Examining the physical health and lifestyle of young people at ultra-high risk for psychosis: A qualitative study involving service users, parents and clinicians

Emerging evidence suggests young people at ultra-high risk for psychosis (UHR) are also at-risk for poor physical health, and display high rates of modifiable cardiometabolic risk factors. However, before we can develop effective interventions there is a need to understand factors affecting lifestyle choices in the UHR group. We conducted semi-structured qualitative interviews with 20 UHR individuals (50% male; mean age 21.7), 5 parents (4 mothers, 1 father), and 6 clinicians from early intervention services in the Northwest of England to identify barriers and facilitators to living a healthy lifestyle, including achieving regular exercise, eating well and refraining from excessive substance use. Thematic analysis revealed the main barriers to living a healthy lifestyle related to psychiatric symptoms, beliefs about self, social withdrawal and practical considerations such as accessibility and cost. Provision of social support and promoting autonomy emerged as the two main themes which would facilitate a healthy lifestyle. Promoting physical health in people with emerging symptoms of psychosis is an important, yet neglected area of mental health practice and warrants further investigation. UHR individuals experience numerous barriers to living a healthy lifestyle, and


Introduction
People with psychosis are more likely to live unhealthy lifestyles and experience poor physical health at a young age compared with the general population (Mitchell et al., 2013;Shiers et al., 2015). This results in a 10-25 year reduction in life expectancy, mostly due to cardiovascular disease, (Laursen et al., 2012). Physical inactivity, diets low in nutritional value or high in convenience food, smoking and excessive alcohol or substance use are all examples of unhealthy lifestyle behaviours common in people with psychosis. Emerging evidence suggests this unhealthy profile may begin even prior to the onset of full psychotic symptoms; that is in those at ultra-high risk (UHR) for psychosis (Carney et al., 2016. The UHR criteria, also known as prodromal, clinical high risk (CHR), or at-risk mental state (ARMS criteria), enable the identification of individuals at high risk for psychosis (Yung et al., 2003;Yung et al., 1996;Fusar-Poli et al., 2013). In order to meet UHR status, an individual must fulfil one or a combination of the following criteria; attenuated psychotic symptoms, brief limited intermittent psychotic symptoms (BLIPS), or a genetic risk combined with a recent decline in functioning (Yung et al., 2004). An individual meeting the UHR criteria is at greatly increased risk of developing a first episode of psychosis within 1-2 years compared to individuals in the general population (Fusar-Poli et al., 2012).
In a recent study, unmedicated UHR individuals displayed a higher prevalence of cardiometabolic risk factors compared with age matched controls, including higher blood pressure, increased waist circumference and increased fasting blood glucose (Cordes et al., 2017). A recent cross-sectional analysis of cardiometabolic risk factors in the UHR group also found evidence for low levels of physical activity and poor quality sleep (Lederman et al., under review). High rates of cardiometabolic risk factors can largely be attributed to lifestyle factors observed in this group, such as reduced physical activity, and increased rates of smoking and alcohol abuse (Carney et al., 2016). These behaviours are potentially modifiable. Therefore, the UHR phase represents an important opportunity for early intervention, to prevent future ill-health.
Despite the need for physical health interventions in this group, there remains a paucity of research examining physical health promo-tion for young people in the UHR phase. Physical health measures are not routinely monitored in early detection settings (Carney et al., 2015) and there have been no documented physical health interventions for this group. However, before we can develop a feasible, acceptable and potentially efficacious intervention there is a need to understand more clearly why the UHR group have poorer lifestyle profiles compared to individuals who are not UHR (Carney et al., 2016;Carney et al., 2017;Lederman et al., under review). Qualitative research enables us to gain insight into a person's subjective experience of physical health and lifestyle. The limited amount of qualitative studies in this group have focused on functional impairment and experience of symptoms (Byrne and Morrison, 2010;Ben-David et al., 2014) however, this approach has not yet been used to explore the physical health of this group. Therefore, we conducted a qualitative study in order to assess the perceptions of UHR individuals, their families and the professionals who worked with them, regarding factors that prevent or promote them living more healthy lifestyles and how they could be supported to improve their physical health.

