"Finding my voice again" - women's experiences of psychological therapy in perinatal secondary care settings: a qualitative study.

Introduction: Although women often experience mental health comorbidities in the perinatal period, the evidence-base for psychological therapy across diagnostic boundaries in the perinatal period remains limited. As there is a need to understand experiences of therapy, irrespective of diagnosis, to inform intervention provision, the aims of this study were to explore women's experiences of psychological therapy for perinatal mental health difficulties and to identify the mechanisms that women attributed to the most significant therapeutic change for themselves and/or the mother-infant relationship. Method: Semi-structured interviews were conducted with 16 women who received therapy within specialist perinatal community mental health settings in the Northwest of England, the UK. Interview data were analysed using reflexive thematic analysis. Results: One overarching theme entitled participant life stories were at the heart of therapy was identified alongside three other main themes: 1.) We're in this together - therapeutic bond and establishing a coherent sense of self, 2.) Surfing the urge to 'fix' feelings - Sitting with emotions improved regulation and 3.) Seeing myself in a new light - Shifting self-blame to self-compassion enhanced self-efficacy. Theme 1 consisted of three subthemes. Participants described the quality of the therapeutic relationship as the fundamental foundation to (re)connecting with their needs, values and boundaries, which improved their sense of agency, self-esteem, therapeutic engagement and self-understanding. Shifting emotional avoidance to emotional engagement improved their self-regulation. Considering alternative factors that could have contributed to their experiences helped them to defuse self-blame and enhance self-compassion. Finally, changes in their mental health led to positive relational changes in their relationship with their infant and improved communication with partners. Discussion: Sensitivity, engagement and responsivity experienced in the therapist-woman relationship was reported to be mirrored in the mother-infant relationship. Developing a coherent sense of self and self-regulation skills both appeared to heighten women's self-compassion and empathy for their infants, which also seemed to improve their ability to tolerate uncertainty and mixed emotions within themselves and their infants. The mechanisms of change in the perinatal period are important to consider at a stakeholder, therapist and service management level to parsimoniously and best meet the needs of women and the mother-infant relationship.

A systematic review of clinical psychological guidance for perinatal mental health.

BACKGROUND: Guidelines on psychological and/or psychosocial assessment and intervention in the perinatal period can provide beneficial practice guidance for healthcare professions to reduce maternal distress and potential mortality. As little is known about the similarities in recommendations across guidelines, which could impact the quality of therapeutic intervention women receive, this systematic review was conducted to draw out the consistent guidance for perinatal psychological and/or psychosocial therapeutic input. METHOD: Eight literature and two guideline databases were searched alongside guideline development institutions, and organisations of maternity or perinatal mental health care. All relevant guidance was searched for and extracted before guideline quality was assessed using the AGREE-II instrument. Included guidelines had a primary or secondary focus on psychological assessment and therapeutic intervention for perinatal mental health difficulties. Using a narrative synthesis approach, recommendation consistencies and inconsistencies were outlined. RESULTS: From the 92 records screened, seven guidelines met the inclusion criteria. Only two guidelines were rated high (> 80%) across all assessed domains, with the other guidelines scoring between poor and excellent across domains. Highest rated domains across all seven guidelines were clarity of presentation (75%) and scope and purpose (70%). Recommendations for structured psychological assessment and intervention were most commonly reported in the guidelines; however, the level of detail and depth of information varied across guidelines. Whilst assessment and intervention recommendations for mother-infant dyad and partners were considered, research into working therapeutically with these client groups in perinatal mental health services is only just emerging. Hence, guideline recommendations for working with the mother-infant dyad and partners were based on consensus of expert opinion. CONCLUSION: Perinatal mental health guidelines were consistent in scope but showed considerable variability in quality and depth of recommendations, which could have implications for standards of clinical practice. However, there is still a need to improve the evidence underpinning recommendations in perinatal mental health guidelines to advance the implementation of psychological and/or psychosocial interventions. High quality interventions in the perinatal period could improve outcomes for women and their families.

What about the children? Adult mental health practitioners' experiences and views of family-focused practice in Early Intervention Services.

