Showing papers by "Max Birchwood published in 2019"

Stigma and access to care in first-episode psychosis.

Abstract: Aim Mental health‐related stigma is considered a significant barrier to help‐seeking and accessing care in those experiencing mental illness. Long duration of untreated psychosis is associated with poorer outcomes. The impact of stigma on the duration of untreated psychosis, in first‐episode psychosis remains unexplored. To examine the association between mental health‐related stigma and access to care in people experiencing first‐episode psychosis in Birmingham, UK. Methods We collected data on a prospective cohort of first‐episode psychosis. The Stigma Scale was used as a measure of mental health‐related stigma, and duration of untreated psychosis as a measure of delay in accessing care. We performed logistic and linear regression analyses to explore the relationship between mental health‐related stigma and duration of untreated psychosis, adjusting for sex, age, educational level, religion and ethnicity. Results On the 89 participants included in this study, linear regression analysis revealed that overall stigma and the discrimination sub‐factor were significant predictors of longer duration of untreated psychosis, whereas logistic regression identified the disclosure sub‐factor to be a significant predictor of longer duration of untreated psychosis. Conclusions These findings demonstrate that stigmatizing views of mental illness from the patient's perspectives can result in delayed access to care. This emphasizes the importance of tackling mental health‐related stigma to ensure early treatment and improved outcomes for people experiencing first‐episode psychosis.

Development and validation of multivariable prediction models of remission, recovery, and quality of life outcomes in people with first episode psychosis: A machine learning approach

Abstract: Summary Background Outcomes for people with first-episode psychosis are highly heterogeneous. Few reliable validated methods are available to predict the outcome for individual patients in the first clinical contact. In this study, we aimed to build multivariable prediction models of 1-year remission and recovery outcomes using baseline clinical variables in people with first-episode psychosis. Methods In this machine learning approach, we applied supervised machine learning, using regularised regression and nested leave-one-site-out cross-validation, to baseline clinical data from the English Evaluating the Development and Impact of Early Intervention Services (EDEN) study (n=1027), to develop and internally validate prediction models at 1-year follow-up. We assessed four binary outcomes that were recorded at 1 year: symptom remission, social recovery, vocational recovery, and quality of life (QoL). We externally validated the prediction models by selecting from the top predictor variables identified in the internal validation models the variables shared with the external validation datasets comprised of two Scottish longitudinal cohort studies (n=162) and the OPUS trial, a randomised controlled trial of specialised assertive intervention versus standard treatment (n=578). Findings The performance of prediction models was robust for the four 1-year outcomes of symptom remission (area under the receiver operating characteristic curve [AUC] 0·703, 95% CI 0·664–0·742), social recovery (0·731, 0·697–0·765), vocational recovery (0·736, 0·702–0·771), and QoL (0·704, 0·667–0·742; p Interpretation In our machine learning analysis, we showed that prediction models can reliably and prospectively identify poor remission and recovery outcomes at 1 year for patients with first-episode psychosis using baseline clinical variables at first clinical contact. Funding Lundbeck Foundation.

Refining a model of collaborative care for people with a diagnosis of bipolar, schizophrenia or other psychoses in England: a qualitative formative evaluation

Abstract: Many people diagnosed with schizophrenia, bipolar or other psychoses in England receive the majority of their healthcare from primary care. Primary care practitioners may not be well equipped to meet their needs and there is often poor communication with secondary care. Collaborative care is a promising alternative model but has not been trialled specifically with this service user group in England. Collaborative care for other mental health conditions has not been widely implemented despite evidence of its effectiveness. We carried out a formative evaluation of the PARTNERS model of collaborative care, with the aim of establishing barriers and facilitators to delivery, identifying implementation support requirements and testing the initial programme theory. The PARTNERS intervention was delivered on a small scale in three sites. Qualitative data was collected from primary and secondary care practitioners, service users and family carers, using semi-structured interviews, session recordings and tape-assisted recall. Deductive and inductive thematic analysis was carried out; themes were compared to the programme theory and used to inform an implementation support strategy. Key components of the intervention that were not consistently delivered as intended were: interaction with primary care teams, the use of coaching, and supervision. Barriers and facilitators identified were related to service commitment, care partner skills, supervisor understanding and service user motivation. An implementation support strategy was developed, with researcher facilitation of communication and supervision and additional training for practitioners. Some components of the intervention were not experienced as intended; this appeared to reflect difficulties with operationalising the intervention. Analysis of data relating to the intended outcomes of the intervention indicated that the mechanisms proposed in the programme theory had operated as expected. Additional implementation support is likely to be required for the PARTNERS model to be delivered; the effectiveness of such support may be affected by practitioner and service user readiness to change. There is also a need to test the programme theory more fully. These issues will be addressed in the process evaluation of our full trial. ISRCTN95702682 , 26 October 2017.

