This study aimed to establish consensus about the meaning of recovery among individuals with experience of psychosis. A Delphi approach was utilized to allow a large sample of service users to be ...anonymously consulted about their views on recovery. Service users were invited to take part in a 3-stage consultation process. A total of 381 participants gave their views on recovery in the main stage of this study, with 100 of these taking part in the final review stage. The final list of statements about recovery included 94 items, which were rated as essential or important by >80% of respondents. These statements covered items which define recovery, factors which help recovery, factors which hinder recovery, and factors which show that someone is recovering. As far as we are aware, it is the first study to identify areas of consensus in relation to definitions of recovery from a service user perspective, which are typically reported to be an idiosyncratic process. Implications and recommendations for clinical practice and future research are discussed.
Evidence from randomised controlled trials suggest that both antipsychotic medication and cognitive behaviour therapy (CBT) can be helpful to people with a diagnosis of a schizophrenia spectrum ...disorder. On this basis, many clinical guidelines recommend that people with psychosis should be offered both antipsychotic medication and CBT and that they should be collaboratively involved in the decisions about which treatment options they choose. The reality of service provision is often very different, with data regarding the availability of such treatment options and the extent of user involvement in decision making suggesting that medication is much more widely available and that service users are often not involved in these decisions, despite retaining decision making capacity. Many patients choose not to take antipsychotic medication, often due to inefficacy or side effects, but there is little evidence regarding whether CBT can be effective as an alternative to antipsychotic medication. However, several recent trials suggest that CBT without medication may be a safe and acceptable option for people with psychosis. The implications for clinical practice and future research are considered and it is recommended that informed choices that include the option to try CBT without antipsychotic medication are supported.
In the UK almost 60% of people with a diagnosis of schizophrenia who use mental health services say they are not involved in decisions about their treatment. Guidelines and policy documents recommend ...that shared decision-making should be implemented, yet whether it leads to greater treatment-related empowerment for this group has not been systematically assessed.
To examine the effects of shared decision-making on indices of treatment-related empowerment of people with psychosis.
We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of shared decision-making concerning current or future treatment for psychosis (PROSPERO registration CRD42013006161). Primary outcomes were indices of treatment-related empowerment and objective coercion (compulsory treatment). Secondary outcomes were treatment decision-making ability and the quality of the therapeutic relationship.
We identified 11 RCTs. Small beneficial effects of increased shared decision-making were found on indices of treatment-related empowerment (6 RCTs; g = 0.30, 95% CI 0.09-0.51), although the effect was smaller if trials with >25% missing data were excluded. There was a trend towards shared decision-making for future care leading to reduced use of compulsory treatment over 15-18 months (3 RCTs; RR = 0.59, 95% CI 0.35-1.02), with a number needed to treat of approximately 10 (95% CI 5-∞). No clear effect on treatment decision-making ability (3 RCTs) or the quality of the therapeutic relationship (8 RCTs) was found, but data were heterogeneous.
For people with psychosis the implementation of shared treatment decision-making appears to have small beneficial effects on indices of treatment-related empowerment, but more direct evidence is required.
Recovery from psychosis is increasingly being viewed as a combination of symptomatic, functional, and personal recovery. Negative and depressive symptoms have been linked to community functioning, ...and negative affect has been linked to personal recovery. The current study examines differential associations of symptoms with functional and personal recovery, and the interaction of cognitive and emotional components of psychotic experiences in predicting recovery.
Baseline data from four studies of individuals with schizophrenia-spectrum disorders were amalgamated for the current analyses. All studies utilized the Positive and Negative Syndrome Scale, Psychotic Symptom Rating Scale, Personal and Social Performance Scale, and the Questionnaire about the Process of Recovery.
971 individuals participated across the four studies. Affective symptoms were most strongly associated with personal recovery, accounting for 30% of the variance in personal recovery and only 2% of the variance in objective functioning. Negative and disorganized symptoms were related to both functional and personal recovery, excitement symptoms were only related to personal recovery, and broad measures of positive symptoms were not associated with either functional or personal recovery. Cognitive interpretations of psychotic experiences were more strongly related to objective functioning, and emotional components of psychotic experiences were more strongly related to personal recovery; cognitive interpretations moderated the relationship between emotional characteristics and recovery measures.
Functional and personal recovery are distinct domains of recovery with differential relationships to symptomatology. Interventions that target cognitive interpretations of psychotic experiences and negative affect may be more likely to affect multiple domains of recovery.
Abstract It is acknowledged that people with a schizophrenia-spectrum diagnosis experience higher levels of stigma compared to any other mental health diagnosis. As a consequence, their experience of ...internalised stigma is likely to be the most detrimental and pervasive. Internalised stigma interventions have shown some benefits in those who experience serious mental illness including those with a schizophrenia-spectrum diagnosis. A systematic narrative review and meta-analysis were conducted examining the efficacy of internalised stigma interventions for people with a schizophrenia-spectrum diagnosis. Randomised Controlled Trials, controlled trials, and cohort studies were included and assessed against quality criteria. The search identified 12 studies; 7 randomised controlled trials, 3 cohort studies and 2 controlled trials. A variety of psychosocial interventions were utilised with the majority employing Cognitive Behaviour Therapy (CBT), psychoeducation and social skills training. The core outcomes used to examine the efficacy of the intervention were internalised stigma, self-esteem, empowerment, and functioning. The meta-analysis revealed an improvement in internalised stigma favouring the internalised stigma intervention but was not significant (5 RCTs, n = 200). Self-efficacy and insight were significantly improved favouring the internalised stigma intervention. Internalised stigma interventions show promise in those with schizophrenia-spectrum diagnoses. Existing interventions have demonstrated small effects and employed small samples. Large scale RCTs are required to further develop the evidence base of more targeted interventions.
Anxiety and depression symptoms are frequently experienced by individuals with psychosis, although prevalence rates have not been reviewed in first-episode psychosis (FEP). The aim of this systematic ...review was to focus on the prevalence rates for both anxiety and depression, comparing the rates within the same study population. A systematic review and meta-analysis was completed for all studies measuring both anxiety and depression in FEP at baseline. The search identified 6040 citations, of which n = 10 met inclusion criteria. These reported 1265 patients (age 28.3 ± 9.1, females: 39.9%) with diagnosed FEP. Studies which used diagnosis to define comorbidity count were included in separate meta-analyses for anxiety and depression, although the heterogeneity was high limiting interpretation of separate prevalence rates. A random-effects meta-analysis also compared the mean difference between anxiety and depression within the same studies. We show that anxiety and depression co-occur at a similar rate within FEP, although the exact rates are not reliable due to the heterogeneity between the small number of studies. Future research in FEP should consider routinely measuring anxiety and depression using continuous self-report measures of symptoms. Clinically we recommend that both anxiety and depression are equally targeted during psychological intervention in FEP, together with the psychotic symptoms.
Abstract The latent structure, reliability and validity of the Questionnaire about the Process of Recovery (QPR) (Neil et al., 2009) were examined in a sample of participants with experience of ...psychosis (N = 335). The original two factor model proposed by Neil et al. (2009) was examined using exploratory factor analysis followed by a further independent exploratory factor analysis to test revised solutions. Model fit statistics indicated that the most interpretable solution was a one factor model using 15 items from the original measure. Internal consistency, test re-test reliability and convergent validity of this new 15 item version were found to be high. Recommendations for the utility of the QPR in routine clinical practice along with suggestions for future research are discussed.
Objective To determine whether any psychological, pharmacological, or nutritional interventions can prevent or delay transition to psychotic disorders for people at high risk.Design Systematic review ...and meta-analysis. Data sources Embase, Medline, PreMedline, PsycINFO, and CENTRAL were searched to November 2011 without restriction to publication status. Review methods Randomised trials comparing any psychological, pharmacological, nutritional, or combined intervention with usual services or another treatment. Studies of participants with a formal diagnosis of schizophrenia or bipolar disorder were excluded. Studies were assessed for bias, and relevant limitations were considered in summarising the results.Results 11 trials including 1246 participants and eight comparisons were included. Median sample size of included trials was 81 (range 51-288). Meta-analyses were performed for transition to psychosis, symptoms of psychosis, depression, and mania; quality of life; weight; and discontinuation of treatment. Evidence of moderate quality showed an effect for cognitive behavioural therapy on reducing transition to psychosis at 12 months (risk ratio 0.54 (95% confidence interval 0.34 to 0.86); risk difference −0.07 (−0.14 to −0.01). Very low quality evidence for omega-3 fatty acids and low to very low quality evidence for integrated psychotherapy also indicated that these interventions were associated with reductions in transition to psychosis at 12 months.Conclusions Although evidence of benefits for any specific intervention is not conclusive, these findings suggest that it might be possible to delay or prevent transition to psychosis. Further research should be undertaken to establish conclusively the potential for benefit of psychological interventions in the treatment of people at high risk of psychosis.
NICE guidelines recommend use of treatment protocols that have trial-based evidence of efficacy to guide the delivery of CBT for psychosis. The rationale for using such an approach, and a manual that ...has been used to ensure fidelity and adherence within six clinical trials, is described. The protocol emphasises principles and values, such as collaborative teamwork, active participation involving between session tasks for service users and therapists and a normalising philosophy, as well as specific milestones such as early agreement of a shared goal, maintenance formulations and use of defined change strategies. Challenges to implementation and methods for promoting good practice are considered and implications for future research and practice are discussed.
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