Juliana Onwumere

King's College London, Londinium, England, United Kingdom

Are you Juliana Onwumere?

Claim your profile

Publications (26)63.72 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: High expressed emotion (EE) is a robust predictor of elevated rates of relapse and readmission in schizophrenia. However, far less is known about how high EE leads to poorer patient outcomes. This study was designed to examine links between high EE (criticism), affect, and multidimensional aspects of positive symptoms in patients with psychosis. Thirty-eight individuals with nonaffective psychosis were randomly exposed to proxy high-EE or neutral speech samples and completed self-report measures of affect and psychosis symptoms. Patients reported significant increases in anxiety, anger, and distress after exposure to the proxy high-EE speech sample as well as increases in their appraisals of psychosis symptoms: voice controllability, delusional preoccupation, and conviction. These findings offer further evidence of the potential deleterious impact of a negative interpersonal environment on patient symptoms in psychosis.
    The Journal of nervous and mental disease. 11/2014; 202(11):829-32.
  • Sarah Roddy, Juliana Onwumere, Elizabeth Kuipers
    [Show abstract] [Hide abstract]
    ABSTRACT: Caregivers play an important role in the treatment and recovery of people with psychosis but they have different needs from service users and can experience significant distress as part of their role. Responding to caregiver needs is not readily identified as being the primary responsibility of clinical services that have limited resources. A small pilot study sought to evaluate the effect and acceptability of providing a brief, needs-led intervention to long-term caregivers of service users with psychosis. A two or three session, interactive and structured intervention, adapted from family work with psychosis, focused on facilitated carer access to reliable information about psychosis, goal setting and adaptive problem-solving. Measures of affect, coping and care-giving impact were completed at baseline and post-intervention. Data for the first four caregivers who attended individual sessions are presented. Post-intervention scores indicate reductions in levels of carer distress and depressive symptoms. Caregivers reported high levels of acceptability and satisfaction. Further studies are required to evaluate the impact of such interventions on a larger number and wider range of caregivers.Practitioner pointsTo date, it has proved difficult for clinical services to meet the needs of caregivers of service users with psychosis.The caregivers of service users with psychosis have readily identifiable needs that can be met with a brief, structured, individualized and interactive intervention.Offering a time-limited intervention to carers who would like support with their role has benefits for both the caregivers and the service.
    Journal of Family Therapy 10/2014; · 0.94 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This study investigates potential explanations of the association between caring and common mental disorder, using the English Adult Psychiatric Morbidity Survey 2007. We examined whether carers are more exposed to other stressors additional to caring – such as domestic violence and debt – and if so whether this explains their elevated rates of mental disorder. We analysed differences between carers and non-carers in common mental disorders (CMD), suicidal thoughts, suicidal attempts, recent stressors, social support, and social participation. We used multivariate models to investigate whether differences between carers and non-carers in identifiable stressors and supports explained the association between caring and CMD, as measured by the revised Clinical Interview Schedule. The prevalence of CMD (OR = 1.64 95% CI 1.37–1.97), suicidal thoughts in the last week (OR = 2.71 95% CI 1.31–5.62) and fatigue (OR = 1.33 95% CI 1.14–1.54) was increased in carers. However, caring remained independently associated with CMD (OR = 1.58 1.30–1.91) after adjustment for other stressors and social support. Thus caring itself is associated with increased risk of CMD that is not explained by other identified social stressors. Carers should be recognized as being at increased risk of CMD independent of the other life stressors they have to deal with. Interventions aimed at a direct reduction of the stressfulness of caring are indicated. However, carers also reported higher rates of debt problems and domestic violence and perceived social support was slightly lower in carers than in non-carers. So carers are also more likely to experience stressors other than caring and it is likely that they will need support not only aimed at their caring role, but also at other aspects of their lives.
    Social Science & Medicine. 09/2014; 120:190–198.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Caregivers make a significant and growing contribution to the social and medical care of people with long-standing disorders. The effective provision of this care is dependent on their own continuing health. Aims To investigate the relationship between weekly time spent caregiving and psychiatric and physical morbidity in a representative sample of the population of England. Method Primary outcome measures were obtained from the Adult Psychiatric Morbidity Survey 2007. Self-report measures of mental and physical health were used, along with total symptom scores for common mental disorder derived from the Clinical Interview Schedule - Revised. Results In total, 25% (n = 1883) of the sample identified themselves as caregivers. They had poorer mental health and higher psychiatric symptom scores than non-caregivers. There was an observable decline in mental health above 10 h per week. A twofold increase in psychiatric symptom scores in the clinical range was recorded in those providing care for more than 20 h per week. In adjusted analyses, there was no excess of physical disorders in caregivers. Conclusions We found strong evidence that caregiving affects the mental health of caregivers. Distress frequently reaches clinical thresholds, particularly in those providing most care. Strategies for maintaining the mental health of caregivers are needed, particularly as demographic changes are set to increase involvement in caregiving roles.
    The British journal of psychiatry: the journal of mental science 07/2014; · 6.62 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Social anxiety due to rejection sensitivity (RS) exacerbates psychosis-like experiences in the general population. While reduced dorsal anterior cingulate cortex (dACC) activity during social rejection in high schizotypy has suggested self-distancing from rejection, earlier stages of mental processing such as feature encoding could also contribute to psychosis-like experiences. This study aimed to determine the stage of mental processing of social rejection that relates to positive schizotypy. Forty-one healthy participants were assessed for schizotypy and RS. Event-related potential amplitudes (ERPs) were measured at frontal, temporal and parieto-occipital sites and their cortical sources (dACC, temporal pole and lingual gyrus) at early (N100) and late (P300 and late slow wave, LSW) timeframes during rejection, acceptance and neutral scenes. ERPs were compared between social interaction types. Correlations were performed between positive schizotypy (defined as the presence of perceptual aberrations, hallucinatory experiences and magical thinking), RS and ERPs during rejection. Amplitude was greater during rejection than acceptance or neutral conditions at the dACC-P300, parieto-occipital-P300, dACC-LSW and frontal-LSW. RS correlated positively with positive schizotypy. Reduced dACC N100 activity during rejection correlated with greater positive schizotypy and RS. Reduced dACC N100 activity and greater RS independently predicted positive schizotypy. An N100 deficit that indicates reduced feature encoding of rejection scenes increases with greater positive schizotypy and RS. Higher RS shows that a greater tendency to misattribute ambiguous social situations as rejecting also increases with positive schizotypy. These two processes, namely primary bottom-up sensory processing and secondary misattribution of rejection, combine to increase psychosis-like experiences.
    Neuropsychologia 07/2014; · 3.48 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Aggressive behaviour in psychosis is not uncommon. Community provision for people with psychosis has left informal caregivers to take on a greater role in their care. However, few studies have explored links between patient-initiated violence in mental health caregiving relationships and caregiver functioning. Our study investigated caregiver reports of aggressive acts committed by their relative with psychosis and their links to caregiver appraisals of the caregiving relationship and caregiver outcomes.
    Canadian journal of psychiatry. Revue canadienne de psychiatrie 07/2014; 59(7):376-384. · 2.48 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Historically, it has been difficult to demonstrate an impact of training in psychological interventions for people with psychosis on routine practice and on patient outcomes. A recent pilot evaluation suggested that postgraduate training in Cognitive Behavioural Therapy for Psychosis (CBTp) increased the delivery of competent therapy in routine services. In this study, we evaluated clinical outcomes for patients receiving therapy from therapists who successfully completed training, and their association with ratings of therapist competence and therapy content. Aims: To characterize the therapy delivered during training and to inform both a calculation of effect size for its clinical impact, and the development of competence benchmarks to ensure that training standards are sufficient to deliver clinical improvement. Method: Paired patient-reported outcome measures (PROMS) were extracted from anonymized therapy case reports, and were matched with therapy ratings for each therapist. Results: Twenty clients received a course of competent therapy, including a high frequency of active therapy techniques, from nine therapists. Pre-post effect size for change in psychotic symptoms was large (d = 1.0) and for affect, medium (d = 0.6), but improved outcomes were not associated with therapist competence or therapy content. Conclusions: Therapists trained to research trial standards of competence achieved excellent clinical outcomes. Therapy effect sizes suggest that training costs may be offset by clinical benefit. Larger, methodologically stringent evaluations of training are now required. Future research should assess the necessary and sufficient training required to achieve real-world clinical effectiveness, and the cost-effectiveness of training.
    Behavioural and Cognitive Psychotherapy 12/2013; · 1.69 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Increasing access to evidence-based talking therapies for people with psychosis is a national health priority. We have piloted a new, "low intensity" (LI) CBT intervention specifically designed to be delivered by frontline mental health staff, following brief training, and with ongoing supervision and support. A pilot feasibility study has demonstrated significant improvement in service user outcomes. This study is a qualitative analysis of the experiences of the staff and service users taking part in the evaluation. Aims: To evaluate the acceptability of the training protocol and the therapy, and to examine the factors promoting and restraining implementation. Method: All trained staff and service users completed a semi-structured interview that was transcribed and subjected to thematic analysis. Results: Service users spoke about learning new skills and achieving their goals. Staff spoke about being able to use a brief, structured intervention to achieve positive outcomes for their clients. Both groups felt that longer, more sophisticated interventions were required to address more complex problems. The positive clinical outcomes motivated therapists to continue using the approach, despite organizational barriers. Conclusions: For both trained staff and service users, taking part in the study was a positive experience. Staff members' perceived skill development and positive reaction to seeing their clients improve should help to promote implementation. Work is needed to clarify whether and how more complex difficulties should be addressed by frontline staff.
    Behavioural and Cognitive Psychotherapy 10/2013; · 1.69 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To investigate social support and network features in people with first-episode psychosis, and to examine anxiety as a possible mediator between loneliness and a rating of paranoia. Thirty-eight people with first-episode psychosis were recruited for a cross-sectional study. Self-report questionnaires and structured interviews assessed symptoms, functioning, and qualitative social network and support features. A mood-induction task involved watching anxiety-inducing pictures on a computer screen. Visual analogue scales assessed changes in paranoia, anxiety and loneliness and a mediation analysis was conducted. One-third of the sample (34 %) had no confidant [95 % CI (18.4, 50.0 %)]. The average number of weekly contacts was 3.9, with 2.6 lonely days. Poor perceived social support, loneliness and the absence of a confidant were strongly associated with psychosis and depressive symptoms (0.35 < rs < 0.60). The association between loneliness and paranoia was mediated through anxiety (ab = 0.43, z = 3.5; p < 0.001). Even at first episode, a large proportion of people with psychosis have poor perceived support, no confidant and report several lonely days a week. Patients without a confidant appear to be more susceptible to feeling lonely and anxious. Anxiety may be one pathway through which loneliness affects psychosis. Interventions which focus on this are indicated.
    Social Psychiatry 08/2013; · 2.05 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: AIM: This study explored the relationship between individuals with early psychosis and first-degree relatives who were carers, to see whether negative and distressing experiences of the patient-carer relationship were associated with social cognition difficulties in both groups. METHOD: The study had a cross-sectional correlational design. A total of 33 patients with early psychosis (within 3 years of first psychotic episode) and 24 first-degree relative carers (all parents) completed measures of mood, expressed emotion and negative experiences of caregiving. Social cognition measures of theory of mind and emotion recognition were also collected. RESULTS: Patient perceptions of carer criticism were related to increased anxiety and depression. Carer negative experiences of caregiving were related to higher levels of expressed emotion, anxiety and depression. Both patients and carers showed impaired performance on social cognition tasks. However, patient social cognition was not related to perceptions of carer criticism or symptoms. Carer social cognition was not related to expressed emotion or carer burden. CONCLUSION: Even in the early stages of psychosis, both patients and carers were reporting negative experiences of the caregiving relationship. These were related to higher levels of anxiety and depression. Social cognition difficulties were found in both early psychosis patients and first-degree relatives, but did not relate to caregiving relationships. The findings underscore the importance of providing targeted family interventions to individuals with early psychosis and their carers that address appraisals of the relationship and low mood.
    Early Intervention in Psychiatry 03/2013; · 1.65 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: AIMS: High incidence of psychosis and compulsory treatment within black and minority ethnic (BME) groups in the UK remain a concern. Psychosis has an impact on families and family involvement is important in predicting compulsory treatment. We therefore aimed to report the levels and predictors of caregiver burden in first-episode psychosis, in white British, and BME groups of carers, and investigate their relevance to compulsory treatment. METHODS: A total of 124 caregivers were interviewed soon after the onset of psychosis using the General Health Questionnaire, GHQ-28, the Experience of Caregiving Inventory, the Personal and Psychiatric History Schedule, and the MRC Sociodemographic Schedule. RESULTS: The overall level of distress as measured by GHQ-28 was high (mean 50, SD 11.4). Feelings of carer burden were also high (mean total negative score 72.5, SD 34.8), increased in men, and with carer age. Neither ethnicity nor social class nor social support was associated with distress or burden. Compulsory treatment was predicted by carer burden (as indicated by carer reports of 'problems with services' (OR 1.08; 95% CI 1.01, 1.15; P = 0.023)); this was particularly evident in the black Caribbean group of carers (OR 1.28; 95% CI 1.04, 1.57; P = 0.02) CONCLUSION: Carers of adults with first-episode psychosis experience considerable psychological distress and feelings of burden. There was a specific association between carer burden, specifically in terms of experience of services, and compulsory admission of service users, particularly in the black Caribbean group. Better ways of liaising with carers and targeted efforts to reduce carer burden at illness onset are needed.
    Early Intervention in Psychiatry 03/2013; · 1.65 Impact Factor
  • Epidemiology and Psychiatric Sciences 10/2012; · 3.36 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND AND OBJECTIVES: The dissemination and delivery of psychological therapies for people with psychosis has been limited by workforce and organisational factors. 'Low Intensity' (LI) delivery, whereby staff are trained to deliver brief, focused, manualised interventions, may be one way of improving access. In this study, we piloted a new LI intervention specifically for people with psychosis, aimed at helping people to reach a personal recovery goal, whilst targeting anxious avoidance or depression-related inactivity. Frontline mental health workers were trained to deliver the intervention. We report here on the impact of the intervention on therapeutic outcomes. METHODS: Twelve people with psychosis and either anxious avoidance or low mood, who wanted to work towards a personal goal, completed the intervention and a battery of assessments of mood, functioning and psychotic symptoms. RESULTS: Eleven out of the twelve participants achieved their personal goals. The results of a series of Friedman K related sample tests revealed significant improvements in depression, clinical distress, activity levels, negative symptoms and delusions across the three time points, and no change in hallucinations, or anxious avoidance. Staff and participant satisfaction was high. LIMITATIONS: The study is a small uncontrolled pilot study. Outcomes should therefore be interpreted with caution, pending replication. CONCLUSIONS: The new LI intervention shows preliminary evidence of effectiveness and is a feasible model of therapy delivery for people with psychosis. The results suggest that frontline mental health workers can be trained relatively easily to deliver the intervention. A larger, randomised controlled trial is warranted to determine the effectiveness of the intervention and training programme.
    Journal of Behavior Therapy and Experimental Psychiatry 08/2012; 44(1):98-104. · 2.23 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Cognitive behavioural therapy for psychosis (CBTp) is recommended for people with schizophrenia, but routine delivery remains limited. Obstacles to increasing access include inadequate training, organisational support and supervision, resulting in low levels of staff competence and confidence. This study is a preliminary evaluation of a CBTp training programme, designed to overcome these obstacles and to increase routine delivery of competent CBTp. Training outcomes for a pilot group and for the first three cohorts to complete training were analysed to identify predictors of successful completion and of therapy delivery after training. Objective competence was attained by 37 students (out of 58), who delivered therapy to over 160 service users. Successful completion was associated with previous CBT therapy experience. Delivery after one year was associated with working in a therapy rather than a care co-ordination role. The programme succeeded in training therapists to deliver competent therapy. Our results suggest that preliminary training in CBT for other disorders may improve success rates in CBTp. Despite extensive service liaison, delivery remained problematic for care co-ordinators without role change and provision of dedicated time. The findings should inform future implementation strategies.
    Behaviour Research and Therapy 04/2012; 50(7-8):457-62. · 3.85 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Meta-analyses show that cognitive behaviour therapy for psychosis (CBT-P) improves distressing positive symptoms. However, it is a complex intervention involving a range of techniques. No previous study has assessed the delivery of the different elements of treatment and their effect on outcome. Our aim was to assess the differential effect of type of treatment delivered on the effectiveness of CBT-P, using novel statistical methodology. The Psychological Prevention of Relapse in Psychosis (PRP) trial was a multi-centre randomized controlled trial (RCT) that compared CBT-P with treatment as usual (TAU). Therapy was manualized, and detailed evaluations of therapy delivery and client engagement were made. Follow-up assessments were made at 12 and 24 months. In a planned analysis, we applied principal stratification (involving structural equation modelling with finite mixtures) to estimate intention-to-treat (ITT) effects for subgroups of participants, defined by qualitative and quantitative differences in receipt of therapy, while maintaining the constraints of randomization. Consistent delivery of full therapy, including specific cognitive and behavioural techniques, was associated with clinically and statistically significant increases in months in remission, and decreases in psychotic and affective symptoms. Delivery of partial therapy involving engagement and assessment was not effective. Our analyses suggest that CBT-P is of significant benefit on multiple outcomes to patients able to engage in the full range of therapy procedures. The novel statistical methods illustrated in this report have general application to the evaluation of heterogeneity in the effects of treatment.
    Psychological Medicine 09/2011; 42(5):1057-68. · 5.59 Impact Factor
  • J Onwumere, P Bebbington, E Kuipers
    [Show abstract] [Hide abstract]
    ABSTRACT: The first episode of psychosis frequently occurs during adolescence and early adulthood, and is associated with high levels of trauma, affective disturbance and suicide. The social networks of service users often decrease significantly following the first onset, although many will remain in close contact with some family members particularly during the early phases. However, the negative impact of psychosis on families and their relationship with the identified service user are well documented. Family intervention is a recommended and evidence-based treatment in later psychosis. In this paper, we review the literature on family interventions in early psychosis in the context of new evidence for its efficacy and its routine incorporation in early intervention services for psychosis.
    Epidemiology and Psychiatric Sciences 06/2011; 20(2):113-9. · 3.36 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Avoidant coping is associated with distress in carers of people with psychosis. We hypothesized that this form of coping would abate as carers adapt their coping strategies in the course of the illness. One hundred and forty-one carers of two groups of patients, with recent onset and longer established psychosis, respectively, completed self-report measures of coping and general distress. We found that avoidant coping strategies were associated with carer distress but not with duration of illness. These results argue the need for interventions to reduce the carers' reliance on maladaptive (avoidant) strategies at any stage of the illness.
    The Journal of nervous and mental disease 06/2011; 199(6):423-4. · 1.77 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Despite national guidelines recommending cognitive-behavioural therapy (CBT) and family intervention (FI) in the treatment of schizophrenia, levels of implementation in routine care remain low. The present study investigates attitudinal factors amongst community mental health team (CMHT) staff affecting guideline implementation. CMHTs were audited to measure the capacity and delivery of CBT and FI, and semi-structured interviews were conducted with staff from the teams. Methods. Four CMHTs were audited, and five care coordinators from each team were interviewed. A purposive approach to sampling was used to represent the range of professional training of care coordinating staff. Data were analysed using thematic content analysis. Positive views towards guidelines were evident, although tempered by specific implementation issues. Employing simple psychological interventions and approaches as part of the care coordinating role also emerged as highly valued by staff. Severe workload, time pressure and the need for specialist staff were crucial barriers to implementation. Pessimistic views of recovery for clients with psychosis were also apparent and may affect implementation. Staff attitudes and knowledge are an important area of research when examining guideline implementation and require further study. Key themes that have emerged could inform future training agendas and should be considered when developing guideline implementation strategies for the updated 2009 guidelines.
    Clinical Psychology & Psychotherapy 01/2011; 18(1):48-59. · 2.59 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The aim of the study was to determine how carer need for closure relates to expressed emotion. It also examined the links between carer need for closure and patient functioning including patient need for closure. In a cross-sectional study, 70 caregivers of patients with psychosis completed the Need for Closure Scale (NFCS), the Camberwell Family Interview (CFI) and measures of distress, burden, coping and social network. The NFCS was assessed in terms of its two primary dimensions: a need for simple structure (NFSS) and Decisiveness. Patients also completed measures of psychotic symptoms and affect, and in 50 matched caregiver patient dyads, direct comparisons were undertaken between caregiver and patient NFCS scores. No links were found between caregiver NFC and EE in this predominately low EE sample. More decisive carers had higher levels of self esteem, were less distressed, and resorted less to avoidant coping. The need for simple structure was greater in carers who lacked a confidante. As predicted, patients reported significantly higher NFSS and lower Decisiveness scores than carers, but no relationship was observed between caregiver NFC and patient symptoms of psychosis. Carers reporting confident decision making were also more likely to report adaptive functioning in terms of having lower levels of avoidant coping and distress, and higher levels of self esteem. The results suggest that this style of thinking might be a helpful way of coping with some of the difficulties involved in caring for someone with psychosis. D
    Epidemiologia e psichiatria sociale 06/2010; 19(2):159-67. · 3.16 Impact Factor
  • Elizabeth Kuipers, Juliana Onwumere, Paul Bebbington
    [Show abstract] [Hide abstract]
    ABSTRACT: There is a long history of research into the attributes of carers of people with psychosis, but few interventions target their distress or their difficulties. To describe an empirically based model of the relationships of those caring for people with psychosis to inform clinical and theoretical advances. We developed a model of informal carer relationships in psychosis, based on an integration of the literature elaborating the concept of expressed emotion. The model accounts for divergent outcomes of three relationship types: positive, overinvolved and critical/hostile relationships. Good evidence supports a number of hypotheses concerning the origin and maintenance of these relationship outcomes, which relate to specific differences in carer attributions, illness perceptions, coping behaviour, social support, distress, depression and low self-esteem predicted by our model. We propose that interventions aimed at modifying the specific maintenance factors involved in the different styles of relationships will optimise therapeutic change both for service users with psychosis and for their carers. Family work in psychosis, which improves relationships through problem-solving, reduces service user relapse. It is now time to consider theory-based interventions focused on improving carer outcomes.
    The British journal of psychiatry: the journal of mental science 04/2010; 196(4):259-65. · 6.62 Impact Factor

Publication Stats

126 Citations
63.72 Total Impact Points

Institutions

  • 2007–2014
    • King's College London
      • • Institute of Psychiatry
      • • Department of Psychology
      Londinium, England, United Kingdom
  • 2013
    • Royal Society of Medicine
      Londinium, England, United Kingdom
    • South London and Maudsley NHS Foundation Trust
      Londinium, England, United Kingdom
  • 2008
    • ICL
      Londinium, England, United Kingdom