University of Manchester



Suicidal ideation in people with psychosis not taking antipsychotic medication: Do negative appraisals and negative metacognitive beliefs mediate the effect of symptoms?Running Head: Suicidal ideation and psychosisPaul Hutton1*Francesca Di Rienzo2Douglas Turkington3, 4Helen Spencer3, 4Peter Taylor41School of Health and Social Care, Edinburgh Napier University, 9 Sighthill Court, Edinburgh, EH11 4BN2Department of Clinical and Health Psychology, School of Health in Social Science, Doorway 6, Medical School Quad, Teviot Place, University of Edinburgh3Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, United Kingdom4Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom5Division of Psychology & Mental Health, School of Psychological Sciences, Zochonis Building, Brunswick Street, University of Manchester, Manchester Academic Health Sciences Centre, M13 9PL*Corresponding author; Email: p.hutton@napier.ac.uk; Tel: +44(0)131 455 3335AbstractBetween 5 and 10 percent of people with psychosis will die by suicide, a rate which is 20 to 75 times higher than the general population. This risk is even greater in those not taking antipsychotic medication. We examined whether negative appraisals of psychotic experiences and negative metacognitive beliefs about losing mental control mediated a relationship between psychotic symptoms and suicidal ideation in this group. Participants were diagnosed with schizophrenia-spectrum disorders, antipsychotic-free for 6 months at baseline, and were participating in an 18-month randomised controlled trial of cognitive therapy v. treatment as usual. We conducted a series of mediation analyses with bootstrapping on baseline (N=68), follow-up data (9-18 months; n=49), and longitudinal data (n=47). Concurrent general symptoms were directly associated with suicidal ideation at baseline, and concurrent negative symptoms were directly associated with suicidal ideation at 9-18 months. Concurrent positive, negative, general and overall symptoms were each indirectly associated with suicidal ideation via negative appraisals and/or negative metacognitive beliefs, at baseline and 9-18 months, except for negative symptoms at baseline. Controlling for baseline suicidal ideation and treatment allocation, baseline general symptoms were indirectly associated with later suicidal ideation, via baseline negative appraisals and negative metacognitive beliefs. Baseline negative metacognitive beliefs also had a direct association with later suicidal ideation. These findings suggest the clinical assessment of suicidal ideation in psychosis may be enhanced by considering metacognitive beliefs about the probability and consequences of losing mental control.Keywords: Psychosis, schizophrenia, suicide, antipsychotic medication, appraisals, metacognitive beliefsWord Count:Abstract: 236Main text (including acknowledgements and figure legends): 3738 Total word count: 3974IntroductionEstimates of suicide rates among individuals diagnosed with schizophrenia spectrum disorders range from 5 to 10 percent, making it a leading cause of premature death in this population.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1093/schbul/16.4.571","ISSN":"05867614","PMID":"2077636","abstract":"Suicide rates among schizophrenic individuals are disturbingly high. At present, suicide is the number one cause of premature death among schizophrenics, with 10 to 13 percent killing themselves. Recent studies place the risk of suicide for persons with schizophrenia at a level comparable to that for persons with affective disorder. Depression, especially the symptom of self-reported or perceived hopelessness, is an important comorbidity factor in assessing this risk. Young white schizophrenic men with high levels of premorbid functioning and high expectations are at particularly high risk. Schizophrenic women, unlike women in the general population, behave more like men when it comes to choosing suicide. This article reviews recent studies reporting suicide rates and risk factors for suicide among schizophrenic patients. Current issues concerning the prediction, prevention, and treatment of suicidality among persons with schizophrenia are also discussed.","author":[{"dropping-particle":"","family":"Caldwell","given":"Constance B.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gottesman","given":"Irving I.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Schizophr Bull","id":"ITEM-1","issue":"4","issued":{"date-parts":[["1990"]]},"page":"571-589","title":"Schizophrenics Kill Themselves Too: A Review of Risk Factors for Suicide","type":"article-journal","volume":"16"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1001/archpsyc.62.3.247","ISBN":"0003-990X","ISSN":"0003-990X","PMID":"15753237","abstract":"BACKGROUND: The psychiatry literature routinely quotes a lifetime schizophrenia suicide prevalence of 10% based on 1 meta-analysis and 2 studies of chronic schizophrenics. OBJECTIVES: To build a methodology for extrapolating lifetime suicide prevalence estimates from published cohorts and to apply this approach to studies that meet inclusion criteria. DATA SOURCES: We began with a MEDLINE search (1966-present) for articles that observed cohorts of schizophrenic patients. Exhaustive bibliography searching of each identified article brought the total number of articles reviewed to 632. STUDY SELECTION: Studies included in the meta-analysis observed a cohort of schizophrenic patients for at least 2 years, with at least 90% follow-up, and reported suicides. Articles are excluded for systematic age bias (ie, adolescents). DATA EXTRACTION: Extracted data included sample size, number of deaths, number of suicides, percentage of follow-up, and diagnostic system used. Data were extracted independently by 2 of us, and differences were resolved by consensus after re-review. DATA SYNTHESIS: Studies were divided into 2 groups: 32 studies of schizophrenics enrolled at various illness points (25 578 subjects) and 29 studies of schizophrenics identified at either illness onset or first admission (22 598 subjects). Regression models of the intersection of proportionate mortality (the percentage of the dead who died by suicide) and case fatality (the percentage of the total sample who died by suicide) were used to calculate suicide risk in each group. The estimate of lifetime suicide prevalence in those observed from first admission or illness onset was 5.6% (95% confidence interval, 3.7%-8.5%). Mixed samples showed a rate of 1.8% (95% confidence interval, 1.4%-2.3%). Case fatality rates showed no significant differences when studies of patients diagnosed with the use of newer systems were compared with studies of patients diagnosed under older criteria. CONCLUSION: This study estimates that 4.9% of schizophrenics will commit suicide during their lifetimes, usually near illness onset.","author":[{"dropping-particle":"","family":"Palmer","given":"Brian a","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pankratz","given":"V Shane","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bostwick","given":"John Michael","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Archives of general psychiatry","id":"ITEM-2","issue":"3","issued":{"date-parts":[["2005"]]},"page":"247-253","title":"The lifetime risk of suicide in schizophrenia: a reexamination.","type":"article-journal","volume":"62"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1192/bjp.187.1.9","ISBN":"9781847471","ISSN":"0007-1250","PMID":"15994566","abstract":"BACKGROUND: Suicide risk is greatly increased in schizophrenia. Detection of those at risk is clinically important. AIMS: To identify risk factors for suicide in schizophrenia. METHOD: The international literature on case-control and cohort studies of patients with schizophrenia or related conditions in which suicide was reported as an outcome was systematically reviewed. Studies were identified through searching electronic databases and reference lists, and by consulting experts. RESULTS: Twenty-nine eligible studies were identified. Factors with robust evidence of increased risk of suicide were previous depressive disorders (OR=3.03, 95% CI 2.06-4.46), previous suicide attempts (OR=4.09, 95% CI 2.79-6.01), drug misuse (OR=3.21, 95% CI 1.99-5.17), agitation or motor restlessness (OR=2.61, 95% CI 1.54-4.41), fear of mental disintegration (OR=12.1, 95% CI 1.89-81.3), poor adherence to treatment (OR=3.75, 95% CI 2.20-6.37) and recent loss (OR=4.03, 95% CI 1.37-11.8). Reduced risk was associated with hallucinations (OR=0.50, 95% CI 0.35-0.71). CONCLUSIONS: Prevention of suicide in schizophrenia is likely to result from treatment of affective symptoms, improving adherence to treatment, and maintaining special vigilance in patients with risk factors, especially after losses.","author":[{"dropping-particle":"","family":"Hawton","given":"Keith","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sutton","given":"Lesley","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haw","given":"Camilla","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sinclair","given":"Julia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Deeks","given":"Jonathan J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The British journal of psychiatry : the journal of mental science","id":"ITEM-3","issued":{"date-parts":[["2005"]]},"page":"9-20","title":"Schizophrenia and suicide: systematic review of risk factors.","type":"article-journal","volume":"187"},"uris":[""]}],"mendeley":{"formattedCitation":"^1–3","plainTextFormattedCitation":"1–3","previouslyFormattedCitation":"^1–3"},"properties":{"noteIndex":0},"schema":""}1–3 Non-use of antipsychotics is thought to increase this risk further, with one large observational study reporting a 37 times greater risk of suicide in inpatients who were not taking antipsychotics.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/bmj.38881.382755.2F","ISBN":"1756-1833","ISSN":"09598146","PMID":"16825203","abstract":"Objective To study the association between prescribed antipsychotic drugs and outcome in schizophrenia or schizoaffective disorder in the community.\\nDesign Prospective cohort study using national central registers.\\nSetting Community care in Finland.\\nParticipants Nationwide cohort of 2230 consecutive adults hospitalised in Finland for the first time because of schizophrenia or schizoaffective disorder, January 1995 to December 2001.\\nMain outcome measures Rates of discontinuation of drugs (all causes), rates of rehospitalisation, and mortality associated with monotherapy with the 10 most commonly used antipsychotic drugs. Multivariate models and propensity score methods were used to adjust estimates of effectiveness.\\nResults Initial use of clozapine (adjusted relative risk 0.17, 95% confidence interval 0.10 to 0.29), perphenazine depot (0.24, 0.13 to 0.47), and olanzapine (0.35, 0.18 to 0.71) were associated with the lowest rates of discontinuation for any reason when compared with oral haloperidol. During an average follow-up of 3.6 years, 4640 cases of rehospitalisation were recorded. Current use of perphenazine depot (0.32, 0.22 to 0.49), olanzapine (0.54, 0.41 to 0.71), and clozapine (0.64, 0.48 to 0.85) were associated with the lowest risk of rehospitalisation. Use of haloperidol was associated with a poor outcome among women. Mortality was markedly raised in patients not taking antipsychotics (12.3, 6.0 to 24.1) and the risk of suicide was high (37.4, 5.1 to 276).\\nConclusions The effectiveness of first and second generation antipsychotics varies greatly in the community. Patients treated with perphenazine depot, clozapine, or olanzapine have a substantially lower risk of rehospitalisation or discontinuation (for any reason) of their initial treatment than do patients treated with haloperidol. Excess mortality is seen mostly in patients not using antipsychotic drugs.","author":[{"dropping-particle":"","family":"Tiihonen","given":"Jari","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wahlbeck","given":"Kristian","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"L?nnqvist","given":"Jouko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Klaukka","given":"Timo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ioannidis","given":"John P.A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Volavka","given":"Jan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haukka","given":"Jari","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Medical Journal","id":"ITEM-1","issued":{"date-parts":[["2006"]]},"title":"Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: Observational follow-up study","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"⁴","plainTextFormattedCitation":"4","previouslyFormattedCitation":"⁴"},"properties":{"noteIndex":0},"schema":""}4 Given antipsychotics have their strongest effects on the positive symptoms of psychosisADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S0140-6736(13)60733-3","ISBN":"1474-547X (Electronic)\\r0140-6736 (Linking)","ISSN":"01406736","PMID":"23810019","abstract":"Background: The question of which antipsychotic drug should be preferred for the treatment of schizophrenia is controversial, and conventional pairwise meta-analyses cannot provide a hierarchy based on the randomised evidence. We aimed to integrate the available evidence to create hierarchies of the comparative efficacy, risk of all-cause discontinuation, and major side-effects of antipsychotic drugs. Methods: We did a Bayesian-framework, multiple-treatments meta-analysis (which uses both direct and indirect comparisons) of randomised controlled trials to compare 15 antipsychotic drugs and placebo in the acute treatment of schizophrenia. We searched the Cochrane Schizophrenia Group's specialised register, Medline, Embase, the Cochrane Central Register of Controlled Trials, and for reports published up to Sept 1, 2012. Search results were supplemented by reports from the US Food and Drug Administration website and by data requested from pharmaceutical companies. Blinded, randomised controlled trials of patients with schizophrenia or related disorders were eligible. We excluded trials done in patients with predominant negative symptoms, concomitant medical illness, or treatment resistance, and those done in stable patients. Data for seven outcomes were independently extracted by two reviewers. The primary outcome was efficacy, as measured by mean overall change in symptoms. We also examined all-cause discontinuation, weight gain, extrapyramidal side-effects, prolactin increase, QTc prolongation, and sedation. Findings: We identified 212 suitable trials, with data for 43 049 participants. All drugs were significantly more effective than placebo. The standardised mean differences with 95% credible intervals were: clozapine 0.88, 0.73-1.03; amisulpride 0.66, 0.53-0.78; olanzapine 0.59, 0.53-0.65; risperidone 0.56, 0.50-0.63; paliperidone 0.50, 0.39-0.60; zotepine 0.49, 0.31-0.66; haloperidol 0.45, 0.39-0.51; quetiapine 0.44, 0.35-0.52; aripiprazole 0.43, 0.34-0.52; sertindole 0.39, 0.26-0.52; ziprasidone 0.39, 0.30-0.49; chlorpromazine 0.38, 0.23-0.54; asenapine 0.38, 0.25-0.51; lurasidone 0.33, 0.21-0.45; and iloperidone 0.33, 0.22-0.43. Odds ratios compared with placebo for all-cause discontinuation ranged from 0.43 for the best drug (amisulpride) to 0.80 for the worst drug (haloperidol); for extrapyramidal side-effects 0.30 (clozapine) to 4.76 (haloperidol); and for sedation 1.42 (amisulpride) to 8.82 (clozapine). Standardised mean diff…","author":[{"dropping-particle":"","family":"Leucht","given":"Stefan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cipriani","given":"Andrea","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Spineli","given":"Loukia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mavridis","given":"Dimitris","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"??rey","given":"Deniz","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Richter","given":"Franziska","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Samara","given":"Myrto","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Barbui","given":"Corrado","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Engel","given":"Rolf R.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Geddes","given":"John R.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kissling","given":"Werner","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Stapf","given":"Marko Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"L??ssig","given":"Bettina","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Salanti","given":"Georgia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Davis","given":"John M.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Lancet","id":"ITEM-1","issue":"9896","issued":{"date-parts":[["2013"]]},"page":"951-962","title":"Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: A multiple-treatments meta-analysis","type":"article-journal","volume":"382"},"uris":["",""]}],"mendeley":{"formattedCitation":"⁵","plainTextFormattedCitation":"5","previouslyFormattedCitation":"⁵"},"properties":{"noteIndex":0},"schema":""}5 it is plausible that individuals not taking this medication may have greater positive symptom severity than those who do - and that this accounts for their increased suicide risk. However the evidence on the contribution of positive symptoms to suicide risk remains unclear. One meta-analysis suggested they were associated with a lower risk,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1192/bjp.187.1.9","ISBN":"9781847471","ISSN":"0007-1250","PMID":"15994566","abstract":"BACKGROUND: Suicide risk is greatly increased in schizophrenia. Detection of those at risk is clinically important. AIMS: To identify risk factors for suicide in schizophrenia. METHOD: The international literature on case-control and cohort studies of patients with schizophrenia or related conditions in which suicide was reported as an outcome was systematically reviewed. Studies were identified through searching electronic databases and reference lists, and by consulting experts. RESULTS: Twenty-nine eligible studies were identified. Factors with robust evidence of increased risk of suicide were previous depressive disorders (OR=3.03, 95% CI 2.06-4.46), previous suicide attempts (OR=4.09, 95% CI 2.79-6.01), drug misuse (OR=3.21, 95% CI 1.99-5.17), agitation or motor restlessness (OR=2.61, 95% CI 1.54-4.41), fear of mental disintegration (OR=12.1, 95% CI 1.89-81.3), poor adherence to treatment (OR=3.75, 95% CI 2.20-6.37) and recent loss (OR=4.03, 95% CI 1.37-11.8). Reduced risk was associated with hallucinations (OR=0.50, 95% CI 0.35-0.71). CONCLUSIONS: Prevention of suicide in schizophrenia is likely to result from treatment of affective symptoms, improving adherence to treatment, and maintaining special vigilance in patients with risk factors, especially after losses.","author":[{"dropping-particle":"","family":"Hawton","given":"Keith","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sutton","given":"Lesley","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haw","given":"Camilla","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sinclair","given":"Julia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Deeks","given":"Jonathan J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The British journal of psychiatry : the journal of mental science","id":"ITEM-1","issued":{"date-parts":[["2005"]]},"page":"9-20","title":"Schizophrenia and suicide: systematic review of risk factors.","type":"article-journal","volume":"187"},"uris":[""]}],"mendeley":{"formattedCitation":"³","plainTextFormattedCitation":"3","previouslyFormattedCitation":"³"},"properties":{"noteIndex":0},"schema":""}3 one found no associationADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1093/schbul/sbx131","ISSN":"0586-7614","PMID":"29036388","abstract":"The lifetime risk of suicide and suicide attempt in patients with schizophrenia are 5% and 25%-50%, respectively. The current meta-analysis aims to determine risk factors associated with suicidality in subjects with schizophrenia. We searched Pubmed, Web of Science, EMBASE, and the reference lists of included studies. Inclusion criteria were met if an article reported a dichotomous sample of patients with schizophrenia with suicidal ideation, attempted suicide, or suicide compared to patients without. We also performed a cohort study meta-analysis as a supplemental analysis. A total of 96 studies with 80488 participants were included in our analysis. Depressive symptoms (P < .0001), Positive and Negative Symptom Scale (PANSS) general score (P < .0001) and number of psychiatric hospitalizations (P < .0001) were higher in patients with suicide ideation. History of alcohol use (P = .0001), family history of psychiatric illness (P < .0001), physical comorbidity (P < .0001), history of depression (P < .0001), family history of suicide (P < .0001), history of drug use (P = .0024), history of tobacco use (P = .0034), being white (P = .0022), and depressive symptoms (P < .0001) were the most consistent variables associated with suicide attempts. The first two were also significant in the cohort meta-analysis. Being male (P = .0005), history of attempted suicide (P < .0001), younger age (P = .0266), higher intelligence quotient (P < .0001), poor adherence to treatment (P < .0001), and hopelessness (P < .0001) were the most consistently associated with suicide. The first three were also significant in the cohort meta-analysis. Our findings may help with future development of preventive strategies to combat suicide. Future studies may combine the above-mentioned variables by using multivariate predictive analysis techniques to objectively stratify suicidality in schizophrenia.","author":[{"dropping-particle":"","family":"Cassidy","given":"Ryan Michael","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yang","given":"Fang","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kapczinski","given":"Flávio","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Passos","given":"Ives Cavalcante","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Schizophrenia Bulletin","id":"ITEM-1","issued":{"date-parts":[["2017"]]},"title":"Risk Factors for Suicidality in Patients With Schizophrenia: A Systematic Review, Meta-analysis, and Meta-regression of 96 Studies","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"⁶","plainTextFormattedCitation":"6","previouslyFormattedCitation":"⁶"},"properties":{"noteIndex":0},"schema":""}6 whereas another found they were associated with a higher risk.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1017/S0033291717002136","ISBN":"0033-2917","ISSN":"0033-2917","abstract":"Research has long noted higher prevalence rates of suicidal thoughts and behaviors among individuals with psychotic symptoms. Major theories have proposed several explanations to account for this association. Given the differences in the literature regarding the operationalization of psychosis and sample characteristics, a quantitative review is needed to determine to what extent and how psychosis confers risk for suicidality. We searched PsycInfo, PubMed, and GoogleScholar for studies published before 1 January 2016. To be included in the analysis, studies must have used at least one psychosis-related factor to longitudinally predict suicide ideation, attempt, or death. The initial search yielded 2541 studies. Fifty studies were retained for analysis, yielding 128 statistical tests. Suicide death was the most commonly studied outcome (43.0%), followed by attempt (39.1%) and ideation (18.0%). The median follow-up length was 7.5 years. Overall, psychosis significantly conferred risk across three outcomes, with weighted mean ORs of 1.70 (1.39–2.08) for ideation, 1.36 (1.25–1.48) for attempt, and 1.40 (1.14–1.72) for death. Detailed analyses indicated that positive symptoms consistently conferred risk across outcomes; negative symptoms were not significantly associated with ideation, and were protective against death. Some small moderator effects were detected for sample characteristics. Psychosis is a significant risk factor for suicide ideation, attempt, and death. The finding that positive symptoms increased suicide risk and negative symptoms seemed to decrease risk sheds light on the potential mechanisms for the association between psychosis and suicidality. We note several limitations of the literature and offer suggestions for future directions.","author":[{"dropping-particle":"","family":"Huang","given":"X.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fox","given":"K. R.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ribeiro","given":"J. D.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Franklin","given":"J. C.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychological Medicine","id":"ITEM-1","issued":{"date-parts":[["2017"]]},"title":"Psychosis as a risk factor for suicidal thoughts and behaviors: a meta-analysis of longitudinal studies","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"⁷","plainTextFormattedCitation":"7","previouslyFormattedCitation":"⁷"},"properties":{"noteIndex":0},"schema":""}7 Although this inconsistency may reflect methodological differences, the absence of a robust relationship may indicate the presence of underlying mechanisms that have yet to be fully accounted for. As predicted by cognitive theories,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1017/S0033291701003312","ISBN":"0033-2917 (Print)\\n0033-2917 (Linking)","ISSN":"0033-2917","PMID":"11232907","abstract":"In the last 10 years a consensus has developed that the symptoms of psychosis may be better understood by linking the steps between the phenomenological experiences and social, psychological and neurobiological levels of explanation. Cognitive models of psychosis are an important link in this chain. They provide a psychological description of the phenomena from which hypotheses concerning causal processes can be derived and tested; social, individual, and neurobiological factors can then be integrated via their impact on these cognitive processes. In this paper, we set out the cognitive processes that we think lead to the formation and maintenance of the positive symptoms of psychosis and we attempt to integrate into our model research in social factors. If this model proves useful, a fuller integration with the findings of biological research will be required (Frith, 1992).","author":[{"dropping-particle":"","family":"Garety","given":"P a","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kuipers","given":"E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fowler","given":"D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Freeman","given":"D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bebbington","given":"P E","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychological medicine","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2001"]]},"page":"189-195","title":"A cognitive model of the positive symptoms of psychosis.","type":"article-journal","volume":"31"},"uris":["",""]},{"id":"ITEM-2","itemData":{"DOI":"10.1017/S1352465801003010","ISBN":"1469-1833","ISSN":"1352-4658","abstract":"The interpretation of intrusions in psychosis: an integrative cognitive approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy, 29(3), 257-276.","author":[{"dropping-particle":"","family":"Morrison","given":"Anthony P.