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This long-awaited third edition of Seminars in General Adult Psychiatry provides a highly readable and comprehensive account of modern general adult psychiatry. The text has been fully updated throughout by leading figures in modern psychiatry. This new edition covers developments in the understanding of mental disorders, service delivery, changes to risk assessment and management, collaborate care plans and 'trauma-informed' care. Coverage will also be given to the implementation of the ICD-11 and DSM-5 classification systems, and the impact on diagnosis and treatment. Key features of the previous edition that have been updated include the detailed clinical descriptions of psychiatric disorders and historical sections with access to the classic studies of psychiatry. Additional topics include autism, ADHD and physical health. This is a key text for psychiatric trainees studying for their MRCPsych exams, and a source of continuing professional development for psychiatrists and other mental health professionals.
Measuring outcomes is becoming an increasingly standard (and highly complex) part of what mental health services are expected to do. Practising psychiatrists will need to have a good understanding of approaches to outcome measurement: used well, they have the potential to amplify the patient voice, promote good-quality services and facilitate research. We discuss what constitutes an outcome measure, the different ways that such measures can be obtained and the mechanisms for assessing the quality and appropriateness of an outcome measure. We outline the rapidly evolving research and policy context regarding outcome measurement, with particular reference to the UK's National Health Service. We also consider the potential pitfalls to outcome measurement, such as added clinical burden, inappropriate incentivisation of behaviour and incorrect interpretation of results. We discuss ways that such difficulties can be avoided or their effects mitigated.
Biological research has produced major advances in our understanding of our bodies and, where systems go wrong, is producing remedies to address these, but it has yet to do the same for the mind. This is because no causative biological evidence has been found for the major mental disorders in contrast to the wealth of psychosocial findings. This disparity in regard and resource needs to be addressed.
The Green et al., Paranoid Thoughts Scale (GPTS) – comprising two 16-item scales assessing ideas of reference (Part A) and ideas of persecution (Part B) – was developed over a decade ago. Our aim was to conduct the first large-scale psychometric evaluation.
In total, 10 551 individuals provided GPTS data. Four hundred and twenty-two patients with psychosis and 805 non-clinical individuals completed GPTS Parts A and B. An additional 1743 patients with psychosis and 7581 non-clinical individuals completed GPTS Part B. Factor analysis, item response theory, and receiver operating characteristic analyses were conducted.
The original two-factor structure of the GPTS had an inadequate model fit: Part A did not form a unidimensional scale and multiple items were locally dependant. A Revised-GPTS (R-GPTS) was formed, comprising eight-item ideas of reference and 10-item ideas of persecution subscales, which had an excellent model fit. All items in the new Reference (a = 2.09–3.67) and Persecution (a = 2.37–4.38) scales were strongly discriminative of shifts in paranoia and had high reliability across the spectrum of severity (a > 0.90). The R-GPTS score ranges are: average (Reference: 0–9; Persecution: 0–4); elevated (Reference: 10–15; Persecution: 5–10); moderately severe (Reference: 16–20; Persecution:11–17); severe (Reference: 21–24; Persecution: 18–27); and very severe (Reference: 25+; Persecution: 28+). Recommended cut-offs on the persecution scale are 11 to discriminate clinical levels of persecutory ideation and 18 for a likely persecutory delusion.
The psychometric evaluation indicated a need to improve the GPTS. The R-GPTS is a more precise measure, has excellent psychometric properties, and is recommended for future studies of paranoia.
Refractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.
To estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627).
We undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life.
The additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold.
In its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.
Declaration of interest
R.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.
Individuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression.
To compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627).
RO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated.
After 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94–9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI –2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI –2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group.
The RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.
Implementation of evidence-based psychosocial interventions in accordance with National Institute of Health and Care Excellence guidelines and quality standards has been incomplete. This project involved allocation of adults under mental health services to six guideline categories, completion of a clinician- and patient-rated outcome measure, and individual assessment against clinical standards.
In the first 3 months of the project, 5048 patients were allocated to a pathway and 3734 (73%) were assessed against at least one of the relevant standards. All were assessed using the Health of the Nation Outcome Scales (91–93% of scales completed) and 1866 (36%) completed the patient-rated outcome measure, DIALOG.
Clinicians will allocate patients to pathways, complete outcome measures and assess against standards, providing data to guide practice, service design and costing of mental health systems with supporting technology to assist data entry and presentation. This has the potential to provide much improved and readily accessible information about individual outcomes and standards for people with mental health problems and those working with them. It could also provide a method for payment for services which directly support good clinical practice.
