The underlying causes of major mental illness are not understood and diagnoses are made largely on the basis of characteristic clinical symptoms described by the patient. A long-standing aim of biological psychiatry is to identify clinical measurements related to illness that may assist in diagnosis in the same way that the measurement of blood glucose level is used in the diagnosis of diabetes. In genetic studies such biological markers of disease have been termed "endophenotypes". Neuropsychological impairments are well described in schizophrenia and bipolar disorder. This study investigates a possible role of specific neuropsychological impairments as markers and "endophenotypes" of illness. The aims of the present study were to (a) confirm previous findings in schizophrenia and bipolar affective disorder of selected cognitive impairments and effects of clinical state and medication, and (b) to establish whether members of a large family multiply affected with bipolar and unipolar affective disorder showing linkage to a chromosome 4 locus, show changes similar to the population group of bipolar and unipolar patients. Groups of forty-one unipolar affective disorder patients, thirty-seven bipolar affective disorder patients, twenty-six schizophrenic patients, fifteen high risk family members and thirty-one healthy controls were assessed with a neuropsychological test battery focussing mainly on the domains of memory and executive function. Bipolar and schizophrenic patients had similar impairments of verbal learning and memory relative to controls. Schizophrenic patients were also impaired on executive function tasks. Performance was not due to symptom severity or medication. There were no significant differences between unipolar affective disorder patients and controls. The second major finding from this work is that cognitive deficits were measured in relatives in one family who were at high genetic risk of developing bipolar disorder but who had not developed symptoms of the disorder. It can be concluded that these cognitive deficits may be considered as 'endophenotypes' in genetic studies of bipolar disorder.

Background: Recovery in psychosis is increasingly recognised as more than merely symptom reduction, rather it is about rebuilding meaningful lives. Compassionate Mind Training (CMT) was trialled within community samples and found to reduce feelings of shame and self criticism that can act as barriers to recovery (Gilbert and Irons, 2004; Mayhew & Gilbert, 2008; Gilbert & Proctor, 2006). Forensic patients often suffer high levels of shame and stigma in relation to their illness, their crime and their detention (Laithwaite & Gumley, 2007). Laithwaite (2007) therefore developed and trialled a 'Recovery After Psychosis' (RAP) programme for forensic patients, based upon the principles of CMT. The programme has been found to have positive outcomes in terms of improving self esteem, and reducing both depression and general psychopathology (Laithwaite et al., 2009). Due to the constraints of quantitative methodologies this study was however, unable to explore the process of change that occurred from a patients' perspective. Aims: The current qualitative study aims to gain a better understanding of the process of change for participants of the RAP programme in order to inform both content and delivery methods of future programmes. Method: Semi structured interviews were conducted with eight participants, following their participation in RAP. All interviews were transcribed and analysed using Interpretative Phenomenological Analysis (Smith et al, 2009). Results: Six super-ordinate themes emerged in the patients responses: 'limited resources as consequences of upbringing'; 'mistrust'; 'the fragility of the mind'; 'institutional barriers to recovery'; 'self reflection and understanding' and 'personal development'. Discussion: The participants told of a journey of personal development. They discussed their upbringing and how this limited their academic abilities. They described feelings of mistrust and anxiety surrounding the 'power of their mind' during psychosis, and their fears of discussing any of these issues with others. The group setting appears to have been a unique environment that acted as a vehicle to facilitate change, overcome fears and normalise their experiences. The themes raised recommendations for improving the RAP programme and provided more general recommendations to improve the experience of hospitalisation of forensic mental health patients.

The ways in which individuals cope with stress has been the subject of much psychological research. Traditionally, coping has been understood as either a disposition, implying stability of individual coping style across situations, or as a process involving individual appraisal of situations and resources, leading to use of a variety of coping strategies. There is considerable evidence of maladaptive psychological and physical health outcomes in relation to different coping styles. More recent research suggests that flexibility in choice of coping response may be more adaptive than any particular style or strategy. The concept of coping adaptiveness, as measured by the Personal Functioning Inventory (PFI), is a relatively recent addition to the stress and coping literature. It emphasises the importance of accurate judgement of the controllability of the stressor in the coping process, as well as sufficient determination and self-control to ensure the most adaptive coping response when faced with obstacles or pressures to respond otherwise. The concept of discriminative facility has been shown to be a useful predictor of individual appraisal of controllability, and in the absence of scales designed specifically to measure determination and self-control, it is proposed in the present study that discriminative facility, general self-efficacy (which may be similar or related to determination), and mindfulness (which may help an individual have greater control over their responses), may be related to coping adaptiveness. Further predictions are that coping adaptiveness is negatively related to psychological distress, and positively with psychological wellbeing, and that coping adaptiveness mediates the proposed predictive relationships between general self-efficacy and mindfulness with psychological wellbeing. In a cross sectional design, 37 participants from a primary care adult clinical population, experiencing a variety of stress and mood related difficulties (study 1), and 159 undergraduate students and nonclinical associates of the researcher (study 2) took part in this study, by completing standardised questionnaires. The results of correlational analysis broadly supported associations in the theoretically predicted directions, and mediational analysis in study 2 suggested a significant mediation effect of coping adaptiveness in the relationship between mindfulness and psychological wellbeing, and general self-efficacy and psychological wellbeing in the nonclinical sample. Results from both studies are discussed in relation to methodological, theoretical and clinical implications.

Over the last decade an increasing number of studies have investigated the impact of mindfulness-based training on young people’s well-being and cognitive performance. There has also been an upsurge of interest from educators and policy makers given the potential of mindfulness training to enhance well-being, which is becoming a key area of health and education policy change. Despite this keen interest, our understanding of the neurocognitive mechanisms underlying mindfulness from a developmental perspective is limited. Nevertheless, such understanding could help guide further research and implementation efforts within education. To that end, this project aimed to discuss and evaluate a mindfulness-based training programme for older adolescents who are at a sensitive period of psychological development, both from a neurodevelopmental and clinical mental health perspective. The first three chapters of this thesis provide its theoretical grounding, including an overview of the current state of adolescent well-being, a review of developmental and neuroscientific mindfulness intervention research, and introduces electroencephalographic methodology. Chapters Four and Five then outline the longitudinal mindfulness intervention studies with 16-18 year old students following a non-randomised wait-list control design. The findings indicated that an 8-week mindfulness programme can result in enhanced attention inhibition for task-irrelevant stimuli (indexed by more a negative N200 event-related potential [ERP]) and sustained attention to emotional faces (marked by maintained P3b positivity over time). These ERP modifications were supported by converging evidence from self-report measures – increases in metacognition and well-being, as well as high levels of course acceptability. The potential ramifications of these findings are discussed further in Chapters Six and Seven, including the broader implications for further developmental research on mindfulness, and well-being policy in schools. In conclusion, mindfulness-based training in schools may facilitate specific neural maturation processes in older adolescents, particularly within the frontal lobe regions associated with cognitive control, which could positively impact their learning and emotion regulation skills.

The literature review focuses on the perceptions and beliefs that individuals with schizophrenia hold about their illness, and how these may relate to outcome. The literature regarding Illness Perception in general, and Recovery Style in particular, illustrates how Health Psychology-based models may be useful in terms of understanding illness behaviour. The review concludes that this may well be a fruitful area for the development of theory-driven interventions to improve individuals' quality of life after a diagnosis of schizophrenia. The empirical paper reports a cross-sectional study investigating whether Illness Perceptions and Recovery Style are related to impairment or quality of life in a sample with relatively chronic schizophrenia. The main findings were that a more Integrating Recovery Style was associated with better outcome in all domains and that Illness Perceptions of greater coherence of the illness experience, and less emotional distress were associated with both better quality of life and a more Integrating Recovery Style. The critical review addresses the main topics of the clinical, practical and scientific implications of the findings of the empirical paper and attempts to link the findings to related areas of research such as models of trauma and attachment, in order understand the meaning of the findings in the context of this particular illness.

BACKGROUND: Loneliness is more prevalent among people with mental health problems than in the general population. However, loneliness has not been a particularly prominent focus in recent research on outcomes of mental illness. Loneliness interventions have also received little attention. AIMS: 1) To review literature for the definition and conceptual model of loneliness and its closely related concepts, and for well-developed measures of these concepts. 2) To systematically review the impact of loneliness and perceived social support on mental health outcomes 3) To explore the severity of loneliness among people leaving Crisis Resolution Teams (CRTs), and identify factors cross-sectionally associated with loneliness. 4) To determine whether loneliness at baseline predicts poor outcomes at 4-month follow-up, including overall symptom severity, affective symptoms, self-rated recovery and health-related quality of life. 5) To examine whether there is any difference in loneliness at 4-month follow-up between a peer-provided self-management intervention group and a control group in a randomised controlled trial. METHOD: A conceptual framework of loneliness and related concepts was developed and measures identified of main concepts. A systematic review of longitudinal studies examining the effect of loneliness and perceived social support on mental illness prognosis was conducted. The sample (n=399) was taken from patients participating in a research trial from CRTs. Participants in the trial intervention group were offered up to ten meetings by a peer support worker and a self-management workbook. Participants in the control group were only provided a self-management workbook. Respondents (n=310) completed the follow-up measurement four months after baseline. RESULTS: A model with five domains was proposed to incorporate all terms relating to loneliness. Well-developed measures assessing each domain or covering multi-domains were identified. Perceived social support and loneliness were associated with mental health outcomes. The severity of loneliness was high among people leaving CRTs. Greater loneliness was significantly associated with small social network size, limited social capital, severe affective symptoms and long-term mental illness history. Greater loneliness at baseline predicted poorer health-related quality of life at 4-month follow-up. Loneliness was also a better predictor of clinical outcomes than objective social isolation and social capital. Loneliness at follow-up was not significantly different between the intervention group and the control group. DISCUSSION Loneliness is an important issue in mental health service users. It could be a promising target to improve recovery for people with mental health problems. The efficacy of peer-provided self-management intervention on loneliness was not confirmed. More research is necessary to explore beneficial loneliness interventions so as to aid the development of recovery-oriented mental health services.

Cardiovascular disease (CVD) is the leading cause of death amongst people with severe mental illness (SMI) and drives substantial portion of the 15-20 year deficit in life expectancy experienced by this group relative to the general population. Statins form a core part of CVD prevention in the general population, but the evidence-base for people with SMI is unclear. Evidence on the effectiveness of statins for primary prevention of CVD was systematically searched but did not identify any studies investigating CVD events or associated mortality in people with SMI; therefore highlighting the need for studies on the long term impacts of statin prescribing. Two analytical studies were undertaken using longitudinal data from The Health Improvement Network (THIN) primary care database to investigate: 1) CVD screening and statin prescribing in people with and without SMI and 2) to explore the effectiveness of statins for CVD prevention in individuals with SMI. Collectively the work has established that CVD screening and statin prescribing is increasingly accessed by individuals with SMI at levels that are comparable to people without similar mental health conditions. The results from this study provide the first evidence that statin prescribing to people with SMI is associated with statistically significant reductions in total cholesterol (of 1.2mmol/L for up to 2 years, p < 0.001). There were small non-significant reductions in the rate of combined MI and stroke (0.89; 95% CI; 0.68-1.15) and all-cause mortality 0.89 (95% CI; 0.78, 1.02). This study provides evidence that statin prescribing to people with SMI may have a magnitude of effectiveness that is broadly similar to the general population.

BACKGROUND: People from Black and Minority Ethnic backgrounds tend to seek help later in the course of dementia than people from the majority ethnic population. Aim: To develop an intervention to encourage people from South Asian backgrounds to seek help earlier for memory problems and test its acceptability and feasibility. Methods: I systematically reviewed the literature and analysed routinely collected data to find interventions which improved dementia diagnostic rates. I then completed my qualitative study with South Asian community members to inform the development of an intervention to encourage earlier help seeking for memory difficulties by South Asian people. After piloting, I tested the intervention in a pilot cluster randomised controlled trial (RCT) with South Asian patients from participating GP practices. Primary outcomes were: 1. Feasibility - recruitment and retention rates 2. Acceptability - rating on a Likert scale. Results: No trials to increase dementia diagnosis rates have been successful, but rates increased significantly after implementation of the English National Dementia Strategy. South Asian community members said that understanding, through a story, that dementia was a physical illness, would normalise dutiful family members seeking interventions. I developed a bilingual leaflet and trilingual DVD with this content. I recruited and randomised 8 GP practices; 78/102 (76%) patients who allowed me to contact them, consented to the study (37 treatment-as-usual and 41 intervention). 76 (97%) participated in follow-up. 37/41 (90%) who received the intervention found it acceptable. Conclusion: I designed the first culturally-appropriate intervention to encourage help-seeking for dementia in the South Asian population. Participants found it acceptable. It was feasible to recruit and follow-up participants. A full-scale RCT would require a very large number of GP practices to participate so is likely to be expensive. It may be preferable to make this acceptable and simple intervention available and disseminate it.