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Behavioural and Cognitive Psychotherapy","id":"ITEM-2","issue":"03","issued":{"date-parts":[["2001"]]},"page":"257-276","title":"The interpretation of intrusions in psychosis: An integrative cognitive approach to psychotic symptoms","type":"article-journal","volume":"29"},"uris":["",""]}],"mendeley":{"formattedCitation":"^8,9","plainTextFormattedCitation":"8,9","previouslyFormattedCitation":"^8,9"},"properties":{"noteIndex":0},"schema":""}8,9 several studies have found that the way a person interprets or ‘appraises’ their psychotic experiences may be more important than symptom severity for predicting suicidal behaviour.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/j.1600-0447.2006.00849.x","ISBN":"0001-690X (Print) 0001-690X (Linking)","ISSN":"0001690X","PMID":"16889588","abstract":"OBJECTIVE: To examine the clinically important phenomenon of suicidal ideation in psychosis in relation to affective processes and the multidimensional nature of hallucinations and delusions. METHOD: In a cross-sectional study of 290 individuals with psychosis, the associations between level of suicidal ideation, affective processes, positive symptoms, clinical and demographic variables were examined. RESULTS: Forty-one per cent of participants expressed current suicidal ideation. Suicidal ideation was associated with depressed mood, anxiety, low self-esteem, negative illness perceptions, negative evaluative beliefs about the self and others and daily alcohol consumption. Frequency of auditory hallucinations and preoccupation with delusions were not associated with suicidal ideation; however, positive symptom distress did relate to suicidal thoughts. CONCLUSION: Affective dysfunction, including distress in response to hallucinations and delusions, was a key factor associated with suicidal ideation in individuals with psychotic relapse. Suicidal ideation in psychosis appears to be an understandable, mood-driven process, rather than being of irrational or 'psychotic' origin.","author":[{"dropping-particle":"","family":"Fialko","given":"L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Freeman","given":"D.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bebbington","given":"P. E.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kuipers","given":"E.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Garety","given":"P. A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dunn","given":"G.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fowler","given":"D.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Acta Psychiatrica Scandinavica","id":"ITEM-1","issue":"3","issued":{"date-parts":[["2006"]]},"page":"177-186","title":"Understanding suicidal ideation in psychosis: Findings from the Psychological Prevention of Relapse in Psychosis (PRP) trial","type":"article-journal","volume":"114"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.psychres.2009.10.015","ISBN":"0165-1781 (Print)\\r0165-1781 (Linking)","ISSN":"01651781","PMID":"20472304","abstract":"The current study tests whether perceptions of defeat and entrapment are the psychological mechanisms underlying the link between positive psychotic symptoms and suicidal ideation in schizophrenia. A sample of 78 patients with schizophrenia spectrum disorders completed self-report measures and a clinical interview. Of this sample, 21.8% reported a single past suicide attempt and 50% reported multiple past attempts. It was found that perceptions of defeat and entrapment, conceptualised as a single variable, accounted for a large proportion (31%) of the variance in suicidal ideation and behaviour. Defeat and entrapment also mediated the relationship between positive symptom severity and suicidal ideation. This result held whilst controlling for levels of hopelessness and depression. Secondary analyses suggested that suspiciousness in particular was linked to suicidal ideation. The results support a socio-cognitive model (The Schematic Appraisals Model of Suicide: SAMS) of suicide in psychosis. ?? 2009 Elsevier Ltd.","author":[{"dropping-particle":"","family":"Taylor","given":"Peter James","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gooding","given":"Patricia A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wood","given":"Alex M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Johnson","given":"Judith","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pratt","given":"Daniel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tarrier","given":"Nicholas","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychiatry Research","id":"ITEM-2","issue":"2","issued":{"date-parts":[["2010"]]},"page":"244-248","publisher":"Elsevier Ltd","title":"Defeat and entrapment in schizophrenia: The relationship with suicidal ideation and positive psychotic symptoms","type":"article-journal","volume":"178"},"uris":[""]}],"mendeley":{"formattedCitation":"^10,11","plainTextFormattedCitation":"10,11","previouslyFormattedCitation":"^10,11"},"properties":{"noteIndex":0},"schema":""}10,11 Importantly, one review found found that people with psychosis who die by suicide were more likely to have ‘fears of mental disintegration’ than matched controls.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1192/bjp.187.1.9","ISBN":"9781847471","ISSN":"0007-1250","PMID":"15994566","abstract":"BACKGROUND: Suicide risk is greatly increased in schizophrenia. Detection of those at risk is clinically important. AIMS: To identify risk factors for suicide in schizophrenia. METHOD: The international literature on case-control and cohort studies of patients with schizophrenia or related conditions in which suicide was reported as an outcome was systematically reviewed. Studies were identified through searching electronic databases and reference lists, and by consulting experts. RESULTS: Twenty-nine eligible studies were identified. Factors with robust evidence of increased risk of suicide were previous depressive disorders (OR=3.03, 95% CI 2.06-4.46), previous suicide attempts (OR=4.09, 95% CI 2.79-6.01), drug misuse (OR=3.21, 95% CI 1.99-5.17), agitation or motor restlessness (OR=2.61, 95% CI 1.54-4.41), fear of mental disintegration (OR=12.1, 95% CI 1.89-81.3), poor adherence to treatment (OR=3.75, 95% CI 2.20-6.37) and recent loss (OR=4.03, 95% CI 1.37-11.8). Reduced risk was associated with hallucinations (OR=0.50, 95% CI 0.35-0.71). CONCLUSIONS: Prevention of suicide in schizophrenia is likely to result from treatment of affective symptoms, improving adherence to treatment, and maintaining special vigilance in patients with risk factors, especially after losses.","author":[{"dropping-particle":"","family":"Hawton","given":"Keith","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sutton","given":"Lesley","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haw","given":"Camilla","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sinclair","given":"Julia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Deeks","given":"Jonathan J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The British journal of psychiatry : the journal of mental science","id":"ITEM-1","issued":{"date-parts":[["2005"]]},"page":"9-20","title":"Schizophrenia and suicide: systematic review of risk factors.","type":"article-journal","volume":"187"},"uris":[""]}],"mendeley":{"formattedCitation":"³","plainTextFormattedCitation":"3","previouslyFormattedCitation":"³"},"properties":{"noteIndex":0},"schema":""}3 This latter finding suggests ‘metacognition’ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1037/0003-066X.34.10.906","ISBN":"0003-066X 1935-990X","ISSN":"0003066X","PMID":"16950075","abstract":"Studies suggest that young children are quite limited in their knowledge about cognitive phenomena—or in their metacognition—and do relatively little monitoring of their own memory, comprehension, and other cognitive enterprises. Metacognitive knowledge is one's stored knowledge or beliefs about oneself and others as cognitive agents, about tasks, about actions or strategies, and about how all these interact to affect the outcomes of any sort of intellectual enterprise. Metacognitive experiences are conscious cognitive or affective experiences that occur during the enterprise and concern any aspect of it—often, how well it is going. Research is needed to describe and explain spontaneous developmental acquisitions in this area and find effective ways of teaching metacognitive knowledge and cognitive monitoring skills. (9 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)","author":[{"dropping-particle":"","family":"Flavell","given":"John H.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"American Psychologist","id":"ITEM-1","issued":{"date-parts":[["1979"]]},"title":"Metacognition and cognitive monitoring: A new area of cognitive-developmental inquiry","type":"article-journal"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.schres.2018.06.001","ISSN":"15732509","PMID":"29903626","abstract":"In the last two decades years, several interventions have been designed for people with major psychological disorders that all have “metacognitive” in their name: Metacognitive Therapy (MCT), Metacognitive Training (e.g., for people with psychosis) and Metacognitive Reflection and Insight Therapy (MERIT). Two of these interventions are primarily targeted at patients with schizophrenia. Prompted by a recent discussion about what constitutes “true” metacognitive treatment, we will first explore the original concept of metacognition as defined by James H. Flavell. Then, we will describe each approach in detail before highlighting how each intervention picks up on slightly different aspects of Flavell's original metacognitive construct. We will also discuss inherent problems with the label “metacognition.”","author":[{"dropping-particle":"","family":"Moritz","given":"Steffen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lysaker","given":"Paul H.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Schizophrenia Research","id":"ITEM-2","issued":{"date-parts":[["2018"]]},"title":"Metacognition – What did James H. Flavell really say and the implications for the conceptualization and design of metacognitive interventions","type":"article-newspaper"},"uris":[""]}],"mendeley":{"formattedCitation":"^12,13","plainTextFormattedCitation":"12,13","previouslyFormattedCitation":"^12,13"},"properties":{"noteIndex":0},"schema":""}12,13 may be important for understanding their suicidality. Whereas cognition refers to knowledge and appraisals of the external world, metacognition refers to knowledge and beliefs relating to the structure and integrity of the self, and one’s own cognitive processes. Although the distinction between metacognition and cognition has been debated,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.schres.2018.06.001","ISSN":"15732509","PMID":"29903626","abstract":"In the last two decades years, several interventions have been designed for people with major psychological disorders that all have “metacognitive” in their name: Metacognitive Therapy (MCT), Metacognitive Training (e.g., for people with psychosis) and Metacognitive Reflection and Insight Therapy (MERIT). Two of these interventions are primarily targeted at patients with schizophrenia. Prompted by a recent discussion about what constitutes “true” metacognitive treatment, we will first explore the original concept of metacognition as defined by James H. Flavell. Then, we will describe each approach in detail before highlighting how each intervention picks up on slightly different aspects of Flavell's original metacognitive construct. We will also discuss inherent problems with the label “metacognition.”","author":[{"dropping-particle":"","family":"Moritz","given":"Steffen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lysaker","given":"Paul H.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Schizophrenia Research","id":"ITEM-1","issued":{"date-parts":[["2018"]]},"title":"Metacognition – What did James H. Flavell really say and the implications for the conceptualization and design of metacognitive interventions","type":"article-newspaper"},"uris":[""]}],"mendeley":{"formattedCitation":"¹³","plainTextFormattedCitation":"13","previouslyFormattedCitation":"¹³"},"properties":{"noteIndex":0},"schema":""}13 Moritz and LysakerADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.schres.2018.06.001","ISSN":"15732509","PMID":"29903626","abstract":"In the last two decades years, several interventions have been designed for people with major psychological disorders that all have “metacognitive” in their name: Metacognitive Therapy (MCT), Metacognitive Training (e.g., for people with psychosis) and Metacognitive Reflection and Insight Therapy (MERIT). Two of these interventions are primarily targeted at patients with schizophrenia. Prompted by a recent discussion about what constitutes “true” metacognitive treatment, we will first explore the original concept of metacognition as defined by James H. Flavell. Then, we will describe each approach in detail before highlighting how each intervention picks up on slightly different aspects of Flavell's original metacognitive construct. We will also discuss inherent problems with the label “metacognition.”","author":[{"dropping-particle":"","family":"Moritz","given":"Steffen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lysaker","given":"Paul H.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Schizophrenia Research","id":"ITEM-1","issued":{"date-parts":[["2018"]]},"title":"Metacognition – What did James H. Flavell really say and the implications for the conceptualization and design of metacognitive interventions","type":"article-newspaper"},"uris":[""]}],"mendeley":{"formattedCitation":"¹³","plainTextFormattedCitation":"13","previouslyFormattedCitation":"¹³"},"properties":{"noteIndex":0},"schema":""}13 review how it has been usefully applied in psychosis to understanding the psychological mechanisms implicated in (i) awareness of cognitive biases,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.cpr.2014.04.004","ISBN":"0272-7358","ISSN":"18737811","PMID":"24866025","abstract":"The present article provides a narrative review of empirical studies on metacognitive training in psychosis (MCT). MCT represents an amalgam of cognitive-behavioral therapy (CBT), cognitive remediation (CRT) and psychoeducation. The intervention is available in either a group (MCT) or an individualized (MCT. +) format. By sowing the seeds of doubt in a playful and entertaining fashion, the program targets positive symptoms, particularly delusions. It aims to raise patients' awareness for common cognitive traps or biases (e.g., jumping to conclusions, overconfidence in errors, bias against disconfirmatory evidence) that are implicated in the formation and maintenance of psychosis. The majority of studies confirm that MCT meets its core aim, the reduction of delusions. Problems (e.g., potential allegiance effects) and knowledge gaps (i.e., outcome predictors) are highlighted. The preliminary data suggest that the individual MCT format is especially effective in addressing symptoms, cognitive biases and insight. We conclude that MCT appears to be a worthwhile complement to pharmacotherapy. ?? 2014 Elsevier Ltd.","author":[{"dropping-particle":"","family":"Moritz","given":"Steffen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Andreou","given":"Christina","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Schneider","given":"Brooke C.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wittekind","given":"Charlotte E.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Menon","given":"Mahesh","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Balzan","given":"Ryan P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Woodward","given":"Todd S.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Clinical Psychology Review","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2014"]]},"page":"358-366","title":"Sowing the seeds of doubt: A narrative review on metacognitive training in schizophrenia","type":"article","volume":"34"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁴","plainTextFormattedCitation":"14","previouslyFormattedCitation":"¹⁴"},"properties":{"noteIndex":0},"schema":""}14 such as the ‘jumping to conclusions’ bias,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1080/14640748808402300","ISBN":"0272-4987 (Print)\\r0272-4987 (Linking)","ISSN":"0272-4987","PMID":"3212213","abstract":"An experiment is described in which deluded subjects were compared with a non-deluded psychiatric control group and a normal control group on a probabilistic inference task. Deluded subjects were found to request less information before reaching a decision and to express higher certainty levels than either control group. They also exhibited over-confidence on estimates of the probability of a future event. Delusion. A false personal belief based on incorrect inference about external reality and firmly sustained in spite of what almost everyone else believes and in spite of what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person's subculture.","author":[{"dropping-particle":"","family":"Huq","given":"S. F.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Garety","given":"P. A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hemsley","given":"D. R.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Quarterly Journal of Experimental Psychology Section A","id":"ITEM-1","issue":"4","issued":{"date-parts":[["1988"]]},"page":"801-812","title":"Probabilistic judgements in deluded and non-deluded subjects","type":"article-journal","volume":"40"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1093/schbul/sbv150","ISSN":"17451701","abstract":"? The Author 2015. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. We did a systematic review and meta-analysis to investigate the magnitude and specificity of the \"jumping to conclusions\" (JTC) bias in psychosis and delusions. We examined the extent to which people with psychosis, and people with delusions specifically, required less information before making decisions. We examined (1) the average amount of information required to make a decision and (2) numbers who demonstrated an extreme JTC bias, as assessed by the \"beads task.\" We compared people with psychosis to people with and without nonpsychotic mental health problems, and people with psychosis with and without delusions. We examined whether reduced data-gathering was associated with increased delusion severity. We identified 55 relevant studies, and acquired previously unpublished data from 16 authors. People with psychosis required significantly less information to make decisions than healthy individuals (k = 33, N = 1935, g = -0.53, 95% CI -0.69, -0.36) and those with nonpsychotic mental health problems (k = 13, N = 667, g = -0.58, 95% CI -0.80, -0.35). The odds of extreme responding in psychosis were between 4 and 6 times higher than the odds of extreme responding by healthy participants and participants with nonpsychotic mental health problems. The JTC bias was linked to a greater probability of delusion occurrence in psychosis (k = 14, N = 770, OR 1.52, 95% CI 1.12, 2.05). There was a trend-level inverse association between data-gathering and delusion severity (k = 18; N = 794; r = -.09, 95% CI -0.21, 0.03). Hence, nonaffective psychosis is characterized by a hasty decision-making style, which is linked to an increased probability of delusions.","author":[{"dropping-particle":"","family":"Dudley","given":"R.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Taylor","given":"P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wickham","given":"S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hutton","given":"P.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Schizophrenia Bulletin","id":"ITEM-2","issue":"3","issued":{"date-parts":[["2016"]]},"title":"Psychosis, delusions and the \"Jumping to Conclusions\" reasoning bias: A systematic review and meta-analysis","type":"article-journal","volume":"42"},"uris":[""]}],"mendeley":{"formattedCitation":"^15,16","plainTextFormattedCitation":"15,16","previouslyFormattedCitation":"^15,16"},"properties":{"noteIndex":0},"schema":""}15,16 (ii) concepts of self and others, including perceived self-integrationADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Lysaker","given":"P.H.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lyskaker","given":"J.T.","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2008"]]},"publisher":"Oxford University Press","publisher-place":"Oxford","title":"Schizophrenia and the Fate of the Self","type":"book"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁷","plainTextFormattedCitation":"17","previouslyFormattedCitation":"¹⁷"},"properties":{"noteIndex":0},"schema":""}17 and (iii) negative metacognitive beliefs about the controllability and danger of worry and rumination.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1017/S1352465808004803","ISBN":"1352465808004","ISSN":"13524658","abstract":"The theory and principles of Meta cognitive therapy (MCT) are described and data supporting its effects are summarized. MCT does not advocate challenging of negative automatic thoughts or traditional schemas. It proposes the existence of a universal maladaptive thinking style that causes disorder and focuses on helping patients regulate their cognition more adaptively. It aims to reduce worry and rumination and alter problematic patterns of attention and coping. In doing so it targets underlying metacognition that controls thinking and helps patients develop new ways of consciously experiencing inner events. Data from treatment studies suggest that individual MCT techniques and full treatment are highly effective. Further randomized trials are clearly warranted. (PsycINFO Database Record (c) 2012 APA, all rights reserved) (journal abstract)","author":[{"dropping-particle":"","family":"Wells","given":"Adrian","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Behavioural and Cognitive Psychotherapy","id":"ITEM-1","issued":{"date-parts":[["2008"]]},"title":"Metacognitive therapy: Cognition applied to regulating cognition","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁸","plainTextFormattedCitation":"18","previouslyFormattedCitation":"¹⁸"},"properties":{"noteIndex":0},"schema":""}18 In relation to the latter, high levels of negative metacognitive beliefs are associated with psychotic symptom severity and chronicity,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.psychres.2015.09.006","ISSN":"18727123","PMID":"26381182","abstract":"Metacognitive abnormalities have been implicated in the experience of psychotic symptoms; however, the process through which this occurs remains unclear. The aim of this study was to clarify the association of self-reported schizotypy with metacognitive beliefs and neural activity related to higher-order cognition. Event-related potentials (ERPs) including the error-related negativity (ERN) and error positivity (Pe) were recorded during a Flanker task in 20 controls and 22 individuals with high self-reported schizotypy on the Schizotypal Personality Questionnaire-Brief Revised (SPQ-BR). Participants continuously evaluated their task performance and completed the Metacognitions Questionnaire-30 (MCQ-30). The high schizotypy group demonstrated higher scores on all subscales of the MCQ-30. In contrast, task performance, accuracy of self-performance evaluation, and amplitudes of the ERN and Pe did not differ between groups. The MCQ-30 factors that measure cognitive confidence and positive beliefs about worry significantly predicted SPQ-BR total score, whereas ERPs did not. High self-reported schizotypy appears to be more associated with dysfunctional metacognitive beliefs than physiological abnormalities in brain areas related to metacognition.","author":[{"dropping-particle":"","family":"Chan","given":"Chi C.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Spencer","given":"Christopher C.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"West","given":"Chloe","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Viegas","given":"Carina","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bedwell","given":"Jeffrey S.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychiatry Research","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2015"]]},"page":"279-286","title":"Metacognitive processes in psychometrically defined schizotypy","type":"article-journal","volume":"230"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.schres.2016.09.032","ISSN":"09209964","abstract":"This meta-analysis investigated whether the five metacognitive beliefs implicated in the Self-Regulatory Executive Function (S-REF) model (Wells and Matthews, 1994; Wells and Matthews, 1996) are elevated in people with clinical psychosis compared to people with emotional disorder and non-psychiatric controls. The review followed guidance set-out in the PRISMA statement. Primary analyses compared summary effect sizes on each sub-scale of the Metacognitions Questionnaire (MCQ) for people with psychosis and non-psychiatric controls; and people with psychosis and people with emotional disorder. Eleven eligible studies were identified comprised of 568 psychosis participants, 212 emotional disorder participants and 776 non-psychiatric controls. Findings indicated that people with psychosis had higher scores on all sub-scales of the MCQ compared to non-psychiatric controls; and higher scores on the positive beliefs about worry sub-scale compared to people with emotional disorder. This suggests metacognitive beliefs may be associated with the presence of psychological disorder and distress in general, rather than specific diagnoses. Implications for models of psychosis and treatment are discussed.","author":[{"dropping-particle":"","family":"Sellers","given":"Rachel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Varese","given":"Filippo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wells","given":"Adrian","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Morrison","given":"Anthony P.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Schizophrenia Research","id":"ITEM-2","issued":{"date-parts":[["2017"]]},"page":"75-84","title":"A meta-analysis of metacognitive beliefs as implicated in the self-regulatory executive function model in clinical psychosis","type":"article-journal","volume":"179"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1007/s10608-014-9633-9","ISSN":"0147-5916","author":[{"dropping-particle":"","family":"Austin","given":"Stephen F.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mors","given":"Ole","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nordentoft","given":"Merete","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hjorth?j","given":"Carsten R.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Secher","given":"Rikke G.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hesse","given":"Morten","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hagen","given":"Roger","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Spada","given":"Marcantonio","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wells","given":"Adrian","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Cognitive Therapy and Research","id":"ITEM-3","issue":"1","issued":{"date-parts":[["2015","2","7"]]},"page":"61-69","publisher":"Springer US","title":"Schizophrenia and Metacognition: An Investigation of Course of Illness and Metacognitive Beliefs Within a First Episode Psychosis","type":"article-journal","volume":"39"},"uris":[""]},{"id":"ITEM-4","itemData":{"DOI":"10.1016/S0005-7967(02)00095-5","ISSN":"00057967","abstract":"This study tested the hypothesis that metacognitions are a general vulnerability factor for psychological disorder. It was predicted that patients with psychosis (hallucinations or delusions), and patients with panic disorder would score higher than non-patients on measures of metacognition. Moreover, it was hypothesised that patients showing most dysregulation of thinking (voice-hearers) would endorse significantly higher metacognition scores than individuals in the other groups. The Meta-Cognitions Questionnaire (MCQ: Cartwright-Hatton & Wells, Journal of Anxiety Disorders 11 (1997) 279) was administered to patients who met DSM-IV criteria for schizophrenia spectrum disorders with auditory hallucinations, patients who met DSM-IV criteria for schizophrenia spectrum disorders with persecutory delusions, patients who met DSM-IV criteria for panic disorder and non-patients. The results showed that psychotic patients who experience auditory hallucinations tended to exhibit higher levels of dysfunctional metacognitive beliefs than other patient groups, scoring significantly higher than at least two of the three control groups on positive beliefs about worry, negative beliefs about uncontrollability and danger, cognitive confidence and negative beliefs including superstition, punishment and responsibility. It was also found that the metacognitive beliefs of patients with persecutory delusions and panic patients were often similar to each other, and elevated in comparison to non-patients, suggesting that such beliefs are generic vulnerability factors. The theoretical and clinical implications of these findings are discussed.","author":[{"dropping-particle":"","family":"Morrison","given":"Anthony P","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wells","given":"Adrian","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Behaviour Research and Therapy","id":"ITEM-4","issue":"2","issued":{"date-parts":[["2003"]]},"number-of-pages":"251-256","title":"A comparison of metacognitions in patients with hallucinations, delusions, panic disorder, and non-patient controls","type":"report","volume":"41"},"uris":[""]}],"mendeley":{"formattedCitation":"^19–22","plainTextFormattedCitation":"19–22","previouslyFormattedCitation":"^19–22"},"properties":{"noteIndex":0},"schema":""}19–22 and changing these beliefs may lead to improvements in psychotic symptoms. ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1017/S1352465812001026","ISSN":"13524658","abstract":"Background: More effective psychological treatments for psychosis are required. Case series data and pilot trials suggest metacognitive therapy (MCT) is a promising treatment for anxiety and depression. Other research has found negative metacognitive beliefs and thought-control strategies may be involved in the development and maintenance of hallucinations and delusions. The potential of MCT in treating psychosis has yet to be investigated. Aims: Our aim was to find out whether a short number of MCT sessions would be associated with clinically significant and sustained improvements in delusions, hallucinations, anxiety, depression and subjective recovery in patients with treatment-resistant long-standing psychosis. Method: Three consecutively referred patients, each with a diagnosis of paranoid schizophrenia and continuing symptoms, completed a series of multiple baseline assessments. Each then received between 11 and 13 sessions of MCT and completed regular assessments of progress, during therapy, post-therapy and at 3-month follow-up. Results: Two out of 3 participants achieved clinically significant reductions across a range of symptom-based outcomes at end-of-therapy. Improvement was sustained at 3-month follow-up for one participant. Conclusions: Our study demonstrates the feasibility of using MCT with people with medication-resistant psychosis. MCT was acceptable to the participants and associated with meaningful change. Some modifications may be required for this population, after which a controlled trial may be warranted. ? British Association for Behavioural and Cognitive Psychotherapies 2013.","author":[{"dropping-particle":"","family":"Hutton","given":"P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Morrison","given":"A.P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wardle","given":"M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wells","given":"A.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Behavioural and Cognitive Psychotherapy","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2014"]]},"title":"Metacognitive therapy in treatment-resistant psychosis: A multiple-baseline study","type":"article-journal","volume":"42"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.jbtep.2013.11.003","ISBN":"0005-7916; EN :1873-7943","ISSN":"00057916","PMID":"24440585","abstract":"Background and objectives Cognitive behaviour therapy (CBT) for psychosis has been shown to be effective, but there are recent suggestions that it is less efficacious than initially thought. Metacognitive therapy (MCT), which focuses on metacognitive mechanisms, has led to positive results in other disorders, but has yet to be evaluated in people with schizophrenia spectrum diagnoses. This study evaluates the feasibility of MCT for people with psychotic disorders. Methods Ten participants with schizophrenia spectrum disorders received up to 12 sessions of MCT in an open trial. Outcomes included psychiatric symptoms measured using the PANSS, at baseline, 9 months (end of treatment) and at 12 months (follow-up), as well as dimensions of hallucinations and delusions, emotional dysfunction, self-rated recovery, social functioning and metacognitive beliefs. Results T-tests and Wilcoxon's signed ranks tests revealed significant beneficial effects on several outcomes at end-of-treatment and follow-up. Cohen's d effect sizes were moderate to large (for PANSS total, d = 1.0 at end of treatment; d = 0.95 at follow-up). A response rate analysis found 50% and 40% of participants achieved at least a 25% reduction in PANSS total scores by end of therapy and follow-up, respectively. Exploratory analyses revealed that metacognitive beliefs significantly changed over treatment and follow-up periods. Limitations This study had no control group and was not randomised; therefore, it is likely that effect sizes were inflated. Conclusions This study provides preliminary evidence that MCT is a feasible treatment for people with psychosis. An adequately powered randomised controlled trial is warranted. ?? 2013 Elsevier Ltd. All rights reserved.","author":[{"dropping-particle":"","family":"Morrison","given":"Anthony P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pyle","given":"Melissa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chapman","given":"Nicola","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"French","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Parker","given":"Sophie K.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wells","given":"Adrian","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Behavior Therapy and Experimental Psychiatry","id":"ITEM-2","issue":"2","issued":{"date-parts":[["2014"]]},"page":"280-284","title":"Metacognitive therapy in people with a schizophrenia spectrum diagnosis and medication resistant symptoms: A feasibility study","type":"article-journal","volume":"45"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1016/j.jbtep.2009.09.001","ISBN":"ES:1873-7943 IL:0005-7916","ISSN":"00057916","PMID":"19818953","abstract":"Recent research has shown that worry is associated with distressing paranoia. Therefore, the aim was to target worry in a therapeutic intervention for individuals with delusions. It was predicted that a worry intervention would reduce levels of worry and paranoia distress. Twenty-four individuals with persistent persecutory delusions and high levels of worry were randomly assigned to receive a four session cognitive-behavioural worry intervention (W-CBT) or treatment as usual (TAU). The worry intervention was specifically designed not to target the content of delusions. In this open-label evaluation, assessments of worry and paranoia were conducted at baseline, at one month (end of treatment) and at two months. The worry intervention achieved a statistically significant reduction in worry which was maintained at two month follow up. A significant reduction in delusional distress was also reported. There was an indication that the worry intervention may also reduce the frequency of paranoid thoughts but this was not statistically significant. In the first trial specifically for persecutory delusions, a brief worry intervention was shown to have benefits. The results support a causal role for worry in paranoid experience. ?? 2009 Elsevier Ltd. All rights reserved.","author":[{"dropping-particle":"","family":"Foster","given":"Chloe","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Startup","given":"Helen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Potts","given":"Laura","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Freeman","given":"Daniel","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Behavior Therapy and Experimental Psychiatry","id":"ITEM-3","issue":"1","issued":{"date-parts":[["2010"]]},"page":"45-51","title":"A randomised controlled trial of a worry intervention for individuals with persistent persecutory delusions","type":"article-journal","volume":"41"},"uris":[""]},{"id":"ITEM-4","itemData":{"DOI":"10.1016/S2215-0366(15)00039-5","ISBN":"2215-0374","ISSN":"22150366","PMID":"26360083","abstract":"Background: Worry might be a contributory causal factor in the occurrence of persecutory delusions in patients with psychotic disorders. Therefore we postulated that reducing worry with cognitive behaviour therapy (CBT) would reduce persecutory delusions. Methods: For our two-arm, assessor-blinded, randomised controlled trial (Worry Intervention Trial [WIT]), we recruited patients aged 18-65 years with persistent persecutory delusions but non-affective psychosis from two centres: the Oxford Health National Health Service (NHS) Foundation Trust (Oxford, UK) and the Southern Health NHS Foundation Trust (Southampton, UK). The key inclusion criteria for participants were a score of at least 3 on the Psychotic Symptoms Rating Scale (PSYRATS) denoting a current persecutory delusion; that the delusion had persisted for at least 3 months; a clinical diagnosis of schizophrenia, schizoaffective disorder, or delusional disorder; and a clinically significant level of worry. We randomly assigned (1:1) eligible patients, using a randomly permuted block procedure with variable block sizes and division by four strata, to either six sessions of worry-reduction CBT intervention done over 8 weeks added to standard care (the CBT-intervention group), or to standard care alone (the control group). The assessors were masked to patient allocations and did their assessments at week 0 (baseline), 8 weeks (end of treatment), and 24 weeks, follow-up. The primary outcomes were worry measured by the Penn State Worry Questionnaire (PSWQ) and delusions measured by the PSYRATS-delusion scale, we did the analyses in the intention-to-treat population, and also did a planned mediation analysis. This trial is registered with the ISRCTN Registry (number ISRCTN23197625) and is closed to new participants. Findings: From Nov 1, 2011, to Sept 9, 2013, we recruited 150 eligible participants and randomly assigned 73 to the CBT intervention group, and 77 to the control group. 143 patients (95%) provided primary outcome follow-up data. Compared with standard care alone, at 8 weeks the CBT intervention significantly reduced worry (mean difference 6·35 [SE 1·56] PSWQ units, 95% CI 3·30-9·40; p<0·001) and persecutory delusions (2·08 [SE 0·73] PSYRATS units, 95% CI 0·64-3·51; p=0·005). The reductions were maintained to 24 weeks follow-up. The mediation analysis suggested that the change in worry accounted for 66% of the change in delusion. No patients died or were admitted to secure units during our st…","author":[{"dropping-particle":"","family":"Freeman","given":"Daniel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dunn","given":"Graham","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Startup","given":"Helen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pugh","given":"Katherine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cordwell","given":"Jacinta","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mander","given":"Helen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"?ernis","given":"Emma","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wingham","given":"Gail","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shirvell","given":"Katherine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kingdon","given":"David","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Lancet Psychiatry","id":"ITEM-4","issue":"4","issued":{"date-parts":[["2015"]]},"page":"305-313","title":"Effects of cognitive behaviour therapy for worry on persecutory delusions in patients with psychosis (WIT): A parallel, single-blind, randomised controlled trial with a mediation analysis","type":"article-journal","volume":"2"},"uris":[""]}],"mendeley":{"formattedCitation":"^23–26","plainTextFormattedCitation":"23–26","previouslyFormattedCitation":"^23–26"},"properties":{"noteIndex":0},"schema":""}23–26 Although worry and rumination are associated with suicidality in various populationsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Kerkhof","given":"A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Spijker","given":"B","non-dropping-particle":"van","parse-names":false,"suffix":""}],"container-title":"International Handbook of Suicide Prevention","editor":[{"dropping-particle":"","family":"O'Connor","given":"R","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Platt","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gordon","given":"J","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2011"]]},"publisher":"Wiley Blackwell","publisher-place":"Chichester","title":"Worrying and Rumination as proximal risk factors for suicidal behaviour","type":"chapter"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1037/gpr0000101","ISSN":"10892680","abstract":"Rumination has been implicated as a risk factor for suicidal ideation and attempts, yet the literature to date has not been synthesized. We conducted a meta-analysis of the association between rumination and both suicidal ideation and attempts to consolidate the existing literature (k = 29). Results indicated that the relationships between global rumination (k = 13; Hedge’s g = .74, p < .001, 95% CI [.45, 1.04]), brooding (k = 12; Hedge’s g = .63, p < .001, 95% CI [.35, .90]), and reflection (k = 12; Hedge’s g = .38, p = .002, 95% CI [.10, .65]) with suicidal ideation were significant. Associations between global rumination (k = 3; Hedge’s g = .26, p < .001, 95% CI [.08, .44]) and brooding (k = 4; Hedge’s g = .47, p = .004, 95% CI [.02, .91]) and suicide attempts were significant, but reflection (k = 4; Hedge’s g = .09, p = .646, 95% CI [?.54, .72]) was unrelated. However, given the limited studies included in suicide attempt analyses—and the exclusive use of cross-sectional designs and heterogeneity with regard to samples and measures—these parameters should be taken with caution. Generally, age, gender, race/ethnicity, and year of publication were not moderators, and there was little evidence for publication bias across effects, with the exception of the effect of global rumination on suicidal ideation. Several future research directions are discussed.","author":[{"dropping-particle":"","family":"Rogers","given":"Megan L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Joiner","given":"Thomas E.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Review of General Psychology","id":"ITEM-2","issued":{"date-parts":[["2017"]]},"title":"Rumination, suicidal ideation, and suicide attempts: A meta-analytic review","type":"article-journal"},"uris":[""]},{"id":"ITEM-3","itemData":{"author":[{"dropping-particle":"","family":"O'Connor","given":"R.C.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kirtley","given":"O.J.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Philosophical Transactions of the Royal Society B: Biological Sciences","id":"ITEM-3","issue":"1754","issued":{"date-parts":[["2018"]]},"title":"The integrated motivational–volitional model of suicidal behaviour","type":"article-journal","volume":"373"},"uris":[""]}],"mendeley":{"formattedCitation":"^27–29","plainTextFormattedCitation":"27–29","previouslyFormattedCitation":"^27–30"},"properties":{"noteIndex":0},"schema":""}27–29 and although a cross-sectional study (N=1920) found that rumination was associated with increased suicidality in people with schizophrenia,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/j.1600-0447.1996.tb09829.x","ISBN":"0001-690X (Print)\\r0001-690X (Linking)","ISSN":"0001690X","PMID":"8883567","abstract":"Biological findings such as low 5-HIAA levels in cerebrospinal fluid (CSF) in suicidal patients compared to non-suicidal patients independent of the type of psychiatric disorder indicate a broad basis for suicidality. It is therefore important to ask whether a suicidality syndrome can be delineated on a phenomenological level, and whether it is independent of specific major psychiatric disorders which are otherwise considered to be aetiologically different. This paper reports on a study of 2383 schizophrenic and 1920 depressive unselected patients with and without suicidality. They were assessed during the first 24 h after admission to a psychiatric in-patient facility using a comprehensive psychopathological assessment (AMDP system). Using multiple variance analysis and logistic regression analysis based on single symptoms, for both suicidal and non-suicidal patients it was shown that a suicidality syndrome independent of the underlying illness can be delineated. In schizophrenia as well as in major affective disorders it was found that hopelessness, ruminative thinking, social withdrawal and lack of activity are core symptoms of this suicidal syndrome. The finding of a suicidality syndrome, not associated with a specific major affective disorder, indicates the need to identify this syndrome, which should be seen as an independent dimension and diagnosed separately, and not regarded merely as a secondary symptom of major psychiatric disorders, particularly affective disorders.","author":[{"dropping-particle":"","family":"Ahrens","given":"B.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Linden","given":"M.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Acta Psychiatrica Scandinavica","id":"ITEM-1","issued":{"date-parts":[["1996"]]},"title":"Is there a suicidality syndrome independent of specific major psychiatric disorder? Results of a split half multiple regression analysis","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"³⁰","plainTextFormattedCitation":"30","previouslyFormattedCitation":"³¹"},"properties":{"noteIndex":0},"schema":""}30 negative metacognitive beliefs have not featured prominently in theoretical accounts of their increased suicide risk.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.cpr.2006.12.001","ISBN":"0272-7358","ISSN":"02727358","PMID":"17229508","abstract":"People with a diagnosis of schizophrenia are at increased risk of suicidal behaviour yet little is understood of the psychological underpinnings of this vulnerability. The biopsychosocial 'Cry of Pain' model [Williams, J.M.G. (1997). Cry of pain. Harmondsworth: Penguin.] provides a broad framework from which to understand suicidal behaviour. However, the utility of the model in relation to suicide in schizophrenia has not yet been explored. This was the primary goal of this paper. Six components of the 'Cry of Pain' model were identified and evaluated with respect to whether they contributed to i. common transdiagnostic factors underlying suicide, ii. factors relating to co-morbid depression which account for suicidal behaviour, or iii. factors which are specific to schizophrenia and underlie suicide risk. The potential for applying the model to clinical management of suicide in schizophrenia is illustrated.","author":[{"dropping-particle":"","family":"Bolton","given":"Catherine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gooding","given":"Patricia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kapur","given":"Nav","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Barrowclough","given":"Christine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tarrier","given":"Nicholas","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Clinical Psychology Review","id":"ITEM-1","issued":{"date-parts":[["2007"]]},"title":"Developing psychological perspectives of suicidal behaviour and risk in people with a diagnosis of schizophrenia: We know they kill themselves but do we understand why?","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"³¹","plainTextFormattedCitation":"31","previouslyFormattedCitation":"³²"},"properties":{"noteIndex":0},"schema":""}31 In this study, we set out to test a metacognitive model of suicidal ideation in this group (see Figure 1).ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S0140-6736(13)62246-1","ISBN":"1474-547X","ISSN":"1474-547X","PMID":"24508320","abstract":"BACKGROUND: Antipsychotic drugs are usually the first line of treatment for schizophrenia; however, many patients refuse or discontinue their pharmacological treatment. We aimed to establish whether cognitive therapy was effective in reducing psychiatric symptoms in people with schizophrenia spectrum disorders who had chosen not to take antipsychotic drugs.\\n\\nMETHODS: We did a single-blind randomised controlled trial at two UK centres between Feb 15, 2010, and May 30, 2013. Participants aged 16-65 years with schizophrenia spectrum disorders, who had chosen not to take antipsychotic drugs for psychosis, were randomly assigned (1:1), by a computerised system with permuted block sizes of four or six, to receive cognitive therapy plus treatment as usual, or treatment as usual alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. Our primary outcome was total score on the positive and negative syndrome scale (PANSS), which we assessed at baseline, and at months 3, 6, 9, 12, 15, and 18. Analysis was by intention to treat, with an ANCOVA model adjusted for site, age, sex, and baseline symptoms. This study is registered as an International Standard Randomised Controlled Trial, number 29607432.\\n\\nFINDINGS: 74 individuals were randomly assigned to receive either cognitive therapy plus treatment as usual (n=37), or treatment as usual alone (n=37). Mean PANSS total scores were consistently lower in the cognitive therapy group than in the treatment as usual group, with an estimated between-group effect size of -6.52 (95% CI -10.79 to -2.25; p=0.003). We recorded eight serious adverse events: two in patients in the cognitive therapy group (one attempted overdose and one patient presenting risk to others, both after therapy), and six in those in the treatment as usual group (two deaths, both of which were deemed unrelated to trial participation or mental health; three compulsory admissions to hospital for treatment under the mental health act; and one attempted overdose).\\n\\nINTERPRETATION: Cognitive therapy significantly reduced psychiatric symptoms and seems to be a safe and acceptable alternative for people with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs. Evidence-based treatments should be available to these individuals. A larger, definitive trial is needed.\\n\\nFUNDING: National Institute for Health Research.","author":[{"dropping-particle":"","family":"Morrison","given":"Anthony P","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Turkington","given":"Douglas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pyle","given":"Melissa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Spencer","given":"Helen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brabban","given":"Alison","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dunn","given":"Graham","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Christodoulides","given":"Tom","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dudley","given":"Rob","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chapman","given":"Nicola","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Callcott","given":"Pauline","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Grace","given":"Tim","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lumley","given":"Victoria","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Drage","given":"Laura","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tully","given":"Sarah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Irving","given":"Kerry","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cummings","given":"Anna","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Byrne","given":"Rory","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Davies","given":"Linda M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hutton","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Lancet","id":"ITEM-1","issue":"9926","issued":{"date-parts":[["2014"]]},"page":"1395-403","title":"Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial.","type":"article-journal","volume":"383"},"uris":[""]}],"mendeley":{"formattedCitation":"³²","plainTextFormattedCitation":"32","previouslyFormattedCitation":"³³"},"properties":{"noteIndex":0},"schema":""}32 We focused on recent suicidal ideation (past 2 weeks) because of its strong relationship to dying from suicide in psychosis (OR 30, 95% CI 12-73)ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1192/bjp.187.1.9","ISBN":"9781847471","ISSN":"0007-1250","PMID":"15994566","abstract":"BACKGROUND: Suicide risk is greatly increased in schizophrenia. Detection of those at risk is clinically important. AIMS: To identify risk factors for suicide in schizophrenia. METHOD: The international literature on case-control and cohort studies of patients with schizophrenia or related conditions in which suicide was reported as an outcome was systematically reviewed. Studies were identified through searching electronic databases and reference lists, and by consulting experts. RESULTS: Twenty-nine eligible studies were identified. Factors with robust evidence of increased risk of suicide were previous depressive disorders (OR=3.03, 95% CI 2.06-4.46), previous suicide attempts (OR=4.09, 95% CI 2.79-6.01), drug misuse (OR=3.21, 95% CI 1.99-5.17), agitation or motor restlessness (OR=2.61, 95% CI 1.54-4.41), fear of mental disintegration (OR=12.1, 95% CI 1.89-81.3), poor adherence to treatment (OR=3.75, 95% CI 2.20-6.37) and recent loss (OR=4.03, 95% CI 1.37-11.8). Reduced risk was associated with hallucinations (OR=0.50, 95% CI 0.35-0.71). CONCLUSIONS: Prevention of suicide in schizophrenia is likely to result from treatment of affective symptoms, improving adherence to treatment, and maintaining special vigilance in patients with risk factors, especially after losses.","author":[{"dropping-particle":"","family":"Hawton","given":"Keith","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sutton","given":"Lesley","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haw","given":"Camilla","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sinclair","given":"Julia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Deeks","given":"Jonathan J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The British journal of psychiatry : the journal of mental science","id":"ITEM-1","issued":{"date-parts":[["2005"]]},"page":"9-20","title":"Schizophrenia and suicide: systematic review of risk factors.","type":"article-journal","volume":"187"},"uris":[""]}],"mendeley":{"formattedCitation":"³","plainTextFormattedCitation":"3","previouslyFormattedCitation":"³"},"properties":{"noteIndex":0},"schema":""}3 and we focused on those who have been antipsychotic-free for an extended period of time, because they are considered to be at particularly high risk of suicide.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/bmj.38881.382755.2F","ISBN":"1756-1833","ISSN":"09598146","PMID":"16825203","abstract":"Objective To study the association between prescribed antipsychotic drugs and outcome in schizophrenia or schizoaffective disorder in the community.\\nDesign Prospective cohort study using national central registers.\\nSetting Community care in Finland.\\nParticipants Nationwide cohort of 2230 consecutive adults hospitalised in Finland for the first time because of schizophrenia or schizoaffective disorder, January 1995 to December 2001.\\nMain outcome measures Rates of discontinuation of drugs (all causes), rates of rehospitalisation, and mortality associated with monotherapy with the 10 most commonly used antipsychotic drugs. Multivariate models and propensity score methods were used to adjust estimates of effectiveness.\\nResults Initial use of clozapine (adjusted relative risk 0.17, 95% confidence interval 0.10 to 0.29), perphenazine depot (0.24, 0.13 to 0.47), and olanzapine (0.35, 0.18 to 0.71) were associated with the lowest rates of discontinuation for any reason when compared with oral haloperidol. During an average follow-up of 3.6 years, 4640 cases of rehospitalisation were recorded. Current use of perphenazine depot (0.32, 0.22 to 0.49), olanzapine (0.54, 0.41 to 0.71), and clozapine (0.64, 0.48 to 0.85) were associated with the lowest risk of rehospitalisation. Use of haloperidol was associated with a poor outcome among women. Mortality was markedly raised in patients not taking antipsychotics (12.3, 6.0 to 24.1) and the risk of suicide was high (37.4, 5.1 to 276).\\nConclusions The effectiveness of first and second generation antipsychotics varies greatly in the community. Patients treated with perphenazine depot, clozapine, or olanzapine have a substantially lower risk of rehospitalisation or discontinuation (for any reason) of their initial treatment than do patients treated with haloperidol. Excess mortality is seen mostly in patients not using antipsychotic drugs.","author":[{"dropping-particle":"","family":"Tiihonen","given":"Jari","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wahlbeck","given":"Kristian","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"L?nnqvist","given":"Jouko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Klaukka","given":"Timo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ioannidis","given":"John P.A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Volavka","given":"Jan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haukka","given":"Jari","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Medical Journal","id":"ITEM-1","issued":{"date-parts":[["2006"]]},"title":"Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: Observational follow-up study","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"⁴","plainTextFormattedCitation":"4","previouslyFormattedCitation":"⁴"},"properties":{"noteIndex":0},"schema":""}4 The model we tested is a version of a model of psychosis-related distress we developed for a recent case-series of metacognitive therapy (MCT),ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1017/S1352465812001026","ISBN":"1352465812001","ISSN":"1352-4658","PMID":"23286558","abstract":"BACKGROUND More effective psychological treatments for psychosis are required. Case series data and pilot trials suggest metacognitive therapy (MCT) is a promising treatment for anxiety and depression. Other research has found negative metacognitive beliefs and thought-control strategies may be involved in the development and maintenance of hallucinations and delusions. The potential of MCT in treating psychosis has yet to be investigated. AIMS Our aim was to find out whether a short number of MCT sessions would be associated with clinically significant and sustained improvements in delusions, hallucinations, anxiety, depression and subjective recovery in patients with treatment-resistant long-standing psychosis. METHOD Three consecutively referred patients, each with a diagnosis of paranoid schizophrenia and continuing symptoms, completed a series of multiple baseline assessments. Each then received between 11 and 13 sessions of MCT and completed regular assessments of progress, during therapy, post-therapy and at 3-month follow-up. RESULTS Two out of 3 participants achieved clinically significant reductions across a range of symptom-based outcomes at end-of-therapy. Improvement was sustained at 3-month follow-up for one participant. CONCLUSIONS Our study demonstrates the feasibility of using MCT with people with medication-resistant psychosis. MCT was acceptable to the participants and associated with meaningful change. Some modifications may be required for this population, after which a controlled trial may be warranted.","author":[{"dropping-particle":"","family":"Hutton","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Morrison","given":"Anthony P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wardle","given":"Melissa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wells","given":"Adrian","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Behavioural and Cognitive Psychotherapy","id":"ITEM-1","issue":"02","issued":{"date-parts":[["2014"]]},"page":"166-185","title":"Metacognitive Therapy in Treatment-Resistant Psychosis: A Multiple-Baseline Study","type":"article-journal","volume":"42"},"uris":[""]}],"mendeley":{"formattedCitation":"³³","plainTextFormattedCitation":"33","previouslyFormattedCitation":"³⁴"},"properties":{"noteIndex":0},"schema":""}33 but adapted to explain suicidality. According to this, a person may have suicidal thoughts because of an increase in the severity and negative content of their psychotic symptoms, which may in turn activate cognitive appraisals involving defeat and hopelessness (e.g., “I am powerless to influence or control my experiences”).ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.psychres.2009.10.015","ISBN":"0165-1781 (Print)\\r0165-1781 (Linking)","ISSN":"01651781","PMID":"20472304","abstract":"The current study tests whether perceptions of defeat and entrapment are the psychological mechanisms underlying the link between positive psychotic symptoms and suicidal ideation in schizophrenia. A sample of 78 patients with schizophrenia spectrum disorders completed self-report measures and a clinical interview. Of this sample, 21.8% reported a single past suicide attempt and 50% reported multiple past attempts. It was found that perceptions of defeat and entrapment, conceptualised as a single variable, accounted for a large proportion (31%) of the variance in suicidal ideation and behaviour. Defeat and entrapment also mediated the relationship between positive symptom severity and suicidal ideation. This result held whilst controlling for levels of hopelessness and depression. Secondary analyses suggested that suspiciousness in particular was linked to suicidal ideation. The results support a socio-cognitive model (The Schematic Appraisals Model of Suicide: SAMS) of suicide in psychosis. ?? 2009 Elsevier Ltd.","author":[{"dropping-particle":"","family":"Taylor","given":"Peter James","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gooding","given":"Patricia A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wood","given":"Alex M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Johnson","given":"Judith","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pratt","given":"Daniel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tarrier","given":"Nicholas","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychiatry Research","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2010"]]},"page":"244-248","publisher":"Elsevier Ltd","title":"Defeat and entrapment in schizophrenia: The relationship with suicidal ideation and positive psychotic symptoms","type":"article-journal","volume":"178"},"uris":[""]}],"mendeley":{"formattedCitation":"¹¹","plainTextFormattedCitation":"11","previouslyFormattedCitation":"¹¹"},"properties":{"noteIndex":0},"schema":""}11 However, the effect of symptoms and symptom appraisals on suicidal ideation will be magnified by negative ‘metacognitive’ beliefs about the uncontrollability and danger of worry (e.g., “My worrying thoughts persist, no matter how I try to stop them”, “My worrying could make me go mad”). The emergence of suicidal ideation can be conceptualised as not only a response to symptoms and related perceptions of defeat and entrapment, but also as attempts at cognitive control, motivated by worry about the uncontrollability and danger of worry itself. To test the model, we examined whether negative cognitive appraisals and negative metacognitive beliefs mediate the relationship between psychotic symptoms (overall, positive, negative or general) and suicidal ideation at baseline (month 0) and at follow-up (months 9-18). We then examined whether their initial cognitive appraisals and metacognitive beliefs mediated the relationship between initial symptom severity and future suicidal ideation.MethodsStudy Design, Participants, and ProceduresThis study is a secondary analysis of baseline and 9-18 month data obtained from the ACTION RCT, a pilot trial designed to assess the effects of cognitive therapy in individuals with a schizophrenia spectrum diagnosis not receiving antipsychotic medication for at least 6 months.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S0140-6736(13)62246-1","ISBN":"1474-547X","ISSN":"1474-547X","PMID":"24508320","abstract":"BACKGROUND: Antipsychotic drugs are usually the first line of treatment for schizophrenia; however, many patients refuse or discontinue their pharmacological treatment. We aimed to establish whether cognitive therapy was effective in reducing psychiatric symptoms in people with schizophrenia spectrum disorders who had chosen not to take antipsychotic drugs.\\n\\nMETHODS: We did a single-blind randomised controlled trial at two UK centres between Feb 15, 2010, and May 30, 2013. Participants aged 16-65 years with schizophrenia spectrum disorders, who had chosen not to take antipsychotic drugs for psychosis, were randomly assigned (1:1), by a computerised system with permuted block sizes of four or six, to receive cognitive therapy plus treatment as usual, or treatment as usual alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. Our primary outcome was total score on the positive and negative syndrome scale (PANSS), which we assessed at baseline, and at months 3, 6, 9, 12, 15, and 18. Analysis was by intention to treat, with an ANCOVA model adjusted for site, age, sex, and baseline symptoms. This study is registered as an International Standard Randomised Controlled Trial, number 29607432.\\n\\nFINDINGS: 74 individuals were randomly assigned to receive either cognitive therapy plus treatment as usual (n=37), or treatment as usual alone (n=37). Mean PANSS total scores were consistently lower in the cognitive therapy group than in the treatment as usual group, with an estimated between-group effect size of -6.52 (95% CI -10.79 to -2.25; p=0.003). We recorded eight serious adverse events: two in patients in the cognitive therapy group (one attempted overdose and one patient presenting risk to others, both after therapy), and six in those in the treatment as usual group (two deaths, both of which were deemed unrelated to trial participation or mental health; three compulsory admissions to hospital for treatment under the mental health act; and one attempted overdose).\\n\\nINTERPRETATION: Cognitive therapy significantly reduced psychiatric symptoms and seems to be a safe and acceptable alternative for people with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs. Evidence-based treatments should be available to these individuals. A larger, definitive trial is needed.\\n\\nFUNDING: National Institute for Health Research.","author":[{"dropping-particle":"","family":"Morrison","given":"Anthony P","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Turkington","given":"Douglas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pyle","given":"Melissa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Spencer","given":"Helen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brabban","given":"Alison","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dunn","given":"Graham","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Christodoulides","given":"Tom","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dudley","given":"Rob","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chapman","given":"Nicola","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Callcott","given":"Pauline","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Grace","given":"Tim","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lumley","given":"Victoria","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Drage","given":"Laura","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tully","given":"Sarah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Irving","given":"Kerry","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cummings","given":"Anna","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Byrne","given":"Rory","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Davies","given":"Linda M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hutton","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Lancet","id":"ITEM-1","issue":"9926","issued":{"date-parts":[["2014"]]},"page":"1395-403","title":"Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial.","type":"article-journal","volume":"383"},"uris":[""]}],"mendeley":{"formattedCitation":"³²","plainTextFormattedCitation":"32","previouslyFormattedCitation":"³³"},"properties":{"noteIndex":0},"schema":""}32 The trial was approved by the UK NHS National Research Ethics Service (09/H1014/53) and conducted in two sites (Manchester and Newcastle) between 2010 and 2013 (see protocolADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1080/17522439.2012.756539","ISBN":"1752-2439","ISSN":"1752-2439, 1752-2439","abstract":"Aims: Recent evidence regarding over-estimation of the efficacy of antipsychotics and under-estimation of their toxicity, as well as emerging data regarding alternative treatment options, suggest it may be time to introduce patient choice. However, only a small number of studies have reported on the efficacy of interventions for psychological interventions such as cognitive therapy. Early results suggest that cognitive therapy may be an effective, well-tolerated treatment for people who choose not to take antipsychotics. We report on the rationale and design for a multi-site randomised, controlled trial of cognitive therapy for people with a schizophrenia spectrum diagnosis who choose not to take antipsychotics. Methods: The study employs a single-blind design in which all participants receive treatment as usual, and half are randomised to up to 30 sessions of cognitive therapy for up to 9 months. Participants will be followed-up for a minimum of 9 months and to a maximum of 18 months. Results: We report the characteristics of the final sample at baseline (N = 74). Conclusions: Our study aims to expand the currently limited evidence base for best practice in interventions for individuals with psychosis who choose not to take antipsychotics. (PsycINFO Database Record (c) 2013 APA, all rights reserved) (journal abstract)","author":[{"dropping-particle":"","family":"Morrison","given":"Anthony P","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wardle","given":"Melissa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hutton","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dunn","given":"Graham","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brabban","given":"Alison","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Spencer","given":"Helen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Turkington","given":"Douglas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Davies","given":"Linda","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Byrne","given":"Rory","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Drage","given":"Laura","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychosis: Psychological, Social and Integrative Approaches","id":"ITEM-1","issue":"1","issued":{"date-parts":[["2013"]]},"page":"82-92","title":"Assessing Cognitive Therapy Instead Of Neuroleptics: Rationale, study design and sample characteristics of the ACTION trial.","type":"article-journal","volume":"5"},"uris":["",""]}],"mendeley":{"formattedCitation":"³⁴","plainTextFormattedCitation":"34","previouslyFormattedCitation":"³⁵"},"properties":{"noteIndex":0},"schema":""}34 for further information). MeasuresSymptoms: Positive and Negative Syndrome Scale (PANSS)The PANSSADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1093/schbul/13.2.261","ISBN":"1745-1701","ISSN":"0586-7614","PMID":"3616518","abstract":"The variable results of positive- negative research with schizo- phrenics underscore the importance of well-characterized, standardized measurement techniques. We report on the development and initial standardization of the Positive and Negative Syndrome Scale (PANSS) for typological and dimensional as- sessment. Based on two established psychiatric rating systems, the 30- item PANSS was conceived as an operationalized, drug-sensitive in- strument that provides balanced representation of positive and nega- tive symptoms and gauges their re- lationship to one another and to global psychopathology. It thus constitutes four scales measuring positive and negative syndromes, their differential, and general sever- ity of illness. Study of 101 schizo- phrenics found the four scales to be normally distributed and supported their reliability and stability. Posi- tive and negative scores were in- versely correlated once their common association with general psychopathology was extracted, suggesting that they represent mu- tually exclusive constructs. Review of five studies involving the PANSS provided evidence of its cri- terion-related validity with anteced- ent, genealogical, and concurrent measures, its predictive validity, its drug sensitivity, and its utility for both typological and dimensional assessment.","author":[{"dropping-particle":"","family":"Kay SR, Fiszbein A","given":"Opler La.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Schizophr Bull.","id":"ITEM-1","issue":"2","issued":{"date-parts":[["1987"]]},"page":"261-276","title":"The Positive and Negative Syndrome Scale for schizophrenia","type":"article-journal","volume":"13"},"uris":["",""]}],"mendeley":{"formattedCitation":"³⁵","plainTextFormattedCitation":"35","previouslyFormattedCitation":"³⁶"},"properties":{"noteIndex":0},"schema":""}35 is a 30-item interview based measure developed to assess the following symptom subscales associated with schizophrenia: General Psychopathology (16 items), Negative Symptom Scale (7 items), and Positive Symptom Scale (7 items). Symptoms in the preceding week are assessed using a 1-7 point Likert scale.Cognitive appraisals: Personal Beliefs About Experiences Questionnaire (PBEQ)The PBEQ is a revised version of the Personal beliefs about Illness Questionnaire (PBIQ),ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1017/S0033291700028488","ISBN":"0033-2917 (Print)","ISSN":"0033-2917","PMID":"8332655","abstract":"This paper explores the hypothesis that depression in chronic schizophrenia is in part a psychological response to an apparently uncontrollable life-event, namely the illness and its long-term disabilities. It is suggested that depression is linked to patients' perception of controllability of their illness and absorption of cultural stereotypes of mental illness. Clinically and operationally diagnosed schizophrenic and manic-depressive patients receiving long-term maintenance treatment were studied. The cross-sectional prevalence of depression in schizophrenics was 29% and 11% for patients with bipolar affective illness. The hypothesis was supported. Multivariate analyses revealed that patients' perception of controllability of their illness powerfully discriminated depressed from non-depressed psychotic patients. Although those patients who accepted their diagnosis reported a lower perceived control over illness and an external locus of control, label acceptance was not associated with lowered depression, self-esteem or unemployment. The cross-sectional nature of the study makes the direction of causality and the role of intrinsic illness variables difficult to ascertain; however, the results set the scene for prospective and intervention studies and the various possibilities are discussed.","author":[{"dropping-particle":"","family":"Birchwood","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mason","given":"R","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"MacMillan","given":"F","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Healy","given":"J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychological medicine","id":"ITEM-1","issue":"2","issued":{"date-parts":[["1993"]]},"page":"387-395","title":"Depression, demoralization and control over psychotic illness: a comparison of depressed and non-depressed patients with a chronic psychosis.","type":"article-journal","volume":"23"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1111/eip.12098","ISBN":"1751-7885","ISSN":"17517893","PMID":"25775264","abstract":"Aims: To investigate the relationship between internalized stigma, depression, social anxiety and unusual experiences in young people considered to be at risk of developing psychosis. Methods: A total of 288 participants meeting criteria for an at-risk mental state were recruited as part of a multisite randomized controlled trial of cognitive behavioural therapy for people meeting criteria for an at risk mental state (ARMS). The sample was assessed at baseline and 6months using measures of at risk mental states, internalized stigma, depression and social anxiety. Results: The Personal Beliefs about Experiences Questionnaire was validated for use with an ARMS sample. Correlational analyses at baseline indicated significant relationships between internalized stigma and: (i) depression; (ii) social anxiety; (iii) distress associated with unusual psychological experiences; and (iv) suicidal thinking. Regression analysis indicates negative appraisals of unusual experiences contributed significantly to depression scores at 6-month follow up when controlling for baseline depression and unusual psychological experiences. Conclusions: These findings suggest that internalized stigma may contribute to the development and maintenance of depression in young people at risk of psychosis. Copyright ? 