Can feeding good bacteria in the gut help brain function in psychosis?
(i) Psychosis and ‘cognitive impairment’
Psychosis is a mental condition where people lose touch with reality and experience hallucinations (hear voices) and delusions (have false beliefs). People with psychosis also find it difficult to pay attention to what is going on around them, have a harder time solving problems, and cannot easily string together the correct words when speaking. Attention, problem solving, and the ability to easily construct meaningful sentences and remember a lot of words are collectively known as the cognitive functions of the brain. When these functions are not working properly, people are said to have cognitive impairments. There is medication available which can reduce psychotic symptoms in people with psychosis, but this medication does not improve cognitive impairments. So even when people with psychosis are not hallucinating or having delusions, they still have poor attention, problem solving and verbal abilities. This makes it very difficult for these individuals to work properly or stay in relationships. Doctors and scientists, therefore, have spent many years exploring ways to treat cognitive impairment in psychosis.
(ii) Gut bacteria and the brain
It has been known for a while that some bacteria in our guts are ‘good’ because they help us breakdown our food during digestion, and so we get the maximum benefit from our diets. This results in better functioning of all our body processes particularly metabolism, chemical activities that provide the body with energy. Good bacteria can also strengthen our immune system to help us fight off harmful microbes more efficiently. Over the past ten years, scientists have found that good bacteria can also help brain function, and so recently we suggested that feeding these bacteria to make them grow more in the gut, might improve cognitive functions in psychosis. Studies have found that compounds called ‘prebiotics’ grow good bacteria in the gut, and in our laboratory we found that this effect does improve brain function in animals and healthy people. We therefore extended our research to people with psychosis to see if prebiotics can help cognitive impairment.
2) Aim and design of our study
The aim of our study was to test whether eating a prebiotic powder with breakfast every day for 12 weeks, could improve cognitive function in people with psychosis. We recruited volunteers on medication who were not having any psychotic symptoms but had cognitive impairment. We used computer-based tests to determine the severity of their cognitive impairment and expressed this as a score. We were also interested to see if prebiotic intake changed the volunteers’ metabolism which the prebiotics have been shown to do through growing the good bacteria, as mentioned above. This is important, because the medication the volunteers were taking to improve their psychotic symptoms made them gain weight. The volunteers’ weight and waist circumference were therefore taken to see if they reduced with prebiotic in their diet. We also took some blood from the individuals to check if certain chemicals changed in a way that indicated metabolism, and even immunity, were improving.
When people were recruited they were given a 12 week supply (one every day) of either a prebiotic or a placebo. After the 12 weeks, they were then given a 12 week supply of the other compound; so subjects who took a prebiotic daily for 3 months, then took the placebo for the 3months and vice versa. This is called a cross-over trial which allows us to directly measure whether each individual benefits from a prebiotic. The blood samples were taken from volunteers after they finished the cognitive tests, and the weight/waist measurements were made. So altogether, the blood samples were taken from each volunteer at the start of the study, in the middle of the study when they changed to the next compound, and then at the end of the study.
3) Results of our study and future work
We found that the daily intake of a prebiotic for 12 weeks improved the overall cognitive function of participants when compared to taking the placebo. More specifically, individuals appeared to perform better on tests of attention and problem solving but not on verbal tasks. Although the effect was small, we are sure that any increase in cognition can in the long-term improve the mental and social wellbeing of people with psychosis.
Surprisingly, including a prebiotic in the diet neither changed the weight or hip circumference of the volunteers, nor indicators of altered metabolism or the immune system in the blood. It is not clear at this stage, therefore, how growing good gut bacteria improves cognitive function in psychosis, but there are other potential gut-to-brain pathways that the microbes may have affected that were not explored in this study.
In the future, we hope to repeat this research with a lot more volunteers to see if prebiotics can improve cognitive function in everyone with psychosis, and we would also like to see if this helps them in their daily life activities in the long-term. We also plan to measure more chemicals in the blood to try and find out how the prebiotics are working, and even look at stool samples from the same people to test if it is the same bacteria in everyone that are helping brain function.
Oxford study suggests compulsory treatment in the community does not improve outcomes
In mental health care, formal coercion (compulsion) means authorising compulsory treatment through legislation (such as Community Treatment Orders (CTOs)), whereas informal coercion indicates various pressures exerted by professionals and informal carers (including leverage). One example of this might be where a housing provider insists a person takes medication to live in their accommodation. Discussions about the need to use coercion outside hospital has arisen particularly because of the closure of many hospitals and the move of care into the community for people with severe mental illness.
The OCTET Study examined the effects of CTOs on patients with a psychotic illness. We conducted a randomised controlled trial to test whether leaving hospital on a CTO would be beneficial over 12 months compared to having a short period of leave before returning to voluntary treatment. It was not. All measures were the same for the two groups of patients, regardless of whether they were compelled or not. Patients, family carers and psychiatrists reported mixed experiences of CTOs. We concluded that there is no clinical or ethical justification for CTO use.
