BACKGROUND AND HYPOTHESIS:Digital remote monitoring (DRM) captures service users' health-related data remotely using devices such as smartphones and wearables. Data can be analyzed using advanced statistical methods (eg, machine learning) and shared with clinicians to aid assessment of people with psychosis' mental health, enabling timely intervention. Such methods show promise in detecting early signs of psychosis relapse. However, little is known about clinicians' views on the use of DRM for psychosis. This study explores multi-disciplinary staff perspectives on using DRM in practice. STUDY DESIGN:Fifty-nine mental health professionals were interviewed about their views on DRM in psychosis care. Interviews were analyzed using reflexive thematic analysis. Study Results: Five overarching themes were developed, each with subthemes: (1) the perceived value of digital remote monitoring; (2) clinicians' trust in digital remote monitoring (3 subthemes); (3) service user factors (2 subthemes); (4) the technology-service user-clinician interface (2 subthemes); and (5) organizational context (2 subthemes). CONCLUSIONS:Participants saw the value of using DRM to detect early signs of relapse and to encourage service user self-reflection on symptoms. However, the accuracy of data collected, the impact of remote monitoring on therapeutic relationships, data privacy, and workload, responsibility and resource implications were key concerns. Policies and guidelines outlining clinicians' roles in relation to DRM and comprehensive training on its use are essential to support its implementation in practice. Further evaluation regarding the impact of digital remote monitoring on service user outcomes, therapeutic relationships, clinical workflows, and service costs is needed.

Objectives To report on the development and refinement of a questionnaire of personal recovery for use by older adults with bipolar disorder.Design An integrated knowledge translation approach was used to structure collaboration of individuals with clinical, research and service users. Focus groups, online meetings and online feedback were used to support information sharing.Participants Knowledge users from across the UK including older adults with experience of bipolar, clinicians and academics.Primary outcome measure A final draft of the Bipolar Recovery Questionnaire for Older Adults with bipolar (BRQ-OA).Results Five service users and 15 stakeholders engaged with the study. The views and recommendations of the groups were integrated into the development of the BRQ-OA across four phases. Service users identified factors of personal recovery they felt had changed with ageing, including the impact of physical health and the importance of finding a purpose following changes to role. Collaboration with key stakeholders allowed for the development of a personal recovery questionnaire relevant to the experiences of older adults.Conclusions An integrated knowledge translation approach successfully structured engagement with key stakeholders to allow for active and meaningful engagement. Collaboration of individuals with experience of bipolar, clinicians and academics allowed for the development of the first questionnaire of personal recovery specifically adapted for older adults with bipolar. Future research is needed to validate the BRQ-OA in older adult samples so that it can be used in mental health services and intervention studies.

BACKGROUND:Relapses result in negative consequences for individuals with psychosis and considerable health service costs. Digital remote monitoring (DRM) systems incorporating "passive sensing" (sensor data gathered via smartphones/wearables) may be a low-burden method for identifying relapses early, enabling prompt intervention and potentially averting the consequences of full relapse. OBJECTIVE:This study examined detailed views from people with psychosis about using passive sensing in this context. STUDY DESIGN:Qualitative interviews, analyzed using reflexive thematic analysis. Setting: Secondary care mental health services across the United Kingdom. An advisory group with relevant lived experience was involved throughout, from developing the topic guide to analysis. Participants: Clinician confirmed diagnosis of schizophrenia-spectrum psychosis (n = 58). STUDY RESULTS:Four overarching themes were developed. Theme 1 outlined participants' polarized feelings about passive sensing, highlighting specific challenges relating to privacy, especially regarding location data. Theme 2 examined participants' fears that clinicians might judge their movements or routines, creating a sense of pressure to modify their actions and undermining their autonomy. Theme 3 described potential solutions: offering users choice about what data are shared, when, and with whom. Theme 4 outlined specific benefits that participants valued, including intended functions of passive sensing within DRM (ease of use, early identification of relapse, and relevance of sleep monitoring) and novel uses. CONCLUSIONS:Our findings underline the importance of fully informed consent, choice, and autonomy. Given the potential privacy impacts, individuals are unlikely to engage with passive sensing unless they perceive clear personal benefits. Prospective DRM users need clear, accessible information about passive data collection and its relevant costs and benefits.

Team formulation is associated with better working relationships between staff and service users. However, there is a need for greater standardization of practice. We aimed to investigate the inter-rater reliability of the Team Formulation Quality Rating Scale (TFQS) and explore what aspects of team formulation practices were most frequently adhered to. Staff at nine acute mental health wards participated in team formulation sessions facilitated by Health Care Professions Council registered psychologists. Formulation sessions were audio recorded, and raters used recordings to complete the TFQS. At least two raters rated 19 team formulation sessions. The TFQS demonstrated excellent inter-reliability for the total scale (ICC = .926, 95% CI = .820 to .971) and moderate inter-rater reliability for subsection A (ICC = .660; 95% CI = .278 to .862) and subsection B (ICC = .733; 95% CI = .361 to .898). Overall, the items for ‘collaboration’ and ‘consideration of life events’ were rated better in terms of quality, compared with items relating to ‘close of meeting’ and ‘consideration of goals and values’ which tended to receive lower quality ratings. The TFQS is a reliable tool for measuring quality of team formulation within inpatient settings and should be used in future research and clinical practice. Psychometric properties should be assessed across different clinical settings. Training and supervision should ensure that psychologists' formulations incorporate a focus on the individual's goals and values impacting problem development and resolution.