2015 Wiley Publishing Asia Pty Ltd.","author":[{"dropping-particle":"","family":"Pyle","given":"Melissa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Stewart","given":"Suzanne L K","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"French","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Byrne","given":"Rory","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Patterson","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gumley","given":"Andrew","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Birchwood","given":"Max","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Morrison","given":"Anthony P.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Early Intervention in Psychiatry","id":"ITEM-2","issue":"2","issued":{"date-parts":[["2015"]]},"page":"133-140","title":"Internalized stigma, emotional dysfunction and unusual experiences in young people at risk of psychosis","type":"article-journal","volume":"9"},"uris":["",""]}],"mendeley":{"formattedCitation":"^36,37","plainTextFormattedCitation":"36,37","previouslyFormattedCitation":"^37,38"},"properties":{"noteIndex":0},"schema":""}36,37 and is designed to measure cognitive appraisals about psychotic experiences. Rating of the 13 items is on a 4-point Likert type scale, which ranges from ‘strongly disagree’ to ‘strongly agree’. Factor analysis suggests the PBEQ measures three specific domains of cognitions: Negative Appraisal of Experience (5 items), External Shame (2 items), and Internal Shame/Defectiveness (6 items).ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/bjc.12079","ISBN":"0144-6657","ISSN":"20448260","PMID":"25752586","abstract":"Objectives Negative beliefs about psychosis and other mental health difficulties may contribute to depression and distress in individuals with these experiences. The Personal Beliefs about Experience Questionnaire (PBEQ) and Personal Beliefs about Illness Questionnaire (PBIllQ) are two widely used measures of these beliefs. It is currently uncertain how the items on these measures map onto different underlying factors. This study therefore aimed to test the factor structure of these two measures. Methods Confirmatory factor analysis (CFA) was used to test three alternative, pre-specified, factor structures for the PBIllQ and PBEQ in a sample of individuals diagnosed with bipolar disorder (n = 202) and a sample of individuals with experien-ces of psychosis (n = 362). Associations with depressive symptoms were also examined. Result A three-factor structure was supported for both measures, which included Negative Expectations/Appraisals (NEA), Internal Shame/Defectiveness (ISD) and External Shame (ES) factors. The NEA and ISD subscales also had consistent independent associations with depressive symptoms. Conclusions The results suggest that the PBIllQ and PBEQ may capture three distinct sets of negative beliefs in individuals with psychosis or bipolar disorder and that these beliefs may have important consequences for subsequent difficulties in these populations such as depression. Both measures may be helpful in supporting assessment and formulation in clinical practice and in evaluating belief change in intervention trials. However, when used in these settings, the three subscales identified in this study may be the most valid way of calculating scores on these measures. Practitioner points * Negative personal beliefs about the causes, meaning and consequences of psychosis and bipolar disorder are associated with greater distress and depression. Two related measures, the PBIllQ and PBEQ, have been developed to assess these beliefs. * Our analyses suggest that scores on these questionnaires are best broken down into three subscales which capture perceptions of internal shame or defectiveness, general negative appraisals and perceptions of external shame. * These subscales may capture key underlying sets of negative beliefs within individuals with psychosis or bipolar disorder, which in turn impact upon well-being, such as being associated with greater depression. * These subscales can be used to aid assessment and formulation within clinical practice but…","author":[{"dropping-particle":"","family":"Taylor","given":"Peter J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pyle","given":"Melissa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Schwannauer","given":"Matthias","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hutton","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Morrison","given":"Anthony","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Journal of Clinical Psychology","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2015"]]},"page":"361-377","title":"Confirming the structure of negative beliefs about psychosis and bipolar disorder: A confirmatory factor analysis study of the Personal Beliefs about Experience Questionnaire and Personal Beliefs about Illness Questionnaire","type":"article-journal","volume":"54"},"uris":[""]}],"mendeley":{"formattedCitation":"³⁸","plainTextFormattedCitation":"38","previouslyFormattedCitation":"³⁹"},"properties":{"noteIndex":0},"schema":""}38 The PBEQ was also shown to have adequate internal reliability and validity. The Negative Appraisal of Experience subscale, which assesses the respondent’s negative appraisals and expectations of their own psychotic experiences, was used in this analysis. Items include “I am powerless to influence or control my experiences” and “My experiences frighten me”. Negative metacognitive beliefs: The Metacognitions Questionnaire 30-item version (MCQ-30)The MCQ-30ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S0005-7967(03)00147-5","ISBN":"0005-7967 (Print)\\r0005-7967 (Linking)","ISSN":"00057967","PMID":"14998733","abstract":"The metacognitions questionnaire (MCQ) measures individual differences in a selection of metacognitive beliefs, judgments and monitoring tendencies considered important in the metacognitive model of psychological disorders. The development and properties of a shortened 30-item version of the MCQ, the MCQ-30, are reported. Construct validity was evaluated by confirmatory and exploratory factor analysis. Overall, the fit indices suggested an acceptable fit to a five-factor model consistent with the original MCQ. Exploratory factor analysis supported a five-factor structure, which was almost identical to the original solution obtained in previous studies with the full MCQ. The five factors are cognitive confidence, positive beliefs about worry, cognitive self-consciousness, negative beliefs about uncontrollability of thoughts and danger, and beliefs about need to control thoughts. The MCQ-30 showed good internal consistency and convergent validity, and acceptable to good test-retest reliability. Positive relationships between metacognitions and measures of worry and obsessive-compulsive symptoms provided further support for the validity of the measure and the metacognitive theory of intrusive thoughts. The psychometric properties of MCQ-30 suggest that the instrument is a valuable addition to the assessment of metacognitions that has the advantage of being more economical to use compared with the original MCQ. ?? 2003 Elsevier Ltd. All rights reserved.","author":[{"dropping-particle":"","family":"Wells","given":"Adrian","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cartwright-Hatton","given":"Sam","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Behaviour Research and Therapy","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2004"]]},"page":"385-396","title":"A short form of the metacognitions questionnaire: Properties of the MCQ-30","type":"article-journal","volume":"42"},"uris":["",""]}],"mendeley":{"formattedCitation":"³⁹","plainTextFormattedCitation":"39","previouslyFormattedCitation":"⁴⁰"},"properties":{"noteIndex":0},"schema":""}39 is a 30-item self-report questionnaire, which measures individual metacognitive beliefs and processes, grouped under five different subscales; positive beliefs about worrying, negative beliefs about uncontrollability and danger of worry, cognitive confidence, beliefs about the need to control thoughts, and cognitive self-consciousness. Items are scored on a 4-point Likert type scale with 1 representing ‘I do not agree’ and 4 representing ‘I agree very much’. The MCQ-30 has good internal consistency, validity, and reliability.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S0005-7967(03)00147-5","ISBN":"0005-7967 (Print)\\r0005-7967 (Linking)","ISSN":"00057967","PMID":"14998733","abstract":"The metacognitions questionnaire (MCQ) measures individual differences in a selection of metacognitive beliefs, judgments and monitoring tendencies considered important in the metacognitive model of psychological disorders. The development and properties of a shortened 30-item version of the MCQ, the MCQ-30, are reported. Construct validity was evaluated by confirmatory and exploratory factor analysis. Overall, the fit indices suggested an acceptable fit to a five-factor model consistent with the original MCQ. Exploratory factor analysis supported a five-factor structure, which was almost identical to the original solution obtained in previous studies with the full MCQ. The five factors are cognitive confidence, positive beliefs about worry, cognitive self-consciousness, negative beliefs about uncontrollability of thoughts and danger, and beliefs about need to control thoughts. The MCQ-30 showed good internal consistency and convergent validity, and acceptable to good test-retest reliability. Positive relationships between metacognitions and measures of worry and obsessive-compulsive symptoms provided further support for the validity of the measure and the metacognitive theory of intrusive thoughts. The psychometric properties of MCQ-30 suggest that the instrument is a valuable addition to the assessment of metacognitions that has the advantage of being more economical to use compared with the original MCQ. ?? 2003 Elsevier Ltd. All rights reserved.","author":[{"dropping-particle":"","family":"Wells","given":"Adrian","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cartwright-Hatton","given":"Sam","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Behaviour Research and Therapy","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2004"]]},"page":"385-396","title":"A short form of the metacognitions questionnaire: Properties of the MCQ-30","type":"article-journal","volume":"42"},"uris":["",""]}],"mendeley":{"formattedCitation":"³⁹","plainTextFormattedCitation":"39","previouslyFormattedCitation":"⁴⁰"},"properties":{"noteIndex":0},"schema":""}39 We used the ‘Negative beliefs about uncontrollability and dangerousness of thoughts’ subscale in the current analysis. This assesses negative metacognitive appraisals and expectations about worrying and thinking. Items include “My worrying could make me go mad” and “My worrying is dangerous for me”.The Beck Depression Inventory for Primary Care (BDI-PC)The Beck Depression Inventory for Primary Care (BDI-PC)ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S0005-7967(97)00025-9","ISBN":"0005-7967 (Print)\\n0005-7967 (Linking)","ISSN":"00057967","PMID":"9256522","abstract":"To ascertain how effective the Beck Depression Inventory for Primary Care (BDI-PC) was for differentiating medical inpatients who were and were not diagnosed with DSM-IV major depression disorders (MDD), this 7-item self-report instrument composed of cognitive and affective symptoms was administered to 50 medical inpatients along with the Depression subscale (HDS) from the Hospital Anxiety and Depression Scale. The Mood Module from the Primary Care Evaluation of Mental Disorders was used to diagnose MDD. The internal consistency of the BDI-PC was high (α = 0.86), and it was moderately correlated with the HDS (r = 0.62, P < 0.001). The BDI-PC was not significantly correlated with sex, age, ethnicity, or type of medical diagnosis. A BDI-PC cut-off score of 4 and above yielded the maximum clinical efficiency with both 82% sensitivity and specificity rates. The clinical utility of the BDI-PC for identifying medical inpatients who should be evaluated for MDD is discussed.","author":[{"dropping-particle":"","family":"Beck","given":"Aaron T.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Guth","given":"David","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Steer","given":"Robert A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ball","given":"Roberta","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Behaviour Research and Therapy","id":"ITEM-1","issue":"8","issued":{"date-parts":[["1997"]]},"page":"785-791","title":"Screening for major depression disorders in medical inpatients with the Beck Depression Inventory for Primary Care","type":"article-journal","volume":"35"},"uris":[""]}],"mendeley":{"formattedCitation":"⁴⁰","plainTextFormattedCitation":"40","previouslyFormattedCitation":"⁴¹"},"properties":{"noteIndex":0},"schema":""}40 is a self-report questionnaire which measures depression severity. In this analysis, responses to item 7 (item 9 in the full BDI-2) were used to measure suicidal ideation. This item requires participants to select which of four statements best describe their experiences over the preceding 2 weeks. The statements are “I don’t have any thoughts of killing myself” (score of 0), “I have thoughts of killing myself, but I would not carry them out” (score of 1), “I would like to kill myself” (score of 2), and “I would kill myself if I had the chance” (score of 3). Responses correlate highly with the Beck Scale of Suicidal Ideation (r = 0.56 - 0.58),ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Beck","given":"AT","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Steer","given":"RA","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["1991"]]},"publisher":"The Psychological Corporation","publisher-place":"San Antonio","title":"Manual for the Beck Scale for suicidal ideation","type":"book"},"uris":["",""]}],"mendeley":{"formattedCitation":"⁴¹","plainTextFormattedCitation":"41","previouslyFormattedCitation":"⁴²"},"properties":{"noteIndex":0},"schema":""}41 and individuals scoring ≥2 on this item were 6.9 times more likely to commit suicide than those scoring <2.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISSN":"<null>","abstract":"The purpose of this review is to provide a systematic examination of the psychometric properties of measures of suicidal ideation and behavior for younger and older adults. Although several of the measures in this review may be utilized with children and adolescents, a more detailed and comprehensive review of suicide measures for these populations is available (see Goldston, 2000). Instruments were selected if they focused on suicidal behaviors or other behaviors that are closely associated with suicidal risk. Hence, the following categories of assessment instruments are reviewed: (1) Suicide ideation and behavior, (2) lethality of suicide attempts, (3) brief screening measures, (4) hopelessness, (5) reasons for living, (6) provider attitudes and knowledge concerning suicide and (7) measures in development. Athough some measures do not directly assess suicidal behavior, such as measures concerning hopelessness or reasons for living, these variables have been closely associated with suicide and are potentially modifiable with treatment. Therefore, these measures have been included in the review.","author":[{"dropping-particle":"","family":"Brown","given":"G.K.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Nimh","id":"ITEM-1","issued":{"date-parts":[["2000"]]},"title":"A review of suicide Assessment mesaures for intervention research with adults and older adults","type":"article-journal"},"uris":["",""]}],"mendeley":{"formattedCitation":"⁴²","plainTextFormattedCitation":"42","previouslyFormattedCitation":"⁴³"},"properties":{"noteIndex":0},"schema":""}42 Statistical Analyses Mediation analyses were conducted to concurrently test the direct effect of psychotic symptoms (overall, positive, negative or general) on suicidal ideation, and their hypothesised indirect effects through cognitive appraisals and metacognitive beliefs, at the two time points when we assessed each variable. To minimise the loss of power introduced by missing data at follow-up, we combined into one group those who had full datasets at either 9 months (n=39) or 18 months (n=10). To assess the risk of bias introducing by missing data, we tested for differences in baseline characteristics between the full baseline sample (N=68) and those for whom we had full baseline and full follow-up data (n=47). We also ran all baseline mediation analyses in both samples, and covaried for the follow-up assessment time-point (9 or 18 months). We tested a model whereby, after controlling for participant differences in age, gender, years of education, group allocation (follow-up analysis only) and the point when suicidal ideation was assessed (follow-up analysis only), psychotic symptoms activate negative cognitive appraisals, which then activate negative metacognitive beliefs, which in turn activates greater suicidal ideation (Figure 1). All mediation analyses were performed using Model 6 of the PROCESSADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"978-1-60918-230-4","ISBN":"9781609182304","ISSN":"<null>","PMID":"17658881","abstract":"This engaging book explains the fundamentals of mediation and moderation analysis and their integration as “conditional process analysis.” Procedures are described for testing hypotheses about the mechanisms by which causal effects operate, the conditions under which they occur, and the moderation of mechanisms. Relying on the principles of ordinary least squares regression, Andrew Hayes carefully explains the estimation and interpretation of direct and indirect effects, probing and visualization of interactions, and testing of questions about moderated mediation. Examples using data from published studies illustrate how to conduct and report the analyses described in the book. Of special value, the book introduces and documents PROCESS, a macro for SPSS and SAS that does all the computations described in the book. The author's website () offers free downloads of PROCESS plus data files for the book's examples.","author":[{"dropping-particle":"","family":"Hayes","given":"Af","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"New York, NY: Guilford","id":"ITEM-1","issued":{"date-parts":[["2013"]]},"page":"3-4","title":"Introduction to mediation, moderation, and conditional process analysis","type":"article-journal"},"uris":["",""]}],"mendeley":{"formattedCitation":"⁴³","plainTextFormattedCitation":"43","previouslyFormattedCitation":"⁴⁴"},"properties":{"noteIndex":0},"schema":""}43 macro for the IBM Statistical Package for Social Sciences (SPSS) (see Figure 2). This macro is based on a logistic regression-based path analytic framework and employs bootstrapping to determine the magnitude and significance of the direct (unmediated) and indirect (mediated) effects.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.3758/BRM.40.3.879","ISBN":"1554-351X","ISSN":"1554-351X","PMID":"18697684","abstract":"Hypotheses involving mediation are common in the behavioral sciences. Mediation exists when a predictor affects a dependent variable indirectly through at least one intervening variable, or mediator. Methods to assess mediation involving multiple simultaneous mediators have received little attention in the methodological literature despite a clear need. We provide an overview of simple and multiple mediation and explore three approaches that can be used to investigate indirect processes, as well as methods for contrasting two or more mediators within a single model. We present an illustrative example, assessing and contrasting potential mediators of the relationship between the helpfulness of socialization agents and job satisfaction. We also provide SAS and SPSS macros, as well as Mplus and LISREL syntax, to facilitate the use of these methods in applications.","author":[{"dropping-particle":"","family":"Preacher","given":"Kristopher J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hayes","given":"Andrew F","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Behavior research methods","id":"ITEM-1","issue":"3","issued":{"date-parts":[["2008"]]},"page":"879-891","title":"Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models.","type":"article-journal","volume":"40"},"uris":["",""]}],"mendeley":{"formattedCitation":"⁴⁴","plainTextFormattedCitation":"44","previouslyFormattedCitation":"⁴⁵"},"properties":{"noteIndex":0},"schema":""}44 Bootstrapping is a non-parametric approach that can be applied to smaller sample sizes and non-normal data.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.3758/BF03206553","ISBN":"0743-3808","ISSN":"0743-3808","PMID":"15641418","abstract":"Researchers often conduct mediation analysis in order to indirectly assess the effect of a proposed cause on some outcome through a proposed mediator. The utility of mediation analysis stems from its ability to go beyond the merely descriptive to a more functional understanding of the relationships among variables. A necessary component of mediation is a statistically and practically significant indirect effect. Although mediation hypotheses are frequently explored in psychological research, formal significance tests of indirect effects are rarely conducted. After a brief overview of mediation, we argue the importance of directly testing the significance of indirect effects and provide SPSS and SAS macros that facilitate estimation of the indirect effect with a normal theory approach and a bootstrap approach to obtaining confidence intervals, as well as the traditional approach advocated by Baron and Kenny (1986). We hope that this discussion and the macros will enhance the frequency of formal mediation tests in the psychology literature. Electronic copies of these macros may be downloaded from the Psychonomic Society's Web archive at archive/.","author":[{"dropping-particle":"","family":"Preacher","given":"Kristopher J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hayes","given":"Andrew F","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Behavior research methods, instruments, & computers","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2004"]]},"page":"717-731","title":"SPSS and SAS procedures for estimating indirect effects in simple mediation models","type":"article-journal","volume":"36"},"uris":["",""]}],"mendeley":{"formattedCitation":"⁴⁵","plainTextFormattedCitation":"45","previouslyFormattedCitation":"⁴⁶"},"properties":{"noteIndex":0},"schema":""}45 All models were conducted with bias-corrected confidence intervals based on 5,000 samples. In line with previous studies,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1192/bjp.2017.24","ISSN":"14721465","author":[{"dropping-particle":"","family":"N?slund","given":"Jakob","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hieronymus","given":"Fredrik","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lisinski","given":"Alexander","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nilsson","given":"Staffan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Eriksson","given":"Elias","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Journal of Psychiatry","id":"ITEM-1","issued":{"date-parts":[["2018"]]},"title":"Effects of selective serotonin reuptake inhibitors on rating-scale-assessed suicidality in adults with depression","type":"article-journal"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.ijchp.2017.08.001","ISSN":"16972600","abstract":"Background/Objective: Depression and suicide ideation regularly occur together. Yet, little is known about factors that buffer individuals against the development of suicide ideation. The present study investigated, whether positive mental health buffers the association between depression and suicide ideation in a longitudinal study design. Methods: A total of 207 German students (70.3% female; age: M = 26.04, SD = 5.33) were assessed at a baseline evaluation and again twelve months later. Data were collected using self-report questionnaires. Linear hierarchical regression analysis was used to analyze the data. Positive mental health was considered to moderate the impact of depression on suicide ideation - controlling for age and gender. Results: Positive mental health was shown to moderate the impact of depression on suicide ideation: in those students who reported higher levels of positive mental health, depression severity showed no association with suicide ideation over time. Conclusion: Positive mental health seems to confer resilience and should be taken into account, when assessing individuals for suicide risk.","author":[{"dropping-particle":"","family":"Teismann","given":"Tobias","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Forkmann","given":"Thomas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brailovskaia","given":"Julia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Siegmann","given":"Paula","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Glaesmer","given":"Heide","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Margraf","given":"Jürgen","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"International Journal of Clinical and Health Psychology","id":"ITEM-2","issued":{"date-parts":[["2017"]]},"title":"Positive mental health moderates the association between depression and suicide ideation: A longitudinal study","type":"article-journal"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.3389/fpsyt.2017.00242","ISBN":"1664-0640","ISSN":"16640640","PMID":"29249990","abstract":"Suicidality is highly prevalent in patients at clinical high risk (CHR) for psychosis. Childhood adversities and trauma are generally predictive of suicidality. However, the differential effects of adversity/trauma-domains and CHR-criteria, i.e. ultra-high risk and basic symptom criteria, on suicidality remain unclear. Furthermore, the underlying mechanisms and thus worthwhile targets for suicide-prevention are still poorly understood. Therefore, structural equation modeling was used to test theory-driven models in 73 CHR-patients. Mediators were psychological variables, i.e. beliefs about one’s own competencies as well as the controllability of events and coping styles. Additionally, symptomatic variables (depressiveness, basic symptoms, attenuated psychotic symptoms) were hypothesized to mediate the effect of psychological mediators on suicidality as the final outcome variable. Results showed two independent pathways. In the first pathway, emotional and sexual but not physical adversity/trauma was associated with suicidality, which was mediated by dysfunctional competence/control beliefs, a lack of positive coping strategies and depressiveness. In the second pathway, cognitive basic symptoms but not attenuated psychotic symptoms mediated the relationship between trauma/adversity and suicidality. CHR-patients are thus particularly prone to suicidality if adversity/trauma is followed by the development of depressiveness. Regarding the second pathway, this is the first study showing that adversity/trauma led to suicidality through an increased risk for psychosis as indicated by cognitive basic symptoms. As insight is generally associated with suicidality, this may explain why self-experienced basic symptoms increase the risk for it. Consequently, these mediators should be monitored regularly and targeted by integrated interventions as early as possible to enhance resilience against suicidality.","author":[{"dropping-particle":"","family":"Schmidt","given":"Stefanie J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Schultze-Lutter","given":"Frauke","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bendall","given":"Sarah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Groth","given":"Nicola","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Michel","given":"Chantal","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Inderbitzin","given":"Nadja","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Schimmelmann","given":"Benno G.