Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: randomised controlled trial

Objectives To evaluate the effectiveness of integrated motivational interviewing and cognitive behaviour therapy in addition to standard care for patients with psychosis and a co-morbid substance use problem. Design Two-centre, open, rater-blind randomised controlled trial Setting UK Secondary Care Participants 327 patients with clinical diagnoses of schizophrenia, schizophreniform or schizoaffective disorder and DSM-IV diagnoses of drug and/or alcohol dependence or abuse Interventions Participants were randomly allocated to integrated motivational interviewing and cognitive behaviour therapy or standard care. Therapy has two phases. Phase one – “motivation building” – concerns engaging the patient, then exploring and resolving ambivalence for change in substance use. Phase two –“Action” – supports and facilitates change using cognitive behavioural approaches. Up to 26 therapy sessions were delivered over one year. Main outcomes The primary outcome was death from any cause or admission to hospital in the 12 months after therapy. Secondary outcomes were frequency and amount of substance use (Timeline Followback), readiness to change, perceived negative consequences of use, psychotic symptom ratings, number and duration of relapses, global assessment of functioning and deliberate self harm, at 12 and 24 months, with additional Timeline Followback assessments at 6 and 18 months. Analysis was by intention-to-treat with robust treatment effect estimates. Results 327 participants were randomised. 326 (99.7%) were assessed on the primary outcome, 246 (75.2%) on main secondary outcomes at 24 months. Regarding the primary outcome, there was no beneficial treatment effect on hospital admissions/ death during follow-up, with 20.2% (33/163) of controls and 23.3% (38/163) of the therapy group deceased or admitted (adjusted odds-ratio 1.16; P= 0.579; 95% confidence interval 0.68 to 1.99). For secondary outcomes there was no treatment effect on frequency of substance use or perceived negative consequences, but a statistically significant effect of therapy on amount used per substance-using day (adjusted odds-ratios: (a) for main substance 1.50; P=0.016; 1.08 to 2.09, (b) all substances 1.48; P=0.017; 1.07 to 2.05). There was a statistically significant treatment effect on readiness to change use at 12 months (adjusted odds-ratio 2.05; P=0.004; 1.26 to 3.31), not maintained at 24 months. There were no treatment effects on assessed clinical outcomes. Conclusions Integrated motivational interviewing and cognitive behaviour therapy for people with psychosis and substance misuse does not improve outcome in terms of hospitalisation, symptom outcomes or functioning. It does result in a reduction in amount of substance use which is maintained over the year’s follow up. Trial registration Current Controlled Trials: ISRCTN14404480

Thermogenic and metabolic consequences of thyroid hormone treatment in brown and white adipose tissue

Male rats were treated with triiodothyronine in the drinking water for 12 days. In vitro rates of isoprenaline stimulated lipolysis were significantly greater in brown but not white adipose tissue. Rates of [14C]glucose incorporation into triacylglycerols were significantly reduced in BAT (brown adipose tissue) and WAT (white adipose tissue) under basal and isoprenaline stimulated conditions. In a second experiment, hyperthyroid animals showed impaired weight gain, despite increased food intake during 19 days' treatment. Energy expenditure on days 5 and 12, and BAT core temperature differences (TBAT - TCORE) on day 19, were significantly greater than in control animals. Epididymal white fat pad weight was reduced and interscapular brown fat pad weight increased by triiodothyronine treatment.

