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There is increasing interest in potential harmful effects of mindfulness-based interventions. In relation to psychosis, inconsistency and shortcomings in how harm is monitored and reported are holding back our understanding. We offer eight recommendations to help build a firmer evidence base on potential harm in mindfulness for psychosis.
Psychosis, and in particular auditory verbal hallucinations (AVHs), are associated with adversity exposure. However, AVHs also occur in populations with no need for care or distress.
This study investigated whether adversity exposure would differentiate clinical and healthy voice-hearers within the context of a ‘three-hit’ model of vulnerability and stress exposure.
Samples of 57 clinical and 45 healthy voice-hearers were compared on the three ‘hits’: familial risk; adversity exposure in childhood and in adolescence/adulthood.
Clinical voice-hearers showed greater familial risk than healthy voice-hearers, with more family members with a history of psychosis, but not with other mental disorders. The two groups did not differ in their exposure to adversity in childhood [sexual and non-sexual, victimisation; discrimination and socio-economic status (SES)]. Contrary to expectations, clinical voice-hearers did not differ from healthy voice-hearers in their exposure to victimisation (sexual/non-sexual) and discrimination in adolescence/adulthood, but reported more cannabis and substance misuse, and lower SES.
The current study found no evidence that clinical and healthy voice-hearers differ in lifetime victimisation exposure, suggesting victimisation may be linked to the emergence of AVHs generally, rather than need-for-care. Familial risk, substance misuse and lower SES may be additional risk factors involved in the emergence of need-for-care and distress.
Background: There is an emerging evidence base that mindfulness for psychosis is a safe and effective intervention. However, empirical data on the within-session effects of mindfulness meditation was hitherto lacking. Aims: The aim of the study was to assess the impact of taking part in a mindfulness for psychosis group, using a within-session self-report measure of general stress, and symptom-related distress. Method: Users of a secondary mental health service (n = 34), who experienced enduring psychotic symptoms, took part in an 8-week mindfulness for psychosis group in a community setting. Mindfulness meditations were limited to 10 minutes and included explicit reference to psychotic experience arising during the practice. Participants self-rated general stress, and symptom-related distress, before and after each group session using a visual analogue scale. Results: Average ratings of general stress and symptom-related distress decreased from pre- to post-session for all eight sessions, although not all differences were statistically significant. There was no increase in general stress, or symptom-related distress across any session. Conclusions: There was evidence of positive effects and no evidence of any harmful effects arising from people with psychotic symptoms taking part in a mindfulness for psychosis session.
People with psychotic disorders account for most acute admissions to psychiatric wards. Psychological therapies are a treatment adjunct to standard medication and nursing care, but the evidence base for such therapies within in-patient settings is unclear.
To conduct a systematic scoping review of the current evidence base for psychological therapies for psychosis delivered within acute in-patient settings (PROSPERO: CRD42015025623).
All study designs, and therapy models, were eligible for inclusion in the review. We searched PubMed, PsycINFO, EThOS, ProQuest, conference abstracts and trial registries.
We found 65 studies that met criteria for inclusion in the review, 21 of which were randomised controlled trials (RCTs). The majority of studies evaluated cognitive–behavioural interventions. Quality was variable across all study types. The RCTs were mostly small (n<25 in the treatment arm), and many had methodological limitations including poorly described randomisation methods, inadequate allocation concealment and non-masked outcome assessments. We found studies used a wide range of different outcome measures, and relatively few studies reported affective symptoms or recovery-based outcomes. Many studies described adaptations to treatment delivery within in-patient settings, including increased frequency of sessions, briefer interventions and use of single-session formats.
Based on these findings, there is a clear need to improve methodological rigour within in-patient research. Interpretation of the current evidence base is challenging given the wide range of different therapies, outcome measures and models of delivery described in the literature.
Hearing voices can be a distressing and disabling experience for some, whilst it is a valued experience for others, so-called ‘healthy voice-hearers’. Cognitive models of psychosis highlight the role of memory, appraisal and cognitive biases in determining emotional and behavioural responses to voices. A memory bias potentially associated with distressing voices is the overgeneral memory bias (OGM), namely the tendency to recall a summary of events rather than specific occasions. It may limit access to autobiographical information that could be helpful in re-appraising distressing experiences, including voices.
We investigated the possible links between OGM and distressing voices in psychosis by comparing three groups: (1) clinical voice-hearers (N = 39), (2) non-clinical voice-hearers (N = 35) and (3) controls without voices (N = 77) on a standard version of the autobiographical memory test (AMT). Clinical and non-clinical voice-hearers also completed a newly adapted version of the task, designed to assess voices-related memories (vAMT).
As hypothesised, the clinical group displayed an OGM bias by retrieving fewer specific autobiographical memories on the AMT compared with both the non-clinical and control groups, who did not differ from each other. The clinical group also showed an OGM bias in recall of voice-related memories on the vAMT, compared with the non-clinical group.