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hubl","given":"Daniela","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nelson","given":"Barnaby","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Frontiers in Psychiatry","id":"ITEM-3","issued":{"date-parts":[["2017"]]},"title":"Mediators linking childhood adversities and trauma to suicidality in individuals at risk for psychosis","type":"article-journal"},"uris":[""]},{"id":"ITEM-4","itemData":{"author":[{"dropping-particle":"","family":"Brown","given":"LA","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Contractor","given":"A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Benhamou","given":"K","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychiatry Research","id":"ITEM-4","issued":{"date-parts":[["2018"]]},"title":"Posttraumatic Stress Disorder Clusters and Suicidal Ideation","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"^46–49","plainTextFormattedCitation":"46–49","previouslyFormattedCitation":"^47–50"},"properties":{"noteIndex":0},"schema":""}46–49 suicidal ideation scores were treated as a continuous variable in all analyses.We used linear regression to explore the potential prospective association between psychotic symptoms, metacognitive beliefs and suicidal ideation over time. This analysis focuses on the residual variance in suicidal ideation once baseline levels are accounted for. For the linear regression model, suicidal ideation at 9-18 months was first regressed onto symptoms (positive, negative and general) and covariates (same as 9-18 month cross-sectional analysis, but with the addition of baseline suicidal ideation). We then examined whether models also incorporating (a) baseline negative cognitive appraisals and (b) baseline negative metacognitive beliefs helped to explain additional variance. We then tested whether cognitive appraisals and negative metacognitive beliefs at baseline mediated a relationship between psychotic symptoms at baseline and suicidal ideation at 9-18 months, using the same covariates for the linear regression. For this, the baseline value of each symptom category was the independent variable, the mediating variables of interest were baseline appraisals and metacognitive beliefs, and the dependent variable was suicidal ideation at 9-18 months. We also examined the effect of symptom categories with and without other symptom categories as covariates.For all mediation analyses the unstandardised direct (UDE) or indirect (UIE) effects, and the completely standardised (CSE) indirect effects were calculated as measures of effect size. The UDE and UIE represent the unit change in the dependent variable per unit change in the independent, whether direct (unmediated; UDE) or indirect (mediated; UIE). The CSE represents the proportion of standard deviation change in the dependent variable per 1 standard deviation (SD) unit change in the independent variable, occuring through change in the mediator. Cohen’s guidelines for interpreting standardised mean differences can therefore be applied to the CSE to provide an approximate appraisal of the magnitude of the dependent variable change (0.2=small; 0.5=moderate; 0.8=large),ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1234/12345678","ISBN":"0805802835","ISSN":"01621459","PMID":"17877467","abstract":"Statistical Power Analysisis a nontechnical guide to power analysis in research planning that provides users of applied statistics with the tools they need for more effective analysis. The Second Edition includes: a chapter covering power analysis in set correlation and multivariate methods; a chapter considering effect size, psychometric reliability, and the efficacy of \"qualifying\" dependent variables and; expanded power and sample size tables for multiple regression/correlation.","author":[{"dropping-particle":"","family":"Cohen","given":"J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Statistical Power Analysis for the Behavioral Sciences","id":"ITEM-1","issued":{"date-parts":[["1988"]]},"page":"567","title":"Statistical power analysis for the behavioral sciences","type":"article","volume":"2nd"},"uris":[""]}],"mendeley":{"formattedCitation":"⁵⁰","plainTextFormattedCitation":"50","previouslyFormattedCitation":"⁵¹"},"properties":{"noteIndex":0},"schema":""}50 per a large (1 SD) change in the independent variable. Cohen’s criteria were also used to interpret correlations (0.1=small; 0.3=moderate; 0.5=large).ResultsParticipant Characteristics (Table 1) The mean age of the full sample (N=68) was 31 (SD = 12.75). Just under half (n=31, 46%) were female. Overall, 60% (n=41) of these participants reported suicidal ideation at trial entry; 50% (n=34) reported having mild suicidal ideation whereas 10% (n=7) reported severe to very severe ideation involving intent. There were no significant differences in demographics, symptom severity, suicidal ideation, negative cognitive appraisals or negative metacognitive beliefs between the full sample, and those who provided full data at baseline and 9-18 months (all p>0.1).Correlations (Table 2).No correlation was observed between suicidal ideation and negative symptoms at baseline, but a moderate correlation (r=0.30) was evident at 9-18 months. At baseline, moderate correlations were observed between suicidal ideation and positive and overall symptoms for the sample with 9-18-month data. These associations were large at 9-18 months (r=0.47-0.51). Large correlations (r=0.43-0.57) between suicidal ideation and negative cognitive appraisals, negative metacognitive beliefs and general symptoms were also observed at both baseline (both samples) and at 9-18 months. Cross-sectional analyses Baseline (Supplementary Table 1)All results in the full sample (reported here) were replicated in those with full baseline and follow-up data. Total symptoms were related to suicidal ideation through the negative cognitive appraisals alone (CSE 0.13, 95% CI 0.04, 0.25) and the combined negative cognitive appraisals and negative metacognitive beliefs pathways (CSE 0.03, 95% CI -0.00, 0.11). No direct (unmediated) effect was observed. The same pattern was observed for positive symptoms. Overall, the effects suggest a 1 SD increase in overall or positive symptoms were indirectly associated with small increases in suicidal ideation (CSEs 0.12 - 0.18), with approximately 70% of the indirect effects accounted for by the negative cognitive appraisals alone pathway, and 20% by the combined negative cognitive appraisals and negative metacognitive beliefs pathway. Negative symptoms did not have a direct or indirect relationship with suicidal ideation. General symptoms had both a direct effect on suicidal ideation, suggesting a 0.03 unit increase in suicidal ideation scores for each unit increase in general symptoms [unstandardised direct effect (UDE) 0.03, standard error (SE) 0.012, p<0.05] and an indirect (mediated) effect (CSE 0.19, 95% CI 0.09, 0.34), suggesting that for a 1 SD increase in general symptoms, there was an additional 0.19 SD increase in suicidal ideation. As with total and positive symptoms, approximately 70% of this was accounted for by negative cognitive appraisals (CSE 0.14, 95% 0.05, 0.26). The indirect effect of positive symptoms was not robust to controlling for negative and general symptoms. However, both the direct and indirect effects of general symptoms remained significant after controlling for positive and negative symptoms. Although the overall indirect effect was marginally smaller (CSE 0.17, 95% CI 0.06, 0.31), the proportion explained by negative cognitive appraisals was larger (80%) in this analysis.9-18 months (Supplementary Table 3)No direct effect of total symptom severity on suicidal ideation was observed at 9-18 months, however this had an indirect effect through the combined pathway of negative cognitive appraisals and negative metacognitive beliefs (CSE 0.10, -0.00, 0.29). For a 1 SD increase in total symptoms, there was an overall 0.27 SD (95% CI 0.06, 0.26) indirect increase in suicidal ideation. The combined appraisals and negative metacognitive beliefs pathway accounted for approximately 37% of this effect. There was also no direct effect of positive symptoms. Although they had a significant indirect effect on suicidal ideation, with a 1 SD increase in positive symptoms indirectly associated with a 0.31 SD (95% CI 0.04, 0.61) increase in suicidal ideation, no one individual pathway was significant. The relative contributions of each individual pathway to this effect was similar to that for total symptoms. Negative symptoms had a direct effect on suicidal ideation at this timepoint, but no indirect effect. For each unit increase in negative symptoms, there was a 0.043 unit increase in suicidal ideation (SE 0.021, p<.05). As with total and positive symptoms, general symptoms were not directly associated with suicidal ideation. As with total symptoms, general symptoms had an indirect effect on suicidal ideation via the combined appraisals and metacognitive beliefs pathway (CSE 0.10, 95% CI 0.01, 0.30). The effect sizes and relative contribution of individual pathways was similar to that for total and positive symptoms. When we entered other symptom categories as covariates in the analyses of positive, negative and general symptoms, the indirect effects for positive symptoms were no longer significant and the analysis of negative symptoms remained unchanged. General symptoms continued to not have a direct effect after controlling for positive and negative symptoms. The indirect effect remained significant, however the contribution of the individual pathways changed, and the total indirect effect fell from a 0.32 SD (95% CI 0.09, 0.58) change in suicidal ideation per 1 SD change in general symptoms, to a 0.22 SD (95% CI 0.04, 0.45) change. The contribution of negative metacognitive beliefs to this effect increased from a nonsignificant 49% to a significant 70% (CSE 0.16, 95% CI 0.01, 0.43), and the contribution of the combined appraisals and metacognitive beliefs pathway fell from a significant 31% to a non-significant 24%. Longitudinal analysesMultiple linear regression (Supplementary Table 2)Baseline psychotic symptoms and suicidal ideation, together with covariates, accounted for 54% of the variance in suicidal ideation at 9-18 months. Adding baseline negative cognitive appraisals to the model did not account for additional variance, however adding negative metacognitive beliefs accounted for a further 5% (p<0.05). An effect of female gender also emerged; this was associated with a significant reduction in BDI suicidal ideation scores (0.4 points, p<0.05).Mediation analysis (Table 3)No direct effects of baseline symptoms on suicidal ideation at 9-18 months were observed. There were also no indirect effects of baseline negative or positive symptoms. Baseline total symptoms and general symptoms, however, had indirect effects on suicidal ideation at follow-up via the combined appraisals and metacognitive beliefs pathway. A 1 SD increase in baseline overall symptoms and baseline general symptoms accounted for a 0.03 SD (95% CI 0.00, 0.12) and 0.04 SD (95% CI 0.00, 0.14) increase in suicidal ideation at 9-18 months via this pathway, respectively. The analyses for general, positive and negative symptoms were largely unaffected by controlling for other symptom categories, although a significant direct effect of baseline negative metacognitive beliefs (UDE 0.051, SE 0.023, p=0.03) emerged in the general symptoms analysis and, as with the linear regression, a significant association between suicidal ideation and female gender emerged in each analysis, with a similar effect size.4. DiscussionWe tested a metacognitive model of suicidal ideation in people with psychosis not taking antipsychotic medication, a group considered to be at particularly high risk of suicide.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/bmj.38881.382755.2F","ISBN":"1756-1833","ISSN":"09598146","PMID":"16825203","abstract":"Objective To study the association between prescribed antipsychotic drugs and outcome in schizophrenia or schizoaffective disorder in the community.\\nDesign Prospective cohort study using national central registers.\\nSetting Community care in Finland.\\nParticipants Nationwide cohort of 2230 consecutive adults hospitalised in Finland for the first time because of schizophrenia or schizoaffective disorder, January 1995 to December 2001.\\nMain outcome measures Rates of discontinuation of drugs (all causes), rates of rehospitalisation, and mortality associated with monotherapy with the 10 most commonly used antipsychotic drugs. Multivariate models and propensity score methods were used to adjust estimates of effectiveness.\\nResults Initial use of clozapine (adjusted relative risk 0.17, 95% confidence interval 0.10 to 0.29), perphenazine depot (0.24, 0.13 to 0.47), and olanzapine (0.35, 0.18 to 0.71) were associated with the lowest rates of discontinuation for any reason when compared with oral haloperidol. During an average follow-up of 3.6 years, 4640 cases of rehospitalisation were recorded. Current use of perphenazine depot (0.32, 0.22 to 0.49), olanzapine (0.54, 0.41 to 0.71), and clozapine (0.64, 0.48 to 0.85) were associated with the lowest risk of rehospitalisation. Use of haloperidol was associated with a poor outcome among women. Mortality was markedly raised in patients not taking antipsychotics (12.3, 6.0 to 24.1) and the risk of suicide was high (37.4, 5.1 to 276).\\nConclusions The effectiveness of first and second generation antipsychotics varies greatly in the community. Patients treated with perphenazine depot, clozapine, or olanzapine have a substantially lower risk of rehospitalisation or discontinuation (for any reason) of their initial treatment than do patients treated with haloperidol. Excess mortality is seen mostly in patients not using antipsychotic drugs.","author":[{"dropping-particle":"","family":"Tiihonen","given":"Jari","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wahlbeck","given":"Kristian","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"L?nnqvist","given":"Jouko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Klaukka","given":"Timo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ioannidis","given":"John P.A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Volavka","given":"Jan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haukka","given":"Jari","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Medical Journal","id":"ITEM-1","issued":{"date-parts":[["2006"]]},"title":"Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: Observational follow-up study","type":"article-journal"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1192/bjp.187.1.9","ISBN":"9781847471","ISSN":"0007-1250","PMID":"15994566","abstract":"BACKGROUND: Suicide risk is greatly increased in schizophrenia. Detection of those at risk is clinically important. AIMS: To identify risk factors for suicide in schizophrenia. METHOD: The international literature on case-control and cohort studies of patients with schizophrenia or related conditions in which suicide was reported as an outcome was systematically reviewed. Studies were identified through searching electronic databases and reference lists, and by consulting experts. RESULTS: Twenty-nine eligible studies were identified. Factors with robust evidence of increased risk of suicide were previous depressive disorders (OR=3.03, 95% CI 2.06-4.46), previous suicide attempts (OR=4.09, 95% CI 2.79-6.01), drug misuse (OR=3.21, 95% CI 1.99-5.17), agitation or motor restlessness (OR=2.61, 95% CI 1.54-4.41), fear of mental disintegration (OR=12.1, 95% CI 1.89-81.3), poor adherence to treatment (OR=3.75, 95% CI 2.20-6.37) and recent loss (OR=4.03, 95% CI 1.37-11.8). Reduced risk was associated with hallucinations (OR=0.50, 95% CI 0.35-0.71). CONCLUSIONS: Prevention of suicide in schizophrenia is likely to result from treatment of affective symptoms, improving adherence to treatment, and maintaining special vigilance in patients with risk factors, especially after losses.","author":[{"dropping-particle":"","family":"Hawton","given":"Keith","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sutton","given":"Lesley","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haw","given":"Camilla","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sinclair","given":"Julia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Deeks","given":"Jonathan J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The British journal of psychiatry : the journal of mental science","id":"ITEM-2","issued":{"date-parts":[["2005"]]},"page":"9-20","title":"Schizophrenia and suicide: systematic review of risk factors.","type":"article-journal","volume":"187"},"uris":[""]}],"mendeley":{"formattedCitation":"^3,4","plainTextFormattedCitation":"3,4","previouslyFormattedCitation":"^3,4"},"properties":{"noteIndex":0},"schema":""}3,4 We tested whether psychotic symptoms may contribute to increased suicidal ideation not only directly, but also indirectly via appraisals of symptoms, and metacognitive beliefs about the probability and consequences of losing mental control.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1017/S1352465812001026","ISBN":"1352465812001","ISSN":"1352-4658","PMID":"23286558","abstract":"BACKGROUND More effective psychological treatments for psychosis are required. Case series data and pilot trials suggest metacognitive therapy (MCT) is a promising treatment for anxiety and depression. Other research has found negative metacognitive beliefs and thought-control strategies may be involved in the development and maintenance of hallucinations and delusions. The potential of MCT in treating psychosis has yet to be investigated. AIMS Our aim was to find out whether a short number of MCT sessions would be associated with clinically significant and sustained improvements in delusions, hallucinations, anxiety, depression and subjective recovery in patients with treatment-resistant long-standing psychosis. METHOD Three consecutively referred patients, each with a diagnosis of paranoid schizophrenia and continuing symptoms, completed a series of multiple baseline assessments. Each then received between 11 and 13 sessions of MCT and completed regular assessments of progress, during therapy, post-therapy and at 3-month follow-up. RESULTS Two out of 3 participants achieved clinically significant reductions across a range of symptom-based outcomes at end-of-therapy. Improvement was sustained at 3-month follow-up for one participant. CONCLUSIONS Our study demonstrates the feasibility of using MCT with people with medication-resistant psychosis. MCT was acceptable to the participants and associated with meaningful change. Some modifications may be required for this population, after which a controlled trial may be warranted.","author":[{"dropping-particle":"","family":"Hutton","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Morrison","given":"Anthony P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wardle","given":"Melissa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wells","given":"Adrian","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Behavioural and Cognitive Psychotherapy","id":"ITEM-1","issue":"02","issued":{"date-parts":[["2014"]]},"page":"166-185","title":"Metacognitive Therapy in Treatment-Resistant Psychosis: A Multiple-Baseline Study","type":"article-journal","volume":"42"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.jbtep.2013.11.003","ISBN":"0005-7916; EN :1873-7943","ISSN":"00057916","PMID":"24440585","abstract":"Background and objectives Cognitive behaviour therapy (CBT) for psychosis has been shown to be effective, but there are recent suggestions that it is less efficacious than initially thought. Metacognitive therapy (MCT), which focuses on metacognitive mechanisms, has led to positive results in other disorders, but has yet to be evaluated in people with schizophrenia spectrum diagnoses. This study evaluates the feasibility of MCT for people with psychotic disorders. Methods Ten participants with schizophrenia spectrum disorders received up to 12 sessions of MCT in an open trial. Outcomes included psychiatric symptoms measured using the PANSS, at baseline, 9 months (end of treatment) and at 12 months (follow-up), as well as dimensions of hallucinations and delusions, emotional dysfunction, self-rated recovery, social functioning and metacognitive beliefs. Results T-tests and Wilcoxon's signed ranks tests revealed significant beneficial effects on several outcomes at end-of-treatment and follow-up. Cohen's d effect sizes were moderate to large (for PANSS total, d = 1.0 at end of treatment; d = 0.95 at follow-up). A response rate analysis found 50% and 40% of participants achieved at least a 25% reduction in PANSS total scores by end of therapy and follow-up, respectively. Exploratory analyses revealed that metacognitive beliefs significantly changed over treatment and follow-up periods. Limitations This study had no control group and was not randomised; therefore, it is likely that effect sizes were inflated. Conclusions This study provides preliminary evidence that MCT is a feasible treatment for people with psychosis. An adequately powered randomised controlled trial is warranted. ?? 2013 Elsevier Ltd. All rights reserved.","author":[{"dropping-particle":"","family":"Morrison","given":"Anthony P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pyle","given":"Melissa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chapman","given":"Nicola","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"French","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Parker","given":"Sophie K.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wells","given":"Adrian","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Behavior Therapy and Experimental Psychiatry","id":"ITEM-2","issue":"2","issued":{"date-parts":[["2014"]]},"page":"280-284","title":"Metacognitive therapy in people with a schizophrenia spectrum diagnosis and medication resistant symptoms: A feasibility study","type":"article-journal","volume":"45"},"uris":[""]}],"mendeley":{"formattedCitation":"^24,33","plainTextFormattedCitation":"24,33","previouslyFormattedCitation":"^24,34"},"properties":{"noteIndex":0},"schema":""}24,33We found no evidence that positive or total symptom severity has a direct effect on suicidal ideation in this group. Only concurrent general symptoms had a direct effect at baseline, and only concurrent negative symptoms had a direct effect at follow-up. Concurrent general symptoms also had an indirect effect on baseline suicidal ideation, mediated by negative cognitive appraisals. This was robust to controlling for other symptom categories. However no indirect effect of negative symptoms was found, and the indirect effect of positive symptoms was not not robust to controlling for general and negative symptoms. At 9-18 months, a similar pattern emerged. However, negative metacognitive beliefs played a more significant role at this point, which suggests the psychological mechanisms involved in suicidal ideation in psychosis may change over time in this group. They either formed part of the indirect pathway, mediating the mediating effect of negative cognitive appraisals (positive symptoms, general symptoms), or were a sole mediator (general symptoms controlling for positive and negative symptoms). Again, the pathway linking general symptoms and suicidal ideation was the only indirect pathway robust to controlling for other symptom categories. The longitudinal analyses are relevant to interpreting these findings. No direct effect of baseline general symptoms on later suicidal ideation was evident, but it had an indirect effect through concurrently measured negative cognitive appraisals and negative metacognitive beliefs. Although this indirect pathway explained only a very small amount of future suicidal ideation, both the linear regression and the mediation analyses (general symptoms, controlling for negative and positive symptoms) suggested a 1 point increase in baseline negative metacognitive beliefs may directly account for a 0.05 point increase in suicidal ideation at 9-18 months, which corresponds to a 0.5 point increase on the BDI suicide item (scored 0-3) per 10-point increase in negative metacognitive beliefs (scored 6-24). Notably, these beliefs did not predict concurrent suicidal ideation at baseline. If further research confirms these findings, high negative metacognitive beliefs at baseline may be a useful predictor of later increases in suicidal ideation in people with psychosis who are not currently taking antipsychotic medication, both directly and as a mediator of early general symptoms. LimitationsWe used a single-item measure of suicidal ideation, however Dessailes and colleagues, in a study of 281 suicide-attempters,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.jad.2011.11.013","ISBN":"0165-0327","ISSN":"01650327","PMID":"22154567","abstract":"Objective: To date, most researchers rely on suicidal items of scales primarily designed to measure depression severity to capture suicidal ideation (SI). This study aims at investigating how well the suicide item of the clinician rated Hamilton Scale for Depression (HAM-D) and principal factors derived from this scale correlate with SI scores derived from a well validated measure of SI: the Beck's scale for SI (SSI). Method: 281 suicide attempters consecutively hospitalized between 2007 and 2009 were assessed by using the SSI, the HAM-D and the self-report Beck Depression Inventory (BDI). Principal Component Analysis (PCA) was computed to extract main factors. Correlations between these factors, BDI's and HAM-D's suicide items and the SSI scores were then computed. Results: Three components were derived from the PCA. Factor 2 showed a major loading for the HAM-D suicide item. Both the HAM-D suicide item and Factor 2 positively correlated with the SSI total score (both p < 0.00001). Moreover, the BDI suicide item highly correlated with the Factor 2 (p < 0.001) and the SSI total score (p < 0.00001). Finally, the HAM-D suicide item correlated significantly with the number of suicide attempts (p = 0.0001) and the age at the first attempt (p = 0.002). Limitations: Our sample was heterogeneous and future studies should refine the taxonomy of the suicidal behavior in specific sub-populations. The study design was cross-sectional and replication in a prospective study is needed. Conclusion: These findings suggest that the use of a single suicide item or a dimensional factor derived from a depression scale might be a valid approach to assess the suicidal ideations. Moreover, the results suggest that clinician rated scales as well as self-report questionnaires are equally valid to do so. ? 2011 Elsevier B.V. All rights reserved.","author":[{"dropping-particle":"","family":"Desseilles","given":"Martin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Perroud","given":"Nader","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Guillaume","given":"Sébastien","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jaussent","given":"Isabelle","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Genty","given":"Catherine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Malafosse","given":"Alain","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Courtet","given":"Philippe","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Affective Disorders","id":"ITEM-1","issued":{"date-parts":[["2012"]]},"title":"Is it valid to measure suicidal ideation by depression rating scales?","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"⁵¹","plainTextFormattedCitation":"51","previouslyFormattedCitation":"⁵²"},"properties":{"noteIndex":0},"schema":""}51 concluded the single suicide item represented a valid approach to assess suicidal ideation, a finding replicated by Brown and colleagues in a sample of 5319 patients.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.4088/JCP.14m09391","ISBN":"0160-6689","ISSN":"01606689","PMID":"26717528","abstract":"OBJECTIVE: The current study examines the predictive validity of the Beck Depression Inventory (BDI) suicide item for death by suicide and suicide attempts. METHOD: The study included 2 samples: (1) 5,200 psychiatric outpatients who were evaluated between 1975 and 1995 and followed prospectively for up to 20 years (all psychiatric diagnoses based on DSM-III and DSM-III-R), and (2) 119 patients who, between 2000 and 2004, participated in a randomized controlled trial of outpatient Cognitive Therapy for Suicide Prevention after a suicide attempt and were followed for 18 months (all psychiatric diagnoses based on DSM-IV-TR). All patients completed structured diagnostic interviews, as well as the BDI and Scale for Suicide Ideation. RESULTS: Cox regression models demonstrated that the BDI suicide item significantly predicted both deaths by suicide (Wald χ(2)1 = 35.67; P CONCLUSIONS: The BDI suicide item is associated with both risk of repeat suicide attempts and death by suicide. The use of the item as a brief, efficient screen for suicide risk in routine clinical care is recommended. Clinicians would then conduct a comprehensive suicide risk assessment in response to a positive screen. Future research examining the item's performance in other at-risk groups (ie, older adults, adolescents, inpatients, etc) is encouraged. Language: en","author":[{"dropping-particle":"","family":"Green","given":"Kelly L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brown","given":"Gregory K.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jager-Hyman","given":"Shari","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cha","given":"Jason","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Steer","given":"Robert A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Beck","given":"Aaron T.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Clinical Psychiatry","id":"ITEM-1","issued":{"date-parts":[["2015"]]},"title":"The predictive validity of the Beck Depression Inventory suicide item","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"⁵²","plainTextFormattedCitation":"52","previouslyFormattedCitation":"⁵³"},"properties":{"noteIndex":0},"schema":""}52 Endorsing suicidal ideation on the BDI item also has important implications for clinical risk assessment.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.4088/JCP.14m09391","ISBN":"0160-6689","ISSN":"01606689","PMID":"26717528","abstract":"OBJECTIVE: The current study examines the predictive validity of the Beck Depression Inventory (BDI) suicide item for death by suicide and suicide attempts. METHOD: The study included 2 samples: (1) 5,200 psychiatric outpatients who were evaluated between 1975 and 1995 and followed prospectively for up to 20 years (all psychiatric diagnoses based on DSM-III and DSM-III-R), and (2) 119 patients who, between 2000 and 2004, participated in a randomized controlled trial of outpatient Cognitive Therapy for Suicide Prevention after a suicide attempt and were followed for 18 months (all psychiatric diagnoses based on DSM-IV-TR). All patients completed structured diagnostic interviews, as well as the BDI and Scale for Suicide Ideation. RESULTS: Cox regression models demonstrated that the BDI suicide item significantly predicted both deaths by suicide (Wald χ(2)1 = 35.67; P CONCLUSIONS: The BDI suicide item is associated with both risk of repeat suicide attempts and death by suicide. The use of the item as a brief, efficient screen for suicide risk in routine clinical care is recommended. Clinicians would then conduct a comprehensive suicide risk assessment in response to a positive screen. Future research examining the item's performance in other at-risk groups (ie, older adults, adolescents, inpatients, etc) is encouraged. Language: en","author":[{"dropping-particle":"","family":"Green","given":"Kelly L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brown","given":"Gregory K.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jager-Hyman","given":"Shari","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cha","given":"Jason","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Steer","given":"Robert A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Beck","given":"Aaron T.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Clinical Psychiatry","id":"ITEM-1","issued":{"date-parts":[["2015"]]},"title":"The predictive validity of the Beck Depression Inventory suicide item","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"⁵²","plainTextFormattedCitation":"52","previouslyFormattedCitation":"⁵³"},"properties":{"noteIndex":0},"schema":""}52 The BDI data were treated as interval for the analyses. This is in line with previous studies,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1192/bjp.2017.24","ISSN":"14721465","author":[{"dropping-particle":"","family":"N?slund","given":"Jakob","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hieronymus","given":"Fredrik","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lisinski","given":"Alexander","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nilsson","given":"Staffan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Eriksson","given":"Elias","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Journal of Psychiatry","id":"ITEM-1","issued":{"date-parts":[["2018"]]},"title":"Effects of selective serotonin reuptake inhibitors on rating-scale-assessed suicidality in adults with depression","type":"article-journal"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.ijchp.2017.08.001","ISSN":"16972600","abstract":"Background/Objective: Depression and suicide ideation regularly occur together. Yet, little is known about factors that buffer individuals against the development of suicide ideation. The present study investigated, whether positive mental health buffers the association between depression and suicide ideation in a longitudinal study design. Methods: A total of 207 German students (70.3% female; age: M = 26.04, SD = 5.33) were assessed at a baseline evaluation and again twelve months later. Data were collected using self-report questionnaires. Linear hierarchical regression analysis was used to analyze the data. Positive mental health was considered to moderate the impact of depression on suicide ideation - controlling for age and gender. Results: Positive mental health was shown to moderate the impact of depression on suicide ideation: in those students who reported higher levels of positive mental health, depression severity showed no association with suicide ideation over time. Conclusion: Positive mental health seems to confer resilience and should be taken into account, when assessing individuals for suicide risk.","author":[{"dropping-particle":"","family":"Teismann","given":"Tobias","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Forkmann","given":"Thomas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brailovskaia","given":"Julia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Siegmann","given":"Paula","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Glaesmer","given":"Heide","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Margraf","given":"Jürgen","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"International Journal of Clinical and Health Psychology","id":"ITEM-2","issued":{"date-parts":[["2017"]]},"title":"Positive mental health moderates the association between depression and suicide ideation: A longitudinal study","type":"article-journal"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.3389/fpsyt.2017.00242","ISBN":"1664-0640","ISSN":"16640640","PMID":"29249990","abstract":"Suicidality is highly prevalent in patients at clinical high risk (CHR) for psychosis. Childhood adversities and trauma are generally predictive of suicidality. However, the differential effects of adversity/trauma-domains and CHR-criteria, i.e. ultra-high risk and basic symptom criteria, on suicidality remain unclear. Furthermore, the underlying mechanisms and thus worthwhile targets for suicide-prevention are still poorly understood. Therefore, structural equation modeling was used to test theory-driven models in 73 CHR-patients. Mediators were psychological variables, i.e. beliefs about one’s own competencies as well as the controllability of events and coping styles. Additionally, symptomatic variables (depressiveness, basic symptoms, attenuated psychotic symptoms) were hypothesized to mediate the effect of psychological mediators on suicidality as the final outcome variable. Results showed two independent pathways. In the first pathway, emotional and sexual but not physical adversity/trauma was associated with suicidality, which was mediated by dysfunctional competence/control beliefs, a lack of positive coping strategies and depressiveness. In the second pathway, cognitive basic symptoms but not attenuated psychotic symptoms mediated the relationship between trauma/adversity and suicidality. CHR-patients are thus particularly prone to suicidality if adversity/trauma is followed by the development of depressiveness. Regarding the second pathway, this is the first study showing that adversity/trauma led to suicidality through an increased risk for psychosis as indicated by cognitive basic symptoms. As insight is generally associated with suicidality, this may explain why self-experienced basic symptoms increase the risk for it. Consequently, these mediators should be monitored regularly and targeted by integrated interventions as early as possible to enhance resilience against suicidality.","author":[{"dropping-particle":"","family":"Schmidt","given":"Stefanie J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Schultze-Lutter","given":"Frauke","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bendall","given":"Sarah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Groth","given":"Nicola","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Michel","given":"Chantal","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Inderbitzin","given":"Nadja","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Schimmelmann","given":"Benno G.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hubl","given":"Daniela","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nelson","given":"Barnaby","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Frontiers in Psychiatry","id":"ITEM-3","issued":{"date-parts":[["2017"]]},"title":"Mediators linking childhood adversities and trauma to suicidality in individuals at risk for psychosis","type":"article-journal"},"uris":[""]},{"id":"ITEM-4","itemData":{"author":[{"dropping-particle":"","family":"Brown","given":"LA","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Contractor","given":"A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Benhamou","given":"K","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychiatry Research","id":"ITEM-4","issued":{"date-parts":[["2018"]]},"title":"Posttraumatic Stress Disorder Clusters and Suicidal Ideation","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"^46–49","plainTextFormattedCitation":"46–49","previouslyFormattedCitation":"^47–50"},"properties":{"noteIndex":0},"schema":""}46–49 and dichotomising the data for logistic regression would incur a substantial loss of statistical power.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Altman","given":"DG.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Royston","given":"P","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BMJ","id":"ITEM-1","issue":"7549","issued":{"date-parts":[["2006"]]},"page":"1080","title":"The cost of dichotomising continuous variables","type":"article-journal","volume":"332"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1017/S2045796012000613","ISSN":"20457960","PMID":"23089232","abstract":"In psychiatry, the use of rating scales as measures of outcome in clinical trials allows us to generate continuous outcome data, where each individual's outcome is measured in numbers. Continuous outcomes can be divided into two categories, such as improved and not improved, or may be kept continuous. This article briefly presents the main advantages and disadvantages of these two approaches, which are commonly employed in the analyses of rating scale scores in clinical trials and systematic reviews.","author":[{"dropping-particle":"","family":"Purgato","given":"M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Barbui","given":"C.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Epidemiology and Psychiatric Sciences","id":"ITEM-2","issued":{"date-parts":[["2013"]]},"title":"Dichotomizing rating scale scores in psychiatry: A bad idea?","type":"article"},"uris":[""]}],"mendeley":{"formattedCitation":"^53,54","plainTextFormattedCitation":"53,54","previouslyFormattedCitation":"^54,55"},"properties":{"noteIndex":0},"schema":""}53,54 There is debate over the best way to conceptualise questionnaire data,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/j.1365-2929.2004.02012.x","ISBN":"0033-524X","ISSN":"0033524X","abstract":"Allen, I. E., & Seaman, C. A. (2007). Likert scales and data analyses. Quality Progress, 40(7), 64.","author":[{"dropping-particle":"","family":"Allen","given":"IE","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Seaman","given":"CA","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Quality Progress","id":"ITEM-1","issued":{"date-parts":[["2007"]]},"title":"Likert scales and data analyses","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"⁵⁵","plainTextFormattedCitation":"55","previouslyFormattedCitation":"⁵⁶"},"properties":{"noteIndex":0},"schema":""}55 but we encourage attempts to replicate these findings using full scale measures (e.g., the Beck Scale for Suicidal IdeationADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1037/0022-006X.47.2.343","ISBN":"1939-2117","ISSN":"0022006X","PMID":"469082","abstract":" Describes the rationale, development, and validation of the Scale for Suicide Ideation, a 19-item clinical research instrument designed to quantify and assess suicidal intention. In a sample with 90 hospitalized Ss, the scale was found to have high internal consistency and moderately high correlations with clinical ratings of suicidal risk and self-administered measures of self-harm. Furthermore, it was sensitive to changes in levels of depression and hopelessness (Beck Depression Inventory and Hopelessness Scale, respectively) over time. Its construct validity was supported by 2 studies by different investigators testing the relationship between hopelessness, depression, and suicidal ideation and by a study demonstrating a significant relationship between high level of suicidal ideation and \"dichotomous\" attitudes about life and related concepts on a semantic differential test. Factor analysis yielded 3 meaningful factors: Active Suicidal Desire, Specific Plans for Suicide, and Passive Suicidal Desire. (29 ref) (PsycINFO Database Record (c) 2013 APA, all rights reserved)","author":[{"dropping-particle":"","family":"Beck","given":"Aaron T.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kovacs","given":"Maria","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Weissman","given":"Arlene","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Consulting and Clinical Psychology","id":"ITEM-1","issued":{"date-parts":[["1979"]]},"title":"Assessment of suicidal intention: The Scale for Suicide Ideation","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"⁵⁶","plainTextFormattedCitation":"56","previouslyFormattedCitation":"⁵⁷"},"properties":{"noteIndex":0},"schema":""}56). Evidence suggests the PANSS may have a 5-factor structure.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.schres.2006.04.001","ISBN":"0920-9964 (Print)","ISSN":"09209964","PMID":"16730430","abstract":"Objective: The aim of this study was to test the goodness-of-fit of all previously published five-factor models of the Positive and Negative Syndrome Scale (PANSS). Methods: We used confirmatory factor analysis (CFA) with a large data set (N = 5769). Results: The different subsamples were tested for heterogeneity and were found to be homogeneous. This indicates that despite variability in age, sex, duration of illness, admission status, etc., in the different subsamples, the structure of symptoms is the same for all patients with schizophrenia. Although previous research has shown that a five-factor model fits the data better than models with three or four factors, no satisfactory fit for any of the 25 published five-factor models was found with CFA. Conclusions: Variability in age, sex, admission status and duration of illness has no substantial effect on the structure of symptoms in schizophrenia. The lack of fit can be caused by ill-defined items that aim to measure several properties in a single rating. Another explanation is that well-defined symptoms can have two or more causes. Then a double or triple loading item should not be discarded, but included because the complexity of symptoms in schizophrenia is represented by these multiple loadings. Such a complex model not only needs confirmation by CFA, but also has to be proven stable. A 10-fold cross-validation is suggested to develop a complex and stable model. ? 2006 Elsevier B.V. All rights reserved.","author":[{"dropping-particle":"","family":"Gaag","given":"Mark","non-dropping-particle":"van der","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cuijpers","given":"Anke","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hoffman","given":"Tonko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Remijsen","given":"Mila","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hijman","given":"Ron","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haan","given":"Lieuwe","non-dropping-particle":"de","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Meijel","given":"Berno","non-dropping-particle":"van","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Harten","given":"Peter N.","non-dropping-particle":"van","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Valmaggia","given":"Lucia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hert","given":"Marc","non-dropping-particle":"de","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wiersma","given":"Durk","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Schizophrenia Research","id":"ITEM-1","issued":{"date-parts":[["2006"]]},"title":"The five-factor model of the Positive and Negative Syndrome Scale I: Confirmatory factor analysis fails to confirm 25 published five-factor solutions","type":"article-journal"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.schres.2006.03.021","ISBN":"0920-9964 (Print)","ISSN":"09209964","PMID":"16730429","abstract":"Objective: The lack of fit of 25 previously published five-factor models for the PANSS items, can be due to the statistics used. The purpose of this study was to use a 'new' statistical method to develop and confirm an improved five-factor model. The improved model is both complex and stable. Complex means that symptoms can have multiple factor loadings, because they have multiple causes, not because they are ill defined. Stable means that the complex structure is found repeatedly in validations. Methods: A ten-fold cross-validation (10?CV) was applied on a large data set (N = 5769) to achieve an improved factor model for the PANSS items. The advantages of 10?CV are minimal effect of sample characteristics and the ability to investigate the stability of items loading on multiple factors. Results: The results show that twenty-five items contributed to the same factor all ten validations with one item showing a consistent loading on two factors. Three items were contributing to the same factor nine out of ten validations, and two items were contributing to the same factor six to eight times. The resulting five-factor model covers all thirty items of the PANSS, subdivided in the factors: positive symptoms, negative symptoms, disorganization, excitement, and emotional distress. The five-factor model has a satisfactory goodness-of-fit (Comparative Fit Index = .905; Root Mean Square Error of Approximation = .052). Conclusions: The five-factor model developed in this study is an improvement above previously published models as it represents a complex factor model and is more stable. ? 