Duration of untreated psychosis and clinical outcomes of first episode psychosis: An observational and an instrumental variables analysis.

Abstract: Aim Duration of untreated psychosis (DUP) is considered a key prognostic variable in psychosis. Yet it is unclear whether a longer DUP causes worse outcomes or whether reported associations have alternative explanations. Methods Data from two cohorts of patients with first episode psychosis were used (n=2134). Measures of DUP were assessed at baseline and outcomes at 12 months. Regression models were used to investigate associations between DUP and outcomes. We also investigated whether any associations were replicated using instrumental variables analysis to reduce the effect of residual confounding and measurement bias. Results There were associations between DUP per 1 year increase and positive psychotic symptoms (7.0% in symptom score increase 95% CI 4.0%,10.0% p<0.001), worse recovery (risk difference (RD) 0.78 95% CI 0.68,0.83 p<0.001) and worse global functioning (0.62 decrease in functioning score 95% CI -1.19,- 0.04 p=0.035). There was no evidence of an association with negative psychotic symptoms (1.0% 95% CI -2.0%,5.0% p=0.455). The instrumental variables analysis showed weaker evidence of associations in the same direction between DUP per 1-year increase and positive psychotic symptoms, recovery and global functioning. However, there was evidence of an inverse association with negative psychotic symptoms (decrease of 15.0% in symptom score 95% CI -26.0% ,-3.0% p=0.016). Conclusions We have confirmed previous findings of a positive association between positive psychotic symptoms, global functioning and recovery and DUP using regression analysis. Instrumental variables analysis shows some support for these findings. Future investigation using instrumental variables analysis should be repeated in large datasets.

Vulnerability to psychosocial disability in psychosis.

Abstract: Psychosocial disability affects a number of individuals with psychosis and often begins years before the formal onset of disorder This suggests that for many, their psychosocial disability is enduring, and targeted interventions are therefore needed earlier in their developmental trajectories to ensure that psychosocial disability does not become entrenched Poor psychosocial functioning also affects individuals with a range of different emerging mental health problems, putting these young people at risk of long-term social marginalisation and economic disadvantage; all of which are known risk factors for the development of psychosis Identification of the markers of poor psychosocial functioning will help to inform effective treatments This editorial will discern the early trajectories and markers of poor psychosocial outcome in psychosis, and highlight which individuals are most at risk of having a poor outcome This editorial will also discuss whether early interventions are currently being targeted appropriately and will propose how intervention and preventative strategies can be implemented, to restore psychosocial trajectories in a way that enables young people to maximise their life chances

Childhood adversity predicts persistence of suicidal thoughts differently in females and males at clinical high-risk patients of psychosis. Results of the EPOS project.

Abstract: Aim Depression and suicidal ideation (SUI) and behaviour are more prevalent in females than males, and common in clinical high-risk (CHR) patients. Childhood adversities and trauma (CAT) are associated with adult depression and SUI. The role of gender as a moderator and depression as a mediator for the effect of CAT on SUI has not been explored in CHR patients. Methods In all, 245 young help-seeking CHR patients were assessed for SUI (thoughts of killing themselves) with the Beck Depression Inventory at baseline, 9-month and 18-month follow-ups. At baseline, clinical depression was assessed by the Structured Clinical Interview for DSM-IV (SCID-I), and CAT by the Trauma and Distress Scale (TADS) which includes the five domains of emotional, physical and sexual abuse, emotional and physical neglect. Results CAT total and all domains except physical neglect predicted SUI over the study period. The effect of CAT on SUI was mediated via clinical depression and concurrent depression symptoms differently for females and males. In females, the effect of emotional abuse and neglect on SUI was mediated via baseline depression. In males, emotional and physical abuse had a direct effect on SUI, and the effect of sexual abuse and emotional neglect was partly mediated via concurrent depression symptoms. Conclusions For CHR females, the effect of CAT on adult SUI is mediated via depression, while for males, CAT and its domains have mainly direct effects in maintaining SUI. These gender differences should be taken into account when treating CHR patients with SUI.

