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Treatment-resistant schizophrenia is a major disabling illness which often proves challenging to manage in a secondary care setting. The National Psychosis Unit (NPU) is a specialised tertiary in-patient facility that provides evidence-based, personalised, multidisciplinary interventions for complex treatment-resistant psychosis, in order to reduce the risk of readmission and long-term care costs.
This study aimed to assess the long-term effectiveness of treatment at the NPU by considering naturalistic outcome measures.
Using a mirror image design, we compared the numbers of psychiatric and general hospital admissions, in-patient days, acuity of placement, number of psychotropic medications and dose of antipsychotic medication prescribed before and following NPU admission. Data were obtained from the Clinical Records Interactive Search system, an anonymised database sourced from the South London and Maudsley NHS Trust electronic records, and by means of anonymous linkage to the Hospital Episode Statistics system.
Compared with the 2 years before NPU admission, patients had fewer mental health admissions (1.65 ± 1.44 v. 0.87 ± 0.99, z = 5.594, P < 0.0001) and less mental health bed usage (335.31 ± 272.67 v. 199.42 ± 261.96, z = 5.195 P < 0.0001) after NPU admission. Total in-patient days in physical health hospitals and total number of in-patient days were also significantly reduced (16.51 ± 85.77 v. 2.83 ± 17.38, z = 2.046, P = 0.0408; 351.82 ± 269.09 v. 202.25 ± 261.05, z = 5.621, P < 0.0001). The reduction in level of support required after treatment at the NPU was statistically significant (z = −8.099, P < 0.0001).
This study demonstrates the long-term effectiveness of a tertiary service specialising in treatment-resistant psychosis.
Clozapine is uniquely effective in treatment-resistant psychosis but remains underutilised, partly owing to psychotic symptoms leading to non-adherence to oral medication. An intramuscular formulation is available in the UK but outcomes remain unexplored.
This was a retrospective clinical effectiveness study of intramuscular clozapine prescription for treatment initiation and maintenance in treatment-resistant psychosis over a 3-year period.
Successful initiation of oral clozapine after intramuscular prescription was the primary outcome. Secondary outcomes included all-cause clozapine discontinuation 2 years following initiation, and 1 year after discharge. Discontinuation rates were compared with a cohort prescribed only oral clozapine. Propensity scores were used to address confounding by indication.
Among 39 patients prescribed intramuscular clozapine, 19 received at least one injection, whereas 20 accepted oral clozapine when given an enforced choice between the two. Thirty-six (92%) patients successfully initiated oral clozapine after intramuscular prescription; three never transitioned to oral. Eight discontinued oral clozapine during the 2-year follow-up, compared with 83 out of 162 in the comparator group (discontinuation rates of 24% and 50%, respectively). Discontinuation rates at 1-year post-discharge were 21%, compared with 44% in the comparison group. Intramuscular clozapine prescription was associated with a non-significantly lower hazard of discontinuation 2 years after initiation (hazard ratio 0.39, 95% CI 0.14–1.06) and 1 year after discharge (hazard ratio 0.37, 95% CI 0.11–1.24). The only reported adverse event specific to the intramuscular formulation was injection site pain and swelling.
Intramuscular clozapine prescription allowed transition to oral maintenance in an initially non-adherent cohort. Discontinuation rates were similar to patients only prescribed oral clozapine and comparable to existing literature.
Cognitive difficulties are common in people with psychosis and associated with considerable disability. Cognitive remediation (CR) can reduce the burden of cognitive difficulties and improve functioning. While mental health care has predominantly shifted to the community, people with greater illness severity and complexity, and those with poor response to treatment and concomitant greater cognitive difficulties, continue to receive inpatient care. The aim of this study is to review and evaluate the acceptability and efficacy of CR for inpatients with psychosis. A systematic search was used to identify randomized controlled trials of CR for inpatients with psychosis. Demographic and clinical information was extracted by independent raters together with therapy outcomes. Study quality was assessed using the Cochrane Collaboration Risk of Bias Assessment tool. Standardized mean change for cognitive and functional outcomes was calculated using Hedges's g and used to infer therapy effects with meta-analysis. Twenty studies were identified considering 1509 participants. Results from random-effect models suggested that CR was effective in improving processing speed (g = 0.48), memory (g = 0.48) and working memory (g = 0.56). While there was an indication of improvements in the levels of vocational, social and global functioning, these were less reliable. On average, 7% of participants dropped-out of treatment. Studies methodological quality was moderate. CR is an acceptable intervention for inpatients with psychosis and can lead to significant cognitive improvements. Evidence for improvement in functioning requires more robust and converging evidence. Future research should extend the evaluation of inpatient CR to subsequent post-discharge community functioning and further need for care.