2006 Elsevier B.V. All rights reserved.","author":[{"dropping-particle":"","family":"Gaag","given":"Mark","non-dropping-particle":"van der","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hoffman","given":"Tonko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Remijsen","given":"Mila","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hijman","given":"Ron","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haan","given":"Lieuwe","non-dropping-particle":"de","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Meijel","given":"Berno","non-dropping-particle":"van","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Harten","given":"Peter N.","non-dropping-particle":"van","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Valmaggia","given":"Lucia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hert","given":"Marc","non-dropping-particle":"de","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cuijpers","given":"Anke","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wiersma","given":"Durk","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Schizophrenia Research","id":"ITEM-2","issued":{"date-parts":[["2006"]]},"title":"The five-factor model of the Positive and Negative Syndrome Scale II: A ten-fold cross-validation of a revised model","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"^57,58","plainTextFormattedCitation":"57,58","previouslyFormattedCitation":"^58,59"},"properties":{"noteIndex":0},"schema":""}57,58 We used the traditional 3-factor structure,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1093/schbul/13.2.261","ISBN":"1745-1701","ISSN":"0586-7614","PMID":"3616518","abstract":"The variable results of positive- negative research with schizo- phrenics underscore the importance of well-characterized, standardized measurement techniques. We report on the development and initial standardization of the Positive and Negative Syndrome Scale (PANSS) for typological and dimensional as- sessment. Based on two established psychiatric rating systems, the 30- item PANSS was conceived as an operationalized, drug-sensitive in- strument that provides balanced representation of positive and nega- tive symptoms and gauges their re- lationship to one another and to global psychopathology. It thus constitutes four scales measuring positive and negative syndromes, their differential, and general sever- ity of illness. Study of 101 schizo- phrenics found the four scales to be normally distributed and supported their reliability and stability. Posi- tive and negative scores were in- versely correlated once their common association with general psychopathology was extracted, suggesting that they represent mu- tually exclusive constructs. Review of five studies involving the PANSS provided evidence of its cri- terion-related validity with anteced- ent, genealogical, and concurrent measures, its predictive validity, its drug sensitivity, and its utility for both typological and dimensional assessment.","author":[{"dropping-particle":"","family":"Kay SR, Fiszbein A","given":"Opler La.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Schizophr Bull.","id":"ITEM-1","issue":"2","issued":{"date-parts":[["1987"]]},"page":"261-276","title":"The Positive and Negative Syndrome Scale for schizophrenia","type":"article-journal","volume":"13"},"uris":[""]}],"mendeley":{"formattedCitation":"³⁵","plainTextFormattedCitation":"35","previouslyFormattedCitation":"³⁶"},"properties":{"noteIndex":0},"schema":""}35 since this is widely used and interpretable by clinicians.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1176/appi.ajp.2017.16121358","ISSN":"15357228","PMID":"28541090","abstract":"OBJECTIVE:Antipsychotic drug efficacy may have decreased over recent decades. The authors present a meta-analysis of all placebo-controlled trials in patients with acute exacerbations of schizophrenia, and they investigate which trial characteristics have changed over the years and which are moderators of drug-placebo efficacy differences.\n\nMETHOD:The search included multiple electronic databases. The outcomes were overall efficacy (primary outcome); responder and dropout rates; positive, negative, and depressive symptoms; quality of life; functioning; and major side effects. Potential moderators of efficacy were analyzed by meta-regression.\n\nRESULTS:The analysis included 167 double-blind randomized controlled trials with 28,102 mainly chronic participants. The standardized mean difference (SMD) for overall efficacy was 0.47 (95% credible interval 0.42, 0.51), but accounting for small-trial effects and publication bias reduced the SMD to 0.38. At least a \"minimal\" response occurred in 51% of the antipsychotic group versus 30% in the placebo group, and 23% versus 14% had a \"good\" response. Positive symptoms (SMD 0.45) improved more than negative symptoms (SMD 0.35) and depression (SMD 0.27). Quality of life (SMD 0.35) and functioning (SMD 0.34) improved even in the short term. Antipsychotics differed substantially in side effects. Of the response predictors analyzed, 16 trial characteristics changed over the decades. However, in a multivariable meta-regression, only industry sponsorship and increasing placebo response were significant moderators of effect sizes. Drug response remained stable over time.\n\nCONCLUSIONS:Approximately twice as many patients improved with antipsychotics as with placebo, but only a minority experienced a good response. Effect sizes were reduced by industry sponsorship and increasing placebo response, not decreasing drug response. Drug development may benefit from smaller samples but better-selected patients.","author":[{"dropping-particle":"","family":"Leucht","given":"Stefan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Leucht","given":"Claudia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Huhn","given":"Maximilian","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chaimani","given":"Anna","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mavridis","given":"Dimitris","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Helfer","given":"Bartosz","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Samara","given":"Myrto","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rabaioli","given":"Matteo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"B?cher","given":"Susanne","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cipriani","given":"Andrea","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Geddes","given":"John R.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Salanti","given":"Georgia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Davis","given":"John M.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"American Journal of Psychiatry","id":"ITEM-1","issue":"10","issued":{"date-parts":[["2017"]]},"page":"927-942","title":"Sixty years of placebo-controlled antipsychotic drug trials in acute schizophrenia: Systematic review, Bayesian meta-analysis, and meta-regression of efficacy predictors","type":"article","volume":"174"},"uris":[""]}],"mendeley":{"formattedCitation":"⁵⁹","plainTextFormattedCitation":"59","previouslyFormattedCitation":"⁶⁰"},"properties":{"noteIndex":0},"schema":""}59 Although a larger sample would have greater power to detect smaller effects with greater precision, in-depth psychological studies of people with psychosis who are antipsychotic-free are rare, partly because few people with psychosis are not taking antipsychotics. Finally, the analyses tested a theoretically driven model, but alternative ordering of the variables is also plausible. Causal claims await the results of randomised controlled ‘interventionist-causal’ trials,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1017/S0033291708004467","ISBN":"0033-2917 (Print)","ISSN":"00332917","PMID":"18845010","abstract":"The diversity of research methods applied to psychiatric disorders results in a confusing plethora of causal claims. To help make sense of these claims, the interventionist model (IM) of causality has several attractive features. First, it connects causation with the practical interests of psychiatry, defining causation in terms of ' what would happen under interventions ', a question of key interest to those of us whose interest is ultimately in intervening to prevent and treat illness. Second, it distinguishes between predictive-correlative and true causal relationships, an essential issue cutting across many areas in psychiatric research. Third, the IM is non-reductive and agnostic to issues of mind–body problem. Fourth, the IM model cleanly separates issues of causation from questions about the underlying mechanism. Clarifying causal influences can usefully structure the search for underlying mechanisms. Fifth, it provides a sorely needed conceptual rigor to multi-level modeling, thereby avoiding a return to uncritical holistic approaches that ' everything is relevant ' to psychiatric illness. Sixth, the IM provides a clear way to judge both the generality and depth of explanations. In conclusion, the IM can provide a single, clear empirical framework for the evaluation of all causal claims of relevance to psychiatry and presents psychiatry with a method of avoiding the sterile metaphysical arguments about mind and brain which have preoccupied our field but yielded little of practical benefit.","author":[{"dropping-particle":"","family":"Kendler","given":"K. S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Campbell","given":"J.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychological Medicine","id":"ITEM-1","issue":"6","issued":{"date-parts":[["2009"]]},"page":"881-887","title":"Interventionist causal models in psychiatry: Repositioning the mind-body problem","type":"article","volume":"39"},"uris":[""]}],"mendeley":{"formattedCitation":"⁶⁰","plainTextFormattedCitation":"60","previouslyFormattedCitation":"⁶¹"},"properties":{"noteIndex":0},"schema":""}60 where the effect of selectively reduce negative metacognitive beliefs on suicidality can be assessed. ImplicationsConsistent with previous findings, that fears of mental disintegration are strongly associated with suicide in psychosis,ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1192/bjp.187.1.9","ISBN":"9781847471","ISSN":"0007-1250","PMID":"15994566","abstract":"BACKGROUND: Suicide risk is greatly increased in schizophrenia. Detection of those at risk is clinically important. AIMS: To identify risk factors for suicide in schizophrenia. METHOD: The international literature on case-control and cohort studies of patients with schizophrenia or related conditions in which suicide was reported as an outcome was systematically reviewed. Studies were identified through searching electronic databases and reference lists, and by consulting experts. RESULTS: Twenty-nine eligible studies were identified. Factors with robust evidence of increased risk of suicide were previous depressive disorders (OR=3.03, 95% CI 2.06-4.46), previous suicide attempts (OR=4.09, 95% CI 2.79-6.01), drug misuse (OR=3.21, 95% CI 1.99-5.17), agitation or motor restlessness (OR=2.61, 95% CI 1.54-4.41), fear of mental disintegration (OR=12.1, 95% CI 1.89-81.3), poor adherence to treatment (OR=3.75, 95% CI 2.20-6.37) and recent loss (OR=4.03, 95% CI 1.37-11.8). Reduced risk was associated with hallucinations (OR=0.50, 95% CI 0.35-0.71). CONCLUSIONS: Prevention of suicide in schizophrenia is likely to result from treatment of affective symptoms, improving adherence to treatment, and maintaining special vigilance in patients with risk factors, especially after losses.","author":[{"dropping-particle":"","family":"Hawton","given":"Keith","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sutton","given":"Lesley","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haw","given":"Camilla","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sinclair","given":"Julia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Deeks","given":"Jonathan J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The British journal of psychiatry : the journal of mental science","id":"ITEM-1","issued":{"date-parts":[["2005"]]},"page":"9-20","title":"Schizophrenia and suicide: systematic review of risk factors.","type":"article-journal","volume":"187"},"uris":[""]}],"mendeley":{"formattedCitation":"³","plainTextFormattedCitation":"3","previouslyFormattedCitation":"³"},"properties":{"noteIndex":0},"schema":""}3 our results suggest that the way people appraise their symptoms and their consequences, including whether they heighten concerns about losing mental control, may partly determine whether they lead to thoughts of suicide. RCTs of interventions which either address negative metacognitive beliefs, such as Metacognitive Therapy (MCT),ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1017/S1352465808004803","ISBN":"1352465808004","ISSN":"1352-4658","abstract":"The theory and principles of Meta cognitive therapy (MCT) are described and data supporting its effects are summarized. MCT does not advocate challenging of negative automatic thoughts or traditional schemas. It proposes the existence of a universal maladaptive thinking style that causes disorder and focuses on helping patients regulate their cognition more adaptively. It aims to reduce worry and rumination and alter problematic patterns of attention and coping. In doing so it targets underlying metacognition that controls thinking and helps patients develop new ways of consciously experiencing inner events. Data from treatment studies suggest that individual MCT techniques and full treatment are highly effective. Further randomized trials are clearly warranted. (PsycINFO Database Record (c) 2012 APA, all rights reserved) (journal abstract)","author":[{"dropping-particle":"","family":"Wells","given":"Adrian","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Behavioural and Cognitive Psychotherapy","id":"ITEM-1","issue":"06","issued":{"date-parts":[["2008"]]},"page":"651","title":"Metacognitive Therapy: Cognition Applied To Regulating Cognition","type":"article-journal","volume":"36"},"uris":[""]}],"mendeley":{"formattedCitation":"⁶¹","plainTextFormattedCitation":"61","previouslyFormattedCitation":"⁶²"},"properties":{"noteIndex":0},"schema":""}61 or directly enhance self-integration, such as Metacognitive Reflection and Insight Therapy (MERIT)ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Lysaker","given":"P.H.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Klion","given":"R.","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2017"]]},"publisher":"Routledge","publisher-place":"New York","title":"Recovery, Meaning-making, and Severe Mental Illness: A Comprehensive Guide to Metacognitive Reflection and Insight Therapy.","type":"book"},"uris":[""]}],"mendeley":{"formattedCitation":"⁶²","plainTextFormattedCitation":"62","previouslyFormattedCitation":"⁶³"},"properties":{"noteIndex":0},"schema":""}62 and Cognitive Analytic Therapy (CAT)ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1080/17522439.2014.956785","ISSN":"17522447","abstract":"? 2014 Taylor & Francis. In the interests of providing patient choice and developing more effective interventions for people struggling with psychosis, it is important that alternative talking therapies are explored. Cognitive Analytic Therapy is an integrative therapy which has specific features that may be particularly suited to psychosis. The current report briefly outlines this approach and its potential benefits.","author":[{"dropping-particle":"","family":"Taylor","given":"P.J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Perry","given":"A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hutton","given":"P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Seddon","given":"C.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tan","given":"R.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychosis","id":"ITEM-1","issue":"3","issued":{"date-parts":[["2015"]]},"title":"Curiosity and the CAT: Considering Cognitive Analytic Therapy as an intervention for psychosis","type":"article-journal","volume":"7"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1111/papt.12183","ISSN":"20448341","abstract":"? 2018 The British Psychological Society. Objectives: Cognitive Analytic Therapy (CAT) is an effective psychological intervention for several different mental health conditions. However, whether it is acceptable, safe, and beneficial for people with psychosis remains unclear, as is the feasibility of providing and evaluating it within a research context. The aim of this study was to begin to address these questions and to obtain for the first time a rich and detailed understanding of the experience of receiving CAT for psychosis. Design: A mixed-methods case series design. Method: Seven individuals who experienced non-affective psychosis received CAT. They completed assessments at the start of CAT, 16 weeks, and 28 weeks post-baseline. Qualitative interviews were completed with four individuals following completion of or withdrawal from therapy. Results: Six participants attended at least four sessions of therapy and four went on to complete therapy. There were no serious adverse events, and self-reported adverse experiences were minimal. Qualitative interviews suggested CAT is acceptable and provided a way to understand and work therapeutically with psychosis. There was limited evidence of change in psychotic symptoms, but improvement in perceived recovery and personality integration was observed. Conclusions: The results suggest that CAT is a safe and acceptable intervention for psychosis. Personality integration, perceived recovery, and functioning are relevant outcomes for future evaluations of CAT for psychosis. Practitioner points: It is feasible to conduct research evaluating CAT for people with psychosis. Within this case series, CAT appears acceptable and safe to individuals with psychosis. Within this case series, clients reported that CAT was a positive and helpful experience. There is a mixed picture with regard to secondary outcomes, but the design and aims of this case series limit conclusion that can be drawn from this data.","author":[{"dropping-particle":"","family":"Taylor","given":"P.J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Perry","given":"A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hutton","given":"P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tan","given":"R.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fisher","given":"N.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Focone","given":"C.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Griffiths","given":"D.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Seddon","given":"C.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychology and Psychotherapy: Theory, Research and Practice","id":"ITEM-2","issued":{"date-parts":[["2018"]]},"title":"Cognitive Analytic Therapy for psychosis: A case series","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"^63,64","plainTextFormattedCitation":"63,64","previouslyFormattedCitation":"^64,65"},"properties":{"noteIndex":0},"schema":""}63,64 may be warranted to examine their effect on suicidality. Overall, our findings emphasise the importance of clinicians promoting a recovery-focused and appropriately optimistic outlook when working with people with psychosis, taking care to avoid providing information that might heighten negative illness appraisals and/or fears of losing mental control. FundingThis is a secondary analysis of a trial funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit Programme (Grant reference number PB-PG-1208-18053). The views expressed are those of the authors and not necessarily those of the UK National Health Service, the NIHR or the Department of Health.Conflict of interest statementDT receives royalties from books he has published on cognitive therapy, has received fees for delivering workshops on cognitive therapy, and has received lecture fees from pharmaceutical companies. PH, FD, HS and PT declare they have no conflicts of interest.AcknowledgementsWe would like to thank Professor Anthony P Morrison (ACTION Trial Principal Investigator), Dr Melissa Pyle (ACTION Trial Manager) and the ACTION Trial research team. References1. Caldwell CB, Gottesman II. Schizophrenics Kill Themselves Too: A Review of Risk Factors for Suicide. Schizophr Bull. 1990;16(4):571-589. doi:10.1093/schbul/16.4.571.2. Palmer BA, Pankratz VS, Bostwick JM. The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry. 2005;62(3):247-253. doi:10.1001/archpsyc.62.3.247.3. Hawton K, Sutton L, Haw C, Sinclair J, Deeks JJ. Schizophrenia and suicide: systematic review of risk factors. Br J Psychiatry. 2005;187:9-20. doi:10.1192/bjp.187.1.9.4. Tiihonen J, Wahlbeck K, L?nnqvist J, et al. 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Psychol Psychother Theory Res Pract. 2018. doi:10.1111/papt.12183 TablesTable 1: Participant characteristicsAll9-18 month completersVariable0 months (N=68)0 months (n=47-49)9-18 months (n=49)Age, mean (SD)31.28 (12.75)29.92 (11.18)Gender, n female (%)31 (46%)23 (47%)Years of education, mean (SD)12.59 (3.03)12.31 (2.86)MCQ-30: ‘Negative Beliefs about Uncontrollability and Danger’ subscale, mean (SD)17.28 (4.82)16.98 (4.55)115.87 (4.70)PBEQ: ‘Negative Appraisals of Experiences’ subscale, mean (SD)14.09 (3.16)14.22 (3.16)212.92 (3.78)PANSS: Positive symptoms, mean (SD)20.99 (4.89)20.29 (4.30)16.63 (6.21)PANSS: Negative symptoms, mean (SD)14.75 (4.52)14.73 (4.90)13.90 (4.48)PANSS: General symptoms, mean (SD)36.69 (7.54)36.02 (7.36)31.98 (9.34)PANSS: Total symptoms, mean (SD)72.43 (13.77)71.04 (13.41)62.51 (17.44)BDI-7: Suicidal ideation, mean (SD)0.74 (0.73)0.73 (0.81)0.53 (0.71)BDI-7: Suicidal ideation, n no ideation (%)27 (40%)22 (45%)28 (57%)BDI-7: Suicidal ideation, n mild (%)34 (50%)20 (41%)17 (35%)BDI-7: Suicidal ideation, n moderate-severe (%)5 (7.4%)5 (10%)3 (6%)BDI-7: Suicidal ideation, n severe (%)2 (3%)2 (4%)1 (2%)Note: SD, Standard Deviation; MCQ-30, Metacognition Questionnaire 30-item version; PBEQ, Personal Beliefs about Experiences Questionnaire; PANSS, Positive and Negative Syndrome Scale; BDI-7, Beck Depression Inventory 7-item version. 1N=48; 2N=47Table 2: Correlations between variables (Pearson’s r, 2-tailed)Time-point (month)NAgeEducationMCQ Negative beliefsPBEQ Negative appraisalsPositive symptomsNegative symptomsGeneral symptomsOverall symptomsEducation068-.02049-.179-1849-.17MCQ Negative beliefs068-.08.10048-.14-.089-1849.02-.12PBEQ Negative appraisals068-.17-.01.59**047-.04-.10.58**9-1849.12-.10.72**Positive symptoms068.20-.05.16.17047-49.081-.061.302*.293*9-1849.23-.24.64**.58**Negative symptoms068-.12-.21-.02.13.25*047-49-.161-.231.052.133.2719-1849.06-.13.15.31*.39**General symptoms068-.03-.04.37**.42**.60**.49**047-49-.151-.031.402**.433**.591**.481**9-1849.19-.04.63**.58**.78**.56**Overall symptoms068.01-.11.25*.33**.77**.68**.92**047-49-.121-.121.332*.383**.741**.721**.911**9-1849.20-.14.60**.59**.87**.69**.96**BDI-7 suicidal ideation068-.01-.02.43**.51**.25*.00.45**.34**047-49-.021-.021.462**.513**.361*-.021.451**.361*9-1849.11-.07.57**.47**.50**.30*.47**.51**Note: BDI-7, Beck Depression Inventory, 7-item version; MCQ, Metacognitions Questionnaire 30-item version; PBQ, Personal Beliefs about Experiences Questionnaire; 1N=49; 2N=48; 3N=47; *p<0.05; ** p<0.01; All significant results (p<0.05) are highlighted in boldTable 3: Results of longitudinal mediation analysesModel (all n=47)PredictorSuicidal ideation in 9 or 18 month completers, bUnstandardised coefficients (SE)Completely standardised coefficients (95% CI)Overall symptomsControl variablesAge (baseline)0.010 (0.008)-Gender (fixed)-0.325 (0.170)?-Education (baseline)-0.013 (0.029)-Treatment allocation2-0.082 (0.168)-Suicidal ideation at month 00.515 (0.122)**-9 or 18-month data0.299 (0.200)-Independent variablesOverall symptoms at month 0 (direct effect)0.001 (0.007)-Negative cognitive appraisals at month 0-0.022 (0.034)-Negative metacognitive beliefs at month 00.043 (0.023)?-R20.562**Bootstrap indirect effects of:Overall symptoms1 > Negative cognitive appraisals1-0.001 (0.002)95% CI (-0.007, 0.001)-0.022 (-0.049, 0.253)Overall symptoms1 > Negative metacognitive beliefs1 0.002 (0.003)95% CI (-0.001, 0.011)0.038 (-0.029, 0.235)Overall symptoms1 > Negative cognitive appraisals1 > Negative metacognitive beliefs10.001* (0.001)95% CI (0.000, 0.006)0.028* (0.000, 0.120)Total indirect effect0.002 (0.003)95% CI (-0.002, 0.012)0.045 (-0.049, 0.253)Positive symptomsControl variablesAge (baseline)0.010 (0.008)-Gender (fixed)-0.354* (0.167)1-Education (baseline)-0.014 (0.029)-Treatment allocation2-0.067 (0.166)-Suicidal ideation at month 00.538** (0.121)1-9 or 18-month data0.308 (0.196)-Independent variablesPositive symptoms at month 0 (direct effect)-0.012 (0.020)-Negative cognitive appraisals at month 0-0.020 (0.034)-Negative metacognitive beliefs at month 00.045? (0.023)1-R20.566**1-Positive symptoms1 > Negative cognitive appraisals1-0.002 (0.004)95% CI (-0.017, 0.002)-0.013 (-0.135, 0.018)Positive symptoms1 > Negative metacognitive beliefs1 0.005 (0.009)95% CI (-0.005, 0.032)0.041 (-0.040, 0.231)Positive symptoms1 > Negative cognitive appraisals1 > Negative metacognitive beliefs10.002 (0.004)95% CI (-0.002, 0.014)0.019 (-0.013, 0.105)Total indirect effect0.006 (0.009)95% CI (-0.017, 0.002)0.048 (-0.054, 0.236)Negative symptomsControl variablesAge (baseline)0.011 (0.007)-Gender (fixed)-0.322? (0.161)1-Education (baseline)-0.005 (0.029)-Treatment allocation2-0.125 (0.167)-Suicidal ideation at month 00.522** (0.115)1-9 or 18-month data0.269 (0.194)-Independent variablesNegative symptoms at month 0 (direct effect)0.022 (0.017)-Negative cognitive appraisals at month 0-0.024 (0.033)-Negative metacognitive beliefs at month 00.044? (0.022)1-R20.580**1-Independent variablesNegative symptoms1 > Negative cognitive appraisals1-0.001 (0.006)95% CI (-0.015, 0.002)-0.009 (-0.118, 0.016)Negative symptoms1 > Negative metacognitive beliefs1 -0.001 (0.006)95% CI (-0.014, 0.011)-0.013 (-0.125 0.079)Negative symptoms1 > Negative cognitive appraisals1 > Negative metacognitive beliefs10.001 (0.003)95% CI (-0.002, 0.011)0.011 (-0.018, 0.016)Total indirect effect-0.001 (0.006)95% CI (-0.012, 0.014)-0.010 (-0.111, 0.105)General symptomsControl variablesAge (baseline)0.009 (0.008)-Gender (fixed)-0.347? (0.173)1-Education (baseline)-0.014 (0.029)-Treatment allocation2-0.075 (0.166)-Suicidal ideation at month 00.531** (0.125)1-9 or 18-month data0.318 (0.203)-Independent variablesGeneral symptoms at month 0 (direct effect)-0.004 (0.014)-Negative cognitive appraisals at month 0-0.020 (0.034)-Negative metacognitive beliefs at month 00.044? (0.023)1-R20.562**1-General symptoms1 > Negative cognitive appraisals1-0.002 (0.004)95% CI (-0.015, 0.003)-0.025 (-0.171, 0.035)General symptoms1 > Negative metacognitive beliefs1 0.005 (0.006)95% CI (-0.001, 0.023)0.061 (-0.019, 0.248)General symptoms1 > Negative cognitive appraisals1 > Negative metacognitive beliefs10.003* (0.002)195% CI (0.000, 0.013)0.035* (0.004, 0.141)Total indirect effect0.006 (0.007)195% CI (-0.031, 0.024)0.071 (-0.044, 0.279)Note: Exact p-values for completely standardised indirect effects not available. Significance (p<0.05) inferred when 95% confidence intervals exclude zero; ?p<0.1;*p<0.05; **p<0.01; 1Remained or became significant (p<0.05) after entering other symptom groups as covariates; All significant results (p<0.05) are highlighted in bold. ................
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