The moderating effects of coping and self-esteem on the relationship between defeat, entrapment and suicidality in a sample of prisoners at high risk of suicide.

BACKGROUND: Research is sparse which examines pathways to suicide, and resilience to suicide, in people who are particularly vulnerable to suicide, for example, prison inmates. The purpose of this study was to examine the ways in which perceptions of self-esteem and coping ability interacted with defeat and entrapment to both amplify suicidal thoughts and feelings, and to act as a buffer against suicidal thoughts and feelings. METHODS: Participants were 65 male prisoners at high risk of suicide. A cross-sectional questionnaire design was used. Questionnaire measures of depression, defeat, entrapment, self-esteem, coping ability and suicidal probability were administered. RESULTS: For the hopelessness component of the suicide probability measure, high levels of coping ability together with low levels of defeat resulted in the lowest levels of suicidality indicative of a resilience factor. In contrast, low levels of coping skills together with high levels of entrapment were a high risk factor for this hopelessness component of suicide. This pattern of results pertained when controlling for depression levels. CONCLUSIONS: This is the first study to examine interactions between defeat, entrapment and appraisals of self-esteem and coping ability. Therapeutic interventions would benefit from boosting perceptions and appraisals of coping ability, in particular, in people who are at high risk for suicide.

Cognitive-behavioural suicide prevention for male prisoners: a pilot randomized controlled trial.

BACKGROUND: Prisoners have an exceptional risk of suicide. Cognitive-behavioural therapy for suicidal behaviour has been shown to offer considerable potential, but has yet to be formally evaluated within prisons. This study investigated the feasibility of delivering and evaluating a novel, manualized cognitive-behavioural suicide prevention (CBSP) therapy for suicidal male prisoners. METHOD: A pilot randomized controlled trial of CBSP in addition to treatment as usual (CBSP; n = 31) compared with treatment as usual (TAU; n = 31) alone was conducted in a male prison in England. The primary outcome was self-injurious behaviour occurring within the past 6 months. Secondary outcomes were dimensions of suicidal ideation, psychiatric symptomatology, personality dysfunction and psychological determinants of suicide, including depression and hopelessness. The trial was prospectively registered (number ISRCTN59909209). RESULTS: Relative to TAU, participants receiving CBSP therapy achieved a significantly greater reduction in suicidal behaviours with a moderate treatment effect [Cohen's d = -0.72, 95% confidence interval -1.71 to 0.09; baseline mean TAU: 1.39 (S.D. = 3.28) v. CBSP: 1.06 (S.D. = 2.10), 6 months mean TAU: 1.48 (S.D. = 3.23) v. CBSP: 0.58 (S.D. = 1.52)]. Significant improvements were achieved on measures of psychiatric symptomatology and personality dysfunction. Improvements on psychological determinants of suicide were non-significant. More than half of the participants in the CBSP group achieved a clinically significant recovery by the end of therapy, compared with a quarter of the TAU group. CONCLUSIONS: The delivery and evaluation of CBSP therapy within a prison is feasible. CBSP therapy offers significant promise in the prevention of prison suicide and an adequately powered randomized controlled trial is warranted.

Collateral outcomes in e-mental health: a systematic review of the evidence for added benefits of computerized cognitive behavior therapy interventions for mental health.

BACKGROUND: E-mental health is a growing research field and an increasing number of computerized cognitive behavior therapy (cCBT) interventions are available for numerous mental health issues. Such interventions are often claimed to have added benefits, or collateral outcomes, when compared with traditional delivery platforms. Our aim was to systematically review the evidence of the cost-effectiveness, geographic flexibility, time flexibility, waiting time for treatment, stigma, therapist time, effects on help-seeking and treatment satisfaction of cCBT interventions for mental health. METHOD: The electronic databases Medline and Web of Science were searched for peer-reviewed controlled trials investigating collateral outcomes in computerized and internet-based CBT. RESULTS: The literature search identified 101 published papers (95 studies), which were included in this review. The results suggest that cCBT interventions are cost-effective and often cheaper than usual care. Limited evidence was found with regard to geographic flexibility, time flexibility, waiting time for treatment, stigma and the effects on help-seeking. Personal support in cCBT was found to take many forms, was not limited only to therapists, and seemed to increase treatment adherence and reduce attrition. Treatment satisfaction with cCBT was found to be high, but more research on attrition due to dissatisfaction is required. CONCLUSIONS: Although the results of this systematic review on the collateral outcomes provide support for the potential of cCBT, these outcomes need to be better assessed within individual e-mental health studies.