Background Suicide is a leading cause of death worldwide, particularly in people with severe mental health problems, including schizophrenia. The development, and testing, of suicide-focused psychological interventions which can combat suicidal experiences is an unrealised necessity. However, it is vital that suicide-focused therapies are derived from robust, evidence-based mechanistic suicide theories. The Schematic Appraisals Model of Suicide is one such theory. Objective(s) The Cognitive AppRoaches to coMbatting Suicidality project had two objectives. First, based on the Schematic Appraisals Model of Suicide, to test psychological pathways underlying suicidal thoughts, plans and attempts. Second, to test the efficacy of Cognitive–Behavioural Suicide Prevention for psychosis, a suicide-focused intervention developed by our team. Design The randomised controlled trial had two groups: our suicide-focused therapy, Cognitive–Behavioural Suicide Prevention adapted Cognitive–Behavioural Suicide Prevention for psychosis, plus treatment as usual (treatment) versus treatment as usual only (control). There were three assessment time points of baseline, 6 and 12 months, with the 6-month time point being the critical point for the main primary outcome. Four qualitative methods workstreams were nested within the randomised controlled trial design. Settings Four National Health Service Trust sites in the North West of England, United Kingdom: Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, Lancashire and South Cumbria NHS Foundation Trust, and the former North West Boroughs Healthcare NHS Foundation Trust. Participants Main inclusion criteria: (1) non-affective psychosis (e.g. schizophrenia), (2) suicidal experiences in the 3 months prior to recruitment; (3) under the care of an National Health Service mental health services team and (iv) aged 18 or over. Main outcome measures The primary outcome measure was the Adult Suicidal Ideation Questionnaire, which measures suicidal ideation severity over the past month using 25 self-report items. The 6-month follow-up assessment point was the critical time point. There were two secondary suicide measures. Mechanism measures captured six appraisals of emotional difficulties, lack of social support, interpersonal problem-solving difficulties, defeat, entrapment and hopelessness. Results Recruitment ensued from on 21 June 2017 and lasted until 25 November 2020. The last 12-month follow-up assessment was completed on 10 January 2022. Two hundred and ninety-two participants were randomly allocated to the treatment (N = 149) and control (N = 143) groups. Reductions in suicidal ideation severity were not significantly greater in the treatment compared to the control group (p = 0.07; 95% confidence interval −15.41 to 0.68) at month 6. There were, similarly, no significant treatment effects for the secondary suicide outcomes. A therapy ‘dose–response’ showed that each therapy session reduced the suicidal ideation severity score by 0.46, but this effect was also not significant (p = 0.056; 95% confidence interval −0.94 to 0.01), nor was a compliance-adjusted analysis in which only participants who attended at least one session of therapy were included (p = 0.052; 95% confidence interval −0.39 to 0.00). However, a predicted mediation pathway was statistically significant for one of the six mechanism measures, in which the therapy group relative to the control group improved social support appraisals, which, in turn, reduced suicidal ideation severity at month 6 (effect = −2.85, 95% confidence interval −7.00 to −0.23). Qualitative and mixed-methods findings showed that (1) feelings of not mattering, disconnection and irrelevance were central to suicidal thoughts, (2) it is vital to develop better ways of communicating about suicide, (3) our suicide-focused therapy was acceptable and feasible and (4) that being part of suicide work in a trial was largely a positive experience. Limitations The sample was predominantly White/Caucasian and conducted in one geographical United Kingdom location, the primary outcome measure captured only suicidal thought severity, and there were only two follow-up time points. Conclusions This suicide-focused psychological intervention did not demonstrate a treatment effect in the primary suicide outcome measure at month 6 at the 5% significance threshold. There was also no significant treatment effect for secondary suicide outcomes. Future work Research programmes founded on convergent methods, and evidenced-based psychological suicide models are needed to examine how to bolster appraisals of poor social support, disconnection, and not mattering in the context of suicidal mind-sets, and in tandem with the development of creative and inclusive communication tools to relay suicidal experiences. In addition, exploration of the role of ‘dose’ of therapy is crucial for further treatment development. Trial registration This trial is registered as ClinicalTrials.gov NCT03114917 and ISRCTN17776666. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Efficacy and Mechanism Evaluation (EME) programme (NIHR award ref: 13/161/25) and is published in full in Efficacy and Mechanism Evaluation; Vol. 13, No. 3. See the NIHR Funding and Awards website for further award information. Plain language summary Suicidal experiences are strikingly common. They are even more common in people with severe mental health problems, such as non-affective psychosis (e.g. schizophrenia). People with psychosis experience persistent and distressing hallucinations, delusions and paranoid feelings and beliefs. In order to take action against suicide, we have to better understand the psychological mind-sets of people who have suicidal experiences. Based on that understanding, we then have to develop psychological therapies which directly target these suicidal experiences. We have developed and started to test a type of psychological talking therapy which is specifically focused on suicide. In the next stage of our research, we wanted to further our understanding of the psychological mind-sets underpinning suicide, and in addition, to determine how much our suicide-focused therapy would actually reduce the severity of suicidal thoughts in people with non-affective psychosis across 6 months. We randomly split people into two groups – treatment and control. One hundred and forty-nine participants were offered our suicide-focused therapy, together with any ongoing treatment (treatment group), and 143 carried on with their usual treatment (control group). Those in the treatment group were offered up to 24 sessions of suicide-focused therapy, with each session lasting around 50 minutes and usually occurring weekly. We asked people to complete assessments at baseline, at 6 months and at 12 months. The main analyses showed that reductions in suicidal ideation severity were not significantly greater in the treatment compared to the control group across 6 months. Analyses designed to examine compliance with the therapy also did not result in a significant treatment effect. However, we did find that the suicide-focused therapy improved social support appraisals, which in turn improved suicidal ideation severity at 6 months. This indirect pathway was significant. Our qualitative interviews expanded on the impact of social support and social connectedness. Our participants also told us in qualitative work that the suicide-focused therapy was needed, acceptable and implementable in National Health Service services. Scientific summary Background The prevalence of suicidal thoughts, suicide plans, attempts and fatalities increase markedly in people with severe mental health problems, such as non-affective psychosis (e.g. schizophrenia). Suicidal experiences, including thoughts, plans, images, compulsions/urges, often derive from immense psychological pain and distress which, in the case of people with non-affective psychosis, can be compounded by seemingly relentless hallucinations, delusions and paranoid feelings and beliefs. Yet, such suicidal experiences can be countered with psychological ‘talking therapies’, such as forms of cognitive–behavioural therapy (CBT), but only if such therapies are developed specifically to be suicide-focused and to target the psychological mechanisms which underpin suicidal experiences. This means that it is vital to advance, and test, psychological models of suicidal experiences which can then act as a foundation for suicide-focused therapy development. The Schematic Appraisals Model of Suicide (SAMS) assimilates and expands evidence that negative appraisals of (1) emotional difficulties, (2) interpersonal social problem-solving difficulties and (3) lack of social support and perceptions of defeat, entrapment and hopelessness are central in pathways to suicidal experiences. Based on the SAMS, we have developed a transdiagnostic suicide-focused CBT called ‘Cognitive–Behavioural Suicide Prevention’, which we have further evolved for people with psychosis, termed ‘Cognitive–Behavioural Suicide Prevention for psychosis’ (CBSPp). Pilot work with people in the community with psychosis and male prisoners showed that this therapy was efficacious in reducing suicidal thoughts and behaviours, and was acceptable and feasible. The next stage in our suicide prevention work required us to (1) further investigate and advance the purported underlying psychological suicide mechanisms and (2) further test the efficacy of our suicide-focused psychological therapy, specifically in people experiencing psychosis. These were the overall goals of the Cognitive AppRoaches to coMbatting Suicidality (CARMS) project, which used convergent quantitative, qualitative and mixed methods to achieve four key objectives. Objectives To determine the extent to which a suicide-focused CBSPp in addition to usual care (i.e. the treatment group) would be more efficacious in reducing suicidal ideation severity compared to usual care alone (i.e. the control group) over 6 months. To test the extent to which appraisals of lack of social support, emotional difficulties and interpersonal problem-solving difficulties, defeat, entrapment and hopelessness would (1) be reduced in the treatment relative to the control group over 6 months and (2) mediate any positive treatment effect on suicidal ideation severity at 6 months. To determine to what extent the suicide-focused therapy was considered acceptable and implementable in NHS mental health services from the perspectives of both participants and mental health professionals. To investigate the positive and negative experiences of participating in a suicide-focused randomised controlled trial (RCT) as relayed by the participants themselves. Methods Design The design followed Consolidated Standards of Reporting Trials and Standard Protocol Items: Recommendations for Interventional Trials guidelines, and the Template for Intervention Description and Replication checklist and guide. It comprised a RCT with two groups of treatment [CBSPp therapy plus treatment as usual (TAU)] versus control (TAU alone), and stratification of NHS recruitment site and the use of antidepressant medication (yes/no). There were three assessment time points of baseline, month 6 and month 12, of which the 6-month time point was critical for assessing the effect of treatment on the primary outcome measure of suicidal ideation severity. Four qualitative and mixed-methods workstreams were nested within the RCT design, which examined psychological mechanisms, acceptability, implementation and participant’s experiences of taking part in a suicide-focused RCT. Sites Four NHS Trust sites in the North West (NW) of England, UK, namely Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, Lancashire and South Cumbria NHS Foundation Trust, and the former North West Boroughs Healthcare NHS Foundation Trust. Inclusion criteria There were six inclusion criteria, which were (1) adults, aged 18 or over; (2) able to give informed consent; (3) the presence of suicidal experiences (e.g. thoughts, plans, urges, compulsions, images, attempts) in the 3 months prior to recruitment; (4) experiences of a non-affective psychosis (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision classifications F20–F29); (5) being under the care of an NHS mental health services team with a care co-ordinator (the care co-ordinator could be the participant’s general practitioner or psychiatrist) and (6) having English as the participant’s primary language or having enough English-language fluency and abilities to take part without an interpreter. Exclusion criteria There were only two exclusion criteria of (1) dementia or organic brain disorder and (2) currently participating in a psychological intervention clinical trial. Randomised controlled trial sample sizes and attrition rate: the target sample size was 250 participants in total, with 125 in each of the treatment and control groups for the primary analyses based on a power of 80%, an alpha level of 0.05 and an effect size of 0.42. We account for clustering in the treatment group with an intraclass coefficient = 0.02, with 6 therapists seeing an average of 21 clients/participants and a variance of 21 participants. The number of clients/participants seen by each therapist is a count variable, meaning that we assume it follows a Poisson process so that the mean and variance are the same. There is no clustering in the TAU arm. An attrition rate of 25% was initially estimated across 6 months, meaning a target total of 333 was required. However, as retention levels consistently exceeded 75%, the desired target total was adjusted to 295. Therapy Our suicide-focused therapy (CBSPp) is highly collaborative, formulation-driven and based on general cognitive–behavioural principles but honed and advanced to explore evidence-based psychological mechanisms founded on the SAMS, which give rise to, and maintain, suicidal experiences. Participants allocated to the RCT treatment group were offered up to 24 sessions of therapy. Each session lasted approximately 50 minutes and usually took place weekly. Primary suicide outcome measure The Adult Suicidal Ideation Questionnaire, which is a self-report measure of suicidal ideation severity, over the past month. Secondary suicide outcome measures Two self-report questionnaires, namely the Suicide Probability Scale and the Beck Scale for Suicidal Ideation. In addition, where possible, a diary Timeline Followback method was used to document self-reported suicide attempts, serious self-harm incidents, suicide plans and suicidal thoughts. Mechanistic outcome measures Self-report questionnaires capturing six negative appraisals of emotional difficulties, interpersonal social problem-solving difficulties, lack of social support, defeat, entrapment and hopelessness. Clinical measures Structured clinical interviews were used to generate information about psychosis symptom severity, the cognitive–emotional impact of hallucinations and delusions, depression, sleep problems, general social and self-care functioning and general psychiatric symptoms. Participants in the treatment group and their therapists completed a measure of the Working Alliance Inventory at around session 4 of therapy and at therapy cessation. Statistical analysis plan Intention-to-treat principles were used across analyses. Data were presumed ‘missing at random’. Linear, mixed regression models were fitted to primary suicidal ideation severity scores at 6 and 12 months to assess efficacy, with the 6-month time point being critical. The treatment effect was the between-group adjusted mean difference between allocated groups, with 95% confidence intervals (CIs) and two-sided p-values. The same modelling procedure was applied to the secondary suicide outcomes, and mechanistic and clinical outcomes. Causal mediation analyses were based on parametric regression models, for which the primary suicidal ideation severity measure at 6 months was the outcome variable; allocated RCT group was the predictor variable; and mechanism outcomes at 6 months were mediators. Baseline scores were covariates. Indirect, direct and total effects were estimated. Two types of compliance analyses were planned, which were (1) systematic exclusion and (2) instrumental modelling of a therapy ‘dose–response’. Results Recruitment and retention Overall, CARMS recruited to target in that 252 participants completed the primary suicide outcome measure at 6 months. Attrition rates were less than expected, given that the target population had severe mental health problems of non-affective psychosis and recent suicidal experiences. Furthermore, excellent retention occurred despite the CARMS project needing to instantiate substantial procedural adjustments due to the COVID-19 pandemic. Efficacy findings There was no significant treatment effect in that across 6 months, suicidal ideation severity did not significantly decrease more in the treatment (suicide-focused therapy + TAU) group compared to the control (TAU) group {adjusted difference –7.36 [standard error (SE) 4.10]; 95% CI −15.41 to 0.68; p = 0.07}. After 12 months, suicidal ideation severity was statistically equivalent in both trial groups. This pattern of non-significance at both month 6 and month 12 extended to the secondary suicide outcome measures. Planned compliance analyses Participants had a median of 16 therapy sessions. When participants in the treatment group were excluded from the analysis if they had not attended any therapy sessions by 6 months, then the treatment effect was still not significant [adjusted difference −7.13 (SE 3.68), 95% CI −0.39 to 0.00; p = 0.052]. Using an instrumental modelling approach with randomisation as an instrument, at 6 months each additional session of therapy reduced the suicidal ideation severity score by 0.46 points, although this also failed to reach significance (95% CI −0.94 to 0.01; p = 0.056). Mediated (indirect) effects There was a significant mediated or indirect effect whereby appraisals of lack of social support (i.e. the mediator) were differentially improved in the treatment relative to the control group, which, in turn, gave rise to a reduction in suicidal ideation severity [effect = −2.85, SE 1.58 (95% CI −7.00 to −0.23)]. The direct effect was not significant. Although there were significant associations between the additional five appraisals of (1) emotional difficulties, (2) interpersonal problem-solving difficulties, (3) defeat, (4) entrapment and (5) hopelessness, and suicidal ideation severity at 6 months, the RCT allocation group did not differentially affect these five appraisals. Hence, the mediation effect was evident for only one out of six potential mediators. Qualitative thematic analyses of interview data provided an extended and expanded understanding of the significant mediated effect involving appraisals of poor social support, in that dynamics involving (1) mattering versus not mattering and (2) being connected versus becoming disconnected were fundamental to the inter-relationships between suicidal and psychotic experiences. Therapy endorsement and calls for implementation Qualitative work highlighted that while aspects of therapy could be perceived by participants as difficult and ‘hard work’, this was offset by (1) an expressed need for therapy, (2) a requirement for suicide to be a focus of therapy, (3) an increased and deepening understanding of suicide through therapy and (4) a growing confidence in using the gains of therapy outside in the ‘real world’. These sentiments were echoed when implementation of suicide-focused therapies in NHS services were discussed with both participants and mental healthcare professionals in that they emphasised that it was vital that suicide-focused therapies were readily available in NHS services, but also in a way that optimised and simplified access routes both to the therapy and also to staff training in suicide-focused therapies. Central to positive experiences of therapy and calls for implementation of suicide-focused therapies was an emphasis on the importance of creating genuine ‘safe spaces’ to talk and the need to be aware of, and open to, different ways of communicating about suicidal experiences. Experiences of being part of a randomised controlled trial about suicide Using a mixed, qualitative and quantitative methods approach, being part of CARMS was largely perceived in ways that were positive in both the shorter and longer terms. Data were collected using diverse methods of mini qualitative interviews, adjective checklists and a simple visual analogue scale mood rating at the end of every assessment/interview appointment. That the data converged provide confidence in the overall message that participation, while sometimes anxiety-provoking and/or distressing, was ‘worth it’ and of benefit. Serious adverse events Three participants died over the course of the CARMS project. However, the reports from the Coroner’s Office documented that these were not suicide-related deaths. The majority of serious adverse events (SAEs) were expected, and judged to be unrelated to the CARMS project. Furthermore, the number of participants involved in SAEs was similar across the two RCT groups. This lends reassurance to an increased impetus for the implementation of suicide-focused psychological therapies in mental health services. Conclusions and clinical implications This suicide-focused therapy intervention, CBSPp, did not demonstrate a significant treatment effect at the 5% significance threshold at month 6. Similarly, while an increasing ‘dose’ of therapy was associated with an increase in a reduction in suicidal ideation, this again did not meet statistical significance. However, there was a significant indirect (mediated) effect at 6 months, in which therapy improved participant’s appraisals of social support, which, in turn, reduced the severity of their suicidal thoughts over 6 months. Exploring appraisals of social support and social connectedness provides a pragmatic starting point for suicide-focused therapies. That said, social support appraisals were one of six different types of appraisals which were measured as part of the CARMS project, meaning that replication of the mediation effect is vital. Nevertheless, qualitative work did converge with the mediated pathway, and suggested that an important focus may be transitions from feeling disconnected to connected, and from a sense of not mattering to being of value. Although working with changing perceptions of social and interpersonal relationships might be expected to be a common aspect of therapeutic work, the CARMS qualitative work delineates how these perceptions are impacted by suicidal mind-sets. Qualitative workstreams from the CARMS project further illustrated how suicide-focused therapy was needed and desired by participants. The median number of therapy sessions attended was 16, demonstrating that people with some of the severest forms of mental health problems can engage with, and maintain, therapy attendance. Ratings of the therapeutic alliance by both participants/clients and therapists were robust, lending some reassurance to the ‘suitability’ of offering a formulation-driven, collaborative, suicide-focused therapy to people who live with both psychotic and suicidal experiences. Implications for future research The convergence between qualitative mechanism findings and the mediation analyses highlighted that we need to better understand how individuals with suicidal and psychotic experiences make transitions between (1) feeling irrelevant and inconsequential to feeling valued and appreciated, (2) feeling disconnected and an ‘outcast’ to feeling a sense of connection and belonging and (3) feeling ‘un-understandable’ to feeling ‘heard’ and worthy of being ‘heard’. Micro-longitudinal designs with both qualitative and quantitative components are needed to develop and maximise this understanding. Examining ways in which individuals fluctuate from having suicidal thoughts and urges to acting on those urges was beyond the scope of CARMS but is a research direction that is vital to advance. In the first instance, qualitative work using multimedia diary methods conjoint with experience sampling methodologies seem best suited to this research endeavour because these fluctuations seem non-linear, interactive, context-dependent and highly dynamic. CARMS investigated transdiagnostic psychological suicide mechanisms based on the SAMS. It is now essential to further develop these mechanisms so that they can explain ways in which specific mental health problems, for example, hallucinations, delusions and paranoid thoughts/beliefs, impact these mechanisms by investigating complex pathways using longitudinal and micro-longitudinal moderated mediation designs together with network analysis. A realist evaluation approach was beyond the scope of CARMS, but this approach offers the potential to better understand how multilayered contextual factors impact putative mechanisms and outcomes dependent on contextual factors. Qualitative findings revealed difficulties in navigating ‘suicide talk’. We need an improved understanding of how to communicate about suicide in ways that create genuine and trusted ‘safe spaces’, using diverse and creative channels that can be readily embraced by people with suicidal experiences, but also by health professionals, colleagues, friends, partners and family. Finally, that participants could attain high levels of formulation, experience high levels of therapeutic alliance, and that therapy ‘dose’ may confer therapy benefits suggest that these therapy process variables might be further explored. Trial registration This trial is registered as ClinicalTrials.gov NCT03114917 and ISRCTN17776666. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Efficacy and Mechanism Evaluation (EME) programme (NIHR award ref: 13/161/25) and is published in full in Efficacy and Mechanism Evaluation; Vol. 13, No. 3. See the NIHR Funding and Awards website for further award information.