The OCTET Follow-up Study followed up the same patients for another 24 months. There was still no evidence for CTOs being beneficial. We also found no indication that CTO use led to disengagement from mental health services.
The ULTIMA Study investigated lifetime informal coercion experienced by people receiving care voluntarily from mental health and substance misuse services. One third reported that they had been leveraged to comply with treatment, support with housing being most common. This is similar to research in the US. Patients and professionals expressed a range of views and we identified a wider range of pressures that people under the care of mental health services experience in connection with their finances, housing, access to children, and the criminal justice system. We also produced ethical guidance for mental health professionals about how to decide whether informal coercion may be ethically justifiable.
The OCTET study in particular has been used in the recent review of the Mental Health Act, that is suggesting mental health teams work together with patients to minimise the use of the Mental Health Act, especially in people from black and minority ethnic backgrounds. The final legal changes are awaited.
Open access link to published paper:
What is the best way to organise integrated care between the hospital and the community?
There are many different ways to organise care for people who use mental health services. We use the term “integration” to describe how services work with each one another. In the COFI study, we were looking at one way of organising mental health care to provide integration. We studied the best way to organise care between the hospital (when a person is an inpatient) and in the community (when the person is an outpatient).
There are two main ways to organise mental health between the hospital and the community:
1. Personal Continuity – the same psychiatrist see the service user in hospital and in the community.
2. Specialisation – the service user is seen by one psychiatrist in hospital, and a different psychiatrist in the community.
Although many people may be involved in a person’s care, the two systems focus on the psychiatrist as they often make decisions about the person’s treatment, including their medication.
In the UK and Italy, whether a person has the same or different psychiatrist (i.e. received personal continuity or specialisation) depends on where the person lives. Each hospital provides either personal continuity or specialisation. In Belgium, Germany and Poland the service user and staff member decides whether a person sees the same or a different psychiatrist when the person is ready to leave the hospital. This means both personal continuity and specialisation can happen within the same hospital.
Policymakers – who are the people who make decisions about the type of care mental health services provide, are currently discussing whether personal continuity or specialisation is better. However, changing the organisation of mental health care can be expensive and disruptive to both staff and service users. We therefore need high quality research evidence to help us decide which approach is best. We designed the COFI study to answer this question.
2) What did we do?
The COFI study took place in five countries in Europe. These were UK, Belgium, Italy, Germany and Poland. In all of these countries, both personal continuity and specialisation are already in place. This meant that we did not have to change anything in the study and did not ask clinicians or service users to do anything new. As we did not change anything, COFI is called a “natural experiment”.
The COFI study wanted to see whether personal continuity or specialisation was best for people who use mental health services. To do this we included people who had been admitted to a psychiatric hospital ward over a 14 month period. People were asked to fill in a questionnaire that asked them about themselves and their experience of mental health care. We then asked the same questions one year later to see if anything had changed. We also looked to see whether the person had been readmitted to the hospital and counted the number of days they spent in hospital over the year. Finally, we were interested in how satisfied people were with their care in the hospital and in the community and checked on the safety of mental health care by measuring whether people had experienced any incidents called “untoward events”.
We included 57 hospitals in the study and 7,302 people filled in our questionnaire. This makes COFI one of the biggest studies including people in hospital ever!
We also wanted to make sure that people had the chance to tell us about their experiences of mental health care. To do this we held interviews with service users and staff who took part in the study. The interviews asked people about worked well and what worked less well in each system. We conducted nearly 200 interviews with service users and over 60 with staff members.
Throughout the study, we had a panel of people with lived experience called SUGAR (Service User and carer Group Advising on Research) who helped us to make sure that all the questionnaires and interview questions made sense to people who use services.
3) What did we find?
After one year, we were able to complete the questionnaires with 6369 out of the 7304 service users. This means we followed up nearly 90% of people who took part in the study.
We found that more than one in three people who leave hospital have to go back to hospital within one year (around 40%). We did not find any differences in the number of people who had to go back into hospital between personal continuity and specialisation. We also did not find any differences in the number of days people spend in hospital.
We checked to see if personal continuity or specialisation worked better for different types of people who use hospital. To do this we looked at “subgroups”. This meant comparing people with certain mental health conditions, people over or under 40 years of age, and people who had previously been in hospital to those who had not been in hospital before. We did not find any differences between personal continuity and specialisation for any of the “subgroups” we looked at.
We did find that people were more satisfied with their hospital treatment if they received personal continuity compared to specialisation. This means people who have the same psychiatrist in the hospital and in the community are more positive about their experience of hospital care.
