An independent audit of electroconvulsive therapy patient information leaflets in Northern Ireland, Scotland and Wales.

OBJECTIVES: To evaluate the accuracy of patient information leaflets about electroconvulsive therapy (ECT) used in Northern Ireland, Scotland and Wales, and their compliance with the principle of informed consent. DESIGN AND METHODS: To replicate an audit in England, Freedom of Information Act requests were sent to the 26 providers of ECT for their ECT patient information leaflet. These were scored, by two independent raters, on the same 40-item accuracy measure used in the England audit. RESULTS: The number of accurate statements (out of a possible 29) ranged from seven to 20, with a mean of 16.9. The most frequently omitted statements included: cardiovascular risks (mentioned by five leaflets), that it is not known how ECT works (3), risk of mortality (2), risks from multiple general anaesthetic procedures (2), how to access a legal advocate (2) and that that there is no evidence of long-term benefits (1). The leaflets made between six and nine inaccurate statements (out of 11) with a mean of 7.0. Nineteen minimised memory loss, blamed the memory loss on depression, claimed that ECT is the 'most effective treatment' and asserted it has very high response rates without mentioning similar placebo response rates. All 23 leaflets wrongly told patients that ECT saves lives. CONCLUSIONS: Electroconvulsive therapy information leaflets in these three nations are barely more accurate than those in England and do not comply with the ethical principle of informed consent. Patients and families across the UK are systematically being misled about the risks they are taking and the limited nature of ECT's benefits.

Young adults' dynamic relationships with their families in early psychosis: Identifying relational strengths and supporting relational agency.

OBJECTIVES: Most existing research on the family context of psychosis focuses on the 'burden' of caring for people experiencing psychosis. This research is the first to ask young people experiencing early psychosis to 'map' and describe their experiences and understandings of their family relationships, and how they have related to their psychosis and recovery. DESIGN: The research took an inductive, multimodal hermeneutic-phenomenological approach (Boden, Larkin & Iyer, 2019, Qual. Res. Psychology, 16, 218-236; Boden & Larkin, 2020, A handbook of visual methods in psychology, 358-375). METHOD: Ten young adults (18-23), under the care of early intervention in psychosis services in the UK, participated in an innovative relational mapping interview (Boden, Larkin & Iyer, 2018), which invited participants to draw a subjective 'map' of their important relationships. This visual methodology enables subtle, complex, ambivalent, and ambiguous aspects of the participants' experiences to be explored. RESULTS: Findings explore the participants' accounts of how they love, protect, and care for their families; how they wrestle with family ties as they mature; and their feelings about talking about their mental health with loved ones, which was typically very difficult. CONCLUSIONS: This paper advances understanding of recovery in psychosis through consideration of the importance of reciprocity, and the identification and nurturance of relational strengths. The capacity of a young person to withdraw or hold back when trying to protect others is understood as an example of relational agency. The possibility for extending strengths-based approaches and family work within the context of early intervention in psychosis services is discussed. PRACTITIONER POINTS: Young adults experiencing early psychosis may benefit from support to identify their relational strengths and the opportunities they have for reciprocity within their family structures, where appropriate. Relational motivations may be important for a range of behaviours, including social withdrawal and non-communication. Services may benefit from exploring the young person's relational context and subjective meaning-making in regard to these actions. Young adults experiencing early psychosis may benefit from opportunities to make sense of their family dynamics and how this impacts on their recovery. Attachment-based and relationally oriented interventions that increase trust and openness, and reduce feelings of burdensomeness are likely to support family functioning as well as individual recovery.

IMPlementation of An online Relatives' Toolkit for psychosis or bipolar (IMPART study): iterative multiple case study to identify key factors impacting on staff uptake and use.

BACKGROUND: Despite the potential of digital health interventions to improve the delivery of psychoeducation to people with mental health problems and their relatives, and substantial investment in their development, there is little evidence of successful implementation into clinical practice. We report the first implementation study of a digital health intervention: Relatives Education And Coping Toolkit (REACT), into routine mental healthcare. Our main aim was to identify critical factors affecting staff uptake and use of this online self-management tool for relatives of people with psychosis or bipolar. METHODS: A mixed-methods, theory-driven (Normalisation Process Theory), iterative multiple case study approach using qualitative analysis of interviews with staff and quantitative reporting of uptake. Carer researchers were part of the research team. RESULTS: In all, 281 staff and 159 relatives from Early Intervention teams across six catchment areas (cases) in England registered on REACT; 129 staff took part in qualitative interviews. Staff were positive about REACT helping services improve support and meet clinical targets. Implementation was hindered by: high staff caseloads and difficulties prioritising carers; perception of REACT implementation as research; technical difficulties using REACT; poor interoperability with trust computer systems and care pathways; lack of access to mobile technology and training; restricted forum populations; staff fears of risk, online trolling, and replacement by technology; and uncertainty around REACT's long-term availability. CONCLUSIONS: Digital health interventions, such as REACT, should be iteratively developed, evaluated, adapted and implemented, in partnership with the services they aim to support, and as part of a long term national strategy to co-develop integrated technology-enabled mental healthcare. Implementation strategies must instil a sense of ownership for staff and ensure they have adequate IT training, appropriate governance protocols for online working, and adequate mobile technologies. Wider contextual factors including adequate funding for mental health services and prioritisation of carer support, also need to be addressed for successful implementation of carer focussed digital interventions. TRIAL REGISTRATION: Study registration: ISCTRN 16267685.

