RSS 1.0Integrated Community Mental Health
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“Flow” Transcranial Direct Current Stimulation (tDCS) for depression treatment in a Community Mental Health Team (CMHT) service: depression, functioning, and health-related quality of life outcomesBackground: People who experience severe mental illness (SMI) have a high prevalence of depression symptoms, which is linked to worse functioning and quality of life. Research evidence indicates that transcranial direct current stimulation (tDCS) can reduce symptoms of depression. Flow FL-100 is a transcranial direct current stimulation (tDCS) device self-administered by a patient at home in combination with a software application that delivered wellbeing behaviour therapy training. Purpose/Aim: This study investigates if Flow can be introduced to a Community Mental Health Team (CMHT) service and the impact of Flow in treating depression. The study addresses the questions: “what are the depression reliable improvement and remission rates?” and “can Flow significantly reduce depressive symptoms and improve real world functioning (everyday, social and occupational functioning) and health-related quality of life?”. Methods: An open-label patient cohort design with no control group. Pre-intervention and 6-week follow-up intervention assessments using the participant self-report measures: Patient Health Questionnaire (PHQ-9), Work and Social Adjustment Scale (WSAS), and EuroQol five-dimension (EQ-5D-5L). Participants were 31 CMHT patients, 15 males and 16 females, with an age range of 21 to 64 years, and average age of 42 years. Results: PHQ-9 reliable improvement and remission rates were 51.61% and 12.9%, respectively. PHQ-9 scores significantly improved, from 20.9 (SD 5.55) to 14.6 (SD 7.33) at 6 weeks, with large effect size. WSAS scores improved from 31.3 (SD 6.02) to 22.5 (SD 11.43) at 6 weeks, with large effect size. EQ-5D-5L results showed significant improvements in the health index score, and three EQ-5D-5L dimensions (“mobility”, “self-care”, and “pain”). Conclusion: Flow tDCS treatment was integrated into a CMHT service and was found to be beneficial in terms of improving functioning and quality of life and reducing depression symptoms. Flow FL100 tDCS and wellbeing behaviour therapy training could be offered through all CMHT services to people with SMI to treat depression, enable better functioning, and improve quality of life.
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Self-administered “Flow” Transcranial Direct Current Stimulation (tDCS) depression treatment in a Crisis Resolution and home Treatment (CRT) service: functioning, and health-related quality of life outcomesBackground: Transcranial direct current stimulation (tDCS) has research evidence that it can reduce symptoms of depression. Flow FL-100 is a transcranial direct current stimulation (tDCS) device self-administered by a patient at home in combination with a software application that delivers wellbeing behaviour therapy training. Purpose/aim: The purpose of this study was to investigate if Flow can be introduced to a Crisis Resolution & Home Treatment (CRT) service and the impact of Flow in treating depression. The study addresses the questions: 1) “what are the depression reliable improvement and remission rates?” and 2) “can Flow significantly reduce depressive symptoms and improve real world functioning (every-day, social and occupational functioning) and health-related quality of life?”. Methods: An open-label patient cohort design with no control group. Pre-intervention and 6-week follow-up intervention assessments using the participant self-report measures: Patient Health Questionnaire (PHQ-9), Work and Social Adjustment Scale (WSAS), and EuroQol five-dimension (EQ-5D-5L). Participants were 49 CRT patients, 19 males and 30 females, with an age range of 20 to 66 years, and average age of 42 years. Results: PHQ-9 reliable improvement and remission rates were 57.1% and 14.3%. PHQ-9 scores significantly improved, from 23.1 (SD 3.44) to 14.8 (SD 6.82) at 6 weeks, with a large effect size. PHQ-9 suicide/self-harm related question significantly improved from 2.51 (SD 0.77) to 1.08 (SD 1.17), with a large effect size. WSAS scores significantly improved, from 33.6 (SD 5.22) to 21.9 (SD 10.82) at 6 weeks, with a large effect size. EQ-5D-5L results showed significant improvements in the health index score, global assessment of health EQ-VAS from 34.2 (22.26) to 51.6 (24.95), and three EQ-5D-5L dimensions (“self-care”, “usual activity”, and “anxiety/depression”). Conclusion: A CRT service effectively integrated Flow tDCS treatment. Flow was beneficial in terms of improving functioning and quality of life and reducing depression symptoms and thoughts of suicide/self-harm. Flow FL100 tDCS and wellbeing behaviour therapy training could be offered through all CRT services to treat depression, reduce thoughts of suicide/self-harm, enable better functioning, and improve quality of life.