Aims
Using qualitative interviews, we aimed to identify: • Barriers that UHR individuals face to living a healthy lifestyle.
• Facilitators to living a healthy lifestyle for UHR individuals.
• Support that would be useful to help this group improve their physical health.

Sample
Sampling was purposive. Eligible participants were aged 16 years or over, were English speakers, and fulfilled at-risk mental state criteria according to the Comprehensive Assessment for At-Risk Mental States (CAARMS; Yung et al., 2005). In line with the National Service Framework for Access and Waiting Time Standards (NHS England, 2016), all individuals were offered cognitive behaviour therapy and mental health monitoring in a specialised early intervention or early detection service in the Northwest of England. Twenty UHR individuals were recruited. Five of their parents, and 6 clinicians from the services also agreed to be interviewed, leaving a total sample size of 31.

Procedure
East Midlands Derby Research Ethics Committee approved the study (ref:15/EM/0559) which took place between January -December 2016. Clinicians were given study information to pass on to their clients and consent to contact was obtained. UHR individuals were contacted by the lead author (RC) and provided with further information before arranging to meet. Written informed consent was sought from all participants prior to all interviews taking place. After taking part, UHR individuals were asked for their consent to contact a parent to complete a similar interview about their physical health. Clinicians were also contacted again and invited to take part. Participants were reimbursed for their time. Data collection was finalised once data saturation had been reached in the UHR sample and no further parents or clinicians were willing or available to be interviewed.

Demographic information
Age, gender, ethnicity, marital, vocational and living status and highest educational qualification were recorded for UHR individuals (Table 1).

Qualitative interviews
A qualitative design was employed using semi-structured interviews. Topic guides were developed by the study team based on previous research (Carney et al., 2016;Bradshaw et al., 2012) (available on request). Semi-structured interviews were conducted by the lead author and covered a range of pre-specified topics regarding participant's lifestyles. Interviews consisted of questions about diet, exercise, alcohol and tobacco use as well as questions about barriers and facilitators to living a healthy lifestyle. Interview schedules were adapted to be appropriate for the three groups of participants, and lasted up to 1 h. Interview guides were flexible using prompts and open questions to encourage participants to talk in depth about their perceptions and experiences. All interviews were digitally recorded and transcribed verbatim for analysis. Participants were assigned pseudonyms to maintain anonymity.

Qualitative analysis
The current study had several pre-specified areas of interest relating to identifying barriers and facilitators to living a healthy lifestyle. A thematic approach was taken to analyse the data in order to identify key themes for each topic. Thematic analysis is a systematic approach whereby patterns and common themes are identified to describe a data set and understand a given phenomenon (Braun and Clarke, 2006). Despite having pre-specified areas of interest, we adopted a bottom up approach to identifying recurring themes in the data. This was conducted according to the method specified by Braun and Clarke (2006): 1. Transcripts were read and re-read to familiarise the researchers with the data 2. Systematic line by line coding to identify common features in the data 3. Codes were reviewed to determine potential themes 4. Themes were reviewed for internal homogeneity and external heterogeneity and ensure they were coherent and distinctive 5. Themes were defined and names generated for each To reduce the risk of bias, all researchers were involved in the analytic process and codes and themes were discussed throughout. Quotes presented within the results section are used to illuminate the findings and add context to each theme. The perceptions of all three groups were synthesised to identify overarching themes and factors affecting lifestyle. All data analysis was conducted using nVivo (Version 11) (NVivo Qualitative Data Analysis Software, 2015).

Results
UHR demographics can be found in Table 1. Four mothers and one father took part in an interview about their son/daughter. Clinicians had a range of healthcare backgrounds, (Clinical psychologist n=3, Mental Health Nurse n=1, Occupational Therapist n=1, Social Worker n=1).