Objective The effects of anxiety on psychological pathways underpinning psychosis and suicidal thoughts are poorly understood. The overall goal of the present study was to rectify this by examining pathways linking emotional distress from psychotic symptoms, specifically, auditory hallucinations and delusions with suicide ideation severity, via anxiety, defeat, entrapment, and hopelessness. Methods Participants had psychosis and recent suicidal experiences and were under the care of mental health services. The design was cross-sectional. Two key mediated models were examined. In the first, the extent to which anxiety mediated the association between distress from psychosis and suicidal ideation severity was tested. In the second, the extent to which distress mediated the association between anxiety and ideation was tested. In both models, defeat, entrapment and hopelessness were parallel, proximal, mediators of suicidal ideation severity. General psychiatric symptoms were statistically controlled, as were severity levels of hallucinations and delusional symptoms. Results There was an indirect, mediated, association linking emotional distress from auditory hallucinations and delusions with ideation severity via anxiety and entrapment. There was also a second mediated effect in which anxiety was associated with suicidal ideation severity via emotional distress from auditory hallucinations and delusions and entrapment. These mediation effects were not significant when symptom severity, rather than distress arising from symptoms, was tested. Conclusion Our findings underscore the importance of incorporating into contemporary suicide theories the complex dynamics underpinning the emotional impact of auditory hallucinations and delusions on suicidal thoughts especially when linked with anxiety and entrapment, whilst simultaneously developing suicide-focused therapies.