Carers of people experiencing a first episode of psychosis are at an increased risk of developing their own physical and mental health problems. Psychoeducation has been found to improve carer wellbeing and reduce distress. However, few psychoeducation interventions have considered the resource constraints on mental health services and the impact that these can have on the implementation of any such interventions. The present service evaluation aimed to evaluate an abbreviated version (sole session) of a previously tested psychoeducation intervention (three sessions) that targets less adaptive illness beliefs (n = 17). Pre–post effect sizes reveal that all of the carers’ illness beliefs changed in the desired direction, with four out of the 10 illness beliefs associated with large to moderate improvements. When compared with the outcomes obtained in our evaluation of the more intensive, three-session version of the intervention, the between-group effects largely favoured the three-session version but were mostly small. Moderate to large effects in favour of the three-session version were found for two of the 10 illness beliefs. These findings support the further investigation of the sole session psychoeducation intervention as part of a randomised controlled trial.
Key learning aims
(1) To evaluate the impact of a sole-session psychoeducation intervention on illness beliefs.
(2) To compare the outcomes of the sole-session psychoeducation intervention to the previous, more intensive (three-session) version of the same intervention.
(3) To consider the value of research approaches to evaluating psychoeducation interventions for carers of people with psychosis.
Schizotypy represents a cluster of personality traits consisting of magical beliefs, perceptual aberrations, disorganisation, and anhedonia. Schizotypy denotes a vulnerability for psychosis, one reason being psychosocial stress. High expressed emotion (EE), a rating of high criticism, hostility, and emotional over-involvement from a close relative, denotes psychosocial stress and vulnerability to psychosis, and is associated with schizotypy. This study aimed to decipher the relationship of schizotypy to perceived criticism and perceived praise in terms of affect and perceived EE.
Ninety-eight healthy participants listened to short audio-clips containing criticism, praise, and neutral comments from a stranger, and evaluated them in terms of the comments’ arousal and personal relevance. Participants also answered self-report questionnaires of schizotypy, depression, mood, and perceived EE. Correlational analyses tested the relationship between schizotypy and the evaluations of criticism and praise. Mediation analyses then tested whether depression, positive mood, and perceived EE explained these relationships.
Greater relevance of standard criticism correlated with higher positive schizotypy. This association was fully mediated by high depression and perceived irritability from a close relative. Lower relevance of standard praise correlated with higher cognitive disorganisation (another schizotypal trait). This relationship was partially mediated by low positive mood and high perceived intrusiveness from a close relative.
Greater perceived criticism and lower perceived praise predict schizotypy in the healthy population. Affect and interpersonal sensitivity towards a close relative explain these relationships, such that depression increases perceived criticism, and positive mood increases perceived praise. Perceived EE defines the interpersonal nature of schizotypy.
Previous research has indicated that nightmares might be a common problem for people with psychotic symptoms. Furthermore, more distressing nightmares have been associated with higher levels of delusional severity, depression, anxiety, stress and working memory. However no known research has investigated the use of nightmare treatments in those with symptoms of psychosis. This study aimed to assess the acceptability and feasibility of using imagery rehearsal (IR) therapy as a treatment of nightmares for those presenting with co-morbid psychotic symptoms. Six participants presenting with frequent distressing nightmares and psychotic symptoms were recruited. Five participants attended 4–6 sessions of IR. Measures of nightmares, sleep quality, psychotic and affective symptoms were completed at baseline and immediately following the intervention. It was feasible to adapt IR for those experiencing psychotic symptoms. Descriptive improvements were noted on measures of nightmare-related distress, vividness and intensity. Positive post-session feedback endorsed the acceptability of IR. Nightmare frequency did not reduce following IR; however, participants described a change in emotional response. IR was an acceptable and feasible intervention for this small sample. A larger study powered to detect group changes, with an additional control is warranted to test the efficacy of the intervention for those with psychosis.
Caregivers make a significant and growing contribution to the social and
medical care of people with long-standing disorders. The effective
provision of this care is dependent on their own continuing health.
To investigate the relationship between weekly time spent caregiving and
psychiatric and physical morbidity in a representative sample of the
population of England.
Primary outcome measures were obtained from the Adult Psychiatric
Morbidity Survey 2007. Self-report measures of mental and physical health
were used, along with total symptom scores for common mental disorder
derived from the Clinical Interview Schedule – Revised.
In total, 25% (n = 1883) of the sample identified
themselves as caregivers. They had poorer mental health and higher
psychiatric symptom scores than non-caregivers. There was an observable
decline in mental health above 10 h per week. A twofold increase in
psychiatric symptom scores in the clinical range was recorded in those
providing care for more than 20 h per week. In adjusted analyses, there
was no excess of physical disorders in caregivers.
We found strong evidence that caregiving affects the mental health of
caregivers. Distress frequently reaches clinical thresholds, particularly
in those providing most care. Strategies for maintaining the mental
health of caregivers are needed, particularly as demographic changes are
set to increase involvement in caregiving roles.
Cognitive remediation therapy (CRT) is a psychological therapy which has been shown to be effective in improving cognitive functioning in service users with schizophrenia spectrum disorders. There are challenges to routinely implementing CRT within inpatient services due to a limited availability of therapists to deliver it. This paper describes a model of service delivery piloted in a specialist inpatient psychosis service which included health-care assistants (HCAs) working under the supervision of a clinical psychologist to help deliver CRT. The experience of the HCAs in undertaking this work is described from a first-person perspective.
In up to a quarter of patients, schizophrenia is resistant to standard treatments. We undertook a naturalistic study of 153 patients treated in the tertiary referral in-patient unit of the National Psychosis Service based at the Maudsley Hospital in London. A retrospective analysis of symptoms on admission and discharge was undertaken using the OPCRIT tool, along with preliminary economic modelling of potential costs related to changes in accommodation.
In-patient treatment demonstrated statistically significant improvements in all symptom categories in patients already identified as having schizophrenia refractory to standard secondary care. The preliminary cost analysis showed net savings to referring authorities due to changes from pre- to post-discharge accommodation.
Despite the enormous clinical, personal and societal burden of refractory psychotic illnesses, there is insufficient information on the outcomes of specialised tertiary-level care. Our pilot data support its utility in all domains measured.
Background: Historically, it has been difficult to demonstrate an impact of training in psychological interventions for people with psychosis on routine practice and on patient outcomes. A recent pilot evaluation suggested that postgraduate training in Cognitive Behavioural Therapy for Psychosis (CBTp) increased the delivery of competent therapy in routine services. In this study, we evaluated clinical outcomes for patients receiving therapy from therapists who successfully completed training, and their association with ratings of therapist competence and therapy content. Aims: To characterize the therapy delivered during training and to inform both a calculation of effect size for its clinical impact, and the development of competence benchmarks to ensure that training standards are sufficient to deliver clinical improvement. Method: Paired patient-reported outcome measures (PROMS) were extracted from anonymized therapy case reports, and were matched with therapy ratings for each therapist. Results: Twenty clients received a course of competent therapy, including a high frequency of active therapy techniques, from nine therapists. Pre–post effect size for change in psychotic symptoms was large (d = 1.0) and for affect, medium (d = 0.6), but improved outcomes were not associated with therapist competence or therapy content. Conclusions: Therapists trained to research trial standards of competence achieved excellent clinical outcomes. Therapy effect sizes suggest that training costs may be offset by clinical benefit. Larger, methodologically stringent evaluations of training are now required. Future research should assess the necessary and sufficient training required to achieve real-world clinical effectiveness, and the cost-effectiveness of training.