Friends interventions in psychosis: a narrative review and call to action.

AIMS: To highlight the importance of friendships to young people with psychosis, and the need for clinical interventions to help maintain peer relationships during illness. To structure a research agenda for developing evidence-based interventions with friends. METHOD: An argument is developed through a narrative review of (i) the proven efficacy of family interventions, and (by comparison) a relative absence of friend-based interventions; (ii) the particular primacy of friendships and dating for young people, and typical effects of exclusion; and (iii) reduced friendship networks and dating experiences in psychosis, in pre-, during and post-psychosis phases, also links between exclusion and psychosis. RESULTS: We put forward a model of how poor friendships can potentially be a causal and/or maintenance factor for psychotic symptoms. Given this model, our thesis is that interventions aiming to maintain social networks can be hugely beneficial clinically for young people with psychosis. We give a case study to show how such an intervention can work. CONCLUSIONS: We call for 'friends interventions' for young people with psychosis to be developed, where professionals directly work with a young person's authentic social group to support key friendships and maintain social continuity. An agenda for future research is presented that will develop and test theoretically driven interventions.

Perception of peer group rank of individuals with early psychosis.

OBJECTIVES: Social rank theory has been applied to psychosis, in particular the relationship between an individual and their voices. However, perceived peer group rank has not been empirically tested in an early psychosis group. The purpose of the study was to test the prediction that individuals with early psychosis will have lower perceived social status, engage in submissive behaviours more frequently, and will feel more entrapped by external events compared to a healthy control group. DESIGN: The study employed a cross-sectional design, comparing individuals with early psychosis and healthy controls. METHODS: A total of 24 participants with early psychosis and 24 matched controls completed self-report measures of social rank, including social comparison, submissive behaviours and entrapment, measures of depression, anxiety and psychotic symptoms, and measures of peer network size and peer relationship quality. RESULTS: Individuals with early psychosis viewed themselves as being of lower social rank and inferior in relation to matched controls, and also reported engaging in submissive behaviours more frequently and felt more entrapped by external events. CONCLUSIONS: Perception of lower social rank and inferiority amongst individuals with early psychosis may impact on engagement in peer relationships and impact on the social decline in early psychosis, which could have significant implications for interventions and recovery.

Quality of life and illness beliefs in individuals with early psychosis.

PURPOSE: Quality of life (QoL) has become an important outcome measure in early psychosis. This study examined associations between illness beliefs (how individuals perceive their mental health problems), symptom factors and QoL in an early psychosis population. METHODS: Eighty-one individuals with early psychosis completed a battery of questionnaires measuring QoL, illness perceptions, psychotic and affective symptoms. RESULTS: QoL was significantly associated with certain illness beliefs, namely treatment control and consequences of psychosis. Lower levels of QoL were associated with higher depression, anxiety and general psychopathology. QoL was found to be predicted by key illness beliefs. CONCLUSIONS: Causality has not been fully established, but these results suggest that beliefs about mental health problems may have a direct impact on outcome, and point towards possible targets for intervention, such as challenging illness-related appraisals. This is consistent with both general cognitive models of psychosis, and Cognitive Behaviour Therapy for this client group.

Understanding cannabis use in first-episode psychosis: an application of the Theory of Planned Behaviour.

AIM: The study aims to examine whether an extended Theory of Planned Behaviour (TPB) model predicts the frequency of past and intended cannabis use in young adults with psychosis. METHODS: A cross-sectional correlational design was used with 32 participants (aged 18-36 years old) within 3 years (mean = 7 months) of their first psychotic episode. TPB variables and a measure of social influence (descriptive norms) were measured. RESULTS: The TPB accounted for a large amount of the variance in both the frequency of past cannabis use (25%) and in the intended frequency of future cannabis use (36%). The addition of descriptive norms (beliefs about the frequency of others' cannabis use) accounted for a significant additional amount of the variance in past use (19%). Adding the 'friends' component of descriptive norms only led to a model that accounted for 52% of the variance in past cannabis use. CONCLUSIONS: Descriptive social norms should be considered when trying to understand cannabis use in early psychosis. Interventions should take account of the individual's attitude towards cannabis, their perceived control over its use and its social context.