ABSTRACT Introduction Psychological therapies are rarely available for UK suicidal prisoners. A pilot feasibility clinical trial of Cognitive Behavioural Suicide Prevention therapy showed that it was possible to deliver therapy offering the potential to improve outcomes for suicidal prisoners. However, there were challenges to engaging male prisoners in therapy as many experienced difficulties in accessing and talking about their emotions. Difficulty in talking about emotions is common amongst male prisoners, yet this is essential for successful engagement in a talking therapy. The current co‐production study aimed to further understand the contextual influences that impact male prisoners' ability to engage with a psychological intervention focused on suicide prevention and to explore user‐generated solutions. Methods Community‐residing male ex‐prisoners with past experience of suicidal thoughts or behaviour during imprisonment participated in individual qualitative interviews followed by a series of six focus groups. Due to COVID‐19 restrictions in place at that time, recruitment and data collection were conducted by remote methods. Data were analysed according to the principles of reflexive thematic analysis. Results Fifteen individuals participated: twelve completed individual interviews, ten participated in the focus groups, with seven individuals participating in both. Three main themes were formed. 1. Negotiating prison personas and identities – Pressures to hide emotions, act tough, and distrust professionals. 2. Command and control in prison – Prison regimes impact on interpersonal relationships with staff and other prisoners to worsen suicide risk, with prisoner's healthcare needs often neglected. 3. Making therapy accessible and acceptable – Prisoners must be able to trust a compassionate therapist for engagement to be successful. Conclusion This study epitomises the feasibility and value of meaningful co‐production in research involving populations from marginalised groups such as ex‐prisoners. Our results reveal how the combination of individual prisoner and prison institution socio‐cultural contextual influences impact suicidal prisoners' engagement in psychotherapy. User‐defined suggestions are provided to promote development of potential remedies. Patient or Public Contribution Co‐production was achieved by the leading role of a salaried peer‐researcher co‐investigator in liaison with members of our Suicide Risk and Safety Research Group (SSRG) comprised of Experts‐by‐Experience (EbEs). Co‐decision making featured throughout all stages of the research, influencing the protocol design and interview schedule. The personal experience knowledge of the peer‐researcher/co‐investigator enabled targeted recruitment strategies and successful engagement of participants. Shared past experiences of prison life and language positively influenced rapport and engagement of participants during data collection, enabling attainment of rich data. Similarly, the peer researcher/co‐investigator's unique personal experiential knowledge ensured a ‘real‐world’ perspective to analysis and co‐authorship of publications.