BACKGROUND: There is a significant risk of negative outcomes for families when a parent experiences serious mental illness. Family-focused practice (FFP) emphasises the "whole family" as the unit of care and has been found to improve outcomes for service users and their families. Despite its benefits, FFP is not routinely implemented in UK adult mental health services. This study explores adult mental health practitioners' experiences and views of FFP within Early Intervention Psychosis Services in the UK. METHODS: Sixteen adult mental health practitioners employed in three Early Intervention Psychosis teams in the Northwest of England were interviewed. Interview data were analysed using thematic analysis. RESULTS: Five core themes were generated: (1) A limited understanding of FFP, (2) Our practitioners, (3) Our approach, (4) Our families and (5) Our services. Practitioners' understanding of FFP was limited and typically excluded dependent children. Practitioners' age, professional and personal experience, and preconceptions of families influenced delivery, and in turn, the engagement approach they adopted impacted families' responsiveness. The diversity and dynamics of service user families such as age, socioeconomic status, culture and stigma impacted FFP. An operational context characterised by insufficient resources reduced FFP; however, organisational structures such as leadership, clinical supervision and multi-disciplinary teams facilitated FFP. CONCLUSIONS: FFP is not yet embedded within Early Intervention Services. Practice recommendations include agreeing on a formal definition of FFP and its scope; the development of FFP policy; clarity in relation to staff responsibilities and identities; the adoption of a collaborative approach which encourages service user choice and for time to be ring-fenced to prioritise FFP. Future research should ascertain service user and family views on the facilitators and barriers to engaging with FFP in Early Intervention Services.

Parents who experience psychosis: A qualitative exploration.

OBJECTIVES: Psychosis can present parents with complex parenting challenges and significant adverse outcomes for parents and their children have been reported. However, remarkably little is known about how parenting is experienced by these parents. Therefore, this qualitative study aimed to understand the lived experiences of parents with psychosis, including how parenting support was experienced. DESIGN AND METHODS: Using interpretative phenomenological analysis (IPA), eight biological parents (five mothers and three fathers) with psychosis were recruited and interviewed from early intervention in psychosis services in the Northwest of England. RESULTS: Three superordinate themes and seven subordinate themes were identified. Theme 1 'Living with the Struggle: Painfully Disconnected' captured a persistent parenting struggle that distanced parents from their children and support due to all-consuming experiences of psychosis, fear and risk-focused service support. Theme 2 'Desired and Vulnerable Position: Comfortably Connected' captured parental experiences of symptom relief through connection with their children, alongside parental need to be integrated with the systems around them. Theme 3 'Exposed: Parenting Under a Spotlight' represented parental experiences of inescapable observation and judgement from the systems around them. CONCLUSIONS: Novel insights into the role of misaligned parent and service priorities in parental perceptions of powerlessness, shame and disconnection from their children, valued parenting identities, and system supports are presented. Systemic interventions that target stigma, provide system-wide psychoeducation and promote person-centred, compassionate and meaningful connections between parents and the systems they live within are needed to promote better parenting outcomes.

Health and social care professionals' views and experiences of supporting parents with serious mental illness.

Introduction: A significant number of individuals with a serious mental illness (SMI) such as schizophrenia or bipolar disorder are also parents of dependent children. Despite the risk of adverse psychological, behavioral, and social outcomes their needs often go unmet. To better understand the needs of parents with SMI and their children it is necessary to gain insight into the perspectives and experiences of the professionals in adult mental health and children's services who work with them, and who, ultimately, are best placed to meet those needs. Aims: To explore the views and experiences of health and social care professionals working with parents with SMI to understand the needs of, and their role supporting, parents with SMI and their children. Methods: Semi-structured interviews were conducted with seventeen professionals from six NHS and Local Authority settings in England, UK. Participants were included if they were employed in adult mental health or local authority children's services and had experience of working with parents with SMI. Sampling was purposive, including a wide range of professions in these settings. Interview data were analyzed using template analysis taking a critical realist perspective. Results: Three top-level themes were generated: (1) Impact of parental SMI on the child, (2) Accessing support from services, (3) Role of professionals working with parents with SMI. Themes highlight diverse, wide-ranging effects of SMI on the child and a reluctance from parents to seek help due to stigma and fear. Available services are reported to be inaccessible and unacceptable to parents with SMI and practitioners experience conflict when balancing the needs of the parent and child. A whole-family approach facilitated by improved communication between services is advocated. Conclusion: Participants believed that parents with SMI experience complex parenting challenges over and above other parents, describing a largely detrimental impact on the child. Support services were deemed inadequate, and participants stressed the need to develop specialist services tailored toward the needs of parents with SMI and their children. Although participants endorsed joined up working across health and social care settings to facilitate a whole family approach, they required greater service knowledge and training in parental SMI.

