Supported discharge service versus inpatient care evaluation (SITE): a randomised controlled trial comparing effectiveness of an intensive community care service versus inpatient treatment as usual for adolescents with severe psychiatric disorders: self-harm, functional impairment, and educational and clinical outcomes.

Clinical guidelines recommend intensive community care service treatment (ICCS) to reduce adolescent psychiatric inpatient care. We have previously reported that the addition of ICCS led to a substantial decrease in hospital use and improved school re-integration. The aim of this study is to undertake a randomised controlled trial (RCT) comparing an inpatient admission followed by an early discharge supported by ICCS with usual inpatient admission (treatment as usual; TAU). In this paper, we report the impact of ICCS on self-harm and other clinical and educational outcomes. 106 patients aged 12-18 admitted for psychiatric inpatient care were randomised (1:1) to either ICCS or TAU. Six months after randomisation, we compared the two treatment arms on the number and severity of self-harm episodes, the functional impairment, severity of psychiatric symptoms, clinical improvement, reading and mathematical ability, weight, height and the use of psychological therapy and medication. At six-month follow-up, there were no differences between the two groups on most measures. Patients receiving ICCS were significantly less likely to report multiple episodes (five or more) of self-harm (OR = 0.18, 95% CI: 0.05-0.64). Patients admitted to private inpatient units spent on average 118.4 (95% CI: 28.2-208.6) fewer days in hospitals if they were in the ICCS group compared to TAU. The addition of ICCS to TAU may lower the risk of multiple self-harm and may reduce the duration of inpatient stay, especially in those patients admitted for private care. Early discharge with ICCS appears to be a viable alternative to standard inpatient treatment.

Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychiatric emergencies: a randomised controlled trial.

BACKGROUND: Intensive community treatment to reduce dependency on adolescent psychiatric inpatient care is recommended in guidelines but has not been assessed in a randomised controlled trial in the UK. We designed a supported discharge service (SDS) provided by an intensive community treatment team and compared outcomes with usual care. METHODS: Eligible patients for this randomised controlled trial were younger than 18 years and had been admitted for psychiatric inpatient care in the South London and Maudsley NHS Foundation Trust. Patients were assigned 1:1 to either the SDS or to usual care by use of a computer-generated pseudorandom code with random permuted blocks of varying sizes. The primary outcome was number of inpatient bed-days, change in Strengths and Difficulties Questionnaire (SDQ) scores, and change in Children's Global Assessment Scale (CGAS) scores at 6 months, assessed by intention to treat. Cost-effectiveness was explored with acceptability curves based on CGAS scores and quality-adjusted life-years (QALYs) calculated from the three-level EuroQol measure of health-related quality of life (EQ-5D-3L), taking a health and social care perspective. This study is registered with the ISRCTN Registry, number ISRCTN82129964. FINDINGS: Hospital use at 6 months was significantly lower in the SDS group than in the usual care group (unadjusted median 34 IQR 17-63 vs 50 days, 19-125, p=0·04). The ratio of mean total inpatient days for usual care to SDS was 1·67 (95% CI 1·02-2·81, p=0·04), which decreased to 1·65 (0·99-2·77, p=0·057) when adjusted for differences in hospital use before randomisation. Scores for SDQ and CGAS did not differ between groups. The cost-effectiveness acceptability curve based on QALYs showed that the probability of SDS being cost-effective compared with usual care was around 60% with a willingness-to-pay threshold of £20 000-30 000 per QALY, and that based on CGAS showed at least 58% probability of SDS being cost-effective compared with usual care irrespective of willingness to pay. We recorded no adverse events attributable to SDS or usual care. INTERPRETATION: SDS provided by an intensive community treatment team reduced bed usage at 6 months' follow-up but had no effect on functional status and symptoms of mental health disorders compared with usual care. The possibility of preventing admissions, particularly through features such as reduced self-harm and improved reintegration into school, with intensive community treatment should be investigated in future studies. FUNDING: South London and Maudsley NHS Trust.

The Coping with Unusual Experiences for Children Study (CUES): A pilot randomized controlled evaluation of the acceptability and potential clinical utility of a cognitive behavioural intervention package for young people aged 8-14 years with unusual experiences and emotional symptoms.