Perceived social support buffers the impact of PTSD symptoms on suicidal behavior: implications into suicide resilience research.

BACKGROUND: A growing body of research has highlighted the importance of identifying resilience factors against suicidal behavior. However, no previous study has investigated potential resilience factors among individuals with Posttraumatic Stress Disorder (PTSD). The aim of this study was to examine whether perceived social support buffered the impact of PTSD symptoms on suicidal behavior. METHODS: Fifty-six individuals who had previously been exposed to a traumatic event and reported PTSD symptoms in the past month (n = 34, 60.7% participants met the full criteria for a current PTSD diagnosis) completed a range of self-report measures assessing PTSD symptoms, perceived social support and suicidal behavior. Hierarchical regression analyses were conducted to examine whether perceived social support moderates the effects of PTSD symptoms on suicidal behavior. RESULTS: The results showed that perceived social support moderated the impact of the number and severity of PTSD symptoms on suicidal behavior. For those who perceived themselves as having high levels of social support, an increased number and severity of PTSD symptoms were less likely to lead to suicidal behavior. CONCLUSIONS: The current findings suggest that perceived social support might confer resilience to individuals with PTSD and counter the development of suicidal thoughts and behaviors. The milieu of social support potentially provides an area of further research and an important aspect to incorporate into clinical interventions for suicidal behavior in PTSD or trauma populations.

Cognitive Behavioral Therapy for Psychosis - Training Practices and Dissemination in the United States.

OBJECTIVE: Cognitive-Behavioral Therapy for psychosis (CBTp) is an evidence-based treatment for psychosis-related disorders. However, despite the strong evidence-base and inclusion in national treatment guidelines, CBTp remains poorly disseminated in the US. It is proposed that this state is a product of lack of CBTp knowledge among clinical training leaders along with limited availability of training opportunities. METHOD: We surveyed training directors in US psychiatry residency and clinical psychology doctoral programs to characterize the penetration of CBTp training and to assess their familiarity with basic CBTp facts. RESULTS: Directors displayed limited knowledge of CBTp effectiveness, with only 50% of psychiatry and 40% of psychology directors believing that CBTp is efficacious. Only 10% of psychiatry and 30% of psychology directors were aware that the CBTp evidence-base is based on meta-analyses. While 45% of all directors reported that their program offer CBTp training, trainees received limited training - 4 hours of didactics, 21 hours of treatment, and 12 hours of supervision. CONCLUSIONS: CBTp dissemination in the US is characterized by training directors' minimal awareness of the CBTp evidence-base along with training opportunities that are so limited, as to be unlikely to be adequate to provide CBTp effectively, hence unlikely to improve patients' psychoses.

A novel, web-based, psychological intervention for people with psoriasis: the electronic Targeted Intervention for Psoriasis (eTIPs) study.

BACKGROUND: Psychological morbidity and reduced quality of life are common and linked with nonadherence to medication in psoriasis. Access to psychological therapy is often poor with long waiting times. Cognitive behavioural therapy (CBT) is a well-accepted therapy for psychological disorders and is particularly effective when tailored to address condition-specific concerns. OBJECTIVES: To determine whether an electronic CBT intervention for Psoriasis (eTIPs) would reduce distress, improve quality of life and clinical severity in patients with psoriasis. METHODS: This was a wait-list, randomized trial of immediate intervention vs. usual care. Self-assessed psoriasis severity (Self-Administered Psoriasis Area and Severity Index), distress (Hospital Anxiety and Depression Scale) and quality of life (Dermatology Life Quality Index) were measured before and after intervention. Analysis was based on complete cases and all cases using multiple imputation to substitute missing values. RESULTS: Anxiety scores between groups were significantly reduced (P < 0·05) for complete cases only; the mean (SD) scores were: intervention 7·6 (3·6) at baseline and 6·1 (3·5) at follow-up vs. control 8·3 (3·5) at baseline and after intervention 8·1 (4·4) (P = 0·004). Depression scores did not change; the experimental group scores at baseline were 5·0 (4·2) and after intervention 4·0 (3·7) vs. control group at baseline 5·2 (3·4) and after intervention 4·9 (3·8). Psoriasis severity scores did not change: baseline scores for the experimental group were 7·5 (6·0) and after intervention 6·5 (8·5) vs. the control group before 8·3 (6·3) and after 7·6 (6·1) (not significant). Quality-of-life scores improved in both analyses (P < 0·05); the intervention group scores before were 6·6 (4·2) and after intervention 5·0 (5·1) vs. control before 7·4 (4·4) and after intervention 7·7 (4·5) (P = 0·042). CONCLUSIONS: This first online CBT intervention for people with skin disease showed improvement in anxiety and quality of life in patients with psoriasis. The results are limited by the large amount of missing data and, at this stage, online delivery cannot substitute for established methods of delivery for CBT.