The Triple P Positive Parenting Program for Parents With Psychosis: A Case Series With Qualitative Evaluation.

Although many people with psychosis are parents, managing the dual demands of poor mental health and parenting can be stressful and may contribute to poorer outcomes for both parent and child. Parenting interventions have the potential to improve outcomes for the whole family but need evaluation of feasibility in this context. The Triple-P Self-Help Workbook was implemented with guidance and support with 10 parents experiencing psychosis in a multiple baseline case series study. Sessions were weekly and home-based. Outcome measures examined facets of parenting, child behavior, self-efficacy and parental mental health. Follow up interviews explored parents' perspectives of the perceived impact of the intervention and apparent mechanisms of change. The program resulted in clinically significant change (>25% improvement) in mental health, parenting and child behavior measures post-intervention for the 50% who completed all 10 sessions and improvements were maintained at 3 and 6 month follow up. Interviews with those who completed the program revealed it to have been transformative: parents reported positive changes in parenting style; they were empowered with regard to their parenting and had a greater sense of control over their mental health. This study provides preliminary evidence that self-directed Triple P might be able to reduce the symptoms of psychosis by improving family functioning. Findings could inform the future development or adaptation of evidence-based parenting interventions for parents with psychosis in order to improve their mental health, aid recovery, and intervene early in the lives of children at risk of poor long-term outcomes.

The role of attachment, coping style and reasons for substance use in substance users with psychosis.

Seventy substance users with psychosis who were participating in a clinical trial of a psychological therapy for psychosis were additionally assessed for attachment, coping styles and self-reported reasons for substance use in order to test a hypothesized sequential mediation model. In this model the relationship between insecure attachment and problematic substance use was assumed to be sequentially mediated by dysfunctional coping and the use of substances to cope with distress. Hypothesized associations between insecure-avoidant attachment and substance use were not supported, but the relationship between insecure-anxious attachment and problematic substance use was confirmed and found to be fully mediated by dysfunctional coping and coping reasons for use. Findings suggest that fostering secure attachments in people with psychosis might promote more successful coping and could prevent or reduce substance use related problems in this group.

Expressed Emotion and Attributions in Parents With Schizophrenia.

We examined expressed emotion (EE) and attributions in parents with schizophrenia and compared them to parents without serious mental illness (SMI) in order to better understand the emotional climate of families in which a parent has schizophrenia. Parenting practices and parental reports of child behavior were also compared between the two groups. The relationship of EE to attributions was examined in each group separately. Relationships between parental mental health, EE, and attributions were explored in the parents with schizophrenia only. The Camberwell Family Interview was used to determine both EE and attributions in 20 parents with schizophrenia and 20 parents without SMI. We found that more parents with schizophrenia were rated as high EE than those without (60 and 35%, respectively) although this was not a statistically significant difference. Parents with schizophrenia demonstrated significantly more hostility and criticism toward their children than those without SMI and made more child-blaming attributions. Blame was associated with increased hostility, less warmth, and fewer positive remarks. Parental warmth was related to greater parenting self-efficacy, less harsh parenting practices, better child behavior, and a more positive parent-child relationship. We conclude that EE and attributions are potential explanatory variables to be considered in the development of preventative and early intervention strategies for families with a parent with schizophrenia or other psychotic disorder. Blame and warmth are modifiable factors that could be targeted within family and parenting interventions.

Views of Practitioners and Researchers on the Use of Virtual Reality in Treatments for Substance Use Disorders.

Virtual Reality Therapy (VRT) has been shown to be effective in treating anxiety disorders and phobias, but has not yet been widely tested for Substance Use Disorders (SUDs) and it is not known whether health care practitioners working with SUDs would use VRT if it were available. We report the results of an interview study exploring practitioners' and researchers' views on the utility of VRT for SUD treatment. Practitioners and researchers with at least two years' experience delivering or researching and designing SUD treatments were recruited (n = 14). Interviews were thematically analyzed, resulting in themes relating to the safety and realism of VRT, and the opportunity for the additional insight it could offer to during SUD treatment. Participants were positive about employing VRT as an additional treatment for SUD. VRT was thought suitable for treating adults and people with mental health issues or trauma, provided that risks were appropriately managed. Subsequent relapse, trauma and over-confidence in the success of treatment were identified as risks. The opportunity VRT offered to include other actors in therapy (via avatar use), and observe reactions, were benefits that could not currently be achieved with other forms of therapy. Overall, VRT was thought to offer the potential for safe, realistic, personalized and insightful exposure to diverse triggering scenarios, and to be acceptable for integration into a wide range of SUD treatments.

