Title: A Randomised Controlled Trial Investigating Attention Training Technique in Psychosis: A Feasibility Study
Funder: Department of Health and Social Care

Abstract: Background: Psychosis is one of the largest challenges for the NHS and is repeatedly a priority for policy makers, commissioners and service providers due to the significant personal, social and financial costs. At least one third of people with psychosis respond poorly to standard treatment e.g. antipsychotic medication and whilst the National Institute of Clinical Excellence (NICE) recommends the psychological treatment of choice for 'schizophrenia' is cognitive behavioural therapy (CBT) national reports show that access to CBT for psychosis is low e.g. 10%. This is an increasing issue given simultaneous resource reduction under growing pressures for cost improvements for mental health within the NHS. The problem requires a number of potential solutions to be offered, one of which would be to develop alternative low-intensity psychological treatments adopting the stepped-care approach successfully applied in IAPT. We have minimal evidence about what to recommend as low-intensity interventions for psychosis. One candidate could be Attention Training Technique (ATT) developed from the Metacognitive Model. ATT has been successful as a stand-alone strategy. Additionally, studies suggest that ATT is promising in the treatment of hallucinations in psychosis along with other psychotic symptoms. ATT has been offered as a brief intervention (4-11 sessions) across disorders including psychosis (7-9 sessions). We conducted a small pilot study (n=29) of ATT for psychosis showing preliminary results of proof of concept. The trial was able to recruit 81% of assessed participants (19% scoring under threshold on psychosis) and retained 86% to one assessment point (8 week: 83%, 12 week: 76%). Preliminary results indicate the treatment could be effective (Cohen s d 0.95, 1.085 correcting for small sample size, NNT = 2). Whilst results are encouraging, work is needed to test the feasibility and acceptability robustly prior to a definitive trial e.g. larger recruitment, retention to a longer follow-up utilising health economic and other measurement and care-coordinators delivering ATT. Aims: This study aims to assess the acceptability and feasibility of providing ATT plus treatment as usual compared with treatment as usual alone under randomised conditions for people with psychosis in order to inform a definitive trial. We will also carry out qualitative interviews to understand individuals experiences of ATT and trial participation as well as staff members experiences of the trial. Method/Plan: This feasibility study will apply a randomised design to test the acceptability of ATT and trial participation/procedures in participants with psychosis. 76 Individuals will be randomised to one of two conditions, in the treatment as usual group they will be monitored for 1 year across 3 follow-up points (3, 6 and 12 months) and in the treatment group they will be assessed over the same period plus given ATT intervention aimed at reducing psychosis symptoms, distress and increasing quality of life. We will also conduct a nested qualitative interview study (n=15-20) with a purposive sub-sample and staff members (n=15-20) to understand experiences and acceptability of ATT and research procedures. Clinical Implications: The five year forward view emphasises the importance of Improving Access to Psychological Therapies (IAPT) to those with severe and enduring mental illness however we require new information to inform low-intensity treatments to ensure the successful delivery of this offer. This study will provide the grounding for subsequent treatment development work and support applications for a phase III trial to test the effectiveness of a novel psychological treatment for patients with psychosis. If positive, this could provide commissioners with valuable data for improving the provision of choices for service users and their families and empower service users and families to make evidence-based, informed choices about options for reducing distress, improving quality of life and promotion of recovery.

Lay abstract: Psychosis causes significant problems and is a growing cost in NHS care. Treatment recommendations include psychological interventions e.g. Cognitive Behavioural Therapy, but often with poor access for service-users (10%). NHS England has committed to improving access to psychological therapies for those with severe and enduring mental illness , this includes psychosis. The successful delivery of IAPT for common mental health problems has used a stepped-care model. In order to deliver this model for those with psychosis we need to develop evidence-based low intensity psychological interventions. One such possible intervention is Attention Training Technique (ATT) which has shown preliminary positive results. The aim of this study is to run a randomised controlled trial (RCT) of Attention Training Technique (ATT) compared to treatment as usual (TAU) for individuals with psychosis to test its feasibility and acceptability. This allows the testing of key questions about recruitment and retention, provides a test of the protocol and will gather information about ATT including training and supervision needs of those providing it. We plan to recruit 76 participants with psychosis randomised to one of two possibilities; ATT plus TAU vs. TAU alone. The ATT intervention will be delivered by care-coordinators over 12 sessions. All participants will be assessed at baseline, 12 weeks, 6 months and 12 months by researchers blind to the randomisation outcome. A user-led qualitative study will explore participants experiences of ATT and of being involved in the trial. An additional qualitative study will explore staff/professionals views of the trial. Information about acceptability and feasibility will be used to develop an application for a definitive large scale trial to test the effectiveness of ATT for psychosis. This study will enable us to deliver a robust definitive trial by giving information for sample size, treatment requirements (e.g. training and supervision) and a finalised protocol.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH