Summary of the impact

Schizophrenia affects 1 in 100 people, with costs to society of £12 billion in England alone. Prevalence is similar across the world, with two thirds of people experiencing relapses despite medical treatment. Researchers at the University of Manchester (UoM) pioneered and disseminated psychological interventions for schizophrenia and related mental health problems which have led to improved outcomes for patients and families (e.g. 20% improvement in symptoms over standard treatment). We have implemented and delivered our intervention protocols, outcome measures, treatment manuals, and training programmes (with over 200 training courses delivered across the UK, Europe, USA, Asia, Australia and Africa). The impact of the research has been commended nationally and internationally by professional bodies (e.g., British Psychological Society, American Association of Behavior Therapy).

Underpinning research

See section 3 for references 1-6. UoM researchers are given in bold.

The impact is based on research that took place at UoM from 1991 to the present day. Key researchers:

• Gillian Haddock (Senior Lecturer, 1996-2001; Reader 2001-2005; Professor, 2005-date)
• Christine Barrowclough (Research Associate, 1994-2012; Professor, 2012-present)
• Anthony Morrison (Senior Lecturer, 2000-2003; Reader, 2003-2005; Professor, 2005-present)
• Richard Bentall (Professor, 1999-2007)
• Nicholas Tarrier (Professor, 1991-2011)
• Shôn Lewis (Professor, 1994-present)
• Linda Davies (Reader, 2000-2008; Professor, 2008-date)
• Graham Dunn (Professor, 1996-present)
• Sara Tai (Lecturer, 2001-2009; Senior Lecturer, 2009-present)

The research has:

1. Increased understanding of the cognitive processes underpinning schizophrenia and of the factors which lead to improved recovery, allowing us to develop effective treatments.
2. Developed and evaluated new psychological treatments of psychosis in more than 10 randomised controlled trials. These trials have been funded by MRC (1), the Wellcome Trust (2), NIHR (6) and other DH funded schemes (3, 4). The MRC-funded MIDAS was the largest ever trial of psychological treatments for psychosis (5). The group has secured funding of over £30m for this work over the last 15 years. The trials have demonstrated that psychological interventions are effective and should be first line treatments for people with psychosis.
3. A significant contribution has been made to the international evidence base on psychological therapies through publication in high quality international peer-reviewed journals such as BMJ, Archives of General Psychiatry and the American Journal of Psychiatry. The group has published over 500 international peer-reviewed publications on this topic.

References to the research

Details of the impact

See section 5 for corroborating sources S1-S8.

Context
Schizophrenia is a serious mental illness and affects about 1% of the population, mostly before the age of 35. Psychosis often becomes a chronic condition and it has substantial economic and social costs, reducing life expectancy by 15-20 years and costing the UK economy more than £12 billion per year. Prior to the development of new psychological treatments for schizophrenia, the first line treatment was hospitalisation and medication. However, only approximately two thirds improve despite optimal medication, with the rest experiencing persistent and distressing hallucinations and delusions and repeated relapses. These often result in lengthy hospitalisations, high service costs and great distress for the individuals and carers concerned. Psychological treatments developed at UoM have significantly improved outcomes and complemented existing treatments, resulting in improved functioning and fewer relapses for the individuals, economic savings and reduced burden of care for relatives and carers.

Pathways to impact
The impact has been achieved through wide publication of high quality, international peer-reviewed publications (over 500 publications on this topic by the group). Publication has disseminated the findings to a worldwide audience who have implemented the approaches using our treatment approaches. Members of the group have contributed to large numbers of international conferences, provided over 200 workshops worldwide, produced over 100 book chapters on the topic in books for clinical and professional audiences, contributed to policy and other bodies (e.g. NICE clinical guideline groups, Schizophrenia Commission, Implementation of Psychological Therapies for Severe Mental Illness group) and worked in close liaison and collaboration with mental health charities on research and dissemination (e.g. MIND, Rethink) to disseminate the findings.

Reach and significance of the impact
Improved assessment, treatment and outcomes for people with schizophrenia
Psychological treatments for people with psychosis, developed by the UoM group, have had a major impact on outcomes for patients and their carers. Significant benefits have been demonstrated on the core symptoms of schizophrenia: functioning, anxiety and mood (ranging from 15-20% over standard treatment). For carers, significant benefits have been shown on wellbeing, burden and functioning. Health economic benefits have also been demonstrated: implementation of psychological treatments has been shown be highly cost effective (i.e cheaper with better clinical outcomes) (S1). We have developed clinical assessment tools which are in regular use in the NHS. For example, the PSYRATS tool, a multi-dimensional assessment of psychotic symptoms, has been translated into 18 languages in Europe, Asia and Africa and has been adopted by the NHS as a national resource for clinicians (Haddock et al., 1999). It is widely used all over the world and is included in the UK Government policy on Improving Access for Psychological Therapies (IAPT, a national initiative to improve the delivery of psychological therapies) for severe mental illness as a core outcome tool throughout the UK. Although the work has focused primarily on schizophrenia and psychosis, the groundbreaking innovation of psychological treatments for schizophrenia at UoM has paved the way for the adoption of these treatments into other conditions such as suicidality, bipolar disorder and personality disorder.

National and international clinical guidelines
Work from the group has contributed directly to NICE guidance for schizophrenia (2009) (S2) and for people with schizophrenia and substance misuse (2011) (S3). The guidance specifically refers to treatments developed by our group, namely individual CBT and family interventions relating to outcomes from the trials reported above (see section 2). In addition, the recent National Schizophrenia Commission (2012) report (S1) specifically recommended the implementation of psychological therapies for people with severe mental illness and their families, again directly linked to the therapies and treatment manuals that we have developed.

Psychological interventions developed by this group are recommended in the Australia and New Zealand Clinical Practice Guidelines for Schizophrenia and by the American Psychiatric Association (S4).

Clinical manuals, outcome measures and other publications
Our treatment manuals and outcome measures are widely used by mental health practitioners throughout the world. For example, the group has published over 20 books which are used as clinical handbooks for mental health practitioners and we have contributed numerous book chapters describing the clinical interventions developed. The books and outcome measures are core materials in mental health professional training, and are widely reprinted and translated into over 15 languages. Similarly, multiple treatment manuals have been produced and these methods have been implemented in the UK and many countries throughout Europe, USA, Asia, Australia and Africa.

National standards for clinical practice
The group has contributed directly to the setting of national standards for practice of psychological therapies in collaboration with the Department of Health (e.g., The Department of Health Improving Access to Psychological Therapies programme) and through charitable organisations such as the BABCP, MIND and Rethink. The standards were developed by members of our group and have been implemented nationally and incorporated into more than 40 postgraduate training programmes with ~3000 trainees. For IAPT (2013), the group also contributed directly to the development and production of core competencies for the practice of cognitive behaviour therapy for people with psychosis. These guidelines form the basis for a national curriculum for all mental health staff working with people with schizophrenia and their carers in the UK (S5, S6). Members of the group have a longstanding record of involvement in the leading organisation for CBT in the UK (the British Association for Behavioural and Cognitive Psychotherapies; BABCP) which is responsible for the promotion and standards of psychological therapies in practice. The group includes three former presidents of this charitable organisation attesting to the leadership of the group in this topic (S7).

National and international training
Our research has impacted on the skills of the workforce delivering psychological treatments. The group has developed numerous training programmes for staff in collaboration with the NHS and academic institutions (e.g., the Thorn Initiative, developed from funding awarded to UoM and London by the Sir Jules Thorn Trust, has delivered 11 courses in the UK since 1992, resulting in ~3000 trained staff) (S5). All of these training programmes have been rolled out nationally in order to train mental health staff to deliver individual and family psychological treatments for people with severe mental illness, with the potential to impact on up to 60,000 patients and their carers. We have delivered more than 200 additional workshops and training programmes (with attendees of up to 100 in each event) in the UK, Europe, Asia, USA, Australia, with potential impact on ~600,000 patients and carers worldwide. These vary from 1 day to year-long training programmes. We have collaborations in relation to training in several international universities and health facilities. New collaborations include Japan, Russia, Lithuania and Maldives.

Awards for the impact of our research
The group has hosted two NIHR senior investigators (Tarrier, Lewis) and all group members are NIHR fellows, i.e., all currently holding funding for their work from the Department of Health. The group has won several prizes including awards from the British Psychological Society (Shapiro Award — Tarrier, May Davidson award — Haddock, Morrison) and international prizes (Tarrier — for the American Association of Behavior Therapy Trailblazer award, 2008). The group has a longstanding history of service user involvement in research and implementation, resulting in a recent prize awarded to members of the group by the national Mental Health Research Network for service user involvement in a psychological treatment trial (S8).

Sources to corroborate the impact

S1. Schizophrenia Commission report http://www.schizophreniacommission.org.uk/the-report/

S2. NICE clinical guideline (number 82) for schizophrenia specifically includes psychological treatment informed by this group. http://www.nice.org.uk/CG82

S3. NICE clinical guidelines (number 120) for dual diagnosis was informed by members of this group. http://publications.nice.org.uk/psychosis-with-coexisting-substance-misuse-cg120

S4. Psychological interventions developed by this group are recommended in the Australia and New Zealand Clinical Practice Guidelines for Schizophrenia
http://www.ranzcp.org/Files/ranzcp-attachments/Resources/Publications/CPG/Clinician/CPG_Clinician_Full_Schizophrenia-pdf.aspx and by the American Psychiatric Association
http://psychiatryonline.org/content.aspx?bookid=28§ionid=1665359

S5. National Improving access for psychological therapies (IAPT). Members of the group have directly contributed to setting of standards and core competencies in this programme.
http://www.iapt.nhs.uk/smi-/ and a national training programme was developed by the group — the Thorn initiative http://www.mhhe.heacademy.ac.uk/links/thorn-initiative/

S6. The group contributed to the development of the IAPT core competency framework.
http://www.ucl.ac.uk/clinical-psychology/CORE/competence_mentalillness_psychosisandbipolar.htmlpsychology/CORE/competence_mentalillness_psychosisandbipolar.html

S7. http://www.babcp.com/About/Past-Executive-Officers-and-Committee.aspx.

S8. The group has awards for service user involvement in research and practice from the MHRN (2009).
http://www.mhrn.info/data/files/FOR_SERVICE_USERS/SUiR_newsletter_summer_2009.pdf