Cognitive behaviour therapy (CBT) as a treatment for schizophrenia and psychotic-related disorders has been shown to have significantly greater drop-out rates in clients of black and minority ethnic (BME) groups. This has resulted in poor outcomes in treatments. Our recent qualitative study thus aimed to develop culturally sensitive CBT for BME clients. The study consisted of individual in-depth 1:1 interviews with patients with a diagnosis of schizophrenia, schizo-affective, delusional disorders or psychosis (n = 15) and focus groups with lay members (n = 52), CBT therapists (n = 22) and mental health practitioners (n = 25) on a data set of 114 participants. Several themes emerged relating to therapist awareness on culturally derived behaviours, beliefs and attitudes that can influence client response and participation in therapy. The current paper aims to explore one of these themes in greater detail, i.e. client-initiated therapist self-disclosure (TSD). Using thematic analysis, the paper highlights key elements of TSD and how this could impact on therapist’s reactions towards TSD, the therapeutic alliance and ultimately, the outcomes of therapy. The findings appear to show that TSD has significant relevance in psychological practice today. Some BME client groups appear to test therapists through initiating TSD. It is not the content of TSD they are testing per se, but how the therapist responds. Consequently, this requires therapists’ cognisance and sensitive responses in a manner that will nurture trust and promote rapport. Further investigation in this area is suggested with a recommendation for guidelines to be created for clinicians and training.
Key learning aims
(1) To develop a dialogue and practice with confidence when addressing issues of self-disclosure with diverse populations.
(2) To appreciate the impact therapist self-disclosure has in early stages of engagement, in particular when working with patients from BME communities.
(3) To understand the impact and role of self-disclosure as initiated by patients.
(4) To increase therapist awareness on cultural differences in self-disclosure and develop ways to address this in therapy.
(5) To challenge therapists to adapt psychological therapies to diverse cultures and be cognisant that ‘one size does not fit all’.
The cognitive process of worry, which keeps negative thoughts in mind and elaborates the content, contributes to the occurrence of many mental health disorders. Our principal aim was to develop a straightforward measure of general problematic worry suitable for research and clinical treatment. Our secondary aim was to develop a measure of problematic worry specifically concerning paranoid fears.
An item pool concerning worry in the past month was evaluated in 250 non-clinical individuals and 50 patients with psychosis in a worry treatment trial. Exploratory factor analysis and item response theory (IRT) informed the selection of scale items. IRT analyses were repeated with the scales administered to 273 non-clinical individuals, 79 patients with psychosis and 93 patients with social anxiety disorder. Other clinical measures were administered to assess concurrent validity. Test-retest reliability was assessed with 75 participants. Sensitivity to change was assessed with 43 patients with psychosis.
A 10-item general worry scale (Dunn Worry Questionnaire; DWQ) and a five-item paranoia worry scale (Paranoia Worries Questionnaire; PWQ) were developed. All items were highly discriminative (DWQ a = 1.98–5.03; PWQ a = 4.10–10.7), indicating small increases in latent worry lead to a high probability of item endorsement. The DWQ was highly informative across a wide range of the worry distribution, whilst the PWQ had greatest precision at clinical levels of paranoia worry. The scales demonstrated excellent internal reliability, test-retest reliability, concurrent validity and sensitivity to change.
The new measures of general problematic worry and worry about paranoid fears have excellent psychometric properties.
The Care Programme Approach (CPA) has been instrumental in embedding principles of holistic collaborative assessment and management into mental health care. Initially, its implementation was assisted by targeting those at greatest need. However dichotomising patients into more and less severe is now considered unhelpful and has been demonstrated to be unreliable. Division of patients into severe and not severe categories is no more logical than such a division of patients with physical health problems. CPA principles are now applied to all patients in mental health services and practice needs to move to individualised care, focusing on meeting quality standards and achieving positive outcomes. A system based on evidence-based clinical pathways and reliable measures of severity and need should replace the current approach.
Efforts to assess and improve the quality of mental health services are often hampered by a lack of information on patient outcomes. Most mental health services in England have been routinely collecting Health of the Nation Outcome Scales (HoNOS) data for some time. In this article we illustrate how clinical teams have used HoNOS data to identify areas where performance could be improved. HoNOS data have the potential to give clinical teams the information they need to assess the quality of care they deliver, as well as develop and test initiatives aimed at improving the services they provide.
Brief cognitive–behavioural therapy (CBT) is an emerging treatment for
schizophrenia in community settings; however, further trials are needed,
especially in non-Western countries.
To test the effects of brief CBT for Chinese patients with schizophrenia
in the community (trial registration: ChiCTR-TRC-13003709).
A total of 220 patients with schizophrenia from four districts of Beijing
were randomly assigned to either brief CBT plus treatment as usual (TAU)
or TAU alone. Patients were assessed at baseline, post-treatment and at
6- and 12-month follow-ups by raters masked to group allocation.
At the post-treatment assessment and the 12-month follow-up, patients who
received brief CBT showed greater improvement in overall symptoms,
general psychopathology, insight and social functioning. In total, 37.3%
of those in the brief CBT plus TAU group experienced a clinically
significant response, compared with only 19.1% of those in the TAU alone
group (P = 0.003).
