Training to recognise the early signs of recurrence in schizophrenia.

BACKGROUND: Schizophrenia has a lifetime prevalence of less than one per cent. Studies have indicated that early symptoms that are idiosyncratic to the person with schizophrenia (early warning signs) often precede acute psychotic relapse. Early warning signs interventions propose that learning to detect and manage early warning signs of impending relapse might prevent or delay acute psychotic relapse. OBJECTIVES: To compare the effectiveness of early warning signs interventions plus treatment as usual involving and not involving a psychological therapy on time to relapse, hospitalisation, functioning, negative and positive symptomatology. SEARCH METHODS: Search databases included the Cochrane Schizophrenia Group Trials Register (July 2007 and May 2012) which is based on regular searches of BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were reviewed for inclusion. We inspected the UK National Research Registe and contacted relevant pharmaceutical companies and authors of trials for additional information. SELECTION CRITERIA: We included all randomised clinical trials (RCTs) comparing early warning signs interventions plus treatment as usual to treatment as usual for people with schizophrenia or other non-affective psychosis DATA COLLECTION AND ANALYSIS: We assessed included studies for quality and extracted data. If more than 50% of participants were lost to follow-up, the study was excluded. For binary outcomes, we calculated standard estimates of risk ratio (RR) and the corresponding 95% confidence intervals (CI), for continuous outcomes, we calculated mean differences (MD) with standard errors estimated, and for time to event outcomes we calculated Cox proportional hazards ratios (HRs) and associated 95 % CI. We assessed risk of bias for included studies and assessed overall study quality using the GRADE approach. MAIN RESULTS: Thirty-two RCTs and two cluster-RCTs that randomised 3554 people satisfied criteria for inclusion. Only one study examined the effects of early warning signs interventions without additional psychological interventions, and many of the outcomes for this review were not reported or poorly-reported. Significantly fewer people relapsed with early warning signs interventions than with usual care (23% versus 43%; RR 0.53, 95% CI 0.36 to 0.79; 15 RCTs, 1502 participants; very low quality evidence). Time to relapse did not significantly differ between intervention groups (6 RCTs, 550 participants; very low quality evidence). Risk of re-hospitalisation was significantly lower with early warning signs interventions compared to usual care (19% versus 39%; RR 0.48, 95% CI 0.35 to 0.66; 15 RCTS, 1457 participants; very low quality evidence). Time to re-hospitalisation did not significantly differ between intervention groups (6 RCTs; 1149 participants; very low quality evidence). Participants' satisfaction with care and economic costs were inconclusive because of a lack of evidence. AUTHORS' CONCLUSIONS: This review indicates that early warning signs interventions may have a positive effect on the proportions of people re-hospitalised and on rates of relapse, but not on time to recurrence. However, the overall quality of the evidence was very low, indicating that we do not know if early warning signs interventions will have similar effects outside trials and that it is very likely that further research will alter these estimates. Moreover, the early warning signs interventions were used along side other psychological interventions, and we do not know if they would be effective on their own. They may be cost-effective due to reduced hospitalisation and relapse rates, but before mental health services consider routinely providing psychological interventions involving the early recognition and prompt management of early warning signs to adults with schizophrenia, further research is required to provide evidence of high or moderate quality regarding the efficacy of early warning signs interventions added to usual care without additional psychological interventions, or to clarify the kinds of additional psychological interventions that might aid its efficacy. Future RCTs should be adequately-powered, and designed to minimise the risk of bias and be transparently reported. They should also systematically evaluate resource costs and resource use, alongside efficacy outcomes and other outcomes that are important to people with serious mental illness and their carers.

Circadian-related sleep disorders and sleep medication use in the New Zealand blind population: an observational prevalence survey.

STUDY OBJECTIVES: To determine the prevalence of self-reported circadian-related sleep disorders, sleep medication and melatonin use in the New Zealand blind population. DESIGN: A telephone survey incorporating 62 questions on sleep habits and medication together with validated questionnaires on sleep quality, chronotype and seasonality. PARTICIPANTS: PARTICIPANTS WERE GROUPED INTO: (i) 157 with reduced conscious perception of light (RLP); (ii) 156 visually impaired with no reduction in light perception (LP) matched for age, sex and socioeconomic status, and (iii) 156 matched fully-sighted controls (FS). SLEEP HABITS AND DISTURBANCES: The incidence of sleep disorders, daytime somnolence, insomnia and sleep timing problems was significantly higher in RLP and LP compared to the FS controls (p<0.001). The RLP group had the highest incidence (55%) of sleep timing problems, and 26% showed drifting sleep patterns (vs. 4% FS). Odds ratios for unconventional sleep timing were 2.41 (RLP) and 1.63 (LP) compared to FS controls. For drifting sleep patterns, they were 7.3 (RLP) and 6.0 (LP). MEDICATION USE: Zopiclone was the most frequently prescribed sleep medication. Melatonin was used by only 4% in the RLP group and 2% in the LP group. CONCLUSIONS: Extrapolations from the current study suggest that 3,000 blind and visually impaired New Zealanders may suffer from circadian-related sleep problems, and that of these, fewer than 15% have been prescribed melatonin. This may represent a therapeutic gap in the treatment of circadian-related sleep disorders in New Zealand, findings that may generalize to other countries.