Perceived stops to suicidal thoughts, plans, and actions in persons experiencing psychosis.

BACKGROUND: Suicide has been conceived as involving a continuum, whereby suicidal plans and acts emerge from thoughts about suicide. Suicide prevention strategies need to determine whether different responses are needed at these points on the continuum. AIMS: This study investigates factors that were perceived to counter suicidal ideation, plans, and acts. METHOD: The 36 participants, all of whom had had experiences of psychosis and some level of suicidality, were presented with a vignette describing a protagonist with psychotic symptoms. They were asked to indicate what would counter the suicidal thoughts, plans, and acts of the protagonist described in the vignette. Qualitative techniques were first used to code these free responses into themes/categories. Correspondence analysis was then applied to the frequency of responses in each of these categories. RESULTS: Social support was identified as a strong counter to suicidal ideation but not as a counter to suicidal plans or acts. Help from health professionals was strongly related to the cessation of suicidal plans as were the opinions of the protagonist's children. Changing cognitions and strengthening psychological resources were more weakly associated with the cessation of suicidal ideation and plans. The protagonist's children were considered potentially helpful in addressing suicidal acts. CONCLUSION: These results suggest that both overlapping and nonoverlapping factors need to be considered in understanding suicide prevention, dependent on whether individuals are thinking about, planning, or attempting suicide.

An empirical investigation of the effectiveness of the broad-minded affective coping procedure (BMAC) to boost mood among individuals with posttraumatic stress disorder (PTSD).

The broaden-and-build theory postulates that positive emotions broaden people's cognitions and actions, and facilitate the building of personal and social resources which enhance resilience in a range of clinical populations. The Broad-Minded Affective Coping procedure (BMAC) is a recently developed clinical technique which utilizes the recall of positive autobiographical memories and mental imagery to elicit positive affect. This study aims to investigate the ability of the BMAC to boost mood among 50 individuals diagnosed currently (n = 31) or previously (n = 19) with Posttraumatic Stress Disorder (PTSD). To assess mood, a series of Visual Analog Scales (VASs) and Likert scales measuring feelings of sadness, calmness, happiness, hopelessness, defeat and frustration were administrated at baseline, immediately following the completion of the BMAC and two hours and two days afterwards. Participants in the BMAC condition demonstrated greater increases in self-reported levels of positive emotions and greater reductions in self-reported levels of negative emotions following the BMAC technique compared to those in the control condition. The results suggest that the BMAC is a useful clinical technique which can be incorporated into other clinical interventions such as cognitive behavioral therapy to elicit positive affect and promote resilience.

Psychological resilience in young and older adults.

BACKGROUND: The goal of the current study was to investigate psychological resilience in the older adults (>64 years) compared with that of the young ones (<26 years). METHODS: Questionnaire measures of depression, hopelessness, general health and resilience were administered to the participants. The resilience measure comprised three sub-scales of social support, emotional regulation and problem solving. RESULTS: The older adults were the more resilient group especially with respect to emotional regulation ability and problem solving. The young ones had more resilience related to social support. Poor perceptions of general health and low energy levels predicted low levels of resilience regardless of age. Low hopelessness scores also predicted greater resilience in both groups. Experiencing higher levels of mental illness and physical dysfunction predicted high resilience scores especially for the social support resilience scale in the older adults. The negative effects of depression on resilience related to emotional regulation were countered by low hopelessness but only in the young adults. CONCLUSIONS: These results highlight the importance of maintaining resilience-related coping skills in both young and older adults but indicate that different psychological processes underlie resilience across the lifespan.

Attitudes of relatives and staff towards family intervention in forensic services using Q methodology.

