Acceptance and commitment therapy for depression after psychosis: a pilot trial

INTERVENTION: Participants will be consecutively recruited, assessed and randomised to ACTdp plus ST or ST alone. Acceptance and Commitment Therapy for depression after psychosis (ACTdp): Individuals will receive up to 5 months of individual ACTdp. ACTdp is based on the rationale that the experience of psychosis can threaten progress in valued life domains. The ACTdp protocol will identify problematic appraisals; highlight how attempts to avoid these appraisals can paradoxically increase their frequency; develop individuals? ability to let go of appraisals rather than get caught up reacting to them; facilitate understanding about how distress can inform values; explore valued life domains; and help individuals to commit to behaviours consistent with these valued life domains. Standard Treatment (ST): We will examine treatment received by all participants in the trial in order to establish parameters of standard treatment according to relevant SIGN and NICE guidance. We will require that all participants are in receipt of antipsychotic medication, psychiatric follow‐up and follow‐up from a secondary specialist mental health service. CONDITION: Schizophrenia ; Mental and Behavioural Disorders ; Schizophrenia, unspecified PRIMARY OUTCOME: 1. The EQ‐5D is a generic, preference‐based quality of life instrument that has been successfully used in schizophrenia patients, and which facilitated the calculation of Quality Adjusted Life Years for health economic analyses.; 2. The Calgary Depression Scale for Schizophrenia (CDSS); The potential for phenomenological overlap between depression, negative symptoms, and extrapyramidal symptoms is addressed by including the CDSS. This clinician administered interview measure is based on items selected from the Hamilton Rating Scale for Depression (HAM‐D) and the Present State Exam (PSE) and was developed in order to reliably distinguish co‐morbid depression from symptoms that are diagnostic features of schizophrenia‐spectrum disorders. When compared to the ?gold standard? SCID assessment of depressive symptoms the CDSS outperforms the BDI, PANSS ? Depression subscale, and HAM‐D for both sensitivity (94%) and specificity (89%); 3. The Positive and Negative Syndrome Scale (PANSS); will be used to measure psychiatric symptoms including negative symptoms. We will utilise the improved 5‐factor model based on 5769 participants which incorporates positive, negative, disorganisation, excitement and emotional distress symptoms. ; 4. The Beck Depression Scale (BDI‐II) is a well established measure of depression with excellent reliability and validity.; 5. The Client Service Receipt Inventory (CSRI) is an instrument developed specifically for capturing service use among psychiatric patients. In addition to the standard health service resource use (e.g. G.P., specialist, hospital visits) the CSRI also includes specific psychiatric resource use (both hospital and community based) plus contacts with the judicial system. SECONDARY OUTCOME: Therapy Mechanisms: ; 1. Kentucky Inventory of Mindfulness Skills (KIMS) is a self‐report inventory for the assessment of four mindfulness skills: observing, describing, acting with awareness, and accepting without judgement. Analyses have shown that the KIMS has good internal consistency, test retest ; reliability and construct validity.; 2. The Acceptance and Action Questionnaire (AAQ‐II) is a 7‐item scale that measures experiential avoidance. Results from 2,816 participants across six samples indicate the satisfactory structure, reliability, and validity of this measure.; 3. The Ruminative Response Scale (RRS) includes 22 items describing responses to depressed mood that are self‐focused, symptom‐focused, and focused on the possible causes and consequences of dysphoric mood. Psychometric evaluations have demonstrated good 5‐month test?retest reliability (r=0.80) and good internal consistency (a=.89; a=.89). ; 4. The Autobiographical Memory Test (AMT) is a widely used recall task based on Crovitz?s classic single word cueing paradigm. Low autobiographical memory (AM) recall specificity is a known predictor of poor clinical outcome for people with unipolar depression34 and it has been argued that these problems with retrieval specificity are related to attempts to avoid ; unwanted mental experiences35. Reducing experiential avoidance is a central aim of the ACT approach36 but previous studies have not determined whether post‐ACT improvements are associated with changes in autobiographical memory functioning. Greater AM retrieval specificity following treatment would indicate a possible mechanism of therapeutic change, namely, less avoidance of unwanted memories and related thoughts. The other main advantage of including the AMT in the current research is that it extends the assessment beyond purely questionnaire methods. Data from the ADAPT trial will provide a more nuanced understanding of the way that various change processes operate in ACT for depression after psychosis. During the administration of the AMT, participants are asked to generate a specific memory detailing an event which can be located in time and place in response to positive and negative cue words. Participants are given three practice words (enjoy, friendly, and bold). Once they are able to perform the task, six positive words (happy, proud, relieved, pleased, excited, and hopeful) and six negative words (miserable, guilty, angry, insecure, lazy, and uncomfortable) are presented in a randomised order. The cue words have been successfully used in previous published studies and the subjects are allowed up to 30 seconds to produce a response. Each word is presented verbally and visually (on a 10 cm x 30 cm card) and the same sentence cue is provided for each trial: ?Can you tell me of something that has happened to you that you are reminded of when you see the word...?''. When it was not clear whether the initial response refers to a specific event the examiner provides a standard prompt specified in Williams' (unpublished) procedures: ?Can you think of a particular time?''. Responses are coded as ?specific'', ?categoric'', ?extended'' or ?uninterpretable'' based on published definitions. Latency to produce a response is timed and answers will be audiotaped ; (if participants consent) to allow reliability checks of the ratings. ; 5. Recovery Outcomes ; 5.1. The Process of Recovery Questionnaire (QPR) is a 22 item self report questionnaire which was developed by service users to measure experiences of recovery after psychosis. The QPR has two subscales measuring intrapersonal tasks and interpersonal factors relevant to personal recovery. The Questionnaire has excellent reliability and validity.; 5.2. The Working Alliance Inventory Short Form Revised (WAI‐SR) is a 12‐item self‐report measure of the working alliance that describes three components of the therapeutic relationship between a patient and therapist: (a) agreement between client and therapist on the goals of therapy, (b) agreement on the tasks of therapy, and (c) the quality of the interpersonal alliance. This measure produces scores for three subscales of alliance (Goal, Task, Bond) as well as a total alliance score and has acceptable internal consistency (.83 to .94). INCLUSION CRITERIA: 1. Outpatients, aged 16 or over, receiving secondary mental health care from community based services in NHS Greater Glasgow and Clyde (NHSGG&C) 2. Meet DSM‐IV‐TR criteria for schizophrenia and criteria for major depression (confirmed by Structured Clinical Interview for DSM / SCID‐I & Calgary Depression Scale / CDSS for Schizophrenia; score >721). Individuals with substance use problems will not be excluded.