OBJECTIVES: Health care guidelines recommend psychological interventions for childhood unusual experiences that are associated with distress or adverse functional impact (UEDs), based on adult, rather than child-specific, evidence. We report the first randomized controlled evaluation of the acceptability and potential clinical utility of cognitive behavioural therapy for childhood UEDs (CBT-UED). DESIGN: Pilot randomized controlled trial. METHODS: Participants aged 8-14 years were recruited from referrals to community services for children with emotional/behavioural problems and screened for self-reported UEDs. RESULTS: Of around 1,000 referrals over 36 months, 304 (30%) were identified to the research team, 174 (57%) were successfully contacted, 110 (63%) consented to screening, 96 (87%) attended a screening assessment, and 51 (53%) reported UEDs. Forty-nine (96%) consented to randomization to either CBT-UED (9-12 weekly sessions of 40-50 min, adjunctive to usual care, n = 24) or treatment-as-usual/waitlist control (TAU/WL, n = 25). Childhood internalizing emotional symptoms (e.g., feeling 'nervous'/'scared'/'tearful'/'worried'/'sick'; proposed primary outcome), UEDs, depression, anxiety, and childhood psychopathology (secondary outcomes) were measured at baseline, at 12 weeks, and, where therapy was ongoing but incomplete (<12 sessions) at 12 weeks, at end-of-treatment (EOT). Twenty-two CBT-UED participants (92%) attended ≥5 sessions. Forty-four participants (90%) completed 12-week assessments (CBT-UED, n = 21/24, 88%; TAU/WL, n = 23/25, 92%). Preliminary findings were encouraging for emotional symptoms and UEDs, but otherwise mixed. CONCLUSIONS: Retention, screening, and consent rates were as anticipated; recruitment took longer than planned. Trial procedures were acceptable to young people, their families, and clinicians. Therapy exceeded 12 weeks, but was well-received, with no serious adverse events attributed to participation. Further evaluation is needed. PRACTITIONER POINTS: Around half of 8- to 14-year-olds in Child and Adolescent Mental Health Services reported distressing unusual experiences. An age-adapted cognitive behavioural intervention appears feasible, and safe to deliver, with the potential to augment standard care. This is a pilot study, and further evaluation is needed. Longer term outcomes should be a focus of future evaluation.

Childhood unusual experiences in community Child and Adolescent Mental Health Services in South East London: Prevalence and impact.

BACKGROUND: Distressing 'psychotic-like' or unusual experiences (UEDs) signify increased mental health risk in the general population, including greater likelihood and severity of co-occurring non-psychotic mental health problems, and, from fourteen years of age, increased risk of a future psychotic illness. Healthcare guidelines for under eighteens recommend psychological intervention for UEDs, to reduce current distress and adverse functional impact, and, potentially, future mental health risk. Children tend not to report UEDs unless directly asked, indicating a need for routine screening. We report on the feasibility of a routine screening methodology, and screening outcomes, in Child and Adolescent Mental Health Services (CAMHS) in South East London, United Kingdom. METHOD: Four general community CAMHS teams were invited to screen, by adding a nine-item self-report UED measure to their routine assessment battery. Screening data were collected over 18months from 02/2015 to 07/2016. RESULTS: All but one team agreed to screen. Each team saw around 300 accepted referrals during the audit period (total: 900); 768 of these (85%) were successfully screened; of those screened, 68% (n=524) self-reported UEs, 60% (n=461) with associated distress/adverse functional impact. Screening was acceptable to clinicians, children and families. CONCLUSIONS: Assessing UEDs routinely in CAMHS is feasible, and suggests that around two thirds of assessed referrals could potentially benefit from interventions targeting UEDs. Additional training may be required for the CAMHS workforce to address this need.

Coping with Unusual ExperienceS for 12-18 year olds (CUES+): a transdiagnostic randomised controlled trial of the effectiveness of cognitive therapy in reducing distress associated with unusual experiences in adolescent mental health services: study protocol for a randomised controlled trial.