The personal meaning of romantic relationships for young people with psychosis.

Romantic relationships are of particular importance to young people, and play a key role in the transition from adolescence to adulthood. Psychosis typically develops during late adolescence or early adulthood, a crucial period for gaining romantic experience. The significance of these relationships for young people with psychosis has never been explored. Eight participants were interviewed about their experiences and perceptions of romantic relationships using a semi-structured interview. The research was conducted using Interpretative Phenomenological Analysis (IPA). Five overarching themes emerged, suggesting that participants experienced conflict regarding romantic relationships, as they considered such relationships incompatible with psychosis, whilst they also associated them with normality and recovery. Relationships were perceived to be "risky", and participants were concerned with strategies for reducing these risks. Respondents typically perceived themselves to have a relative lack of experience and resources, making it more difficult for them to engage in romantic relationships. As romantic relationships are associated with a range of personal and social benefits, young people who have experienced psychosis may benefit from services supporting them in negotiating stigma and facilitating their involvement in romantic relationships.

Cognitive processes during acute psychosis: the role of heightened responsibility and catastrophic misinterpretations.

BACKGROUND: This study investigated the role of cognitive mechanisms underlying obsessive compulsive and panic disorders in psychosis, and in particular, their possible contributions to acute psychosis. METHOD: A total of 90 participants were recruited comprising three equal-size groups, including two clinical groups (acute and stable) and one non-clinical matched control group. Symptom severity and distress was assessed using the PSYRATS, and questionnaire measures of anxiety and obsessive beliefs were administered to all participants. RESULTS: Individuals with a diagnosis of psychosis reported significantly higher levels of obsessional beliefs and anxiety sensitivity than the non-clinical group. Furthermore, acutely psychotic patients reported a significantly higher sense of responsibility and catastrophic misinterpretation than the stable psychiatric controls, and than samples of OCD and GAD patients. CONCLUSIONS: Results suggest that these anxiety processes are particularly important during acute psychotic episodes, beyond the reported comorbidity. The theoretical and clinical implications of these findings, the limitations of the methodology employed, and suggestions for future research are discussed.

A consideration of developmental egocentrism in anorexia nervosa.

Recent research has suggested that normal adolescent processes are important in understanding psychosis, and that young adult individuals with psychosis are often struggling to develop an individual and autonomous self (the "fundamental task" of adolescence). The current paper explores the utility of considering normative adolescent developmental processes in understanding anorexia nervosa. Data were collected from 31 female young-adults with symptoms of anorexia nervosa, 26 female comparison young-adults and 71 female adolescents on measures of adolescent egocentrism. A one-way ANOVA indicated that individuals with symptoms of anorexia nervosa scored more highly than both their peers and the adolescents on several dimensions of egocentric developmental beliefs. Correlations also showed that egocentrism was positively associated with eating concern in participants with symptoms of anorexia. The results suggest that young-adult women with symptoms of anorexia nervosa tended to feel physically invulnerable while also feeling both psychologically vulnerable to others and special or different. Together with the finding of excessive self-consciousness, this supports a notion that they may be experiencing exaggerated versions of normal self-developmental phenomena. Clinically, offering alternative ways of feeling unique other than dieting may be important in therapeutic approaches to anorexia nervosa. Similarly, strategies aimed at normalisation, such as facilitating healthy attachment to peers, may be useful for individuals with anorexia nervosa.

The development of schizophrenia in late adolescence.

Adolescence is an unusual psychologic time. A recent psychodevelopmental approach to psychosis attempted to show how psychotic signs might arise from typical features of adolescence; for example, delusions appear to reflect common adolescent themes of attachment and autonomy. This psychodevelopmental approach emphasizes how normal adolescents grow out of a natural egocentricity and idealism through learning about others; this theory converges with more recent neurologic theories. (Such neurologic theories agree that mentalizing-for others abilities are a crucial mechanism whereby the suspected neurologic problems of psychosis translate into the symptoms.) A psychodevelopmental account implies a therapeutic priority would be reattaching psychosis sufferers with their peer group, perhaps through work placement schemes. It also recommends cognitive work directing self-consciousness into understanding other people. Psychodevelopmental approaches offer a useful theoretic background for psychologic interventions with young "at risk" people.