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Conditionally Discharged Restricted Patients in a General Adult Community Mental Health SettingLittle is known about the proportion and patient profile of conditionally discharged patients supervised by general adult community mental health teams (CMHTs). In this study, the authors evaluate the number of patients and their demographic, clinical and risk profile, and current practice in terms of supervision and structures. Supervision in the community is time- and resource-intensive. There is a need for NHS Trusts to ensure adequate support and structures, supervision, training and joint working opportunity with forensic services to ensure safe quality care.
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Community treatment orders in an early intervention for psychosis serviceLittle is known about the use and effectiveness of community treatment orders (CTOs) in early psychosis. Here, the authors describe their service evaluation of patients within an NHS early intervention for psychosis service subject to CTO over a period of three years in order to evaluate the rates of CTO use, demographic, and clinical characteristics of those subject to CTO, as well as clinical outcomes. This study demonstrates how CTO use, where deemed necessary, can create real-life, positive outcomes for service users.
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A service evaluation of the Behavioural Treatment for Substance Abuse (BTSA) programme for forensic dual diagnosis populationsLiterature links mental health problems comorbid with substance abuse with increased recovery time. There is limited research evaluating the effectiveness of substance abuse treatments for dual-diagnosis patients. This project aimed to evaluate the effectiveness of the BTSA group with this population. Questionnaires measuring motivation, locus of control, confidence to abstain and self-efficacy were administered to six different cohorts of BTSA participants (N = 38) at baseline, post, and follow-up stages. In addition, participants from the most recent BTSA cohort (N = 4) attended a post-program focus group, to provide information about their experiences of the intervention. Statistical analyses revealed that participants’ confidence in their ability to manage substance abuse was significantly higher post group, but the hypotheses that there would also be significant improvements in participants’ self-efficacy, motivation, and locus of control following completion of the program were not supported. Thematic analysis identified three key themes relevant to participants, namely validation, psychoeducation and identifying progress. This project provided valuable insights into participants’ experiences of the group, highlighting what they had gained form the intervention, and the impact on them from having Recovery Champions working in conjunction with NHS staff to facilitate the intervention. Limitations are discussed, alongside recommendations for improving the program.
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Evaluating social drop-in facilities and their impact on social recovery in early intervention in psychosis services“Social recovery” is a long-cited aim within the UK early intervention in psychosis (EIP) services; however, there is a lack of evidence regarding existing social recovery provisions and how these can be improved. This paper aims to evaluate an existing social drop-in facility within an EIP team, ran within the Birmingham and Solihull Mental Health NHS Foundation Trust, and highlight the potential benefits of delivering such services for people diagnosed with first episode psychosis. Attendance and basic demographic statistics (age, gender and ethnicity of attendees) were collected over a period of 13 weeks. In addition, two semi-structured focus groups were conducted: one with EIP staff members (community psychiatric nurses and support workers) and the other with current service users, with both groups describing their satisfaction and experience of the drop-in facility and how it can be improved. Inductive thematic analysis was used to analyse data from both focus groups, with six overarching meta-themes being identified: reflection, environment, emotional experience, recovery, activities and interactions. Service users and staff reflected that the drop-in facility was an asset to the service, although work could be done to improve overall attendance. This paper explores how a social drop-in facility can provide a supportive, positive environment that aids recovery from psychosis for service users and improves working conditions for the EIP staff.
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Clinical practice guideline for clozapine use in patients with COVID-19National and local guidelines focus mainly on clozapine monitoring frequency, and actions based on full blood count results. Prescribing clozapine in the context of COVID-19-positive patients brings a complexity of challenge beyond this. In this article the authors put forward an example of a practical clinical guideline in this regard.
