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Background: In paper I we reported that depression in the acute stage remitted in line with the psychosis and that 36% of patients developed post-psychotic depression (PPD).Aims: We apply our cognitive framework to PPD and chart the appraisal of self and psychosis and their link with the later emergence of PPD.Method: Patients with ICD-10 schizophrenia (n=105) were followed up over 12 months following the acute episode, taking measures of depression, working self-concept, cognitive vulnerability, insight and appraisals of psychosis.Results: Before developing PPD, these patients felt greater loss, humiliation and entrapment by their illness than those who relapsed or did not become depressed, and were more likely to see their future selves in 'lower status' roles. Upon becoming depressed, participants developed greater insight, lower self-esteem and a worsening of their appraisals of psychosis.Conclusions: Depression in psychosis arises from the individual's appraisal of psychosis and its implications for his/her perceived social identity, position and 'group fit'. Patients developing PPD feel forced to accept a subordinate role without opportunity for escape. Implications for treatment are discussed. [ABSTRACT FROM AUTHOR]

Background: Depression in schizophrenia is a rather neglected field of study, perhaps because of its confused nosological status. Three course patterns of depression in schizophrenia, including post-psychotic depression (PPD), are proposed.Aims: We chart the ontogeny of depression and psychotic symptoms from the acute psychotic episode over a 12-month period and test the validity of the proposed course patterns.Method: One hundred and five patients with ICD-10 schizophrenia were followed up on five occasions over 12 months following the acute episode, taking measures of depression, positive symptoms, negative symptoms, neuroleptic exposure and side-effects.Results: Depression accompanied acute psychosis in 70% of cases and remitted in line with the psychosis; 36% developed PPD without a concomitant increase in psychotic symptoms.Conclusions: The results provided support for the validity of two of the three course patterns of depression in schizophrenia, including PPD. Post-psychotic depression occurs de novo without concomitant change in positive or negative symptoms. [ABSTRACT FROM AUTHOR]

Background: We present a revised Beliefs About Voices Questionnaire (BAVQ-R), a self-report measure of patients' beliefs, emotions and behaviour about auditory hallucinations.Aims: To improve measurement of omnipotence, a pivotal concept in understanding auditory hallucinations, and elucidate links between beliefs about voices, anxiety and depression.Methods: Seventy-one participants with chronic auditory hallucinations completed the BAVQ-R, and 58 also completed the Hospital Anxiety and Depression Scale.Results: The mean Cronbach's alpha for the five sub-scales was 0.86 (range 0.74-0.88). The study supports hypotheses about links between beliefs, emotions and behaviour, and presents original data on how these relate to the new omnipotence sub-scale. Original data are also presented on connections with anxiety and depression.Conclusions: The BAVQ-R is more reliable and sensitive to individual differences than the original version, and reliably measures omnipotence. [ABSTRACT FROM AUTHOR]

Background: This paper describes the 5-year outcome of a cohort of patients who had received a cognitive therapy intervention during an acute episode of non-affective psychosis.Method: Thirty-four out of the original 40 patients who had taken part in a randomised controlled trial of a cognitive intervention were assessed, using standardised instruments completed at entry into the study. In the original trial, half the patients received a cognitive therapy programme (CT group) and the other half received recreational activities and support (ATY group).Results: At follow-up no significant differences in relapse rate, positive symptoms or insight between the groups were found, although the CT group did show significantly greater perceived 'Control over illness' than the ATY group. For individuals who had experienced a maximum of one relapse in the follow-up period, self-reported residual delusional beliefs and observer-rated hallucinations and delusions were significantly less in the CT than in the ATY group.Conclusion: Cognitive therapy applied in the acute phase of a psychotic disorder can produce enduring and significant clinical benefits if experience of relapse can be minimised. [ABSTRACT FROM AUTHOR]

The article proposes three key elements of an early therapeutic strategy for patients with schizophrenia. These elements include early detection of at-risk or prodromal mental states, early treatment of the first psychotic episode and interventions targeted during the early phase of psychosis. The following are the three elements of intervention of early psychosis: relapse prevention, psychosocial recovery and treatment resistance.

Background: The application of cognitive therapy (CT) to psychosis is currently being developed in the UK. This paper reports a trial of CT in acute psychosis with the objective of hastening the resolution of positive symptoms and reducing residual symptoms.Method: Of 117 patients with acute non-affective psychosis, 69 satisfied inclusion criteria and 40 proceeded to stratified randomisation. The experimental intervention involving individual and group CT was compared with a group receiving matched hours of therapist input providing structured activities and informal support; routine pharmacotherapy was provided by clinicians blind to group allocation. Patients were monitored weekly using self-report and mental state assessments during admission and over the subsequent nine months.Results: Both groups showed a decline in positive symptoms but this was more marked in the CT group (P < 0.001). At 9 months 5% of the CT group, v.56% of the control group, showed moderate or severe residual symptoms.Conclusion: CT appears to be a potent adjunct to pharmacotherapy and standard care for acute psychosis. Issues concerning internal and external validity of the study and opportunities for further research are discussed. [ABSTRACT FROM AUTHOR]

Background: A trial of CT in acute psychosis conducted by the authors has shown a significant impact on the rate and degree of recovery of positive symptoms, the focus of the intervention. This paper seeks to determine whether these effects generalise to other features of acute psychosis including dysphoria, insight and "low level' psychotic thinking which were not directly targeted.Method: Measures of dysphoria, insight and psychotic thinking were taken over a six-month period following presentation for acute psychosis. Using survival analysis, time to recovery from psychosis using three definitions of increasing stringency was compared between the CT and control group.Results: CT was associated with a 25-50% reduction in recovery time depending on the definition used.Conclusion: The impact of the CT intervention extended beyond positive symptoms to include insight, dysphoria and "low level' psychotic thinking. Nevertheless this kind of "clinical' recovery required a median of 20 weeks to complete. Implications for clinical models of acute care are discussed. [ABSTRACT FROM AUTHOR]

Background: We describe the development and psychometric investigation of the Beliefs About Voices Questionnaire (BAVQ), a self-report measure of how people understand and respond to their voices. The measure is unique in being driven by and gathering data essential to a cognitive formulation of voices.Method: Sixty subjects with chronic hallucinatory voices took part.Results: Psychometric properties of the scales were established, including test-retest reliability (mean = 0.89), internal reliability (mean Cronbach's alpha = 0.85), and construct validity using factor analysis and the criterion group method.Conclusions: The BAVQ was found to be easy to complete and the scale may aid clinical assessment of voices, not least because of the possible value of cognitive therapy as a treatment approach. [ABSTRACT FROM AUTHOR]

We offer provisional support for a new cognitive approach to understanding and treating drug-resistant auditory hallucinations in people with a diagnosis of schizophrenia. Study 1 emphasises the relevance of the cognitive model by detailing the behavioural, cognitive and affective responses to persistent voices in 26 patients, demonstrating that highly disparate relationships with voices-fear, reassurance, engagement and resistance-reflect vital differences in beliefs about the voices. All patients viewed their voices as omnipotent and omniscient. However, beliefs about the voice's identity and meaning led to voices being construed as either 'benevolent' or 'malevolent'. Patients provided cogent reasons (evidence) for these beliefs which were not always linked to voice content; indeed in 31% of cases beliefs were incongruous with content, as would be anticipated by a cognitive model. Without fail, voices believed to be malevolent provoked fear and were resisted and those perceived as benevolent were courted. However, in the case of imperative voices, the primary influence on whether commands were obeyed was the severity of the command. Study 2 illustrates how these core beliefs about voices may become a new target for treatment. We describe the application of an adapted version of cognitive therapy (CT) to the treatment of four patients' drug-resistant voices. Where patients were on medication, this was held constant while beliefs about the voices' omnipotence, identity, and purpose were systematically disputed and tested. Large and stable reductions in conviction in these beliefs were reported, and these were associated with reduced distress, increased adaptive behaviour, and unexpectedly, a fall in voice activity. These changes were corroborated by the responsible psychiatrists. Collectively, the cases attest to the promise of CT as a treatment for auditory hallucinations. [ABSTRACT FROM AUTHOR]