The implementation of family-focused practice in adult mental health services: A systematic review exploring the influence of practitioner and workplace factors.

There is increased recognition of the need for greater and more appropriate support to be offered to families in which a parent experiences mental illness and has dependent children. One way of meeting this need is for adult mental health services to take a more family-focused approach. However, there are recognized difficulties in facilitating family-focused practice (FFP). The current review systematically synthesized quantitative and qualitative literature of practitioner perspectives and experiences of FFP in adult mental health settings to identify modifiable factors associated with its successful implementation. Five databases were searched systematically leading to the inclusion and quality assessment of 19 papers, ten of which were quantitative and nine qualitative. Analysis was guided by a narrative synthesis approach. Factors shown to influence FFP functioned at both practitioner and workplace levels and included personal attitudes, beliefs about job role, and perceptions of workplace support. Practitioners who felt that a family-focussed approach was inappropriate or detrimental to service users or outside of their remit as mental health professionals were less likely to adopt this approach. For those who saw the potential benefits of FFP, lack of confidence in their ability to deliver such an approach and lack of training can be barriers, as can lack of support and resources within services. This review highlights the need for actions to boost the awareness of adult mental health practitioners working with parents and to increase their confidence. It also makes the case for broader organizational support if family-focussed practice is to be implemented successfully.

Adult mental health practitioner beliefs about psychosis, parenting, and the role of the practitioner: A Q methodological investigation.

OBJECTIVES: There is a lack of research into parenting interventions for families which include a parent experiencing psychosis or other serious mental illness (SMI). Preliminary findings highlight the potential benefits of adult mental health practitioners supporting parents experiencing SMI by using self-directed parenting interventions. This study explored beliefs relating to parenting and psychosis held by practitioners working in adult mental health settings, specifically examining their beliefs about the parenting needs of adults experiencing psychosis who have dependent children, as well as their role as adult mental health practitioners. DESIGN: This study used Q methodology to explore the beliefs of mental health practitioners on psychosis and parenting. METHODS: Twenty-one adult mental health practitioners ranked 58 items according to how much they agreed with the belief statement presented. Participants also provided additional written information and interviews to contextualize the Q methodology data. RESULTS: Three factors emerged representing three groups of practitioners with similar beliefs around psychosis and parenting. Factors were labelled: 'Parenting interventions are worthwhile, and I'd deliver them', 'Parenting interventions are worthwhile, but I'm not confident to deliver them', and 'Parenting interventions might be worthwhile, but it's not my responsibility'. CONCLUSION: Using parenting interventions as part of their clinical work was acceptable to most practitioners; however, some lacked confidence in their ability to work in a family-focused way. Efforts now need to focus on enhancing practitioners' skill, knowledge, and confidence in family-focused approaches to provide increased and improved support to families which include a parent experiencing psychosis or other SMI. PRACTITIONER POINTS: Parenting interventions need to be made more available and accessible to parents experiencing serious mental illness (SMI), such as psychosis. Adult mental health practitioners are willing to incorporate parenting interventions into their work with parents accessing their services, but some lack confidence to do this. These results highlight the importance of equipping practitioners with the skill, knowledge, and confidence to engage in family-focused approaches. Further research needs to involve parents experiencing SMI as well practitioners working in adult mental health services.

Young people's beliefs about psychological therapy for psychosis: a Q-Methodological study.

Background: The evidence base for the use of psychological therapies in the treatment of psychosis is growing, however engagement can be difficult and outcomes are variable. Beliefs, attitudes and expectations may have an important influence on whether individuals engage with therapy and on clinical outcomes, however, these beliefs have not been adequately explored.Aims: To examine what young people in Early Intervention Services (EIS) think about psychological therapies for psychosis.Method: Thirty participants were recruited from EIS across five NHS trusts to examine young people's beliefs about psychological therapy.Results: Four distinct factors, or sets of beliefs, about therapy emerged: (1) Therapy is helpful and gives hope for the future; (2) Therapy is just talking, people need medication; (3) Therapy is useful but stigmatising; (4) Therapy is better than medication. Positive views towards different aspects of therapy were present in all four accounts. Other important issues were raised, including concerns about stigma and opposing beliefs about medication.Conclusion: These four factors provide useful insights into young people's beliefs about psychological therapy. Individuals' beliefs and expectations should be recognised and explored in order to promote greater engagement in and better outcomes from therapy.

