Search

Background: Sleep problems are common in mental health service users, but few non-pharmacological therapies are offered. Therapies are being developed and tested, but there may be barriers to these therapies reaching those who need them. Methods: Light-Dark and Activity Rhythm Therapy (L-DART), is a new sleep therapy delivered by an occupational therapist, which has been feasibility tested in people with schizophrenia spectrum diagnoses. This paper presents two surveys, conducted with mental health staff and service users, on sleep problems, treatment wishes; and barriers and facilitators to uptake of L-DART or similar therapies. Descriptive statistics, single-level and multi-level ordinal logistic regression were used to examine factors associated with sleep problems and referral intentions. Findings: Sleep problems were commonly identified by staff and service users, there was demand for non-pharmacological intervention across diagnostic and demographic categories, but staff readiness to refer differed according to NHS Trust and service user diagnosis. Staff and service user reports differed in awareness of sleep disordered breathing and parasomnias, and wish for referral. Staff were more confident identifying sleep problems than addressing them, but more training was associated with greater confidence concerning both assessment and treatment. Conclusions: A range of sleep problems are prevalent and recognised in mental health service users, and there is an unmet need for non-pharmacological sleep interventions. Improving suitable resources to support self-management in this group may help; Staff and service users also reported a high readiness to refer or be referred for sleep interventions. Staff training to improve identification of sleep problems, and differentiation between types of sleep problems, would support access to the most appropriate treatments. Highlights: Self-reported or staff reported sleep problems are common in mental health service users. Staff are less aware of sleep disordered breathing and parasomnias than are service users. There is demand for non-pharmacological sleep interventions and wish to refer/be referred. Staff have had limited training regarding sleep, but more training is associated with greater confidence to assess and address sleep. [ABSTRACT FROM AUTHOR]

Introduction: People with schizophrenia spectrum disorder diagnoses commonly have poor sleep, which predicts various negative outcomes. The problems are diverse, including substantial circadian dysregulation, sleep-wake timing issues, hypersomnia (excessive sleep), and more classic insomnia. Methods: This paper reports on a mixed methods expert opinion study based on the principles of Delphi methodology. The study examines and explores opinion on the optimal contents and format for an occupational therapy intervention to improve poor sleep in this population. Views of clinical and academic topic experts (n = 56), were elicited, examined and explored in three rounds, views from previous rounds being presented back to participants in subsequent rounds. Participants with relevant personal experience (n = 26) then rated and commented on suggestions, with a focus on acceptability. Descriptive statistics and graphs of ratings were triangulated with qualitative content analysis of free-text. Results: Participants emphasised the central importance of intervention personalisation, although the manner and extent of personalisation suggested varied. Many components and domains were acknowledged as important, with the challenge being how to keep such an intervention simple, brief, and feasible for end-users, for sustainable implementation. The strongest consensus was to address evening routine, daytime activity, and environmental interventions. Relaxation, mindfulness, thermoregulation, sensory factors, and cognitive or psychological approaches were rated as less important. There was disagreement on whether to include time in bed restriction, and how to address napping, as well as how far to address medication timing. Clinicians and researchers advocated some version of stimulus control, but participants with personal experience reported low levels of acceptability for this, describing entirely negative experiences using 'the 15-minute rule' (part of stimulus control). Conclusion: These results are informative for clinicians treating sleep problems in people with schizophrenia and related conditions, as well as for decision makers considering the potential contribution of the profession of occupational therapy toward sleep treatment. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: There is good evidence that psychological interventions improve patient well-being and independent living, but patients on acute mental health wards often do not have access to evidence-based psychological therapies which are strongly advised by NICE guidance for severe mental health problems. The overall aim of this programme of work is to increase patient access to psychological therapies on acute mental health inpatient wards. Stage one of the programme (which is complete) aimed to identify barriers and facilitators to delivering therapy in these settings through a large qualitative study. The key output of stage one was an intervention protocol that is designed to be delivered on acute wards to increase patient access to psychologically-informed care and therapy. Stage two of the programme aims to test the effects of the intervention on patient wellbeing and serious incidents on the ward (primary outcomes), patient social functioning and symptoms, staff burnout, ward atmosphere from staff and patient perspectives and cost effectiveness of the intervention (secondary outcomes). Methods: The study is a single blind, pragmatic, cluster randomised controlled trial and will recruit thirty-four wards across England that will be randomised to receive the new intervention plus treatment as usual, or treatment as usual only. Primary and secondary outcomes will be assessed at baseline and 6-month and 9-month follow-ups, with serious incidents on the ward collected at an additional 3-month follow-up. Discussion: The key output will be a potentially effective and cost-effective ward-based psychological intervention that increases patient access to psychological therapy in inpatient settings, is feasible to deliver in inpatient settings and is acceptable to patients. Trial Registration number: ClinicalTrials.gov Identifier: NCT03950388. Registered 15th May 2019. https://clinicaltrials.gov/ct2/show/NCT03950388 [ABSTRACT FROM AUTHOR]