BACKGROUND: Childhood 'unusual experiences' (such as hearing voices that others cannot, or suspicions of being followed) are common, but can become more distressing during adolescence, especially for young people in contact with Child and Adolescent Mental Health Services (CAMHS). Unusual experiences that are distressing or have adverse life impact (UEDs) are associated with a range of current and future emotional, behavioural and mental health difficulties. Recommendations for psychological intervention are based on evidence from adult studies, with some support from small, pilot, child-specific evaluations. Research is needed to ensure that the recommendations suit children as well as adults. The CUES+ study (Coping with Unusual ExperienceS for 12-18 year olds) aims to find out whether cognitive behaviour therapy for UEDs (CBT-UED) is a helpful and cost-effective addition to usual community care for 12-18 year olds presenting to United Kingdom National Health Service Child and Adolescent Mental Health Services in four London boroughs. METHODS: The CUES+ study is a randomised controlled trial comparing CBT-UED plus routine care to routine care alone. CBT-UED comprises up to 16 sessions, including up to 12 individual and up to four family support meetings, each lasting around 45-60 min, delivered weekly. The primary outcome is emotional distress. Secondary outcomes are change in UEDs, risk events (self-harm, attendance at emergency services, other adverse events) and health economic outcomes. Participants will be randomised in a 1:1 ratio after baseline assessment. Randomisation will be stratified by borough and by severity of mental health presentation: 'severe' (an identified psychotic or bipolar disorder) or any 'other' condition. Outcomes will be assessed by a trained assessor blind to treatment condition at 0, 16 and 24 weeks. Recruitment began in February, 2015 and is ongoing until the end of March, 2017. DISCUSSION: The CUES+ study will contribute to the currently limited child-specific evidence base for psychological interventions for UEDs occurring in the context of psychosis or any other mental health presentation. TRIAL REGISTRATION: International Standard Randomised Controlled Trials, ID: ISRCTN21802136 . Prospectively registered on 12 January 2015. Protocol V3 31 August 2015 with screening amended.

The ward as emotional ecology: Adolescent experiences of managing mental health and distress in psychiatric inpatient settings.

Previous research on young people's satisfaction of inpatient services has often relied on the responses of carers and relevant practitioners. It is difficult to ascertain to what extent such reporting accurately represents the satisfaction levels of young people, with emerging research suggesting wide discrepancies. As part of a wider study evaluating the effectiveness of a Supported Discharge Service (SDS) operating within South London & Maudsley NHS Foundation Trust, this paper examines how young people experience inpatient services, on a social and emotional level. Twenty young people, (10 SDS and 10 TAU) participated in a semi-structured visual-interview study to examine their experiences of admission, ward-life and treatment. A thematic decomposition analysis was conducted on the data and specific themes relevant to satisfaction and engagement with inpatient services was examined in-depth. These include a) Behavioural surveillance as care surrogate and b) Managing the delicate emotional ecology of the ward: openness, triggering, sterility and relational engagements. Finally, we explore some of the implications of these inpatient experiences for supported discharge services.

Variation in psychosocial influences according to the dimensions and content of children's unusual experiences: potential routes for the development of targeted interventions.

The psychosocial processes implicated in the development and maintenance of psychosis differ according to both the dimensional attributes (conviction, frequency, associated distress, adverse life impact) and the content or type (e.g. grandiosity, hallucinations, paranoia) of the psychotic symptoms experienced. This has informed the development of 'targeted' cognitive behavioural therapy for psychosis (CBTp): interventions focusing on specific psychological processes in the context of particular symptom presentations. In adults, larger effect sizes for change in primary outcomes are typically reported in trials of targeted interventions, compared to those for trials of generic CBTp approaches with multiple therapeutic foci. We set out to test the theoretical basis for developing targeted CBTp interventions for young people with distressing psychotic-like, or unusual, experiences (UEs). We investigated variations in the psychosocial processes previously associated with self-reported UE severity (reasoning, negative life events, emotional problems) according to UE dimensional attributes and content/type (using an established five-factor model) in a clinically referred sample of 72 young people aged 8-14 years. Regression analyses revealed associations of conviction and grandiosity with reasoning; of frequency, and hallucinations and paranoia, with negative life events; and of distress/adverse life impact, and paranoia and hallucinations, with emotional problems. We conclude that psychological targets for intervention differ according to particular characteristics of childhood UEs in much the same way as for psychotic symptoms in adults. The development of targeted interventions is therefore indicated, and tailoring therapy according to presentation should further improve clinical outcomes for these young people.

Cognitive bias and unusual experiences in childhood.

Cognitive therapy is recommended for children with psychotic-like, or unusual, experiences associated with distress or impairment (UEDs; UK National Institute for Health and Care Excellence, 2013 [1]). Accurate models of the psychological underpinnings of childhood UEDs are required to effectively target therapies. Cognitive biases, such as the jumping to conclusions data-gathering bias (JTC), are implicated in the development and maintenance of psychosis in adults. In this study, we aimed to establish the suitability for children of a task developed to assess JTC in adults. Eighty-six participants (aged 5-14 years) were recruited from Child and Adolescent Mental Health Service (CAMHS) and community (school) settings, and completed the probabilistic reasoning ('Beads') task, alongside measures of intellectual functioning, general psychopathology, and UEDs. Self-reported reasoning strategy was coded as 'probabilistic' or 'other'. Younger children (5-10 years) were more likely than older children (11-14 years) to JTC (OR = 2.7, 95 % CI = 1.1-6.5, p = 0.03); and to use non-probabilistic reasoning strategies (OR = 9.4, 95 % CI = 1.7-48.8, p = 0.008). Both UED presence (OR = 5.1, 95 % CI = 1.2-21.9, p = 0.03) and lower IQ (OR = 0.9, 95 % CI = 0.9-1.0, p = 0.02) were significantly and independently associated with JTC, irrespective of age and task comprehension. Findings replicate research in adults, indicating that the 'Beads' task can be reliably employed in children to assess cognitive biases. Psychological treatments for children with distressing unusual experiences might usefully incorporate reasoning interventions.

Modelling psychosocial influences on the distress and impairment caused by psychotic-like experiences in children and adolescents.

Psychological understanding of psychotic-like experiences (PLEs) occurring in childhood is limited, with no recognised conceptual framework to guide appropriate intervention. We examined the contribution to PLE severity of emotional, cognitive and socio-environmental mechanisms thought to influence the development and maintenance of psychosis. Forty 8-14 year olds referred to a community Child and Adolescent Mental Health Service completed a battery of questionnaires and assessments measuring severity of PLEs, emotional problems, cognitive biases, and negative life events. 85% of children assessed reported having experienced a PLE over the previous year; and 55% reported more than one. 60% had experienced at least one in the previous fortnight. Multiple linear regression demonstrated that each of the variables made a significant and independent contribution to PLE severity, after adjusting for verbal ability and age, accounting together for more than half of the variance (reasoning B = 6.324, p = .049; emotion B = 1.807, p = .005; life events B = 4.039, p = .001). PLEs were common in this clinical sample of children. Psychological factors implicated in the development and maintenance of psychosis in adults were also associated with PLE severity in these children. PLE severity may be reduced by targeting each of these factors in cognitive therapy, at this very early stage. Any improvements in emotional wellbeing and functioning may then increase future resilience.

Innovations in Practice: pilot evaluation of the supported discharge service (SDS): clinical outcomes and service use.

BACKGROUND: The Supported Discharge Service (SDS) is a model of enhanced care in the community for adolescents after inpatient discharge. METHODS: This study comprised the first 20 patients referred to SDS, largely those with delayed discharges. Service use and clinical outcomes were collected and predictors of total contact time were investigated. RESULTS: Significant improvements had been made with SDS. Higher baseline Strengths and Difficulties Questionnaire (SDQ) conduct scores were associated with less contact time. CONCLUSIONS: SDS is a feasible model of care. Adolescents with conduct problems may benefit from engagement strategies. Further rigorous evaluation of the model is required.

The role of ethnicity and diagnosis in rates of adolescent psychiatric admission and compulsory detention: a longitudinal case-note study.

OBJECTIVES: To explore whether ethnic variations in psychiatric admission and detention reported for adults also apply to adolescents and to establish the influence of diagnosis. DESIGN: A longitudinal, case-note study over a 10-year period. SETTING: An adolescent inpatient psychiatric unit in London. PARTICIPANTS: All adolescents admitted to the unit. MAIN OUTCOME MEASURES: Rates of admission and detention under the Mental Health Act, according to catchment area population. RESULTS: Young Black people were nearly six times more likely than the White group to be admitted with psychosis but showed no increase in admission for non-psychotic conditions. Young people in the Other group were over three times more likely to be admitted with psychosis but showed only a modest increase in admission with non-psychotic conditions. Young Asians were over twice as likely to be admitted with psychosis but were only one-third as likely to be admitted with non-psychotic conditions. Young people with psychosis in the Black and Other groups were around three times more likely to have been detained, but there were no significant differences for non-psychotic conditions. CONCLUSIONS: Significant ethnic variation was found in the rates of admission and detention for adolescents. However, diagnosis was also an important consideration and must be taken into account when examining for evidence of ethnic bias in the use of mental health services by young people. Further investigation is required to establish whether adolescent care pathways are providing a safe and appropriate level of inpatient care for all ethnic groups.

Abnormal functional activation and connectivity in the working memory network in early-onset schizophrenia.

OBJECTIVE: Disruption within the working memory (WM) neural network is considered an integral feature of schizophrenia. The WM network, and the dorsolateral prefrontal cortex (DLPFC) in particular, undergo significant remodeling in late adolescence. Potential interactions between developmental changes in the WM network and disease-related processes for schizophrenia remain unclear. The aim of this study was to determine whether DLPFC activation and functional connectivity are impaired during WM in patients with early-onset schizophrenia (EOS; age of onset <18 years). METHOD: We used functional magnetic resonance imaging and psychophysiological interaction analysis to respectively measure blood oxygenation level-dependent signal and to derive functional connectivity estimates in response to the two-back WM task from 25 youths with EOS and 20 matched healthy adolescents. RESULTS: Compared with healthy adolescents, patients with EOS showed reduced engagement of the DLPFC, the anterior cingulate cortex (ACC), and frontal operculum, and had reduced DLPFC connectivity within the WM network. Patients with EOS showed abnormal reduction in the coupling of the DLPFC with the ACC, the inferior parietal lobule, and the middle occipital gyrus. In contrast to healthy adolescents, patients with EOS expressed age-related decrease in the activity of the DLPFC and an increase in its connectivity with the ACC. CONCLUSIONS: Patients with EOS show dysfunctional engagement and reduced integration within the WM neural network. The pattern of abnormal age-related correlations in DLPFC activity and connectivity suggests that schizophrenia-related processes have an impact on brain regions that show significant late developmental changes.

Multimodal analyses identify linked functional and white matter abnormalities within the working memory network in schizophrenia.

BACKGROUND: Dysconnectivity between brain regions is thought to underlie the cognitive abnormalities that characterise schizophrenia (SZ). Consistent with this notion functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) studies in SZ have reliably provided evidence of abnormalities in functional integration and in white matter connectivity. Yet little is known about how alterations at the functional level related to abnormalities in anatomical connectivity. METHODS: We obtained fMRI data during the 2-back working memory task from 25 patients with SZ and 19 healthy controls matched for age, sex and IQ. DTI data were also acquired in the same session. In addition to conventional unimodal analyses we extracted "features" [contrast maps for fMRI and fractional anisotropy (FA) for DTI] that were subjected to joint independent component analysis (JICA) in order to examine interactions between fMRI and DTI data sources. RESULTS: Conventional unimodal analyses revealed both functional and structural deficits in patients with SZ. The JICA identified regions of joint, multimodal brain sources that differed in patients and controls. The fMRI source implicated regions within the anterior cingulate and ventrolateral prefrontal cortex and in the cuneus where patients showed relative hypoactivation and within the frontopolar cortex where patients showed relative hyperactivation. The DTI source localised reduced FA in patients in the splenium and posterior cingulum. CONCLUSIONS: This study promotes our understanding of structure-function relationships in SZ by characterising linked functional and white matter changes that contribute to working memory dysfunction in this disorder.

Autism spectrum disorders and schizophrenia: meta-analysis of the neural correlates of social cognition.

CONTEXT: Impaired social cognition is a cardinal feature of Autism Spectrum Disorders (ASD) and Schizophrenia (SZ). However, the functional neuroanatomy of social cognition in either disorder remains unclear due to variability in primary literature. Additionally, it is not known whether deficits in ASD and SZ arise from similar or disease-specific disruption of the social cognition network. OBJECTIVE: To identify regions most robustly implicated in social cognition processing in SZ and ASD. DATA SOURCES: Systematic review of English language articles using MEDLINE (1995-2010) and reference lists. STUDY SELECTION: Studies were required to use fMRI to compare ASD or SZ subjects to a matched healthy control group, provide coordinates in standard stereotactic space, and employ standardized facial emotion recognition (FER) or theory of mind (TOM) paradigms. DATA EXTRACTION: Activation foci from studies meeting inclusion criteria (n = 33) were subjected to a quantitative voxel-based meta-analysis using activation likelihood estimation, and encompassed 146 subjects with ASD, 336 SZ patients and 492 healthy controls. RESULTS: Both SZ and ASD showed medial prefrontal hypoactivation, which was more pronounced in ASD, while ventrolateral prefrontal dysfunction was associated mostly with SZ. Amygdala hypoactivation was observed in SZ patients during FER and in ASD during more complex ToM tasks. Both disorders were associated with hypoactivation within the Superior Temporal Sulcus (STS) during ToM tasks, but activation in these regions was increased in ASD during affect processing. Disease-specific differences were noted in somatosensory engagement, which was increased in SZ and decreased in ASD. Reduced thalamic activation was uniquely seen in SZ. CONCLUSIONS: Reduced frontolimbic and STS engagement emerged as a shared feature of social cognition deficits in SZ and ASD. However, there were disease- and stimulus-specific differences. These findings may aid future studies on SZ and ASD and facilitate the formulation of new hypotheses regarding their pathophysiology.

Global and temporal cortical folding in patients with early-onset schizophrenia.

OBJECTIVE: Adult-onset schizophrenia has repeatedly been associated with disturbances in the temporal lobes and alterations in cortical folding, which are thought to reflect neurodevelopmental impairment. Early-onset schizophrenia (EOS; onset before 18 years) is considered to involve even more pronounced neurodevelopmental deviance across a wide range of brain structural measures. We hypothesized that overall alteration of cortical folding also applies to EOS, and EOS involves prominent structural aberrations in superior temporal and collateral sulci. METHOD: Magnetic resonance T1 images of 51 patients with EOS and 59 healthy participants were investigated. A fully automated method was applied to the images to extract, label, and measure the sulcus area in the whole cortex. Cortical folding was assessed by computing global sulcal indices (the ratio between total sulcal area and total outer cortex area) for each hemisphere and local sulcal indices (the ratio between the area of labeled sulcus and total outer cortex area in the corresponding hemisphere) for superior temporal and collateral sulci. RESULTS: Relative to healthy individuals, patients with EOS had significantly lower global sulcal indices in both hemispheres and a lower local sulcal index in the left collateral sulcus. CONCLUSIONS: Reduced hemispheric sulcation appears to be a feature of schizophrenia, irrespective of age at onset. Structural aberration involving the left collateral sulcus may contribute to neurobiological substrate of EOS.

Increased developmental deviance and premorbid dysfunction in early onset schizophrenia.

Abnormal neurodevelopment and poor premorbid function have been described in schizophrenia. It is unclear whether abnormalities in these domains are increased in patients with early onset schizophrenia (EOS; onset before the 18th birthday) and whether they act to precipitate the earlier onset of the disorder. To address these questions, we collected information based on maternal interviews about the premorbid function of 40 adolescents with recent onset schizophrenia and an equal number of healthy controls using the Developmental Scale Score, the Premorbid Schizoid and Schizotypal Trait Scale (PSST) and Premorbid Adjustment Scale (PAS). Data on the PSST and PAS were also available in 54 patients with adult onset schizophrenia (AOS; onset after the 20th birthday). Compared to healthy controls, EOS patients had (a). delayed speech milestones, difficulties in reading and spelling and greater overall developmental deviance; (b). poor premorbid adjustment in childhood, which became even more deviant in adolescence particularly in boys and (c). more schizophrenia spectrum traits. Both premorbid adjustment and personality traits were more abnormal in patients with increased developmental deviance suggesting the possibility that they represent different manifestations of ongoing abnormalities in developmental processes. EOS patients had more impaired premorbid adjustment in adolescence and schizophrenia spectrum traits compared to AOS cases. Age of onset was related to developmental deviance, premorbid schizophrenia spectrum traits and childhood adjustment in EOS patients only.