Clinical voice-hearers display an OGM bias when compared with non-clinical voice-hearers on both general and voices-specific recall tasks. These findings have implications for the refinement and targeting of psychological interventions for psychosis.
Mindfulness treatments and research have burgeoned over the past decade. With psychosis, progress has been slow and likely held back by clinicians' belief that mindfulness may be harmful for this client group. There is emerging evidence that mindfulness for psychosis – when used in an adapted form – is safe and therapeutic.
Background: There is a small body of research indicating that mindfulness training can be beneficial for people with distressing psychosis. What is not yet clear is whether mindfulness effects change in affect and cognition associated with voices specifically. This study examined the hypothesis that mindfulness training alone would lead to change in distress and cognition (belief conviction) in people with distressing voices. Method: Two case studies are presented. Participants experienced long-standing distressing voices. Belief conviction and distress were measured twice weekly through baseline and mindfulness intervention. Mindfulness in relation to voices was measured at the start of baseline and end of intervention. Results: Following a relatively stable baseline phase, after 2–3 weeks of mindfulness practice, belief conviction and distress fell for both participants. Both participants' mindfulness scores were higher post treatment. Conclusion: Findings show that mindfulness training has an impact on cognition and affect specifically associated with voices, and thereby beneficially alters relationship with voices.
To determine whether a process of care planning for people with diabetes, combining a patient-centred approach by practitioners with measures to promote self-management by patients, improve health outcomes.
Health policy, in many countries, seeks to engage people with long-term conditions in protecting their health. This review was conducted by members of a working group established by the Department of Health and Diabetes, UK to consider the potential for personalized care planning in UK diabetes services.
Review of systematic reviews. The Cochrane Library and Database of Reviews of Effectiveness were searched to identify reviews concerned with components of care planning. Reviews conducted before 1990, and those involving education outside the consultation were excluded. Abstracts were reviewed and data extraction undertaken by reviewers working independently in pairs.
In all, 86 reviews were identified as potentially relevant and 22 included. Patient-focused interventions, such as pre-consultation prompts, enhanced the role patients played in consultations. Personalized approaches using tailored information influenced health behaviour more than uniform approaches. Decision aids and computerized knowledge management improved the process of decision-making. Although effective communication was important, focusing solely on changing practitioner behaviour appeared inadequate. Taken together, there was good evidence that the processes involved in personalized care planning would engage patients more effectively in managing their care, but little robust research on the impact on health outcomes of doing so.
The present review identifies effective interventions that are available for clinicians to use in diabetes consultations, but engaging patients requires more than this. Mechanisms to share information and decision-making need further development and evaluation to assess their impact on health outcomes. Narrowly targeted interventions focused on practitioner behaviour appear less effective than whole-system approaches. Personalized care planning offers a mechanism to integrate patient-centred medicine and support for self-management to improve diabetes care.
Background: The clinical literature cautions against use of meditation by people with psychosis. There is, however, evidence for acceptance-based therapy reducing relapse, and some evidence for clinical benefits of mindfulness groups for people with distressing psychosis, though no data on whether participants became more mindful. Aims: To assess feasibility of randomized evaluation of group mindfulness therapy for psychosis, to replicate clinical gains observed in one small uncontrolled study, and to assess for changes in mindfulness. Method: Twenty-two participants with current distressing psychotic experiences were allocated at random between group-based mindfulness training and a waiting list for this therapy. Mindfulness training comprised twice-weekly sessions for 5 weeks, plus home practice (meditation CDs were supplied), followed by 5 weeks of home practice. Results: There were no significant differences between intervention and waiting-list participants. Secondary analyses combining both groups and comparing scores before and after mindfulness training revealed significant improvement in clinical functioning (p = .013) and mindfulness of distressing thoughts and images (p = .037). Conclusions: Findings on feasibility are encouraging and secondary analyses replicated earlier clinical benefits and showed improved mindfulness of thoughts and images, but not voices.
Five 18 week skills training groups based on Dialectical Behaviour Therapy (DBT) were provided for 34 participants with parasuicidal behaviours; 26 participants completed the programme. Monthly support/education groups for their keyworkers were also provided. Inpatient admissions decreased by 30% and out-patient appointments for those without admission by 61% over the 18 months from the initial pre-group formulation meeting, compared with the preceding 18 months. Statistical analysis (N = 17) showed significant reduction in CORE scores over the intervention period, and a similar effect in scores on the Work and Social Adjustment Scale. User satisfaction was high and drop out low (23.5%). Results indicate DBT skills group might be a useful service where full DBT is unavailable.