Psychosis is a major mental illness with first onset in young adults. The prognosis is poor in around half of the people affected, and difficult to predict. The few tools available to predict prognosis have major weaknesses which limit their use in clinical practice. We aimed to develop and validate a risk prediction model of symptom nonremission in first-episode psychosis. Our development cohort consisted of 1027 patients with first-episode psychosis recruited between 2005 and 2010 from 14 early intervention services across the National Health Service in England. Our validation cohort consisted of 399 patients with first-episode psychosis recruited between 2006 and 2009 from a further 11 English early intervention services. The one-year nonremission rate was 52% and 54% in the development and validation cohorts, respectively. Multivariable logistic regression was used to develop a risk prediction model for nonremission, which was externally validated. The prediction model showed good discrimination C-statistic of 0.73 (0.71, 0.75) and adequate calibration with intercept alpha of 0.12 (0.02, 0.22) and slope beta of 0.98 (0.85, 1.11). Our model improved the net-benefit by 15% at a risk threshold of 50% compared to the strategy of treating all, equivalent to 15 more detected nonremitted first-episode psychosis individuals per 100 without incorrectly classifying remitted cases. Once prospectively validated, our first episode psychosis prediction model could help identify patients at increased risk of nonremission at initial clinical contact. [ABSTRACT FROM AUTHOR]

Objective: To estimate prevalence of major cardiovascular events among people with schizophrenia who had experience of sleep disturbance, sedentary behavior or muscular weakness, and assess evidence for raised prevalence in these individuals compared to people with schizophrenia without these characteristics. Methods: UK Biobank data on individuals diagnosed with schizophrenia (n = 1544) were used to examine the prevalence of major cardiovascular events, specifically myocardial infarction, stroke, heart failure and cardiovascular death, among participants with candidate risk factors. Generalized linear models were fitted to estimate prevalence ratios (PRs) for major cardiovascular events among participants with self-reported sleep disturbance, self-reported sedentary behavior, and muscular weakness measured using a handgrip dynamometer. These ratios were adjusted for QRISK3 score--a validated cardiovascular risk prediction algorithm for the UK population. Results: Prevalence of major cardiovascular events was significantly higher among participants with daytime sleepiness, independent of QRISK3 score, and snoring, a proxy for sleep-disordered breathing (adjusted PR 1.26; 95% CI 1.03, 1.55, P = .03). Prevalence was also independently higher among participants with low muscular strength (adjusted PR1.36; 95% CI 1.05, 1.75, P = .02). The adjusted prevalence ratios among participants with short or prolonged sleep duration, insomnia, or sedentary behavior did not indicate independently raised prevalence among these groups. Conclusion: Prevalence of major cardiovascular events among people with schizophrenia was higher in participants with muscular weakness and sleep disturbance evidenced by daytime sleepiness. Further research is required to determine how these factors can be routinely identified and addressed in the clinical management of cardiovascular risk among patients with schizophrenia. [ABSTRACT FROM AUTHOR]