Study protocol for a randomised controlled trial of CBT vs antipsychotics vs both in 14-18-year-olds: Managing Adolescent first episode Psychosis: A feasibility study (MAPS)

Abstract: Adolescent-onset psychosis is associated with more severe symptoms and poorer outcomes than adult-onset psychosis. The National Institute for Clinical Excellence (NICE) recommend that adolescents with first episode psychosis (FEP) should be offered a combination of antipsychotic medication (APs), cognitive behavioural therapy (CBT) and family intervention (FI). The evidence for APs in treating psychosis is limited in adolescents compared to adults. Nevertheless, it indicates that APs can reduce overall symptoms in adolescents but may cause more severe side effects, including cardiovascular and metabolic effects, than in adults. CBT and FI can improve outcomes in adults, but there are no studies of psychological interventions (PI) in patients under 18 years old. Given this limited evidence base, NICE made a specific research recommendation for determining the clinical and cost effectiveness of APs versus PI versus both treatments for adolescent FEP. The current study aimed to establish the feasibility and acceptability of conducting such a trial by recruiting 14–18-year-olds with a first episode of psychosis into a feasibility prospective randomised open blinded evaluation (PROBE) design, three-arm, randomised controlled trial of APs alone versus PI alone versus a combination of both treatments. We aimed to recruit 90 participants from Early Intervention and Child and Adolescent Mental Health Teams in seven UK sites. APs were prescribed by participants’ usual psychiatrists. PI comprised standardised cognitive behavioural therapy and family intervention sessions. This is the first study to compare APs to PI in an adolescent population with FEP. Recruitment finished on 31 October 2018. The study faced difficulties with recruitment across most sites due to factors including clinician and service-user treatment preferences. Current controlled trial with ISRCTN, ISRCTN80567433 . Registered on 27 February 2017.

Cognitive Therapy for Voices

Abstract: This chapter is concerned with voices, that is, hallucinations which are experienced as someone talking. It argues that viewing voices from a cognitive perspective increases understanding of the maintenance of voices and reveals a new treatment approach of considerable promise. Auditory hallucinations are traditionally associated with a diagnosis of schizophrenia. The explanatory power of the cognitive model was weakest in relation to compliance. The cognitive approach within clinical psychology is based on two premises. The major premise states that extreme feelings and behaviour are consequences of particular beliefs rather than events. The minor premise states that if these beliefs can be weakened using cognitive therapy, then the associated distress and behaviour will diminish. The therapist then engineers situations to increase and then decrease the probability of hearing voices. An initial thorough cognitive assessment should identify the cues that provoke voices, and one technique with a high likelihood of eliminating voices for its duration is concurrent verbalisation.

Mental Health Hospital Admissions: a Teachable Moment and Window of Opportunity To Promote Change in Drug and Alcohol Misuse

Abstract: Hospital admissions provide a “teachable moment”. Many patients admitted to mental health hospitals have co-existing substance misuse. As acute symptoms decline, a window of increased insight into factors that contributed to becoming unwell and admission may present. This study used this “teachable” opportunity to assess the acceptability of delivering a brief integrated motivational intervention (BIMI) to inpatients and the feasibility of delivery by inpatient staff. Qualitative interviews were completed with 21 inpatients experiencing co-occurring schizophrenia-related or bipolar disorder diagnoses and substance misuse who received the BIMI. Twelve staff members completed either individual interviews or a focus group. Four themes were identified from the qualitative interviews with participants; these were openness/readiness to talk about substance use, feeling valued, understanding substance use and helpful skills and processes; each with a number of subthemes. Participants appeared to find the intervention useful; although, felt they did not always have the “headspace”. One theme emerged from the staff data, the acceptability of the approach for inpatient ward staff, which had four subthemes; training in the intervention; delivering the intervention; joint working; and feasibility. Staff considered the targeted style of the BIMI useful. Delivery considerations included “timing” and competing ward duties. Hospital admission presents a natural window of opportunity for staff to start conversations with inpatients about substance misuse.