Barriers to living a healthy lifestyle
UHR individuals experience numerous and frequent barriers to living a healthy lifestyle which result in low levels of physical activity, poor diet, and excessive substance use. The main barriers related to psychiatric symptoms, beliefs about self and social withdrawal ( Table 2).

Psychiatric symptoms
A wide range of psychiatric symptoms impacted on the ability of UHR individuals to live a healthy lifestyle. These symptoms included suspiciousness, paranoid thinking, perceptual abnormalities, and affective symptoms such as depression and anxiety.
"Clinician: they don't do any physical exercise, and mainly it's because of the suspiciousness and the paranoia, linked with social anxiety and depression that they don't get out of the house." Lack of motivation was a major barrier. This was linked to symptoms of depression, loss of interest in activities, and low energy. Relying on quick fixes was common, such as convenience food and highly caffeinated drinks to boost mood and energy.
"UHR: But on the days where you eat rubbish, partly it's because you are feeling rubbish that day anyway so I eat like the wrong stuff and then, that doesn't really make anything better… it's generally on a day when I'm feeling down and like lack motivation and I'm not up for anything so sometimes you go for like fizzy drinks." Despite being aware of the benefits of a healthy lifestyle, UHR individuals were often unable to overcome barriers associated with positive symptoms and anxiety. Increased paranoia and suspiciousness prevented many from attending places such as gyms, through fear of being judged by other people. Additionally, diet was often poor and related to symptoms. For example, comfort eating when depressed, or under-eating when anxious.
"UHR: I normally snack, like with chocolate, crisps.. which I know I shouldn't do. I get that, but it's comfort eating. I still comfort eat. Like cause of the voices, like my voices I start like bottling inside it." Substance use was also linked, with some people claiming they smoke more or use alcohol when they feel depressed or anxious as a way of calming themselves down.
"UHR: So half of the time everyone else is also drinking, but some of the time I'll be with everyone else and I'll be the only one drinking… possibly, but it's just to take the edge off the anxiety and stuff, so it just makes it Table 2 Barriers and facilitators to living a healthy lifestyle.

Barriers to living a healthy lifestyle Psychiatric Symptoms
Kate: it was easier to sit in my room and eat a load of crème eggs than to go outside for a walk and stuff. Even though the walk would have helped me more than a box of crème eggs. Parent: as he walks in a room he thinks every single person has eyes on him and they are judging him straight away. They are thinking look at him, look at the way he's looking, look at his hair, look at his glasses, look at his shoes, look at his….. So to him everybody's judging him, everybody's laughing at him. Clinician: when people are depressed, they don't have that motivation to look after themselves properly. Beliefs about self Anthony: the way they feel about themselves, if they're feeling tender and see themselves as not really having that high self-esteem that might be a barrier.
Beth: it is always like portrayed as like happy people, like people being all like positive and like when you are in like a bad state of mind that is not me, that is not something I can do. Parent: They will gain self-confidence not just because they are more active, and that makes things more easier to achieve because you are fit, but because they are doing something for themselves and they are healthy and I think it all feeds into the mood. Clinician: a lot of the people I see, they are overweight, they've got poor self-image, they don't do any physical exercise Social withdrawal Alison: when you are having like quite a low day and you are feeling quite down or you are feeling like really agitated or really anxious and stuff you just, you don't want to go anywhere, you don't want to do anything, you don't want to see people, and don't want to be around anyone. So it puts you off doing that, especially with eating because you think I just don't wanna eat. Parent: They need to do like more exercise and not eat like loads of junk and keep going out. They don't go out and mix with people, like she doesn't go out and mix with anybody. She's just in her bedroom. She won't even come downstairs she just stays in her bedroom. Clinician: sat in their bedroom, not interacting with people, on the computer. You know and often I think how that can impact on them, you know it's bound to impact on not only their mood, but their social skills as well. And physical health in terms of they're not physically active. Clinician: what we find with our clients, particularly with the ones who are more anxious or suspicious is that they will probably need a little bit of help or adaptation to access services Promoting autonomy Erin: That's the main thing that puts me off doing exercise when someone says have you done this, you should be doing this. And like that instantly makes me not want to do it. Parent: being told things all the time you tend to switch off whereas when you experience something it sticks with you. Clinician: It's got to mean something to that person, it's got to be important to them, they've gotta want to change. If you try and force it on them it's not gonna work….. Not only you encouraging them to be more active but for them to want to be more active.
easier to interact with people."