Aim: Many young people at ultra‐high risk (UHR) of developing psychosis exhibit marked and persistent impairments in social and occupational functioning. We aimed to explore UHR patients' subjective experiences of these difficulties and their causes. Methods: We conducted semi‐structured interviews with 20 UHR individuals recruited from Early Detection and Intervention Teams in Northwest England. Topics covered included how participants spent their time, their interpersonal relationships, academic and occupational performance, premorbid functioning and clinical treatment. Thematic analysis was used to examine the prevailing themes. Results: The sample included individuals with varying degrees of functional impairment, ranging from mild to severe difficulties in functioning. Analysis of the qualitative data elicited themes around 2 topics: breadth of functional difficulties and subjective reasons for poor functioning. Participants reported a range of impairments in their social and occupational functioning which they attributed to a combination of clinical, cognitive and psychological factors. These included variables previously identified in the quantitative literature such as psychiatric symptoms, adverse life experiences and cognitive deficits. However, our findings also included other factors which have received comparably little attention such as self‐stigmatizing attitudes and dysfunctional metacognitive beliefs. Conclusions: We propose a model that attempts to explain how these variables interact to drive and sustain functional impairment in the UHR population. This will assist in the development of clinical interventions aimed at promoting functional recovery among UHR individuals. [ABSTRACT FROM AUTHOR]

Objectives Shared decision-making is the pinnacle of patient-centred care; mental health stakeholders value shared decision-making but find it difficult to enact. The objective was to compare and synthesise mental health stakeholder views on antipsychotic prescribing in one NHS Trust, to understand potential reasons for the difficult enactment of shared decision-making in practice. Methods We conducted 12 interviews and 5 focus groups with 33 mental health stakeholders, after obtaining their informed consent. They shared their experiences in and perceptions of antipsychotic prescribing and were recruited from Manchester Mental Health and Social Care Trust. Results Stakeholders agreed that successful shared decision-making demands a collaborative approach. We elucidated a striking divergence in views of the decision-making process and understanding of collaboration. Nurses, consultants and the pharmacist seemed most satisfied with the amount of collaboration but most pessimistic about the scope for it. Carers and most service users did not feel that there was any collaboration. Discussion Comparison of perspectives demonstrated the complexity of shared decision-making which is not addressed in current operational definitions or policy or nursing practice initiatives. The findings have the potential to progress initiatives in the mental health field from those that emphasise the need for shared decision-making to those that develop tools to promote shared decision-making. [ABSTRACT FROM AUTHOR]

Objective: Research and clinical translation in schizophrenia is limited by inconsistent definitions of treatment resistance and response. To address this issue, the authors evaluated current approaches and then developed consensus criteria and guidelines.Method: A systematic review of randomized antipsychotic clinical trials in treatment-resistant schizophrenia was performed, and definitions of treatment resistance were extracted. Subsequently, consensus operationalized criteria were developed through 1) a multiphase, mixed methods approach, 2) identification of key criteria via an online survey, and 3) meetings to achieve consensus.Results: Of 2,808 studies identified, 42 met inclusion criteria. Of these, 21 studies (50%) did not provide operationalized criteria. In the remaining studies, criteria varied considerably, particularly regarding symptom severity, prior treatment duration, and antipsychotic dosage thresholds; only two studies (5%) utilized the same criteria. The consensus group identified minimum and optimal criteria, employing the following principles: 1) current symptoms of a minimum duration and severity determined by a standardized rating scale; 2) moderate or worse functional impairment; 3) prior treatment consisting of at least two different antipsychotic trials, each for a minimum duration and dosage; 4) systematic monitoring of adherence and meeting of minimum adherence criteria; 5) ideally at least one prospective treatment trial; and 6) criteria that clearly separate responsive from treatment-resistant patients.Conclusions: There is considerable variation in current approaches to defining treatment resistance in schizophrenia. The authors present consensus guidelines that operationalize criteria for determining and reporting treatment resistance, adequate treatment, and treatment response, providing a benchmark for research and clinical translation. [ABSTRACT FROM AUTHOR]