OBJECTIVE:The objectives were to examine the role of two therapy process variables (formulation level and therapy "dose") in a mechanism involving links between improved social support appraisals and reduced suicidal ideation severity over time in people with psychosis and to determine which aspects of social support were key to improvements in suicidal ideation. METHOD:Participants (N = 106) had nonaffective psychosis and recent suicidal experiences and had received a suicide-focused talking therapy. A model was tested in which, across 6 months, changes in social support appraisals were associated with changes in suicidal ideation severity with sequential mediators of therapy "dose" (number of sessions) and therapy formulation level (1-5). Multivariate techniques were used to probe which social support items clustered around suicidal ideation improvements and the two therapy process variables. RESULTS:The highest levels of formulation (Levels 4 and 5) were attained by 77% of participants, with median therapy attendance of 17 sessions. Therapy "dose" and therapy formulation level acted as sequential mediators in a significant indirect pathway in which improvements to social support appraisals led to consequent improvements in suicidal ideation severity, with social support from family being key. Aspects of social connectedness of particular importance included feeling important to others, being able to rely on family, being relied upon by family, and being cared for by family. CONCLUSIONS:People with some of the most severe mental health problems can fully engage with suicide-focused therapy. Individualized formulation is recommended which is to focus upon transitions within social connectedness appraisals. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