Brief CBT has a positive effect on Chinese patients with schizophrenia in
Cognitive–behavioural therapy (CBT) can be used across cultures, but only if appropriately adapted (Rathod et al, 2010). A personalised and pragmatic therapy, CBT uses reasoning to provide a conceptual framework of mental illness that is not inconsistent with Eastern and other philosophies (Rathod & Kingdon, 2009). The client (patient) and therapist develop a collaborative understanding of the client's perceived problems, so that a mutually respectful exploration of the problem can be developed to work on the issues identified (Bhui & Bhugra, 2004). The collaborative approach allows the patient to take an active role as an expert of their own culture and the therapist to personalise the therapy to the patient's needs.
People with depressive illness and anxiety usually have beliefs about the self, others and the world that are unhelpful. Cognitive–behavioural therapy involves exploration of these core beliefs and attempts to modify them, and there is a strong focus on involvement of the patient in the therapeutic process. However, core beliefs, underlying assumptions and even the content of automatic thoughts might vary with culture (Padesky & Greenberger, 1995). The practice of CBT without adaptation in minority groups can adversely affect the therapeutic alliance between patient and therapist and risks disengagement of patients from therapy (Rathod et al, 2005). In patients, this can lead to disappointment and loss of hope, particularly as people from ethnic minority groups are less likely to trust mental health services in the first place (Thornicroft et al, 1999). In therapists, a patient's disengagement might leave them feeling incompetent, especially if they do not understand the cultural issues involved.
Griner & Smith (2006), in their meta-analysis, provided suggestive evidence that culturally adapted interventions are effective. Some findings pointed to the possibility that clients who had the greatest need for accommodations (i.e. poorly acculturated, non-English-speaking adults) received the greatest benefit from such adaptations. Small pilots from many cultural groups have found adapted CBT to be successful in ethnic minority populations (Patel et al, 2007; Rojas et al, 2007; Rahman et al, 2008). Muñoz and colleagues have conducted a number of studies on the cultural adaptation of CBT for the treatment and prevention of depression in adults from ethnic minority groups in the USA (e.g. Kohn et al, 2002; Miranda et al, 2003; Muñoz & Mendelson, 2005).
A better therapeutic relationship predicts better outcomes. However,
there is no trial-based evidence on how to improve therapeutic
relationships in psychosis.
To test the effectiveness of communication training for psychiatrists on
improving shared understanding and the therapeutic relationship (trial
In a cluster randomised controlled trial in the UK, 21 psychiatrists were
randomised. Ninety-seven (51% of those approached) out-patients with
schizophrenia/schizoaffective disorder were recruited, and 64 (66% of the
sample recruited at baseline) were followed up after 5 months. The
intervention group received four group and one individualised session.
The primary outcome, rated blind, was psychiatrist effort in establishing
shared understanding (self-repair). Secondary outcome was the therapeutic
Psychiatrists receiving the intervention used 44% more self-repair than
the control group (adjusted difference in means 6.4, 95% CI 1.46–11.33,
P<0.011, a large effect) adjusting for baseline
self-repair. Psychiatrists rated the therapeutic relationship more
positively (adjusted difference in means 0.20, 95% CI 0.03–0.37,
P = 0.022, a medium effect), as did patients
(adjusted difference in means 0.21, 95% CI 0.01–0.41, P
= 0.043, a medium effect).
Shared understanding can be successfully targeted in training and
improves relationships in treating psychosis.
Background: Ruminative negative thinking has typically been considered as a factor maintaining common emotional disorders and has recently been shown to maintain persecutory delusions in psychosis. The Perseverative Thinking Questionnaire (PTQ) (Ehring et al., 2011) is a transdiagnostic measure of ruminative negative thinking that shows promise as a “content-free” measure of ruminative negative thinking. Aims: The PTQ has not previously been studied in a psychosis patient group. In this study we report for the first time on the psychometric properties of Ehring et al.'s PTQ in such a group. Method: The PTQ was completed by 142 patients with current persecutory delusions and 273 non-clinical participants. Participants also completed measures of worry and paranoia. A confirmatory factor analysis was performed on the clinical group's PTQ responses to assess the factor structure of the measure. Differences between groups were used to assess criterion reliability. Results: A three lower-order factor structure of the PTQ (core characteristics of ruminative negative thinking, perceived unproductiveness, and capturing mental capacity) was replicated in the clinical sample. Patients with persecutory delusions were shown to experience significantly higher levels of ruminative negative thinking on the PTQ than the general population sample. The PTQ demonstrated high internal reliability. Conclusions: This study did not include test-retest data, and did not compare the PTQ against a measure of depressive rumination but, nevertheless, lends support for the validity of the PTQ as a measure of negative ruminative thinking in patients with psychosis.