There is overwhelming evidence that the outcome for people with schizophrenia in Western industrialised countries is inferior to that of those living in the Third World. Extended family structures, greater opportunities for social reintegration, and more positive constructions of mental illness have been offered as possible explanations for this effect. The Asian community in the UK retains many of these features as well as strong links with native cultures of origin. The issue arises as to whether similar differences in outcome may be observed in the UK. An exploratory study was undertaken, examining the early progress of schizophrenia in a first-episode sample (n = 137), and based on systematic examination of case-note data. A lower rate of relapse/readmission in the first 12 months after discharge was found in the Asian (16%) as compared with white (30%) and Afro-Caribbean (49%) patients. Available evidence suggested that speed of access to care, living with a family, and employment may account for this effect. Medication compliance may have contributed to differences in relapse between white and Afro-Caribbeans but was not a factor influencing the low rate among Asians. The limitations and strengths of case-note studies are discussed at length, and it is concluded that a prospective study is warranted and would be highly instructive. [ABSTRACT FROM AUTHOR]

Three methods of delivering an educational intervention to families living with a schizophrenic relative were compared in terms of their efficacy in improving understanding and promoting family and patient well-being. Relatives receiving education in a group acquired more information than relatives receiving information by post or on video, but these differences were not maintained at six-month follow-up. The inclusion of homework assignments did not significantly affect gains in knowledge or any of the non-specific effects observed. The intervention overall led to considerable gains in knowledge, increased optimism concerning the family's role in treatment, and reductions in relatives' stress, which were maintained at follow-up. Fear was reduced in the short-term. Significant improvements in social function were observed at follow-up. The results suggest that the delivery of information, rather than the mode of delivery, is the crucial element in the intervention; however, the additional contextual factors operating in a group may be important if the full potential of education is to be realised. [ABSTRACT FROM AUTHOR]

Social functioning as an outcome variable in family interventions with schizophrenic patients has been a relatively neglected area. The requirements of a scale of social functioning to measure the efficacy of family interventions include: the measurement of skill/behaviour relevant to the impairments and the demography of this group; the ability to yield considerable information with an economy of clinical time; and the establishment of 'comparative' need through comparison between subscales and with appropriate reference groups. Results from three samples show that the Social Functioning Scale is reliable, valid, sensitive and responsive to change. [ABSTRACT FROM AUTHOR]

Considerable advances have been made in the family management of schizophrenia but there remains a major challenge for the psychiatric services to integrate these innovations into clinical practice. A number of important issues need to be considered in developing routine clinical services: the problem of engaging families in a therapeutic programme; the utility of the concept of 'expressed emotion'; and procedures for clinical practice. The latter include the needs of low-EE families; maintaining quality of intervention in a clinical context; responding to the multiplicity of needs of the patient and family; and integrating family interventions with ongoing rehabilitation practice. A model of service provision is described. [ABSTRACT FROM AUTHOR]

A brief educational intervention with families living with a schizophrenic relative is described and evaluated in terms of benefits for relatives' well-being and patient recovery. Education led to considerable knowledge gains and to reductions in relatives' reported stress symptoms and fear of the patient. There was a trend for relatives to be more optimistic concerning their role in treatment. At 6 months follow-up, only knowledge gains were maintained; however, relatives' perceptions of family burden were significantly reduced. The evidence suggests that family education may be useful both as a cost-effective intervention in its own right and in facilitating a more receptive attitude to subsequent family intervention. [ABSTRACT FROM AUTHOR]

A schizophrenic patient whose severe level of auditory hallucinations had proved refractory to neuroleptic medication was given two treatment techniques derived from Green's theory that hallucinations represent verbal activity in the non-dominant hemisphere. Voice activity was markedly reduced in frequency and severity over a six-month period, and led to general improvements in interpersonal functioning. There was evidence for independent and additive effects of the two techniques. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to an article on the validity of the Northwick Park Study in the September 1987 issue.