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Changes in parental sleep from pregnancy to postpartum: a meta-analytic review of actigraphy studiesSleep changes in new parents are widely observed but there is no extant meta-analysis of changes to sleep parameters in this group. We completed a meta-analysis of changes in actigraphy-measured parent sleep between pregnancy and the end of the first year of a child's life. A search of six databases was completed. Following review using predetermined inclusion and exclusion criteria, 16 papers were left for review. Data were extracted, analysed and each paper was reviewed for methodological quality. Where possible, subgroup analysis was completed based on time since birth and location of the study, and meta-regression of parent age. Parents' total sleep time and sleep efficiency were shown to decrease following the birth of a child, with wake after sleep onset increasing. This change was most notably observed in the first four weeks after birth. Up to 16 weeks post-birth, differences were still apparent, but sleep parameters were beginning to return to pre-birth levels. New parents experience a significant change in multiple sleep parameters following the birth of a child. Future data collection, using best practice actigraphy measurement, reporting a broader range of variables and including fathers, as well as mothers, is warranted.
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Automated virtual reality cognitive therapy versus virtual reality mental relaxation therapy for the treatment of persistent persecutory delusions in patients with psychosis (THRIVE): a parallel-group, single-blind, randomised controlled trial in England with mediation analysesBackground Persecutory delusions are a major psychiatric problem that often do not respond sufficiently to standard pharmacological or psychological treatments. We developed a new brief automated virtual reality (VR) cognitive treatment that has the potential to be used easily in clinical services. We aimed to compare VR cognitive therapy with an alternative VR therapy (mental relaxation), with an emphasis on understanding potential mechanisms of action. Methods THRIVE was a parallel-group, single-blind, randomised controlled trial across four UK National Health Service trusts in England. Participants were included if they were aged 16 years or older, had a persistent (at least 3 months) persecutory delusion held with at least 50% conviction, reported feeling threatened when outside with other people, and had a primary diagnosis from the referring clinical team of a non-affective psychotic disorder. We randomly assigned (1:1) patients to either THRIVE VR cognitive therapy or VR mental relaxation, using a permuted blocks algorithm with randomly varying block size, stratified by severity of delusion. Usual care continued for all participants. Each VR therapy was provided in four sessions over approximately 4 weeks, supported by an assistant psychologist or clinical psychologist. Trial assessors were masked to group allocation. Outcomes were assessed at 0, 2 (therapy mid-point), 4 (primary endpoint, end of treatment), 8, 16, and 24 weeks. The primary outcome was persecutory delusion conviction, assessed by the Psychotic Symptoms Rating Scale (PSYRATS; rated 0–100%). Outcome analyses were done in the intention-to-treat population. We assessed the treatment credibility and expectancy of the interventions and the two mechanisms (defence behaviours and safety beliefs) that the cognitive intervention was designed to target. This trial is prospectively registered with the ISRCTN registry, ISRCTN12497310. Findings From Sept 21, 2018, to May 13, 2021 (with a pause due to COVID-19 pandemic restrictions from March 16, 2020, to Sept 14, 2020), we recruited 80 participants with persistent persecutory delusions (49 [61%] men, 31 [39%] women, with a mean age of 40 years [SD 13, range 18–73], 64 [80%] White, six [8%] Black, one [1%] Indian, three [4%] Pakistani, and six [8%] other race or ethnicity). We randomly assigned 39 (49%) participants assigned to VR cognitive therapy and 41 (51%) participants to VR mental relaxation. 33 (85%) participants who were assigned to VR cognitive therapy attended all four sessions, and 35 (85%) participants assigned to VR mental relaxation attended all four sessions. We found no significant differences between the two VR interventions in participant ratings of treatment credibility (adjusted mean difference –1·55 [95% CI –3·68 to 0·58]; p=0·15) and outcome expectancy (–0·91 [–3·42 to 1·61]; p=0·47). 77 (96%) participants provided follow-up data at the primary timepoint. Compared with VR mental relaxation, VR cognitive therapy did not lead to a greater improvement in persecutory delusions (adjusted mean difference –2·16 [–12·77 to 8·44]; p=0·69). Compared with VR mental relaxation, VR cognitive therapy did not lead to a greater reduction in use of defence behaviours (adjusted mean difference –0·71 [–4·21 to 2·79]; p=0·69) or a greater increase in belief in safety (–5·89 [–16·83 to 5·05]; p=0·29). There were 17 serious adverse events unrelated to the trial (ten events in seven participants in the VR cognitive therapy group and seven events in five participants in the VR mental relaxation group). Interpretation The two VR interventions performed similarly, despite the fact that they had been designed to affect different mechanisms. Both interventions had high uptake rates and were associated with large improvements in persecutory delusions but it cannot be determined that the treatments accounted for the change. Immersive technologies hold promise for the treatment of severe mental health problems. However, their use will likely benefit from experimental research on the application of different therapeutic techniques and the effects on a range of potential mechanisms of action.
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Racialised minority women's experiences of psychological intervention across perinatal and maternal mental health services.Policies such as The Perinatal Mental Health Care Pathways document (2018) state mothers and birthing people experiencing psychological difficulties should have timely access to evidence-based psychological therapies. However, psychological distress often goes unidentified in racialised minority women and birthing people who have poorer experiences and outcomes within perinatal contexts compared to White women. Whilst limited research has focused on this within the perinatal period, there is greater recognition concerning how culturally sensitive practices can facilitate equity in care outcomes. This service evaluation aimed to explore racialised minority women's experiences of psychological intervention within a Perinatal and a Maternal Mental Health Service to evaluate service provision and inform service development. Semi-structured interviews with eight women who accessed psychological intervention were analysed using thematic analysis. Two superordinate themes were constructed, with findings suggesting participants had mostly positive experiences of psychological intervention. Cornerstones of therapeutic engagement comprised six subthemes: empathy, flexibility, the utility of psychological approaches, acknowledging family and community systems, points of difference and cultural context as a 'spotlight'. This theme encapsulated psychological therapist's relational and interventional approaches alongside participant preferences which influenced intervention experiences. Therapists were generally experienced as empathic and flexible although some participants desired greater flexibility relating to various practical aspects. Psychological approaches were experienced as beneficial although some wanted greater exploration of childhood trauma and found trauma-focused CBT emotionally demanding. Most participants preferred female therapists due to various socio-cultural reasons and felt systemic factors and their cultural context were acknowledged which enhanced the therapeutic relationship and outcomes where relevant with the inverse also apparent. History repeating itself comprised three subthemes (lack of representation, mistrust of the system and disorientation in help-seeking). This reflected mainly Black participants' negative healthcare experiences and structural racism. Therapeutic and organisational implications are discussed. Copyright © 2024, British Psychological Society. All rights reserved.
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What racialised aspiring clinical psychologists need from a mentoring schemeIt has been long recognised that there is an increased gap between the application and acceptance rates of racialised applicants to clinical psychology training in the UK, relative to White applicants. In 2020, Health Education England released funding for UK training programmes to develop mentoring schemes for aspiring clinical psychologists from racialised groups. This study was undertaken to explore how such mentoring schemes might best support racialised applicants. Three focus groups, comprising a total of 24 racialised aspiring, trainee, and qualified clinical psychologists, were undertaken to gather views regarding how a mentoring scheme could support racialised aspiring clinical psychologists. Data was analysed utilising reflexive thematic analysis. Three themes were developed: ‘Gaining Access to a White Profession – What’s the White thing to say?’ captured participants’ views that mentoring schemes should support mentees to present themselves in ways that fit with what selection assessors will be looking for. ‘A Safe Space to Explore the Impact of Racialisation’ related to the importance of mentoring schemes creating safe opportunities to make sense of the impact of racism within their career. ‘Troubling Whiteness’ spoke to the importance of mentees being empowered to think with other racialised individuals about ways they could actively address Whiteness within the profession and services. The three themes have implications for the delivery and evaluation of mentoring schemes for racialised aspiring clinical psychologists.
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Acute psychosis following baclofen overdoseBaclofen is widely used as a muscle relaxant in neurological and other physical health conditions, as well as for its anticraving effects in substance use disorder. Here the authors describe a case of baclofen overdose resulting in acute psychosis. Clinicians need to consider this in the differential diagnosis of first episode psychosis presentations, as unrecognised, and untreated baclofen overdose-induced psychosis can be associated with significant morbidity and potential mortality.
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The over-35s: prediabetes and diabetes within an EIP serviceLittle is known about the rates of prediabetes and diabetes in those over the age of 35 years in UK early intervention for psychosis (EIP) services. In this article, the authors discuss their retrospective case note service evaluation of patients within an NHS EIP service where they evaluate the prevalence of prediabetes and diabetes in the‘over-35’ cohort, its monitoring and management.The ‘over-35’ cohort represented a third of the EIP caseload and is a high-risk group for prediabetes and diabetes. More research and innovative strategies are needed in terms of both lifestyle and pharmacological interventionsin this patient population to reduce the risk of developing, and improve management of type 2 diabetes.
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An interpretative phenomenological analysis on the experience of probation officers in managing people with antisocial personality disorderPeople who are managed by the National Probation Service and convicted of high risk offences will often meet criteria for antisocial personality disorder and have complex psychosocial needs; this group of people present with high risk behavior which may professionals have been reluctant to work with in the past who are associated with higher rates of recidivism. This study investigated the experiences of probation officers in managing people who meet the criteria for Anti Social Personality Disorder. Semi structured interviews were conducted with six participants to capture their experiences of working with this population, the challenges they faced, and coping mechanisms employed, through analysis using Interpretative Phenomenological Analysis (IPA). Three superordinate themes were identified which revealed participants internal feeling, strategies employed, and external challenges. They spoke about internal negative feelings, specifically feeling controlled, having mistrust, a lack of confidence, being overwhelmed with emotion, and experiencing a fear of risk behaviors. Other themes involved external pressures as well as different coping responses. Implications are discussed to help probation officers to understand this population, for the organization to support staff to work with challenging behaviors and prevent burn out, to enable positive outcomes, and for potentially reducing reoffending.
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“Well-Track”: Fitbit based physical activity and sleep hygiene intervention for early intervention in psychosis (EIP) and at-risk mental state (ARMS) service patientsBackground: Compared to the general population, people who are at a high risk of or experience severe mental illness (SMI) such as psychosis, are more likely to have low levels of physical activity, high levels of sedentary behaviour, and sleep problems. Intervention: The Well-Track intervention comprises a wearable activity and sleep tracker (Fitbit); one session with mental health service staff providing physical activity and sleep hygiene advice; a brief motivational interview; completing a goal setting workbook; and one or two further engagement, feedback and discussion sessions. Participants: Twenty-four participants using an early intervention in psychosis (EIP) or at-risk mental state (ARMS) service completed an eight-week, three session intervention (14 males and 10 females), with an age range of 18 - 61, and average age of 27.75 years. Methods: An open-label patient cohort design with no control group. Pre-intervention, 4-week and 8-week intervention assessments using participant self-report measures: Patient Health Questionnaire (PHQ-9) (depression), Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS), and Sleep Conditioning Index (SCI); and clinician measurement of body weight. Results: Mean scores showed a significant improvement in PHQ-9 from 9.29 (SD 5.89) to 5.58 (SD 3.68) at 4 weeks and to 5.83 (SD 4.40) at 8 weeks, with large effect sizes. For those who met a diagnosis of depression at baseline, at 4 week follow-up seven participants (26%) experienced remission and nine (33%) reliable improvement, and at 8 week follow-up four (21%) experienced remission and seven (37%) reliable improvement. WEMWBS scores significantly improved, from 44.04 (SD 9.44) to 48.54 (SD 8.71) at 4 weeks and to 48.67 (SD 8.76) at 8 weeks, with large effect sizes. Body weight did not change significantly, remaining unchanged at 4 weeks and reduced from a mean of 82.8 kg (baseline) to 80.15 kg at 8 weeks, a reduction of 2.65 kg. Conclusion: Well-Track was integrated into an EIP and ARMS service and was found to be beneficial in terms of wellbeing, depression, sleep, and preventing weight gain (either as a two or three engagement point intervention). Well-Track could be delivered through EIP and ARMS services to promote healthy lifestyle behaviours.
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Experiences of shame and intellectual disabilities: Two case studiesShame is a trans-diagnostic phenomenon that underlies a variety of mental health difficulties. People with intellectual disabilities (IDs) are reported to be one of the most stigmatized and excluded groups in society and are more likely to experience mental health problems than the general population. Consequently, this group may be at a significant risk of shame-related distress. However, there is a lack of research that investigates the experience of shame in people with ID, and there is currently a lack of interventions targeting shame in people with ID. Two case studies were undertaken to document the experiences of stigma, discrimination, and shame in people with ID and to explore how shame may present in this population. Shame was found to be a significant barrier to social inclusion and to contribute towards poor psychological health in people with ID. The development of interventions that specifically target shame in this population is recommended.