Beliefs about self
UHR individuals often held a negative view about themselves, with many having low self-esteem, poor confidence and a lack of belief in their own ability.
"UHR: The biggest barrier I think a young person can ever have themselves is the opinion they have of themselves; which can act as maybe a positive thing or an actual barrier to self-improvement" This had a profound impact on their lifestyle for example, feeling self-conscious in public places, fearing judgement from others and comparing themselves to other people. Internalised self-stigma was also common. Many individuals reported feeling different to other people as a result of their mental health difficulties and poor self-image, which presented a further barrier to engaging in social opportunities.
"Parent: self-image, I think any of the young 'uns with mental health issues are very conscious of it and they think everyone else can see 'em. Because I know Joe has said that"

Social withdrawal
Social withdrawal as a result of poor mental health and low selfesteem was also a barrier. Factors included fear of others, failure and ridicule, and finding unfamiliar situations or group tasks intimidating.
"UHR: I think the idea of group activities can be a bit intimidating and just…. I think sometimes it's hard to like tell yourself, that you like you need to do more exercise, or like you need to eat better" Increased isolation and avoidance of others often resulted in young people having fewer opportunities to engage in healthy behaviours such as walking, and playing sports. Although a proportion of individuals were in college or employment, many spent a lot of their time participating in unstructured activities, and isolating themselves from others.
"Parent: They need to do like more exercise and not eat like loads of junk and keep going out. They don't go out and mix with people, like she doesn't go out and mix with anybody. She's just in her bedroom. She won't even come downstairs she just stays in her bedroom." Social factors also impacted on whether a young person engaged in unhealthy behaviours. For example, many used alcohol and other substances as a way of improving social confidence and making them feel more relaxed around other people.

Practical issues
Finally, numerous practical barriers were presented, which generally related to accessibility and the surrounding environment. This included cost, time, and having the skills and knowledge to live a healthy lifestyle, for example not knowing how to prepare a healthy meal.
"Clinician: that would be around access really, so cost, availability, ease of access and then erm… for many people I think Salford wise it is you know, not only the cost of the exercise itself but the cost of transport." "UHR: it makes me feel down because like, I want to eat like, I want to eat healthier, but obviously I can't cook myself. Like I can't use a cooker, I can only just manage like the stove part of a cooker, I can only just manage to do that now, and I'm 17. That's embarrassing for a 17 year old not to cook, and because my mum would never let me touch anything." The physical and social environment affected the lifestyle choices people made, such as the behaviours of other people in the household, past experiences, availability of food, and opportunities available in the local area.

Facilitators to living a healthy lifestyle
The main facilitators to living a healthy lifestyle were linked to social support and promoting autonomy, (Table 2).

Social support
A range of social factors were acknowledged as useful facilitators to living a healthy lifestyle. A prevalent theme throughout was having someone to support this change in behaviour, such as having someone to exercise with or attend groups with. Parents and clinicians also discussed the value of having support from young people who may have had similar experiences with mental health issues, and who may represent useful role models. Social support may encourage UHR individuals to make positive changes to their physical health and may reduce self-stigma and low confidence in this group.
"UHR: If someone would come with me that I know… because I'd have someone there that would be able to say, they are not talking about you and just reassure me." Reassurance from people who they trust was also a facilitator in helping UHR individuals overcome some of the barriers they face associated with symptoms, such as distracting people in public places if they are thinking people are looking at them, or are feeling paranoid.

