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Purpose: Psychosis disproportionally affects ethnic minority groups in high-income countries, yet evidence of disparities in outcomes following intensive early intervention service (EIS) for First Episode Psychosis (FEP) is less conclusive. We investigated 5-year clinical and social outcomes of young people with FEP from different racial groups following EIS care. Method: Data were analysed from the UK-wide NIHR SUPEREDEN study. The sample at baseline (n = 978) included White (n = 750), Black (n = 71), and Asian (n = 157) individuals, assessed during the 3 years of EIS, and up to 2 years post-discharge (n = 296; Black [n = 23]; Asian [n = 52] and White [n = 221]). Outcome trajectories were modelled for psychosis symptoms (positive, negative, and general), functioning, and depression, using linear mixed effect models (with random intercept and slopes), whilst controlling for social deprivation. Discharge service was also explored across racial groups, 2 years following EIS. Results: Variation in linear growth over time was accounted for by racial group status for psychosis symptoms—positive (95% CI [0.679, 1.235]), negative (95% CI [0.315, 0.783]), and general (95% CI [1.961, 3.428])—as well as for functioning (95% CI [11.212, 17.677]) and depressive symptoms (95% CI [0.261, 0.648]). Social deprivation contributed to this variance. Black individuals experienced greater levels of deprivation (p < 0.001, 95% CI [0.187, 0.624]). Finally, there was a greater likelihood for Asian (OR = 3.04; 95% CI [2.050, 4.498]) and Black individuals (OR = 2.47; 95% CI [1.354, 4.520]) to remain in secondary care by follow-up. Conclusion: Findings suggest variations in long-term clinical and social outcomes following EIS across racial groups; social deprivation contributed to this variance. Black and Asian individuals appear to make less improvement in long-term recovery and are less likely to be discharged from mental health services. Replication is needed in large, complete data, to fully understand disparities and blind spots to care. [ABSTRACT FROM AUTHOR]

Aim: The 0‐19 model is an example of a service that has been retransformed in line with UK's recent policies. However, there is limited qualitative research exploring young people's experiences with the accessibility and acceptability of retransformed models through more participatory qualitative approaches. This study aimed to understand service users' experiences of accessibility and acceptability with the 0‐19 model and its service provision. In addition, we also aim to outline the process and application of the Lego® Serious Play® methodology to the context of children and young people's mental health research and reflect on the usefulness of this novel approach and its potential for further research use. Methods: A qualitative methodology based on the Lego® Serious Play® approach was used to investigate service users' perceptions of the accessibility and acceptability of the 0‐19 model. This novel approach is viewed as a facilitator of engagement, which also stimulates critical thinking and reflective practice. All interviews were thematically analysed. Results: Seven participants constructed 14 models and provided metaphorical narratives for them besides engaging in group discussions. Thematic analysis of the participants' models and narratives resulted in six identified themes: accessibility, doors into the unknown, let it out, overcoming obstacles, less is sometimes better and satisfaction with the 0‐19 model and its provision. Conclusion: Participants in this study perceived the 0‐19 model as acceptable and, to a degree, accessible. Participants identified a range of barriers to accessibility, such as inconvenient locations, long waiting and inflexible working times. [ABSTRACT FROM AUTHOR]

Aim: Existing children and adolescent mental health services in the United Kingdom have many gaps, such as reduced access to community‐based services, and a lack of early intervention, prevention, and 24/7 crisis care. These gaps prevent timely access to appropriate levels of care, decrease children and young people's engagement with providers, and lead to increased pressures on urgent and emergency care. In this paper, we outline a newly created 0‐19 model and its crisis service, which have been transformed into a fully integrated, "joint partnership" service, in line with the recommendations from the recent UK policies that aim to meet the aforementioned challenges. Method: The "Solar" service is described as a case study of a 0‐19 service model. We cover the national and local contexts of the service, in addition to its rationale, aims, organizational structure, strengths and limitations. Results: The presented model is a fully integrated and innovative example of a service model that operates without tiers, and helps to create an inclusive, compassionate, stigma‐free and youth‐friendly environment. Additionally, the model aims to prioritize recovery, early intervention, prevention and the development of resilience. Conclusion: The 0‐19 model is a result of the recent transformation of children and youth mental health services in the United Kingdom. The ongoing evaluation of the 0‐19 model and its crisis component will investigate the model's effectiveness, accessibility and acceptability, as well as understanding the potential of the model to contribute towards solving numerous gaps in the existing mental health service provision within the United Kingdom. [ABSTRACT FROM AUTHOR]

Background Children in the UK care system often face multiple disadvantages in terms of health, education and future employment. This is especially true of mental health where they present with greater mental health needs than other children. Although transition from care - the process of leaving the local authority as a child-in-care to independence - is a key juncture for young people, it is often experienced negatively with inconsistency in care and exacerbation of existing mental illness. Those receiving support from child and adolescent mental health services ( CAMHS), often experience an additional, concurrent transfer to adult services ( AMHS), which are guided by different service models which can create a care gap between services. Method This qualitative study explored care-leavers' experiences of mental illness, and transition in social care and mental health services. Twelve care-leavers with mental health needs were interviewed and data analysed using framework analysis. Results Sixteen individual themes were grouped into four superordinate themes: overarching attitudes towards the care journey, experience of social care, experience of mental health services and recommendations. Conclusions Existing social care and mental health teams can improve the care of care-leavers navigating multiple personal, practical and service transitions. Recommendations include effective Pathway Planning, multiagency coordination, and stating who is responsible for mental health care and its coordination. Participants asked that youth mental health services span the social care transition; and provide continuity of mental health provision when care-leavers are at risk of feeling abandoned and isolated, suffering deteriorating mental health and struggling to establish new relationships with professionals. Young people say that the key to successful transition and achieving independence is maintaining trust and support from services. [ABSTRACT FROM AUTHOR]

Background: No evidence based approach to reduce duration of untreated psychosis (DUP) has been effective in the UK. Existing interventions have many components and have been difficult to replicate. The majority of DUP in Birmingham, UK is accounted for by delays within mental health services (MHS) followed by help-seeking delay and, we hypothesise, these require explicit targeting. This study examined the feasibility and impact of an intervention to reduce DUP, targeting help-seeking and MHSs delays. Methods: A dual-component intervention, comprising a direct care pathway, for 16-25 year olds, and a community psychosis awareness campaign, using our youth-friendly website as the central hub, was implemented, targeting the primary sources of care pathway delays experienced by those with long DUP. Evaluation, using a quasi-experimental, design compared DUP of cases in two areas of the city receiving early detection vs detection as usual, controlling for baseline DUP in each area. Results: DUP in the intervention area was reduced from a median 71 days (mean 285) to 39 days (mean 104) following the intervention, with no change in the control area. Relative risk for the reduction in DUP was 0.74 (95 % CI 0.35 to 0.89; p = .004). Delays in MHSs and help-seeking were also reduced. Conclusions: Our targeted approach appears to be successful in reducing DUP and could provide a generalizable methodology applicable in a variety of healthcare contexts with differing sources of delay. More research is needed, however, to establish whether our approach is truly effective. [ABSTRACT FROM AUTHOR]

Background: Despite increasing calls for shared decision making (SDM), the precise mechanisms for its attainment are unclear. Sharing decisions in mental health care may be especially complex. Fluctuations in service user capacity and significant power differences are particular barriers. Objective and design: We trialled a form of facilitated SDM that aimed to generate patients' treatment preferences in advance of a possible relapse. The ‘Joint Crisis Plan’ (JCP) intervention was trialled in four mental health trusts in England between 2008 and 2011. This qualitative study used grounded theory methods to analyse focus group and interview data to understand how stakeholders perceived the intervention and the barriers to SDM in the form of a JCP. Results: Fifty service users with psychotic disorders and 45 clinicians participated in focus groups or interviews between February 2010 and November 2011. Results suggested four barriers to clinician engagement in the JCP: (i) ambivalence about care planning; (ii) perceptions that they were ‘already doing SDM’; (iii) concerns regarding the clinical ‘appropriateness of service users’ choices'; and (iv) limited ‘availability of service users’ choices'. Service users reported barriers to SDM in routine practice, most of which were addressed by the JCP process. Barriers identified by clinicians led to their lack of constructive engagement in the process, undermining the service users' experience. Conclusions: Future work requires interventions targeted at the engagement of clinicians addressing their concerns about SDM. Particular strategies include organizational investment in implementation of service users' choices and directly training clinicians in SDM communication processes. [ABSTRACT FROM AUTHOR]