Effective elements of cognitive behaviour therapy for psychosis: results of a novel type of subgroup analysis based on principal stratification

Background. Meta-analyses show that cognitive behaviour therapy for psychosis (CBT-P) improves distressing positive symptoms. However, it is a complex intervention involving a range of techniques. No previous study has assessed the delivery of the different elements of treatment and their effect on outcome. Our aim was to assess the differential effect of type of treatment delivered on the effectiveness of CBT-P, using novel statistical methodology. Method. The Psychological Prevention of Relapse in Psychosis (PRP) trial was a multi-centre randomized controlled trial (RCT) that compared CBT-P with treatment as usual (TAU). Therapy was manualized, and detailed evaluations of therapy delivery and client engagement were made. Follow-up assessments were made at 12 and 24 months. In a planned analysis, we applied principal stratification (involving structural equation modelling with finite mixtures) to estimate intention-to-treat (ITT) effects for subgroups of participants, defined by qualitative and quantitative differences in receipt of therapy, while maintaining the constraints of randomization. Results. Consistent delivery of full therapy, including specific cognitive and behavioural techniques, was associated with clinically and statistically significant increases in months in remission, and decreases in psychotic and affective symptoms. Delivery of partial therapy involving engagement and assessment was not effective. Conclusions. Our analyses suggest that CBT-P is of significant benefit on multiple outcomes to patients able to engage in the full range of therapy procedures. The novel statistical methods illustrated in this report have general application to the evaluation of heterogeneity in the effects of treatment.

'John James' and 'The White Stones' p. 71: Music, rhyme, and home

An essay relating 'The Dragon House' by John James to 'Thoughts on the Esterhazy Court Uniform' by J. H. Prynne

Extension of explicit formulas in Poissonian white noise analysis using harmonic analysis on configuration spaces

Harmonic analysis on configuration spaces is used in order to extend explicit expressions for the images of creation, annihilation, and second quantization operators in L2-spaces with respect to Poisson point processes to a set of functions larger than the space obtained by directly using chaos expansion. This permits, in particular, to derive an explicit expression for the generator of the second quantization of a sub-Markovian contraction semigroup on a set of functions which forms a core of the generator.

Intrusions in trauma and psychosis: information processing and phenomenology

Background: Intrusions are common symptoms of both posttraumatic stress disorder (PTSD) and schizophrenia. Steel et al (2005) suggest that an information processing style characterized by weak trait contextual integration renders psychotic individuals vulnerable to intrusive experiences. This ‘contextual integration hypothesis’ was tested in individuals reporting anomalous experiences in the absence of a need-for-care. Methods: Twenty-six low schizotypes and twenty-three individuals reporting anomalous experiences were shown a traumatic film with and without a concurrent visuo-spatial task. Participants rated post-traumatic intrusions for frequency and form, and completed self-report measures of information processing style. It was predicted that, due to their weaker trait contextual integration, the anomalous experiences group would (1) exhibit more intrusions following exposure to the trauma-film; (2) display intrusions characterised by more PTSD qualities and (3) show a greater reduction of intrusions with the concurrent visuo-spatial task. Results: As predicted, the anomalous experiences group reported a lower level of trait contextual integration and more intrusions than the low schizotypes, both immediately after watching the film, and during the following seven days. Their post-traumatic intrusive memories were more PTSD-like (more intrusive, vivid and associated with emotion). The visuo-spatial task had no effect on number of intrusions in either group. Conclusions: These findings provide some support for the proposal that weak trait contextual integration underlies the development of intrusions within both PTSD and psychosis.

The child in wolf’s clothing: the meanings of the ‘wolf’ and questions of identity in Jack London’s White Fang

The criticism of Jack London’s work has been dominated by a reliance upon ideas of the ‘real’, the ‘authentic’ and the ‘archetypal’. One of the figures in London’s work around which these ideas crystallize is that of the ‘wolf’. This article will examine the way the wolf is mobilized both in the criticism of Jack London’s work and in an example of the work: the novel White Fang (1906). This novel, though it has often been read as clearly delimiting and demarcating the realms of nature and culture, can be read conversely as unpicking the deceptive simplicity of such categories, as troubling essentialist notions of identity (human/animal, male/female, white/Indian) and as engaging with the complexity of the journey in which a ‘small animal … becomes human-sexual by crossing the infinite divide that separates life from humanity, the biological from the historical, “nature” from “culture” ’ (Althusser 1971: 206).