Although people who had the same psychiatrist were more satisfied with their hospital care, there was no difference in how satisfied they were with their overall care in the community. We also did not find any differences in their quality of life and in the safety of mental health care between personal continuity and specialisation.
We looked at the interviews to see what people said about their experience of mental health care. Service users and staff members identified a number of good and bad points about both personal continuity and specialisation.
4) What does this mean?
Whether or not the person sees the same or a different psychiatrist between the hospital and the community is a hotly debated question. However, we did not find it made any difference to service users after one year on the questionnaires. Service users preferred their hospital treatment when they receive personal continuity (i.e. the same psychiatrist) but this did not make a difference in the longer term. We found that service users and clinicians named advantages and disadvantages of both systems.
The COFI study is a large and important study for people who use, work in and make decisions about mental health services. From the findings of the study, we were able to recommend:
1. Costly reorganisations of mental health care systems should not focus on changing from specialisation to personal continuity of care or vice versa, if the aim is to improve long-term outcomes for people.
2. If we want to improve the experience of people using inpatient services, personal continuity may be better.
3. Both personal continuity and specialisation have strengths and weaknesses – the individual experiences in a local context may favour one or the other.
4. Research and policy should focus less on the organisation of care but should instead focus on improving the content of care.
COFI website: http://cofi.qmul.ac.uk/projectoverview/
NHS service users and clinicians disagree on cultural adaptations in practice
A recently published article in the International Review of Psychiatry states the results from the CoACtION study (Cultural Adaptations in Clinical Interactions). This was a multi-site survey study to assess what cultural adaptations are made by clinicians in different settings. The aims were to identify what interactions that are culturally influenced are used by clinicians in England and how these interactions are experienced by patients who are from a Non-White or Non-Western Background.
Those who completed the surveys were clinicians working in Mental Health in 25 areas of England and patients in those areas who were of a Non-White or non-Western background. A total of 2805 participants took part in the study between 1st April and 30th June 2018, 87% Clinicians and 13% Patients. Questionnaires were written in English and support was available from carers or staff members for those who needed it. Only those with capacity and those willing to complete the questionnaires took part.
Participants generally came from NHS community mental health teams or inpatient services. The most common role for clinicians was that of nurse with most clinicians working 1 – 5 years in their role. Most patients had been with services for over 10 years. In terms of gender, those that completed the questionnaires were mainly female clinicians and male patients (55%). The majority of the clinicians were white and a majority reported they had less than 40% of their practice population from minority cultures. 67% of the patient participants spoke English as their first language.
The results of the questionnaire when analysed showed that often the opinions of the clinicians and the patients differed except to most often agree that a culturally specific assessment tool was never used and that levels of acculturation were most of the time or always considered. Disagreement though was recorded around other factors (whether the setting of interaction was culturally appropriate, whether preferred language, migration history, barriers to accessing services, influence of religion, alternative pathways to care and cultural values relating to goals and social support networks were discussed). Clinicians most often felt these factors were always or most of the time taken into account, but patients felt that they were rarely or never taken into account. So a disconnect was shown to exist. Other questions given solely to clinicians showed that they considered the areas of cultural importance mentioned ‘most of the time’ or ‘always’ and most felt they were attending to cultural needs. In comparison those questions just answered by patients showed the majority of patients received care from someone of a different cultural background and that ‘often’ their cultural needs were not met, however some reported that their cultural needs were addressed.
Using some statistical tests on the answers to the questionnaires it was possible to see that Clinicians are more likely to feel cultural needs were being met if they had been working in their role for more than 10 years, had specific training to work with cultural groups and they had a high percentage of their patients come from minority cultural groups.
The results of this study are in line with other research done previously, showing a disconnect between how clinicians rate their communication skills and how patients report these as not satisfactory. This study shows that within the sphere of cultural competence the clinicians’ assessment of their perceived cultural competence and the patients view that their cultural needs are not being met points to a disparity between the two viewpoints. This must be addressed going forward.
This research was funded by the Pakistan Association of Cognitive Therapists (PACT) and sponsored by Southern Health NHS Foundation Trust. The Chief Investigator was Professor Shanaya Rathod. The full article can be read here:
Voucher rewards do not reduce frequency of cannabis use or relapse in people with early psychosis
Contingency management – the use of positive reinforcement in the form of supermarket vouchers to shape behaviour – makes no difference in the frequency of cannabis use or relapse rates in those with early psychosis. Although psychotic symptoms initially decrease, these changes are not sustained over the longer term and are no better than with an optimised educational intervention.
This NIHR-funded multicentre randomised controlled trial included 551 young adults who were being treated in an ‘Early Intervention in Psychosis’ service of 23 NHS trusts in the Midlands and south-east of England. It found no clinical difference in time to relapse, frequency of cannabis use, symptom severity, or engagement in education or work. The total cost of inpatient hospital admissions was slightly lower for those receiving contingency management, but the reason for this is not clear.