Facilitators and Barriers to Participating in a Randomized Controlled Trial of a Psychological Therapy for Substance Use.

Research involving substance users with psychosis has high refusal and attrition rates. Understanding participants' experiences of research participation is therefore important. Twenty-two cannabis users with schizophrenia spectrum disorders were recruited. They were involved in a randomized controlled trial exploring the effectiveness of motivational interviewing plus cognitive behavioral therapy. Semistructured interviews were conducted, and their responses were analyzed using thematic analysis. Thematic analysis identified facilitators such as therapeutic benefit, knowledge about medical conditions, awareness of own drug habits, helping others, confidentiality, rapport with researchers, desiring social contact, and views of significant others. Barriers identified were cognitive challenge, amount of assessments, duration, and discussions about the past. Based on these insights, we recommend informing participants about clinical equipoise, confidentiality, and demands of the study; minimizing demands on participants; acknowledging participants' efforts; involving potential participants' significant others during recruitment; advertising research as an opportunity to help; and training researchers in building rapport.

Does exercise improve sleep for adults with insomnia? A systematic review with quality appraisal.

Insomnia is recognised as the most prevalent sleep disorder. Untreated insomnia carries a heavy burden for patients and society. Exercise is proposed as a safe, inexpensive, and accessible non-pharmacological treatment. To the author's knowledge this is the first systematic review to investigate the sleep-enhancing effects of exercise by focusing exclusively on controlled trials comprising poor sleepers only and examining interventions consistent with national guidelines. Using a narrative synthesis, this review aimed to identify whether exercise improves objective and subjective sleep outcomes for people with insomnia. Five papers including participants with insomnia disorder, and six papers including participants with insomnia symptoms were identified through electronic database searches (CINAHL plus, PsycINFO, EMBASE, MEDLINE, SPORTDiscus, CENTRAL) and quality assessed using the Clinical Trial Assessment Measure. We found that exercise interventions led to improvements in subjective sleep quality for people with insomnia disorder and insomnia symptoms. However, exercise only improved objective and subjective measures of sleep continuity (sleep onset latency and sleep efficiency) for people presenting with insomnia symptoms, with a reduction in sleep onset latency being the most consistently observed effect across studies. The reliability of significant findings is reduced by methodological limitations. Recommendations are made to improve the quality of future research.

Attachment and therapeutic alliance in psychological therapy for people with recent onset psychosis who use cannabis.

We examine associations between client attachment style and therapeutic alliance in a 3-arm randomized controlled trial of brief motivational interviewing and cognitive-behavioural therapy compared with longer term motivational interviewing and cognitive-behavioural therapy or standard care alone. Client self-report measures of attachment style were completed at baseline, and both clients and therapists in the treatment arms of the trial completed alliance measures 1 month into therapy. We found that insecure-anxious attachment was positively associated with therapist-rated alliance, whereas clients with insecure-avoidant attachment were more likely to report poorer bond with therapist. There was no evidence that client attachment significantly predicted clinical or substance misuse outcomes either directly or indirectly via alliance. Nor evidence that the length of therapy offered interacted with attachment to predict alliance.

Therapeutic alliance in psychological therapy for people with recent onset psychosis who use cannabis.