Making the choice for themselves
A strong theme which emerged across the data was that UHR individuals do not find it useful if they are told by a clinician or parent what to do.
"UHR: if you tell someone to do something, they're not gonna want to do it but if you got that option there to do it, it's gonna make people give it a go" Alternatively, when young people are empowered to make decisions themselves regarding their physical health they feel much more in control and motivated to do so. Providing individuals with the knowledge to enable them to make an informed choice was seen as useful throughout the interviews. Promoting self-efficacy and autonomy are therefore, facilitators in helping young people be more healthy and active and help address motivational difficulties.

Summary of findings
Qualitative interviews were conducted to investigate physical health and lifestyle in an UHR cohort. Multiple barriers to living a healthy lifestyle were experienced resulting in high rates of cardiometabolic risk factors in this group. The main difficulties were linked to low motivation and psychiatric symptoms, including symptoms such as suspiciousness, anxiety and depression. These experiences increase the likelihood of becoming isolated and socially withdrawn, and reduce the opportunity to lead a healthy lifestyle. Despite this, many are keen to improve their physical health if activities were available and if they had appropriate support from others to help overcome their difficulties. These findings highlight the growing need to develop healthy lifestyle interventions for people at high risk of psychosis.
Our findings can be interpreted in the context of the COM-B model which states a person must have the Capability, Opportunity and Motivation to engage in behaviours (Michie et al., 2011;See Fig. 1). Firstly, UHR individuals displayed substantial deficits in motivation. Research in FEP groups has also found that motivation, particularly autonomous motivation, is one of the primary barriers to living a healthy lifestyle (Firth et al., 2016a(Firth et al., , 2016b(Firth et al., , 2016d. Autonomous motivation refers to a person valuing the importance of behaviour, taking control and making the decision to engage in behaviour by aligning it with their personal views (Deci and Ryan, 2010). Intrinsic motivation, one aspect of autonomy, plays an important role in facilitating initial uptake and long-term maintenance of exercise in people with FEP (Firth et al., 2016c;Vancampfort et al., 2016), however, promoting autonomy is often overlooked in youth mental health services, (Plaistow et al., 2014).
We found that costs and accessibility of attending a gym were barriers affecting opportunity to engage in healthy behaviours. Assisting with these issues could include the provision of low cost gym memberships, assistance with transport, or making people aware of local facilities they are able to access. This could then encourage long-term behaviour change, as young people may continue to access local facilities in the absence of support and guidance from mental health services.
Lack of knowledge about how to live a healthy lifestyle was also evident in some of our participants. Some participants reported that they were unsure how to prepare a healthy meal, and had relatively few cooking skills. Increasing this knowledge would increase their capability. For example, showing young people how to cook healthy food on a budget may be useful, in order to reduce the amount of convenience foods consumed, and over-reliance on caffeinated drinks as a source of energy.
However, providing advice and access to gym facilities is insufficient to encourage people with serious mental illness to increase their physical activity (Archie et al., 2003). Our findings support previous work that showed the importance of social support in overcoming psychological barriers to exercise (Firth et al., 2016c(Firth et al., , 2016d. Providing social support increases people's capability to engage in healthy behaviours. Exercise and lifestyle interventions which draw on social support are feasible and useful for people with FEP (Firth et al., 2015;Bradshaw et al., 2012). Support to exercise could be facilitated by employing physical health therapists and peer mentors within services. This holistic lifestyle approach has been trialled in Early Intervention for Psychosis services in Australia with demonstrable benefits to both physical and mental health (Curtis et al., 2016).
Providing social support can also help address factors associated with poor social functioning in this group. A culmination of factors including psychiatric symptoms, poor self-esteem and low motivation often result in UHR individuals becoming increasingly withdrawn and isolated from others (Cotter et al., 2014;Meyer et al., 2014;Glenthøj et al., 2017). For example, we found that emerging positive symptoms such as suspiciousness, paranoia and perceptual abnormalities reduce a person's psychological capability to engage in meaningful activities for physical health, and increase the likelihood of them becoming more withdrawn. This in turn reduces the amount of opportunities young people have to engage in health behaviours, such as attending sports groups, or going to the gym. Therefore, living a healthy lifestyle is difficult for this group, particularly for those with marked impairment in social functioning who spend a lot of time home alone, participating in unstructured activities.
UHR individuals are at an important stage in their life in terms of occupational functioning, and long-term employment outcomes are often poor in this cohort (Cotter et al., 2014. Therefore, it is important to adopt a multifaceted approach to health care provision for this group. An early qualitative study interviewed parents about the time leading up to a first-episode of psychosis, and identified similar themes to our study (Cocoran et al., 2003). For example, prior to FEP individuals experienced a decline in functioning, particularly social functioning which could have impacted on their ability to engage in exercise. Support to overcome psychosocial barriers may help increase people's capability to engage in physical activities to improve physical R. Carney et al. Psychiatry Research 255 (2017) 87-93 health, and also open up further opportunities as a result of increased confidence and self-esteem. Support for this comes from a recent exercise intervention in a FEP group where participants reported the benefits of engaging in exercise extended to other aspects of their life such as improving social confidence and self-esteem (Firth et al., 2016c). Therefore, there may be a virtuous cycle whereby improving physical health can result in greater self-esteem and confidence, which in turn improves motivation and capability to engage in both healthy lifestyle activities and overall social functioning.