Background Quality of life (QoL) is considered an important outcome in health research. It can be rated by the patient, or by an external assessor. We wished to identify the predictors of any discrepancies between these two approaches in people with schizophrenia. Methods Patients with DSM schizophrenia and related disorders (N = 80) completed both patient-rated (Lancashire Quality of Life Profile; LQOLP) and assessor-rated (Heinrich's Quality of Life Scale; QLS) measures of QoL. Results Patient-rated (LQOLP) and assessor-rated (QLS) measures showed a modest correlation (r = 0.38). In a regression analysis, independent predictors of subjectively-rated QoL being higher than objectively-assessed QoL in the same patient, were low insight score (BIS), negative symptoms (PANSS), absence of depression (CDSS), and less positive attitude toward prescribed treatment (DAI). Conclusions In people with schizophrenia, scores on objectively- and subjectively-rated measures of quality of life can differ markedly. When comparing subjective to objective assessments, patients with depressive symptoms will value their QoL lower, and those with low insight will value their QoL higher. This has important implications for the utility and interpretation of QoL measures in schizophrenia. [ABSTRACT FROM AUTHOR]

Background: It is uncertain whether antipsychotic long-acting injection (LAI) medication in schizophrenia is associated with better clinical outcomes than oral preparations.Aims: To examine the impact of prior treatment delivery route on treatment outcomes and whether any differences are moderated by adherence.Method: Analysis of data from two pragmatic 1-year clinical trials in which patients with schizophrenia were randomised to either an oral first-generation antipsychotic (FGA), or a non-clozapine second-generation antipsychotic (SGA, CUtLASS 1 study), or a non-clozapine SGA or clozapine (CUtLASS 2 study).Results: Across both trials, 43% (n = 155) of participants were prescribed an FGA-LAI before randomisation. At 1-year follow-up they showed less improvement in quality of life, symptoms and global functioning than those randomised from oral medication. This difference was confined to patients rated as less than consistently adherent pre-randomisation. The relatively poor improvement in the patients prescribed an LAI pre-randomisation was ameliorated if they had been randomised to clozapine rather than another SGA. There was no advantage to being randomly assigned from an LAI at baseline to a non-clozapine oral SGA rather than an oral FGA.Conclusions: A switch at randomisation from an LAI to an oral antipsychotic was associated with poorer clinical and functional outcomes at 1-year follow-up compared with switching from one oral antipsychotic to another. This effect appears to be moderated by adherence, and may not extend to switching to clozapine. This has implications for clinical trial design: the drug from which a participant is randomised may have a greater effect than the drug to which they are randomised. [ABSTRACT FROM AUTHOR]

Objectives. The aim of the study was to investigate sexual function in patients with schizophrenia receiving treatment with a first-generation antipsychotic (FGA) or a second-generation antipsychotic (SGA) drug. Sexual function is an important aspect of human experience, which can be affected by antipsychotic drug treatment. Sexual dysfunction in patients with schizophrenia may be less prevalent with SGA than with FGA drug treatment. Methods. A cross-sectional prevalence study assessed sexual function in a sample of 144 patients with DSM-IV schizophrenia aged between 18 and 65, using the Derogatis Interview for Sexual Functioning (self-report version: DISF-SR). Two equal-sized groups ( N = 72) received treatment with an FGA or an SGA drug for at least 12 weeks. Results. No significant differences were seen on DISF-SR total score or subscale score between the two treatment groups. Conclusions. There are no differences in measured sexual function of non-randomised patients with schizophrenia treated with an FGA compared with SGA-treated patients. [ABSTRACT FROM AUTHOR]

The impact of antipsychotic drug treatment on sexual function was investigated during a randomised trial comparing first generation antipsychotics (FGAs) to (nonclozapine) second generation antipsychotics (SGAs). Sexual function and quality of life were (rater-blind) assessed in 42 patients with DSM-IV schizophrenia (aged 18-65) using the self-report version of the Derogatis Interview for Sexual Function (DISF-SR) and the Heinrichs Quality of Life Scale (QLS), prior to, and 12 weeks following, a change in medication from an FGA drug to either an FGA or SGA drug. SGAs significantly improved sexual function compared to FGAs. Change in sexual function was associated with change in quality of life. Where impaired sexual functioning is a distressing adverse effect of treatment with an FGA agent, consideration should be given to switching to an SGA. [ABSTRACT FROM AUTHOR]

