experiences, failed to yield significant results. Future research with PRS derived from larger samples, as well as larger adolescent validation samples, would improve the predictive power to test these hypotheses further. The challenges of relating adult clinical diagnostic constructs such as schizophrenia to adolescent psychotic experiences at a genetic level are discussed

Association between stressful life events and psychotic experiences in adolescence: evidence for gene-environment correlations

- Background: Stressful life events (SLEs) are associated with psychotic experiences (PEs). SLEs might act as an environmental risk factor, but may also share a genetic propensity with PEs. - Aims: Estimate the extent to which genetic and environmental factors influence the relationship between SLEs and PEs. - Method: Self and parent-reports from a community-based twin sample (4,830 16-year-old pairs) were analysed using structural equation model-fitting. - Results: SLEs correlated with positive PEs (r = .12-.14, all p<. 001). Modest heritability was shown for PEs (25-57%) and dependent SLEs (32%). Genetic influences explained the majority of the modest covariation between dependent SLEs and paranoia and cognitive disorganisation (bivariate heritabilities = 74-86%). The relationship between SLEs and hallucinations and grandiosity was explained by both genetic and common environmental effects. - Conclusion: Further to dependent SLEs being an environmental risk factor, individuals may have an underlying genetic propensity increasing their risk of dependent SLEs and positive PEs

Clinical Indicators of Symptom Dimensions and Cognitive Ability in Schizophrenia

INTRODUCTION: Schizophrenia is a heterogeneous disorder and it is unknown what causes individual variability in symptoms and cognitive ability. OBJECTIVES: To examine the association between nine clinical predictors measurable at the onset of schizophrenia and five phenotype dimensions: positive, negative (diminished expressivity), negative (motivation and pleasure), disorganised symptoms and cognitive ability. METHODS: 852 participants (mean age 49 years old) with a diagnosis of schizophrenia or schizoaffective depression were included from the CardiffCOGS cross-sectional sample. Phenotype dimensions were created using confirmatory factor analysis and a 5-factor model. Associations were tested using linear regression, adjusting for age and sex. A Bonferroni correction was applied for (p<1.1x10(-3)) for multiple testing. RESULTS: Age of onset of psychosis was significantly associated with positive symptoms (β=-0.18, p=4.0 x10(-6)). Lower premorbid IQ was associated with diminished expressivity (β=-0.25, p= 7.0x10(-13)), reduced motivation and pleasure (β=-0.23, p= 4.3x10(-11)), disorganised symptoms (β=-0.14, p= 7.6x10(-5)) and reduced cognition (β=0.54, p= 4.8x10(-77)). Poor premorbid social adjustment held associations with all except positive. Developmental delay was associated with reduced cognition (β=-0.35, p= 4.3x10(-5)). Cannabis use (year before onset), psychosocial stressors (within 6 months), childhood abuse and family history of schizophrenia held no associations. CONCLUSIONS: Clinical indicators measurable at schizophrenia onset are associated with lifetime symptom variability. A younger psychosis onset is associated with more severe positive symptoms, suggesting possible age-targeted management. Pre-established links of lower premorbid IQ with poor premorbid social adjustment and negative symptom severity with cognition are strengthened. Further investigation could potentially improve diagnosis and guide treatment choice for aspects of schizophrenia with poor outcomes. DISCLOSURE: No significant relationships

A proposal for reducing maximum target doses of drugs for psychosis: Reviewing dose–response literature

Background: Presently, there is limited guidance on the maximal dosing of psychosis drugs that is based on effectiveness rather than safety or toxicity. Current maximum dosing recommendations may far exceed the necessary degree of dopamine D2 receptor blockade required to treat psychosis. This may lead to excess harm through cognitive impairment and side effects. Aims: This analysis aimed to establish guidance for prescribers by optimally dosing drugs for psychosis based on efficacy and benefit. Methods: We used data from two dose–response meta-analyses and reviewed seven of the most prescribed drugs for psychosis in the UK. Where data were not available, we used appropriate comparison techniques based on D2 receptor occupancy to extrapolate our recommendations. Results: We found that the likely threshold dose for achieving remission of psychotic symptoms was often significantly below the currently licensed dose for these drugs. We therefore recommend that clinicians are cautious about exceeding our recommended doses. Individual factors, however, should be accounted for. We outline potentially relevant factors including age, ethnicity, sex, smoking status and pharmacogenetics. Additionally, we recommend therapeutic drug monitoring as a tool to determine individual pharmacokinetic variation. Conclusions: In summary, we propose a new set of maximum target doses for psychosis drugs based on efficacy. Further research through randomised controlled trials should be undertaken to evaluate the effect of reducing doses from current licensing maximums or from doses that are above our recommendations. However, dose reductions should be implemented in a manner that accounts for and reduces the effects of drug withdrawal

Characterization of psychotic experiences in adolescence using the Specific Psychotic Experiences Questionnaire (SPEQ): findings from a study of 5000 16-year-old twins

We aimed to characterize multiple psychotic experiences, each assessed on a spectrum of severity (ie, quantitatively), in a general population sample of adolescents. Over five thousand 16-year-old twins and their parents completed the newly devised Specific Psychotic Experiences Questionnaire (SPEQ); a subsample repeated it approximately 9 months later. SPEQ was investigated in terms of factor structure, intersubscale correlations, frequency of endorsement and reported distress, reliability and validity, associations with traits of anxiety, depression and personality, and sex differences. Principal component analysis revealed a 6-component solution: paranoia, hallucinations, cognitive disorganization, grandiosity, anhedonia, and parent-rated negative symptoms. These components formed the basis of 6 subscales. Correlations between different experiences were low to moderate. All SPEQ subscales, except Grandiosity, correlated significantly with traits of anxiety, depression, and neuroticism. Scales showed good internal consistency, test-retest reliability, and convergent validity. Girls endorsed more paranoia, hallucinations, and cognitive disorganization; boys reported more grandiosity and anhedonia and had more parent-rated negative symptoms. As in adults at high risk for psychosis and with psychotic disorders, psychotic experiences in adolescents are characterized by multiple components. The study of psychotic experiences as distinct dimensional quantitative traits is likely to prove an important strategy for future research, and the SPEQ is a self- and parent-report questionnaire battery that embodies this approach