Clinical implications
Addressing the physical health of people with emerging psychological difficulties is an important, yet neglected area of mental health and warrants further investigation (Carney et al., 2015). Encouraging this group to live a healthy lifestyle is important for several reasons. First, it protects against future metabolic ill-health commonly associated with disease progression. Second, it may reduce the risk of developing psychosis, as a recent cohort study found low levels of physical activity during childhood and adolescence was an independent predictor of psychosis in adulthood (Sormunen et al., 2017). Third, although the majority of this cohort will not develop psychosis, a large proportion will develop mood, anxiety and substance use disorders, (Lin et al., 2015) and continue to function poorly even in the absence of symptoms, (Cotter et al., 2014;Yung et al., 2015). Therefore, even in those who do not develop psychosis, promoting physical health may be beneficial. Finally, intervening at the earliest stage and adopting a preventative approach is more cost-effective and associated with better long-term outcome (Tsiachristas et al., 2016).

Strengths and limitations
This is the first qualitative exploration of physical health in the UHR cohort. Interviewing parents and clinicians and integrating this data with opinions of the UHR individuals enabled us to gain a more holistic view of the factors affecting physical health in this group. Some of the barriers to living a healthy lifestyle may not be unique to the UHR cohort, and may be experienced by other young people, for example, cost, knowledge and accessibility. However, some of the key themes can be linked to symptoms and psychopathology of this group. Our findings suggest this cohort experience difficulties with motivation, social anxiety and symptomatic barriers which have an effect on their lifestyle and health behaviours. Given the importance of identifying appropriate methods of physical health promotion for this group, to ameliorate cardiometabolic risk, our findings provide an important contribution to the wider literature.
Our sample had an equal number of males and females, all of whom were white British. Although this is representative of the service, our findings may not be culturally representative of the whole UHR cohort. All patients met at-risk criteria on the CAARMS (Yung et al., 2005); however, due to the qualitative nature of the study individuals with more severe symptoms may not have volunteered.

Conclusion
UHR individuals experience numerous barriers to living a healthy lifestyle. We recommend the development of a structured lifestyle intervention to support UHR individuals to engage in healthy behaviours. Interventions should focus primarily on targeting autonomous motivation and providing social support to facilitate this change. Preventing physical ill-health and promoting wellbeing in this vulnerable group should be a priority for future development.

Conflict of interest
None.