Background: It is unclear what determines duration of untreated psychosis (DUP) in schizophrenia and why long DUP predicts poor outcome.Aims: First, to test the hypothesis that specific patterns of symptoms and social functioning acting before treatment prolong DUP. Second, to clarify the mechanisms linking DUP with recovery after treatment.Method: Two hundred and forty-eight consecutive first admissions with schizophrenia were interviewed to assess DUP, symptoms and social functioning at admission, and symptoms were re-assessed after 6-12 weeks.Results: Median DUP was 12 weeks. Long DUP was predicted by poor insight, social isolation and preserved coping skills, but not by demographic factors. Even allowing for all these variables, long DUP predicted poor outcome.Conclusions: Longer DUP results partly from a pattern of symptoms and social functioning which reduces concern by the sufferer and relevant others. DUP's relationship to outcome is strongest in the initial months of psychosis. This has implications for targeting early intervention. [ABSTRACT FROM AUTHOR]

Background: People with schizophrenia have a higher premature mortality risk compared with the general population mainly due to cardiovascular disease (CVD). Despite this, people with schizophrenia are less likely to access physical health services or have their physical health investigated and monitored.Aims: To examine the beliefs and actions of mental health professionals regarding the physical health of people with schizophrenia.Method: Two hundred and fifty-five healthcare professionals who support people with schizophrenia within Greater Manchester Mental Health NHS Foundation Trust (GMMH), United Kingdom and Pennine Care NHS Foundation Trust (PCFT), United Kingdom took part. Beliefs and actions were assessed using a self-administered questionnaire, which was constructed around two primary domains (1) CVD risk factors; and (2) physical health interventions. Descriptive statistics were reported and responses between different healthcare professional groups were compared.Results: The overwhelming majority of participants were aware of established CVD risk factors with 98% identifying family history of CVD, 98% for smoking and 96% for high blood pressure. Most participants believed nearly all healthcare professionals were responsible for monitoring the physical health of people with schizophrenia, regardless of job speciality. There were 67% of participants who reported delivering an intervention to improve sedentary behaviour for people with schizophrenia. However, awareness of government and NHS recommended lifestyle interventions were low.Conclusions: This study found good knowledge regarding many established CVD risk factors but little clarity regarding who is responsible for monitoring the physical health of people with schizophrenia and how often brief lifestyle interventions are being implemented. [ABSTRACT FROM AUTHOR]

Background: Clozapine is the only medication licensed for the treatment of resistant schizophrenia in the UK. Although efficacious, a common and unpopular side effect of clozapine treatment is clozapine-induced hypersalivation (CIH), which can contribute to non-adherence. The standard treatment for CIH in the UK is hyoscine hydrobromide but this may aggravate cognitive deficits in patients with schizophrenia while glycopyrrolate may be an effective alternative with a more tolerable side effect profile. There is currently no convincing evidence for hyoscine, or any other medication, as an effective treatment for CIH.Methods/design: This is a multicentre randomised, double-blind, placebo-controlled feasibility study of glycopyrronium bromide (glycopyrrolate) and hyoscine hydrobromide (hyoscine) in patients with clozapine-induced hypersalivation. We aim to recruit 42 patients who have been prescribed clozapine and are experiencing hypersalivation, and randomise them to one of three study arms (either hyoscine, glycopyrrolate or placebo). The primary outcome measures will be the participant recruitment and attrition rates, and the secondary outcome will be the metrics of the daytime hypersalivation measure. After a 1-week washout period (discontinuing CIH medication, if any), there will be a 4-week treatment period where participants will be titrated up to the maximum tolerated dose of hyoscine, glycopyrrolate or placebo. Measurements of daytime salivation, nocturnal salivation, cognition and side effects will be taken during home visits in week 2 and week 5. Information on salivation and side effects will also be taken through telephone calls in week 3 and week 4. To gather information on the experience of study participants, exit interviews will also be requested with all participants who drop out of the study and a sample of participants who complete the study.Discussion: There is currently no convincing evidence for hyoscine, or any other medication, as an effective treatment for CIH. There is promising evidence that glycopyrrolate may be more successful in the treatment of CIH causing fewer cognitive side effects. We propose to conduct a randomised placebo-controlled feasibility study of glycopyrrolate and hyoscine in the treatment of clozapine-induced hypersalivation to inform the design of a future efficacy trial.Trial Registration: Clinicaltrials.gov NCT02613494 , 23 November 2015. [ABSTRACT FROM AUTHOR]