BACKGROUND: This paper examines the role of therapeutic alliance in predicting outcomes in a Randomized Controlled Trial of Motivational Interviewing and Cognitive Behavioral Therapy (MICBT) for problematic cannabis use in recent onset psychosis. METHODS: All clients were participating in a three arm pragmatic rater-blind randomized controlled trial of brief MICBT plus standard care compared with longer term MICBT plus standard care and standard care alone. Participants completed measures to assess clinical symptoms, global functioning and substance misuse at baseline, 4.5months, 9months and 18months. Clients and therapists completed the Working Alliance Inventory approximately one month into therapy. Client alliance data was available for 35 participants randomized to therapy and therapist alliance data was available for 52 participants randomized to therapy. RESULTS: At baseline, poorer client-rated alliance was associated with more negative symptoms, poorer insight and greater cannabis use, whereas poorer therapist-rated alliance was only associated with amount of cannabis used per cannabis using day. Alliance ratings were also positively associated with amount of therapy: client-rated alliance was higher in the longer compared to the briefer therapy; therapist-rated alliance was associated with greater number of sessions attended (controlling for type of therapy) and therapy completion. In predicting outcome, client-rated alliance predicted total symptom scores and global functioning scores at follow-up. Neither client nor therapist alliance predicted changes in substance misuse at any time point. CONCLUSIONS: Findings demonstrate that individuals with psychosis and substance misuse who form better alliances with their therapists gain greater benefits from therapy, at least in terms of improvements in global functioning.

Individuals' experiences and opinions of psychological therapies for psychosis: A narrative synthesis.

Beliefs, attitudes and expectations about therapy are likely to influence engagement, adherence and outcomes in psychological therapy but despite increased research interest in this area, the evidence has not been systematically reviewed or synthesised. This review is the first to explore service user beliefs by synthesising existing quantitative and qualitative research in order to develop a comprehensive understanding of beliefs about psychological therapy in people with psychosis and to identify gaps in the literature. Thirty-five papers were included in this review and synthesised. Themes and subthemes of both service user expectations (including outcomes, process and barriers) and experiences (including satisfaction, outcomes, process and therapist characteristics) are described. High levels of satisfaction and positive regard towards therapy for psychosis were found. However, many clients refuse, do not attend or withdraw from psychological therapy. Data were primarily limited to people who have completed therapy. Expectations about therapy have not been adequately addressed and warrant further exploration. Understanding and managing expectations, including consideration of fears, misconceptions, and potential challenges, could promote engagement. Exploration of beliefs, particularly in those who refuse or terminate therapy, is essential to further our understanding of factors affecting services users' decision-making processes, as well as the efficacy of therapy.

Therapist-client relationships in a psychological therapy trial for psychosis and substance misuse.

BACKGROUND: This study aimed to explore factors associated with outcomes in a randomised controlled trial of integrated motivational interviewing and cognitive behavioural therapy for psychosis and substance misuse. METHOD: Clients and therapists completed self-report measures of alliance and clients completed a self-report measure of adult attachment. Trial therapists were also asked to identify challenges in therapy, client strengths and reasons for client making and not making changes in relation to substance misuse. RESULTS: Neither therapist-rated nor client-rated alliance was significantly related to objective outcomes. Client insecure attachment avoidance was associated with poorer symptoms and functioning at 12 and 24 months; although not changes in substance misuse. Therapists' perceptions of therapeutic processes (e.g., challenges to therapy, client strengths, client reasons for change and alliance) were consistent with previous literature. Therapists' perceptions of client improvement were associated with reductions in substance use at the end of treatment and their ratings of therapeutic alliance. CONCLUSION: Insecure adult attachment styles may be a potentially important predictor of symptom outcomes for people with psychosis and substance misuse. Trial therapists may also provide an important source of information about therapeutic processes and factors associated with outcome.

The impact of cannabis use on clinical outcomes in recent onset psychosis.

BACKGROUND: There are inconsistencies in findings as to whether cannabis use has a negative impact on clinical outcomes for people with established psychosis. Effects may be more evident on patients with recent onset psychosis. AIM: To investigate the relationship between cannabis use and clinical outcome, including whether change in cannabis use affects psychotic symptoms, affective symptoms, functioning and psychotic relapse in a sample of people in early psychosis with comorbid cannabis abuse or dependence. METHODS: One hundred and ten participants were examined prospectively with repeated measures of substance use antecedent to psychopathology at baseline, 4.5, 9, and 18 months. We used random intercept models to estimate the effects of cannabis dose on subsequent clinical outcomes and whether change in cannabis use was associated with change in outcomes. RESULTS: There was no evidence of a specific association between cannabis use and positive symptoms, or negative symptoms, relapse or hospital admissions. However, a greater dose of cannabis was associated with subsequent higher depression and anxiety. Change in the amount of cannabis used was associated with statistically significant corresponding change in anxiety scores, but not depression. Additionally, reductions in cannabis exposure were related to improved patient functioning. CONCLUSIONS: Reducing cannabis may be directly associated with improvements in anxiety and functioning, but not other specific symptoms.