Parental criticism and adolescent depression: does adolescent self-evaluation act as a mediator?

BACKGROUND: A better understanding of relationships between adolescent depression and family functioning may help in devising ways to prevent development of depression and design effective therapeutic interventions. AIMS: This study explored the relationship of parental emotional attitudes, (perceived criticism and expressed emotion) to adolescent self-evaluation and depression. METHODS: A sample of 28 clinic-referred adolescents and their mothers participated. The Five Minute Speech Sample was used to measure parental expressed emotion, and the adolescents completed the Children's Depression Inventory, Self-Perception Profile for Children global self-worth scale, a self-criticism scale and a perceived parental criticism scale. RESULTS: There was partial support for a model of adolescent negative self-evaluation as a mediator in the relationship between parental emotional attitudes and adolescent depressive symptoms. The data also supported an alternative hypothesis whereby adolescent depressive symptoms are related to negative self-evaluation. CONCLUSIONS: The overall pattern of results emphasizes the significance of adolescents' perceptions of parental criticism, rather than actual levels, in understanding the relationship between parental emotional attitudes and adolescent depressive symptoms.

Psychological factors linked to self-reported depression symptoms in late adolescence.

BACKGROUND: The likelihood of developing depression increases throughout adolescence. AIMS: Understanding the relative contribution of psychosocial and cognitive variables to depressive symptoms during the transitional stage of late adolescence should increase the scope for effective prevention and intervention. METHOD: The Inventory of Parent and Peer Attachment (IPPA), Adolescents' Cognitive Style (ACSQ), Relationship Rating Scales (RRS), The Life Events Checklist, and the Children's Depression Inventory (CDI) were completed by 140 adolescents aged 16-18 years. RESULTS: Alienation from parents and peers, helpless attributional style, gender, and perceived criticism from teachers contributed significantly to variance in scores for depressive symptoms. Negative self-inference and helpless attributions moderated the relationship between perceived criticism and depression in male participants. CONCLUSIONS: Different approaches to intervention may be more successful for males and females.

Developing psychological perspectives of suicidal behaviour and risk in people with a diagnosis of schizophrenia: we know they kill themselves but do we understand why?

People with a diagnosis of schizophrenia are at increased risk of suicidal behaviour yet little is understood of the psychological underpinnings of this vulnerability. The biopsychosocial 'Cry of Pain' model [Williams, J.M.G. (1997). Cry of pain. Harmondsworth: Penguin.] provides a broad framework from which to understand suicidal behaviour. However, the utility of the model in relation to suicide in schizophrenia has not yet been explored. This was the primary goal of this paper. Six components of the 'Cry of Pain' model were identified and evaluated with respect to whether they contributed to i. common transdiagnostic factors underlying suicide, ii. factors relating to co-morbid depression which account for suicidal behaviour, or iii. factors which are specific to schizophrenia and underlie suicide risk. The potential for applying the model to clinical management of suicide in schizophrenia is illustrated.

Expressed emotion, attributions and depression in mothers of children with problem behaviour.

BACKGROUND: This was an initial study seeking to examine the relationship between Expressed Emotion (EE), spontaneous causal attributions and depression in mothers of children referred for problem behaviour. METHOD: Sixty-one mothers were interviewed using the Camberwell Family Interview (CFI). The CFI was coded for maternal EE and spontaneous causal attributions regarding the child's behaviour. Self-report measures of child problem behaviour and maternal depressive symptoms were also completed. RESULTS: Consistent with previous research, high EE mothers, compared to low EE mothers, were more likely to make attributions thatjudged the cause of problem behaviour to be personal to and controllable by the child and also made more 'child-blaming' attributions than low EE mothers. Mothers' scores on the Beck Depression Inventory were found to be associated with 'child-blaming' attributions and higher levels of EE. Regression analyses did not support the hypothesised role of attributions as a mediator between depression and EE but did identify EE as a potential mediator in the relationship between maternal depressed mood and ratings of child problem behaviour. CONCLUSIONS: These results indicate the relevance of both EE and attributions in mothers of children with problem behaviour and suggest that maternal depressed mood is an important factor which is related to both of these.

Maternal expressed emotion, attributions and depression and entry into therapy for children with behaviour problems.

OBJECTIVES: Maternal expressed emotion (EE), attributions, depression and parenting stress in mothers of children with behaviour problems referred for therapy were tested for associations with entry to therapy. METHOD: In all, 57 mothers were assessed prior to first appointment using the Camberwell Family Interview coded for EE and attributions (LACS), and completed the Beck Depression Inventory (BDI) and Parenting Stress Index (PSI). RESULTS: Mothers who did not attend scored higher on EE dimensions of critical comments, hostility or emotional over-involvement, BDI or PSI. CONCLUSIONS: Some of the most distressed families referred may not attend, and need a different approach to engagement.