Nutrigenomics is the study of how constituents of the diet interact with genes, and their products, to alter phenotype and, conversely, how genes and their products metabolise these constituents into nutrients, antinutrients, and bioactive compounds. Results from molecular and genetic epidemiological studies indicate that dietary unbalance can alter gene–nutrient interactions in ways that increase the risk of developing chronic disease. The interplay of human genetic variation and environmental factors will make identifying causative genes and nutrients a formidable, but not intractable, challenge. We provide specific recommendations for how to best meet this challenge and discuss the need for new methodologies and the use of comprehensive analyses of nutrient–genotype interactions involving large and diverse populations. The objective of the present paper is to stimulate discourse and collaboration among nutrigenomic researchers and stakeholders, a process that will lead to an increase in global health and wellness by reducing health disparities in developed and developing countries.
The study's objective was to assess the impact on clinical functioning of group based mindfulness training alongside standard psychiatric care for people with current, subjectively distressing psychosis. Data are presented from the first 10 people to complete one of four Mindfulness Groups, each lasting six sessions. People were taught mindfulness of the breath, and encouraged to let unpleasant experiences come into awareness, to observe and note them, and let them go without judgment, clinging or struggle. There was a significant pre-post drop in scores on the CORE (z=−2.655, p=.008). Secondary data indicated improvement in mindfulness skills, and the subjective importance of mindfulness to the group process (N=11). The results are encouraging and warrant further controlled outcome and process research.
Greenberg, Rice and Elliott (1993) elaborate in detail different applications of the two-chair method within an experiential therapy framework. In the present paper we present an adapted two-chair method for use in cognitive therapy. The principal aims of the adapted method are to elaborate a positive self-schema that has an emotional (“lived”) quality, and to use this experience to create a new model of self as emotionally and cognitively varied and changing. Procedurally, the first two steps are to (1) summarize the negative self-schema (Chair 1) and (2) draw out a positive self-schema (Chair 2). In Steps 3 and 4 the client remains in Chair 2 and is encouraged to accept the two self-schemata, and to integrate them both within a broader, more diverse metacognitive model of self. We present key themes from analysis of two clients' reflections on the method, which highlight issues of generalization and the process of change, and conclude with clinical and research implications.
When does a therapeutic intervention become an accepted part of standard clinical practice? Is it when there is sufficient research evidence? But what constitutes ‘sufficient’? What about available resources and acceptability to patients? Do we have to wait until the National Institute for Clinical Excellence pronounces? A convincing evidence base for family work in schizophrenia (Kuipers, 2000) has existed for many years but has been poorly implemented (Anderson & Adams, 1996). Will cognitive-behavioural therapy (CBT) for psychosis suffer the same fate? Which professional group will champion such an implementation? The evidence for other psychological treatments is less robust. Psychoeducation may prolong time to relapse and improve insight but at the cost of increasing suicidal ideation (Carroll et al, 1998). Personal therapy (Hogarty et al, 1997) may be of value but is contra-indicated for patients who are living alone in the community. Psychodynamic approaches are advocated (Mace & Margison, 1997) but most psychiatrists do not support their use in practice, owing to lack of evidence of efficacy.
In paper I we reported that depression in the acute stage remitted in line with the psychosis and that 36% of patients developed post-psychotic depression (PPD).
We apply our cognitive framework to PPD and chart the appraisal of self and psychosis and their link with the later emergence of PPD.
Patients with ICD–10 schizophrenia (n=105) were followed up over 12 months following the acute episode, taking measures of depression, working self-concept, cognitive vulnerability, insight and appraisals of psychosis.
Before developing PPD, these patients felt greater loss, humiliation and entrapment by their illness than those who relapsed or did not become depressed, and were more likely to see their future selves in ‘lower status’ roles. Upon becoming depressed, participants developed greater insight, lower self-esteem and a worsening of their appraisals of psychosis.
Depression in psychosis arises from the individual's appraisal of psychosis and its implications for his/her perceived social identity, position and ‘group fit’. Patients developing PPD feel forced to accept a subordinate role without opportunity for escape. Implications for treatment are discussed.
Depression in schizophrenia is a rather neglected field of study, perhaps because of its confused nosological status. Three course patterns of depression in schizophrenia, including post-psychotic depression (PPD), are proposed.
We chart the ontogeny of depression and psychotic symptoms from the acute psychotic episode over a 12-month period and test the validity of the proposed course patterns.
One hundred and five patients with ICD–10 schizophrenia were followed up on five occasions over 12 months following the acute episode, taking measures of depression, positive symptoms, negative symptoms, neuroleptic exposure and side-effects.
Depression accompanied acute psychosis in 70% of cases and remitted in line with the psychosis; 36% developed PPD without a concomitant increase in psychotic symptoms.
The results provided support for the validity of two of the three course patterns of depression in schizophrenia, including PPD. Post-psychotic depression occurs de novo without concomitant change in positive or negative symptoms.