Background Despite evidence that the mental health experiences of older adults are qualitatively different to those of younger adults, little research has investigated the recovery preferences of people aged 60 years and over (Chen et al, 2027). This paper presents the first measure of personal recovery developed specifically for older adults with bipolar disorder (BD). Methods Collaboration with older adults who had lived experience of BD, clinicians and academics supported the development of the Bipolar Recovery Questionnaire for Older Adults (BRQ-OA). A total of 55 participants aged 60+ (mean=66.98, SD=8.19) with a diagnosis of BD completed the BRQ-OA alongside symptom and quality of life measures. The BRQ-OA was completed again four weeks later. It was hypothesised that the BRQ-OA would be a reliable and valid measure of personal recovery. Results The BRQ-OA had good internal consistency, and scores were reliable over a 4-week period. Scores on the BRQ-OA were significantly associated with lower depression and mania scores and higher scores on quality of life and functioning measures. Limitations Small sample size restricted understanding of factors underlying the BRQ-OA. Participants were primarily White British with high levels of education, therefore generalisability to other groups is unclear. Conclusions Findings indicate the BRQ-OA is a reliable and valid measure of personal recovery for older adults with BD. Scores are significantly associated with factors commonly defined as part of personal recovery. This is the first mental health measure designed with and for older adults to support the use of recovery-focused approaches in clinical practice and research.

AVATAR therapy involves facilitated dialogs between a voice hearer and a digital embodiment of their distressing voice ("the avatar"). We conducted a multi-site single-blind randomized controlled trial to evaluate the efficacy of brief (AV-BRF) and extended (AV-EXT) forms of AVATAR therapy, compared with treatment as usual (TAU) alone (AVATAR2). This study reports the data from experience sampling method (ESM) assessments conducted at baseline, end of therapy (16 weeks), and follow-up (28 weeks). The research questions focused on whether those in the AV-BRF or AV-EXT arms experienced less voice-related distress, anxiety, and beliefs as measured by ESM, compared to TAU. Separate mixed-effects models were fitted for each research question. The final sample (n = 200) completed approximately 40% of questionnaires across all timepoints. Participants who received AV-EXT therapy, but not AV-BRF, reported reduced momentary voice-related distress at 16 (P = .022) and 28 weeks (p = .029). Appraisals of voice control were also reduced in the AV-EXT arm at 16 weeks when the voice was present (P = .002) or not (P = .008). Voice power appraisals were reduced (P < .035) in both arms when the voice was "not present but on my mind" at all timepoints. There were no changes in the frequency of voice hearing, appraisals of voice intent, or assertive responding. These findings from everyday life, reported for the first time, provide evidence of the impact on the primary AVATAR therapy treatment targets, including appraisals of voice power and control. The weight of evidence favors the AV-EXT protocol in the further development and implementation of AVATAR therapy.

OBJECTIVES:Team formulation is associated with better working relationships between staff and service users. However, there is a need for greater standardization of practice. We aimed to investigate the inter-rater reliability of the Team Formulation Quality Rating Scale (TFQS) and explore what aspects of team formulation practices were most frequently adhered to. METHOD:Staff at nine acute mental health wards participated in team formulation sessions facilitated by Health Care Professions Council registered psychologists. Formulation sessions were audio recorded, and raters used recordings to complete the TFQS. At least two raters rated 19 team formulation sessions. RESULTS:The TFQS demonstrated excellent inter-reliability for the total scale (ICC = .926, 95% CI = .820 to .971) and moderate inter-rater reliability for subsection A (ICC = .660; 95% CI = .278 to .862) and subsection B (ICC = .733; 95% CI = .361 to .898). Overall, the items for 'collaboration' and 'consideration of life events' were rated better in terms of quality, compared with items relating to 'close of meeting' and 'consideration of goals and values' which tended to receive lower quality ratings. CONCLUSION:The TFQS is a reliable tool for measuring quality of team formulation within inpatient settings and should be used in future research and clinical practice. Psychometric properties should be assessed across different clinical settings. Training and supervision should ensure that psychologists' formulations incorporate a focus on the individual's goals and values impacting problem development and resolution.

Suicidal experiences (e.g. suicidal thoughts, plans, urges, compulsions, images, acts, attempts) are common in the early stages of psychosis and represent a global healthcare concern. As well as hallucinations and delusions, psychosis is associated with difficulties in forming interpersonal relationships, causing isolation, disconnectedness, and significant psychological distress. This systematic literature review aimed to examine the effects of perceptions of offline and online social connectedness and disconnectedness on suicidal experiences in people with recent onset psychosis. We proposed a Social Connectedness and Disconnectedness (SoCaD) conceptual framework comprising six domains which guided the analytic process. A convergent, sequential explanatory approach to analysis was used. Fourteen studies were included from four electronic databases (i.e. PsycInfo, Embase, MEDLINE, Web of Science). The study screening and quality assessment procedures were checked by an independent researcher. Findings pertaining to five SoCaD domains were identified: 1. Supportive relationships with others; 2. Social identity and purpose; 3. A sense of belonging; 4. Perceived social value; and 5. A sense of mattering to others. No studies were identified that specifically examined experiences and perceptions of social connectedness or disconnectedness in the context of online social media activity and communication. This represents a substantial gap in the evidence. Overall, only a few studies made a useful contribution to better understanding the relationships between social connectedness and disconnectedness, recent onset psychosis, and suicidal experiences. Future research should methodically examine domains of social connectedness and disconnectedness across offline and online contexts and focus on context-specific understanding of these social dynamics to enhance suicide prevention strategies in this vulnerable population. Not applicable.

Non-affective psychosis is associated with elevated risk of suicide, self-harm, and reduced life expectancy. Symptoms of dissociation are common in non-affective psychosis, and dissociative experiences are known to be linked to multiple markers of elevated clinical risk, including sleep disturbance and negative affect. The present review represents the first comprehensive quantification of dissociative phenomena severity across multiple instruments in non-affective psychosis. Six databases (Embase, MEDLINE, PsycINFO, PubMed, Scopus, Web of Science) were searched from inception and systematically screened. Eligibility was established against ICD/DSM criteria or service-defined categorisation, including first-episode psychosis, brief limited intermittent psychotic symptoms, and at-risk of psychosis mental states. In total, data were extracted for 22 measures. Four random effects meta-analyses were conducted for measures with three or more independent datasets: the Dissociative Experiences Scale (DES) (k = 51; n = 3,878); the Cambridge Depersonalization Scale (CDS) (k = 6; n = 351); the Examination of Anomalous Self Experience scale, using the dichotomous scoring method (EASE-D) (k = 11; n = 340); and the Examination of Anomalous Self Experience scale, using the continuous scoring method (EASE-C) (k = 6; n = 235). DES data yielded a pooled mean of 21.28 (95

People are at increased risk of suicide following discharge from inpatient mental health units. Understanding the reasons for this increased risk is important for reducing the number of people who die by suicide. Whilst reviews of quantitative research have identified risk factors, no reviews of the qualitative literature exist which could provide more nuanced explanations of elevated suicide risk during the post-discharge period. This systematic review is the first to meta-synthesise qualitative research on experiences of suicidality after being discharged from inpatient mental health units. We searched PsycINFO, MEDLINE, Web of Science, PubMed and ProQuest using relevant search terms. We identified 29 studies that met inclusion criteria and were included in the review. We analysed the data using thematic synthesis and identified five analytic themes: (1) Feeling prepared for the transition home, (2) Returning from safety to everyday hardship, (3) The need for connection and understanding, (4) Feeling neglected by the system, (5) Taking the reins on recovery. This review indicates that reducing post-inpatient discharge suicides could be achieved through collaborative discharge preparation, immediate and intensive post-discharge support, and empowering service-user recovery.

BackgroundPreventing relapses of psychosis is difficult and important. Digital remote monitoring (DRM) systems are being developed and tested to support this. Increasingly, these systems use algorithm-based relapse prediction. Hence, understanding stakeholder views about algorithmic prediction is crucial. Existing qualitative work has explored health professionals’ views, but very few studies have examined the perspectives of people with psychosis on this topic. ObjectiveThis paper aimed to provide an in-depth examination of the views of people with psychosis regarding algorithmic relapse prediction within a DRM system that incorporates active symptom monitoring and passive sensing data. MethodsPeople with psychosis (n=58) were recruited from 6 geographically distinct areas of the United Kingdom. They participated in semistructured qualitative interviews exploring their views about using a DRM system that predicts psychosis relapse based on a machine learning algorithm. Transcripts were analyzed using reflexive thematic analysis. People with lived experience of psychosis were involved extensively in study design, analysis, and reporting. ResultsFindings were described across 4 themes. First, accuracy was a prominent theme. Participants emphasized that transparency about algorithm sensitivity and specificity is crucial and discussed the risks of the relapse prediction algorithm producing false positives (flagging that someone was relapsing when they were not) and false negatives (missing actual relapses). In both cases, participants said that errors may be partially mitigated through a human-in-the-loop approach (theme 2), with DRM blended with human oversight, from clinicians or a dedicated digital monitoring team, and calibrated based on service user, carer, and clinician feedback. The third theme, trust, fears, and choice, noted the interplay between users’ trust in the DRM system and their relationship with the clinical team. This theme described participants’ fears about potential overreactions (hospitalization or excessive medication) or underreactions (no additional support) from the clinical team in response to algorithm-generated relapse predictions. It emphasized the importance of retaining choice around the use of relapse detection algorithms and the sharing of personal data. The final theme described participants’ views about the benefits of using a relapse prediction algorithm, including facilitating early intervention, triaging care according to need, minimizing human bias in assessment, and efficiency in saving staff time. ConclusionsPeople with psychosis acknowledged potential benefits of algorithm-assisted relapse prediction for receiving timely or efficient care, but with several caveats. Algorithm-generated relapse alerts need to be sufficiently accurate and must be interpreted, with understanding of their limitations, by a trustworthy human who is aware of the relevant context. Algorithm-based relapse predictions should only be used with valid consent, in a way that promotes and respects the autonomy and voice of service users and avoids increasing the use of excessive restriction.