Background: Deinstitutionalisation and the movement of people with intellectual disabilities (ID) to the community have seen the emergence of care philosophies aimed at tailoring services to individuals’ needs. Person-centred support has been widely advocated and considered synonymous of good care. It is useful to investigate if day-to-day support provided by paid carers in the community is person-centred. / Aims: 1. To explore person-centred support and choice in adults with ID and challenging behaviour. 2. To investigate correlates of person-centred support, including challenging behaviour. 3. To investigate whether the results of self-report questionnaires and direct- observations are comparable. / Methods: 1. Self-report measures of person-centred support typically used by staff supporting older adults with dementia were adapted for use by staff supporting adults with ID and challenging behaviour. A measure of choice availability was also updated. 2. A cross-sectional study of 109 paid carers supporting adults with mild to severe ID was conducted to address aims 1 and 2. 3. Naturalistic observations of eighteen participants with ID were conducted to complement the results of the cross-sectional study. Data was collected using momentary time-sampling and narrative descriptions. / Results: Paid carers reported high levels of person-centred support and choice availability for service-users. No significant associations were found between person-centred support and characteristics of the living environments, however choice availability was significantly higher in supported living compared to residential care homes and in living environments with fewer residents. Carers who reported higher levels of person-centred support experienced less subjective burden in their jobs. There was an association between choice and service-users’ adaptive behaviour. No association was found between person-centred support/choice and global challenging behaviour; stereotyped behaviour however was negatively associated with autonomy and carers’ knowledge of individuals with ID. The findings from the observations showed lower levels of person-centred support than those reported by paid carers, suggesting desirability effects in carers’ responses. Low levels of engagement in meaningful activities, assistance and contact from staff were observed, although there was much variability at the individual level. There were few instances of challenging behaviours and these mostly consisted of stereotyped/repetitive movements which were prevalent in disengaged participants. / Implications: The support for people with ID and challenging behaviour requires improvement but quality evaluation criteria adopted by inspectors and regulators may need to be reconsidered. Improvements in day-to-day support could reduce stereotyped behaviour but input from skilled professionals may be required for other types of challenging behaviour.

Background: Analgesic medication is widely used in care homes but little is known about how often this medication is prescribed or administered, or what factors influence its use. Aim: To describe the prescription and administration of regular and PRN analgesic medication in care homes; to investigate whether individual or care home differences are associated with analgesic use; and to compare analgesic prescribing in English care homes to international prescriptions. Methods: This study is embedded in a longitudinal study of 86 care homes in England. Data were collected at 0-, 4-, and 12-months. Residents were eligible if they had diagnosed or probable dementia. Analgesic prescriptions are presented by drug and class. Administration of PRN analgesics is described. Individual differences (sociodemographic; agitation [Cohen-Mansfield Agitation Inventory]; dementia severity [Clinical Dementia Rating]; psychotropic drug prescriptions) and care home differences (type; ownership; number of beds; dementia-registered/specialist; CQC rating) are explored using multilevel models. Results: Data were available for 1483 residents. Around 70% of residents were prescribed analgesics at all study visits, predominantly PRN paracetamol. Overall, PRN analgesics were not administered frequently. There were differences between care homes in administration but these differences were not accounted for by the modelled care home-level variables. Residents with more severe dementia, and males, appear to be more at risk of untreated pain. Conclusion: This is the largest study to date exploring analgesic administration in care homes. Prescription levels of regular analgesics are lower in England compared to other countries, however it is unclear why. Pain management in care homes is largely reliant on PRN paracetamol that is frequently prescribed but infrequently administered. Care homes differ in how often they administer PRN analgesics and this is likely due to internal factors. Therefore care home residents are likely to have untreated pain, and some groups are more at risk than others.