Stigma of mental health conditions hinders recovery and well-being. The Honest, Open, Proud (HOP) program shows promise in reducing stigma but there is uncertainty about the feasibility of a randomized trial to evaluate a peer-delivered, individual adaptation of HOP for psychosis (Let's Talk).

A multi-site, Prospective Randomized Open Blinded Evaluation (PROBE) design, feasibility randomised controlled trial (RCT) comparing the peer-delivered intervention (Let's Talk) to treatment as usual (TAU). Follow-up was 2.5 and 6 months. Randomization was via a web-based system, with permuted blocks of random size. Up to 10 sessions of the intervention over 10 weeks were offered. The primary outcome was feasibility data (recruitment, retention, intervention attendance). Primary outcomes were analyzed by intention to treat. Safety outcomes were reported by as treated status. The study was prospectively registered: https://doi.org/10.1186/ISRCTN17197043.

149 patients were referred to the study and 70 were recruited. 35 were randomly assigned to intervention + TAU and 35 to TAU. Recruitment was 93% of the target sample size. Retention rate was high (81% at 2.5 months primary endpoint), and intervention attendance rate was high (83%). 21% of 33 patients in Let's talk + TAU had an adverse event and 16% of 37 patients in TAU. One serious adverse event (pre-randomization) was partially related and expected.

This is the first trial to show that it is feasible and safe to conduct a RCT of HOP adapted for people with psychosis and individual delivery. An adequately powered trial is required to provide robust evidence.

Neuropsychological (NP) tests are increasingly computerized, which automates testing, scoring, and administration. These innovations are well-suited for use in resource-limited settings, such as low- to middle- income countries (LMICs), which often lack specialized testing resources (e.g., trained staff, forms, norms, equipment). Despite this, there is a dearth of research on their acceptability and usability which could affect performance, particularly in LMICs with varying levels of access to computer technology. NeuroScreen is a tablet-based battery of tests assessing learning, memory, working memory, processing speed, executive functions, and motor speed. This study evaluated the acceptability and usability of NeuroScreen among two groups of LMIC adolescents with and without HIV from Cape Town, South Africa and Kampala, Uganda.

Adolescents in Cape Town (n=131) and Kampala (n=80) completed NeuroScreen and questions about their use and ownership of, as well as comfort with computer technology and their experiences completing NeuroScreen. Participants rated their technology use -comfort with and ease-of-use of computers, tablets, smartphones, and NeuroScreen on a Likert-type scale: (1) Very Easy/Very Comfortable to (6) Very Difficult/Very Uncomfortable. For analyses, responses of Somewhat Easy/Comfortable to Very Easy/Comfortable were collapsed to codify comfort and ease. Descriptive statistics assessed technology use and experiences of using the NeuroScreen tool. A qualitative question asked how participants would feel receiving NeuroScreen routinely in the future; responses were coded as positive, negative, or neutral (e.g., “I would enjoy it”). Chi-squares assessed for group differences.

South African adolescents were 15.42 years on average, 50.3% male, and 49% were HIV-positive. Ugandan adolescents were 15.64 years on average, 50.6% male, and 54% HIVpositive. South African participants were more likely than Ugandan participants to have ever used a computer (71% vs. 49%; p<.005), or tablet (58% vs. 40%; p<.05), whereas smartphone use was similar (94% vs 87%). South African participants reported higher rates of comfort using a computer (86% vs. 46%; p<.001) and smartphone (96% vs. 88%; p<.05) compared to Ugandan participants. Ugandan adolescents rated using NeuroScreen as easier than South African adolescents (96% vs. 87%; p<.05).). Regarding within-sample differences by HIV status, Ugandan participants with HIV were less likely to have used a computer than participants without HIV (70% vs. 57%; p<.05, respectively).The Finger Tapping test was rated as the easiest by both South African (73%) and Ugandan (64%) participants. Trail Making was rated as the most difficult test among Ugandan participants (37%); 75% of South African participants reported no tasks as difficult followed by Finger Tapping as most difficult (8%). When asked about completing NeuroScreen at routine doctor’s visits, most South Africans (85%) and Ugandans (72%) responded positively.

This study found that even with low prior tablet use and varying levels of comfort in using technology, South African and Ugandan adolescents rated NeuroScreen with high acceptability and usability. These data suggest that scaling up NeuroScreen in LMICs, where technology use might be limited, may be appropriate for adolescent populations. Further research should examine prior experience and comfort with tablets as predictors NeuroScreen test performance.

People with psychotic disorders often experience neurocognitive deficits, such as neurocognitive impairment (NCI), which can negatively affect their daily activities (e.g., performing independent tasks) and recovery. Because of this, the American Psychology Association advocates integrating neurocognitive testing into routine care for people living with psychotic disorders, especially those in their first episode, to inform treatment and improve clinical outcomes. However, in low-and-middle income countries (LMICs), such as Uganda where the current study took place, administering neurocognitive tests in healthcare settings presents numerous challenges. In Uganda there are few resources (e.g., trained clinical staff, and culturally relevant and normed tests) to routinely offer testing in healthcare settings. NeuroScreen is a brief, highly automated, tablet-based neurocognitive testing tool that can be administered by all levels of healthcare staff and has been translated into indigenous Ugandan languages. To examine the psychometric properties of NeuroScreen, we measured convergent and criterion validity of the NeuroScreen tests by comparing performance on them to performance on a traditional battery of neurocognitive tests widely used to assess neurocognition in people with psychotic disorders, the Matric Consensus Cognitive Battery (MCCB).

Sixty-five patients admitted into Butabika Mental Referral Hospital in Uganda after experiencing a psychotic episode and forty-seven demographically similar control participants completed two neurocognitive test batteries: the MCCB and NeuroScreen. Both batteries include tests measuring the neurocognitive domains of executive functioning, working memory, verbal learning, and processing speed. Prior to completing each battery, patients were medically stabilized and could not exhibit any positive symptoms on the day of testing. On the day of testing, medication dosages were scheduled so that patients would not experience sedative effects while testing. To examine convergent validity, we examined correlations between overall performance on NeuroScreen and the MCCB, as well as tests that measured the same neurocognitive domains. To examine criterion validity, an ROC curve was computed to examine the sensitivity and specificity of NeuroScreen to detect NCI as defined by the MCCB.

There was a large correlation between overall performance on NeuroScreen and the MCCB battery of tests, r(110) = .65, p < .001. Correlations of various strengths were found among tests measuring the same neurocognitive domains in each battery: executive functioning [r(110) = .56 p <.001], processing speed [r(110) = .44, p <.001)], working memory [r(110) = .29, p<.01], and verbal learning [r(110) = .22, p < .01]. ROC analysis of the ability of NeuroScreen to detect MCCB defined NCI showed an area under curve of .798 and optimal sensitivity and specificity of 83% and 60%, respectively.

Overall test performance between the NeuroScreen and MCCB test batteries was similar in this sample of Ugandans with and without a psychotic disorder, with the strongest correlations in tests of executive functioning and processing speed. ROC analysis provided criterion validity evidence of NeuroScreen to detect MCCB defined NCI. These results provide support for use of NeuroScreen to assess neurocognitive functioning among patients with psychotic disorders in Uganda, however more work needs to be to determine how well it can be implemented in this setting. Future directions include assessing cultural acceptability of NeuroScreen and generating normative data from a larger population of Ugandan test-takers.

There is wide variation in the problems prioritised by people with psychosis in cognitive behavioural therapy for psychosis (CBTp). While research trials and mental health services have often prioritised reduction in psychiatric symptoms, service users may prioritise issues not directly related to psychosis. This discrepancy suggests potential challenges in treatment outcome research.

The present study aimed to examine the types of problems that were recorded on problem lists generated in CBTp trials.

Problem and goals lists for 110 participants were extracted from CBTp therapy notes. Subsequently, problems were coded into 23 distinct categories by pooling together items that appeared thematically related.

More than half of participants (59.62%) listed a non-psychosis-related priority problem, and 22.12% did not list any psychosis related problems. Chi-square tests indicated there was no difference between participants from early intervention (EI) and other services in terms of priority problem (χ2 = 0.06, p = .804), but that those from EI were more likely to include any psychosis-related problems in their lists (χ2 = 6.66, p = .010).

The findings of this study suggest that psychiatric symptom reduction is not the primary goal of CBTp for most service users, particularly those who are not under the care of EI services. The implications for future research and clinical practice are discussed.

Automated virtual reality therapies are being developed to increase access to psychological interventions. We assessed the experience with one such therapy of patients diagnosed with psychosis, including satisfaction, side effects, and positive experiences of access to the technology. We tested whether side effects affected therapy.

In a clinical trial 122 patients diagnosed with psychosis completed baseline measures of psychiatric symptoms, received gameChange VR therapy, and then completed a satisfaction questionnaire, the Oxford-VR Side Effects Checklist, and outcome measures.

79 (65.8%) patients were very satisfied with VR therapy, 37 (30.8%) were mostly satisfied, 3 (2.5%) were indifferent/mildly dissatisfied, and 1 (0.8%) person was quite dissatisfied. The most common side effects were: difficulties concentrating because of thinking about what might be happening in the room (n = 17, 14.2%); lasting headache (n = 10, 8.3%); and the headset causing feelings of panic (n = 9, 7.4%). Side effects formed three factors: difficulties concentrating when wearing a headset, feelings of panic using VR, and worries following VR. The occurrence of side effects was not associated with number of VR sessions, therapy outcomes, or psychiatric symptoms. Difficulties concentrating in VR were associated with slightly lower satisfaction. VR therapy provision and engagement made patients feel: proud (n = 99, 81.8%); valued (n = 97, 80.2%); and optimistic (n = 96, 79.3%).

Patients with psychosis were generally very positive towards the VR therapy, valued having the opportunity to try the technology, and experienced few adverse effects. Side effects did not significantly impact VR therapy. Patient experience of VR is likely to facilitate widespread adoption.

Many patients with mental health disorders become increasingly isolated at home due to anxiety about going outside. A cognitive perspective on this difficulty is that threat cognitions lead to the safety-seeking behavioural response of agoraphobic avoidance.

We sought to develop a brief questionnaire, suitable for research and clinical practice, to assess a wide range of cognitions likely to lead to agoraphobic avoidance. We also included two additional subscales assessing two types of safety-seeking defensive responses: anxious avoidance and within-situation safety behaviours.

198 patients with psychosis and agoraphobic avoidance and 1947 non-clinical individuals completed the item pool and measures of agoraphobic avoidance, generalised anxiety, social anxiety, depression and paranoia. Factor analyses were used to derive the Oxford Cognitions and Defences Questionnaire (O-CDQ).

The O-CDQ consists of three subscales: threat cognitions (14 items), anxious avoidance (11 items), and within-situation safety behaviours (8 items). Separate confirmatory factor analyses demonstrated a good model fit for all subscales. The cognitions subscale was significantly associated with agoraphobic avoidance (r = .672, p < .001), social anxiety (r = .617, p < .001), generalized anxiety (r = .746, p < .001), depression (r = .619, p < .001) and paranoia (r = .655, p < .001). Additionally, both the O-CDQ avoidance (r = .867, p < .001) and within-situation safety behaviours (r = .757, p < .001) subscales were highly correlated with agoraphobic avoidance. The O-CDQ demonstrated excellent internal consistency (cognitions Cronbach’s alpha = .93, avoidance Cronbach’s alpha = .94, within-situation Cronbach’s alpha = .93) and test–re-test reliability (cognitions ICC = 0.88, avoidance ICC = 0.92, within-situation ICC = 0.89).

The O-CDQ, consisting of three separate scales, has excellent psychometric properties and may prove a helpful tool for understanding agoraphobic avoidance across mental health disorders.

Agoraphobic avoidance of everyday situations is a common feature in many mental health disorders. Avoidance can be due to a variety of fears, including concerns about negative social evaluation, panicking, and harm from others. The result is inactivity and isolation. Behavioural avoidance tasks (BATs) provide an objective assessment of avoidance and in situ anxiety but are challenging to administer and lack standardisation. Our aim was to draw on the principles of BATs to develop a self-report measure of agoraphobia symptoms.

The scale was developed with 194 patients with agoraphobia in the context of psychosis, 427 individuals in the general population with high levels of agoraphobia, and 1094 individuals with low levels of agoraphobia. Factor analysis, item response theory, and receiver operating characteristic analyses were used. Validity was assessed against a BAT, actigraphy data, and an existing agoraphobia measure. Test–retest reliability was assessed with 264 participants.

An eight-item questionnaire with avoidance and distress response scales was developed. The avoidance and distress scales each had an excellent model fit and reliably assessed agoraphobic symptoms across the severity spectrum. All items were highly discriminative (avoidance: a = 1.24–5.43; distress: a = 1.60–5.48), indicating that small increases in agoraphobic symptoms led to a high probability of item endorsement. The scale demonstrated good internal reliability, test–retest reliability, and validity.

The Oxford Agoraphobic Avoidance Scale has excellent psychometric properties. Clinical cut-offs and score ranges are provided. This precise assessment tool may help focus attention on the clinically important problem of agoraphobic avoidance.

The period before the formation of a persecutory delusion may provide causal insights. Patient accounts are invaluable in informing this understanding.

To inform the understanding of delusion formation, we asked patients about the occurrence of potential causal factors – identified from a cognitive model – before delusion onset.

A total of 100 patients with persecutory delusions completed a checklist about their subjective experiences in the weeks before belief onset. The checklist included items concerning worry, images, low self-esteem, poor sleep, mood dysregulation, dissociation, manic-type symptoms, aberrant salience, hallucinations, substance use and stressors. Time to reach certainty in the delusion was also assessed.

Most commonly it took patients several months to reach delusion certainty (n = 30), although other patients took a few weeks (n = 24), years (n = 21), knew instantly (n = 17) or took a few days (n = 6). The most frequent experiences occurring before delusion onset were: low self-confidence (n = 84); excessive worry (n = 80); not feeling like normal self (n = 77); difficulties concentrating (n = 77); going over problems again and again (n = 75); being very negative about the self (n = 75); images of bad things happening (n = 75); and sleep problems (n = 75). The average number of experiences occurring was high (mean 23.5, s.d. = 8.7). The experiences clustered into six main types, with patients reporting an average of 5.4 (s.d. = 1.0) different types.

Patients report numerous different experiences in the period before full persecutory delusion onset that could be contributory causal factors, consistent with a complex multifactorial view of delusion occurrence. This study, however, relied on retrospective self-report and could not determine causality.

None.

To explore the factors affecting intra-household food allocation practices to inform the development of interventions to prevent low birth weight in rural plains of Nepal.

Qualitative methodology using purposive sampling to explore the barriers and facilitating factors to improved maternal nutrition.

Rural Dhanusha District, Nepal.

We purposively sampled twenty-five young daughters-in-law from marginalised groups living in extended families and conducted semi-structured interviews with them. We also conducted one focus group discussion with men and one with female community health volunteers who were mothers-in-law.

Gender and age hierarchies were important in household decision making. The mother-in-law was responsible for ensuring that a meal was provided to productive household members. The youngest daughter-in-law usually cooked last and ate less than other family members, and showed respect for other family members by cooking only when permitted and deferring to others’ choice of food. There were limited opportunities for these women to snack between main meals. Daughters-in-law’ movement outside the household was restricted and therefore family members perceived that their nutritional need was less. Poverty affected food choice and families considered cost before nutritional value.

It is important to work with the whole household, particularly mothers-in-law, to improve maternal nutrition. We present five barriers to behaviour change: poverty; lack of knowledge about cheap nutritional food, the value of snacking, and cheap nutritional food that does not require cooking; sharing food; lack of self-confidence; and deference to household guardians. We discuss how we have targeted our interventions to develop knowledge, discuss strategies to overcome barriers, engage mothers-in-law, and build the confidence and social support networks of pregnant women.

Research has highlighted the importance of recovery as defined by the service user, and suggests a link to negative emotion, although little is known about the role of negative emotion in predicting subjective recovery.

To investigate longitudinal predictors of variability in recovery scores with a focus on the role of negative emotion.

Participants (n=110) with experience of psychosis completed measures of psychiatric symptoms, social functioning, subjective recovery, depression, hopelessness and self-esteem at baseline and 6 months later. Path analysis was used to examine predictive factors for recovery and negative emotion.

Subjective recovery scores were predicted by negative emotion, positive self-esteem and hopelessness, and to a lesser extent by symptoms and functioning. Current recovery score was not predicted by past recovery score after accounting for past symptoms, current hopelessness and current positive self-esteem.

Psychosocial factors and negative emotion appear to be the strongest longitudinal predictors of variation in subjective recovery, rather than psychiatric symptoms.

In the UK almost 60% of people with a diagnosis of schizophrenia who use mental health services say they are not involved in decisions about their treatment. Guidelines and policy documents recommend that shared decision-making should be implemented, yet whether it leads to greater treatment-related empowerment for this group has not been systematically assessed.

To examine the effects of shared decision-making on indices of treatment-related empowerment of people with psychosis.

We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of shared decision-making concerning current or future treatment for psychosis (PROSPERO registration CRD42013006161). Primary outcomes were indices of treatment-related empowerment and objective coercion (compulsory treatment). Secondary outcomes were treatment decision-making ability and the quality of the therapeutic relationship.

We identified 11 RCTs. Small beneficial effects of increased shared decision-making were found on indices of treatment-related empowerment (6 RCTs; g = 0.30, 95% CI 0.09–0.51), although the effect was smaller if trials with >25% missing data were excluded. There was a trend towards shared decision-making for future care leading to reduced use of compulsory treatment over 15–18 months (3 RCTs; RR = 0.59, 95% CI 0.35–1.02), with a number needed to treat of approximately 10 (95% CI 5–∞). No clear effect on treatment decision-making ability (3 RCTs) or the quality of the therapeutic relationship (8 RCTs) was found, but data were heterogeneous.

For people with psychosis the implementation of shared treatment decision-making appears to have small beneficial effects on indices of treatment-related empowerment, but more direct evidence is required.

Research suggests that the way in which cognitive therapy is delivered is an important factor in determining outcomes. We test the hypotheses in which the development of a shared problem list, use of case formulation, homework tasks and active intervention strategies will act as process variables.

Presence of these components during therapy is taken from therapist notes. The direct and indirect effect of the intervention is estimated by an instrumental variable analysis.

A significant decrease in the symptom score for case formulation (coefficient =–23, 95% CI –44 to –1.7, P = 0.036) and homework (coefficient =–0.26, 95% CI –0.51 to –0.001, P = 0.049) is found. Improvement with the inclusion of active change strategies is of borderline significance (coefficient =–0.23, 95% CI –0.47 to 0.005, P = 0.056).

There is a greater treatment effect if formulation and homework are involved in therapy. However, high correlation between components means that these may be indicators of overall treatment fidelity.