Attitudes about family interventions have been identified as a possible reason for the poor implementation of such treatments. The current study used Q methodology to investigate the attitudes of relatives of forensic service users and clinical staff towards family interventions in medium secure forensic units, particularly when facilitated by a web camera. Eighteen relatives and twenty-nine staff completed a sixty-one item Q sort to obtain their idiosyncratic views about family intervention. The results indicated that relatives and staff mostly held positive attitudes towards family intervention. Relatives showed some uncertainty towards family intervention that may reflect the lack of involvement they receive from the forensic service. Staff highlighted key barriers to successful implementation such as lack of dedicated staff time for family work and few staff adequately trained in family intervention. Despite agreement with the web-based forensic family intervention technique and its benefits, both staff and relatives predicted problems in the technique.

Resilience to suicidal ideation in psychosis: Positive self-appraisals buffer the impact of hopelessness.

Recent years have seen growing interest into concepts of resilience, but minimal research has explored resilience to suicide and none has investigated resilience to suicide amongst clinical groups. The current study aimed to examine whether a proposed resilience factor, positive self-appraisals of the ability to cope with emotions, difficult situations and the ability to gain social support, could buffer against the negative impact of hopelessness amongst individuals with psychosis-spectrum disorders when measured cross-sectionally. Seventy-seven participants with schizophrenia-spectrum disorders completed self-report measures of suicidal ideation, hopelessness and positive self-appraisals. Positive self-appraisals were found to moderate the association between hopelessness and suicidal ideation. For those reporting high levels of positive self-appraisals, increased levels of hopelessness were significantly less likely to lead to suicidality. These results provide cross-sectional evidence suggest that positive self-appraisals may buffer individuals with psychosis against the pernicious impact of a well known clinical risk factor, hopelessness. Accounting for positive self-appraisals may improve identification of individuals at high risk of suicidality, and may be an important area to target for suicide interventions.

Resilience as positive coping appraisals: Testing the schematic appraisals model of suicide (SAMS).

AIMS: The Schematic Appraisals Model of Suicide (SAMS) suggests that positive self-appraisals may be important for buffering suicidal thoughts and behaviours, potentially providing a key source of resilience. The current study aimed to explore whether positive self-appraisals buffered individuals from suicidality in the face of stressful life events. METHOD: 78 participants who reported experiencing some degree of suicidality were recruited from a student population. They completed a battery of questionnaires including measures of suicidality, stressful life events and positive self-appraisals. RESULTS: Positive self-appraisals moderated the association between stressful life events and suicidality. For those reporting moderate or high levels of positive self-appraisals, raised incidence of stressful life events did not lead to increases in suicidality. DISCUSSION: These results support the SAMS framework, and suggest that positive self-appraisals may confer resilience to suicide. Positive self-appraisals may be a promising avenue for further resilience research, and an important area to target for suicide interventions.

Reactivity to images in health and irritable bowel syndrome.

BACKGROUND: We have been using a medical artist to record and paint the images patients have of their irritable bowel syndrome (IBS) and have hypothesized that the reaction to such images might differ in health and IBS, which could have practical implications for future research. AIM: To examine reactivity to images in health and IBS. METHODS: Twelve paintings of IBS were shown to 70 patients to determine the four most evocative images. The spontaneous response to these images and four 'non-IBS painful' and four neutral paintings was assessed in another 100 IBS patients and 100 controls. The prompted reaction in terms of whether an image evoked the notion of pain, bloating or discomfort and to what degree was also recorded. RESULTS: Four images depicting bloating and pain scored the highest. These IBS images triggered significantly different reactivity between patients and controls in terms of their spontaneous and prompted responses. Even 'non-IBS painful' and neutral images resulted in exaggerated and frequently significantly different responses in patients than in controls. CONCLUSIONS: Visual hypersensitivity appears to be another manifestation of the tendency of IBS patients to react adversely to a variety of endogenous and exogenous stimuli. Identifying how individuals relate to different images might also give useful insights into understanding gastrointestinal symptoms.

Pre-existing psychiatric disorders, psychological reactions to stress and the recovery of burn survivors.

This study aimed to investigate whether previous findings from a small retrospective study could be replicated prospectively. The previous study showed that patients with an existing diagnosis of psychosis or depression, admitted to a burns service, had longer hospital stays and longer wound healing times when compared with controls matched for burn injury but without a pre-existing psychiatric condition [1]. In this study it was hypothesised that those patients without pre-existing psychiatric diagnosis, but with high levels of psychological distress after burn would also show a similar pattern of delayed recovery to those with a pre-existing psychiatric illness. In addition, we examined potential mechanisms for slowed recovery, including; adherence with treatment; delayed discharge on social grounds and psychological distress. It was hypothesised that patients with pre-existing psychiatric diagnosis would exhibit poorer adherence and delayed placement due to social reasons, compared to patients without pre-existing psychiatric diagnoses. 107 consecutive admissions to a burns service over a seven-month period were included in the study. Psychiatric history and level of psychological distress post-burn were collected for all patients as part of routine psychological screening. Patients were compared on the following outcome variables: number of days spent in hospital and number of procedures required. 24% (n=27) were found to have a pre-existing psychiatric diagnosis. This group were also found to have significantly longer hospital stays (Mann-Whitney U=585.50, p<0.01) and required more surgical procedures than the group without a psychiatric history (Mann-Whitney U=569.00, p=<0.001). The pattern of results for the group with high psychological distress but without pre-existing psychiatric diagnoses mirrored that of the group with pre-existing psychiatric diagnoses, suggesting that heightened psychological distress alone, has a significant delaying effect upon the rate of recovery (Kruskal-Wallis X=24.75, p<0.01). An exploratory model entering all the variables stepwise at the same stage identified poor adherence and delayed discharge issues as making significant contributions to the final model (r=0.81 adjusted r(2)=62.9, F (4, 42)=20.48, p<0.001). In conclusion, this study supports the role of psychosocial factors, such as pre-existing psychiatric diagnosis and in hospital psychological distress, in contributing the recovery of survivors of burns. This suggests that identifying and working with these difficulties may impact not only on psychosocial, but also physical aspects of recovery.

A longitudinal investigation of psychological morbidity in patients with ovarian cancer.

Ovarian cancer patients may experience psychological disorders due to the aggressive nature of the illness and treatment. We investigated the presence of psychological disorders longitudinally in women with a new diagnosis of ovarian cancer and the factors that predicted development and maintenance of these disorders. Patients were assessed in a prospective longitudinal study at the beginning of chemotherapy treatment, mid-treatment, end of treatment and 3 months follow-up for depression, anxiety, perceived social support, neuroticism and cognitive strategies to control unwanted thoughts. A total of 121 patients were recruited and 85 patients were assessed at all four time points. Three different longitudinal profiles of anxiety and depression caseness were found: non-cases (never cases), occasional cases (cases on at least one but not all four occasions) and stable cases (cases on all four occasions). Most of the women were occasional cases of anxiety (52%, 44), whereas for depression, the majority of women were non-cases (55%, 47). A subset of patients were stable cases of anxiety (22%, 19). Neuroticism and marital status were significant independent predictors of anxiety caseness profile. Neuroticism and use of anti-depressants were independent predictors of depression caseness profile. Social support was not related to psychological morbidity.

Needs-based cognitive-behavioural family intervention for patients suffering from schizophrenia: 5-year follow-up of a randomized controlled effectiveness trial.

OBJECTIVE: To determine whether a 24-week, needs-based cognitive-behaviourally oriented family intervention for patients suffering from schizophrenia led to improved relapse profiles over a 5-year follow-up period. METHOD: The case notes of 60 patients who had participated in a randomized, controlled effectiveness trial were examined to determine relapse rates over a 5-year period. RESULTS: Patients were less likely to relapse over the 5-year follow-up when they received the needs-based family intervention, especially in relation to exacerbations of symptoms not requiring inpatient admissions: 86.7% of control participants relapsed compared with 53.3% (P = 0.01). Survival analysis indicated that the relapse risk was 2.5 times higher for patients receiving routine care, compared with those receiving family intervention. A similar trend was observed for the final 4 years of follow-up. CONCLUSION: The present study provides some tentative support for the long-term effectiveness of family-based interventions for the management of schizophrenia in general mental health services.

Where to start? Attempting to meet the psychological needs of burned patients.

The National Burn Care Review Committee [National Burn Care Review Committee. National Burns Care Review. Standards and Strategy for Burn Care; 2001] recommend routine psychosocial screening for all burned in-patients, as well as access to different levels of psychological input. This paper aims to report on: (1) a system which integrates routine clinical practice, psychological screening and a system of data collection to identify level of need; (2) an audit of the range of levels of psychological input required to meet this need. All consecutive admissions (n=72) to a regional burns unit were screened within a week of admission using the Hospital Anxiety and Depression Scale (HADS), the Impact of Event Scale (IES) and a screening tool developed in the unit. Clinical input was provided as required and recorded. Thirty-five percent reported a previous mental health problem. Forty percent fell into 'borderline' or 'caseness' on the HADS. Fifteen percent met a level of clinical 'caseness' on both the intrusions and avoidance subscales of the IES. Sixty-three percent required some level of psychological input during their in-patient stay. Given the high level of need identified and the range of levels of psychological intervention identified, a system of routine screening and a tiered model of psychological care is proposed to best utilise psychological resources.

Conducting research in everyday psychiatric settings: identifying the challenges to meaningful evaluation.

A distinction is often made between research into the efficacy of a treatment, i.e. whether it can be shown to work under ideal conditions, and research into the effectiveness of a treatment, i.e. whether it can be shown to work within a routine health service or usual clinical practice. The purpose of this article is to use descriptive information collected from personnel on the implementation and evaluation of a psychological intervention as a way to highlight some of the challenges faced when conducting research within everyday clinical settings. A psychological intervention for low self-esteem was evaluated within a standard inpatient ward for dual diagnosis patients. Descriptive information was collected from interviews to identify the challenges encountered during the research process. A qualitative analysis of interview content was undertaken to identify the major themes. Personnel described a range of patient variables, staff characteristics and organizational factors that hindered the research process. A detailed account of these factors along with potential solutions that can facilitate research in clinical settings is provided. Conducting research within clinical settings requires considerable planning and monitoring throughout the whole research process. Particular attention should be given to the impact of patient characteristics, staff variables and organizational context when designing and implementing research protocols. The value of this type of research within everyday clinical settings has significant implications for improving patient treatment and outcomes across psychiatric services.

The evolution of insight, paranoia and depression during early schizophrenia.

BACKGROUND: How insight, paranoia and depression evolve in relation to each other during and after the first episode of schizophrenia is poorly understood but of clinical importance. METHOD: Serial assessments over 18 months were made using multiple instruments in a consecutive sample of 257 patients with first episode DSM-IV non-affective psychosis. Repeated measures of paranoia, insight, depression and self-esteem were analysed using structural equation modelling, to examine the direction of relationships over time after controlling for confounds. RESULTS: Depression was predicted directly by greater insight, particularly at baseline, and by greater paranoia at every stage of follow-up. Neither relationship was mediated by self-esteem, although there was a weak association of lower self-esteem with greater depression and better insight. Paranoia was not strongly associated with insight. Duration of untreated psychosis and substance use at baseline predicted depression at 18 months. CONCLUSIONS: In first-episode psychosis, good insight predicts depression. Subsequently, paranoia is the strongest predictor. Neither effect is mediated by low self-esteem. Effective treatment of positive symptoms is important in preventing and treating low mood in early schizophrenia.

The Family Questionnaire (FQ): a scale for measuring symptom appraisal in relatives of schizophrenic patients.

OBJECTIVE: This study examined the psychometric properties of the Family Questionnaire (FQ): a self-report measure of relatives' perceptions of the behaviours and symptoms of schizophrenic patients in terms of three dimensions: the frequency of symptoms, the relatives' concern (primary appraisal) and their ability to cope (secondary appraisal) with the symptoms. METHOD: Factor analysis of the FQ, test-retest and inter-rater reliability, and measures of validity were examined. RESULTS: Factor analysis supported the validity of five subscales labelled negative symptoms, antisocial behaviours, interpersonal problems, affective symptoms and psychotic symptoms. Test-retest reliability for all scales was good and the prediction that there would be limited correspondence between two different relatives' scores was supported for the subscales of negative symptoms and affective symptoms. Concurrent measures of relatives' distress, burden and patients' symptomatology indicated that the FQ showed acceptable validity. In particular, the study showed that high expressed emotion relatives have higher scores on the appraisal dimensions of some subscales. CONCLUSION: The study provides evidence that the FQ is a useful tool for measuring relatives' perceptions of schizophrenic illness, particularly within the context of family interventions where it may be utilized to help to understand the factors mediating relatives' burden and distress.