BackgroundAVATAR therapy is a novel psychological therapy that aims to reduce distress associated with hearing voices. The approach involves a series of therapist-facilitated dialogues between a voice-hearer and a digital embodiment of their main distressing voice (the avatar), which aim to increase coping and self-empowerment. ObjectiveThis study explored therapeutic processes that are distinctive to AVATAR therapy, including direct early work with voice content and the role of the therapist in dialogue enactment. MethodsPeople with lived experience relating to psychosis (peer researchers) contributed to each stage of the study. Peer researchers led semistructured interviews, which were conducted with 19 participants who received AVATAR therapy as part of the AVATAR2 trial, including 3 participants who dropped out of therapy. Data were analyzed using interpretative phenomenological analysis (n=5) and template analysis (n=14). ResultsParticipants described the initial challenges of experiential work with distressing voice content; however, most reported a meaningful increase in power and control over the course of dialogues and improvements with voices in daily life. A strong therapeutic alliance was experienced by all participants, including those who chose to discontinue therapy, often mitigating the discomfort associated with initial challenges by enhancing their sense of safety. Several important themes relating to individual engagement were highlighted, such as the emotional intensity of the experience and the importance of participants’ determination and open-minded attitudes despite initial doubts. Those who decided not to continue with therapy described challenges with the realism of working dialogically with a digital representation of their distressing voice. ConclusionsThis study has provided a deeper understanding of the experience of engaging in AVATAR therapy, in particular the challenges and opportunities of direct work with voice content. The importance of therapeutic alliance and establishing a sense of voice presence has been emphasized. Implications for the planned optimization and wider implementation of AVATAR therapy in routine care settings are discussed. Trial RegistrationISRCTN Registry ISRCTN55682735; https://www.isrctn.com/ISRCTN55682735

BackgroundDigital remote monitoring technologies, including smartphones and wearables, offer promising avenues for early detection of psychosis relapse. However, selecting devices that are acceptable to participants and produce high-quality data remains challenging. ObjectiveThe aim of this nested pilot study was to assess the acceptability and data quality of 3 commercially available wearable devices in people with psychosis recruited to the CONNECT cohort study. MethodsParticipants recruited to the CONNECT study before July 31, 2024, were included in the pilot study and selected 1 of 3 wearable devices: a Fitbit Charge 5, Samsung Galaxy Watch 5, or Apple Watch SE. Baseline demographics were compared between device groups. Acceptability of devices to participants was assessed through a Wearable Device Satisfaction Questionnaire after 3 months of use, with the proportion of positive responses to each question calculated and compared. Data completeness was also assessed by calculating the number (and percentage) of valid days of step count, heart rate, and sleep data, and comparing between groups. Data quality was assessed through summarizing the amount of troubleshooting required, additional metrics available from the wearables, and continuity of data completeness by calculating the proportion of participants with at least 3 days of heart rate data per week for the first 20 weeks of follow-up. Predefined criteria were used to determine the next steps for the wider CONNECT study: if one device was superior, this would be selected; if none were found to be superior and the Fitbit was found to be noninferior, then Fitbit would be retained. ResultsOf the first 107 participants recruited to CONNECT, 105 were included in the pilot study evaluation. The Samsung Galaxy Watch was selected most frequently by participants (46/105, 43.8%), followed by the Apple Watch (27/105, 25.7%), and Fitbit Charge (23/105, 21.9%). Differences in participant demographics were observed across device groups. Self-reported acceptability after use did not differ substantially between devices. However, in terms of data completeness, the median proportion of valid heart rate data days was significantly lower for Samsung Galaxy (median 31.2%, IQR 8.5%-46.0%) compared to Fitbit (median 80.1%, IQR 26.7%-95.0%; P=.003) and Apple Watch (median 49.3%, IQR 21.5%-86.0%; P=.02). There was no significant difference between Fitbit and Apple Watch. Similar patterns were observed for step count and sleep data. The Samsung Galaxy Watch required more frequent troubleshooting for data flow issues and lacked additional physiological metrics, available from the other devices. ConclusionsDue to comparatively lower data quality and technical performance, the Samsung Galaxy Watch was discontinued for use in the subsequent phase of the CONNECT study. The study highlights the importance of incorporating nested evaluations of devices in long-term research.

OBJECTIVE:Psychological mindedness has been positively associated with psychological wellbeing and positive outcomes in psychological therapy. Valid and reliable measures of psychological mindedness are needed for accurate measurement of the construct. This paper is the first to provide a comprehensive review of existing measures of psychological mindedness. METHODS:The review protocol was pre-registered and systematic with methods reported according to PRISMA criteria. The quality of studies reporting on psychometric properties of measurement tools was evaluated against the COSMIN criteria. RESULTS:Twenty-three studies relating to six measures of psychological mindedness were included in the review. No measure demonstrated sufficient evidence when evaluated against all COSMIN measurement criteria. However, the Balanced Index of Psychological Mindedness (BIPM) demonstrated the most robust psychometric properties with sufficient evidence of structural validity and internal consistency demonstrated through studies of high quality. CONCLUSIONS:Whilst the BIPM demonstrated the most robust measurement properties, further research is needed in relation to its content validity, cross-cultural validity, and responsiveness. The BIPM also does not incorporate 'other-oriented' psychological mindedness. Alternative measures such as the PMS and PMAP are available to measure psychological mindedness towards others but have less sufficient evidence of psychometric rigour.

AVATAR therapy is an innovative form of relational therapy for the treatment of distressing auditory verbal hallucinations, or voice-hearing, targeted at reducing voice-related distress. AVATAR therapy involves the creation of a digital simulation of a single voice, termed an 'avatar', which is used in a series of three-way therapeutic dialogues. This paper presents the AVATAR Therapy Dialogues Corpus, a specialised corpus containing orthographic transcriptions of AVATAR therapy sessions. We offer an overview of the corpus contents, and a detailed discussion of the design and construction of the corpus. We describe the processes and specialised tools created, transcription conventions, and mark-up designed to capture para-linguistic and non-speech features which may have clinical relevance. Finally, we discuss the potential of the corpus to provide a genuine innovation in clinical care, offering clinicians a data stream that could augment their understanding of patient experiences.