Background: Social disability is a hallmark of severe mental illness yet individual differences and factors predicting outcome are largely unknown.Aim: To explore trajectories and predictors of social recovery following a first episode of psychosis (FEP).Method: A sample of 764 individuals with FEP were assessed on entry into early intervention in psychosis (EIP) services and followed up over 12 months. Social recovery profiles were examined using latent class growth analysis.Results: Three types of social recovery profile were identified: Low Stable (66%), Moderate-Increasing (27%), and High-Decreasing (7%). Poor social recovery was predicted by male gender, ethnic minority status, younger age at onset of psychosis, increased negative symptoms, and poor premorbid adjustment.Conclusions: Social disability is prevalent in FEP, although distinct recovery profiles are evident. Where social disability is present on entry into EIP services it can remain stable, highlighting a need for targeted intervention. [ABSTRACT FROM AUTHOR]

Aims National EDEN aims to evaluate the implementation and impact on key outcomes of somewhat differently configured Early Intervention Services ( EIS) across sites in England and to develop a model of variance in patient outcomes that includes key variables of duration of untreated psychosis ( DUP), fidelity to the EIS model and service engagement. The cohort is being followed up for two further years as patients are discharged, to observe the stability of change and the impact of the discharge settings. Methods A longitudinal cohort study of patients with a first episode of a psychosis, managed by EIS in six services across England. Patients are followed up 12 months after inception, then up to 2 years following discharge. Measures of DUP, psychosis, social functioning and relapse were taken. User and carer experience of EIS were monitored over time; as was the fidelity of each EIS to national guidelines. Service use is costed for a health economic evaluation. Results 1027 people consented to the study of which 75% were successfully followed up at 12 months, with almost 100% data on treatment, relapse and recovery and service use. Conclusions National EDEN is the largest cohort study of young people with psychosis receiving care under EIS. It will be able definitively to indicate whether this major investment in the United Kingdom in EI is achieving meaningful change for its users in practice and provide indications concerning who does well under this approach and who does not, and the long-term stability of any improvements. [ABSTRACT FROM AUTHOR]

Objective Embedded in attachment theory is its association with affect regulation, which provides a framework for affective dysregulation in the emerging psychosis. Method Fifty-one participants meeting criteria for ultra-high risk ( UHR) of developing psychosis were recruited from a youth mental health service within the United Kingdom. At intake baseline, prior to starting therapeutic intervention, all clients were assessed on measures of affective dysregulation and attachment. Results A large proportion of our sample ( N = 51) reported clinically significant levels of depression (78%), state anxiety (59%), and social anxiety (65%). Eighty per cent of the UHR sample was insecurely attached. Insecure attachment was significantly associated with elevated depression and social anxiety. Attachment styles were associated with anxiety, depression, and social anxiety. There was no support for a mediating role of social anxiety between attachment styles and depression. Conclusion Clinically significant levels of distress and anxiety experienced by the young people at high risk of psychosis. Clinical implications for the treatment of affective dysregulation in young people at UHR in relation to their attachment styles have been discussed. Practitioner points The treatment of affective dysregulation has implications on social integration, crucial to the recovery of young people in the emerging psychosis., Assessment of adult attachment difficulties may bring to the forefront specific negative internal working models (and interpersonal schemas) which may indicate vulnerability to social anxiety and depression., Young adults at ultra-high risk of psychosis with emotional difficulties may be better at help seeking and therefore over-represented in this sample., Cross-sectional data analysis makes it difficult to draw aetiological links between adult attachment and affective dysregulation. [ABSTRACT FROM AUTHOR]