Background: Increasing access to evidence-based talking therapies for people with psychosis is a national health priority. We have piloted a new, “low intensity” (LI) CBT intervention specifically designed to be delivered by frontline mental health staff, following brief training, and with ongoing supervision and support. A pilot feasibility study has demonstrated significant improvement in service user outcomes. This study is a qualitative analysis of the experiences of the staff and service users taking part in the evaluation. Aims: To evaluate the acceptability of the training protocol and the therapy, and to examine the factors promoting and restraining implementation. Method: All trained staff and service users completed a semi-structured interview that was transcribed and subjected to thematic analysis. Results: Service users spoke about learning new skills and achieving their goals. Staff spoke about being able to use a brief, structured intervention to achieve positive outcomes for their clients. Both groups felt that longer, more sophisticated interventions were required to address more complex problems. The positive clinical outcomes motivated therapists to continue using the approach, despite organizational barriers. Conclusions: For both trained staff and service users, taking part in the study was a positive experience. Staff members’ perceived skill development and positive reaction to seeing their clients improve should help to promote implementation. Work is needed to clarify whether and how more complex difficulties should be addressed by frontline staff.
Aim – The aim of the study was to determine how carer need for closure relates to expressed emotion. It also examined the links between carer need for closure and patient functioning including patient need for closure. Methods – In a cross-sectional study, 70 caregivers of patients with psychosis completed the Need for Closure Scale (NFCS), the Camberwell Family Interview (CFI) and measures of distress, burden, coping and social network. The NFCS was assessed in terms of its two primary dimensions: a need for simple structure (NFSS) and Decisiveness. Patients also completed measures of psychotic symptoms and affect, and in 50 matched caregiver patient dyads, direct comparisons were undertaken between caregiver and patient NFCS scores. Results – No links were found between caregiver NFC and EE in this predominately low EE sample. More decisive carers had higher levels of self esteem, were less distressed, and resorted less to avoidant coping. The need for simple structure was greater in carers who lacked a confidante. As predicted, patients reported significantly higher NFSS and lower Decisiveness scores than carers, but no relationship was observed between caregiver NFC and patient symptoms of psychosis. Conclusions – Carers reporting confident decision making were also more likely to report adaptive functioning in terms of having lower levels of avoidant coping and distress, and higher levels of self esteem. The results suggest that this style of thinking might be a helpful way of coping with some of the difficulties involved in caring for someone with psychosis.
There is a long history of research into the attributes of carers of
people with psychosis, but few interventions target their distress or
To describe an empirically based model of the relationships of those
caring for people with psychosis to inform clinical and theoretical
We developed a model of informal carer relationships in psychosis, based
on an integration of the literature elaborating the concept of expressed
emotion. The model accounts for divergent outcomes of three relationship
types: positive, overinvolved and critical/hostile relationships.
Good evidence supports a number of hypotheses concerning the origin and
maintenance of these relationship outcomes, which relate to specific
differences in carer attributions, illness perceptions, coping behaviour,
social support, distress, depression and low self-esteem predicted by our
model. We propose that interventions aimed at modifying the specific
maintenance factors involved in the different styles of relationships
will optimise therapeutic change both for service users with psychosis
and for their carers.
Family work in psychosis, which improves relationships through
problem-solving, reduces service user relapse. It is now time to consider
theory-based interventions focused on improving carer outcomes.
This paper reports the psychometric properties of a CBT for psychosis adherence scale, the Revised Cognitive Therapy for Psychosis Adherence Scale (R-CTPAS). The scale's factor structure, inter-rater reliability and concurrent validity were analysed in a sample of 67 audiotaped sessions of CBT for psychosis. The concurrent validity of the scale was examined through comparison with the Cognitive Therapy Scale (CTS, Young and Beck, 1980). Principal components analysis of the trial data suggested three factors: “engagement/assessment work”, “relapse prevention work” and “formulation/schema work”. Satisfactory levels of inter-rater reliability were established between rater dyads. Moderate correlations with the CTS provided an indication of concurrent validity. The R-CTPAS is concluded to be a reliable and useful instrument that can assess adherence to CBT for psychosis using the Fowler, Garety and Kuipers (1995) therapy model.
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