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A qualitative study of early intervention psychosis (EIP) service patient’s experience of sleep, exercise, sleep hygiene advice and Fitbit wearable activity and sleep trackerBackground: In psychosis physical activity, sleep, mental health, physical health, wellbeing, quality of life, cognition and functioning are interconnected. People who experience psychosis are more likely than the general population to have low levels of physical activity, high levels of sedentary behaviour and sleep problems. This project was innovative in seeking to address these issues through provision of a wearable activity and sleep tracker (a Fitbit) and sleep hygiene advice. Participants: Participants using an early intervention psychosis (EIP) service took part in an eight-week intervention, which incorporated the provision of a Fitbit, sleep hygiene advice as well as three engagement, feedback and discussion points with a clinician. Methods: A qualitative approach was used to conduct in-depth semi-structured interviews with 12 of the 25 intervention participants (5 male; 7 female). Thematic and content analyses were employed to analyse the data. Results: Participants provided valuable insights into their experience of sleep, exercise, Fitbit use and sleep hygiene advice use. It was found that participants placed a high value on effective night time sleep, recognized improvements in physical activity and noted a positive effect on mood and wellbeing as a result of Fitbit use. The negative impact of having ineffective night time sleep and insufficient physical activity was described. Participants demonstrated a good level of understanding of the connection between sleep, exercise, wellbeing, and health. Conclusion: Participants reported the Fitbit and sleep hygiene advice received through an EIP service to be beneficial for improved levels of physical activity and exercise, and more effective sleep. This is a simple and low cost intervention which could be made widely available through EIP and other mental health services.
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Effectiveness of a Fitbit Based Sleep and Physical Activity Intervention in an Early Intervention Psychosis (EIP) ServicePurpose: Compared to levels in the general population, people with experiences of psychosis have poorer physical fitness, more sedentary behaviour, lower physical activity, more sleep problems, and a higher incidence of insomnia. The aim of the current study was to examine the feasibility and impact of an intervention with the goal of addressing these issues. Method: Design: intervention with outcome measure data collection, with no control group. Forty-nine early intervention psychosis (EIP) service patients took part in an intervention: provision of a Fitbit, Fitbit software apps, sleep hygiene, and physical activity guidance, and three discussion sessions with clinicians. The sample consisted of 29 males and 20 females, with age range of 17 - 54 years, and average age of 29.5 years. Measures used were Fitbit activity and sleep data, and self-rated Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS) and Positive and Negative Affect Schedule (PANAS). Results: WEMWBS scores significantly improved, with a medium effect size. PANAS negative affect (NA) dropped significantly. Analysis of Fitbit activity and sleep data yielded non-significant results. Conclusion: The intervention was acceptable to EIP patients and is feasible. Improvements in mental wellbeing and negative affect indicate the positive impact of the intervention on mental health. EIP services should consider assessing sleep quality and physical activity/exercise levels, and using this study’s intervention to promote wellbeing and mental health within recovery focused practice. Further research could be undertaken through a sufficiently powered randomised control trial (RCT) comparing this intervention and treatment as usual (TAU).
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The impact of COVID-19 on acute psychiatric admissions for first and repeated episode psychosisAbstract Background: There is limited evidence of the longer-term impact of the COVID-19 pandemic on acute admissions for psychosis in the UK. Aims: We examined the impact of COVID-19 on rates of admissions for first and repeated episode psychosis, and changes in patient profile and seasonal patterns, over a period of 12 months. Method: We conducted a retrospective case note review of all patients admitted with a primary psychosis (F20-29 ICD 10 diagnosis) to an NHS psychiatric inpatient unit. We compared the 12 months pre-COVID-19 period between 1 March 2019 and 28 February 2020, and the 12 months post-COVID-19 period between 1 March 2020 and 28 February 2021. Results: The results showed increase rates of admissions post-COVID-19 in both first and repeated episode psychosis, the patient profile had more females and older age in the repeated episode group, with increased employment rates. Combined group data for both pre- and post-COVID-19 periods showed an increased trend in spring and summer admissions, and even though not statistically significant, more pronounced post-COVID-19. Conclusions: Our findings highlight the effect of the COVID-19 pandemic on acute psychosis admissions over a 12-month period. The results provide evidence for the ‘stress-pathogenesis’ in the context of genetic vulnerability in psychosis. Preventative strategies in the context of the ‘stress-pathogenesis model’, improved access to and responsiveness within NHS transformation efforts needs to be adjusted to fit local need and environmental changes.