Background: Interventions to reduce treatment delay in first-episode psychosis have met with mixed results. Systematic reviews highlight the need for greater understanding of delays within the care pathway if successful strategies are to be developed.Aims: To document the care-pathway components of duration of untreated psychosis (DUP) and their link with delays in accessing specialised early intervention services (EIS). To model the likely impact on efforts to reduce DUP of targeted changes in the care pathway.Method: Data for 343 individuals from the Birmingham, UK, lead site of the National EDEN cohort study were analysed.Results: A third of the cohort had a DUP exceeding 6 months. The greatest contribution to DUP for the whole cohort came from delays within mental health services, followed by help-seeking delays. It was found that delay in reaching EIS was strongly correlated with longer DUP.Conclusions: Community education and awareness campaigns to reduce DUP may be constrained by later delays within mental health services, especially access to EIS. Our methodology, based on analysis of care pathways, will have international application when devising strategies to reduce DUP. [ABSTRACT FROM AUTHOR]

Objectives The current study examined shame in a clinical sample recovering from a first episode of psychosis by focusing on the contribution of different types of shame to post-psychotic trauma while controlling for current affective symptoms. Design The study used a cross-sectional correlational design. Method Fifty individuals who met the criteria for a psychotic disorder whose acute psychotic symptoms were in remission completed measures of internal and external shame associated with psychosis, general shame, post-psychotic trauma, and depression. Results Post-psychotic trauma symptoms were correlated with internal and external shame associated with psychosis and general shame. However, the relation between post-psychotic trauma and external shame associated with psychosis remained after controlling for general shame and current affective symptoms. In addition, internal shame had a stronger association with depression. Thus, internal and external shame due to psychosis had different associations with different types of post-psychotic emotional dysfunction. Conclusions The results support the importance of assessing shame as a multi-faceted construct and suggest that assessing shame directly associated with mental illness is a worthwhile endeavour. Practitioner Points Assessing different types of shame following psychosis can inform assessments, formulations, and interventions with post-psychotic trauma., Our results support the application of Compassionate Mind Therapy to psychosis., However, we did not assess self-criticism or self-reassurance., We also did not investigate the relation between specific psychotic symptoms and different types of shame. [ABSTRACT FROM AUTHOR]

Background: Reducing the duration of untreated psychosis (DUP) is an aspiration of international guidelines for first episode psychosis; however, public health initiatives have met with mixed results. Systematic reviews suggest that greater focus on the sources of delay within care pathways, (which will vary between healthcare settings) is needed to achieve sustainable reductions in DUP (BJP 198: 256-263; 2011). Methods/Design: A quasi-experimental trial, comparing a targeted intervention area with a 'detection as usual' area in the same city. A proof-of-principle trial, no a priori assumptions are made regarding effect size; key outcome will be an estimate of the potential effect size for a definitive trial. DUP and number of new cases will be collected over an 18-month period in target and control areas and compared; historical data on DUP collected in both areas over the previous three years, will serve as a benchmark. The intervention will focus on reducing two significant DUP component delays within the overall care pathway: delays within the mental health service and help-seeking delay. Discussion: This pragmatic trial will be the first to target known delays within the care pathway for those with a first episode of psychosis. If successful, this will provide a generalizable methodology that can be implemented in a variety of healthcare contexts with differing sources of delay. [ABSTRACT FROM AUTHOR]

Objective:This article reports the results of an evaluation of a consultation-liaison service for people with combined mental health and substance use problems. The service is one component of an overall integrated service framework for this group of clients developed and delivered across one of the largest Mental Health Foundation Trusts in the UK. A full description of the client group referred to consultation-liaison over a 3-year period is provided, as well as a description of different referral pathways and a preliminary evaluation of a brief intervention offered as part of the service.Methods:Service evaluation data were collected through routine practice and provided demographic and diagnostic information on the clients who were referred to the consultation-liaison service (N= 173). A sample of these clients (n= 39) received a full brief motivational intervention consisting of six sessions delivered over a 12-week period. Quantitative questionnaire data collected for clients who received this component subsequently allowed a baseline and follow-up cohort assessment of changes on various substance-related outcomes in those receiving the brief intervention.Results:The results indicated that clients referred to the service (N= 173) were typically male (69.9%), in their mid-30s (M= 36.6 years,SD= 9.98) and considered to be white British (61.8%). They often presented with psychotic (52.6%) or depressive (16.8%) disorders and were commonly using alcohol (67.1%) or cannabis (47.4%). Of the clients who completed the full brief intervention (n= 39), baseline and follow-up outcome measures were available on a subsample (nranged from 11 to 25 depending on each specific measure) and results showed significant changes in a number of areas, including increased engagement with treatment (p< .001), reduced alcohol (p= .001) and cannabis use (p= .015), fewer signs of hazardous alcohol use (p= .026), and improved confidence to change substance use (p= .006). These findings have to be considered as preliminary given the limitations of the service evaluation methodology.Conclusions:The consultation-liaison service appears to be a helpful component within an overall service framework for dual diagnosis in a number of ways, for example through the enhancement of existing services such as assessment, advice, and consultation, as well as the delivery of a brief intervention. [ABSTRACT FROM AUTHOR]

It has been found that the Muslim population in the UK seek spiritual advice from traditional faith healers for psychiatric and related problems. The important role that religious beliefs may have on perceptions of mental illness and substance misuse warrants further investigation. The aims were to examine the views of Muslims faith healers on symptoms and changes in behaviour commonly described as “psychosis” and “substance misuse”. Eight semi-structured interviews were conducted with Muslim faith healers from various backgrounds. Data were analysed according to the conventions of qualitative research using grounded theory methods. Religious conceptualisations played a key role in the understanding of both the disorders and consequently the guidance given. There were similarities and differences in the narratives given for psychosis and substance misuse. Healers expressed doubt towards other faith healers and the methods utilised by scientific means. The findings suggest a need for close collaboration between faith healers and mental health workers in order to achieve a culturally sensitive health care system. [ABSTRACT FROM PUBLISHER]

In this review, we summarize and review reforms to the mental health service in the United Kingdom from 1999 to the present. Our analysis is based on government documents describing the reforms and providing guidelines for their implementation. In addition, we summarize prospective studies of psychosis from the first episode and early treatment studies on the basis of existing systematic reviews. The UK mental health reforms have attracted major government funding and have been used to commission specialized ("functional") community teams for people with severe mental illness. The reforms include changes to services for first-episode psychosis, which have attracted considerable consumer support. The UK service reforms are continuing, with the aim of providing services fit for the 21st century. [ABSTRACT FROM AUTHOR]

The need for a measure of engagement with Community Mental Health Services has been identified. This article reports on the development and preliminary psychometric evaluation of a scale, Service Engagement Scale (SES), to measure engagement with community mental health services. Five Community Psychiatric Nurses completed the SES for 66 clients receiving Assertive Outreach services with an ICD-10 diagnosis of schizophrenia. Test–retest reliability of the subscale items and scale total is in the good to excellent range. Validity is supported by good internal consistency and by the criterion group method. Although preliminary psychometric results are promising, further psychometric study is necessary to evaluate the scale's factor structure. The SES appears to evaluate engagement with services, and may therefore be a useful tool to identify areas of concern with clients experiencing engagement difficulties. [ABSTRACT FROM AUTHOR]

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]

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]

Examines the problems in diagnosing psychosis in Great Britain. Problems in the mental health services; Development of a medical team to support the 'integrated shared care approach'; Characteristics of the Randomized Controlled Trial, a device for clinical interventions.

Background: 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.Methods/design: 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.Discussion: 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.Trial Registration: Current controlled trial with ISRCTN, ISRCTN80567433 . Registered on 27 February 2017. [ABSTRACT FROM AUTHOR]

Abstract: Aims: Understanding how adolescents perceive mental illness is important for clinicians wishing to improve engagement, and for the development of educational programmes and health‐behaviour directed policies. The current research aimed to develop a preliminary model of how adolescents perceive mental illness and construct their understanding of mental health. Method: Forty‐six participants aged 11–18 from six schools in Birmingham, UK, took part in one of 12 group interviews. Results: A thematic analysis highlighted a dual perception of mental illness. Adolescents discussed stereotypes and extreme examples of illness, but also displayed an insightful understanding of mental distress which had developed through participants' own experiences. Participants attempted to reconcile and negotiate these conflicting perceptions by creating distinctions between concepts of ‘craziness’ and ‘normality’, and reported experiencing negative emotions relating to both perceptions of illness. Conclusions: The findings suggest that once media stereotypes have been acknowledged, adolescents demonstrate a relatively sophisticated understanding of mental illness, although one which differed at times from the diagnostic medical model of mental illness. Focusing on individual symptoms, prevalence rates and prior contact adolescents have had with individuals with mental illnesses provides a framework to discuss mental health and ill‐health with adolescents. [ABSTRACT FROM AUTHOR]

The author comments on the article "From Commitment to Reality--Early Intervention in Psychosis Services in England." He addresses the lack of change in the provision of mental health services in Great Britain since the decision of the government in 2001 to finance the roll-out early intervention services (EIS). He mentions the benefits provided by EIS. He emphasizes the importance of service structure.

Objective: The extant literature is inconsistent over whether manic symptoms in first-episode psychosis (FEP) impact on its development and trajectory. This study addressed the following: (1) Does Duration of Untreated Illness (DUI) and Duration of Untreated Psychosis (DUP) differ between FEP patients with and without manic symptoms? (2) Do manic symptoms in FEP have an impact on time to remission over 1 year?, Methods: We used data from the National EDEN study, a longitudinal cohort of patients with FEP accessing early intervention services (EIS) in England, which measured manic, positive and negative psychotic symptoms, depression and functioning at service entry and 1 year. Data from 913 patients with FEP (639 without manic symptoms, 237 with manic symptoms) were analysed using both general linear modelling and survival analysis., Results: Compared to FEP patients without manic symptoms, those with manic symptoms had a significantly longer DUI, though no difference in DUP. At baseline, people with manic symptoms had higher levels of positive and negative psychotic symptoms, depression and worse functioning. At 12 months, people with manic symptoms had significantly poorer functioning and more positive psychotic symptoms. The presence of manic symptoms delayed time to remission over 1 year. There was a 19% reduced rate of remission for people with manic symptoms compared to those without., Conclusions: Manic symptoms in FEP are associated with delays to treatment. This poorer trajectory persists over 1 year. They appear to be a vulnerable and under-recognised group for poor outcome and need more focussed early intervention treatment., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Aims: Co-design implies genuine partnership in the generation of knowledge between service users and researchers. Service user involvement in research has been encouraged in government policy, but it is rarely achieved, especially at trial initial stages. Co-designed with service users, we adapted existing manualised social cognition intervention for people with a first episode of psychosis to a virtual world environment., Methods: We invited a group of young people who have used mental health services to co-design a virtual environment to deliver an accessible social cognition intervention to a hard to engage service user group. We used an iterative process with young service users and the design team that included developing initial ideas, creating a prototype and testing the virtual world., Results: Twenty young service users of local mental healthcare services provided feedback on the design and delivery of the intervention. Reflecting the demographic of the sample, young people felt the virtual environment should be familiar, urban spaces, akin to therapy rooms or classrooms they have used in real-life situations rather than non-traditional therapy spaces that were initially proposed., Conclusion: The co-design process led to the development of a specific design, approach and protocol to be tested in a proof-of-concept trial. Young service users were integral to an agile and iterative design. Technological innovations should be routinely co-designed and co-produced if they are to realise their potential to deliver acceptable and affordable mental health interventions., (© 2019 John Wiley & Sons Australia, Ltd.)

Objective: Self-harm remains a serious public health concern; however, identifying adolescents at risk is challenging. While self-harm has been linked with difficulties in emotional regulation postinjury, comparatively little is known about how such difficulties may impact on the future development of self-harm behavior., Methods: A total of 318 pupils aged 14-15 years completed measures on history of direct self-injurious behavior (D-SIB), emotional regulation, depression, and anxiety at two time points across a six-month period., Results: Of 13% (42) of participants reported their first episode of D-SIB over the six-month period and reported increased difficulties with emotional regulation prior to initial D-SIB. Regression analyses found significant associations for emotional regulation and specifically lack of emotional clarity prior to first episode of D-SIB. Lack of emotional awareness and difficulties with impulse control was significantly associated in those with ongoing D-SIB., Conclusions: Prior to first episode of D-SIB, young people may experience difficulty regulating emotions, a difficulty which appears less pronounced following their engagement with D-SIB. Our findings implicate difficulties in the early evaluation and understanding of emotions which may later impair attempts at emotion modulation and increase risk of D-SIB. Such findings might help inform early identification of adolescents at risk of initial D-SIB., (© 2018 The American Association of Suicidology.)

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., (© 2018 John Wiley & Sons Australia, Ltd.)

Objectives: To explore service user experiences of a 9-month cognitive behavioural therapy for command hallucinations in the context of a randomised controlled trial including their views on acceptability and tolerability of the intervention., Design: Qualitative study using semistructured interviews., Setting: The study took place across three sites: Birmingham, Manchester and London. Interviews were carried out at the sites where therapy took place which included service bases and participants' homes., Participants: Of 197 patients who consented to the trial, 98 received the Cognitive Behavior Therapy for Command Hallucinations (CTCH) intervention; 25 (15 males) of whom were randomly selected and consented to the qualitative study. The mean age of the sample was 42 years, and 68% were white British., Results: Two superordinate themes were identified: participants' views about the aspects of CTCH they found most helpful; and participants' concerns with therapy. Helpful aspects of the therapy included gaining control over the voices, challenging the power and omniscience of the voices, following a structured approach, normalisation and mainstreaming of the experience of voices, and having peer support alongside the therapy. Concerns with the therapy included anxiety about completing CTCH tasks, fear of talking back to voices, the need for follow-up and ongoing support and concerns with adaptability of the therapy., Conclusions: Interpretation: CTCH was generally well received and the narratives validated the overall approach. Participants did not find it an easy therapy to undertake as they were challenging a persecutor they believed had great power to harm; many were concerned, anxious and occasionally disappointed that the voices did not disappear altogether. The trusting relationship with the therapist was crucial. The need for continued support was expressed., Trial Registration Number: ISRCTN62304114, Pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: The use of cannabis during the early stage of psychosis has been linked with increased psychotic symptoms. This study aimed to examine the use of cannabis in the 12 months following a first-episode of psychosis (FEP) and the link with symptomatic course and outcome over 1 year post psychosis onset., Design and Setting: One thousand twenty-seven FEP patients were recruited upon inception to specialized early intervention services (EIS) for psychosis in the United Kingdom. Participants completed assessments at baseline, 6 and 12 months., Results: The results indicate that the use of cannabis was significantly associated with increased severity of psychotic symptoms, mania, depression and poorer psychosocial functioning. Continued use of cannabis following the FEP was associated with poorer outcome at 1 year for Positive and Negative Syndrome Scale total score, negative psychotic symptoms, depression and psychosocial functioning, an effect not explained by age, gender, duration of untreated psychosis, age of psychosis onset, ethnicity or other substance use., Conclusion: This is the largest cohort study of FEP patients receiving care within EIS. Cannabis use, particularly "continued use," was associated with poorer symptomatic and functional outcome during the FEP. The results highlight the need for effective and early intervention for cannabis use in FEP., (© The Author 2015. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: The development of early intervention services for young people with first-episode psychosis is a priority internationally., Aims: To evaluate the development, implementation and impact of existing and newly formed early intervention services in England., Method: Multiple-case study involving staff, users, carers and commissioners of 14 early intervention services., Results: Service numbers increased in response to national policy directives. They were still actively working with 90.6% of service users 12 months after inception. They were highly valued by users and carers as providing a personal service that contrasted with previous experiences of care. Tensions between providing a quality service and meeting case-load targets linked to future funding led teams to adopt a series of survival strategies with some unintended consequences., Conclusions: Early intervention services are highly valued by consumers and engage users effectively after 12 months. Implementation of these services is threatened unless sufficient consistent funding is made available.