Why was this study needed?
Psychosis is a mental health condition that causes people to perceive or interpret things differently from those around them. Psychosis may involve hallucinations or delusions. The use of cannabis, particularly high-potency cannabis, significantly increases the likelihood of psychotic disorder compared with never users. Cannabis was the most commonly used drug in England and Wales in 2017/18. About 2.4 million adults (16 to 59 years) used it that year, including around one million young adults from 16 to 24 years old.
Contingency management, a set of techniques used to reinforce certain behaviours, has proven clinically effective and cost-effective in a variety of contexts including severe mental illness, smoking and alcohol misuse. Most contingency management research has been undertaken in the US.
This trial aimed to examine the impact of a shopping voucher reward contingency management programme on cannabis use and relapse in those with early psychosis to see if it could work in England.
What did this study do?
This trial randomised 511 people aged 18 to 36 to either a combined voucher reward contingency management and optimised psychoeducational intervention or the psychoeducation intervention alone. Contingency management rewarded self-reported abstinence from cannabis use, confirmed by urine analysis, with shopping vouchers. Vouchers began at £5 and rose by £5 every two weeks of abstinence to a maximum of £240 over 12 weeks.
The optimised psychoeducational intervention was six 30-minute sessions on the potential advantages and disadvantages of cannabis use and abstinence. Interviews, questionnaires and electronic patient records were used to determine relapse rates and background data.
A high proportion of participants did not engage in either the contingency management or psychoeducation sessions (they declined or discontinued the intervention). This lack of retention might have reduced the chance of finding a difference if one existed.
What did it find?
- Similar numbers of participants receiving the psychoeducation sessions (61%) and in the contingency arm (57%) had cannabis-positive urine at 18 months (OR 0.84, 95% CI 0.49 to 1.41). Self-reported cannabis-using days at three months and 18 months were also similar.
- Clinical outcomes were similar for readmission rate: time to admission (hazard ratio [HR] 1.03, 95% CI 0.76 to 1.40); or likelihood of at least one admission (OR 1.02, 95% CI 0.70 to 1.48).
- No variance was found in the likelihood of participant engagement in work (OR 0.95, 95% CI 0.62 to 1.46) or study (OR 0.82, 95% CI 0.50 to 1.35).
- There were mixed results for Early Intervention in Psychosis service users receiving contingency management, with lower rates of positive symptoms at three months (coefficient –0.07, 95% CI –14 to 0) but not at 18 months (coefficient –0.04, CI –0.13 to 0.05).
What does current guidance say on this issue?
The NICE 2017 guideline on drug misuse prevention advocates targeted interventions for people at risk of drug misuse. The NICE 2007 guideline on drug misuse in over 16s advocates a nationwide training programme for NHS staff in contingency management. This guideline reports that the lack of training coupled with staff, service user and public concerns about the longevity of any behavioural change, and the possibility of an intervention appearing to reward drug use, makes the introduction of contingency management in drug misuse services a challenge.
What are the implications?
Contingency management, using the current value of shopping vouchers, is not effective in reducing cannabis use or relapse in people with early psychosis.
The researchers thought that modifying the contingency management programme design or reward level may produce different outcomes. On a positive note, the number of days of cannabis use had reduced in both groups by six months which may indicate that the psychoeducation sessions were beneficial, and they suggest that this is worth exploring further.
Open access link to published paper:
REACT website no more effective in reducing relatives’ distress than currently available resources.
Relatives of people with severe mental health problems need better access to information and emotional support. The Relatives’ Education And Coping Toolkit (REACT) is a website designed to do this. It includes lots of information presented in text and video, an online forum for relatives to share knowledge and experience, a messaging system where they can ask questions in confidence and a comprehensive directory of contact details for national organisations offering relevant support. Trained relatives support the forum and messaging.
In the UK, we recruited 800 relatives of people with severe mental health problems: all were aged ≥ 16 years, had high levels of distress, had access to the internet and wanted help. We divided them into two equal groups: one group received REACT (including the resource directory), whereas the other group received the resource directory only. To ensure that there were no differences between groups at the start, relatives were allocated to the two groups randomly, so they had an equal chance of being in either group. We followed up with both groups at 12 and 24 weeks and received data from approximately three-quarters of the participants.
This trial found that REACT was acceptable, safe and inexpensive to deliver (£62.27 per relative), compared with face-to-face interventions, and that relatives using it felt well supported. However, once we accounted for missing data (relatives who dropped out of the trial or did not complete the follow-up questionnaires), there were no significant differences between the groups. There was no evidence that REACT increased relatives’ quality of life or saved money for the NHS.
Open access link to published paper: